Monday, March 26, 2012

What is Medicaid?

This blog frequently discusses the rules governing qualification for Medicaid payment of long-term care costs for the elderly. Medicaid is the primary source of public support for families who are struggling to meet the needs of a loved one who needs care and support services on a long term basis. But I realized that some of the readers of this blog may be unfamiliar with the Medicaid program. And many well informed people continue to confuse Medicaid with Medicare. So, I thought I should take a few moments to give readers an overview of the Medicaid program.

Medicaid is a joint federal/state program that provides medical assistance to eligible persons. The federal Medicaid statute is found in Title XIX of the Social Security Act which is codified in federal law beginning at 42 U.S.C. § 1396.  Unlike Medicare, Medicaid is not a uniform federal program. It is partially funded and administered by the states and each state has its own distinct program. “While state participation in the program is voluntary, participating states must adopt plans that comply with certain requirements imposed by federal statutes and regulations.” [1] Although they all must conform to federal requirements, individual state Medicaid programs vary widely. The Pennsylvania Medicaid program is called “Medical Assistance” (or MA for short).  

Medicaid is means-tested, with eligibility for benefits dependent upon the applicant’s income and resources. Asset transfers may also affect financial eligibility for Medicaid long-term care benefits. States are given some latitude in establishing these financial eligibility criteria.

Medicaid is our country’s largest health-care program. It is the primary way we finance health care for our most vulnerable and needy persons, including long-term care for the elderly and disabled. It is our health-care program of last resort. For most people on Medicaid, there is no other program to take its place.

First established in 1965, “Medicaid has evolved from a program providing medical assistance to the welfare population to a broad and multifaceted safety net addressing the needs of low income families, the elderly, and those with chronic, disabling health conditions. In the face of these challenges, Medicaid has achieved remarkable success in helping to close gaps in access to care and served as an essential safety net for long-term care services in the community and in institutions.”[2] Medicaid has become the nation’s fundamental source of financing health-care and long-term care services for over 58 million low-income Americans.

A significant expansion of the Medicaid rolls is set to take place in 2014 as a part of the Affordable Care Act (ACA). It is estimated that approximately 16 million low income people will be added to the program in 2014 as a primary means of extending health coverage to most Americans. Although this expansion will be financed almost entirely by the federal government, some states have objected. The legality of this Medicaid portion of the ACA is one of the issues is being debated this week (March 26, 2012) before the United States Supreme Court.  If the ACA law is allowed to take effect, the Congressional Budget office estimates that 95% of Americans will have health insurance by 2019.  

Many elder law attorneys spend a lot of their time working on Medicaid benefits for persons over age 65 (and disabled younger persons) who require long-term care services in a nursing facility or in their homes. Most, but not all, skilled nursing facilities accept Medicaid as a form of payment. Whether a particular nursing home is a participant in the program should be established by inquiring of the facility prior to admission.

Readers are cautioned that Medicaid rules are variable, complex, and ever changing. Changes may have occurred after the date of publication of anything you read online about Medicaid. States are constantly making political and administrative choices about the level of resources they are willing to devote to Medicaid funded health care and long term care. As a result program revisions are pretty much continuous.  Case and administrative rulings may also result in program modifications. Consumers who need advice about Medicaid eligibility rules should consult a Certified Elder Law Attorney or other lawyer in their state who focuses on this area of legal practice and stays current as the program requirements undergo change.

[1] Mertz v. Houstoun, 155 F.Supp.2d 415, 420 (E.D. Pa. 2001) (citing Wilder v. Virginia Hosp. Ass’n, 496 U.S. 498, 502 (1990)).
[2] Schneider, The Medicaid Resource Book, The Kaiser Commission on Medicaid and the Uninsured, July 2002,

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