Medicaid Explained
Al Waller: Medicaid is an invaluable social safety net that provides health care coverage and services for millions of lower income Americans. However, only one in five have a “great deal” of knowledge about it, according to a survey by Transamerica Institute1.
Welcome to ClearPath – Your Roadmap to Health & WealthSM. I'm your host, Al Waller. Joining me today is Mihaela Vincze, public health expert, for nonprofit Transamerica Institute®. We will discuss why Medicaid is so important, eligibility criteria, and how to enroll. We’ll also go over options for those who are not eligible for Medicaid but cannot afford private insurance either.
Mihaela, it’s good to have you on the show.
Mihaela Vincze: It's good to be back.
Al Waller: Before we jump in, can you give us a brief overview of Medicaid? What is it?
Mihaela Vincze: Medicaid is a federal and state-funded health care program that provides health coverage for eligible low-income individuals and families. It plays an essential role in providing health care for those who would not be able to afford it otherwise.
Al Waller: Yes, by ensuring that everyone has access to health care, regardless of their financial situation, we can help level the playing field and reduce disparities. So, let’s start this segment by going over the importance of Medicaid. Why is Medicaid so important?
Mihaela Vincze: Medicaid provides access to health care. Medicaid provides services like preventive care, hospital visits, and prescriptions for those who cannot afford it. It offers health coverage to eligible adults, pregnant women, children, and those with disabilities. Generally, Medicaid requires little to no cost sharing from enrollees— so, ultimately, it makes health care more affordable for eligible individuals and families.
Al Waller: Health care is essential for maintaining and improving individual health. With health insurance, I would think that more people would turn to preventive health services, thus they would have better health outcomes in the long term. How else is Medicaid important?
Mihaela Vincze: Medicaid reduces health care costs. Since Medicaid covers preventive care, costs can be reduced by preventing more serious and costly conditions from developing. Preventive care includes immunizations, screenings, and annual physicals. Medicaid is also a large purchaser of health care services and has bargaining power tonegotiate lower prices with pharmaceutical companies, hospitals, and medical providers. These negotiated rates may help reduce the overall costs of health care.
Al Waller: That’s great that it helps lower health care costs. I would also presume that when people have health insurance, they’re less likely to be sick and more likely to be productive members of society—going to school, work, and participating in their communities—which positively impacts the economy. How does Medicaid contribute to this?
Mihaela Vincze: Medicaid provides support for those with chronic conditions, which if left untreated, can wreak havoc on people’s lives. Medicaid can provide support for individuals with chronic conditions such as heart disease and diabetes by covering care and prescriptions. Medicaid also provides support through coverage of medical services, home and community-based services, care coordination, and specialized programs.
Al Waller: Managing chronic conditions is essential for good health. What exactly is “care coordination?”
Mihaela Vincze: Care coordination can help individuals manage their chronic disease and get care when they need it. This can include case management, help with scheduling appointments, and managing prescriptions. Care coordination can help individuals with chronic conditions receive the care they need and potentially avoid unnecessary hospitalizations.
Al Waller: That sounds helpful in navigating a chronic illness. And to that point, a number of years back I worked with a client that was actually one of the early wellness-disease management companies that provided telephonic support to client employees.
What the nurses would do in these call centers – like focus on, among other things, diabetes, high blood pressure, etc. – really went a long way in successfully addressing and treating their issues in a timely fashion. And I might also add, this business model also gave these nurses a new lease on life, extending their careers in health care by providing their services telephonically, without the typical and physical demands associated.
I’m also curious about home and community-based services? What do these services involve?
Mihaela Vincze: Home and community-based services help individuals who need day to day assistance. These services can improve the quality of life for these individuals, as well as reduce health care costs. These include skilled nursing care, case management, personal care, and more.
Al Waller: It’s profound to hear about all the supports Medicaid provides for disease management. How else does Medicaid benefit people?
Mihaela Vince: I’d like to highlight that Medicaid also …
- Supports children and families. Families and children can receive necessary medical care they may not otherwise be able to afford. Medicaid ensures that children can get necessary medical care regardless of their family’s financial situation.
- Supports older adults and individuals with disabilities. Medicaid provides critical support for older adults who may have limited resources and need access to health care services. Medicaid can pay for nursing home care for older adults who require long-term care and have limited resources. Medicaid can also cover care in the community, such as adult day care.
Al Waller: It’s encouraging to hear that Medicaid supports so many populations. Now that we’ve gone over the importance of this program, who is eligible for Medicaid?
Mihaela Vincze: Eligibility rules are dependent on a few factors and vary state by state. Generally speaking, Medicaid eligibility depends on:
Income. In most states, you’ll be eligible for Medicaid if your income is at or below 138% of the federal poverty level. For 2023, this equates to $20,120 for a household size of one, and $41,400 for a household of four—according to the Assistant Secretary for Planning and Evaluation. Keep in mind that a household includes your spouse and anyone who you are claiming as a dependent on your taxes. You’ll need to check in with your local Medicaid agency to determine the eligible income in your state.
Al Waller: Right—because it varies from state to state. What else does Medicaid eligibility depend on?
Mihaela Vincze: You may need tomeet certain immigration requirements to be eligible for Medicaid – check with your specific state to get the details.
There may be other eligibility criteria for certain groups, such as pregnant people, those with disabilities, and children. For instance, there is pregnancy-related Medicaid for women who are not eligible for regular Medicaid—eligibility varies state by state.
Al Waller: Now that we’ve reviewed the eligibility criteria, how can one enroll in Medicaid?
Mihaela Vincze: To enroll in Medicaid, follow these four steps.
Step 1: Check your eligibility.
Consult the Medicaid Eligibility & Enrollment Toolkit on Medicaid.gov to see if you’re eligible for Medicaid in your state. Eligibility is based on income, household size, and other factors.
Step 2: Gather your documents.
You may need some documentation such as proof of income, proof of immigration status, proof of residency, valid identification, and more when applying for Medicaid. Again, check with your local Medicaid agency as requirements vary.
Al Waller: Ok—so first, check your eligibility. Second, gather those documents! What’s step three?
Mihaela Vincze: Step 3: Apply for Medicaid.
You can apply by phone or visiting your local Medicaid office. To apply online, go to Healthcare.gov and follow the prompts to find your state’s Medicaid website. From there, you can submit your application online.
Step 4: Receive a determination.
Once your application has been processed, you will receive a determination from your state Medicaid agency letting you know your eligibility for the program. If you are eligible, you will receive an enrollment package that includes information about your Medicaid benefits.
Al Waller: What if you’re not eligible because your income is too high for Medicaid but too low to buy private health insurance? What then?
Mihaela Vincze: If you’re not eligible for Medicaid, but you can’t afford private insurance, there may be some options such as:
- The Affordable Care Act marketplace. Depending on your income, you may be eligible for subsidies that can help lower your “premium”, or monthly payment. Visit healthcare.gov to explore your options and see if you qualify for financial assistance. Transamerica Institute also has a Marketplace Open Enrollment guide that you can check out for more information.
- Children's Health Insurance Program (CHIP). CHIP is a federal program that provides low-cost health insurance coverage as an alternative to children in families with incomes too high to qualify for Medicaid, but who can’t afford to buy private insurance. CHIP may also cover pregnant women in certain states. You can apply for CHIP through your state’s Medicaid agency or through the Health Insurance Marketplace.
Al Waller: That makes me wonder—what about getting care if you don’t have health insurance? Where can you get care in that circumstance?
Mihaela Vincze: That’s a good question because there are options in those situations:
- Community Health Centers. These are also known as federally qualified health centers (FQHC), and they provide health care regardless of your ability to pay. These centers charge on a sliding fee scale based on income, so, you may be able to access care at a way lower cost. Transamerica Institute also has an FQHC guide that you can check out for more information.
- Safety net hospitals. These are health care facilities that provide care to patients who are not insured, or are underinsured, or cannot afford medical care.
Al Waller: Thank you, Mihaela.
Health care is essential because it supports good health, saves lives, improves quality of life, and positively impacts society. Join us in spreading the word about Medicaid to those who may benefit from it.
If you’d like to check out any of the source materials mentioned today, visit transamericainstitute.org/podcast to review the episode’s transcript.
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Until the next time, I’m your host Al Waller. Stay safe, be well and thanks for listening.
ClearPath – Your Roadmap to Health & Wealth is brought to you by Transamerica Institute, a nonprofit private foundation dedicated to identifying, researching, and educating the public about health and wellness, employment, financial literacy, longevity, and retirement.
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1 “22nd Annual Transamerica Retirement Survey,” nonprofit Transamerica Center for Retirement Studies (TCRS), 2021. TCRS is an operating division of Transamerica Institute.
