Health Care : Medicaid

What is Medicaid?

Medicaid is a publicly funded health insurance program for low-income people.

It covers most medically necessary services and is low or no cost to eligible recipients. Medicaid is funded with both state and federal funds.

In Ohio, the Medicaid program is administered by the Ohio Department of Job and Family Services (ODJFS).

Who can get Medicaid?

Medicaid eligibility is complicated and different eligibility standards apply to different groups of people.

The main eligibility categories include children, families, nursing home residents, and people who are blind, 65 or older, or disabled.

The ODJFS website has a summary of eligibility for Medicaid.

How can I apply for Medicaid?

Any Ohioan can apply for Medicaid and other public benefits at the County Department of Job and Family Services in the county in which they live.

Find your local CDJFS.

The application form for all Public Benefits is the ODJFS 7200.

You can use this form to apply for Medicaid, Food Stamps, and Cash Assistance. You can either print this form, fill it out, and take it to your County Department. Or, you can get a copy from the County Department and fill it out there.

If you don’t have all the information you need to complete the application, fill in as much of the information as you know. Then sign and date the application and submit it to the County. This is important because the date you apply determines when you can start getting benefits.

You can give the County more information after you submit the application.

What services does Medicaid cover?

Medicaid will cover the cost of most medically necessary services.

The federal government requires some services to be covered and the state can choose to cover additional services.

The list below lists what services are covered by Medicaid in Ohio. If your doctor thinks you need other services, you can ask Medicaid to cover them even though they are not on the list.

Your doctor will have to explain why she thinks they are medically necessary.

Services Required by Federal Law:

  • Ambulatory Surgery Centers

  • Certified family nurse practitioner services

  • Certified pediatric nurse practitioner services

  • Transportation to Medicaid services (NET)

  • Family planning services & supplies

  • Healthchek (EPSDT) program services (screening & treatment services to children 21 and younger)

  • Home health services

  • Inpatient hospital

  • Lab & x-ray

  • Medical & surgical dental services

  • Medical & surgical vision services

  • Medicare Premium Assistance

  • Non-Emergency Transportation

  • Nurse midwife services

  • Nursing Facility care

  • Outpatient services, including those provided by Rural Health Clinics & Federally Qualified

  • Health Centers

  • Physician services

Other services that Ohio has decided to cover:

  • Ambulances / Ambulettes

  • Chiropractic services for children

  • Community alcohol & drug addiction treatment

  • Community mental health services

  • Dental services

  • Durable medical equipment & supplies

  • Home and Community Based Services

  • Waivers

  • Hospice care

  • Independent psychological services for children

  • Intermediate Care Facility services for people with Mental Retardation (ICF-MR)

  • Occupational therapy

  • Physical therapy

  • Podiatry

  • Prescription drugs

  • Private Duty Nursing

  • Speech therapy

  • Vision care, including eyeglasses

Where can I get Medicaid services?

You must get Medicaid services from a Medicaid provider.

A Medicaid provider is a doctor, hospital, laboratory, nursing home, drug store or other health care provider who has a contract with Ohio Medicaid to provide care to Medicaid recipients.

Before you get any Medicaid services, ask your health care provider if they are a Medicaid provider.

In many counties in Ohio, most Medicaid recipients must use a managed care organization (MCO) or a health maintenance organization (HMO) to get their Medicaid covered services. I

f you are in a Medicaid managed care program, you must use health care providers who work with your managed care organization.

ODJFS has more information about Medicaid managed care on its website.

What are Medicaid Eligibility Categories?

Eligibility for Medicaid differs for different groups of people.  Eligibility is determined by federal poverty level; however, parents can be eligible for Medicaid only if their family income is 90% of the federal poverty level (FPL) or lower.

What if my doctor, hospital, or pharmacy sends me a bill for the costs that Medicaid did not pay?

When any health care provider agrees to accept Medicaid as payment for services, the provider agrees not to bill the patient for any services or costs not paid by Medicaid. This is called “Balanced Billing” and in most situations it violates state and federal laws.

If your medical provider tries to bill you more for Medicaid services, contact your local legal aid office.

The only time that a medical provider can bill a Medicaid recipient for any service is if the provider tells the patient in writing in advance that the service is not covered by Medicaid and the patient agrees in writing in advance to pay the charges.

What is Medicaid Spend-down?

Some people fit the Aged, Blind, or Disabled category of Medicaid, but have income higher than the Medicaid limit for this category.

The income limit is about 64% of the federal poverty level.

How can I meet my Medicaid Spend-down?

There are several ways to meet Spend-down.

1. You, or someone else, can pay the amount of the Spend-down to the CDJFS each month just like an insurance premium.

2. You, or a family member for whom you are responsible, can incur medical care or services with the value of your Spend-down each month and submit these bills to your CDJFS. You only need to incur the cost of the medical care, you do not have to pay the bills to use them for Spend-down.

3. You can use unpaid past medical bills from a month when you were not eligible for Medicaid or Medicaid Spend-down.

Do I need to meet my Spend-down every month?

No, you do not have to meet your Spend-down every month.

You really only need to meet your Spend-down if you need care or need a prescription.

In fact, if you do not need medical care every month, but you do take prescription medications, you can meet your Spend-down every other month.

The way to do this is to meet your Spend-down on the first or second day of the month and fill your prescriptions that day; then, after you have used 80% of your prescription medications, you can get a refill before the end of the month.

How will I know if I am eligible for Medicaid?

The state Medicaid program will send you notices about your Medicaid benefits and also other public benefits programs.

These notices will tell you whether you are eligible to get the benefits and for what time periods you are eligible.

These notices may be confusing. If you don’t understand what the notice is about or if you have other questions, contact your caseworker.

What if I cannot reach my caseworker?

If you cannot reach your caseworker and he or she does not return your phone calls within a reasonable time, you should call back and ask to talk to your caseworker’s supervisor.

If you still cannot reach someone who can answer your questions, contact your local legal aid program.

What if I disagree with a decision about my Medicaid?

If you disagree with a decision about your Medicaid, you have a right to appeal.

The first step in an appeal is either a county conference or a state hearing.

If you ask for a county conference, you can later ask for a state hearing.

If you still disagree after a state hearing, you can ask for an administrative appeal. After an administrative appeal you can take your case to Common Pleas Court.

You can bring a lawyer, advocate, or friend to the hearings to help you.

If you want to talk with a lawyer, contact your local legal aid office.

What notices will Medicaid send me?

The state Medicaid program will send you notices about your Medicaid benefits and also other public benefits programs.

These notices will tell you whether you are eligible to get the benefits and for what time periods you are eligible.

These notices may be confusing.

If you don’t understand what the notice is about or if you have other questions, contact your caseworker. Make sure you keep all of the notices you receive from the state about your Medicaid.

Do I have a right to a hearing?

Yes, you have a right to a hearing if you disagree with a decision about your Medicaid. If you disagree with a decision about your Medicaid, you have a right to appeal.

The first step in an appeal is either a county conference or a state hearing. If you ask for a county conference, you can later ask for a state hearing. If you still disagree after a state hearing, you can ask for an administrative appeal.

After an administrative appeal you can take your case to Common Pleas Court.

How can I ask for a hearing about my Medicaid?

Every notice you receive from the state will have a “Hearing Request” page. This will be on the last two pages of the notice. This is a self-mailer so you can fold it in thirds and tape it closed. The back will already include the address and postage.

Complete this form and mail it to the state to request a hearing.  Find out more about hearings on the ODJFS Bureau of State Hearings website.

Will my Medicaid continue during my appeal?

If you request an appeal within 15 days of the date of the notice terminating your Medicaid, you can continue to get Medicaid while you appeal. If you lose your appeal, Medicaid can ask you to pay for the services you received after the notice.

What kind of citizenship documentation do I need to apply for Medicaid?

Federal law now requires all U.S. citizens to provide documentation when they apply for Medicaid or when their eligibility is reviewed by the state.

Applicants have to provide one document like a passport that proves both who they are and that they are a citizen, or they have to provide two documents--one that proves who they are and the other that proves they are a citizen.

For more information, see the ODJFS fact sheet.

What is Medicaid Managed Care?

Medicaid Managed Care is a system of providing Medicaid services using Managed Care Organizations (MCOs).

Almost all Medicaid recipients in Ohio, and most other states, now get their care from MCOs. MCOs, or Health Maintenance Organizations (HMOs), are paid by the state to provide care to Medicaid recipients. Medicaid recipients have to join a MCO to get Medicaid services.

Medicaid recipients can choose which MCO they will join, but if they do not choose a MCO, the state will pick one for them.

All MCOs have member handbooks that include the rights and responsibilities of the MCO and the members.

What is a Managed Care Network?

Each MCO must have a network of doctors, dentists, hospitals, pharmacies, and other medical providers to meet all of its members' medical and health needs.

The network must also be available in all of the geographic areas served by the MCO.

Do I have to use a doctor in my MCO’s network?

MCO members must get all their services from the MCO network.

If a member needs a service that is not available in the network, the MCO must find, and pay for, a provider outside of the network.

If a member uses a doctor, or other provider, not in the MCO network without getting approval from the MCO in advance, the member may have to pay for the services herself.

What if I have an emergency and have to go to a doctor or an emergency room that is not in my MCO’s network?

You can go to a provider outside of the network if you have an emergency or if you are outside of the area served by your MCO.

You should give the provider your MCO card and ask them to contact the MCO to explain why you need care.

Your MCO member handbook will tell you what to do if you have an emergency or need care outside of the area.

What is a Medicaid waiver? Who can get a waiver?

Medicaid waivers allow some Medicaid recipients to get care at home instead of a nursing home or other long term care facility.

The guidelines for the eight different waivers available in Ohio are very technical. There are limited spaces in the waiver programs.

ODJFS has two fact sheets about Medicaid waivers in Ohio: Home and Community-Based Services Waivers and Assisted Living Waiver.

What if I am eligible for both Medicaid and Medicare?

You can be eligible for, and receive services from, both Medicaid and Medicare.

If you are disabled or age 65 or older, you should apply for both Medicaid and Medicare.

If you are eligible for both, your caseworker will help you understand how the services are coordinated.

Can I get Medicaid if I already have private insurance?

Yes, if they meet the eligibility requirements, many people can get Medicaid even if they already have private insurance coverage.

If you qualify for both private insurance and Medicaid, the private insurance will always be billed first and then any remaining costs will be billed to Medicaid.

Some children in higher-income families may not be eligible for Medicaid if they have private insurance that covers doctor visits and hospitalization.

What if my income goes up or I get a job so I make too much to qualify for Medicaid?

If you are eligible for Medicaid and your income increases above the Medicaid eligibility level for your family, you can get Transitional Medicaid for as long as a year.

You must report all changes in income to your caseworker.

You have no limit on the amount of your income for the first six months of Transitional Medicaid. The limit for the next six months is 185% of the federal poverty level.

Will Medicaid ever ask me to pay for the services I receive?

There are copayments required for some Medicaid services, but Medicaid will never send you a bill for services you received while covered.

When you die, Medicaid may send a bill to your estate for any services you received at age 55 or older. This is called Estate Recovery.

Can I buy in to the Medicaid program?

MBIWD is an Ohio Medicaid program that provides health care coverage to working Ohioans with disabilities.

Historically, people with disabilities were often discouraged from working because their earnings made them ineligible for Medicaid coverage.

MBIWD was created to enable Ohioans with disabilities to work and still keep their health care coverage.

Can I get Medicaid for routine health care if I am an undocumented resident or worker?

No, most undocumented residents or workers cannot get Medicaid. Medicaid eligibility is limited to U.S. citizens and certain non-citizens.

ODJFS has a fact sheet on immigrant Medicaid eligibility.

Can I get Medicaid for emergency health care if I am an undocumented resident or worker?

Yes, people who do not meet the citizenship requirements or exceptions for Medicaid can use a Medicaid program--the Alien Emergency Medical Assistance program (AEMA)--for emergency medical needs and care arising out of the emergency situation.

You cannot apply for AEMA in advance like regular Medicaid or other health insurance.

You can apply for AEMA only when or after you have received the services, so you cannot know if AEMA will be approved before you go for care.

If you think you need health care, you should get the care you need and get help paying for it afterwards.

If you have questions about AEMA, or need help applying for AEMA or any Medicaid program, contact your local legal services program.

Can my children get Medicaid if I am not a citizen and I do not fit into one of the non-citizen exceptions?

Every person’s eligibility is based on their own circumstances so your children may be eligible for Medicaid even if you are not.

If your child is a U.S. citizen, they can be eligible for Medicaid if they meet the other Medicaid requirements.

Medicaid Program Overview

If your children are citizens or if they fall into one of the non-citizen exceptions, they can get Medicaid regardless of your citizen or residency status. If your child was born in the United States, s/he is automatically a U.S. Citizen.

If you or your child’s other parent was a U.S. citizen when the child was born, the child is automatically a citizen. (If you or the other parent are citizens of another country, your child may have dual citizenship in the U. S. and the other country.)

ODJFS has fact sheets on immigrant Medicaid eligibility.

You will not have to give any information in your child’s Medicaid application about your citizenship or residency.

How will the American Recovery and Reinvestment Act affect my Medicaid benefits?

Find out more about how your Medicaid benefits, including cash assistance, child care, and health care, are affected from the Ohio.gov Recovery website.

See also the Forms & Education tab in this section for more information.

The information in this site is not intended as legal advice.
Back to Top of Page | Didn't find it? Use Advanced Search | Back to Step 1


Click here to find legal help near you.

To find a civil legal aid provider, call

1.866.LAW.OHIO (1.866.529.6446)



For the hearing impaired:
Use this site to find the local
Ohio legal aid provider in your
area. Then, call the Ohio Relay
Service at 1-800-750-0750 and
ask the service operator to
connect you to the provider
you are trying to call.


The information in this site is
not intended as legal advice.


 

Personal tools