[MCD 101] Lesson 3: Who can get Medicaid?

You must first complete [MCD 101] Lesson 2: What is the difference between MediCAID and MediCARE? before viewing this Lesson

Lesson Goal

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For you to have a detailed understand of required covered groups and groups states have options to cover.

Lesson Summary

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The rules and requirements that help states decide who is eligible for their Medicaid program are generally referred to as “eligibility.” There are state and federal rules that must be followed. States must cover certain eligibility groups, and they have options on others.

Key concepts in this section include the use of the Federal Poverty level to determine income-based eligibility, mandatory versus optional eligibility groups and tools states have to obtain waivers to certain eligibility rules.

The Big Topics in This Lesson

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1- Member Eligibility Overview

The information under this topic covers high level concepts related to the characteristics of populations required to be covered by Medicaid. There is also discussion of optional eligibility groups.

2- The Federal Poverty Level

The information under this topic introduces this important calculation that is used to determine whether a person makes too much money to be eligible for Medicaid.

3- Variations in Medicaid Eligibility Requirements and Management

The information under this topic explains the differences in eligibility levels seen across states.

Lesson Video

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Lesson Q & A

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Click on each question to learn more

Q1: What are the major eligibility groups?


States provide Medicaid coverage to people who fall into the categorically needy, medically needy or special groups. Within these groups are more specific breakouts, such as Aged with or without Medicare coverage or people with Breast and Cervical Cancer.

Q2: What are the mandatory vs optional eligibility groups?


In order to get the significant federal funding, states are required to cover certain eligibility groups, including children and pregnant women below minimum FPL levels, disabled SSI beneficiaries and certain Medicare eligible groups. Optional populations children and pregnant women above minimum FPL levels, disabled persons above SSI levels, some working disabled members and other groups.

Q3: What is retro-active eligibility?


In certain cases, a person may need healthcare services but have no current coverage.  This often happens for emergency or obstetrical care in hospitals, which (generally speaking) must provide the care whether or not payment is available at the time.  Depending on the state Medicaid program, the hospital can often submit an application for the person to be covered by Medicaid retro-actively. If the application is approved, the person is given coverage made effective in the past, or “retro-active” coverage.  This way the hospital can get paid for the service even though the person was not eligible for Medicaid at the time.  This practice greatly impacts monthly eligibility reporting by Medicaid agencies, and must be accounted for in program management.

Q4: What is the Federal Poverty Level (FPL)?


The Federal Poverty Level (FPL) is a number used by Medicaid agencies to determine if a person (and their family) is poor enough to be eligible for Medicaid.  It starts out with numbers put out by the US Census Bureau, called the federal poverty threshold.  The Department of Health and Human Services (DHHS) then issues guidance on how to use the numbers in eligibility processes.  State Medicaid programs have to cover people below a certain percentage of the FPL (children under six in families below 133% of FPL, for example), but have discretion in being more generous with coverage. Some states cover children and their families with up to 300% of the FPL in annual income.

Q5: How is FPL used in Medicaid programs?


States use percentages of FPL to set eligibility criteria for Medicaid assistance. Some states will cover anyone (whether or not they have a child) up to 100% of FPL. Most states cover children living in homes up to 200% or more of the FPL. And if a state recently expanded under the ACA, they have to cover children and adults up to 133% FPL to receive the enhanced federal funding.


Q6: Can states change the levels of FPL they use for eligibility in their programs?


Yes. States can change the FPL level they use in a few ways. If they want to change it for their entire Medicaid program, they would need to do that in a change to their State Medicaid Plan (a document that lays out eligibility and services, as well as other things, included in an agreement with CMS). If they want to change eligibility for only a specific population within their program in order to target certain services (such as developmentally disabled members), they can do with a waiver agreement with CMS. The most recent example of states changing eligibility requirements would likely be Medicaid expansion under ACA. States that decided to expanded changed their FPL levels for general Medicaid eligibility to be at least 133% of FPL in order to received the additional federal funding for Medicaid expansion.

Q7: What are the different FPL-based eligibility requirements across states for Medicaid?


As discussed in earlier parts of the lesson, there is variability in the different FPL levels used for state Medicaid eligibility. States set different levels for children, pregnant women and adults compared to other states. Check out the maps in the lesson video to see more detail on this variability.

Q8: How do waivers and state plan amendments allow different eligibility requirements across states?


A state can submit a waiver application or state plan amendment to CMS to modify requirements of its program that may vary from established federal rules. There are three main l types of waivers, but generally they are used to allow specific populations to get very custom services. Waivers also allow a state to only offer the services to a limited amount of people (as opposed to the full Medicaid benefit, which must be offered to anyone who is deemed eligible). Historically waivers have been limited for changes related to managed care, home and community based services or demonstrations of innovative programs. However, through use of the 1115 waiver type, states have been able to get more variety in the types of program changes approved. State plan amendments (SPAs) can be used to change any aspect of the program (not just the 3 waiver types listed in the SSA).

Q9: What are the different approaches to eligibility application systems across states?


In addition to staffing and workflows that each state can determine in its eligibility processing model, each state can make decisions about the application forms used for Medicaid. Each state can also select technologies and vendors based on the needs in its state.


Medicaid Dictionary

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 New Terms from this lesson:

FPL Federal Poverty Level. A level of income measure used to determine eligibility.

MAGI Medicaid Adjusted Gross Income. A standardization of income assessment for income.

Aid Category Groupings related to Aged, Blind and Disabled (ABD) or Low Income Medicaid (LIM) status.

Express Lane Eligibility (ELE) Allows states to use available income data from another public agency to determine if a child is eligible for Medicaid or CHIP

ABD Aged, blind or disabled.

LIM Low income Medicaid

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