What should I know about Medicaid?

Contents

• What is Medicaid?
• What kinds of health care does Medicaid cover?
• What are Medicaid’s waiver programs?
• When does Medicaid cover copays, deductibles and premiums?
• When does Medicaid cover long-term care?
• What is Emergency Medical Assistance?
• What are my rights with Medicaid?
• What are my responsibilities with Medicaid?

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What is Medicaid?

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:

  • Pregnant,

  • Under 19,

  • 65 or older,

  • Blind, or

  • Disabled.

• 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:

• Health care coverage,

• Waivers for home and community based services,

• Long-term care coverage,

• Copay, deductible, and premiums assistance, and

• Emergency medical assistance.

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What kinds of health care does Medicaid cover?

In general, Medicaid health care covers:

• Doctors visits,

• Prescription drugs,

• Laboratory and x-ray services, 

• Physical therapy, 

• Occupational therapy, 

• Inpatient hospital services,

• Outpatient hospital services,

• Nursing homes,

• Emergency ambulance expenses,

• Preventative dental care, fillings and oral surgery for children,

• Transportation to and from medical appointments,

• Medical equipment and supplies,

• Family planning services,

• Home health services,

• Hospice care services,

• Vision care for children,

• Hearing services for children.

 

Medicaid may also cover additional services, depending on the program and eligibility. 

 

All Medicaid health care participants in Georgia are enrolled in the Georgia Families program except those:

• Over 65,

• Blind, 

• Disabled,

• In nursing homes,

• In Hospice.

Those participants are enrolled in Aged, Blind and Disabled (ABD) Medicaid. 

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What are Medicaid’s waiver programs?

In addition to general health care, Georgia Medicaid offers a number of waiver programs that help people who: 

• Are elderly or have a disability, and

• Need help to live in their home or community instead of a:

  • Nursing home, or

  • Care facility for people with intellectual or developmental disabilities.

 

The waiver programs include:

• New Options Waiver Program (NOW) and Comprehensive Supports Waiver Program (COMP). These programs provide services and support for people with intellectual and developmental disabilities. NOW and COMP are run by the Georgia Department of Behavioral Health and Developmental Disabilities. 

• Independent Care Waiver Program (ICWP). ICWP provides services to adults between ages 21 and 64 with severe physical disabilities or traumatic brain injury. This program is run through Alliant Georgia Medical Care Foundation.

• Community Care Services Program (CCSP) and Service Options Using Resources in a Community Environment (SOURCE). These programs provide in-home services to elderly and disabled people who would otherwise be in a nursing home. These programs are run through the Georgia Aging and Disability Resource Connections. 

• The Georgia Pediatric Program (GAPP). This program provides services to children who need in-home medical and personal care. 

 

Be aware that the state may put a lien on the estate of a person over 55 who gets a Medicaid waiver for home care. This is called Medicaid Estate Recovery.

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When does Medicaid cover copays, deductibles and premiums?

In some instances, instead of providing health care services, Medicaid will pay for the costs of other health insurance programs.

 

Medicare Savings Programs

If you qualify for Medicare and have a low income and limited assets, then in general you will:

• Receive Medicare health coverage, and 

• Can apply to Medicaid to have your copays and premiums paid through a Medicare Savings Program.

 

There are four Medicare Savings Programs. These are Medicaid benefits that assist low-income Medicare beneficiaries with some or all of their Medicare costs.

• Qualified Medicare Beneficiary (QMB) Program. QMB helps pay for:

  • Part A premiums,

  • Part B premiums,

  • Deductibles, coinsurance, and copays.

• 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.

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When does Medicaid cover long-term care?

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.

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What is Emergency Medical Assistance?

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.

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What are my rights with Medicaid?

• You have the right to apply for any Medicaid program.

• You have the right to have your disability accommodated while you apply and during the review process.

• You have the right to timely notice of Medicaid decisions. If the Medicaid program ends your benefits, you must get notice in writing.

• If you disagree with any Medicaid decision, you have the right to a fair hearing.

• You cannot be denied Medicaid because of your:

  • Race,

  • Age,

  • Sex,

  • Disability,

  • National origin,

  • Political, or 

  • Religions beliefs.

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What are my responsibilities with Medicaid?

• You are responsible for providing true information on your Medicaid application, including:

  • Your complete income,

  • The size of your family,

  • Citizenship,

  • Information about your disability.

• You are responsible for reporting any changes, including:

  • Your income,

  • Resources,

  • Living arrangements,

  • Family size.

• You are responsible for letting Medicaid know if you have any other health or dental insurance. This includes:

  • Private health insurance,

  • Medicare, and

  • TRICARE.

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Contents

• How can I apply for Medicaid?
• What do I need to apply for Medicaid?
• How do I appeal a Medicaid decision?
• What is Medicaid estate recovery?

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How can I apply for Medicaid?

If you are applying for Medicaid health care coverage, you can apply at the following locations:

• County Division of Family and Children Services (DFCS) offices,

• Social Security Administration offices (if you are over 65, blind or have a disability),

• Health departments, some hospitals, and nursing homes,

• Local Right from the Start Medicaid (RSM) project offices (for family, children and pregnant women),

• Online through Georgia Gateway.

 

However, you should apply either in person or by mail, using the application form for the program, if you are applying for:

• A waiver program,

  • For NOW and COMP: Apply through the Department of Behavioral Health and Developmental Disabilities Services.

  • For ICWP,  contact Alliant Health Solutions at 888-669-7195.  

  • For CCSP and SOURCE, apply and find instructions to apply on the Georgia Aging and Disability Resource Connections.

  • For GAPP, contact a GAPP provider agency directly. Find an agency here. 

• Health Insurance Premium Payment Program (HIPP),

• To apply for HIPP, contact your local County Division of Family and Children Services.

• A Medical Savings Program. Fill out the Georgia Application for Medicaid & Medicare Savings for Qualified Beneficiaries. Mail or deliver the application to your county DFCS office.

• Katie Beckett Medicaid. Fill out the Katie Beckett Medicaid Application. The completed application should be mailed or faxed to:

  • Katie Beckett Medicaid Team

5815 Live Oak Parkway

Suite 2-F

Norcross, GA 30093-1700

 

• Centralized Katie Beckett Medicaid Team

Phone: 678-248-7449

Fax: 678-248-7459

 

Although you can technically apply online for these programs, you are more likely to be approved if you apply in person.

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What do I need to apply for Medicaid?

To apply for Medicaid, you may need:

• A copy of your birth certificate or other proof of identity,

• Proof of citizenship or immigration status,

• Picture ID,

• Social Security number,

• Income proof, including check stubs or payroll records;

• Letters or forms that show your income from other benefit programs,

• Current health insurance information,

• Life insurance policies,

• Most recent tax returns and bank statements,

• Information on any property you own.

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How do I appeal a Medicaid decision?

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.)

 

Call or visit your county Department of Family and Children’s Services (DFCS) to ask for a fair hearing.

 

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. 

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What is Medicaid estate recovery?

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:

• A house,

• Land,

• Vehicles,

• Cash,

• Investments,

• Other property.  

 

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.”

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