Editing Medicaid (section)

=== Differences by state ===
While states have significant autonomy in implementing the Medicaid program, their flexibility is bounded by federal requirements designed to ensure a baseline of coverage and access. For example, federal law mandates that certain services, such as inpatient and outpatient hospital services, laboratory and X-ray services, and physician services, must be covered by all state Medicaid programs. Additionally, states must adhere to federal guidelines regarding beneficiary protections and quality standards. Any state-initiated changes that seek to modify these fundamental aspects typically require approval through federal waivers, ensuring that state innovations align with national objectives and statutory requirements.<ref>{{Cite web |last=Artiga |first=Samantha |last2=Hinton |first2=Elizabeth |last3=Rudowitz |first3=Robin |last4=Published |first4=MaryBeth Musumeci |date=2017-01-31 |title=Current Flexibility in Medicaid: An Overview of Federal Standards and State Options |url=https://www.kff.org/medicaid/issue-brief/current-flexibility-in-medicaid-an-overview-of-federal-standards-and-state-options/?utm_source=chatgpt.com |access-date=2025-02-26 |website=[[Kaiser Family Foundation]] |language=en-US}}</ref>

==== Eligibility and coverage ====
Broadly, the program provides health benefits to low-income individuals, including children, pregnant women, parents, seniors, and people with disabilities. The ACA expanded Medicaid eligibility to adults with incomes at or below 133% of the [[Poverty in the United States|federal poverty level]], though states have the option to implement this expansion.<ref>{{Cite web |title=Eligibility Policy |url=https://www.medicaid.gov/medicaid/eligibility-policy/index.html |access-date=2025-02-26 |website=[[Centers for Medicare & Medicaid Services]] |publisher=[[U.S. Department of Health and Human Services]]}}</ref>

Eligibility is primarily determined using the [[Adjusted gross income|modified adjusted gross income]] system, which standardizes income calculations across Medicaid, CHIP, and health insurance marketplace subsidies.<ref>{{Cite web |title=Medicaid Income Eligibility Limits for Adults as a Percent of the Federal Poverty Level |url=https://www.kff.org/affordable-care-act/state-indicator/medicaid-income-eligibility-limits-for-adults-as-a-percent-of-the-federal-poverty-level/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D |access-date=2025-02-26 |website=[[Kaiser Family Foundation]] |language=en-US}}</ref> However, certain groups, such as seniors and individuals with disabilities, have their eligibility determined using [[Supplemental Security Income]] (SSI) rules, which may include asset tests.<ref>{{Cite journal |last=Cornelio |first=Noelle |last2=McInerney |first2=Melissa Powell |last3=Mellor |first3=Jennifer M. |last4=Roberts |first4=Eric T. |last5=Sabik |first5=Lindsay M. |date=2021 |title=Increasing Medicaid's Stagnant Asset Test For People Eligible For Medicare And Medicaid Will Help Vulnerable Seniors |url=https://pubmed.ncbi.nlm.nih.gov/34871073 |journal=Health Affairs |volume=40 |issue=12 |pages=1943–1952 |doi=10.1377/hlthaff.2021.00841 |issn=2694-233X |pmc=11558658 |pmid=34871073}}</ref> Medicaid also includes provisions for individuals with significant medical expenses who do not otherwise qualify financially, allowing them to "spend down" their income on medical costs to become eligible.<ref>{{Cite web |date=2024-08-12 |title=How Does a Medicaid Spend Down Work? |url=https://www.ncoa.org/article/what-is-medicaid-spend-down/ |access-date=2025-02-26 |website=[[National Council on Aging]] |language=en}}</ref>

In addition to financial criteria, Medicaid applicants must meet non-financial requirements, including residency in the state where they apply and U.S. citizenship or qualifying non-citizen status.<ref>{{Cite web |last= |date=2025-01-15 |title=Key Facts on Health Coverage of Immigrants |url=https://www.kff.org/racial-equity-and-health-policy/fact-sheet/key-facts-on-health-coverage-of-immigrants/ |access-date=2025-02-26 |website=[[Kaiser Family Foundation]] |language=en-US}}</ref> Some eligibility groups, such as children in [[foster care]] under [[Title IV of the Patriot Act|Title IV-E]] and certain former foster youth, automatically qualify regardless of income. Coverage begins either on the date of application or the first day of the application month, with potential retroactive coverage for up to three months.

States also have the option to offer “medically needy” programs for individuals whose incomes exceed standard Medicaid limits but who have substantial medical expenses.<ref>{{cite web |title=Medicaid Eligibility Policy |url=https://www.medicaid.gov/medicaid/eligibility-policy/index.html |website=Medicaid.gov |publisher=Centers for Medicare & Medicaid Services |access-date=3 March 2025}}</ref><ref>{{cite web |title=How Does Medically Needy Medicaid Pay For Long-Term Care? |url=https://www.ncoa.org/article/why-is-medically-needy-medicaid-good-for-long-term-care/ |website=www.ncoa.org |publisher=National Council on Aging, Inc. |access-date=3 March 2025 |language=en |date=7 May 2024}}</ref> Additional Medicaid policies address estate recovery,<ref>{{Cite web |date=2021-06-17 |title=What Is Medicaid Estate Recovery? And How Does It Work? |url=https://www.ncoa.org/article/what-is-medicaid-estate-recovery-and-how-does-it-work/ |access-date=2025-02-26 |website=[[National Council on Aging]] |language=en}}</ref> third-party liability, and spousal impoverishment protections<ref>{{Cite web |title=Spousal Impoverishment |url=https://www.medicaid.gov/medicaid/eligibility/spousal-impoverishment/index.html |archive-url=https://web.archive.org/web/20250222123059/https://www.medicaid.gov/medicaid/eligibility/spousal-impoverishment/index.html |archive-date=2025-02-22 |access-date=2025-02-26 |website=[[Centers for Medicare & Medicaid Services]]}}</ref> for long-term care applicants. If an individual is denied Medicaid, they have the right to appeal the decision through state-administered processes.<ref>{{cite web |title=Appealing Denials {{!}} CMS |url=https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/indexappealingdenials |website=CMS.gov |publisher=U.S. Centers for Medicare & Medicaid Services |access-date=3 March 2025 |date=10 September 2024}}</ref>

==== Reimbursement for care providers ====
Beyond the variance in eligibility and coverage between states, there is a large variance in the reimbursements Medicaid offers to care providers; the clearest examples of this are common [[Orthopedic surgery|orthopedic procedures]]. For instance, in 2013, the average difference in reimbursement for 10 common orthopedic procedures in the states of New Jersey and [[Delaware]] was $3,047.<ref>{{cite journal |last1=Lalezari |first1=Ramin M. |last2=Pozen |first2=Alexis |last3=Dy |first3=Christopher J. |title=State Variation in Medicaid Reimbursements for Orthopaedic Surgery |journal=The Journal of Bone and Joint Surgery |date=February 2018 |volume=100 |issue=3 |pages=236–242 |doi=10.2106/JBJS.17.00279 |pmid=29406345 |s2cid=25818917 |url=https://digitalcommons.wustl.edu/cgi/viewcontent.cgi?article=7654&context=open_access_pubs }}</ref> The discrepancy in the reimbursements Medicaid offers may affect the type of care provided to patients.

In general, Medicaid plans pay providers significantly less than commercial insurers or Medicare would pay for the same care, paying around 67% as much as Medicare would for primary care and 78% as much for other services. This disparity has been linked to lower provider rates of participation in Medicaid programs vs Medicare or commercial insurance, and thus decreased access to care for Medicaid patients.<ref>{{cite journal | url=https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2020.00611 | doi=10.1377/hlthaff.2020.00611 | title=Medicaid Physician Fees Remained Substantially Below Fees Paid by Medicare in 2019 | year=2021 | last1=Zuckerman | first1=Stephen | last2=Skopec | first2=Laura | last3=Aarons | first3=Joshua | journal=Health Affairs | volume=40 | issue=2 | pages=343–348 | pmid=33523743 | s2cid=231755138 }}</ref> One component of the Affordable Care Act was a federally-funded increase in 2013 and 2014 in Medicaid payments to bring them up to 100% of equivalent Medicare payments, in an effort to increase provider participation. Most states did not subsequently continue this provision.<ref>{{citation | doi=10.1377/hpb20150511.588737 | title=Medicaid Primary Care Parity | year=2015 | doi-access=free }}</ref>