Medicaid-Related Programs

Programs like the Program of All-Inclusive Care for the Elderly (PACE) provide a variety of benefits to meet the healthcare needs of enrollees. PACE participants can get the care they need in the community rather than a nursing facility.

PACE is a healthcare plan designed to allow these individuals to remain in their home’s if they can live safely and independently. To qualify for the program, individuals must be at least 55 years of age and have either Medicare or Medicaid. Many individuals in this voluntary program are dual eligible for both. Through Medicaid, individuals such as undocumented immigrants and those who are medically needy also receive quality and affordable health care they might not otherwise receive.

Children’s Health Insurance Program (CHIP)

The CHIP program provides low-cost health care to uninsured children of families who do not qualify for Medicaid. To qualify, for CHIP insurance, beneficiaries must be under 19 years of age. They must also be a resident of the state which they are applying and have legal citizenship status. CHIP coverage ends on the beneficiary’s 19th birthday. However, they may still be eligible for standard Medicaid once their CHIP coverage ends. Medicaid coverage is not automatic, and they must apply for standard Medicaid to determine their eligibility.

Related Article: Medicaid Eligibility

The CHIP insurance is a comprehensive health care package that provides coverage for routine check-ups, doctor visits and immunizations. Many states also offer dental care as a part of the insurance plan. Individuals may apply for the CHIP program at any time throughout the year even if open enrollment has closed. Coverage begins immediately after approval. As such, beneficiaries may start using their coverage prior to receiving their card in the mail. They may present the approval letter as proof of insurance when making the appointment.

Medical Care Provided Through Program of All-Inclusive Care for the Elderly (PACE)

The Program of All-Inclusive Care for The Elderly (PACE) provides medical benefits to elderly individuals. Specifically, PACE healthcare is a program designed to provide medical care through community resources rather than those of a nursing home. The program is designed to reduce the need for nursing home care for those individuals who are independent enough to remain in the community. This plan provides a variety of benefits which include:

  • Dentistry
  • Home Care
  • Hospital Care
  • Meals
  • Prescription Drugs
  • Medical Specialty Services (Examples include Cardiology, Orthopedics or Optometry)

Most program participants meet eligibility requirements for Medicaid and Medicare, and this is called dual eligibility. To qualify, participants must be age 55 or older. Additionally, participants must be eligible for nursing care yet able to live in the community without jeopardizing their health or safety. They must also live in the service area of a PACE organization. Enrollment in the program is voluntary, and participants may disenroll at any time. Enrollment in the PACE program for the elderly continues until the individual’s death.

Participants in the program may have out-of-pocket costs depending on their financial situation. Those who have Medicaid are not required to pay a monthly premium for long-term care coverage. If, however, an individual doesn’t qualify for Medicaid but does have Medicare, they must pay the premium for Medicare Part D prescription drugs. They must also pay a monthly premium for the PACE long-term care coverage. Those who do not have Medicare or Medicaid may elect to pay for their PACE healthcare privately.

Emergency Medicaid for Non-Citizens

Per federal guidelines, only U.S. citizens and legal non-citizens qualify for Medicaid. However, Medicaid has a special program for emergency Medicaid for undocumented immigrants. With emergency Medicaid, undocumented immigrants may receive care according to a specific criterion for emergency medical services. An emergency medical condition is defined as a sudden onset of symptoms that could put the patient’s health in serious jeopardy or cause impairment to body function. The term also applies to the dysfunction of a bodily organ. Coverage must continue until the patient’s condition has stabilized and no longer meets the condition of a medical emergency.

Related Article: Health Care Resources 

Emergency Medicaid is not a pre-approved benefit. It is only authorized after emergency care has been rendered. Patients must apply within three months of the date of the emergency care. Otherwise, Medicaid may not pay for the services provided.

Patients must inform the medical staff where they are receiving treatment that they wish to apply for these benefits. The staff may take the application and submit it to the Medicaid agency. Alternatively, they may refer the individual to the local Medicaid office. An immigrant without proof of legal presence is not eligible for standard Medicaid. However, he or she may apply for standard Medicaid should their citizenship status change during or after emergency medical care.

Emergency Medicaid is not for care that would be available at an alternate level of care such as hospital care or rehabilitative services. The length of emergency coverage through Medicaid in most states is limited to 30 consecutive days.

Medicaid Benefits for The Medically Needy

Under the Medically needy guidelines for Medicaid, the program provides health care to individuals who do not qualify for the program because their income is too high. Per program rules, beneficiaries are defined as medically needy if they have significant health issues that would cause them to incur excessive healthcare costs. Specifically, these costs must be such that they create an undue financial hardship on the patient.

To qualify for Medically Needy Medicaid, individuals must “spend down” their income. To do this, they must incur medical expenses for which they do not have health insurance. Once the medical expenses exceed the difference between the applicant’s income and the required “spenddown” amount, the applicant may apply for the program.

This form of Medicaid covers many services covered under standard Medicaid. The program includes inpatient services, outpatient hospital services, laboratory and X-ray services. In some cases, they qualify for prescription drugs as well as dental care if it is a service offered in their state.

Related Article: Using Medicaid Benefits

It might also interest you: