Medicaid: Frequently Asked Questions
Who is covered by Medicaid?
Ohio’s Medicaid program provides health care coverage to people who meet certain eligibility requirements. Depending on income, insurance status may affect eligibility and some consumers may be required to pay monthly premiums or co-pays. The following individuals who meet eligibility criteria are covered by Medicaid:
- Children younger than age 19
- Pregnant women
- Families with children younger than age 18
- Adults age 65 and older may be eligible. Ohioans of any age who have disabilities, (including those who are legally blind) may also qualify for Medicaid.
- Individuals with low income and also Medicare eligible can receive help with all or part of their Part-B premiums, coinsurance and/or other deductibles through the Medicare Premium Assistance Program. The amount of assistance available per individual depends on their income.
How do consumers receive Medicaid services?
Medicaid provides health care services through both a managed care or fee-for service system. Each delivery system provides all medically necessary primary care, specialty care, emergency care and preventive health care services. Medicaid also provides home health care and facility-based services for consumers requiring a long-term care benefit package.
What services does Medicaid cover?
Ohio’s Medicaid program includes services mandated by the federal government as well as some optional services Ohio has elected to provide. Some services are limited by dollar amount, the number of visits per year, or the setting in which they are provided. With some exceptions, medically necessary services are available to all Medicaid consumers. For a list of Medicaid services, go to: http://jfs.ohio.gov/OHP/consumers/benefits.stm
What is the citizenship requirement to qualify for Medicaid?
The citizenship requirement, which became effective Sept. 25, 2006, is a result of the Deficit Reduction Act of 2005 (DRA). The citizenship requirement is meant to ensure those receiving public assistance are U.S. citizens. The law requires everyone applying for Medicaid to provide original documents to establish legal citizenship. Previously, Medicaid applicants could self-declare their U.S. citizenship. (Immigrants applying for Medicaid have always been required to document their status.) Additionally, Medicaid consumers who were approved before the DRA was enacted must verify their citizenship status at the time of their reapplication for Medicaid benefits. Citizenship needs to be established only once.
What documents satisfy the citizenship requirement?
Federal guidelines establish a hierarchy of documents (identical to the hierarchy used by other programs with the same requirement) that are accepted as proof of U.S. citizenship. The hierarchy comprises four tiers, which caseworkers must use to seek documents. Examples of acceptable documents are provided on the next page. To view the hierarchy in its entirety, visit http://www.cms.hhs.gov/MedicaidEligibility/05_ProofofCitizenship.asp.
In order to comply with federal law, caseworkers must see the original document, record within the individual’s file that the document was seen and make a photo copy to keep in the file. If the original document is not available, a copy certified by the originating agency will be accepted.
What if consumers cannot provide verification documents?
At the time of application or redetermination, the county caseworker must give the consumer a “reasonable opportunity” to provide documents that fulfill the U.S. citizenship requirement. While an existing Medicaid consumer gathers the appropriate documents, he or she will remain eligible for Medicaid benefits; however, new applicants will not become eligible until the requirement has been satisfied. The county caseworker is responsible for assisting consumers in obtaining the appropriate documents.
Do consumers have to provide citizenship verification if they have established U.S. citizenship with another government agency?
Yes. The only consumers exempt from this requirement are those applying for Disability Medical Assistance, enrolled in Medicare, receiving SSI or SSDI or applying for Alien Emergency Medical Assistance. If a consumer receives cash or food stamp assistance, he or she is still required to document citizenship at the time of Medicaid application or reapplication.
What is Healthchek?
The federal government requires state Medicaid programs to provide a comprehensive and preventative benefit package for children and young adults younger than age 21. The federal government calls this Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program. Ohio Medicaid calls its EPSDT Program Healthchek. Healthchek provides greater availability and accessibility to child health care and assists in the effective use of resources. Healthchek provides the following services:
Screening Services: These include a comprehensive health and developmental history, which assesses both physical and mental health. This is conducted by a Medicaid-qualified physician or advanced practice nurse who screens for potential health problems (vision, dental, hearing, nutrition, and a child’s general physical health). The provider will also do any necessary laboratory tests, immunizations, blood lead screening, and provide health education, nutritional advice and referrals to other health providers.
Vision, Dental and Hearing Services: Once a referral has been made by a doctor, teacher, parent or any responsible adult, a child may receive diagnosis and treatment from a medical provider for vision, dental and hearing problemsâï¿½ï¿½ all of which can be billed to Medicaid. These screenings may be performed by the child’s general practitioner and if a problem is not identified, no further screenings are necessary at that time.
Additional Services: If a screening reveals a medical condition, Medicaid can be billed for any necessary health service provided on a later date to treat the child’s medical condition.
Aged, Blind, and Disabled (ABD) Medicaid Questions
What is ABD Medicaid?
Medicaid for the Aged, Blind or Disabled (ABD) is available to certain Ohioans to assist with medical expenses. Ohioans who are aged, blind or have a disability (as classified by the Social Security Administration) must meet established financial guidelines in order to be eligible. Some consumers in the ABD Medicaid program (125,000 consumers) access services through managed care while the remaining population access care through a fee-for-service delivery system.
What services are covered under Medicaid?
ABD health care coverage consists of the primary and acute care benefit package and long-term care if a person has the required level of care need. Covered services include prescription drugs*, home care, doctor visits, hospital care, laboratory and X-rays, medical equipment and supplies, dental care, transportation, mental health, vision services, long-term care, alcohol and drug rehabilitation and other services.
What long-term care services are available?
ABD Medicaid provides long-term care services in nursing facilities and Intermediate Care Facilities for Individuals with Mental Retardation (ICF/MR)s. Home and community-based services waivers provide home health care to individuals who wish to stay in their home but otherwise need institutional care. The number of consumers that can be enrolled in a waiver program at any one time is limited. There are several types of waivers:
- Ohio Home Care Waivers meet the home care needs of individuals, up to age 60, whose medical condition would otherwise require them to live in a nursing home or other institution.
- PASSPORT Waivers provide in-home services to individuals age 60 and older.
- Individual Options and Level One Waivers provide support services for individuals with developmental disabilities.
- Assisted Living Waivers offer more supervision and services than what may be available in a traditional home setting and allows consumers to have more independence and fewer restrictions than a nursing facility.
What if an Ohioan meets ABD eligibility requirements except his or her income is too high?
Ohioans who are aged, blind or have a disability may qualify for Medicaid after they have incurred or paid a specific amount of medical bills. This is called Medicaid spend-down. Spend-down allows individuals to deduct medical expenses from their income so that income will fall within Medicaid income guidelines.
If eligible for spend-down, the consumer is required to submit proof of medical expenses that meet or exceed the spend-down amount, or the consumer can pay the spend-down amount to the county department of job and family services. Once the spend-down has been met, the consumer is eligible for Medicaid. The date of Medicaid eligibility depends on the date the consumer reaches his or her spend-down. Spend-down eligibility is a monthly process.
Medicaid Spend-Down Questions
What is Medicaid Spend-down?
Ohio’s Medicaid’s Spend-down program offers certain Ohioans a chance to still qualify for Medicaid – even if their income is too high. This program is for Ohioans who are aged, blind or have a disability. It allows them to deduct medical expenses from their income, so they may fall within Medicaid financial guidelines.
The Medicaid Spend-down Program requires consumers to submit proof of medical expenses that meet the Spend-down amount. Once the Spend-down has been reached, the consumer is then eligible for Medicaid for the remainder of the month. Expenses covered by other insurance are not eligible to be used towards meeting the spend-down.
How is Medicaid Spend-down met?
Spend-downs can be met in three ways:
- Consumers provide verification of recurring or monthly medical expenses (e.g. documentation of medical premiums or unpaid past bills) that consistently meet or exceed the SD amount
- Consumers submit proof of medical expenses to SCJFS.
- Medicaid eligibility begins on the day the SD amount is met, and ends the last day of that month.
- Commonly referred to as “Pre-Pay SD” option.
- Consumers can pay the SD amount directly to SCJFS each month.
The Medicaid card will cover the entire month and should be dated from the first day to the last day of the month.
How is Medicaid Spend-down determined?
Click here for an example that demonstrates how a spend-down is determined.
What type of expenses can be applied toward spend-down?
Medical expenses and bills can be submitted to SCJFS to apply toward a consumer’s SD. Once verification is received, the agency will determine if the expenses can be applied to the SD.
- Medical bills
- Medical insurance premiums
- Medical insurance co-pays and deductibles
- Medicare premiums
- Verification of travel expenses to get access medical care
- Disposable medical supplies that are prescribed and medically necessary, such as adult disposable diapers, gauze and sterile water
How are unpaid past medical bills used to meet Spend-down?
Unpaid past medical bills may be used to meet a spend-down. For example, if a monthly spend-down is $100 and there is an unpaid past medical bill of $800, that medical bill can be used to meet the spend-down for 8 months. ($800 bill/$100 monthly spend-down = 8 months that the spend-down is met.)
These unpaid past medical bills must be given to the caseworker for documentation.
Please note: Consumers are still responsible for payment of the bills
Can a family member’s medical bills be used to help meet a Spend-down?
Depending upon a consumer’s situation, medical bills of certain family members may be used to help meet a Spend-down. Contact your local JFS for information.
Can Medicare costs paid through the Medicare Premium Assistance Program be applied toward Spend-down?
No. The Medicare Premium Assistance Program is for certain people eligible for Medicare. This program helps people with limited income and assets get help in paying one or more of the following: Medicare premium(s), Medicare deductibles, Medicare coinsurance. For more information and answers to your questions, please call:
Medicaid Consumer Hotline: 1-800-324-8680
TTY for hearing impaired: 1-800-292-3572
Or visit: www.jfs.ohio.gov/ohp/consumers
Medicaid Buy-In for Workers with Disabilities (MBIWD) Questions
What is MBIWD?
MBIWD is an Ohio Medicaid program that provides health care coverage to working Ohioans with disabilities. MBIWD was created to encourage Ohioans with disabilities to work and still keep their health care coverage.
Who is eligible?
To qualify for MBIWD, a person must:
- Be a U.S. citizen or meet citizenship requirements;
- Be a resident of Ohio;
- Be 16 to 64 years old;
- Have a disability as defined by the Social Security Administration (SSA) or be eligible under the MBIWD medically improved category;
- Be employed in paid work (includes part-time and full-time work)
- Pay a premium (if applicable)
- Meet certain financial criteria.
How are premiums calculated?
Premiums are determined through a set of calculations based on income, family size, and certain standard deductions (e.g., health insurance premiums, impairment-related work expenses, etc.). Individuals should direct questions about standard deductions or their premium calculation to their caseworker.
How do applicants apply for MBIWD?
Applicants who are new to Medicaid can complete the application online. Existing Medicaid consumers interested in MBIWD should contact their caseworker or the Medicaid Consumer Hotline: 1-800-324-8680. No face-to-face interview is required for this program.
Can MBIWD consumers receive long-term care and waiver services (e.g., nursing home services, assisted living, etc.)?
Yes. Consumers are permitted to receive long-term care and waiver services while enrolled in MBIWD.
Do MBIWD consumers have to pay a Spend-down?
No. There is no Spend-down for those enrolled in MBIWD.
What happens if an MBIWD consumer loses disability status?
If an MBIWD consumer loses disability status, he/she may continue to receive health care coverage through MBIWD’s medically improved category. To qualify for the medically improved category, consumers must meet certain conditions. Ask a caseworker for more information.
What happens if an MBIWD consumer loses his/her job?
MBIWD consumers that lose their job will have up to six months of MBIWD coverage if they meet certain conditions. (Please note: Premiums are based on the MBIWD consumer’s income. If there is a reduction in income, there will also be a reduction in the premium amount.)
Medicaid Premium Questions
What is a premium?
A premium is a fee that you must pay to get health care coverage. Just like other health insurance plans, certain Medicaid programs now require a monthly premium to obtain health care coverage.
Why do I have to pay a premium?
Premiums allow Ohio to provide health care to people with higher incomes while reducing the burden on taxpayers.
How often do I have to pay my premium?
Premiums must be paid in full every month. Due dates will be provided on your monthly billing statement.
What forms of payment are accepted?
Payments can be made by check, money order or cashier’s check. Payments should be made payable to: Treasurer/State of Ohio ODJFS. Payment must be received by the due date on your billing statement.
Where do I mail my premium payment?
Payments should be mailed to:
Ohio Department of Job and Family ServicesPO Box 713067Cincinnati, OH 45271-3067
Please be sure to include your account number on your form of payment. If you need your account number or you are unable to locate your billing statement, please call the Medicaid Consumer Hotline at 1-800-324- 8680 (voice)/1-800-292-3572 (TTY).
Can I pay my premium at the local county department of job and family services?
No. Do not send your premium to your local county department of job and family services. Please use the addressed envelope included with your billing statement to mail your payment
Immigrants, Their Children, and Medical Assistance/Medicaid
Are non-U.S. citizens eligible for Medicaid?
Depending on the date an immigrant arrived in the United States, they may be eligible for Medicaid. Immigrants who arrived before August 22, 1996 may be eligible for Medicaid as long as the other eligibility guidelines are met. Immigrants who arrived on or after August 22, 1996 are not eligible for Medicaid unless one of the following exceptions are met. To be eligible, an immigrant must be:
- a refugee who has been granted asylum
- a refugee who has been granted status as a victim of a severe form of human trafficking
- a refugee whose deportation is being withheld
- a permanent resident who has worked 40 quarters under the Social Security Act
- a veteran or has been in military active duty status (includes spouse and dependents)
Does Medicaid report non-U.S. citizens to the U.S. Citizenship & Immigration Service (USCIS)?
No. The Medicaid program does not report citizenship information to the USCIS.
Can children of non-U.S. citizens get Medicaid?
If the children are U.S. citizens, they can get Medicaid if they meet the eligibility requirements.
Do non-U.S. citizens who are applying for Medicaid for their U.S.-born children, have to prove citizen status?
No. If the person applying is not a U.S citizen and is applying for Medicaid for U.S. born children, they are not required to provide proof of their citizenship status.
Does a non-U.S. citizen need a social security number if they are applying for their child who is a U.S. citizen?
No. If a non-U.S. citizen applies for Medicaid for a U.S. born child, they do not have to give their social security number. However, the child’s social security number must be provided or the applicant must show proof that they have applied for a number for the child.
Is my sponsor required to supply their income information if I am applying for Medicaid for my children and myself?
As a non-U.S. citizen, your sponsor’s income is used to determine only your Medicaid eligibility. A sponsor’s income is not used when determining Medicaid eligibility for children born in the U.S.; only the parent’s income is used in this case.
What is Refugee Medical Assistance?
The Refugee Medical Assistance program is for those who are classified as refugees by the USCIS and are not eligible for any other type of Medicaid. Refugee Assistance is good only for the first eight months after an individual arrives in the U.S.
What is Alien Emergency Medical Assistance (AEMA)?
Non-U.S. citizens who are not eligible for Medicaid may be eligible for AEMA. AEMA will only pay for medical costs for an emergency medical condition (e.g., cost of childbirth, labor and delivery). Applicants are not required to provide a social security number or documentation of immigration status.
A person who has difficulty speaking or understanding English, or who is hearing impaired and is not able to communicate effectively with county job and family services staff, has the right to an interpreter. The cost of the interpreter will be paid by the county department of job and family services. The county office must provide an interpreter to you if you need one. Individuals may bring an interpreter with them, such as a bilingual friend or relative. However, friends and relatives who are not trained interpreters may not be able to accurately and completely translate some things the agency says. Minor children should never be used as an interpreter.