Health Insurance

Can I Lose My Medicaid Coverage?

Girisha Bharadwaj
Girisha Bharadwaj15 Apr 2022

Medicaid is a federal and state health coverage program that helps make healthcare affordable for those with limited income. There are a few reasons why you might be at risk of losing your Medicaid coverage, including pandemic-related policy changes, changes in income level, and loss of social security insurance benefits. 

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What is Medicaid and Who is Eligible?

Created in 1965, Medicaid is a U.S. public health insurance program that was established to support Americans with greater financial needs. The program provides health coverage to low-income families and individuals including children, parents, pregnant women, seniors, and those with disabilities. Medicaid is funded jointly by the federal and state governments but is run at the state level. 

Medicaid is by far the largest source of medical and health-related services in the country designed specifically for those with limited resources. Roughly 1 in 5 Americans is covered under the Medicaid program. According to estimates by the Centers for Medicare and Medicaid Services (CMS), Medicaid had more than 75 million enrolled users in 2019. However, this number is estimated to be significantly higher in light of the pandemic-related Medicaid expansion that began in 2020. 

COVID-19 Pandemic Medicaid Expansion

The COVID-19 pandemic has caused a devastating impact on the health and financial wellbeing of communities throughout the country. Employment rates in the U.S. fell by 6.2 percent just within the first 6 months of the pandemic and as a result, many individuals lost their employer-sponsored health insurance. 

In an effort to offset this widespread loss of health coverage, the U.S. government signed the Families First Coronavirus Response Act. This act requires that people covered under Medicaid and those who become eligible as result of the public health emergency “shall be treated as eligible” during the emergency. As a result of this act, CMS reported a 15.6 percent increase in the number of Medicaid and CHIP beneficiaries between February 2020 to March 2021. 

Eligibility For Medicaid

Medicaid provides health coverage in all U.S. states. Each state has a different set of requirements that allows a person to become eligible for Medicaid benefits. In January 2014, the Affordable Care Act declared that each state has the authority to expand its Medicaid eligibility if it so chooses. As of July 2021, 12 U.S. states refused to adopt the expansion, including Texas, Florida, Mississippi, Kansas, and others. 

To see if you are eligible to receive health coverage under Medicaid, follow these steps:  

Federal law requires every state to offer coverage to certain mandatory eligibility groups. These groups include but are not limited to low-income families, qualified pregnant women and children, and individuals with Supplemental Security Income (SSI). The table below outlines coverage benefits offered to each of these groups. 

Groups Eligible for Medicaid and Benefits


 

Low-Income Families

  • Pregnant Women: prenatal care and delivery costs
  • Children: routine and specialized care for childhood development (immunizations, dental, vision, speech therapy)
  • Families: affordable coverage to prepare for the unexpected (emergency dental, hospitalizations, antibiotics)


 

Individuals with Disabilities

  • Child with Autism: in-home therapy, speech/occupational therapy
  • Cerebral Palsy: assistance to gain independence (personal care, case management, and assistive technology)
  • HIV/AIDS: physician services, prescription drugs
  • Mental Illness: prescription drugs, physician services



 

Elderly Individuals

  • Medicare Beneficiary: assistance paying for Medicare premiums and cost-sharing
  • Community Waiver Participant: community-based care and personal care
  • Nursing Home Resident: care paid by Medicaid since Medicare does not cover institutional care

Source: www.kff.org

Why You Might Lose Your Medicaid Coverage

While you might qualify for Medicaid and enroll for benefits, your coverage is always at risk of discontinuation. There are several reasons why you might lose your coverage. These reasons may have to do with a change in your income levels, location, family size, and more. 

Pandemic Mandate Changes

In a White House press briefing in February 2022, Dr. Walensky shared that the country is moving closer to a point where the COVID-19 pandemic is no longer “a constant crisis.” All U.S. states have dropped or are close to dropping their mask mandates. In a similar light, it is anticipated that the federal Medicaid Mandate, which enforces that anyone enrolled in Medicaid cannot lose coverage during the pandemic, will come to an end

Once discontinued, this change will lead millions of low-income Americans to lose their Medicaid coverage. State attorney for the Tennessee Justice Center, Gordon Bonnyman, says that “the main concern I have is people are going to be cut off for reasons that have nothing to do with their eligibility.” 

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Income Levels

Another reason someone might get dropped from Medicaid is a change in their income levels. When reapplying for Medicaid, if you find that you are no longer eligible for coverage, a possible reason is that your income has increased beyond your state’s eligibility level. Since Medicaid is designed to help those experiencing financial hardship, states typically revise their eligibility requirements every year based on the current poverty levels. 

Another factor that might be accounted for while determining your income eligibility for Medicaid is your family size. For instance, if your child is no longer considered a dependent, this reduces the number of members in your household. Your income requirement to qualify for Medicaid may now be lower based on this new household size. 

Failure to Pay Monthly Premium

A failure to pay your monthly premiums for most plans will lead to a loss of coverage. However, many health insurance plans offered through the marketplace allow their customers a grace period

This grace period is usually a short time - typically 90 days after your original insurance payment due date. A failure to make your payment by the end of the grace period will lead to a termination of your coverage. In that case, you will only be covered until the end of the month for which you made your last payment. 

Loss of Social Security Insurance Benefits 

Social Security Insurance (SSI) is a program that provides benefits to people with disabilities and limited income. People who have already claimed SSI benefits might automatically be eligible for Medicaid coverage. Some states will automatically enroll those with SSI benefits in their Medicaid program. Others might require individuals to apply before they can receive benefits. 

If you lose your SSI eligibility and are no longer part of the program, your Medicaid eligibility might be affected. However, in most cases, you can continue to receive Medicaid benefits if you fall under the categories defined by the Social Security Act. Find more information about eligibility on the SSA website

If you lose your SSI benefits because you returned to work, you may still keep your Medicaid coverage under certain conditions

  • You are still disabled or blind.
  • You cannot work without Medicaid benefits.
  • Your gross earnings don’t replace Medicaid, SSI, and public funding for necessary attendants.
  • Your SSI payment eligibility lasted at least a month.
  • You meet other SSI requirements.

Medicaid Fraud

Another reason why you might lose your coverage is if you commit Medicaid fraud. The table below outlines some examples of recipient fraud that can result in a loss of Medicaid coverage. 

Examples of Medicaid Fraud

Card Sharing Sharing your Medicaid ID card with someone else so they can obtain medical services. 
CollusionHelping your doctor file false claims by having tests you do not need. 
Drug DiversionAltering a doctor’s prescription, going to multiple doctors to get more of the same drug, or selling your medications to others. 
KickbacksAccepting payment from your doctor for referring other beneficiaries for medical services.
Multiple CardsAltering or duplicating a Medicaid ID card and using it or selling it for someone else to use. 
Program EligibilityProviding incorrect information to qualify for Medicaid. 

Source: www.cms.gov

What To Do If You’re No Longer Eligible For Medicaid

Losing your Medicaid coverage can be very stressful, especially for those who have ongoing medical treatments and are dependent on Medicaid to afford their healthcare costs. If you think you might lose your coverage or have already been notified of the termination of services, there are still several options available for you to obtain coverage. 

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Health Insurance Alternatives

If you have suffered a loss of Medicaid benefits, Mira can be a great option to access affordable health services. Mira is an alternative to health insurance, where you pay a monthly fee of $45 and do not need to meet a deductible. Mira memberships include a range of services

  • At-home COVID-19 and flu test
  • Virtual primary care
  • Mental health therapy
  • Urgent care
  • Lab tests
  • Discounted prescriptions
  • Specialist & Imaging referrals
  • Dedicated member care
  • Gym membership discounts

Find more information and sign up here!

Special Enrollment Period

Upon losing your Medicaid coverage, you are eligible for a Special Enrollment Period (SEP). A SEP is a 60-day long period during which you are allowed to enroll in a health insurance marketplace plan without facing a penalty. Without a SEP, individuals can enroll in a new health plan only during the Open Enrollment Period

Subsidies

Even if you are no longer eligible for Medicaid, you might still be eligible for certain government subsidies. These are health coverage plans available at reduced costs or no cost to people who fall below certain income levels. Subsidized coverage can cost anywhere from 0 to 100 percent of the monthly premium. Find more information about subsidized coverage on healthcare.gov

Medicare

Even if you are not covered under Medicaid anymore, you might still be eligible for coverage under the Medicare program. If you are an older adult, who is 65 years or older, you might be automatically enrolled for Medicare if you have started receiving your social security benefits. Even within Medicare, you can choose between various plans based on your healthcare needs.  

Short-Term Plans 

Short-term health plans are another option to get temporary coverage. Short-term health plans typically provide some emergency and preventative coverage. These plans usually require you to pay a copay, deductible, or co-insurance like typical health insurance plans. However, these plans are exempt from the ACA requirements and therefore may not meet the ten essential benefits required of traditional health insurance plans. Each state has a different time limit on how long a short-term health plan can cover you.  

Bottom Line

Individuals may lose Medicaid coverage for various reasons, such as changes in income levels, family size, and pandemic-related policy changes. However, if you lose your Medicaid coverage, you have several options to obtain health coverage. You might also be able to appeal the Medicaid denial or termination letter. 

If you are looking for health care coverage, Mira offers health benefits, including affordable urgent care visits, low-cost lab testing, and discounted prescriptions for just $45 per month. Our care navigation team can also help you find affordable healthcare services in your area! Sign up today to get started.

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