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Affordable Care Act Provides Eligibility for Most Low-income
Adults—In 2014, individuals under age 65 (including
parents and adults without dependent children) with
incomes below 133% of poverty ($14,500 for an
individual in 2011) became eligible for Medicaid in every
state. This change ends the longstanding coverage gap
for low-income adults. States could have chosen to
expand eligibility for adults prior to 2014, and several
states did so.
+ Other Eligibility Groups
Medically Needy—Many states have what are called
‘‘medically needy programs,’’ which are optional for
states. Individuals with significant health needs whose
income is too high to otherwise qualify for Medicaid
under other eligibility groups can still become eligible by
‘‘spending down’’ the amount of income that is above a
particular state's medically needy income standard.
Individuals spend down by incurring expenses for
medical and remedial care. If once those incurred
expenses are subtracted from the person's annual
income and the person's income is at or below the state's
medically needy income standard, the person can be
eligible for Medicaid. The Medicaid program then pays
the cost of services that exceed what the individual had
to incur in the way of expenses in order to become
eligible.
In addition to states with medically needy programs,
states that determine Medicaid eligibility of the aged,
blind, and disabled using more restrictive eligibility
criteria than are used by the Supplemental Security
Income (SSI) program (known as 209(b) states) also allow
individuals to spend down their excess income to the
state's categorically needy income standard. 209(b)
states must allow a spenddown to their categorically
needy income standard even if the state also has a
medically needy program.
Thirty-six states and D.C. use spenddown programs,
either as medically needy programs or as 209(b) states.
Breast and Cervical Cancer Prevention and Treatment
Program—States can choose to provide Medicaid
coverage to certain groups of women who are in need of
treatment for breast and cervical cancer. Women are
screened through CDC's National Breast and Cervical
Cancer Early Detection Program (NBCCEDP). For a
woman to be eligible for Medicaid under this option, she
must have been screened for and found to have breast or
cervical cancer, including precancerous conditions,
through the NBCCEDP; need treatment for breast or
cervical cancer; be under age 65; and be uninsured and
otherwise not eligible for Medicaid.
Tuberculosis (TB)—States can choose to provide Medicaid
financing for coverage of TB-related services to lowincome
individuals who are infected with TB. This
eligibility group serves individuals who are not otherwise
eligible for Medicaid based on the traditional eligibility
categories.
Medicaid operates as a vendor payment program.
States may pay health care providers directly on a feefor-service
basis, or states may pay for Medicaid services
through various prepayment arrangements, such as through
health maintenance organizations or other forms of
managed care. Within federally imposed upper limits and
specific restrictions, each state for the most part has broad
discretion in determining the payment methodology and
payment rate for services. Thus, the Medicaid program
varies considerably from state to state, as well as within
each state over time. For more information, see:
http://www.medicaid.gov/.
(Also see Appendix II, Health expenditures, national; Health
insurance coverage; Health maintenance organization
[HMO]; Managed care; and Appendix I, Medicaid Statistical
Information System [MSIS].)
Medicaid payments—Under the Medicaid program,
medical vendor payments are payments (expenditures) to
medical vendors from the state through a fiscal agent, or to
a health insurance plan. Adjustments are made for Indian
Health Service payments to Medicaid, cost settlements,
third-party recoupments, refunds, voided checks, and other
financial settlements that cannot be related to specific
provided claims. Excluded are payments made for medical
care under the emergency assistance provisions; payments
made from state medical assistance funds that are not
federally matchable; disproportionate-share hospital
payments, cost sharing, or enrollment fees collected from
recipients or a third party; and administration and training
costs. Medicaid payment data presented in Health, United
States are from the Medical Statistical Information System
(MSIS), which obtains payment data from electronic
Medicaid data submitted to the Centers for Medicare &
Medicaid Services by each state. Payment data are based on
adjudicated claims for medical services reimbursed with
Title XIX funds.
Medical specialty—See Appendix II, Physician specialty.
Medicare—Medicare is a nationwide program providing
health insurance coverage to selected groups, regardless of
income. The covered groups are (a) most people aged 65
and over; (b) people entitled to Social Security or Railroad
Retirement disability benefits for at least 24 months (with
the waiting period waived or reduced in certain situations);
(c) government employees or spouses with Medicare-only
coverage who have been disabled for more than 29 months
(with the waiting period waived or reduced in certain
situations); (d) most people with end-stage renal disease;
and (e) certain people in the Libby, Montana, vicinity who
are diagnosed with asbestos-related conditions. The
program was enacted on July 30, 1965, as Title XVIII of the
Social Security Act, ‘‘Health Insurance for the Aged and
Disabled,’’ and became effective on July 1, 1966.
Health, United States, 2014 Appendix II. Definitions and Methods 429