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How Do I Know If I Qualify for Medicaid?

Law Offices of Julie A. Schejbal , CHTD April 10, 2024

Paper with Medicaid and stethoscopeMedicaid is a federal and state program that provides essential health coverage to millions of eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. It offers a lifeline to these individuals by ensuring access to necessary medical services that might otherwise be financially out of reach.

But how do you know if you are eligible for the Medicaid program? Understanding the qualification criteria and the steps to apply for the program or appeal a denied application is essential to determine your eligibility for Medicaid assistance. 

At the Law Offices of Julie A. Schejbal, CHTD, we are experienced in Medicaid and long-term healthcare planning. Located in Dunkirk, Maryland, we proudly serve clients throughout Calvert County, Prince George’s County, Charles County, and St. Mary's County. 

What Is the Medicaid Program? 

Medicaid is a critical healthcare program that is designed to assist individuals and families who may not have the means to afford healthcare. Jointly funded by the federal and state governments and coordinated by the Centers for Medicare & Medicaid Services (CMS), it aims to provide comprehensive health coverage to eligible low-income people across various demographics, including children, pregnant women, elderly adults, and individuals with disabilities. Unlike Medicare, which is primarily for people over the age of 65 regardless of income, Medicaid focuses on providing help to those with limited income and resources.  

Eligibility for Medicaid varies depending on the state, as each state has the flexibility to design its own version of Medicaid within federal guidelines. This means the coverage one might receive and the qualifications for eligibility can differ significantly depending on where you live. 

Medicaid Expansion 

Medicaid expansion is a provision under the Affordable Care Act (ACA) that extends Medicaid eligibility to nearly all low-income individuals with incomes up to 138 percent of the federal poverty level. This initiative targets adults without dependent children, a demographic that historically was not included in Medicaid in many states. 

It's important to note that Medicaid Expansion is optional for states, which has led to varied adoption across the country. States that choose to expand Medicaid coverage receive federal funding to cover the costs associated with the expansion, and residents of participating states may be eligible for Medicaid under the expanded criteria even if they were not eligible under their state's previous guidelines.  

What Does Medicaid Cover?   

Medicaid coverage includes a wide array of essential healthcare services. Maryland's Medicaid program, also referred to as the Maryland Medical Assistance Program, incorporates a broad range of essential healthcare services for eligible individuals aged 21 and above. This includes all federally mandated benefits such as: 

  • Inpatient and outpatient hospital services 

  • Laboratory and X-ray examinations 

  • Physician services 

  • Nursing facility care 

  • Preventative services 

  • Family planning 

  • Pediatric and nurse midwife services 

  • Home healthcare 

Maryland's Medicaid program also extends coverage beyond federal requirements to include: 

  • Prescription drugs 

  • Dental care for adults 

  • Physical therapy 

  • Occupational therapy 

  • Pediatric dental services 

For specific groups, such as pregnant women and individuals under 21, Maryland's Medicaid program offers even broader coverage through programs like the Healthy Start Pregnant Women Program and the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) service. These programs are designed to promote the early detection and treatment of health issues in low-income families and individuals. 

Eligibility Requirements for Medicaid 

To qualify for Medicaid, individuals must meet specific income and resource criteria. While these standards vary by state, they generally align with federal poverty levels (FPLs) and are tailored to each of the eligible groups targeted by the program. The essential eligibility criteria include: 

Income Level 

Medicaid eligibility largely depends on your income level. Applicants must have an income that falls below a certain threshold, typically set relative to the federal poverty level. The Modified Adjusted Gross Income (MAGI) methodology is commonly used to assess an applicant's financial standing, which considers their taxable income and certain deductions such as childcare expenses, student loans, and contributions to retirement accounts. 

In Maryland, adults between the ages of 19 and 64 may qualify for Medicaid if their household income does not exceed 138% of the federal poverty level (FPL). For pregnant women and children, the income eligibility criteria are more generous, allowing for higher income levels. 

Residency and Citizenship 

To be eligible for Medicaid, you must be a resident of the state where you are applying for Medicaid and either a U.S. citizen, permanent resident, or legal alien. This includes green card holders, refugees, asylees, and certain other immigrants who have legal permission to reside in the United States. In Maryland, you must prove you are a resident of the state, meaning you must live in the state with the intention of remaining permanently or for an indefinite period.  

Family Status or Role 

Certain population groups are automatically eligible for Medicaid, irrespective of their income. This includes pregnant women, children, former foster care youth, and individuals receiving Supplemental Security Income (SSI). Additionally, parents or caretakers of a child under a certain age, elderly individuals, and those with disabilities will also usually qualify. 

How to Apply for Medicaid  

The application process is generally state-specific. In Maryland, you can apply online through the Maryland Health Connection, the state’s health insurance marketplace, or in person at The Bureau of Long-Term Care of your local Department of Social Services. To apply, you will need to submit a completed application and the necessary supporting documentation, including: 

  • Proof of identity, such as a driver's license or passport 

  • Proof of income, such as financial records, pay stubs, or tax returns 

  • Proof of residency status, such as proof of address 

  • Proof of citizenship status, such as a birth certificate or immigration documents

Once you apply and are approved for Medicaid, keep in mind that your eligibility will be reviewed annually to ensure continued qualification based on your income and other factors. For assistance during any stage of the process, Maryland’s Health Connection offers support through its helpline, ensuring that applicants have access to the help they need to successfully apply for and receive Medicaid coverage. 

What If I Am Denied Access to Medicaid?  

If you apply for Medicaid and are denied, it's not the end of the road. There are still actions you can take if a Medicaid application doesn’t yield the desired outcome. Understanding these options can be crucial in securing healthcare coverage.  

Appeal the Decision 

You have the right to appeal a Medicaid denial within a specified period. In Maryland, this period is 90 days from the date of the denial notice, so it's important to act swiftly.  

To initiate the appeal process, you must submit a written request to the Maryland Department of Health. Include any new information or documentation that could support your case. Consulting with a legal professional experienced in Medicaid appeals can significantly increase your chances of a favorable outcome. 

Alternative Coverage  

If an appeal still doesn't provide a satisfactory answer, you can explore other forms of coverage that can provide temporary benefits. This can include Health Insurance Marketplace plans or assistance programs offered through local clinics or private organizations.   

Seek Experienced Legal Support 

Understanding whether you are eligible for Medicaid can be challenging. For personalized advice and assistance, consult with Medicaid planners, healthcare advocates, and Medicaid attorneys who have experience with Medicaid law. At the Law Offices of Julie A. Schejbal, CHTD, we have helped numerous individuals and families determine their Medicaid eligibility, and we can provide you with tailored guidance and support. Contact us today to schedule a free consultation and learn more about your options for Medicaid assistance.