Medicaid in the United States is a federal and state program that helps with medical costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and personal care services. The Health Insurance Association of America describes Medicaid as "a government insurance program for persons of all ages whose income and resources are insufficient to pay for health care." Medicaid is the largest source of funding for medical and health-related services for people with low income in the United States, providing free health insurance to 74 million low-income and disabled people (23% of Americans) as of 2017. It is a means-tested program that is jointly funded by the state and federal governments and managed by the states, with each state currently having broad leeway to determine who is eligible for its implementation of the program. States are not required to participate in the program, although all have since 1982. Medicaid recipients must be U.S. citizens or qualified non-citizens, and may include low-income adults, their children, and people with certain disabilities. Poverty alone does not necessarily qualify someone for Medicaid.
The Patient Protection and Affordable Care Act (PPACA) significantly expanded both eligibility for and federal funding of Medicaid. Under the law as written, all U.S. citizens and qualified non-citizens with income up to 133% of the poverty line, including adults without dependent children, would qualify for coverage in any state that participated in the Medicaid program. However, the Supreme Court of the United States ruled in National Federation of Independent Business v. Sebelius that states do not have to agree to this expansion in order to continue to receive previously established levels of Medicaid funding, and some states have chosen to continue with pre-ACA funding levels and eligibility standards.
Research suggests that Medicaid improves health insurance coverage, access to health care, recipients' financial security, and some health outcomes, as well as economic benefits to states and health providers.
Medicaid, Medicare, Tricare, and ChampVA are the four government sponsored medical insurance programs in the United States and the former two are administered by the U.S. Centers for Medicare & Medicaid Services in Baltimore, Maryland.
2.1 Expansion under the Affordable Care Act
3 State implementations
3.1 Differences by state
5 Comparisons with Medicare
7.1 PPACA income test standardization
7.2 Non-PPACA eligibility
7.3 Children and SCHIP
10.1 Oregon Medicaid health experiment and controversy
10.2 Privatization and automation of Medicaid in Indiana
11 See also
13 Further reading
14 External links
Beginning in the 1980s, many states received waivers from the federal government to create Medicaid managed care programs. Under managed care, Medicaid recipients are enrolled in a private health plan, which receives a fixed monthly premium from the state. The health plan is then responsible for providing for all or most of the recipient's healthcare needs. Today, all but a few states use managed care to provide coverage to a significant proportion of Medicaid enrollees. As of 2014, 26 states have contracts with managed care organizations (MCOs) to deliver long-term care for the elderly and individuals with disabilities. The states pay a monthly capitated rate per member to the MCOs that provide comprehensive care and accept the risk of managing total costs. Nationwide, roughly 80% of enrollees are enrolled in managed care plans. Core eligibility groups of poor children and parents are most likely to be enrolled in managed care, while the aged and disabled eligibility groups more often remain in traditional "fee for service" Medicaid.
Because the service level costs vary depending on the care and needs of the enrolled, a cost per person average is only a rough measure of actual cost of care. The annual cost of care will vary state to state depending on state approved Medicaid benefits, as well as the state specific care costs. 2008 average cost per senior was reported as $14,780 (in addition to Medicare), and a state by state listing was provided. In a 2010 national report for all age groups, the per enrolled average cost was calculated to $5,563 and a listing by state and by coverage age is provided.
Health care in the United States
Government Health Programs
Federal Employees Health Benefits Program
Indian Health Service
Medicaid / State Health Insurance Assistance Program (SHIP)
Prescription Assistance (SPAP)
Military Health System / TRICARE
State Children's Health Insurance Program (CHIP)
Program of All-Inclusive Care for the Elderly (PACE)
Veterans Health Administration
Private health coverage
Flexible spending account (FSA)
Health Reimbursement Account
Health savings account (HSA)
High-deductible health plan (HDHP)
Medical savings account (MSA)
Private Fee-For-Service (PFFS)
Health insurance in the United States
Managed care (CCP)
Exclusive provider organization (EPO)
Health maintenance organization (HMO)
Preferred provider organization (PPO)
Health care reform law
Emergency Medical Treatment and Active Labor Act (1986)
Health Insurance Portability and Accountability Act (1996)
Medicare Prescription Drug, Improvement, and Modernization Act (2003)
Patient Safety and Quality Improvement Act (2005)
Health Information Technology for Economic and Clinical Health Act (2009)
Patient Protection and Affordable Care Act (2010)
State level reform
Municipal health coverage
Healthcare in California
Healthy San Francisco
Healthy Way LA
My Health LA
Fair Share Health Care Act (Maryland)
Healthy Howard (Howard Co., Maryland)
The Social Security Amendments of 1965 created Medicaid by adding Title XIX to the Social Security Act, 42 U.S.C. §§ 1396 et seq. Under the program, the federal government provides matching funds to states to enable them to provide medical assistance to residents who meet certain eligibility requirements. The objective is to help states provide medical assistance to residents whose incomes and resources are insufficient to meet the costs of necessary medical services. Medicaid serves as the nation's primary source of health insurance coverage for low-income populations.
States are not required to participate. Those that do must comply with federal Medicaid laws under which each participating state administers its own Medicaid program, establishes eligibility standards, determines the scope and types of services it will cover, and sets the rate of payment. Benefits vary from state to state, and because someone qualifies for Medicaid in one state, it does not mean they will qualify in another. The federal Centers for Medicare and Medicaid Services (CMS) monitors the state-run programs and establishes requirements for service delivery, quality, funding, and eligibility standards.
The Medicaid Drug Rebate Program and the Health Insurance Premium Payment Program (HIPP) were created by the Omnibus Budget Reconciliation Act of 1990 (OBRA-90). This act helped to add Section 1927 to the Social Security Act of 1935 which became effective on January 1, 1991. This program was formed due to the costs that Medicaid programs were paying for outpatient drugs at their discounted prices.
The Omnibus Budget Reconciliation Act of 1993 (OBRA-93) amended Section 1927 of the Act as it brought changes to the Medicaid Drug Rebate Program, as well as requiring states to implement a Medicaid estate recovery program to sue the estate of decedents for long-term-care-related costs paid by Medicaid, and giving states the option of recovering all non-long-term-care costs, including full medical costs. (Estate recovery, when the state recovers all medical costs for people 55 and older, extends to the expanded Medicaid coverage that is part of the ACA.)
Medicaid also offers a Fee for Service (Direct Service) Program to schools throughout the United States for the reimbursement of costs associated with the services delivered to special education students. Federal law mandates that every disabled child in America receive a "free appropriate public education." Decisions by the United States Supreme Court and subsequent changes in federal law make it clear that Medicaid must pay for services provided for all Medicaid-eligible disabled children.