What is Medicaid?

Medicaid is a government benefit that pays for health care for the needy.

“The needy” includes elderly, blind, or disabled people who fall into one of two groups. The first group can’t afford health care because they have very low income and no assets (called “categorically needy” in Medicaid lingo). The second group can’t afford health care because they have a monthly health care bill that is larger than their income (called “medically needy” in Medicaid lingo). This second group includes many middle-class seniors who, despite working and saving all their lives, simply can’t afford a $9,000 nursing home bill every month.

Note: BadgerCare Plus is a similar program that provides health care to low-income Wisconsin residents who are not elderly, blind, or disabled.

That’s a quick summary of a complex program. Once you start getting into the details—like who counts as disabled or what counts as income—it gets complicated.

Why is Medicaid so hard to understand?

What we generally call Medicaid is a system that involves federal, state, and county governments. In this system, the state enacts and administers a plan for “medical assistance.” The federal government provides money to pay for the medical assistance program—if the state meets certain requirements. The counties are the gatekeepers, the “boots on the ground”; the county department of human or social services usually takes the application for medical assistance and decides whether the applicant is eligible.

Note: The terms Medicaid, Medical Assistance, and MA are often used interchangeably. I generally use Medicaid because most people recognize it—it’s even the term Wisconsin DHS uses on its website. In the context of this blog, Medicaid usually means Wisconsin’s medical assistance program, specifically.

So we have federal law, state law, county workers, and a large state administrative agency involved. In fact, the Wisconsin Department of Health Services has several sub-programs for Medicaid, muddying the waters further. These sub-programs, such as Family Care, Community Waivers, or Medicaid Deductible, are mostly about where you receive care—in a nursing home or in the community—and what benefits are available to you.

Medicaid is complex, but it can be explained.

Medicaid is a complicated program, which is why it often takes a legal education to fully understand its rules and operation. But anybody can understand the basics of how Medicaid affects them, and why, if someone will just explain it well. It’s still not rocket science.

And yet, the people who receive Medicaid often never get a good explanation. There are lots of non-lawyers in the system—social workers, nursing home financial managers, and the like—who know the rules and can tell you what they are. But few take the time or have the patience to help a needy person understand why the rules are what they are. That’s important, because the rules often feel unjust and confusing.

I once had a client who talked to social workers for months before hiring me. She never understood why she was getting a bill for thousands of dollars each month while her husband was on Medicaid. Not until I took half an hour to draw her a picture (literally) and carefully explain how Medicaid determines how much money it will pay and how a married couple’s finances are intertwined in the calculation—then, finally, it made sense to her. Imagine how much time and frustration could have been saved if someone had explained it like that from the beginning.

Of course, the social workers tried to tell her the rules many times—but they never explained the rules in a way that made sense. They were treating her like a child who just needed to accept what she was told.

One of the best things I do is simply explain and teach. I love when a client finally gets some clarity; when I see a face light up at last with understanding.

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