Medicare & Medicaid Eligibility Requirements

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The health care industry has been profoundly affected by recent laws. The impact on Medicare and Medicaid merits a closer look given the number of people who are affected. Under the Affordable Care Act, the criteria for eligibility to these programs have been modified. To learn more, checkout this infographic created by Hofstra Law’s Online Master’s in Health Law and Policy program.



Infographic on Medicare and Medicaid Eligibility

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Medicare Eligibility Requirements

Medicare is a national health insurance program funded by the federal government. Its aim is to take care of the most vulnerable people in society including the elderly, the disabled, and the chronically ill. They are the ones who often need to receive treatment or get hospitalized. The amount of money they need to spend on health care can be financially crippling without outside assistance. Medicare can give a helping hand as long as a person is eligible under the strict requirements set by law. Note that the program is exclusive to those with American citizenship or permanent resident status in the US.

For Americans who have reached the age of 65, it is possible to qualify for Part A at no cost but they have to satisfy at least one additional condition. Being the dependent parent of a fully-insured deceased child is one, and having worked for a long while in government while paying Medicare taxes is another. Spouses of government workers get the same privilege. Being eligible to receive Social Security benefits can also be used as basis for acceptance to the Medicare program. For those who are under 65, having ALS, receiving disability benefits, or having permanent kidney failure ensures their eligibility.

Enrolled individuals enjoy substantial relief from medical expenses but the insurance cannot cover everything. Prescription drugs, dental services, ambulance services, mental health care, and hearing aids are all part of the program. Some forms of medical equipment may also be included such as eye glasses, canes, defibrillators, infusion pumps, and the like. Things which are considered as complementary medicines such as massage therapy may be covered as well. Vital preventive screenings for cancer, diabetes, depression, and cardiovascular diseases fall under the program. After all, being able to spot problems early makes them easier and cheaper to treat.

Medicare Enrollee Data

According to the latest data, there are 55 million Americans enrolled in the original Medicare. The majority of them are over 65. Half of the beneficiaries have incomes that fall under $23,500. These people are vulnerable because of their health and financial situation. The program allows them to live with dignity and get the type of care that they wouldn’t otherwise be able to obtain. The Affordable Care Act boosted Medicare in two different ways. First, it introduced savings for both generic and brand- name prescription drugs. Second, it provided more resources for doctors to coordinate care.

Medicaid Eligibility Requirements

Meanwhile, the Medicaid program was designed to be a state-administered health care initiative. It caters to people who have limited resources. There are minimum eligibility requirements as set by law. Pregnant women and children under 18 may qualify if their families earn less than 133% of the federal poverty line. In 2015, this was defined as $32,252.50 for a family of four. Parents may also apply if their income is falls within the eligibility limit of their state. The majority of seniors and persons with disabilities are also covered by the program. They should prove that they are receiving cash assistance through the SSI.

Each state is free to set its own eligibility criteria. However, these must be within the federal minimum standards or else these cannot be legally recognized. They can apply for expansions to the health coverage in case there are other groups they wish to include. Those who plan to enroll in this program will also have to satisfy requirements concerning their residency, immigration status, and citizenship documentation. These are serious matters. Without these papers, it will be difficult to push forward with the application. Interested parties should prepare them in advance. Every detail must be ironed out for faster processing.

As for the mandatory coverage, the list is fairly long and useful. People are covered for several items including inpatient and patient hospital services. Those who require help from nursing facilities will also be able to reduce their expenses with Medicaid. Early and periodic screenings are encouraged under the program as these are known to lower long-term costs. Physician and family nurse services may be compensated. Even the cost of transportation to the medical facility can be included. Optional benefits include things like occupational therapy for work-related conditions, optometry services for better eye health, and prescription drugs for various ailments.

Medicaid Enrollee Data

There are currently 67.4 million Americans who are getting health coverage through Medicaid. Unlike Medicare, the greatest number of beneficiaries here are children at 43M. Next are non-elderly adults at 11M. The non-elderly with disabilities amount to 8.8M while seniors reached 4.6M. These represent a considerable part of each demographic. For instance, 1 in 5 Americans who are 65 or older get Medicaid coverage. About 1 in 3 children under 18 years of age are also covered in case they become ill. Roughly 2 in 3 nursing home residents benefit from the program. There are 32 states which have adopted expansions to Medicaid.

Overview of Dual Eligible Services

These two programs have many similarities. It should not come as a surprise that plenty of Americans qualify for both. These people are called dual eligible. Each state regulates the way that they can collect benefits given their situation. There are also monthly income limits that must be followed. These are largely based on the federal poverty line or FPL. For example, dual-eligible standards are at 100% of the FPL. Specific low-income Medicare beneficiaries can get up to 120%. The typical qualifying individual can receive up to 135% of the current FPL, while those who are disabled yet working can avail of up to 200%.

Medicare is usually the first insurance coverage to be tapped in case of an overlap. Medicaid will only be opened as a last resort in case an item isn’t covered by other programs. It can also take care of the balance if the former provides limited assistance. Examples include nursing home care, community-based services, home-based services, and personal care.