Medicaid Health Care Coverage

Medicaid is a government health care system providing medical coverage for people with limited income and their children. Medicaid provides free health insurance to millions of Americans. People below their state’s qualifying income limits can get medical and health-related services at little to no cost. 

Under federal law, the federal government and state contribute to the cost of Medicaid. However, each state agency is in charge of the program in their state. If you have questions about your legal rights to Medicaid, talk to a Medicaid lawyer.

What Is Medicaid?

Medicaid is a joint federal and state program. The federal government provides general regulations for Medicaid programs. However, each state operates its own Medicaid program. Medicaid eligibility differs depending on where you live. Different states also offer different Medicaid benefits. 

Medicaid provides coverage for medical and health-related services. Medicaid also covers long-term care services, including nursing home care. Federal laws require coverage for children’s vaccinations, prenatal care, and delivery. In some states, Medicaid also covers dental services.

Medicaid is separate from Medicare. Medicare is government health care insurance for people 65 or older and people with certain disabilities. Income level determines Medicaid eligibility. Both programs fall under the U.S. Centers for Medicare & Medicaid Services (CMS).

The Affordable Care Act (ACA), also known as “Obamacare,” expanded Medicaid coverage and eligibility. However, some states did not expand eligibility for Medicaid, after the U.S. Supreme Court ruled in 2012 that they did not have to comply with that portion of the law. Currently, there are 10 states that have not expanded Medicaid eligibility:

• Alabama
• Florida
• Georgia
• Kansas
• Mississippi
• South Carolina
• Tennessee
• Texas
• Wisconsin
• Wyoming

Who Is Eligible for Medicaid Coverage?

Eligibility for Medicaid health plans depends on the state. Generally, eligibility depends on having a low income. It can also include children, pregnant women, people with disabilities, and low-income seniors. Depending on the state, eligibility can also depend on assets, age, disability, income, and other resources. In states that expanded Medicaid eligibility after the ACA went into effect, people or families making up to 138% of the federal poverty level are now eligible based only on income.

What Happens if You Get Denied Medicaid Benefits?

You may encounter situations where Medicaid won’t cover treatments by your health care providers. Denial of your treatment or services can be caused by errors or mistakes by your doctor. For example, your doctor may have entered the wrong type of billing code for your services.

If Medicaid denies coverage for health services, you can file an appeal with your state agency. If your medical treatment is medically necessary, Medicaid should cover the treatment. However, your state may not cover dental services, cosmetic treatments, or experimental therapies.

What Is Medicaid Unwinding?

During the Coronavirus pandemic, Medicaid enrollees received continuing coverage during the public health emergency. However, in 2023, states began to remove people who no longer qualified for the national health law program. Millions of people lost their health insurance when states started redetermining coverage. If you are eligible, you need to complete Medicaid renewal forms to stay covered.  

Can You File a Lawsuit for a Violation of Your Medicaid Rights?

As a Medicaid beneficiary, you can take your case to court if your state violates your Medicaid access rights. A 2022 U.S. Supreme Court ruling preserves the rights of beneficiaries to take their claims to court. In that lawsuit, the family members of Gorgi Talevski filed a lawsuit for nursing home abuse. The court confirmed that states are liable for violations of federal Medicaid rights. 

How Can a Medicaid Lawyer Help With Your Case?

If Medicaid denies your coverage or treatment for serious health conditions, a Medicaid lawyer can help. They can review your case and identify why the program denied care. You should receive a notice of action for denied care. Sometimes, you may be able to submit additional evidence to justify coverage. Your lawyer can help you gather this evidence.

If Medicaid denies you coverage because of the assumption you make too much money, this could be based on incorrect information, or you may be a victim of identity theft. Your lawyer can file an appeal with supporting evidence to advocate for your rights. 

If necessary, your lawyer can represent you during a Medicaid appeal hearing. If you win your case, the court can order the government to pay your attorneys’ fees and court costs.

You have a limited amount of time to file an appeal. Contact a Medicaid lawyer as soon as possible to make sure you can appeal your case in time.