Medicaid is a state-administered health insurance program for low-income families and children, pregnant women, the elderly, people with disabilities and, in some states, other adults. The federal government provides a portion of the funding for Medicaid and sets guidelines for the program. States also have choices in how they design their program, so Medicaid varies state by state and may have a different name in your state (e.g., Healthy Families, Tenncare, MediCal, etc.).

Being enrolled in Medicaid satisfies the “mandate” that you have health insurance.

Medicaid Expansion

States’ Medicaid eligibility categories vary according to the populations they choose to cover, although the federal government also has certain minimum requirements. In 2014, states will also have the option to expand their Medicaid programs to cover nonelderly, non-pregnant adults earning up to 138% of the federal poverty level ($32,499 for a family of four) who are not otherwise eligible for Medicaid or enrolled in or eligible for Medicare.

In states that choose to expand their Medicaid program, they may provide a different type or amount of benefit, called the benchmark or benchmark equivalent package, so it is important to know what your benefits are.

How Medicaid Works after January 1, 2014

Beginning on January 1, 2014, you may be eligible for Medicaid in two different ways. First, you may be “traditionally” eligible. Second, you may be “newly eligible” if your state implements the Medicaid expansion. Whether you are traditionally or newly eligible for Medicaid is an important distinction because it may determine the kind of benefit package for which you are eligible.

The ACA expanded Medicaid eligibility to nonelderly, non-pregnant adults with income at or below 138% of the federal poverty level (FPL) ($32,499 for a family of four) who are not otherwise eligible for a mandatory Medicaid eligibility category or enrolled in or eligible for Medicare. The U. S. Supreme Court subsequently made this mandatory Medicaid expansion optional. This means that states have the option to choose whether to expand Medicaid to individuals earning up to 138% FPL.

If your state chooses to expand Medicaid up to 138% FPL and you become eligible for Medicaid under this expansion, you are considered to be “newly eligible” for Medicaid. If you were already eligible for Medicaid in your state (even if you were not already enrolled), you are considered to be “traditionally eligible” for Medicaid.  See Medicaid Expansion map.

If you are already traditionally eligible for Medicaid, you will likely remain so come January 1, 2014. Because some states are changing their Medicaid eligibility requirements in anticipation of 2014, however, it is a good idea to speak with someone in your state’s Medicaid department just to confirm that you will maintain your traditional Medicaid eligibility come January 1, 2014.

To find out if you will be newly eligible for Medicaid come January 1, 2014, you can use a subsidy calculator .

Although individuals both traditionally and newly eligible for Medicaid will have access to items and services covered as part of the essential health benefit package, the benefit package offered as part of a state’s Medicaid expansion does NOT have to mirror its traditional Medicaid benefit package. Instead, a state can choose to use a “Medicaid benchmark” or “benchmark equivalent” plan for its expansion population (this is different than the benchmark plan described on the EHB page). If it does, the Medicaid expansion population may get a benefit package that is less robust than the state’s traditional Medicaid benefit package. This may impact the availability and types of services offered to meet your bleeding disorder needs.

If you think that you may be newly eligible for Medicaid beginning on January 1, 2014, you should check with your state’s Medicaid department to find out whether it will offer the traditional Medicaid benefit package to its expansion population, or a benchmark or benchmark equivalent package instead.

Contact your state’s Medicaid department to find out if your state intends to expand Medicaid in 2014.  If it does, ask for assistance in determining whether you will be eligible for Medicaid under the expansion.

Resource: Do I qualify for Medicaid?

If you will be eligible for Medicaid under the expansion in 2014, ask someone in your state’s Medicaid department how you can enroll and when you can do that. In 2014, there will be a variety of “helpers” (called Navigators) available to assist individuals in determining whether they are eligible for Medicaid, and also helping them apply for Medicaid.

Children’s Health Insurance Program (CHIP)

CHIP is another insurance program jointly funded by state and federal governments. CHIP provides health coverage to low-income children and, in some states, pregnant women in families who earn too much income to qualify for Medicaid but cannot afford to purchase private health insurance coverage.

States have the option of administering CHIP through their Medicaid programs or through a separate program (or a combination of both). States have one of three choices related to CHIP, each state can choose to:

  1. Operate CHIP as an extension of the Medicaid program to income thresholds higher than those eligible for Medicaid, so the services and benefits are the same for the two programs or
  2. Operate CHIP is a separate program, with a different set of benefits or requirements than Medicaid or
  3. Operate CHIP as a combination of an extension and a stand-alone program.
Medical Subsidy calculator With this calculator, you can enter different income levels, ages, and family sizes to get an estimate of your eligibility for subsidies and how much you could spend on health insurance. As premiums and eligibility requirements may vary, contact your state’s Medicaid office or exchange with enrollment questions. View now >>>
Medical Taxes Tax Break Can Help With Health Coverage, But There’s A Catch – Fact sheet on tax credits and subsidies View now >>>
Status of State Action on the Medicaid Expansion Decision Medicaid Expansion. This link includes an interactive map that allows you to click on a state and learn about the Medicaid expansion efforts. View now >>>
Out of Pocket Maximums Out of Pocket Maximums. The Affordable Care Act (ACA) sets maximum limits on how much a person can be required to pay out-of-pocket annually for his or her health care: HFA Issue Brief. View now >>>
Personal Insurance Toolkit Extensive toolkit developed by the National Hemophilia Foundation (NHF) and APLUS Coalition which HFA is a part of. View now >>> U.S. Government Site for Health Insurance information View now >>>

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Disclaimer. This website is a resource only and should be used for information purposes. Please work with your health care providers, insurance councilors, etc. to determine the best solution for you.

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