Eligibility Rules and Agency/Program Policy the Medicaid

¶ … Eligibility Rules and Agency/Program Policy

The Medicaid Program

Medicaid is a federal assistance program that is administrated at the federal level by the Centers for Medicare and Medicaid Services (CMS) and at the state level by the corresponding state agencies of the individual states. It is a program designed to assist needy individuals with medical expenses. Medicaid eligibility is quite strict and is an example of eligibility by rule and regulation as well as by means testing (Chambers & Wedel, 2005).

The program provides coverage for all of the following healthcare services for program beneficiaries: Inpatient hospital services, Outpatient hospital services, Laboratory and X-ray services including radiation therapy, Physician's services, Podiatric services, Naturopathic services, Vision care, Family planning services, Home health services, Certain chiropractic services, Health clinic services, Early Periodic Screening, Diagnosis and Treatment (EPSDT), Dental services, including orthodontia services, Maternity clinic services, Ambulatory surgical center facility services, Emergency hospital services, Hearing aids and certain hearing aid services, Mental health services, Nursing facility services, Psychiatric hospital services, Some home care services, Prescribed drugs, Medical transportation, Durable medical equipment, Home and community-based services, School-based child health care, Midwives, and Nurse practitioners, soon to be authorized as providers (CMS, 2010).

General Eligibility Issues and Concerns

Criticism of the Medicaid eligibility criteria includes the suggestion that it is unavailable to many individuals who genuinely do not have the means to pay for their necessary medical expenses. That is because its means and asset criteria are set so low that individuals who are genuinely in need must first divest themselves of their only income and assets in order to fall below the poverty level for the purposes of program eligibility. While limiting eligibility to those genuinely in need is a perfectly appropriate interest, the eligibility criteria for Medicaid are so low that they unnecessarily exclude many people for whom a very strong argument could be made to support their inclusion without requiring them to spend down their only assets first.

Eligibility Rules Utilized by the Agency

Eligibility for Medicaid coverage requires both that beneficiaries be under the age of 6 or 65 and above and that they be sufficiently economically needy to pay for their own healthcare (CMS, 2010). The financial eligibility requirements are quite strict. While they vary by state, generally, Medicaid beneficiaries may not earn more than $400 to $500 per month; they may not possess savings in a bank account or stocks or bonds that total more than approximately $1,500 for individuals and approximately $2,500 for couples; and they may not own a burial fund or life insurance in excess of approximately $1,000 or maintain more than approximately $5,000 in an irrevocable contract with a funeral home (CMS, 2010). Where only one spouse is a candidate for Medicaid eligibility, there are limits to the amount of income that the other spouse may earn, set by individual states: those limits can be as low as approximately $20,000 per year and may be as much as approximately $100,000 per year. Furthermore, Medicaid employs a "look back" period of 36 months to 60 months for assets transferred to others in the period immediately preceding application to the program. Assets deemed by auditors to have been transferred without exemption result in a delay in program eligibility according to schedule based on the monthly value of Medicaid coverage. The purpose of these look back provisions is to prevent individuals from merely transferring their assets to family members for the purpose of satisfying Medicaid eligibility criteria (CMS, 2010).

Stigmatization and Fairness Issues

Certainly, the Medicaid program has a legitimate interest and justification for ensuring that its resources are only spent on needy individuals. However, the extremely low maximum allowable income and asset limits present a tremendous hardship for many individuals who are, without a doubt, in legitimate need of services by any reasonable standard. The problem affects the elderly particularly harshly in connection with the need for long-term care in nursing homes necessitated by long-term untreatable illnesses such as Alzheimer's disease. With the average cost of nursing home care amounting to $5,000 or $6,000 per month (and much more in many states), many people who are hardly wealthy or even financially comfortable cannot possibly afford those services without assistance. Under Medicaid eligibility rules, an elderly couple whose combined income is barely above the minimum cost of long-term nursing home care is ineligible for Medicaid coverage unless they reduce their income and "spend down" their financial assets first.