What is Medicaid Insurance? 9 Important Points to Know

Medicaid is the nation’s public insurance program that covers people with low incomes.

Medicaid is the nation’s public health insurance program for low-income people. Medicaid covers one in five Americans. It includes many people with complicated and costly care needs. This program provides the most comprehensive, long-lasting health care coverage for Americans. A large number of Medicaid beneficiaries do not have access to affordable medical insurance. Medicaid covers many health services, and limits the out-of-pocket costs of Medicaid enrollees. The Medicaid financial resources account for nearly a fifth of the total healthcare costs in the United States. They provide substantial funding for hospitals, doctors, nurses houses and other healthcare tasks. The program is governed by Title XIX, the Social Security Act, and a large body of federal policies. It specifies federal Medicaid requirements as well as state options and authorities. Execution of Medicaid is a responsibility of the Centers for Medicare and Medicaid Solutions, which are part of the Department of Health and Person Solutions.

Medicaid is a federal-state partnership

States administer Medicaid. They are subject to federal requirements and can identify covered populations, eligible services, healthcare shipment plans, and methods for paying doctors and hospitals. States may also apply for Area 1115 waivers to be able to assess and perform methods other than what is required by federal statute, provided that the Secretary of HHS has identified advance program goals. This flexibility allows for a wide range of state Medicaid programs.

Two assurances are made under the Medicaid privilege: first, all Americans who meet Medicaid eligibility requirements are guaranteed protection. Second, all states are guaranteed federal coordinating dollars without any cap on certified services provided to qualified enrollees. A formula in the law determines the match rate for many Medicaid enrollees. It offers a match of at least 50% and a higher federal match rate for states that are poorer.

Medicaid protection has been gradually improving.

The 1965 Medicaid law established that Medicaid eligibility was linked to cash support. This included federal Supplemental Security Earnings or Help to Households With Reliant Kids (AFDC), which began in 1972, for parents, children, the poor, the blind, and persons with disabilities. States may offer protection at higher earnings than money support. Over time, Congress increased federal minimum requirements and provided new protection options for states, especially for children, pregnant women, and those with special needs. Congress also needed Medicaid to help pay for the premiums and cost sharing for low-income Medicare beneficiaries. It also allowed states to offer a choice to “buy in” to Medicaid for people with disabilities. Other protection turning points included the severance of the link between Medicaid eligibility, well-being, and the enactment of the Kid’s Medical insurance Program in 1997 to provide coverage for low-income children above the Medicaid cut-off with a higher federal match rate. After these policy changes, states began to conduct outreach and simplified registration procedures in order to enroll qualified children in CHIP and Medicaid. Later reforms, which modify Medicaid as an income-based program for health protection, were triggered by the growth in Medicaid coverage of children.

The Affordable Care Act (ACA), a comprehensive health protection program, expanded Medicaid coverage to all non-elderly grownups earning approximately 138% FPL ($17,236 in 2019). It also provided federal coordinating funds. Before the ACA, individuals had to be unconditionally qualified to receive Medicaid. This left most low-income adults without options. Federal law also excluded grownups who were not dependent on their children from the program. The ACA amendments successfully eliminated categorical eligibility, and allowed grownups to be covered without reliant children. However, states can opt out of the ACA Medicaid expansion due to a 2012 Supreme Court decision. All states were required to improve or enhance Medicaid eligibility and registration processes under the ACA. The historical declines in Medicaid coverage have led to a decrease in the number of children without protection. In states that embrace the ACA Medicaid expansion, there has been a sharp drop in the number of adults without protection. Many Medicaid grownups work, but few have access to company coverage. Prior to the ACA, there were no other options for economic protection.

Medicaid is available to 1 in 5 Americans. It serves diverse populations.

Medicaid provides health care and long-term support for many Americans, including the most vulnerable and poorest. It also serves as a pool of high-risk individuals to the personal and commercial insurance market. Medicaid was used to cover more than 75 million low-income Americans in FY 2017. Since February 2019, 37 states actually have adopted the Medicaid growth. Since FY 2017, when less states were actually accepting the growth, information shows that 12.6million people have been recently qualified for the growth group. More than 4 out 10 Medicaid enrollees are children (43%) and about 1 in 4 Medicaid enrollees are seniors and people with disabilities.

Medicaid is a vital service that covers certain populations: nearly half of all births in the state, 83% of poor kids, 48% of children with unique healthcare needs, 45% of non-elderly adults with special needs, handicaps, mental disorders, major mental illness, distressing brain injury, major psychological disorder, and Alzheimer’s disease, as well as more than 6 out of 10 residents of retirement homes. States have the option to provide Medicaid to children with significant special needs from higher-income families to help fill gaps in their private medical insurance or limit out-of-pocket financial problems. Nearly 5 percent of Medicare beneficiaries receive Medicaid to help with Medicare premiums, cost-sharing, and provide a variety of benefits not covered by Medicare.

Medicaid provides a wide range of long-term and health care services.

Medicaid provides a wide range of services to meet the diverse needs of its beneficiaries. Many states also choose to cover additional services, such as prescription drugs and physical treatment, eyeglasses, and oral health care. Protecting Medicaid growth grownups also includes the ACA’s 10 “vital Health Advantages” which include preventive services, broadened psychological health, and compound usage treatment services. Medicaid serves an important function in combating the opioid epidemic, and linking Medicaid recipients with behavioral health services. Medicaid provides comprehensive benefits for children, known as Early Regular Screening Medical Diagnostics and Treatment (EPSDT). Because children with disabilities often have limited insurance, EPSDT is essential. Medicaid covers long-lasting care, which includes both long-term home care as well as many community-based services and supports. This is in contrast to Medicare and business medical insurance. More than half of Medicaid’s long-term care costs are now for services provided in the home or community that allow elders and persons with special needs to live in their own homes.

Because Medicaid and CHIP recipients have a limited ability to pay out of pocket expenses because they earn less, federal guidelines prohibit states from charging Medicaid premiums to recipients who earn less than 150% FPL. They also forbid or limit expense sharing for certain populations and services and limit overall out-of–pocket costs to no more than 5%. Some states have obtained waivers to allow them to charge higher premiums or share more expense than allowed by federal guidelines. These waivers are primarily for growth grownups, but some also apply to those who meet the traditional eligibility requirements.

Most Medicaid beneficiaries receive care via personal care strategies.

More than two-thirds (65%) of Medicaid recipients are registered with private managed care strategies. These agreements allow states to provide detailed services. Others receive their care through the fee-for service system. They are responsible for ensuring access to Medicaid services via their network of service providers, and they are also at financial risk for their expenses. While the law used to limit care for children and their households to a minimum, they now provide care for people with complex needs. Nearly half of all states cover long-term services and support through risk-based managed care plans. Many states participate in a variety of shipping system and payment reforms to manage costs and improve quality.

These include the application of patient-centered medical homes, better combination of behavioral and physical healthcare, and advancements in “value-based purchasing” methods that link Medicaid supplier payments with health results and other efficiency metrics. The local university hospital is a vital source of medical care. Safety-net medical facilities consist of public and scholastic healthcare centers and offer an abundance of inpatient and emergency care for Medicaid enrollees.

Medicaid provides a range of long-lasting services and supports. These services include house- and community-based services (HCBS), which allow individuals to live in their own homes or in nearby settings, as well as institutional care in nursing centers (NFs), and intermediate care centers for people who have intellectual special needs (ICF/IDs). In FY 2016, HCBS accounted for 57% of Medicaid LTSS expenses, while institutional LTSS accounted for 43 percent. This represents a significant shift from 1995 (two years ago), when institutional settings accounted for 82 percent of all Medicaid LTSS expenditures.

Medicaid helps with accessing care

Research has shown that Medicaid recipients have better access to healthcare than those without insurance. They are also less likely to delay or not receive the care they need due to cost. The rates of Medicaid enrollees’ access to care and satisfaction with care are comparable to rates among people with private insurance

Medicaid coverage for low-income pregnant women and children has led to significant reductions in child and infant deaths in the U.S. Second-order financial benefits include higher taxation as a result of greater adult profits. According to research, state Medicaid expansions to grownups result in increased access to care, improved self-reported health and decreased deaths amongst grownups.

Access to certain suppliers, including psychiatrists, some specialists, and dental professionals, is a continuous problem in Medicaid, as well as in the overall health system, due to total company shortages and geographic maldistribution. Low Medicaid payment rates, especially among experts, have been associated with lower doctor participation in Medicaid. The majority of Medicaid recipients are served by managed care strategies. They are responsible under the agreements they have with states to ensure that there is a sufficient network of service providers. There is no evidence that Medicaid doctor participation is declining. A 2015 study found that 4 out of 10 medical care providers who accepted Medicaid saw an increase in Medicaid clients since January 2014. This was after the protection increases in the ACA.

Medicaid provides coverage for people suffering from opioid dependence and increases state capacity to provide access to treatment and early intervention services. With improved federal funding, Medicaid has allowed states to provide coverage for many grownups who had been excluded from the program. Medicaid covers 4 out of 10 non-elderly adults with opioid dependence.

Medicaid is jointly funded by the federal government and the states.

Medicaid is jointly funded by the federal government and the states. Federal Medicaid costs are covered by the federal government. Based on a federal formula, the federal match rate varies by state and can vary from 50% to nearly 75% in poorest states. The federal match rate for newly qualified grownups was 100% in 2014-2016. It gradually decreased to 90% in 2020, and then to 93% in 2019. 

Federal matching structures provide resources to states for protecting their low-income residents. They also allow state Medicaid programs to respond to financial and group shifts, changing protection requirements, technological developments, public healthcare emergencies such as the opioid dependency crisis and natural disasters. When states are in recession, the federal Medicaid matching funds provide financial relief. Although federal matching rates are not immediately used for financial shifts, Congress has twice increased them temporarily during declines in order to increase assistance to states.

In FY 2017, the total federal and state Medicaid cost was $577 billion. Medicaid, which represents 9.5% of federal expenses in FY 2017, is the third-largest domestic programme in the federal budget plan after Social Security and Medicare. In 2017, Medicaid was second in state budget plans after primary and secondary education.

Federal Medicaid matching funds make up 55.1 percent of the federal income in state budget plans. Medicaid accounts for 26.5% of total state costs. Because Medicaid plays an important role in state spending plans states are interested in program stability and cost containment. Although registration and costs rose significantly following the ACA’s implementation, they have been less in recent years. Slower caseload growth helped to decrease Medicaid investment development in FYs 2018-2019, but higher expenses for prescription drugs and long-lasting support and behavioral health services were highlighted as factors that put upward pressures on Medicaid cost.

Medicaid is primarily for seniors and those with special needs.

While seniors and people with special needs make up one in four recipients, they account for almost two-thirds (or a third) of Medicaid costs. This is due to the high cost per enrollee for long-term and severe care. Medicaid is the primary payer for long-term, community-based services and assistance. There is limited Medicare coverage and few options in the personal insurance marketplace. The highest-cost 5 % of Medicaid enrollees account for more than half of Medicaid’s costs. However, Medicaid is still relatively affordable compared to personal insurance. This is due to the lower Medicaid payment rates companies receive. Analyses show that adult Medicaid enrollees would have more than 25% higher healthcare costs if they had job-based coverage. The Medicaid costs per enrollee have also been increasing slowly than personal insurance premiums or other health cost criteria.

The majority of the public has positive views about Medicaid

Popular opinion poll suggests that Medicaid provides broad assistance. 7 out of 10 Americans claim that they have ever been connected to Medicaid. This includes 3 in 10, who were never covered. Even in political celebrations, bulks support Medicaid and believe that it is working well. A ballot poll revealed that few Americans want to see federal Medicaid funding decrease. Medicaid provides broad-based assistance as well as strong assistance to those who are most in need, including seniors, children with special healthcare needs, and those with disabilities.


Medicaid provides monetary security and protection for many Americans who are still working. Despite their low income, Medicaid enrollees enjoy access rates to care comparable to people who have personal protection. Medicaid provides long-term, expensive healthcare for many seniors and persons with impairments in the community. Medicaid is a high-risk pool that provides protection to many uninsured individuals who are unable to be covered by the personal, mainly employer-based, medical insurance system due to low earnings, poor health, or impairment. Medicaid also supports Medicare by helping low-income Medicare beneficiaries to pay premiums and cost sharing and providing long-term services and support that aren’t covered by Medicare.

Medicaid financing accounts for one-fifth healthcare costs. It is a significant source for assistance for hospitals, doctors, nurses houses and other tasks in the healthcare industry. States have the flexibility to use Medicaid to address health issues such as the opioid crisis. As a safeguard, states can also allow Medicaid to continue to operate as needed in the event of financial shifts or other characteristics.

It is an ongoing source of contention because Medicaid is central to both state and federal budget plans. Medicaid is also the primary source of protection for low income Americans. Attempts to repeal and modify the ACA included basic reforms to Medicaid that would have allowed it to be funded at the highest level through a block grant, or per capita cap. 

These proposals were defeated in 2017. In 2019, the key Medicaid issues to watch are Medicaid growth advancements, continued focus on changing the program through Medicaid presentation waiver activities, which consists of those focused on work requirements and other eligibility restrictions in addition to potential waivers to increase Medicaid funding. Other areas of Medicaid that can be improved include benefits, payment, and shipment systems reforms, efforts to address social factors and manage prescription drug costs, as well as efforts to combat the opioid crisis and provide long-lasting, neighborhood-based care services. The Congress and the states may also consider more comprehensive reforms in health that could expand the role of public programs in healthcare, such as Medicare for All or Medicaid Buy-In programs. This might have significant implications for Medicaid.