Medicaid Explained

Authored By: Partnership for Legal Access


What is Medicaid?

v Medicaid is a type of health insurance for low-income families, children, and people who are elderly or have a disability. The Texas Health and Human Services Commission (TxHHSC) runs the Medicaid program in Texas.

v In most cases, Medicaid pays for doctors' services, laboratory and X-ray charges, medicines, nursing facility and hospital services, family planning, eyeglasses, hearing aids, ambulance, podiatry, chiropractic, maternity, nurse midwife, and other health care services. Medicaid covers more services for children.

v Medicaid pays for most services, but not for everything. Medicaid pays for regular medical checkups for children. Medicaid also covers children's dental care.

v Your Medicaid ID card gives limited information about services that you can get. It also shows when children are due for routine medical and dental services. Look for the toll free numbers to call if you have questions

v People who are elderly or have a disability who need help with daily activities may be able to receive services in their homes. The state also offers some non-Medicaid community care services.

How does Medicaid work?

v TxHHSC issues a Medicaid ID card each month. The card needs to be shown each time you visit the doctor or get a prescription filled.

v Medicaid payments are made directly to service providers, such as the doctor, hospital, pharmacy, or lab. Medicaid will not pay you directly for health care visits.

v Not all medical providers accept Medicaid. Make sure to ask if a doctor takes Medicaid before your appointment.

v If a medical provider accepts Medicaid, the medical provider cannot bill you for the covered services.

Eligibility for Medicaid:

v Medicaid is available to qualifying Texans of all ages and abilities. There are separate programs for families and children and for people who are elderly or have a disability. In general, you must:

Ø Be a Texas resident.

Ø Be able to demonstrate that you are a citizen of the United States or a non-citizen in certain recognized categories.

Ø Meet certain resource and income limits, which vary by eligibility group.

v Three groups of people automatically receive Medicaid:

Ø Families who receive TANF (Temporary Assistance for Needy Families, cash assistance which is sometimes called welfare),

Ø Individuals who receive Refugee Cash Assistance, and

Ø Individuals who receive SSI (Supplemental Security Income benefits issued by the Social Security Administration and are available to people who are elderly, blind, or have a disability) .

vMany children in families with below poverty income may be eligible to receive Medicaid, including:

Ø Teenagers under age 19, and

Ø Children in single-parent or two-parent families can get Medicaid.

v Other people who may qualify for Medicaid depending on their income and resources include:

Ø Pregnant women;

Ø Youths aging out of foster care; and

Ø Many nursing home residents.

v Medicaid Savings Programs for Medicare Recipients:

Ø Medicaid covers out-of-pocket expenses for certain low income Medicare recipients by paying Medicare premiums, deductibles, and co-insurance costs.

Ø If eligible, Medicaid will directly pay Medicare premiums, deductibles, and/or co-insurance costs.

v Special Issues for Medicaid applicants and recipients:

Ø Parents who apply for Medicaid only for their children, do not have to give the parents' Social Security number nor information about the parents' immigration status.

Ø There are no time limits for children to get Medicaid.

Ø There are no parental work requirements for children to receive Medicaid.

vIncome, Resources, and Medicaid:

Ø You are required to provide financial information for everyone in your household.

ØTHHSC will look at your financial resources as well as your income.

Ø The value of a family's first car is not counted for Medicaid eligibility

Ø If the family owns more than one car, each extra car can be worth up to $4,650, without affecting Medicaid eligibility.

Ø If you own the home where you live, the homestead is not counted as a resource for the purposes of Medicaid eligibility.

v You are responsible for reporting - within 10 days - to TxHHSC any changes in your situation, including:

Ø Income,

Ø Resources,

Ø Your job,

Ø Address, and/or

Ø Who lives in your household.

vMedicaid and TANF

ØUnlike TANF, there are no time limits in Medicaid eligibility.

Ø If a family reaches their TANF time limit, the family does not automatically lose Medicaid.

Ø There is transitional Medicaid if a family's earned income goes too high to continue to receive TANF. It is possible a family may still get Medicaid for 12 more months.

Ø Family income limits are much higher for Medicaid than for TANF.

To Apply for Medicaid:

v Visit your local Medicaid office. You may call 2-1-1 for help locating the office closest to you.

v If you have questions, you can call the toll-free Medicaid Hotline at 1-800-252-8263 between 7:30 a.m. and 5:30 p.m., Monday through Friday.

vTo get an application for MEDICAID or CHIP, call 1-877-KIDS-NOW or go to http://www.chipmedicaid.org on the internet.

v Parents new to Medicaid must attend orientation to learn how to use Medicaid properly and all children must receive check-ups and immunizations as described by the Texas Health Steps program. The orientation may be provided over the telephone.

v Once you are qualified for Medicaid, be sure to reapply/recertify on time to prevent loss of your Medicaid.

v Medicaid Managed Care

Ø In most counties in Texas, you will have to enroll in "managed care." Once you are determined to be eligible for Medicaid, you will receive a packet in the mail regarding managed care. It will describe your options.

Ø In managed care, each patient has a "primary care provider" (PCP). Your PCP should provide basic health care for you, and refer you to specialists if needed. You get to choose your PCP from the list in your packet.

Ø You will only be able to see specialist who enroll with the managed care program that you pick.

Ø If you already have doctors that you like, pick a managed care program where those doctors are enrolled.

v If you have difficulties in the Medicaid application process and TxHHSC does not help you to resolve them, you may contact your local legal services provider for assistance in the process.

You Have Rights When Applying For and Receiving Medicaid:

v TxHHSC must give you a written decision on each application for Medicaid within 45 days of the submission of the application, or within 90 days if the application is based on a disability.

v If your application for Medicaid is considered "incomplete" by TxHHSC, you have the right to receive WRITTEN NOTICE of:

Ø What information is missing, and

Ø The date by which you must provide the missing information (at least 10 days).

v You have the right to receive written notice about why the Medicaid application was denied, or benefits were reduced or terminated

Ø The written decision must give a written description of why the benefits are being denied, decreased, or stopped.

Ø On the notice of denial, reduction, or termination of benefits, there must be instructions on how to request an appeal of the decision.

v You have the right to challenge the denial or termination of Medicaid benefits.

v To appeal the denial or termination of Medicaid benefits, you need to request a Fair Hearing

ØA Fair Hearing is a meeting conducted by a regional hearing officer with any applicant or client who disagrees with an agency decision.

Ø TxHHSC accepts requests for Fair Hearings by mail, fax, and phone (dial 2-1-1).

Ø The Fair Hearing is to decide if the decision follows agency policy and rules.

v Deadlines to request a Fair Hearing:

Ø You must request a fair hearing by filing your appeal within 90 days of the letter denying your Medicaid application

Ø If your Medicaid is being reduced or terminated, you may request the continuation of your Medicaid while you wait for a decision on your appeal. To request the continuation of your Medicaid pending the outcome of your appeal, you MUST file your request for Fair Hearing within 10 days of the letter that notifies you of the reduction or termination of your Medicaid. You may still request a Fair Hearing for 90 days after the date of the letter reducing or terminating your Medicaid.

v You should receive WRITTEN NOTICE of when and where the hearing will be held.

vAt the Fair Hearing:

ØYou will have a chance to explain why the decision is wrong.

ØThe case worker gets to explain why the decision is correct.

ØYou can question the case worker and witnesses.

ØYou should bring your own witnesses with you, if you have any.

ØIf your appeal involves a medical issue, you should take a letter from your doctor with you to the hearing.

ØThe hearing officer (judge) can question you and witnesses.

Ø You have the right to an interpreter during the hearing.

v You have the right to a legal representative to assist you in your appeal.

ØYou can have a legal representative present during the fair hearing.

ØYour legal representative does not have to be an attorney.

ØYou may contact your local legal aid organization to request free legal representation at the Fair Hearings.

v You have the right to receive a written decision regarding the outcome of your appeal.