Medicaid is a joint federal and state program that helps low-income people and their families get health care coverage. Many benefits and services are covered under Medicaid, but some are optional. Most Medicaid beneficiaries are enrolled in managed care plans or receive their health care through fee-for-service, with some receiving coverage through premium assistance programs. These arrangements help keep costs down for Medicaid enrollees while ensuring they access high-quality care.
Medicaid is a joint federal and state program that covers medical and health services for people who qualify for income-based benefits, including children, pregnant women, the elderly, and adults with disabilities. It has long-term benefits for enrolled students, including better health outcomes and less need for emergency care and hospitalizations. The funding for Medicaid varies by state. The federal government contributes a fixed cost percentage, called the federal medical assistance percentage (FMAP), and states pay the rest. The FMAP financing structure allows Medicaid to be responsive to economic and policy changes, enabling state programs to meet their residents' needs. However, it also creates tension between the federal government and states about sharing financing. Over the years, states have used legal loopholes to maximize federal funds, sometimes through financing arrangements that artificially inflate the FMAP. Medicaid covers a broad range of health care services, including hospital and physician care, X-rays and lab work, dental and vision services, home health care, nursing facility care and prescription drugs. It also provides coverage for children, pregnant women, seniors and people with disabilities. Low-income people can qualify for Medicaid if they meet certain income eligibility requirements tied to their household size. These include children, pregnant women, parents and adults below the poverty line. In addition, the law allows Medicaid to pay for a wide variety of optional benefits. These can include dental and vision services, hearing aids, and personal care services for people with disabilities and senior citizens. Many low-income families receive their Medicaid coverage through managed care organizations (MCOs) that contract with states to provide comprehensive services. Others receive care through fee-for-service Medicaid, which pays providers a fixed amount for services. Managed care has resulted in lower costs per enrollee than fee-for-service Medicaid, ensuring all beneficiaries can access the services they need. Unlike Medicare and commercial health insurance, Medicaid covers long-term care, including nursing home care and many home and community-based services. These services include assisted living, adult day care, foster care and other options to help seniors or individuals with disabilities live independently and remain as active as possible. Eligibility for long-term care services differs by state but is usually tied to the number of ADLs with which an individual requires assistance. This can include bathing, dressing, eating, and mobility. The state also offers managed long-term care (MLTC) plans in New York that cover these services and other health services like prescriptions, medical equipment, and dental and vision care. MLTC participants can also choose their primary care physicians and use their supplemental Medicaid and Medicare benefits for payment. In addition, some states offer "institutional" Medicaid services that provide comprehensive inpatient benefits in hospitals, intermediate care facilities for people with intellectual disabilities, and nursing facilities. These services assume total care of the institution's person, including room and board. Medicaid pays for various mental health services, including in-person and online therapy. It also covers the medication, which can help individuals manage their symptoms and improve their overall well-being. Low-income people may have difficulty paying for behavioral health care, which is why the Affordable Care Act requires that all Marketplace plans cover mental health treatment. This includes counseling and psychotherapy, which can be an important part of treatment for many mental health disorders. However, barriers to accessing these services remain, including limited provider networks, lack of adherence to parity laws, and high costs. Increasing access to mental health services is critical to address the impact of behavioral health issues on individuals and their families. States with expanded coverage can now provide Medicaid members access to mental health and substance use disorder (SUD) treatment services. This can be a life-saving resource, but states must continue to ensure they have adequate provider networks and sufficient funding to support these services.
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