When it comes to Obamacare and Medicaid, many are confused about what changes are coming. Will you be able to get Medicaid thanks to changes in the program made by the federal health care reform law?
Well, it depends on your income and where you live.
The Patient Protection and Affordable Care Act, which is the official name for Obamacare, became law in 2010. It made changes to Medicaid that will help more consumers get health coverage through the program – and also will improve benefits, experts say.
Medicaid is a program operated by each state that provides affordable health care coverage for low-income individuals and families. Before health care reform, eligibility was always determined by both income and whether an individual fit into a certain group – for example, children, pregnant women and the disabled.Low-income, non-disabled adults who are not pregnant and are not parents or caretakers of dependent children typically don’t qualify for Medicaid now.
How Obamacare has changed Medicaid
Here are the two biggest ways Obamacare has changed Medicaid:
1. Obamacare helps more people get Medicaid
The Affordable Care Act (ACA) expanded eligibility for Medicaid to include anyone with a household income of less than 138 percent of the federal poverty level – which in 2014 is $16,105 for one person and $32,913 for a family of four.
However, a Supreme Court decision made in 2012 allows states to opt out of making those changes. In states that have decided not to expand Medicaid by 2014, many low-income consumers who would have been eligible for Medicaid under ACA rules will not be able to get insurance through the program. To date, 26 states and the District of Columbia have opted to expand Medicaid.
Those consumers will have to shop for private plans through the health insurance exchanges, the marketplaces set up as a result of the federal health care reform law, says Sara Collins, vice-president for affordable health insurance at The Commonwealth Fund, a private foundation that works toward a high-performing health care system.
In the states that do expand Medicaid under the ACA, many now-uninsured consumers will be able to get Medicaid. Determining eligibility based on income alone will open up Medicaid to adults without dependent children or a disability, who’ve mostly been excluded from the program in the past, says Len Nichols, director of the Center for Health Policy Research and Ethics at George Mason University, Washington D.C.
“This really is a big deal,” Nichols says, noting that at least half of the uninsured who gain health insurance through the ACA will be covered by Medicaid due to the expansion. “The whole point is to make sure people have access to coverage.”
Many uninsured individuals in the United States fall into the category of working poor,he says. The U.S. Department of Labor defines “working poor” as people with incomes below the federal poverty line who spent at least 27 weeks in the past year working or looking for work. In some states, in fact, about 45 percent of the uninsured earn less than 133 percent of the federal poverty level, according to the Kaiser Family Foundation. Medicaid is funded by both state and federal governments, but the federal government will fund 100 percent of the expansion for the first three years in states that opt in.
Obamacare also aims to make it easier to shop for insurance by integrating Medicaid with the exchanges. That way, a consumer can go to an exchange, answer some questions and find out if they’re eligible, experts say.
“The exchanges are supposed to be a one-stop shop,” Nichols says.
2. Obamacare will improve Medicaid coverage
“The Medicaid benefits package is very generous,” Nichols says. Even before the ACA, Medicaid had to include coverage for a variety of services, including hospitalization, prescription drugs, laboratory tests and X-rays, family planning and dental visits. However, states must offer other benefits for children but may choose whether to offer them for adults. These benefits include mental health services, physical therapy and prosthetics.
But starting in 2014, anyone who is newly eligible for Medicaid will get a benefits package that includes all of the minimum essential health benefits required by the ACA for all plans sold in the exchanges. What Medicaid offers has to be at least as comprehensive as the private plans sold in the exchanges, Collins says.
Obamacare also improves Medicaid in other ways:
Payments to Medicaid primary care providers for 146 primary care services increased to the same level as those offered by Medicare, starting in January 2013. That change should expand the network of providers by bringing new doctors to Medicaid, according to the Kaiser Family Foundation.
Community First Choice Option, which became available in 2011, allows Medicaid to provide home care and assistance for disabled recipients who would otherwise need to enter a nursing home or other facility.
The Center for Medicare and Medicaid Innovation will help to streamline and coordinate care for Medicare recipients who get Medicaid to help with the costs of their premiums and cost sharing.
The bottom line: experts disagree on how well Medicaid expansion will serve consumers. Critics say expansion will cost taxpayers too much and will worsen existing problems with Medicaid. These issues include fraud and lack of access to providers since many doctors and dentists aren’t taking new Medicaid patients.
But Collins says the many people who are newly eligible for Medicaid will get good coverage and pay little to nothing in premiums and cost sharing.