What is Medicaid and How Do I Know If I Am Eligible?


Most of us have heard about Medicaid and Medicare, but do you ever get mixed up in the details? Do you need help with health insurance coverage, or are you just curious about how the programs work?

We sat down with Ivy Hardy, a Human Services Case Manager in North Carolina, to help us break down the basics of Medicaid and Medicare and to learn some of her insider tips on how to navigate these complex healthcare programs.  

Let’s start with medicaid basics...

What is Medicaid?

Medicaid is a state-administered government program that most commonly provides healthcare coverage for low-income people, families and children, and pregnant women. You can access the national website here. Eligibility and benefits vary on a state-by-state basis, but typically include income, household size, disability, family status, and other factors. Medicaid lists your state-specific details here.

What does Medicaid cover?

Medicaid must cover “mandatory benefits,” which includes services like inpatient and outpatient hospital services, physician services, laboratory and x-ray services, and home health services, among others. Some states also cover “optional benefits” including prescription drugs, case management, physical therapy, and occupational therapy. Check out the full list of mandatory benefits here.

Is Medicaid the same as Medicare?

Nope! While both programs are government-funded, Medicaid is a state-administered program that provides healthcare coverage for low-income families and individuals, while Medicare is nationally-administered government program that most commonly provides healthcare coverage for the elderly.

Want an easy way to remember the difference?

  • MediCARE - care for older people

  • MedicAID - aid for low-income people

What’s the CHIP program?

The Children’s Health Insurance Program (CHIP) provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid. In some states, it may cover pregnant women. Keep in mind that CHIP can go by different names based on the state. For instance, in North Carolina, CHIP is actually called NC Health Choice. Learn more about the program here.

What’s the “Medicaid Expansion” I keep hearing about?

Medicaid Expansion is what it sounds like - some states opted to expand the pool of people who qualify for Medicaid to include anyone whose household income is below 133% of the federal poverty level, regardless of household size, disability status, or any other factors.

Simply put:

  • In states with Medicaid Expansion, more people have healthcare insurance coverage.

  • In states without Medicaid Expansion, more people fall into the gap between qualifying for Medicaid and being able to afford an employer or a subsidized Marketplace Insurance plan.

Learn more about your options here.

Which states have expanded Medicaid?

As of January 1, 2019, 37 states (including DC) adopted Medicaid Expansion and 14 states did not. Find out the status of your state here.

How do I know if I am eligible for Medicaid? How do I apply?

Eligibility depends on a variety of criteria and it varies by state. The good news is that there are a TON of resources to help determine if you are eligible. If you think for even a second that you might be eligible for Medicaid or CHIP, you should do one of the following:

    • Apply through the Health Insurance Marketplace. Follow this link.

      • The Marketplace automatically screens applicants if you meet some baseline criteria. Once you’ve submitted a completed application, it will be sent to your state’s Medicaid office for review. We found out that in North Carolina, the case managers will process the case in less than 45 days.

    • Apply through your state’s Medicaid agency. Find your state’s contact information here, and apply in person or online.

      • If you apply in person, be sure to bring the necessary documents with you. These vary state-to-state, but usually include proof of income and proof of residency. Find a full list on your state’s website.

Okay, so now you understand the Medicaid basics! During our chat with Ivy she taught us a ton of other helpful facts about Medicaid. Keep reading to see what else she had to say.

More Information on Medicaid….

Each state has a Healthcare Navigators program to help you better understand your options.

A Healthcare Navigator is basically your healthcare spirit guide. Anyone can schedule a free appointment with a Healthcare Navigator and the they will walk you through your eligibility for Medicaid, Medicare, or plans on the marketplace. They can also answer questions about how the health insurance plans work and can help determine which one is best for you. These are an invaluable resource that don’t get a ton of publicity. Find your local Healthcare Navigator here. Hint: Try to work with an “Assister” rather than a “Broker.”  We’ve also put direct links to some states below.

If you lose your job, you may be eligible for Medicaid, and your kids are likely to be eligible for CHIP.

This can be MUCH cheaper than paying for COBRA (an extension of your employer’s plan).

    • A loss of job is considered a “change of circumstance,” which allows you to switch insurance plans.

    • There is no charge for talking to a Medicaid counselor, and you can do it in person, on the phone, or online! If you think there is even a chance you might be eligible, apply!

Retroactive coverage (for up to three months) is a possibility.

This means that even if you didn’t have insurance last month but you went to the hospital, you could retroactively apply your current Medicaid benefits to that previous claim! If you want to check your eligibility, contact a Healthcare Navigator or talk to your local Medicaid office.

If you make too much money to qualify for Medicaid but you have a lot of medical expenses, you could qualify for Medicaid through “spend down.”

Unfortunately there is not a simple yes or no to know if you qualify for this - you’ll need to reach out to your local Healthcare Navigator and they can help you determine what you qualify for.

You can have Medicaid and third party insurance simultaneously.

Medicaid will be the payer of last resort, meaning your private insurance will pay on a claim first.

If you are pregnant, talk to a Healthcare Navigator!

Many women apply for Medicaid after their baby is born, but don’t realize all of the benefits of applying during the pregnancy. These include:

  • Prenatal care for the baby

  • Automatic coverage for your baby from birth to the 13th month with no application

We learned so much from talking to Ivy, and hope that you have as well! If you have more questions or tips, hit us up!

Ivy Hardy via    LinkedIn

Ivy Hardy via LinkedIn

Tips from Ivy Hardy:

Ivy here! I’ve worked in Medicaid for about 2 and a half years now and in more than one county in North Carolina. Here are some universal tips that I think may be useful to anyone who is curious about Medicaid, no matter what state you’re in.

  1. You can apply and reapply for Medicaid anytime.

If you’ve lost your job, had a child and are struggling financially, or are simply having trouble making ends meet, don’t wait until the bottom starts to fall out to apply for Medicaid. If you find out you don’t need it in the future, you can always cancel your benefits or withdraw the application, but it doesn’t hurt to apply when you need it. Often times your Medicaid worker can also point you in the direction of other programs and resources that may be beneficial to you that you wouldn’t have been aware of otherwise.

2. Keep us updated on changes in your phone number and address and look out for correspondence from us in the mail once you’ve applied.

Too many times, applications are denied for failure to provide information because we were either unable to reach the client or they never responded to requests or forms we sent them via mail.

3. There is ABSOLUTELY no shame in asking for help when you need it!