The Medicaid program provides health care coverage to individuals and families who meet certain eligibility requirements, including income eligibility requirements. Medicaid is jointly financed by the states and the federal government and is administered by the states in accordance with federal law. Medicaid typically provides comprehensive health coverage at no or very low cost to enrollees, although what services are covered by Medicaid and who is eligible for the program varies by state. In January 2015 approximately 70 million individuals were enrolled in Medicaid in the United States.
Children’s Health Insurance Program (CHIP)
The Children’s Health Insurance Program provides low-cost health coverage to eligible children in families that earn too much money to qualify for Medicaid. In some states, CHIP also covers certain parents and pregnant women. CHIP is administered by states in accordance with federal requirements and the program is funded jointly by states and the federal government. In 2013, 8.1 million children were enrolled in the CHIP program.
Health Insurance Marketplaces
Health insurance marketplaces, also called exchanges, were created by the Affordable Care Act to improve the individual and small group insurance markets and to facilitate access to coverage. Marketplaces are where uninsured individuals and families can shop for health insurance and compare plans. Marketplaces also connect qualified individuals and families to available subsidies that make coverage more affordable. The ACA gives states the option to create and operate their own state-based marketplaces or to have the federal Department of Health and Human Services establish a federally-facilitated marketplace for their state. HHS has also given states the option for a partnership marketplace, where the state and federal government share marketplace responsibilities.
Essential Health Benefits
The essential health benefits (EHBs) package is a broad set of benefits that must be provided under the ACA by all small group and individual market health insurance plans and to individuals enrolled in certain Medicaid coverage, including most of the adults who gain eligibility through the ACA’s Medicaid expansion. EHB benefits include important services such as hospitalization, prescription drugs, and mental health and substance use disorder services. Essential health benefits must also meet certain consumer protection requirements.
Medicaid State Plan
Federal Medicaid law requires all states to have a Medicaid State Plan. Each state outlines the details of their Medicaid program in their State Plan, including the amount, duration, and scope of services and eligibility requirements.
Medicaid provider manual
A state’s Medicaid provider manual is the main source of information for providers about Medicaid policies and procedures. It is regularly updated and includes details on provider responsibilities for participation in the Medicaid program.
Each state has a Medicaid Director who leads the agency that administers the state’s Medicaid program. In most states the Medicaid Director is a political appointee. Medicaid Directors serve many different roles and have a range of responsibilities, but generally oversee the range of Medicaid program functions in the state.
Medicaid Health Homes
The Medicaid health homes option is a delivery system reform created by the Affordable Care Act to reduce costs and provide high-cost patients with a regular source of organized, quality health care. Health homes are meant to create linkages to other community and social support services, to increase coordination between medical and behavioral health care, and to improve health outcomes for high-cost patients. While states have considerable flexibility in how they design their health homes, health homes must meet certain requirements that include addressing the mental health and substance use disorder prevention and treatment needs of health home enrollees. As an incentive to implement health homes, states receive a time-limited enhanced reimbursement rate from the federal government for certain health home services.
Medicaid Alternative Benefit Plans
Certain Medicaid beneficiaries may be enrolled in Medicaid alternative benefit plans (ABPs), including most adult beneficiaries who gain coverage through the ACA’s Medicaid expansion. Unlike other enrollees, individuals enrolled in ABPs must receive coverage that includes the ten categories of essential health benefits that must be provided under the ACA by small employer and individual market insurance plans. ABPs must also meet certain other protections associated with essential health benefit requirements. However, depending on how a state designs its ABP coverage, enrollees in ABPs may not have access to all services provided to other Medicaid beneficiaries. ABPs are sometimes also referred to as Medicaid benchmark plans.
Federally Qualified Health Centers
Federally Qualified Health Centers (FQHCs) are health centers that meet requirements to qualify for certain benefits, including enhanced reimbursement from Medicare and Medicaid. FQHCs must provide comprehensive services, serve an underserved population, and provide care on a sliding scale based on a patient’s income, among other requirements.