Medicaid and the Children's Health Insurance Program (CHIP) are government-funded initiatives that provide free or low-cost health coverage to individuals, families, and children with low incomes, pregnant women, the elderly, and people with disabilities. Some states have even extended their Medicaid programs to cover all people below certain income levels. Medicaid is a joint federal and state program that helps cover medical expenses for some people with limited incomes and resources. The federal government has general rules that all state Medicaid programs must follow, but each state has its own program.
This means that eligibility requirements and benefits may vary from state to state. Medicaid is the country's public health insurance program for people with low incomes. It covers 1 in 5 Americans, including many with complex and expensive care needs. The program is the primary source of long-term care coverage for Americans. The vast majority of Medicaid members don't have access to other affordable health insurance.
Medicaid covers a wide range of health services and limits enrollees' out-of-pocket costs. It funds nearly one-fifth of all personal health care expenses in the U. S. The program is governed by Title XIX of the Social Security Act and a broad set of federal regulations, which define federal Medicaid requirements and state options and authorities. The Centers for Medicare and Medicaid Services (CMS) of the Department of Health and Human Services (HHS) are responsible for implementing Medicaid (Figure).
Subject to federal regulations, states administer Medicaid programs and have the flexibility to determine the populations covered, the services covered, the models of healthcare delivery, and the methods for paying doctors and hospitals. States can also obtain exemptions from Section 1115 to test and implement approaches that differ from what federal law requires, but that the HHS Secretary determines the objectives of the program in advance. Because of this flexibility, there is significant variation between state Medicaid programs. Under the original Medicaid Act of 1965, eligibility for Medicaid was linked to cash assistance (either aid to families with dependent children (AFDC) or to Supplemental Federal Security Income (SSI) starting in 1997 for parents, children and people who are poor, blind and people with disabilities. States may choose to provide coverage at income levels higher than cash assistance.
Over time, Congress expanded federal minimum requirements and provided new coverage options for states, especially for children, pregnant women, and people with disabilities. Congress also required Medicaid to help pay premiums and cost-sharing for low-income Medicare beneficiaries and allowed states to offer a Medicaid “acceptance” option to people who work with disabilities. Other coverage milestones included breaking the link between Medicaid eligibility and social assistance in 1996 and enacting the Children's Health Insurance Program (CHIP) in 1997 to cover low-income children above the Medicaid limit, with an improved federal counterpart rate. Following these policy changes, states conducted outreach campaigns for the first time and simplified enrollment procedures to enroll eligible children in both Medicaid and CHIP. The expansion of Medicaid coverage for children ushered in subsequent reforms that redefined Medicaid as an income-based health coverage program. Because Medicaid and CHIP members have limited ability to pay out-of-pocket expenses because of their modest incomes, federal rules prohibit states from charging Medicaid premiums to beneficiaries with incomes below 150% of the FPL, prohibit or limit cost-sharing for some populations and services, and limiting total out-of-pocket expenses to no more than 5% of family income.
Some states have obtained exemptions from charging premiums and cost-sharing that are higher than those allowed by federal regulations. Many of these exemptions are aimed at adults in the expansion, but some also apply to other groups that qualify through traditional eligibility pathways. Medicaid covers people struggling with opioid addiction and improves state capacity to provide access to early interventions and treatment services. The expansion of Medicaid, with increased federal funding, has provided states with additional resources to cover many adults with addictions who were previously excluded from the program. Medicaid covers 4 out of 10 non-elderly adults with opioid addiction.
Older people and people with disabilities account for 1 in 4 beneficiaries, but account for nearly two-thirds of Medicaid spending, reflecting the high costs per person enrolled in intensive and long-term care (Figure).Medicaid is the main payer of long-term institutional and community services and support, since Medicare has limited coverage and few affordable options in the private insurance market. More than half of Medicaid spending is due to the five percent of enrollees that it costs the most. However, depending on each member, Medicaid is low-cost compared to private insurance, largely due to lower Medicaid payment rates for providers. Analyses show that if adults enrolled in Medicaid instead had employment-based coverage, their average health care costs would be more than 25% higher.
Medicaid spending per member has also grown more slowly than private insurance premiums and other health spending benchmarks. This fact sheet provides basic information about your possible options if your health coverage can no longer afford benefits. For example, there are health coverage providers known as multi-employer wellness agreements (MEWA), which provide health benefits as well as other benefits to employees of two or more unrelated employers. While some MEWAs offer valuable coverage, other MEWAs cannot pay insolvency or fraud claims which can lead them into bankruptcy or bankruptcy proceedings. If this happens to you, here are some options you should consider to get alternative health coverage. These options involve the health coverage portability provisions of the Health Insurance Portability and Accountability Act (HIPAA) as well as the health insurance marketplace provisions of the Patient Protection and Affordable Care Act (ACA).
Medicare is federal health insurance for people age 65 or older as well as some people under age 65 who have certain disabilities or conditions. When you fill out a Marketplace application you can also find out if you or your family are eligible for free or low-cost coverage through a government program such as Medicaid or CHIP. Most states are undertaking a variety of reforms in delivery systems as well as payments in order to control costs while improving quality.
