The Basics of Medicare and Medicaid Judith R. Lave University of Pittsburgh.
Medicaid Basics - The American Health Lawyers Association
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-“...to serve as a public resource on selected healthcare legal issues” —From the Mission Statement of the American Health Lawyers Association MEDICAID BASICS: A QUESTION AND ANSWER GUIDE ABOUT ELIGIBILITY, COVERAGE, AND BENEFITS Health Lawyers’ Public Information Series
Transcript of Medicaid Basics - The American Health Lawyers Association
-“...to serve as a public resource on selected healthcare legal issues”—From the Mission Statement of the American Health Lawyers Association
MEDICAID BASICS: A QUESTION ANDANSWER GUIDE ABOUT ELIGIBILITY,COVERAGE, AND BENEFITS
H e a l t h L a w y e r s ’ P u b l i c I n f o r m a t i o n S e r i e s
Copyright 2006 byAmerican Health Lawyers Association
Second reprint 2008. All websites have been updated as of April 1, 2008.This publication can be downloaded free of charge at
www.healthlawyers.org/medicaidguide and at www.healthlawyers.org/factsheet. Other resources in the PublicInformation Series are available at www.healthlawyers.org/publicinterest/piseries.
This publication may be reproduced in part or in whole without prior written permission from the publisher. Attribution to American Health Lawyers Association is requested.
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E-mail: [email protected]: www.healthlawyers.org
“This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is providedwith the understanding that the publisher is not engaged in rendering legal or other professional services. If legal advice or other
expert assistance is required, the services of a competent professional person should be sought.”
—-from a declaration of the American Bar Association
Medicaid Basics: A Question and Answer Guideabout Eligibility, Coverage, and Benefits
TABLE OF CONTENTS
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Preface ................................................................................2
Introduction ......................................................................4
Q&As ....................................................................................7
What is Medicaid? ................................................7
Is Medicaid a state or federal program? ..............7
Who pays for Medicaid? ......................................7
What is the difference between Medicaid and Medicare?......................................................7
What is CMS? ......................................................8
Why should I apply for Medicaid coverage? ............................................................8
Who qualifies for Medicaid coverage? ................9
May I have both Medicare and Medicaid at thesame time? ..........................................................9
What is Medicaid planning and how does it affect eligibility? ........................................9
What assets may I own and still qualify for Medicaid? ............................................10
What are the “spend down” provisions ofMedicaid? ............................................................10
What is a Medicaid Trust? ....................................11
What does Medicaid cover? ................................11
What are the most commonly covered optionalservices under the Medicaid program?................11
Do I have to obtain pre-authorization from Medicaid before I can retrieve healthcare services? ............................................12
Can I obtain Medicaid coverage if I am out of state? ................................................12
What do I have to pay for if I am on Medicaid? ........................................................12
Will I be able to select any healthcare provider if I have Medicaid? ................................12
Where do I go for help in getting on Medicaid? ........................................................12
What if I don't qualify for Medicaid? Is there any other help for me? ............................13
What can I do if I disagree with a decision made by my Medicaid program?............13
Appendix A:Fact Sheet........................................................................15
Appendix B:Fact Sheet (in Spanish)................................................17
Appendix C:Glossary ..........................................................................19
Authors ................................................................................21
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In January 2006, American Health LawyersAssociation (Health Lawyers) released a MedicaidConsumer Information Fact Sheet. The Fact Sheet wasprepared to help those who needed to navigate theunfamiliar requirements of different states’Medicaid programs and to help those who weredealing with Medicaid for the first time. The FactSheet provided easy-to-use website links and phonenumbers for the Medicaid programs in all 50 statesand was a starting point to aid those needing assis-tance in obtaining payment for medical care.
After all the destruction that has happened in theGulf Coast areas and Florida, we wanted to provide apublication that would help individuals who are unfa-miliar with their new state health laws. I’m confidentthat our newly published Medicaid ConsumerInformation Fact Sheet will help those displaced indi-viduals and the healthcare community find, quicklyand easily, the Medicaid information they need fortheir new area of relocation.
The Fact Sheet is now a part of Medicaid Basics: AQuestion and Answer Guide about Eligibility, Coverage,and Benefits (Guide). Initiated in 2004, the PublicInformation Series is one aspect of Health Lawyers’public interest commitment as a tax-exempt educa-tional association. Written primarily for a publicaudence, the Public Information Series enablesHealth Lawyers’ to share its expertise on topics ofinterest to healthcare attorneys and the broaderhealthcare community, including healthcare profes-sionals, healthcare executives, public health agen-cies, pro bono attorneys, and consumer groups.
The question and answer format in the Guide isdesigned to assist individuals understand the basicsabout the Medicaid program. It includes a generaloverview about the program, eligibility, and cover-age; a glossary of selected healthcare terms; andFact Sheets in English, Spanish, and traditionalChinese.
Health Lawyers’ Public InterestCommitmentHealth Lawyers’ Public Information Series is one of avariety of public interest activities conducted by the10,000-member educational association under its mis-sion statement pledge “...to serve as a public resourceon selected healthcare legal issues.” The Associationfulfills its public interest commitment through twotypes of activities. The Public Information Series andoutreach activities to pro bono attorneys, legal aid soci-
eties, and consumers provide avenues through whichHealth Lawyers shares its members’ legal expertisewith society at large. Health Lawyers’ commitment topublic interest also includes a variety of nonpartisanpublic policy-related activities that seek to further thedevelopment of sound health policy. These includesponsorship of the Conversations with Policymakersteleconference series and periodic issue briefings forhealth policy analysts and reporters. Health Lawyers’public interest activities are financed, in part, throughfinancial contributions from its members and theirfirms or organizations.
Acknowledgements | About the AuthorsThe American Health Lawyers Association wishes toextend special thanks to those who assisted in thepreparation of the Medicaid Consumer InformationFact Sheet as well as this resource on Medicaid Basics:A Question and Answer Guide about Eligibility,Coverage, and Benefits.
Myra C. Selby, Ice Miller, Indianapolis, IN
Thomas W. Coons, OBER | KALER, Baltimore, MD
Special thanks to the former Chair of theRegulation, Accreditation, and Payment PracticeGroup, Eric P. Zimmerman, of McDermott Will &Emery, Washington, DC, for coordinating the proj-ect for the practice group; the former Chair of theLong Term Care Practice Group, Christopher C.Puri, of Boult Cummings Conners & Berry PLC,Nashville, TN, for both coordinating the projectand authoring sections of the text; Nancy C.Armentrout, Director of Legislative Affairs,California Association of Health Facilities,Sacramento, CA; Barbara D.A. Eyman of Ropes &Gray LLP, Washington, DC; Kathryn (Kate)Spaziani, Director of Legislative Affairs, U.S. Rep.Ron Kind (D-WI), Washington, DC; Hemi D.Tewarson, General Counsel’s Office, GovernmentAccountability Office, Washington, DC; and Joel M.Hamme, of Powers Pyles Sutter & Verville PC,Washington, DC.
PREFACE
We would like to thank Lisa Diehl Vandecaveye,Corporate Vice President, Legal Affairs, BotsfordHealthCare Continuum, Farmington Hills, MI, forher assistance and the following students in herHealth Care Regulation course at the University ofToledo College of Law:
Amanda DavisAmy GreeneDaniel HenryJoseph WalshGregory Wolenberg
Last but not least, the Public Interest Committeeextends its appreciation to Kerry B. Hoggard, CAE,PAHM, Vice President of Membership and PublicInterest, for her assistance in the production of thispublication, and to Peter M. Leibold, HealthLawyers’ Executive Vice President/CEO, for sup-porting this type of resource that benefits both
members of the health bar and healthcare con-sumers.
If you have suggestions for future publications inHealth Lawyers’ Public Information Series, pleasecontact Kerry B. Hoggard at (202) 833-0760 [email protected] or Katherine E. Wone,J.D., Manager of Public Interest, at (202) 833-0787or [email protected].
Elise D. BrennanAHLA FellowAuthor, Contributor, Medicaid Basics: A Question andAnswer Guide about Eligibility, Coverage, and BenefitsChair, 2005–2006 Public Interest Committee
INTRODUCTION
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PREFACE
Medicaid Basics: A Questionand Answer Guide aboutEligibility, Coverage, and BenefitsThe complexity of the Social Security Act and itshealthcare programs, including Medicare andMedicaid, is daunting. Indeed, even the courtsentrusted with understanding and interpreting provi-sions related to these programs freely acknowledgetheir bewilderment when confronted with thornyissues relating to their administration. As a result,terms like “Byzantine,” “unintelligible to the uninitiat-ed,” “impenetrable,” and “Serbian bog” abound inMedicare and Medicaid case law.
Given this complexity and the frequency with whichCongress amends and reforms these programs, itshould come as no surprise that many Americans donot understand the basic structure of these pro-grams or the fundamental differences betweenthem. Even worse, the beneficiaries of these pro-grams—many of whom are elderly, poor, and/orunsophisticated—are often forced to navigate theseprograms with little or no assistance. Moreover, evenwhere assistance or resources are available fromstate Medicaid programs, legal aid attorneys or per-sonnel, potential beneficiaries may have no idea ofwhere to turn for help in understanding their rightsand benefits.
Recognizing the plight of many potential Medicaidbeneficiaries and of the attorneys and other individu-als who may be enlisted to assist them, the AmericanHealth Lawyers Association (Health Lawyers) deter-mined that it could furnish timely and useful informa-tion in this area. As such, the Association developedMedicaid Basics: A Question and Answer Guide aboutEligibility, Coverage and Benefits (Guide), as part of itsPublic Information Series. The Guide will be updatedperiodically to account for new trends and additionalinformation. The Guide can be downloaded free ofcharge at www.healthlawyers.org/medicaidguide andat www.healthlawyers.org/factsheet. We hope it willprovide needed information to potential Medicaidbeneficiaries struggling with basic questions about theprogram as well as to attorneys who are confrontedwith such questions but who may not be as conversantwith Medicaid as they would like.
This Guide is divided into multiple sections. The pref-ace identifies the need that led to the development ofthe publication. It is an excellent articulation ofHealth Lawyers’ public interest commitment andacknowledges the individuals whose time, efforts, andexpertise were invaluable in producing this resource.
The Question and Answer component of the publica-tion is divided into several categories:
• Basic information about Medicaid;
• Eligibility issues;
• Coverage questions; and
• General inquiries.
Legal citations are furnished in footnotes to enableattorneys to conduct additional research if needed.The Questions and Answers are the heart of the publi-cation, and although many questions about Medicaidare invariably state-specific, Health Lawyers hasendeavored to furnish general information with perti-nent details. The Association also encourages readersto contact it with additional questions and answers orsupplemental information that would bolster the pub-lication or help keep it current.
Three appendices complete this publication.Appendix A is the Medicaid Consumer Information FactSheet, which includes the web addresses and phonenumbers for all state Medicaid agencies. Thoseaddresses may be utilized to obtain further contactinformation and to answer questions about a particu-lar state’s Medicaid program and its policies.Appendix B is the Spanish version of Appendix A,and a version in traditional Chinese is availableonline. Finally, Appendix C is a glossary of relevantterms related to the Medicaid program.
Health Lawyers hopes that this publication willbecome an indispensable resource not only to itsmembers but also to Medicaid consumers and otherswho work and provide assistance in this area. HealthLawyers is pleased to offer this publication as an inte-gral part of its mission to educate its members and thepublic on health law issues.
Joel M. HammePresident, 2008-2009 American Health Lawyers Association
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INTRODUCTION
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Produced as a part of Health Lawyers’ public interest commitment to serve as a public resource on select-ed healthcare legal issues, these resources enable the Association to share its members’ expertise on top-ics of interest both to healthcare attorneys and the broader healthcare community, including health pro-fessionals, healthcare executives, public health agencies, pro bono attorneys, and consumer groups.Additional resources in the Public Information Series include:
Emergency Preparedness, Response & RecoveryChecklist: Beyond the Emergency Management Planwww.healthlawyers.org/checklist
Lessons Learned from the Gulf Coast Hurricaneswww.healthlawyers.org/lessonslearned
A Legal Guide to Life-Limiting Conditionswww.healthlawyers.org/lifelimiting
Life-Limiting Conditions One Pagerswww.healthlaywers.org/onepagers
Medicaid Basics: A Question and Answer Guideabout Eligibility, Coverage and Benefitswww.healthlawyers.org/medicaidguide
Medicaid Benefits and Eligibility: ConsumerInformation Fact Sheets (in English, Spanish, andtraditional Chinese)www.healthlawyers.org/factsheet
Corporate Responsibility and CorporateCompliance: A Resource for Health Care Boardsof Directorswww.healthlawyers.org/corporatecompliance
An Integrated Approach to Corporate Compliance:A Resource for Health Care Boards of Directorswww.healthlawyers.org/integratedapproach
Corporate Responsibility and Health Care Quality:A Resource for Health Care Boards of Directorswww.healthlawyers.org/healthcarequality
American Health Lawyers AssociationPublic Information Series
Coming June, 2008…
Considerations for People with Disabilities and Their Familieswww.healthlawyers.org/disabilities
Medical Research: A Consumer’s Guide for Participation www.healthlawyers.org/clinicaltrials
Community Pan-Flu Preparedness: A Checklist of Key Legal Issues for Healthcare Providers www.healthlawyers.org/panfluchecklist
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1. What is Medicaid?Medicaid is a joint federal and state entitlement pro-gram that provides coverage for medical and relatedservices. Enacted in 1965 by Congress as a compan-ion to the Medicare program, Medicaid was original-ly designed as a healthcare program for welfarerecipients.1 Today the program is a $270 billion pub-lic health insurance program for low-income indi-viduals and the largest long-term care program forthe disabled and elderly.2
2. Is Medicaid a state or federalprogram?
Medicaid is a federal and state partnership. Thefederal government has established broad guide-lines for the program and pays for a share of theprogram’s costs under a statutory formula.3
Medicaid is a voluntary program for states and terri-tories. States that choose to participate are requiredto meet certain minimum federal standards regard-ing eligibility and services covered, but otherwiseretain broad flexibility in administering their indi-vidual Medicaid programs.4 Despite the voluntarynature of the program, every state and territory par-ticipates in Medicaid.
Although states are responsible for operating theirindividual Medicaid programs, the federal govern-ment possesses significant oversight over these pro-grams. For example, each state must maintain a writ-ten state Medicaid plan (known as a “State Plan”) inorder for services provided to its Medicaid popula-tion to qualify for federal funding. The State Planmust provide details about administration, eligibility,coverage of services, beneficiary protections, andreimbursement methodologies. Exercising its over-sight function, the federal government must
approve all State Plans and any changes that aremade to the Plans (State Plan Amendments).5
3. Who pays for Medicaid?The Medicaid program is generally funded by feder-al and state government dollars. The federal govern-ment reimburses states for a share of costs associat-ed with their Medicaid programs. This federal finan-cial participation (FFP) is available for two types ofcosts incurred by states: those relating to services forMedicaid recipients and those relating to adminis-tering the program.6 The level of FFP for servicecosts varies by state—that is, the federal governmentpays a greater share of Medicaid service costs forsome states than it does for others. This is becausethe statutory formula that determines FFP providesgreater federal assistance to states with lower percapita incomes.7 FFP for Medicaid services mayrange from 50% to 83%.8 Administrative costs in allstates are generally matched by the federal govern-ment at 50% (with the exception of higher federalcontributions for certain types of services).9
States also have the authority to impose limited costsharing on certain Medicaid recipients. These obli-gations, such as enrollment fees, premiums,deductibles, coinsurance, or co-payments, must beidentified and approved in the State Plan.10 Notably,recent changes in federal law have provided stateswith addi tional flexibility to utilize cost sharing. (See Question 13 for additional information.)
4. What is the difference betweenMedicaid and Medicare?
Although the Medicare and Medicaid programswere enacted by Congress at the same time, theywere designed to target different groups of people
MEDICAID BASICS
1 Social Security Act (“SSA”) Amendments of 1965, Pub. L. No. 89-97; Medicaid: A Timeline of Key Developments. Kaiser FamilyFoundation, available at: www.kff.org/medicaid/medicaid_timeline.cfm (last visited April 1, 2008).
2 Historical Health Insurance Tables, U.S. Census Bureau; Medicaid: A Primer, Kaiser Commission on Medicaid and the Uninsured(July 2005).
3 SSA § 1903 (42 U.S.C. § 1396b).4 Medicaid: A Primer, Kaiser Commission on Medicaid and the Uninsured (July 2005). 5 See SSA § 1902 (42 U.S.C. § 1396a) (setting forth requirements for State Plans).6 SSA §§1903(a), 1905(b) (42 U.S.C. §§ 1396b(a), 1396d(b)).7 SSA §§ 1101(a)(8), 1903(a)(1), 1905(b) (42 U.S.C. §§ 1301(a)(8), 1396b(a)(1), 1396d(b)).8 Id.9 SSA § 1903(a)(2)-(7) (42 U.S.C. § 1396b(a)(2)-(7)).
10 SSA § 1916 (42 U.S.C. § 1396o); 42 C.F.R. § 447.50 et seq.
Thomas W. Coons, EsquireElise Dunitz Brennan, EsquireChristopher C. Puri, EsquireHemi D. Tewarson, EsquireKathryn (Kate) Spaziani, EsquireLisa Diehl Vandecaveye, Esquire
Myra C. Selby, Esquire Joel M. Hamme, Esquire Eric P. Zimmerman, Esquire Barbara D.A. Eyman, Esquire Nancy C. Armentrout, Esquire
and to operate in significantly different ways. Bothare entitlement programs—meaning, all individualshave a legal right to apply for the programs, and, ifthey meet the eligibility criteria, they are entitled toreceive coverage.11
Medicare is a federally administered, nationwidehealthcare coverage program for the elderly and thedisabled.12 Individuals who reach the age of 65 orthose who qualify for federal disability benefits underTitle II of the Social Security Act are eligible to enrollin the Medicare program.13 The program is uniform:one set of requirements applies to all Medicare partic-ipating providers and Medicare beneficiaries.14 Forexample, under the traditional Medicare program, allMedicare beneficiaries are entitled to the same cover-age of services and supplies.15 Healthcare providersand suppliers must enroll directly with the federalgovernment in order to participate, and they, in turn,are directly reimbursed for treating Medicare benefi-ciaries by the federal government.16 Under the tradi-tional Medicare program, reimbursement for mostservices and supplies, except for prescription drugs, ismade according to uniform fee schedules set by thefederal government.17
Conversely, as described above, Medicaid is a jointfederal and state partnership that provides healthcarecoverage for certain low-income individuals. Althoughthere are minimum federal standards regarding eligi-bility, coverage and reimbursement, states have con-siderable discretion in designing their Medicaid pro-grams.18 Thus, there are significant differences amongstate Medicaid programs with respect to covered pop-ulations, benefits, cost sharing, delivery systems andreimbursement to providers. To understand how aparticular state Medicaid program works, individualsshould consult individual state websites and the web-site for the Centers for Medicare and MedicaidServices (CMS), at www.cms.hhs.gov/, for more infor-mation.
5. What is CMS?The Centers for Medicare and Medicaid Services(CMS) is a federal agency within the United StatesDepartment of Health and Human Services.19 The
agency is charged with administering the Medicareprogram and overseeing state Medicaid programs. Asnoted above, with respect to Medicaid programs,CMS’s role includes approving the fundamentalparameters of the state Medicaid programs as well asany changes made to the state Medicaid programs.CMS also oversees other aspects of Medicaid pro-grams. For example, CMS has recently assumed anincreasingly active role in overseeing how statesfinance their Medicaid programs, given the fact thatfederal dollars match state expenditures.
6. Why should I apply for Medicaidcoverage?
Medicaid pays for healthcare services that are “med-ically necessary.” Services include: some prescriptions,physician visits, adult day health service, some dentalcare, ambulance services, some home health, X-rayand laboratory costs, orthopedic devices, eyeglasses,hearing aids, and some medical equipment. Medicaidis also the biggest single payer for long-term care. Anindividual may need these items and services and mayqualify if he or she fits within certain categories andsatisfies federal and state financial conditions.
Medicaid is a means-tested program that providesbenefits to certain categories of people who meet rig-orous income and asset rules. Additionally, peoplewho need long term care must meet categorical,financial, and functional eligibility criteria to receiveMedicaid-funded long term care services. They mustbe elderly or disabled (meet a state or federal defini-tion of disability), have limited financial resources,and meet level-of-care criteria for long term care serv-ices. Supplemental Security Income (SSI) and othercategorically-related recipients are automatically eligi-ble. Nationwide, of the 52.4 million people enrolledin Medicaid in 2003, about 4.7 million (9 percent)were elderly and 8.4 million (16 percent) qualified onthe basis of disability.
There are a number of ways of meeting Medicaid’sfinancial eligibility criteria, and elderly and non-elder-ly people, especially those with long-term care needs,often take different paths to Medicaid eligibility. Themajority of the disabled in Medicaid arrive at eligibili-
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11 For example, if Medicaid applications are denied or not acted upon within a reasonable amount of time, applicants must beafforded due process protections. U.S. Const. amend. XIV; SSA § 1902(a)(3) (42 U.S.C. § 1396a(a)(3)); 42 C.F.R. §§ 435.911-.912.
12 SSA § 1811 (42 U.S.C. § 1395c); Medicare Payment Policies. Congr. Research Serv., RL30526 (Feb. 23, 2005).13 SSA §§ 201, 1811 (42 U.S.C. §§ 401, 1395c).14 For certain “high income” Medicare beneficiaries, however, Congress has imposed higher premium payments than are required
of lower income beneficiaries.15 SSA §§ 1812, 1832 (42 U.S.C. §§ 1395d, 1395k). 16 SSA §§ 1814-1815, 1833 (42 U.S.C. §§ 1395f-1395g, 1395l). 17 Id.18 Medicaid: A Primer, Kaiser Commission on Medicaid and the Uninsured (July 2005).19 See www.cms.hhs.gov/ (last visited April 1, 2008).
ty via a “welfare-related pathway.” That is, they qualifyfor Medicaid because they also qualify for some otherform of public assistance. On the other hand, the eld-erly primarily enroll in Medicaid once they need nurs-ing home care and after they have spent down theirincome and assets. They qualify through a “medicallyneedy” or “spend-down” pathway. The determinationof Medicaid eligibility can involve complex calcula-tions with rules that vary widely across states.
In general, an individual should apply for Medicaid ifhis or her income is limited and that person matchesone of the descriptions of the eligibility groups. (Ifthere is uncertainty as to Medicaid eligibility, qualifiedcaseworkers in the states are available to evaluate thesituation.)
ELIGIBILITY
7. Who qualifies for Medicaidcoverage?
Medicaid does not cover everyone who is poor anduninsured. Under federal law, states are required toinclude only certain groups of people in theirMedicaid programs.20 These groups are collectivelyknown as “mandatory categorically needy,” which gen-erally includes low-income children; pregnant or post-partum women; the aged, blind, or disabled; certainlow-income children and families who qualify for fed-eral welfare assistance; and low-income Medicare ben-eficiaries.21
Federal law also permits states to expand Medicaidcoverage to other optional groups of individuals.These groups fall into two categories – “optionalCategorically Needy”22 and “Medically Needy.”23
Although these individuals share many characteristicswith those in the mandatory categories, they generallyhave too much money or resources to qualify forMedicaid under those categories.24
States may also cover other individuals under “waiver”programs. These waiver programs allow CMS to“waive” certain federal Medicaid requirements, thusallowing states, for example, to expand coverage ofpopulations who would not otherwise be able to becovered under Medicaid.25 More information on“waiver programs” may be found at www.cms.hhs.gov/and/or individual state Medicaid programs’ websites.
8. May I have both Medicare andMedicaid at the same time?
Yes, individuals may be covered under both Medicareand Medicaid at the same time. Any Medicare benefi-ciary who meets the eligibility standards for Medicaid(either under a mandatory or covered optional cate-gory) may qualify for coverage for both Medicare andMedicaid at the same time. For these “dual eligibles,”state Medicaid programs generally pay for certain costsharing that is not covered by Medicare and certainservices that are not otherwise covered by Medicare(such as long term care services). For example,Medicaid programs must pay for all Medicare premi-ums, deductibles, and coinsurance for Medicare bene-ficiaries with incomes at or below 100% of the federalpoverty level (FPL) and who meet certain Medicaidcriteria.26
9. What is Medicaid planning and howdoes it affect eligibility?
Medicaid planning is the process by which peoplewho would not immediately qualify for Medicaid“rearrange” their assets to qualify for Medicaid bene-fits, usually for nursing home or long-term care. TheMedicaid program is not an age-based entitlementprogram like Social Security, but is a “means-testedprogram,” meaning that it is intended to provide assis-tance to those individuals whose incomes and assetsare not enough to pay for their healthcare. The goalof Medicaid planning is therefore to minimize thefinancial impact of the cost of health and long-termcare on the individual and his/her family. Medicaidplanning involves a process of analysis and advice, thegoal of which is to make the individual eligible toreceive Medicaid benefits, if possible.
There is considerable debate about whether“Medicaid planning” is appropriate. Opponents arguethat individuals who have assets should be required touse those assets to pay for their care (often long-termcare) until they meet the eligibility rules for Medicaid.They argue “rearranging” or “diverting” those assetsunfairly shifts the cost of the care to the government(in other words, to taxpayers). Proponents argue thatbecause the cost of long-term care is higher thanmany people can afford, and because the rules do notprohibit individuals from “rearranging” “or “reconfig-uring” their assets so as to qualify for Medicaid nurs-
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20 See SSA § 1902(a)(10)(A)(i) (42 U.S.C. § 1396a(a)(10)(A)(i)).21 SSA § 1902(a)(10)(A)(i) (42 U.S.C. § 1396a(a)(10)(A)(i)) ; 42 C.F.R. § 435.100 et seq.22 SSA § 1902(a)(10)(A)(ii) (42 U.S.C. § 1396a(a)(10)(A)(ii)); 42 C.F.R. § 435.200 et seq.23 SSA §§ 1902(a)(10)(C), 1905(a) (42 U.S.C. §§ 1396a(a)(10)(C), 1396d(a)); 42 C.F.R. § 435.300 et seq.; 42 C.F.R. § 435.800 et seq.24 Medicaid At-a-Glance, Ctrs. For Medicare & Medicaid Servs (2005).25 See SSA § 1115 (42 U.S.C. § 1315).26 SSA § 1905(p) (42 U.S.C. § 1396d(p)). These individuals are also known as “Qualified Medicare Beneficiaries” or “QMBs.”
ing home benefits, it is justified to shift the cost oflong-term care from the individual to the governmentin this way.
Whichever view is more correct, Medicaid planning isvery complicated and federal law changes have recent-ly made it harder not to spend those assets for anindividual’s care.27 Medicaid planning usually involvesgetting advice from an attorney.
10. What assets may I own and stillqualify for Medicaid?
As explained above, Medicaid is a “means-tested”program and not everyone is entitled to it. To limitpublic expenditures, an individual must meet finan-cial and categorical eligibility criteria in order to quali-fy for Medicaid. To receive Medicaid covered long-term care services, for example, a person’s incomemust be under certain levels, and he/she must haveassets of less than a certain value. The monthlyincome cap generally ranges from approximately$1,500 to $2,400, and the amount varies every yearand in every state.
Every state also has a limit on what things (“assets”) aMedicaid recipient may own and keep. “Countableassets” consist of all investments such as stocks,bonds, mutual funds, checking and savingsaccounts and certificates of deposit. Countableassets also include personal or real property (land)as well as any art and collectibles. Generally, an indi-vidual may keep a certain amount of “countableassets” without having to sell them to qualify forMedicaid.
All assets that are not specifically excluded are consid-ered countable. The following are examples of“excluded” assets and not counted in determiningMedicaid eligibility, but these may vary from state tostate:
A home or a life estate in a home, up to a certainvalue;28
• In some states, a certain amount of the individual’spersonal possessions or property, like householdgoods and clothing;
• One car, though a state may limit the value of thevehicle that can be excluded;
• A prepaid irrevocable funeral contract, thoughsome states limit the cost of that contract;
• Funds to cover burial and funeral costs, in an
amount that varies by state;
• Burial spaces costs and related items for an individ-ual and his/her immediate family;
• Life insurance, long-term care insurance, and cer-tain other types of term insurance;
• The value of income-producing real property;
• Certain annuities.
In addition, assets that the individual does not havethe legal right to use or sell without the consent ofanyone else or that he/she has been unable to sell aregenerally considered excluded.
Assets in an irrevocable trust (see Question 12 below),in some instances, may be excluded. However, theportion of the principal of the trust from which pay-ment can be made to or for a person’s benefit is con-sidered a countable asset. Furthermore, payments oftrust income must be used to pay for that person’scare. The assets of both a husband and wife are con-sidered together. All of the countable assets owned byeither spouse are totaled as of the first day one spouseenters a hospital or nursing home for long-term care.The total assets are then divided equally betweenthem. The spouse at home (“community spouse”) ispermitted to retain a certain amount, which againvaries by state.
11. What are the “spend down”provisions of Medicaid?
If individuals have the resources to pay for theircare, either in assets or income, Medicaid requiresthem to use that money to pay for their healthcareservices. On the other hand, Medicare has the pri-mary responsibility for the cost of care even if the ben-eficiary could otherwise pay for it. Under Medicaid,income from Social Security, pensions, interest, divi-dends and rents must be used to pay for care. But,Medicaid allows recipients in nursing homes to keep acertain small amount per month as a “personal needsallowance” to be used for things like stamps, newspa-pers, haircuts, etc.
The process under which an individual depleteshis/her assets before qualifying for Medicaid is called“spend down” because those assets must be “spentdown” to the level that makes the person financiallyeligible for Medicaid in his/her state.
Some people are tempted to give away their assets toqualify for Medicaid. There are strict rules, however,
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27 Deficit Reduction Act of 2005, §§ 6011-6016.28 While this amount used to be unlimited, Section 6014 of the Deficit Reduction Act of 2005 capped at $500,000 the amount of
home equity a person can exclude from their assets. A state has the option to increase that cap to $750,000,000, however.
that limit this. Under federal law, if a person givesaway or sells assets for less than they are worth duringthe “look-back” period, he/she is not eligible forMedicaid. The “look back” period is the 60 monthsbefore that individual goes into a nursing home and iseligible to apply for Medicaid. If an individual trans-fers his/her home or any countable assets for lessthan fair market value during this period, he/she willbe ineligible for Medicaid assistance for nursing homecare or community-based care. The period of ineligi-bility is determined by dividing the fair market valueof the property transferred by the average monthlycost of nursing home care in the state, which results inthe number of months that person has to wait to getMedicaid.
12. What is a Medicaid Trust?29
Medicaid Trusts are usually used or set up when anindividual has too much income to qualify forMedicaid. According to CMS, a Medicaid-qualifyingtrust” is a trust or similar legal device that a person(or his/her spouse, guardian or legal representa-tive) creates, under which (a) that person is thebeneficiary of all or part of the payments from thetrust, and (b) the amount of those payments isdetermined by one or more trustees who have dis-cretion as to how much they distribute to that indi-vidual. An attorney almost always drafts legal instru-ments like trusts.
In certain states, another type of trust can be usedwhen a person exceeds the state’s Medicaid incomelimits but does not get enough income to payhis/her medical bills. These instruments are called“Miller Trusts” or “Qualified Income Trusts” and,although money from the trust is used to pay forthat person’s care, the use of the Trust may allowthat individual to qualify for Medicaid even thoughhe/she is technically over the income limits. Thesealso are complicated legal instruments and are besthandled by attorneys.
COVERAGE
13. What does Medicaid cover?State Medicaid programs are required to cover broadcategories of services for the majority of Medicaidbeneficiaries. Required Medicaid services include:inpatient and outpatient hospital services; physician
services; rural health clinic and federally qualifiedhealth center services; laboratory and x-ray services;nursing facility services for individual 21 and over,except for certain mental health populations; earlyperiodic screening, diagnosis, and treatment (EPSDT)for individuals under 21; pregnancy-related services;family planning services and supplies; and homehealthcare services for individuals entitled to nursingfacility services.30 (Unlike Medicare and the majorityof commercial insurers, Medicaid programs generallymust provide coverage of long term care services.)
States may also choose to provide a wide range ofoptional services under their Medicaid programs.These services include prescription drugs, dental serv-ices, and physical therapy.31 States have wide latitudeto determine what optional services to provide.However, if they choose to offer any optional service,they are generally required to provide that same serv-ice to all Medicaid recipients covered under the StatePlan.32
States may also cover other types of services under“waiver” programs. As noted above, waiver programsallow CMS to “waive” certain federal Medicaidrequirements, which includes allowing states toexpand coverage of services that would not otherwisebe covered under Medicaid, as well as to impose a dif-ferent type of Medicaid benefit package that wouldotherwise be required under federal law.33 More infor-mation on “waiver programs” may be found atwww.cms.hhs.gov/ and/or individual state Medicaidprograms’ websites.
Recent changes to federal law will also allow states toalter benefit packages based on “benchmarks” for cer-tain populations through State Plan Amendments.States, however, have yet to utilize this option.34
14. What are the most commonlycovered optional services under theMedicaid program?
Although states have the discretion to determinewhich optional services they choose to provide, thereare some consistencies among coverage across differ-ent Medicaid programs. The most commonly availableoptional services include dental services; physical andoccupational therapy; prescription drugs; prostheticsand eyeglasses; and hospice care.35
11
29 See CMS State Medicaid Manual §3215 and 3259.30 SSA §§ 1902(a)(10)(A), 1905(a); 42 C.F.R. § 440.210.31 SSA §§ 1902(a)(10)(A), 1905(a) (42 U.S.C. §§ 1396a(a)(10)(A), 1396d(a)); 42 C.F.R. § 440.225.32 SSA §§ 1902(a)(10)(B)-(C), 1905(a) (42 U.S.C. §§ 1396a(a)(10)(B)-(C), 1396d(a)).33 SSA §§ 1115, 1915(c)-(e) (42 U.S.C. §§ 1315, 1396n(c)-(e)). 34 See Deficit Reduction Act of 2005, § 6044, Pub. L. No. 109-362 (Feb. 8, 2006).35 See Medicaid At-a-Glance, Ctrs. For Medicare & Medicaid Servs (2005).
15. Do I have to obtain pre-authorizationfrom Medicaid before I can receivehealthcare services?
It depends on the state. Federal law permits states toimpose different types of utilization controls on theuse of both mandatory and optional Medicaid servic-es. For example, states may impose limits on the num-ber of visits that may be covered.36
States also have the option of utilizing managed careprinciples in the operation of their Medicaid pro-grams – either through a “waiver” program orthrough a State Plan Amendment approved by CMS.37
One of the commonly used techniques for control-ling costs in Medicaid managed care programs is theuse of prior authorization (PA), which requiresIndividuals to seek PA before they are able to receivethe service.38 Although many states recently have beenusing PA as a mechanism to control the significantincrease in prescription drug costs, the use of PAvaries from state to state. To determine if a particularstate Medicaid program requires PA for services, anindividual should consult the particular stateMedicaid program’s website.
See Appendix A for State contact information.
16. Can I obtain Medicaid coverage if Iam out of state?
Yes. State Medicaid programs are required to covercertain Medicaid services when Medicaid recipientsare out-of-state (to the extent these services would becovered if the individual received the same service in-state). These services include: (i) services for a med-ical emergency, (ii) services that are needed becausethe individual’s health would be endangered ifhe/she were required to travel to his state of resi-dence, (iii) when necessary medical services are morereadily available in other states, or (iv) when it is ageneral practice for Medicaid recipients to use med-ical resources in another state.39
17. What do I have to pay for if I am onMedicaid?
States have the authority to impose cost sharing oncertain Medicaid recipients. These obligations, suchas enrollment fees, premiums, deductibles, coinsur-ance, or copayments, must be identified andapproved in the state Medicaid plan.40 Cost-sharingobligations will vary state by state.
Historically, states may impose only nominaldeductibles or co-payments on Medicaid recipients:co-payments generally may not exceed $3, deductiblesmay not exceed $2 per family per month, and coin-surance must remain below 5% of the amount paidby the state for the service.41 States are prohibitedfrom imposing cost-sharing on some individuals andservices: children under age 18; pregnant women;institutionalized individuals; and family planning,emergency, and hospice services.42 Providers are pro-hibited from denying services to Medicaid recipientswho are unable to pay any cost-sharing expenses.43
Recent changes in federal Medicaid law, however, pro-vide states with additional flexibility, which includesthe ability to increase cost-sharing amounts, to placecost-sharing requirements on previously protectedpopulations, to establish tiered co-payments, and topermit providers to condition the provision of careupon payment of cost-sharing.44
GENERAL QUESTIONS
18. Will I be able to select anyhealthcare provider if I haveMedicaid?
No. An individual on Medicaid may select any health-care provider that accepts Medicaid. For nursing care,only those facilities that have been certified by theMedicaid program accept this form of payment.
19. Where do I go for help in getting onMedicaid?
Although the Federal government establishesgeneral guidelines for the program, theMedicaid program requirements are actuallyestablished by each State. Whether or not a per-
12
36 SSA § 1902(a)(10)(B) (42 U.S.C. § 1396a(a)(10)(B); 42 C.F.R. § 440.230.37 See, e.g., SSA §§ 1915(b), 1932 (42 U.S.C. § 1396n(b), 1396u-2).38 See, e.g., SSA § 1927(d)(5) (42 U.S.C. § 1396r-8(d)(5)). PA, however, may not be applied to emergency services or certain EPSDT
services.39 SSA § 1902(a)(16) (42 U.S.C. § 1396a(a)(16)); 42 C.F.R. § 431.52.40 SSA § 1916 (42 U.S.C. § 1396o); 42 C.F.R. § 447.50 et seq.41 SSA § 1916 (42 U.S.C. § 1396o); 42 C.F.R. § 447.54.42 SSA § 1916 (42 U.S.C. § 1396o); 42 C.F.R. § 447.53.43 Id.44 Deficit Reduction Act of 2005, §§ 6041-43, Pub. L. No. 109-362 (Feb. 8, 2006).
son is eligible for Medicaid will depend on theState where he or she lives.
American Health Lawyers Association has included itsMedicaid Consumer Fact Sheet, in both English andSpanish, which lists both website links and phonenumbers in each state. To find out more aboutMedicaid call the toll free number or visit the websitefor your State.
A list of toll free numbers can also be found on thefederal Centers for Medicare and Medicaid Services(CMS) website atwww.cms.hhs.gov/medicaid/consumer.asp
CMS has resources available on its website to help youdetermine how to apply for Medicaid benefits. Usethe following link for a list of state contacts:www.cms.hhs.gov/apps/contacts/
For more information, see:
www.cms.hhs.gov/medicaid/eligibility orwww.cms.hhs.gov/medicaid/whoiseligible.asp orwww.cms.hhs.gov/MedicaidEligibility/downloads/MedGlance05.pdf
20. What if I don’t qualify forMedicaid? Is there any other helpfor me?
Medicaid is a large program made up of many sepa-rate programs designed to assist individuals in variousfamily and medical situations. When a person appliesfor Medicaid, the information furnished on theMedicaid Application and any required verificationwill be used to determine which program(s) the appli-cant qualifies for, and which program is best for thatindividual. For example, individual states have caresupport programs that are an adjunct to, but are sepa-rate from, the traditional federal-state Medicaid pro-grams described above.
Also, Medicare may cover up to 100 days of skillednursing care. All persons over 65 who have madeSocial Security contributions are entitled to Medicarebenefits. Health Maintenance Organizations (HMOs)and other health plans may offer long-term care cov-erage. In addition, purchasing low cost health insur-ance may also be an option.
21. What can I do if I disagree with adecision made by my Medicaidprogram?
An applicant may appeal any adverse Medicaid deci-sion, particularly those related to eligibility. He or shemay even file an appeal if there is a delay in makingan eligibility determination. There will be informationon how to appeal printed on the decision notice sentin the mail.
13
APPENDIX AFACT SHEET IN ENGLISH
APPENDIX BFACT SHEET IN SPANISH
APPENDIX CGLOSSARY
NOTE: Fact Sheet is also available in traditionalChinese. The English, Spanish, and Chinese versionscan be downloaded at healthlawyers.org/factsheet
14
APPENDIX A
Med
icai
d B
enef
its
and
Eli
gib
ilit
y
AH
LA M
edic
aid
Co
nsu
mer
Info
rmat
ion
Fac
t Sh
eet
Dur
ing
the
sum
mer
of
2005
, our
Gul
f C
oast
reg
ion
exp
erie
nce
d h
ur-
rica
nes
an
d fl
oodi
ng
that
res
ulte
din
un
prec
eden
ted
num
bers
of
peo-
ple
bein
g fo
rced
to
relo
cate
fro
mth
eir
hom
es t
o n
ew lo
cati
ons,
oft
enin
new
com
mun
itie
s an
d st
ates
.So
me
of t
hes
e in
divi
dual
s w
ere
depe
nde
nt
on m
edic
al a
ssis
tan
cebe
fore
th
e st
orm
s. O
ther
s lo
st jo
bsan
d re
sour
ces
and
are
now
in n
eed
of s
uch
ass
ista
nce
. Con
sequ
entl
y,m
any
peop
le n
ow m
ust
atte
mpt
for
the
firs
t ti
me
to n
avig
ate
the
unfa
-m
iliar
req
uire
men
ts o
f di
ffer
ent
stat
es’ M
edic
aid
prog
ram
s.
Th
is d
ocum
ent
is p
repa
red
to h
elp
thes
e in
divi
dual
s an
d th
ose
wh
oas
sist
th
em: p
hys
icia
ns,
cas
e w
orke
rsan
d th
e lik
e w
ho
them
selv
es m
ay b
ede
alin
g, f
or t
he
firs
t ti
me,
wit
hM
edic
aid.
Th
e do
cum
ent
prov
ides
easy
-to-u
se w
ebsi
te li
nks
to
the
Med
icai
d pr
ogra
ms
in t
he
50 s
tate
s.T
he
docu
men
t is
not
a c
ompr
ehen
-si
ve d
iscu
ssio
n o
f M
edic
aid
and
how
to
qual
ify
for
ben
efit
s un
der
the
prog
ram
. In
stea
d, it
is a
sta
rtin
gpo
int
to a
id t
hos
e w
ho
may
nee
das
sist
ance
in o
btai
nin
g pa
ymen
t fo
rm
edic
al c
are.
We
hop
e th
at y
oufi
nd
it u
sefu
l.
Th
e M
edic
aid
Pro
gra
m
Med
icai
d is
a p
rogr
am t
hat
pro
-vi
des
med
ical
ben
efit
s to
low
-in
com
e in
divi
dual
s. M
edic
aid
elig
i-bi
lity,
un
like
elig
ibili
ty f
orM
edic
are,
doe
s n
ot d
epen
d on
th
eap
plic
ant’s
age
, but
inst
ead
turn
son
on
e’s
fin
anci
al r
esou
rces
. Als
o,
unlik
e th
e fe
dera
lly a
dmin
iste
red
Med
icar
e pr
ogra
m, M
edic
aid
isad
min
iste
red
by e
ach
sta
te, w
hic
hes
tabl
ish
es it
s ow
n r
equi
rem
ents
for
elig
ibili
ty, c
over
ed s
ervi
ces,
an
d pa
y-m
ent
subj
ect
to b
road
fed
eral
para
met
ers.
Med
icai
d pr
ovid
es t
hre
e ty
pes
ofes
sen
tial
hea
lth
pro
tect
ion
:
• H
ealt
h in
sura
nce
for
low
-inco
me
fam
ilies
, ch
ildre
n, t
he
elde
rly,
an
dpe
ople
wit
h d
isab
iliti
es.
• L
ong
term
car
e fo
r ol
der
Am
eric
ans
and
indi
vidu
als
wit
hdi
sabi
litie
s; a
nd
• Su
pple
men
tal c
over
age
for
cer-
tain
low
-inco
me
ben
efic
iari
es.
Elig
ibil
ity
In o
rder
to
be c
onsi
dere
d a
Med
icai
d be
nef
icia
ry a
nd
rece
ive
Med
icai
d se
rvic
es, a
n in
divi
dual
mus
t be
elig
ible
for
an
d en
rolle
d in
the
Med
icai
d pr
ogra
m in
th
e st
ate
in w
hic
h h
e or
sh
e re
side
s. S
tate
sar
e re
quir
ed t
o in
clud
e ce
rtai
nin
divi
dual
s un
der
thei
r M
edic
aid
plan
s an
d m
ay in
clud
e ot
her
s.Ty
pica
lly, s
tate
s cl
assi
fy in
divi
dual
sin
to e
ligib
ility
gro
ups,
wh
ich
incl
ude
the
cate
gori
cally
nee
dy(w
hom
sta
tes
mus
t co
ver)
, th
e m
ed-
ical
ly n
eedy
, an
d ot
her
spe
cial
grou
ps. E
ligib
ility
for
eac
h s
tate
dif
-fe
rs, s
o ch
eck
your
sta
te’s
Med
icai
dw
ebsi
te t
o se
e if
you
are
elig
ible
.
Ala
bam
aA
laba
ma
Med
icai
d A
genc
yh
ttp:
//w
ww.
med
icai
d.st
ate.
al.u
s/(8
00)
362-
1504
Ala
ska
Ala
ska
Hea
lth
and
Soci
al S
ervi
ces
htt
p://
ww
w.h
ss.s
tate
.ak.
us/
(907
) 46
5-30
30
Hea
lth
Car
e Se
rvic
es: M
edic
aid
htt
p://
ww
w.h
ss.s
tate
.ak.
us/
dhcs
/Med
icai
d/de
faul
t.htm
(907
) 46
5-58
24
Pub
lic A
ssis
tanc
e: M
edic
aid
htt
p://
ww
w.h
ss.s
tate
.ak.
us/
dpa/
prog
ram
s/m
edic
aid/
(907
) 46
5-33
47
Ari
zon
aA
rizo
na H
ealt
h C
are
Cos
tC
onta
inm
ent
Syst
emh
ttp:
//w
ww.
ahcc
cs.s
tate
.az.
us/
(800
) 52
3-02
31
Ark
ansa
sA
rkan
sas
Med
icai
dh
ttp:
//w
ww.
med
icai
d.st
ate.
ar.u
s(8
00)
482-
5431
Ark
ansa
s M
edic
aid:
Pro
pose
d ru
les
for
publ
ic c
omm
ent:
htt
p://
ww
w.m
edic
aid.
stat
e.ar
.us/
Inte
rnet
Solu
tion
/gen
eral
/co
mm
ent/
com
men
t.asp
x
Cal
ifo
rnia
Med
i-Cal
htt
p://
ww
w.m
edi-c
al.c
a.go
v/(8
00)
541-
5555
Cal
ifor
nia
Dep
artm
ent
of
Hea
lth
Serv
ices
htt
p://
ww
w.dh
s.ca
.gov
(916
) 44
5-41
71
Co
lora
do
Stat
e of
Col
orad
o D
epar
tmen
t of
Hea
lth
Car
e P
olic
y an
d Fi
nanc
ing
htt
p://
ww
w.ch
cpf.s
tate
.co.
us/
HC
PF/r
efm
at/w
dwic
hc.
htm
l(8
00)
221-
3943
Col
orad
o M
edic
al A
ssis
tanc
eP
rogr
amh
ttp:
//w
ww.
chcp
f.sta
te.c
o.us
/(8
00)
221-
3943
Co
nn
ecti
cut
Dep
artm
ent
of S
ocia
l Ser
vice
sh
ttp:
//w
ww.
dss.
stat
e.ct
.us/
svcs
/me
dica
l/in
dex.
htm
(800
) 84
2-15
08(i
n-s
tate
on
ly);
(8
60)
424-
4908
Con
nect
icut
Med
ical
Ass
ista
nce
Pro
gram
http
://w
ww.c
tmed
ical
prog
ram
.com
/
Del
awar
eD
elaw
are
Hea
lth
and
Soci
alSe
rvic
esh
ttp:
//w
ww.
dhss
.del
awar
e.go
v/dh
ss/d
ss/m
edic
aid.
htm
l(8
00)
372-
2022
(in
-sta
te o
nly
);
(302
) 25
5-90
40
Dis
tric
t o
f C
olu
mb
iaD
epar
tmen
t of
Hea
lth
(Med
ical
Ass
ista
nce
Adm
inis
trat
ion)
htt
p://
doh
.dc.
gov/
doh
/sit
e/(2
02)
442-
5988
Flo
rid
aM
edic
aid
Serv
ices
htt
p://
ww
w.fd
hc.
stat
e.fl
.us/
Med
icai
d(8
88)
419-
3456
Geo
rgia
Geo
rgia
Dep
artm
ent
ofC
omm
unit
y H
ealt
hh
ttp:
//dc
h.g
eorg
ia.g
ov
Geo
rgia
Med
icai
d pa
ge:
htt
p://
dch
.geo
rgia
.gov
/00/
chan
nel
_tit
le/0
,209
4,31
4467
11_
3194
4826
,00.
htm
l(8
00)
766-
4456
Haw
aii
Haw
aii M
ed Q
uest
(H
awai
i Sta
teD
epar
tmen
t of
Hum
an S
ervi
ces)
htt
p://
ww
w.m
ed-q
uest
.us/
(808
) 58
7-35
21
Idah
oD
epar
tmen
t of
Hea
lth
and
Wel
fare
htt
p://
ww
w.h
ealt
han
dwel
fare
.id
aho.
gov/
(877
) 20
0-54
41
Illi
no
isD
epar
tmen
t of
Hea
lthc
are
and
Fam
ily S
ervi
ces
htt
p://
ww
w.h
fs.il
linoi
s.go
v/(8
66)
468-
7543
Ind
ian
aFa
mily
and
Soc
ial S
ervi
ces
Adm
inis
trat
ion
htt
p://
ww
w.in
.gov
/fss
a/h
ealt
hca
re/
(800
) 88
9-99
49
Iow
aD
epar
tmen
t of
Hum
an S
ervi
ces:
Hea
lth
Car
e - D
ivis
ion
of F
inan
cial
,H
ealt
h an
d W
ork
Supp
orts
htt
p://
ww
w.dh
s.st
ate.
ia.u
s/dh
s200
5/dh
s_h
omep
age/
child
ren
_fam
ily/h
ealt
hca
re/
med
icai
d.h
tml
(800
) 97
2-20
17
Kan
sas
Dep
artm
ent
of S
ocia
l and
Reh
abili
tati
on S
ervi
ces
htt
p://
ww
w.sr
skan
sas.
org/
(800
) 76
6-90
12
Ken
tuck
yK
entu
cky
Dep
artm
ent
for
Med
icai
dSe
rvic
esh
ttp:
//ch
fs.k
y.go
v/dm
s/(8
00)
635-
2570
Lou
isia
na
Bur
eau
of H
ealt
h Se
rvic
esFi
nanc
ing:
Lou
isia
na M
edic
aid
htt
p://
ww
w.dh
h.s
tate
.la.u
s/of
fice
s/?I
D=9
2(2
25)
342-
9500
HEA
LTH
LA
WY
ERS’
PU
BLI
C I
NFO
RM
AT
ION
SER
IES
hea
lth
law
yers
.org
/Med
icai
dFa
cts
Am
eric
an H
ealt
h L
awye
rs A
sso
ciat
ion
• 1
025 C
on
nec
ticu
t A
ven
ue,
NW
, Su
ite
600 •
Was
hin
gto
n,
DC
20036-5
405 •
(202)
833-1
100
*All
site
s on
th
is p
age
wer
e la
st v
isit
ed A
pril
1, 2
008
Mai
ne
Off
ice
of M
aine
Car
e Se
rvic
esh
ttp:
//w
ww.
stat
e.m
e.us
/bm
s/(8
00)
321-
5557
Mar
ylan
dM
aryl
and
Med
ical
Ass
ista
nce
htt
p://
ww
w.dh
mh
.sta
te.m
d.us
/mm
a/m
mah
ome.
htm
l(8
00)
492-
5231
Mas
sach
use
tts
Mas
s H
ealt
hh
ttp:
//w
ww.
mas
s.go
v/po
rtal
/in
dex.
jsp?
page
ID=e
ohh
s2su
btop
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L=4
&L
0=H
ome&
L1=
Gov
ern
men
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2=D
epar
tmen
ts+
and+
Div
isio
ns&
L3=
Mas
sHea
lth
&si
d=E
eoh
hs2
(800
) 32
5-52
31
Mic
hig
anM
ichi
gan
Dep
artm
ent
of C
omm
unit
y H
ealt
hh
ttp:
//w
ww.
mic
hig
an.g
ov/m
dch
/0,
1607
,7-1
32-2
943_
4860
---00
.htm
l(5
17)
373-
3740
Firs
t H
ealt
h M
ichi
gan
Med
icai
dw
ww.
mic
hig
an.fh
sc.c
om/
(804
) 96
5-76
19
Min
nes
ota
Dep
artm
ent
of H
uman
Ser
vice
s: H
ealt
h C
are
http
://w
ww.
dhs.s
tate
.mn.
us/m
ain/
grou
p/ h
ealth
-ca
re/d
ocum
ents
/pub
/dhs
_id_
0062
54.h
csp
(800
) 65
7-37
39
Mis
siss
ipp
iM
issi
ssip
pi D
ivis
ion
of M
edic
aid
htt
p://
ww
w.do
m.s
tate
.ms.
us(8
00)
421-
2408
Mis
sou
riD
epar
tmen
t of
Soc
ial S
ervi
ces
htt
p://
ww
w.ds
s.m
o.go
v(8
00)
392-
0938
Serv
ices
of
Mis
sour
i Med
icai
dh
ttp:
//w
ww.
dss.
mo.
gov/
mh
d/in
dex.
htm
Mo
nta
na
Mon
tana
Med
icai
dh
ttp:
//w
ww.
dph
hs.
mt.g
ov/h
psd/
med
icai
d/in
dex.
htm
(800
) 36
2-83
12
Neb
rask
aN
ebra
ska
Hea
lth
and
Hum
an S
ervi
ces:
Med
icai
d P
rogr
amht
tp:/
/ww
w.hh
s.sta
te.n
e.us
/med
/med
prog
.htm
(800
) 43
0-32
44
Nev
ada
Div
isio
n of
Hea
lthc
are
Fina
ncin
g an
d P
olic
y(N
V M
edic
aid)
htt
p://
dhcf
p.st
ate.
nv.
us/
(775
) 68
4-36
76
New
Ham
psh
ire
Dep
artm
ent
of H
ealt
h an
d H
uman
Ser
vice
s:M
edic
aid
Pro
gram
htt
p://
ww
w.dh
hs.
stat
e.n
h.u
s/D
HH
S/M
ED
ICA
IDPR
OG
RA
M/d
efau
lt.h
tm(8
00)
852-
3345
x 4
344
New
Jer
sey
Dep
artm
ent
of H
uman
Ser
vice
s: M
edic
alA
ssis
tanc
e an
d H
ealt
h Se
rvic
esh
ttp:
//w
ww.
stat
e.n
j.us/
hum
anse
rvic
es/
dmah
s/dh
smed
.htm
l(8
00)
356-
1561
New
Mex
ico
NM
Hum
an S
ervi
ces
Dep
artm
ent
- Med
ical
Ass
ista
nce
Div
isio
nht
tp:/
/ww
w.st
ate.
nm.u
s/hs
d/m
ad/I
ndex
.htm
l(8
88)
997-
2583
New
Yo
rkD
epar
tmen
t of
Hea
lth:
Med
icai
dh
ttp:
//w
ww.
hea
lth
.sta
te.n
y.us
/ h
ealt
h_c
are/
med
icai
d/in
dex.
htm
(877
) 47
2-84
11
No
rth
Car
oli
na
Nor
th C
arol
ina
Div
isio
n of
Med
ical
Ass
ista
nce
htt
p://
ww
w.dh
hs.
stat
e.n
c.us
/dm
a/(8
00)
688-
6696
No
rth
Dak
ota
Dep
artm
ent
of H
uman
Ser
vice
s: M
edic
aid:
htt
p://
ww
w.n
d.go
v/dh
s/se
rvic
es/m
edic
alse
rv/
med
icai
d/(8
00)
755-
2604
Oh
ioO
hio’
s M
edic
aid
Pro
gram
htt
p://
jfs.o
hio
.gov
/oh
p/in
dex.
stm
(800
) 32
4-86
80
Okla
ho
ma
Hea
lth
Car
e A
utho
rity
htt
p://
ww
w.oh
ca.s
tate
.ok.
us/
(800
) 52
2-03
10
Ore
go
nO
rego
n H
ealt
h P
lan
htt
p://
ww
w.or
egon
.gov
/DH
S/h
ealt
hpl
an/
inde
x.sh
tml
(800
) 52
7-57
72
Pen
nsy
lvan
iaD
epar
tmen
t of
Pub
lic W
elfa
re: M
edic
aid
http
://w
ww.
dpw.
stat
e.pa
.us/
Serv
ices
Prog
ram
s/M
edic
alA
ssist
ance
/003
6702
96.h
tm(8
00)
692-
7462
Rh
od
e Is
lan
dR
hode
Isl
and
Dep
artm
ent
of H
uman
Ser
vice
sh
ttp:
//w
ww.
dhs.
ri.g
ov/i
nde
x.h
tm(8
00)
964-
6211
Sou
th C
aro
lin
aD
epar
tmen
t of
Hea
lth
and
Hum
an S
ervi
ces:
Med
icai
dh
ttp:
//w
ww.
dhh
s.st
ate.
sc.u
s/dh
hsn
ew/
med
icai
d.as
p(8
88)
549-
0820
Sou
th D
ako
taSo
uth
Dak
ota
Med
ical
Ser
vice
sh
ttp:
//w
ww.
stat
e.sd
.us/
soci
al/m
edic
al/
(800
) 45
2-76
91(i
n-s
tate
on
ly);
(6
05)
773-
3495
Ten
nes
see
Dep
artm
ent
of H
uman
Ser
vice
s: M
edic
aid
http
://w
ww.
stat
e.tn
.us/
hum
anse
rv/m
edi.h
tm(8
00)
523-
2863
Texas
Tex
as M
edic
aid
Pro
gram
htt
p://
ww
w.h
hsc
.sta
te.tx
.us/
Med
icai
d/(8
77)
787-
8999
Uta
hU
tah
Med
icai
d P
rogr
amh
ttp:
//h
ealt
h.u
tah
.gov
/med
icai
d/(8
00)
662-
9651
Ver
mo
nt
Age
ncy
of H
uman
Ser
vice
s: M
edic
aid
http
://w
ww.
path
.stat
e.vt
.us/
Prog
ram
s_Pa
ges/
Hea
lth
care
/med
icai
d.h
tm(8
00)
250-
8427
Vir
gin
iaD
epar
tmen
t of
Soc
ial S
ervi
ces:
Med
icai
dC
over
age
htt
p://
ww
w.ds
s.st
ate.
va.u
s/be
nefit
/m
edic
aid_
cove
rage
.htm
l(8
04)
726-
7000
Was
hin
gto
nD
epar
tmen
t of
Soc
ial a
nd H
ealt
h Se
rvic
es:
Med
ical
Pro
gram
sh
ttps
://w
ws2
.wa.
gov/
dsh
s/on
linec
so/
Med
ical
.asp
(800
) 56
2-30
22
Wes
t V
irg
inia
Dep
artm
ent
of H
ealt
h an
d H
uman
Res
ourc
es:
Med
icai
dh
ttp:
//w
ww.
wvd
hh
r.org
/bcf
/fa
mily
_ass
ista
nce
/med
icai
d.as
p(3
04)
558-
1700
Wis
con
sin
Wis
cons
in M
edic
aid
htt
p://
dhfs
.wis
con
sin
.gov
/Med
icai
d/in
dex.
htm
?ref
=hp
(800
) 36
2-30
02
Wyo
min
gW
yom
ing
Med
icai
dh
ttp:
//w
yequ
alit
ycar
e.ac
s-in
c.co
m/
(800
) 25
1-12
70
Res
ou
rces
:A
n A
dvoc
ate’
s G
uide
to
the
Med
icai
d P
rogr
amh
ttp:
//w
ww.
hea
lth
law.
org
Med
icai
d H
ome
Pag
e w
ith
man
y M
edic
aid-
rela
t-ed
link
sh
ttp:
//w
ww.
cms.
hh
s.go
v/h
ome/
med
icai
d.as
p
Indi
vidu
al s
tate
pla
ns a
nd s
tate
pla
ns
amen
dmen
tsht
tp:/
/ww
w.cm
s.hhs
.gov
/med
icai
d/st
atep
lans
50 s
tate
map
of
Med
icai
d in
form
atio
nh
ttp:
//w
ww.
cms.
hh
s.go
v/m
edic
aid/
stat
epla
ns/
map
.asp
Med
icai
d B
enef
its
and
Eli
gib
ilit
yH
EALT
H L
AW
YER
S’ P
UB
LIC
IN
FOR
MA
TIO
N S
ERIE
S
*All
site
s on
th
is p
age
wer
e la
st v
isit
ed A
pril
1, 2
008
Med
icai
d V
enta
jas
y El
egib
ilid
ad
Foll
eto
in
form
ativ
o d
e la
Aso
ciac
ión
amer
ican
a d
e ab
og
ado
s d
e la
sal
ud
pú
bli
ca (
AH
LA,
po
r su
sig
la e
n i
ng
lés)
par
a lo
s b
enef
icia
rio
s d
el p
rog
ram
aM
edic
aid
C
omo
es d
e pú
blic
o co
noc
imie
nto
, nue
stra
regi
ón d
e la
Cos
ta d
el G
olfo
se
ha
vist
o ab
ati-
da p
or r
ecie
nte
s h
urac
anes
e in
unda
cion
es,
que
han
obl
igad
o a
un s
in n
úmer
o de
per
-so
nas
, com
o n
unca
an
tes
acon
teci
do, a
ten
erqu
e ab
ando
nar
sus
hog
ares
y t
rasl
adar
seh
acia
sit
ios
nue
vos,
por
lo g
ener
al, e
n n
ueva
sco
mun
idad
es y
est
ados
. Par
te d
e es
tos
indi
-vi
duos
dep
endí
an d
e as
iste
nci
a m
édic
a an
tes
de p
adec
er la
lleg
ada
de e
stas
tor
men
tas.
Otr
os p
erdi
eron
sus
tra
bajo
s y
sus
bien
es y
,ah
ora
es c
uan
do m
ás n
eces
itan
de
dich
a as
is-
ten
cia.
En
con
secu
enci
a, m
uch
as p
erso
nas
se
acer
can
par
a in
teri
oriz
arse
, por
pri
mer
a ve
z,ac
erca
de
las
con
dici
ones
de
eleg
ibili
dad
para
acc
eder
a lo
s pr
ogra
mas
de
Med
icai
d,co
nfo
rme
a lo
s cr
iter
ios
adop
tado
s po
r ca
daes
tado
en
par
ticu
lar.
Med
ian
te e
sta
publ
icac
ión
se
pret
ende
ayu
-da
r a
toda
s aq
uella
s pe
rson
as y
a q
uien
es s
epo
nen
al s
ervi
cio
de lo
s n
eces
itad
os. N
oses
tam
os r
efir
ien
do a
los
méd
icos
pro
fesi
on-
ales
, asi
sten
tes
soci
ales
y o
tras
per
son
as e
nes
ta c
ateg
oría
, que
pud
iera
n t
ener
que
tra
tar
con
Med
icai
d po
r pr
imer
a ve
z. A
sim
ism
o, s
efa
cilit
a la
info
rmac
ión
nec
esar
ia p
ara
un f
ácil
acce
so a
en
lace
s de
sit
ios
web
, en
los
cual
esse
des
crib
en lo
s pr
ogra
mas
de
Med
icai
dvi
gen
tes
en 5
0 es
tado
s. L
a in
ten
ción
de
esta
publ
icac
ión
no
es c
rear
un
deb
ate
acer
ca d
eM
edic
aid,
ni t
ampo
co d
ar a
con
ocer
los
cri-
teri
os d
e el
egib
ilida
d en
vir
tud
de lo
s cu
ales
una
pers
ona
adqu
iere
el d
erec
ho
de a
cces
o a
las
pres
taci
ones
y s
ervi
cios
ofr
ecid
os p
or e
lpr
ogra
ma.
Sin
em
barg
o, s
e tr
ata
de e
stab
le-
cer
el p
unto
de
part
ida
para
col
abor
ar c
onaq
uello
s in
divi
duos
que
pue
den
nec
esit
aras
iste
nci
a en
la o
bten
ción
del
pag
o po
r at
en-
ción
méd
ica.
Esp
eram
os q
ue la
info
rmac
ión
sum
inis
trad
a le
sea
de
utili
dad.
El p
rog
ram
a M
edic
aid
M
edic
aid
es u
n p
rogr
ama
que
tien
e co
mo
fin
alid
ad o
frec
er p
rest
acio
nes
méd
icas
a c
ier-
tos
indi
vidu
os y
fam
ilias
de
bajo
s in
gres
os y
recu
rsos
eco
nóm
icos
. Seg
ún e
l cri
teri
o de
eleg
ibili
dad
de M
edic
aid,
en
con
trap
osic
ión
a la
s co
ndi
cion
es d
e el
egib
ilida
d pa
ra a
cced
-
er a
las
pres
taci
ones
de
Med
icar
e, la
eda
dde
l sol
icit
ante
no
repr
esen
ta u
n o
bstá
culo
para
con
side
rars
e be
nef
icia
rio
de la
s pr
esta
-ci
ones
y s
ervi
cios
, sin
o qu
e, p
or e
l con
trar
io,
el p
rogr
ama
se li
mit
a a
con
side
rar
los
recu
r-so
s fi
nan
cier
os d
e di
cha
pers
ona.
Asi
mis
mo,
a di
fere
nci
a de
l pro
gram
a M
edic
are
deal
can
ce n
acio
nal
, el p
lan
Med
icai
d qu
ead
min
istr
a in
divi
dual
men
te c
ada
esta
do,
con
form
e a
su p
ropi
o cr
iter
io, e
stab
lece
las
con
dici
ones
de
eleg
ibili
dad,
los
serv
icio
scu
bier
tos
y el
niv
el d
e pa
go s
ujet
o a
ampl
ios
pará
met
ros
fede
rale
s.
Med
icai
d of
rece
tre
s cl
ases
de
prot
ecci
ón d
ela
sal
ud q
ue r
esul
tan
ese
nci
ales
:
• se
guro
de
salu
d pa
ra f
amili
as, n
iños
,an
cian
os y
per
son
as c
on d
isca
paci
dade
s de
bajo
s in
gres
os y
rec
urso
s ec
onóm
icos
;
• at
enci
ón a
larg
o pl
azo
para
an
cian
os a
mer
i-ca
nos
e in
divi
duos
con
dis
capa
cida
des;
y
• co
bert
ura
supl
emen
tari
a de
stin
ada
a ci
er-
tos
ben
efic
iari
os d
e la
s pr
esta
cion
es,
quie
nes
se
con
side
ran
de
bajo
s in
gres
os y
recu
rsos
eco
nóm
icos
.
Co
nd
icio
nes
de
eleg
ibil
idad
A f
in d
e p
oder
acc
eder
a l
as p
rest
acio
nes
yse
rvic
ios
de
Med
icai
d e
n c
alid
ad d
e be
nef
i-ci
ario
, es
nec
esar
io c
um
pli
r co
n l
as c
ond
i-ci
ones
de
eleg
ibil
idad
dis
pu
esta
s p
or e
lp
rogr
ama
e in
scri
birs
e en
el
esta
do
en e
lcu
al s
e m
anti
ene
el l
uga
r d
e re
sid
enci
a.L
os e
stad
os t
ien
en e
l co
mp
rom
iso
de
incl
uir
a c
iert
os i
nd
ivid
uos
, con
form
e a
sus
pla
nes
Med
icai
d, c
omo
así
tam
bién
pu
eden
inco
rpor
ar a
otr
os. T
ípic
amen
te, l
os e
sta-
dos
cla
sifi
can
a l
os i
nd
ivid
uos
en
gru
pos
,co
nfo
rme
a d
isti
nto
s cr
iter
ios
de
eleg
ibil
i-d
ad, l
os c
ual
es c
onte
mp
lan
a l
os n
eces
ita-
dos
cat
egór
icam
ente
(a
quie
nes
los
est
ados
deb
en c
ubr
ir),
los
nec
esit
ados
qu
ere
quie
ren
ate
nci
ón m
édic
a y
otro
s gr
up
oses
pec
iale
s. P
or c
uan
to c
ada
esta
do
dis
pon
ein
div
idu
alm
ente
su
s co
nd
icio
nes
de
eleg
i-bi
lid
ad, e
s re
com
end
able
rem
itir
se a
l si
tio
web
de
Med
icai
d, s
egú
n c
orre
spon
da
a su
luga
r d
e re
sid
enci
a, a
fin
de
veri
fica
r si
reú
ne
los
requ
isit
os n
eces
ario
s p
ara
obte
n-
er e
l d
erec
ho
a la
s p
rest
acio
nes
y s
ervi
cios
de
salu
d.
Ala
bam
aC
entr
o de
ser
vici
os d
e M
edic
aid
en A
laba
ma
htt
p://
ww
w.m
edic
aid.
stat
e.al
.us/
(8
00)
362-
1504
Ala
ska
Serv
icio
s so
cial
es y
pre
stac
ione
sde
la s
alud
en
Ala
ska
htt
p://
ww
w.h
ss.s
tate
.ak.
us/
(907
) 46
5-30
30
Serv
icio
s de
asi
sten
cia
sani
tari
a: C
entr
ode
ser
vici
os d
e M
edic
aid
htt
p://
ww
w.h
ss.s
tate
.ak.
us/
dhcs
/Med
icai
d/de
faul
t.htm
(907
) 46
5-58
24
Asi
sten
cia
públ
ica:
Cen
tro
de s
ervi
cios
de
Med
icai
dh
ttp:
//w
ww.
hss
.sta
te.a
k.us
/dp
a/pr
ogra
ms/
med
icai
d/(9
07)
465-
3347
Ari
zon
aSi
stem
a de
con
tenc
ión
de c
osto
s de
asis
tenc
ia s
anit
aria
en
Ari
zona
h
ttp:
//w
ww.
ahcc
cs.s
tate
.az.
us/
(800
) 52
3-02
31
Ark
ansa
sC
entr
o de
ser
vici
os d
e M
edic
aid
en A
rkan
sas
htt
p://
ww
w.m
edic
aid.
stat
e.ar
.us
(800
) 48
2-54
31
Med
icai
d A
rkan
sas:
Nor
mas
pro
pues
tas
para
la o
pini
ón p
úblic
a:h
ttp:
//w
ww.
med
icai
d.st
ate.
ar.u
s/In
tern
etSo
luti
on/g
ener
al/
com
men
t/co
mm
ent.a
spx
Cal
ifo
rnia
Med
i-Cal
htt
p://
ww
w.m
edi-c
al.c
a.go
v/(8
00)
541-
5555
Dep
arta
men
to d
e as
iste
ncia
sani
tari
a de
Cal
ifor
nia
htt
p://
ww
w.dh
s.ca
.gov
(916
) 44
5-41
71
Co
lora
do
Dep
arta
men
to d
e po
lític
a y
fina
ncia
mie
nto
de la
pre
stac
ión
de a
sist
enci
a sa
nita
ria
en e
les
tado
de
Col
orad
o h
ttp:
//w
ww.
chcp
f.sta
te.c
o.us
/H
CPF
/ref
mat
/wdw
ich
c.h
tml
(800
) 22
1-39
43
Pro
gram
a de
asi
sten
cia
méd
ica
de C
olor
ado
htt
p://
ww
w.ch
cpf.s
tate
.co.
us/
(800
) 22
1-39
43
Co
nn
ecti
cut
Dep
arta
men
to d
e se
rvic
ios
soci
ales
htt
p://
ww
w.ds
s.st
ate.
ct.u
s/sv
cs/
med
ical
/in
dex.
htm
(800
) 84
2-15
08 (
dent
ro d
el e
stad
o,ún
icam
ente
); (
860)
424
-490
8
Pro
gram
a de
asi
sten
cia
méd
ica
de C
onne
ctic
ut
htt
p://
ww
w.ct
med
ical
prog
ram
.com
/
Del
awar
eSe
rvic
ios
soci
ales
y p
rest
acio
nes
de la
salu
d en
Del
awar
eh
ttp:
//w
ww.
dhss
.del
awar
e.go
v/dh
ss/d
ss/m
edic
aid.
htm
l(8
00)
372-
2022
(de
ntro
del
est
ado,
únic
amen
te);
(30
2)25
5-90
40
Dis
tric
to d
e C
olu
mb
ia
Dep
arta
men
to d
e sa
lud
(Adm
inis
trac
ión
de a
sist
enci
a m
édic
a)
htt
p://
doh
.dc.
gov/
doh
/sit
e/(2
02)
442-
5988
Flo
rid
aC
entr
o de
ser
vici
os d
e M
edic
aid
htt
p://
ww
w.fd
hc.
stat
e.fl
.us/
Med
icai
d(8
88)
419-
3456
Geo
rgia
Dep
arta
men
to d
e sa
lud
com
unit
aria
de
Geo
rgia
h
ttp:
//dc
h.g
eorg
ia.g
ov
Pág
ina
de M
edic
aid:
h
ttp:
//dc
h.g
eorg
ia.g
ov/
00/
chan
nel
_tit
le/
0,20
94,3
1446
711 _
3194
4826
,00.
htm
l(8
00)
766-
4456
Haw
aii
Haw
aii M
ed Q
uest
(Dep
arta
men
to d
e se
rvic
ios
hum
anos
del e
stad
o de
Haw
aii)
h
ttp:
//w
ww.
med
-que
st.u
s/(8
08)
587-
3521
Idah
oD
epar
tam
ento
de
salu
dy
bien
esta
r so
cial
htt
p://
ww
w.h
ealt
han
dwel
fare
.id
aho.
gov/
(877
) 20
0-54
41
Illi
no
isD
epar
tam
ento
de
serv
icio
s a
la f
amili
a y
pres
taci
ones
de
la s
alud
h
ttp:
//w
ww.
hfs
.illin
ois.
gov/
(866
) 46
8-75
43
Ind
ian
aA
dmin
istr
ació
n de
ser
vici
osso
cial
es y
de
la f
amili
ah
ttp:
//w
ww.
in.g
ov/f
ssa/
hea
lth
care
/(8
00)
889-
9949
Iow
aD
epar
tam
ento
de
serv
icio
s hu
man
os:
Asi
sten
cia
sani
tari
a –
Div
isió
n de
sopo
rtes
fin
anci
ero,
asi
sten
cia
sani
tari
ay
trab
ajo
http
://w
ww.
dhs.s
tate
.ia.u
s/dh
s200
5/dh
s_ho
mep
age/
child
ren_
fam
ily/
heal
thca
re/
med
icai
d.ht
ml
(800
) 97
2-20
17
Kan
sas
Dep
arta
men
to d
e se
rvic
ios
soci
ales
y d
ere
habi
litac
ión
htt
p://
ww
w.sr
skan
sas.
org/
(800
) 76
6-90
12
Ken
tuck
yD
epar
tam
ento
a c
argo
de la
s pr
esta
cion
es d
e M
edic
aid
en K
entu
cky
htt
p://
chfs
.ky.
gov/
dms/
(800
) 63
5-25
70
HE
AL
TH
LA
WY
ER
S S
ER
IE
DE
IN
FO
RM
AC
IO
N P
ÚB
LIC
O
hea
lth
law
yers
.org
/Med
icai
dFa
cts
Am
eric
an H
ealt
h L
awye
rs A
sso
ciat
ion
• 1
025 C
on
nec
ticu
t A
ven
ue,
NW
, Su
ite
600 •
Was
hin
gto
n,
DC
20036-5
405 •
(202)
833-1
100
*All
site
s on
th
is p
age
wer
e la
st v
isit
ed A
pril
1, 2
008
Lou
isia
na
Com
ité
de f
inan
ciam
ient
o de
la p
rest
ació
nde
asi
sten
cia
méd
ica:
Cen
tro
de s
ervi
cios
de
Med
icai
d en
Lou
isia
nah
ttp:
//w
ww.
dhh
.sta
te.la
.us/
offi
ces/
?ID
=92
(225
) 34
2-95
00
Mai
ne
Ofi
cina
de
Serv
icio
s de
Mai
neC
are
htt
p://
ww
w.st
ate.
me.
us/b
rns/
(800
) 32
1-55
57
Mar
ylan
dA
sist
enci
a sa
nita
ria
en M
aryl
and
http
://w
ww.
dhm
h.st
ate.
md.
us/m
ma/
mm
ahom
e.ht
ml
(800
) 49
2-52
31
Mas
sach
use
tts
Salu
d pú
blic
ah
ttp:
//w
ww.
mas
s.go
v/po
rtal
/in
dex.
jsp?
page
ID=e
ohh
s2su
btop
ic&
L=4
&L
0=H
ome&
L1=
Gov
ern
men
t&L
2=D
epar
tmen
ts+
and+
Div
isio
ns&
L3=
Mas
sHea
lth
&si
d=E
eoh
hs2
(800
) 32
5-52
31
Mic
hig
anD
epar
tam
ento
de
salu
d pú
blic
a de
Mic
higa
nh
ttp:
//w
ww.
mic
hig
an.g
ov/m
dch
/0,
1607
,7-1
32-2
943_
4860
—-0
0.h
tml
(517
) 37
3-37
40
Firs
t H
ealt
h –
Cen
tro
de s
ervi
cios
de
Med
icai
den
Mic
higa
nh
ttp:
//w
ww.
mic
hig
an.fh
sc.c
om/
(804
) 96
5-76
19
Min
nes
ota
Dep
arta
men
to d
e se
rvic
ios
hum
anos
:A
sist
enci
a sa
nita
ria
htt
p://
ww
w.dh
s.st
ate.
mn
.us/
mai
n/g
roup
s/h
ealt
hca
re/d
ocum
ents
/pub
/dh
s_id
_006
254.
hcs
p(8
00)
657-
3739
Mis
siss
ipp
iD
ivis
ión
de M
edic
aid
en M
issi
ssip
pi
htt
p://
ww
w.do
m.s
tate
.ms.
us(8
00)
421-
2408
Mis
sou
riD
epar
tam
ento
de
serv
icio
s so
cial
esh
ttp:
//w
ww.
dss.
mo.
gov
(800
) 39
2-09
38
Pre
stac
ione
s de
Med
icai
d en
Mis
sour
i h
ttp:
//w
ww.
dss.
mo.
gov/
mh
d/in
dex.
htm
Mo
nta
na
Cen
tro
de s
ervi
cios
de
Med
icai
d en
Mon
tana
http
://w
ww.
dphh
s.mt.g
ov/h
psd/
med
icai
d/in
dex.
htm
(800
) 36
2-83
12
Neb
rask
aSe
rvic
ios
hum
anos
y p
rest
acio
nes
de la
sal
uden
Neb
rask
a:C
entr
o de
ser
vici
os d
e M
edic
aid
htt
p://
ww
w.h
hs.
stat
e.n
e.us
/med
/med
prog
/htm
(800
) 43
0-32
44
Nev
ada
Div
isió
n de
pol
ític
a y
fina
ncia
mie
nto
de la
pre
stac
ión
de a
sist
enci
a sa
nita
ria
(Med
icai
d en
NV
)h
ttp:
//dh
cfp.
sate
.nv.
us(7
75)
684-
3676
New
Ham
psh
ire
Dep
arta
men
to d
e sa
lud
y se
rvic
ios
hum
anos
:C
entr
o de
ser
vici
os d
e M
edic
aid
htt
p://
ww
w.dh
hs.
stat
e.n
h.u
s/D
HH
S/M
ED
ICA
IDPR
OG
RA
M/d
efau
lt.h
tm(8
00)
852-
3345
x 4
344
New
Jer
sey
Dep
arta
men
to d
e se
rvic
ios
hum
anos
: A
sist
enci
a m
édic
a y
pres
taci
ones
de
la s
alud
h
ttp:
//w
ww.
stat
e.n
j.us/
hum
anse
rvic
es/
dmah
s/dh
smed
.htm
l(8
00)
356-
1561
New
Mex
ico
Dep
arta
men
to d
e se
rvic
ios
hum
anos
de
NM
D
ivis
ión
de a
sist
enci
a m
édic
ah
ttp:
//w
ww.
stat
e.n
m.u
s/h
sd/m
ad/I
nde
x.h
tml
(888
) 99
7-25
83
New
Yo
rkD
epar
tam
ento
de
salu
d: C
entr
o de
ser
vici
osde
Med
icai
d h
ttp:
//w
ww.
hea
lth
.sta
te.n
y.us
/hea
lth
_car
e/m
edic
aid/
inde
x.h
tm(8
77)
472-
8411
No
rth
Car
oli
na
Dep
arta
men
to d
e as
iste
ncia
méd
ica
enN
orth
Car
olin
ah
ttp:
//w
ww.
dhh
s.st
ate.
nc.
us/d
ma/
(800
) 68
8-66
96
No
rth
Dak
ota
Dep
arta
men
to d
e se
rvic
ios
hum
anos
:C
entr
o de
ser
vici
os d
e M
edic
aid:
htt
p://
ww
w.n
d.go
v/dh
s/se
rvic
es/m
edic
alse
rv/
med
icai
d/(8
00)
755-
2604
Oh
ioC
entr
o de
ser
vici
os d
e M
edic
aid
en O
hio
htt
p://
jfs.o
hio
.gov
/oh
p/in
dex.
stm
(8
00)
324-
8680
Okla
ho
ma
Ent
idad
a c
argo
de
la a
sist
enci
a sa
nita
ria
htt
p://
ww
w.oh
ca.s
tate
.ok.
us/
(800
) 52
2-03
10
Ore
go
nP
lan
de s
alud
en
Ore
gon
htt
p://
ww
w.or
egon
.gov
/DH
S/h
ealt
hpl
an/
inde
x.sh
tml
(800
) 52
7-57
72
Pen
nsy
lvan
iaD
epar
tam
ento
de
bien
esta
r so
cial
:C
entr
o de
ser
vici
os d
e M
edic
aid
http
://w
ww.
dpw.
stat
e.pa
.us/
Serv
ices
Prog
ram
s/M
edic
alA
ssist
ance
/003
6702
96.h
tm(8
00)
692-
7462
Rh
od
e Is
lan
dD
epar
tam
ento
de
serv
icio
s hu
man
osde
Rho
de I
slan
d h
ttp:
//w
ww.
dhs.
ri.g
ov/i
nde
x.h
tm(8
00)
964-
6211
Sou
th C
aro
lin
aD
epar
tam
ento
de
salu
d y
serv
icio
s hu
man
os:
Cen
tro
de s
ervi
cios
de
Med
icai
dh
ttp:
//w
ww.
dhh
s.st
ate.
sc.u
s/dh
hsn
ew/
med
icai
d.as
p(8
88)
549-
0820
Sou
th D
ako
taA
sist
enci
a m
édic
a en
Sou
th D
akot
a h
ttp:
//w
ww.
stat
e.sd
.us/
soci
al/m
edic
al/
(800
) 45
2-76
91 (
dent
ro d
el e
stad
o, ú
nica
men
te);
(605
) 77
3-34
95
Ten
nes
see
Dep
arta
men
to d
e se
rvic
ios
hum
anos
: Cen
tro
dese
rvic
ios
deM
edic
aid
htt
p://
ww
w.st
ate.
tn.u
s/h
uman
serv
/med
i.htm
(8
00)
523-
2863
Texas
Cen
tro
de s
ervi
cios
de
Med
icai
d en
Tex
ash
ttp:
//w
ww.
hh
sc.s
tate
.tx.u
s/M
edic
aid/
(877
) 78
7-89
99
Uta
hC
entr
o de
ser
vici
os d
e M
edic
aid
en U
tah
htt
p://
hea
lth
.uta
h.g
ov/m
edic
aid/
(8
00)
662-
9651
Ver
mo
nt
Ofi
cina
de
serv
icio
s hu
man
os:
Cen
tro
de s
ervi
cios
de
Med
icai
dh
ttp:
//w
ww.
path
.sta
te.v
t.us/
Prog
ram
s_Pa
ges/
Hea
lth
care
/med
icai
d.h
tm(8
00)
250-
8427
Vir
gin
iaD
epar
tam
ento
de
serv
icio
s so
cial
es:
Cob
ertu
ra d
e M
edic
aid
htt
p://
ww
w.ds
s.st
ate.
va.u
s/be
nef
it/
med
icai
d_co
vera
ge.h
tml
(804
) 72
6-70
00
Was
hin
gto
nD
epar
tam
ento
de
serv
icio
s so
cial
es y
pre
stac
ione
sde
la s
alud
: Pro
gram
as m
édic
osh
ttps
://w
ws2
.wa.
gov/
dsh
s/on
linec
so/
Med
ical
.asp
(800
) 56
2-30
22
Wes
t V
irg
inia
Dep
arta
men
to d
e re
curs
os h
uman
os y
pre
stac
ione
sde
la s
alud
: Cen
tro
de s
ervi
cios
de
Med
icai
dh
ttp:
//w
ww.
wvd
hh
r.org
/bcf
/fam
ily_a
ssis
tan
ce/
med
icai
d.as
p(3
04)
558-
1700
Wis
con
sin
Cen
tro
de s
ervi
cios
de
Med
icai
d en
Wis
cons
in
htt
p://
dhfs
.wis
con
sin
.gov
/Med
icai
d/in
dex.
htm
?ref
=hp
(800
) 36
2-30
02
Wyo
min
gC
entr
o de
ser
vici
os d
e M
edic
aid
en W
yom
ing
htt
p://
wye
qual
ityc
are.
acs-
inc.
com
/ (8
00)
251-
1270
Rec
urs
os:
An
Adv
ocat
e’s
Gui
de t
o th
e M
edic
aid
Pro
gram
(Guí
a de
l pro
gram
a M
edic
aid
para
abo
gado
s)h
ttp:
//w
ww.
hea
lth
law.
org
Med
icai
d H
ome
Pag
e w
ith
man
y M
edic
aid-
rela
ted
links
(P
ágin
a pr
inci
pal d
e M
edic
aid
con
vari
osen
lace
s re
laci
onad
os a
est
e pr
ogra
ma)
htt
p://
ww
w.cm
s.h
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APPENDIX C
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APPENDIX C
GLOSSARY
Assets – To be eligible for Medicaid, a person’sincome must be under certain levels and he/shemust have assets of less than a certain value. Everystate has a limit on what assets a Medicaid benefici-ary may own and keep for purposes of financial eli-gibility. “Countable assets” consist of all investmentssuch as stocks, bonds, mutual funds, checking andsavings accounts, certificates of deposits, personaland real property, art and collectibles. “Excluded”assets are not counted in determining Medicaid eli-gibility and vary from state to state but generallyinclude a home or life estate in a home, burialspace costs and related items, life insurance, long-term insurance, other types of term insurance, thevalue of income-producing real property, and cer-tain annuities.
Beneficiary – An individual who is eligible for andenrolled in their state’s Medicaid program.
Categorically Needy – Certain groups of Medicaidbeneficiaries who qualify for the basic mandatorypackage of Medicaid benefits which generallyincludes low-income children, pregnant or post-partum women, the aged, blind, or disabled, cer-tain low-income children and families who qualifyfor federal welfare assistance, and low-incomeMedicare beneficiaries.
Co-payment – A fixed amount paid by a Medicaidbeneficiary at the time the beneficiary receives acovered service from a participating provider.
Centers for Medicare & Medicaid Services (CMS)The Centers for Medicare & Medicaid Services(CMS) is a Federal agency within the U.S.Department of Health and Human Services withthe responsibility of administering the Medicaid,Medicare, and the State Children’s HealthInsurance programs. CMS was formerly known asthe Health Care Financing Administration(HFCA).
Dual Eligibles – Individuals who are eligible forboth Medicare and Medicaid coverage. StateMedicaid programs generally pay for certain costsharing and services that are not otherwise coveredby Medicare including nursing home services, pre-scription drugs, and payment of Medicare premi-ums, deductibles, and co-insurance.
Federal Financial Participation (FFP) – The federalmatching funds paid to states for expenditures forMedicaid services or administrative costs. The levelof FFP for service costs varies from state to state
because the statutory formula that determines FFPprovides greater federal assistance to states withlower per capita incomes. Administrative costs aregenerally matched by the federal government at50%.
Fee-for-Service – A method of payment for serviceswhereby doctors and hospitals are paid for eachservice they provide.
Financial Eligibility – Financial eligibility require-ments vary from state to state and from category tocategory, but generally financial eligibility require-ments put limits on the amount of income andassets an individual may have in order to qualify forcoverage.
Medicaid Trust: A trust or similar legal device thata person (or his/her spouse, guardian or legal rep-resentative) creates, under which (a) that the per-son is the beneficiary of all or part of the paymentsfrom the trust, and (b) the amount of those pay-ments is determined by one or more trustees whohave discretion as to how much they distribute tothat individual.
Medical Assistance – The term used in the federalMedicaid statute to refer to payment for items andservices covered under a state’s Medicaid programon behalf of individuals eligible for benefits.
Medically Needy – An optional Medicaid eligibilitygroup made up of individuals who qualify for cov-erage because of high medical expenses. Theseindividuals also must be categorically eligible buttheir income is too high to qualify them for “cate-gorically needy.”
Prior Authorization – When an item or servicerequires prior authorization, the state Medicaidagency will not pay for the item or service unlessapproval is obtained in advance by the beneficiary’streating provider.
Spend-Down – In some eligibility categories, indi-viduals may qualify for Medicaid coverage eventhough their incomes are higher than the specifiedincome through a process called “spending down.”Under this process, the medical expenses that anindividual incurs during a specified period is sub-tracted from the individual’s income during thatperiod and once the individual’s income reaches astate-specified level, the individual qualifies forMedicaid benefits for the remainder of the period.
Spousal Impoverishment – A set of rules that statesare required to apply in a situation where aMedicaid beneficiary resides in a nursing facilityand his or her spouse remains in the community.The rules specify the amounts of income and
resources each spouse is allowed to obtain withoutjeopardizing the institutionalized spouse’s eligibilityfor Medicaid benefits and are designed to preventthe impoverishment of the spouse residing in thecommunity.
State Medicaid Plan – A written plan meeting feder-al statutory requirements that is required to be sub-mitted and approved by the Secretary of theDepartment of Health and Human Services (HHS)for each state in order to participate in theMedicaid program. The State Plan must providedetails about administration, eligibility, coverage ofservices, beneficiary protections, and reimburse-ment methodologies. Any changes to the StatePlan, known as State Plan Amendments, must alsobe approved by the Secretary of HHS.
State Children’s Health Insurance Program(SCHIP) – SCHIP is a federal-state matching pro-gram of health care coverage for uninsured, low-income children. Children who are eligible forMedicaid are not eligible for SCHIP.
Supplemental Security Income (SSI) – A Federalentitlement program that provides cash assistanceto low-income aged, blind, and disabled people.Generally, individuals receiving SSI benefits are eli-gible for Medicaid coverage.
Waivers – The Secretary of HHS may, upon therequest of a state, allow the state to receive federalMedicaid matching funds for services for which fed-eral matching funds are not otherwise available. Forexample, a state may use the waiver program toreceive federal matching funds for home and com-munity-based services or to cover certain categoriesof individuals for which federal matching funds arenot otherwise available.
20
ABOUT THE AUTHORS
21
ABOUT THE AUTHORS
About the Editors
Thomas W. CoonsOBER | KALERBaltimore, MDPhone: (410) 347-7389Email: [email protected]
Myra C. SelbyIce Miller LLPIndianapolis, IN Phone: (317) 236-5903Email: [email protected]
About the Authors and Contributors
Nancy C. ArmentroutDirector of Legislative AffairsCalifornia Association of Health FacilitiesSacramento, CA [email protected]
Elise Dunitz Brennan Doerner, Saunders, Daniel & Anderson, LLP Tulsa, OK [email protected]
Barbara D.A. EymanRopes & Gray LLPWashington, DC [email protected]
Joel M. Hamme Powers Pyles Sutter & Verville PC Washington, DC [email protected]
Christopher C. PuriBoult, Cummings, Conners & Berry, PLCNashville, [email protected]
Kathryn (Kate) SpazianiLegislative DirectorU.S. Representative Ron Kind (D-WI)Washington, DC www.house.gov/kind/contact.shtml
Hemi D. TewarsonSenior AttorneyU.S. Government Accountability OfficeOffice of the General CounselWashington, DCtewarsonh@ gao.gov
Lisa Diehl Vandecaveye Corporate Vice President of Legal Affairs Botsford Health Care Continuum Farmington Hills, MI [email protected]
Eric P. Zimmerman McDermott Will & Emery Washington, DC [email protected]
ABOUT THE PRACTICE GROUPS
Long Term Care, Senior Housing, In-Home Care andRehabilitation (LTC-SIR): provides a forum for attor-neys who represent providers across the entire spec-trum of long term care services including skilled nurs-ing facilities, assisted living, senior housing, homehealth, hospice, and long term care pharmacy; followsand addresses developments in the long term caresegment of the healthcare industry including legaltrends, regulatory policy, and operational and transac-tional issues; attempts to provide practical analysis ofthese legal and business trends by producing sum-maries and brief analyses of forms, models, approaches,
structures, and legal analyses relevant to the providersof long term care services; the goal is to keep themembers informed of the most up-to date and rele-vant case law, legislative initiatives, and importanttrends in the industry.
Regulation, Accreditation, and Payment (RAP):addresses issues related to reimbursement and cover-age, including Medicare and other government payorlaws, regulations, and instructions, as well as issuesrelated to healthcare organizational accreditation suchas The Joint Commission and other accrediting entitystandards.
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