Medicaid, also known as ‘Medical Assistance’, is the centerpiece of the U.S. healthcare system. It finances your health care services if you’re disabled, elderly, or earning a low income. Here are facts that you need to know about Medicaid to set the record straight.
Facts About Medicaid
Medicaid Is the Nation’s Public Health Insurance Program for People With Low Income
The Affordable Care Act (ACA) has expanded health coverage for Americans from low-income families. Under the expansion, anyone who earns less than 138 percent of the federal poverty line is eligible for Medicaid.
In 2018, Medicaid provided comprehensive health care to 97 million Americans with low income for the entire year. A report by Congressional Budget Office estimates Medicaid serves approximately 32 million children, 28 million adults with low income, 9 million disabled persons, and 6 million seniors in any given month.
By April 2020, about 35 states, as well as the District of Columbia, had enacted the Medicaid expansion to include low-income persons. According to CBD projections, about 14 million financially disadvantaged adults will be Medicaid enrollees by 2029. In turn, they will access affordable quality health care under the ACA expansion.
Medicaid Covers 1 in 5 Americans
States rely on Medicaid Health plans to advance high-quality, synchronized care for their expanding populations. Over 56 million low-income persons depend on Medicaid plans. This represents 78 percent of the entire Medicaid enrollment. More than 80 million or 1 in 5 Americans are enrolled under the Medicaid health insurance program.
Medicaid Finances Nearly a Fifth of All Personal Health Care Spending in the US
Medicaid offers more comprehensive coverage benefits compared to private insurance programs. As a beneficiary, you get to enjoy all the benefits of private insurance at considerably lower costs. This is because it costs Medicaid a lot less than private insurers to provide coverage to patients.
A research by Urban Institute shows that you are likely to pay 22 percent less for Medicaid Coverage than private insurance. As a result, Medicaid caters for almost a fifth of all personal health care costs in the U.S.
States Administer Medicaid Programs
Medicaid gives states the liberty to design their programs. They can determine covered populations, covered services, health care delivery models, and methods of paying physicians and hospitals. Each state is also mandated to assign a single state agency to run or supervise its Medicaid Program. The designated agency works with other public or private organizations to execute various program functions.
All states are required to cater for covered services that are provided by qualified doctors to eligible Medicaid patients. For this reason, a state must:
- Allow all people to apply for Medicaid coverage.
- Decide on who qualifies for Medicaid and the benefits rendered.
- Establish which health care providers are qualified to render services.
- Decide on provider payment rates.
- Process claims filed by providers.
- Monitor the level of care rendered to Medicaid patients by in-network providers.
- Resolve any arising complaints by providers, beneficiaries, and applicants.
- Send program updates to the Centers for Medicare & Medicaid Services (CMS).
At the federal level, the Centers for Medicare & Medicaid Services (CMS) provide guidance and oversight for Medicaid program administration. These include guidelines on:
§ Nursing facility standards.
§ Eligibility determinations.
§ Specific mandatory health coverage.
§ Data collection.
§ Program reporting.
Medicaid Provides Health and Long-term Care for Millions of Americans
Many Americans need long-term health care services. This is due to the high frequency of chronic ailments and disabling conditions. Survey findings from the 2020 Genworth Cost of Care show that the median national charge for a private room in a nursing facility is $105, 850 every year.
This is why Medicaid is the go-to option for a majority of Americans. It covers the lion’s share of long-term care services and supports. In fact, the amount of Medicaid spending on long-term care and support rose up to 57 percent from 18 percent between 1995 and 2016.
Medicaid allows for the provision of long-term care and support in a variety of settings, including:
§ Nursing facility.
§ A private home.
§ Assisted living facility.
§ Retirement community.
Many States Elect to Cover Optional Services Such as Prescription Drugs, Physical Therapy, Eyeglasses, and Dental Care
Under Federal law, states must provide specific mandatory services. States are also allowed the discretion to choose which other optional benefits to render to beneficiaries.
Mandatory services include:
§ Inpatient & outpatient services.
§ Doctor services.
§ Home health services.
§ X-ray and laboratory services.
§ Ambulance services.
§ Family planning services.
§ Nursing facility services.
Optional services include:
§ Prescription drugs.
§ Occupational therapy.
§ Dental services.
§ Podiatry services.
§ Respiratory care.
§ Optometry services.
§ Chiropractic care.
§ Physical therapy.
§ TB-linked services.
Most Medicaid Enrollees Get Care Through Private Managed Care Plans
Medicaid does not provide direct health care services. Instead, it contracts hospitals, doctors, nursing facilities, and health plans to render covered services to eligible Medicaid patients.
The majority of Medicaid beneficiaries receive their health coverage through some form of managed care. About 82 percent of Medicaid enrollees were getting their care through private health plans as of July 2017.
The reason for this shift is that managed care plans have access to resource pools that state Medicaid organizations don’t have. These include:
§ Information technology.
§ High-tech network contracting.
§ Management systems to realize low-value care and boost the health of patients.
Types of managed care plans include:
§ Comprehensive risk-based managed care.
§ Limited benefit plans.
§ Primary case management.
Medicaid Beneficiaries Have Far Better Access to Care Than the Uninsured
If you earn a low income, you are more likely to do without needed medical services because of lack of medical coverage. However, as a beneficiary of the Medicaid program, you’ll enjoy regular access to health care at a considerably lower cost.
The type of health care services provided by Medicaid to its beneficiaries is comparable to what you would get via employer-sponsored coverage. The difference is that you pay considerably low out-of-pocket costs for a Medicaid plan.
According to a research by America’s Health Insurance Plans (AHIP), Americans using Medicaid have better access to health care services as compared to the uninsured. The report found out that:
· Adults who have enrolled for the program are five times more likely to access consistent health care services as compared to the uninsured.
· Children under Medicaid coverage are more likely to access preventive care services as compared to those without health coverage.
Medicaid Coverage of Low-income Pregnant Women and Children Has Contributed to Dramatic Declines in Infant and Child Mortality in the US
Studies reveal that Medicaid expansion states recorded lower mortality rates for infants than non-expansion states. This is because the expansion allows low-income pregnant women to receive health coverage through Medicaid for pregnant women. Coverage may also extend to a few months following the birth of the baby.
Medicaid Is Financed Jointly by the Federal Government and States
Medicaid financing is a joint responsibility. This is between the federal and state governments as sanctioned under the Social Security act. The Federal government matches at least 50 percent of each state’s Medicaid expenditure. Even though the precise percentage differs from one state to another.
Medicaid Spending Was $577 Billion in FY 2017
During the 2017 fiscal year, Medicaid spending across the U.S. was $577 billion. Total Medicaid expenditure rose by an impressive 33 percent between fiscal years 2012 and 2017.
Seniors and People With Disabilities Make up 1 in 4 Beneficiaries
One out of four Medicaid beneficiaries is either elderly or disabled persons in the community. Medicaid provides a wide range of health care services to help these people live decent lives. Besides, some states help eligible disabled persons find and retain jobs.
Seniors and People With Disabilities Account for Almost Two-thirds of Medicaid Spending
Providing health care services for seniors and persons with disabilities is costly. This is because such patients often require both acute care services and long-term supports. Children with disabilities depend on personalized education plans (PEP). PEPs often comprise services covered by Medicaid for children, including physical and speech therapy. That’s why two-thirds of Medicaid spending go to the elderly and disabled persons.
One in Eight Medicaid Enrollees (or About 11 million Americans) Is an Individual With Disability
Persons with disabilities often require medical and continuing care to maintain their well-being and independence. Through Medicaid, you can lead a productive life in your home or in a nursing facility, thanks to attendant care. Because health care services are costly for the uninsured disabled person, 1 in 8 Medicaid beneficiaries is a person with disability.
64,699, 741 Individuals Were Enrolled in Medicaid as of October 2019
In all the 50 states plus the District Columbia, 64,699, 741 persons were enrolled and getting full benefits from Medicaid as of October 2019. These numbers point to the important role the Medicaid insurance program plays in providing affordable, quality coverage for millions of disadvantaged adults and children.
Average Medicaid Expenditures
Children (ages 0-19)
Adult (ages 20-64)
Expansion adults (ages 20-64)
People with disabilities (ages 0-64)
$ 19, 754
Enroll for a Medicaid Program for Better Health Care
You don’t have to go without proper medical care if you earn a low income. You can access care comparable to that of people with private coverage by enrolling for a Medicaid program. Medicaid also covers long-term care for the elderly and persons with disabilities.