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MMA : Medicaid Eligibility and Benefits

Medicaid Eligibility and Benefits

This summary is intended to give you basic information about the State of Maryland’s Medicaid Program.  Medicaid is also called Medical Assistance.  Medicaid rules change from to time to time, and there are many circumstances that affect eligibility.  There are too many rules to present in this document.  If you have a question or want more information about anything you read in this document, call one of the numbers given on page 9.  Don’t use this information to decide if you or someone else is eligible for Medicaid.  If you need help paying for your own or your family’s medical bills, you should find out for sure about eligibility by filing an application at your Local Department of Social Services.

1. What is Medicaid?

Medicaid is a program that pays the medical bills of the people who have low income, cannot afford medical care, and meet other eligibility requirements.  It is run by the State and pays the medical bills with State and federal tax money.

2. What is Medicare?

Medicare is an insurance program that pays medical bills for people who are at least 65 years old, or who are disabled.  It is available to people who receive Social Security benefits regardless of how much money they have.  It pays medical bills with money from the Social Security Trust Fund, which most people pay into while they work.  Retired and disabled people pay a monthly insurance premium for Medicare Part B.  This is usually taken out of their Social Security check before they get the check.

3. Can I have both Medicaid and Medicare at the same time?

Yes.  Both programs can work together.  If you receive Medicare and qualify for Medicaid, the Medicaid program will pay your monthly Medicare Part B premiums for you (this is called “Buy-In”).  Medicaid will also pay your Medicare co-payments and deductibles.  If you are 65 or over and have not worked long enough to receive free Medicare Part A (hospital insurance), the Medicaid program will also pay the Medicare Part A premium.  When you apply for Medicare, it is important to let the Social Security Administration representative know that you have Medicaid and may be eligible to have the State pay your Medicare Part A premium. 

Whenever you have both Medicare and Medicaid, you should show both cards to your medical care provider each time you receive services.

4. If I have private health insurance, can I be eligible for Medicaid?

Yes.  If you have private health insurance available to you or a member of your family, your eligibility for Medicaid will not be affected.  Any service not covered or only partially covered by a private health insurance plan and listed as a Medicaid covered service will be paid by Medicaid. Medicaid will pay up to the maximum Medicaid is allowed to pay.

Whenever you have both private health insurance and Medicaid, you should show both your Medicaid card and your health insurance card to your medical provider each time you receive services.  

5. How can I get Medicaid?

 All people who receive money through Supplemental Security Income (SSI) or Temporary Cash Assistance (TCA) automatically receive Medicaid.

If you do not get SSI or TCA, you must file an application to find out if you are eligible for Medicaid.  To do this, you must go to the Local Department of Social Services in the city or county where you live.

If you are interested in applying for the Maryland’s Children’s Health Program (MCHP), you may obtain an application from your Local Health Department.  The completed application can be returned by mail or in person.

6. What will I need to do when I apply?

You will be interviewed by an eligibility worker who will ask for information about your income, assets, and private health insurance coverage.  You will be asked to prove what you say is true.

If you are too sick to come to the Local Department of Social Services office to apply, you may send someone to the interview for you who is knowledgeable about your money situation and other circumstances.

MCHP does not have an interview requirement.

7. How will the eligibility worker decide if I can get Medicaid?

First, the eligibility worker will decide if you belong to one of the groups of people covered by Medicaid.  You will also need to show that you are a resident of Maryland and a U.S. citizen, or an alien admitted for permanent residency who has lived in the United States as a qualified alien for at least 5 years or who otherwise qualifies.  You must meet one of the conditions listed below.  Your eligibility will be determined differently depending on the group you fall into.  You must be…

  • At least 65 years old; or
  • Disabled; or
  • Blind; or
  • Under 21 years old; or
  • Caring for a related child in your home; or
  • Pregnant; or
  • The parents of an unmarried child under 21.
  • Some people meet more than one of the conditions above.  If that is so, the person may choose for which eligibility group to apply. The rules are different for different groups and the kinds of medical care covered are different for different groups.

    8. How much money can I have and be eligible for Medicaid?

    After the eligibility worker determines that you meet one of these eligibility conditions, the value of all your assets will be added up.  Assets are cash, money in checking or savings accounts, credit union accounts, stocks, savings bonds, trusts, annuities, or any other money that you have saved or invested.  Assets also include things like boats, trailers, real estate, and life insurance policies or other expensive items you may own. Medicaid does not count as assets the home you live in or personal property (e.g., clothing, furnishings, car).   

    The amount of assets you may have depends on the size of your family and the eligibility group for which you are applying.  This will be determined at the time of application.

    9. How much income can I get and be eligible for Medicaid?

    Income is money that you get from working, or money that someone gives you, or checks that you get, like Social Security, unemployment or disability benefits, child support, retirement benefits, or sick pay.  The amount of income you may have depends on the size of your family and the eligibility group for which you are applying.

    10. What if I have too much money?

    If you have too much in assets, you are not eligible for Medicaid.  However, if you spend your assets on your daily living expenses, medical care, or bills, you may reapply when your assets are lower. 

    If you have too much income, you may qualify under a “spend-down,” or you may decide to apply in a different eligibility group.  This information and your eligibility worker will help you to decide which group is best for you and your family.

    11. What is a Spend-down?

    When a person’s income is more than the amount allowed by Medicaid, the eligibility worker will figure out exactly how much greater the income is than the amount allowed.  This is called “Excess Income.”  If the person can show that his/her medical bills are equal to or greater than the excess income, the person can still get Medicaid.  This is called “Spend-down.” 

    Persons who become eligible under a spend-down are only eligible for a limited time, and they will still have to pay some of their own medical bills.

    12. What are the different eligibility categories?

    Medicaid is for people in two broad categories, “Families and Children” or “Aged, Blind or Disabled”. 

    Families and Children (FAC) is for children under 21 years old.  Parents and other relatives who are providing care for unmarried children living with them may also qualify in this category.  The income limits are very low, but families with too much income may qualify under spend-down.  Families with too much assets cannot qualify until assets are reduced to the amount allowed. For more information about FAC, please click the link for the Medical Assistance for Families Initiative at http://dhmh.maryland.gov/ma4families/

     

    Family Size

    FAC
    Maximum Family Income and Assets

    Countable Monthly Income

    Countable Assets
    1 $ 1,046 $ 2,500
    2 $ 1,408 $ 3,000
    3 $ 1,769 $ 3,100
    4 $ 2,131 $ 3,200
    5 $ 2,493 $ 3,300
    6 $2,854 $ 3,400

    Aged, Blind or Disabled (ABD) is for people 65 years old or older, blind, disabled or with an illness that is expected to result in death.  The income limits are the same as for the FAC category, and people with too much income can qualify under a spend-down.  People with too much assets cannot qualify until the assets are reduced to the amount allowed. 

     

     
    ABD

    Maximum Family Income and Assets

     
    Family Size Countable Monthly Income Countable Assets
    1 $ 350 $ 2500
    2 $ 392 $ 3,000
    3 $ 434 $ 3,100
    4 $ 475 $ 3,200
    5 $ 521 $ 3,300
    6 $ 573 $ 3,400

    Women’s Breast and Cervical Cancer Health Program (WBCCHP)

    Women’s Breast and Cervical Cancer Health Program (WBCCHP) provides full Medicaid coverage for uninsured women aged 40 to 64 years, who are diagnosed with breast or cervical cancer through the local health departments’ Breast and Cervical Cancer Program.

    Maryland Children's Health Program (MCHP)

    Maryland Children’s Health Program (MCHP)is for pregnant women of any age and children up to age 19 if they have a family income that is at or below 200% Federal Poverty Level (FPL) for children and up to 250% FPL for pregnant women and their newborn children.  Click here to view the current family income limits for the Maryland Children’s Health Program. 

    Note:  The poverty guidelines are updated annually in the Federal Register published by the U.S. Department of Health and Human Services under authority of 42 U.S.C. 9902(2).

       Maryland Children's Health Program (MCHP) Premium

    Maryland Children’s Health Program (MCHP) Premium is a program offered to uninsured children up to age 19, who have not dropped employer-sponsored health insurance within the previous six months, and who have paid the monthly premium payment per family.  The family income standard for eligibility is more than 200% and at or below 300% FPL.   

    For both MCHP and MCHP Premium, assets are not considered in determining eligibility.  In addition, MCHP and MCHP Premium beneficiaries receive health benefits through HealthChoice, Maryland’s Medicaid Managed Care Program.  To apply for MCHP or MCHP Premium, applications may be filed by mail or in person at Local Health Departments, or in person at Local Departments of Social Services.

    Click here to view the current family income limits and premium amounts for the Maryland Children’s Health Program (MCHP) Premium Program. 

    Qualified Medicare Beneficiaries (QMB) is for people who receive Medicare (the medical insurance that comes from Social Security).  The amounts of income and assets allowed for people on QMB are higher than for ABD.  Income may not exceed 100% of the Federal Poverty Level.  Assets may not exceed $4,000 for an individual or $6,000 for a couple. 

    Under QMB, Medicaid pays for your monthly Medicare Part B medical insurance premium, your Medicare Part A premium in some cases, your Part A hospital deductible and your annual Part B deductible.  Depending on the doctor you see, Medicaid may also pay your 20% coinsurance for Medicare covered services. 

    Specified Low-Income Medicare Beneficiaries (SLMB) is for people with more income than allowed under QMB.  The asset limit is the same as for QMB.  SLMB pays only for the Medicare Part B premium that gets deducted from the monthly Social Security check. 

    If you need help with your medical expenses, you should go to the Local Department of Social Services and apply for Medicaid.  For MCHP, you may also apply at your Local Health Department.  For QMB or SLMB benefits for Medicare eligibles, you may receive an application to submit by mail by calling your local department of social services or Area Agency on Aging.  People with very high medical expenses can have incomes over the maximum and still qualify for Medicaid under spend-down.  Children and pregnant women can have any amount of assets and still qualify if they meet the income test.  The only way you can be sure is to file an application.  Even if you’re not eligible for coverage of all your medical expenses, you might still be able to get help with some of your expenses.

    13. What Medical Services are available if I am eligible for Medicaid?

    The Maryland Medicaid Program provides many medical services to keep you healthy and to treat you when you are sick.  Limitations apply to some of them.  The major services are listed on the “Covered Services List”, and may be changed based on the State’s budget.

    SERVICES COVERED BY MARYLAND MEDICAL ASSISTANCE (MEDICAID)

    The following services are covered by Maryland’s Medicaid Program, if the services are not covered by Medicare or other insurance and if the Maryland Medicaid Program's specific requirements are met for the service.  If you have any questions, call the Maryland Medicaid Hotline at 410-767-5800 (Baltimore area) or 1-800-492-5231.

    • ambulance and wheelchair van services and emergency medical transportation
    • ambulatory surgical center services
    • cpnic services
    • dental services and dentures (for beneficiaries under 21)
    • diabetes care services (covered under HealthChoice)
    • Early and periodic Screening, Diagnosis and Treatment (EpSDT) Services (for beneficiaries under 21)
    • eye glasses (for beneficiaries under 21)
    • family planning services and supppes
    • hearing aids (for beneficiaries under 21)
    • home and community-based services waiver services for targeted populations of developmentally disabled or mentally retarded individuals, older adults, physically disabled adults, medically fragile children, children with autism spectrum disorder, and adults with traumatic brain injury
    • home health agency services
    • hospice care
    • hospital inpatient and outpatient services (acute, chronic, psychiatric, rehabiptation, specialty)
    • Kidney dialysis services
    • laboratory and x-ray services
    • medical day care services
    • medical equipment and supppes
    • Medicare premiums, co-payments, and  deductibles
    • mental health treatment, case management, and rehabiptation services
    • nurse anesthetist, nurse midwife, and nurse practitioner services nursing facipty services (nursing homes)
    • oxygen services and related respiratory equipment services
    • personal care services
    • pharmacy services (for beneficiaries not epgible for Medicare part D)
    • physical therapy
    • physician services (some dental surgery may be included)
    • podiatry services
    • private duty nursing (for beneficiaries under 21)
    • school-based health-related services (for beneficiaries under 21)
    • Statewide Evaluation and planning Services (STEpS) through local health departments)
    • substance abuse treatment services
    • targeted case management for HIV-infected individuals and other targeted populations
    • transportation services to Medicaid covered services (through local health departments)
    • vision care services (eye examination every two years)

    14. How will I receive my medical care?

    Maryland has a Managed Care Program called HealthChoice that provides a medical home for Medicaid and MCHP recipients.  HealthChoice requires most people in the Medicaid program to join MCOs (managed care organizations).  People on Medicare, living in nursing homes or other institutions, eligible for Medicaid through spenddown, or aged 65 or older are not enrolled in HealthChoice

    The MCOs provide or arrange to provide almost all of the care for Medicaid members who join their plans.  Medicaid members must receive their medical care through the MCO they choose. 

    Persons enrolled in HealthChoice are covered for all Medicaid services.  Some MCOs may choose to offer more benefits.  All MCOs pay special attention to treating little medical problems before they become big, serious medical problems.  Some services received by HealthChoice enrollees are provided fee-for-service, not by the MCO, such as personal care, therapies for children, medical day care, and waiver services. 

    Medicaid eligibles who do not qualify for HealthChoice receive their Medicaid services through “fee-for-service”.  This means that each medical provider who provides services to the Medicaid recipient will bill the Medicaid program for payment.

    15. How do I join a MCO?

    You will receive information in the mail about all of the different Medicaid MCOs in your area.  You may choose any plan.  You will probably want to choose an MCO to which your doctor belongs.  You must sign up within 21 days after you receive the information.  If you need help, call the telephone number found in the information you receive and you will get help.

    16. What if I don’t choose an MCO?

    If you have a doctor, you will be assigned to the MCO to which your doctor belongs.  If you don’t have a doctor, you will be assigned to an MCO.  It’s best if you choose your own MCO.

    17. If I don’t qualify for Medicaid, is there any other help for me?

    Yes. The Maryland Pharmacy Assistance Program provides pharmacy benefits to persons who do not qualify for Medicaid or Medicare. This program has income and asset limits higher than Medicaid. You can apply for the Maryland Pharmacy Assistance Program through the mail by calling 1-800-226-2142.   

    If you are HIV+ or have AIDS, and have private health insurance either directly through an insurance company or through a current or former employer, the Maryland AIDS Insurance Program may pay the cost of your health insurance premiums. The income and asset limits are higher than for Medicaid. You may apply through the mail by calling (410) 767-1780.

    18. What if I am involved in an accident or am injured before or after I become eligible for Medicaid?

    When you are involved in an accident or are injured, and then apply for Medicaid, you should inform the Local Department of Social Services (or Local Health Department for MCHP).  Your caseworker will obtain information from you concerning the accident or injury such as the date it occurred, the names of the persons involved, any doctors you have visited, any attorneys who are involved, etc.  You should also inform your caseworker if you are in an accident or are injured while you are eligible for Medicaid.  You may also call the Division of Medical Assistance Recoveries to report this information at (410) 767-1787.

    IMPORTANT TELEPHONE NUMBERS

    Department of Human Resources
    Which Local Department of Social Services office to go to:
    1-800-332-6347
    Problem with caseworker or supervisor:
    1-800-332-6347
    Department of Health and Mental Hygiene
    Question about Medical Assistance Eligibility Policy:
    (410) 767-1463
    1-800-492-5231, ext., 1463
    Questions about services covered by Maryland Medicaid and other Medicaid questions:
    (410) 767-5800
    1-800-492-5231
     
    Recipient Relations:
    (410) 767-5800
    1-800-492-5231
    Medicare Buy-In Program:
    (410) 767-5376
    1-800-638-3403
     
    Provider Relations:
    (410) 767-5503
    1-800-445-1159
     
    Medical Assistance Problem Resolution (Nursing Homes, Hospitals, and Home Health Providers)
    (410) 767-5457
     
    Maryland Children’s Health Program:
    1-800-456-8900
     
    Maryland Pharmacy Assistance Program:
    1-800-226-2142
     
    Legal Liabilities-TORT (accident or injury) Section, Medical Assistance Recoveries:
    (410) 767-1787
     
    Maryland AIDS Insurance Assistance Program:
    (410) 767-1780
     
    Maryland Department of Aging
    (410) 767-1102
    1-800-243-3425 or 1-800-AGE-DIAL
     
    Legal Aid Bureau
    (410) 296-6705
    1-800-999-8904
    1-800-367-7563 (assistance with nursing home, assisted living and elderly issues)