Factors in Determining Eligibility for Medicaid to Make the Process Easier

Medicaid provides health assistance to more than 72.5 million Americans who don’t have the financial capacity to pay for the treatment they need. Together with the Children’s Health Insurance Program, Medicaid covers a variety of patient groups, including pregnant women, children, the elderly and people with disabilities.

While the Affordable Care Act of 2010 has expanded the coverage to almost all low-income Americans aged 65 and below in all states, there are still eligibility requirements hospitals must follow. Understanding the factors that affect eligibility will help hospitals avoid errors and fast track the process.

Factors That Can Help Hospitals Determine Eligibility for Medicaid

Financial and Non-Financial Eligibilities

A patient’s income level is a top eligibility requirement. It must pass the Modified Adjusted Gross Income (MAGI) criteria that determines the financial eligibility for Medicaid. It takes into account the patient’s taxable income and tax filing in determining whether the patient can avail of Medicaid benefits. There are individuals who are exempted from MAGI, including patients suffering from blindness and other disability and those 65 years and above. The income methodology used for these groups is the one set under the Supplemental Security Income.

Aside from financial eligibility, the residency of the patient is another factor. The individual must be an American citizen and is a resident of the state in which they’re applying for Medicaid assistance. Foreigners can receive Medicaid as well as long as they are considered lawful permanent residents.

Medical Needs

There’s a “medically needy program” for patients requiring significant health assistance whose income levels do not make them eligible for Medicaid outright. All they have to do is “spend down” the amount of income to meet the standard. This process involves incurring expenses for medical care and treatments that aren’t covered by their health insurance. When the amount of expenses go beyond the difference between a state’s medically needy income level and the individual’s income, Medicaid can shoulder some of the cost of services.

Many individuals are still unsure of their eligibility for Medicaid, especially after the program has adjusted its criteria. The changes led to an increase in inquiries and enrollees that hospitals must be able to cope with. This could hamper their revenue cycle management (RCM) and growth. Getting assistance from RCM experts can help hospitals improve their internal systems to accommodate patients wanting to enroll and avail of Medicaid.


Eligibility, Medicaid.gov
Who Is Eligible for Medicaid?, HHS.gov

Pete Ash

Pete is the Vice President of Sales & Client Services at DECO Recovery Management. He covers the Mid Atlantic region and specializes in Medicaid related topics. It is DECO’s Mission to maximize reimbursement to our clients by leveraging innovative technology, processes and compassionate advocates to provide exemplary service.

Categories: Medicaid