Medicaid is a program that covers some or all of the medical costs for those who cannot afford medical insurance. Medicaid is funded by the federal government and the state of Georgia. In Georgia, Medicaid is run by the Georgia Department of Community Health (DCH). Medicaid can be used on its own or along with another health care plan (like Medicare).
Who is eligible for Medicaid?
You may be eligible for Medicaid if you have a low income and you:
Have confirmed you are pregnant,,
Are under age 19,
Note: if your child does not qualify for Medicaid, they may be eligible for Peachcare for Kids.
Were in foster care when you turned 18 and are now under age 26,
Are 65 or older,
Have a disability,
Need nursing home care, or
Get TANF or SSI (or are eligible for those benefits).
Even if your income is not very low, you may also be eligible if you:
Have breast or cervical cancer, or
You have medical bills and are over the income limits, but are:
65 or older,
Have a child who is disabled and requires an institutional level of care. Your child may qualify for Medicare under the Katie Beckett program no matter what your income is.
Medicaid has a number of different parts that provide services to certain populations, including:
Specified Low-Income Medicare Beneficiary (SLMB) Program and Qualifying Individual (QI) Program. These programs pay for Part B premiums for people who have Part A and limited income and resources. The QI Program must be applied for every year. You cannot get QI benefits if you qualify for Medicaid.
Qualified Disabled and Working Individuals (QDWI) Program. This program helps pay for the Part A premium. You may qualify if you:
Are working, disabled, and under 65.
Lost your premium-free Part A when you went back to work.
Health Insurance Premium Payment Program
The Health Insurance Premium Payment Program (HIPP) may pay for the health insurance premium for working Medicaid members. You may qualify for HIPP if:
You have private insurance through your employer, and
You or someone in your family is a Medicaid member.
The Medicaid member must be enrolled in your employer’s health insurance plan.
Medicaid may pay for long-term care services in a nursing home if it is medically necessary. The nursing facility must be Medicaid-certified.
To be eligible:
You must show that nursing care is medically necessary, and
You must meet Georgia’s low income and low assets requirements.
If you or your loved one needs nursing care but is over the Medicaid income limit, it is still possible to get nursing home Medicaid. If you are over the income limit, you can create a Qualified Income Trust, called a “Miller Trust.” This is a complicated legal process and you should contact a lawyer to assist you.
For help with a Miller Trust:
call the Georgia Senior Legal Hotline at 1-888-257-9519 or
call your local Area Agency on Aging at 1-866-55AGING, or
contact a private attorney.
Be aware that the state may put a lien on the estate of a person who gets Medicaid for long-term care. This is called Medicaid Estate Recovery.
If you have a medical emergency and do not have health insurance, you may qualify for Emergency Medicaid benefits. You cannot apply for Emergency Medicaid ahead of time. When you have a medical emergency, the hospital or clinic will help you apply. This only covers true medical emergencies. For example, Emergency Medicaid might cover the labor and delivery costs for an uninsured pregnant woman, but it will not cover other prenatal care.
Unlike other Medicaid benefits, you do not have to be a US citizen to get Emergency Medicaid benefits. However, you must show proof of income to qualify.
You have the right to appeal a decision about Medicaid and request a fair hearing. Times when you may want to ask for a Medicaid fair hearing:
You apply for Medicaid, but are told you are not eligible.
You are not allowed to apply for Medicaid when you ask.
DFCS takes more than 45 days to make a decision on your application (90 days if based on disability).
Your Medicaid is cut off.
Your doctor, pharmacist, transportation broker, dentist, or another health care provider tells you Medicaid will not pay for a service you need. If you are in a CMO (care management organization), you may need to file an appeal with the CMO before asking for a fair hearing.
Medicaid does not pay for a service you have already received.
The state decides you cannot have nursing home care or services under the Community Care Services Program, SOURCE, the Independent Care Waiver, or another waiver program.
Services Medicaid has been paying for are stopped and you believe they should not be stopped.
You have any other problem with Medicaid.
You usually have 30 days from the date on the notice to ask for a fair hearing. If you ask for a hearing within 10 days, you can keep getting Medicaid while you appeal. (If you lose, the state could ask you to pay back benefits it paid while you appealed.)
You must send DFCS a request in writing within 15 days after you first ask for the hearing if you did not do it in writing at that time.
Also, send a copy of your hearing request to the address listed on the notice you received.
What happens at a fair hearing?
A fair hearing is a chance to get state officials to change their decision about your case. An independent judge from the Office of State Administrative Hearings will hear your case. The judge will listen to you, listen to Medicaid workers, read the law, and write a decision.
You can represent yourself or you can take a lawyer or other person to represent you.
You should receive a written decision within 90 days after you ask for the hearing. Sometimes your problem can be solved even before the hearing. Make sure you really agree with what the state is doing before you cancel the hearing. If you are not sure, it is better to go to the hearing and talk to the judge.
If Medicaid pays for your long-term care, the state could have a claim against your estate after you die. This is meant to recover the costs of your care. Your estate could include:
Your estate might be affected if you:
Got nursing home care or waivers for home or community services under Medicaid for at least 6 months AND you were 55 years old or older.
Were a resident of a nursing facility when you died.
Were a resident of an intermediate care facility or mental institution when you died.
Can my heirs avoid estate recovery?
Medicaid will not recover from an estate valued at less than $25,000.
Recovery cannot begin as long as:
You are still alive,
Your spouse is still alive,
Your child is alive and under the age of 21, or
Your child is alive and blind or permanently disabled.
Your heirs may be able to get a hardship waiver. They must show that estate recovery would be an undue hardship. Your heirs could show undue hardship if:
The asset to be recovered is an income-producing farm of one or more heirs, and the annual gross income is $25,000 or less; or
Recovering assets would mean that the heirs become eligible for need-based government public assistance.
A lien might be placed on your home, but Medicaid will delay recovery if certain people are still living in the home:
Your sibling, if they:
Lived in the home for at least one year before you were institutionalized, and
Have been living there continually and legally.
Your child, if they:
Were living in the home for at least two years before you were institutionalized and
Provided care to help you stay in that home for a period of time, and
Have been living there continually and legally.
Can I give away my property now to avoid estate recovery later?
Get legal help before you give away property to try to avoid estate recovery down the road. If you need Medicare later for a nursing home or for community services in your home, the Medicaid agency will look to see if you have:
Given away your home (or other property), or
Sold it for less than it is worth.
If you gave away your property before you needed care, you could be denied Medicaid for a period of time. The Medicaid agency will decide your “penalty period.”