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Medicaid: What It Is, How to Qualify, and When to Seek Legal Advice

Medicare and Medicaid are both government programs which provide medical and other health-related services to specific individuals in the United States. However, the two programs are vastly different, which may make it difficult to determine which program is right for you.

Medicare is a federally-regulated insurance program serving all people over 65 (regardless of income level), younger disabled people, and dialysis patients specifically. If you qualify for Medicare, you will be required to pay part of the costs through deductibles for hospital and other medical costs. Additionally, small monthly premiums may be required for non-hospital coverage.

In contrast, Medicaid is a federal-state assistance program that serves low-income people of every age. Unlike Medicare, which boasts basically the same eligibility requirements nationwide, the requirements to qualify for Medicaid are different from state to state.

If a Medicaid applicant meets the requirements for Medicaid in his or her state, the applicant will usually pay no part of costs for covered medical expenses. A small co-payment is sometimes required.

Who Qualifies for Medicaid? “Georgia is one of the hardest states for individuals to qualify for Medicaid,” explains attorney Drew Tuggle with Whitehurst, Blackburn & Warren. “However, there are some benefits to Georgia’s Medicaid program that other states don’t offer.”

You may be eligible for Medicaid if your income is low, and you match one of the following descriptions:

  • You think you are pregnant.

  • You are a child or teenager.

  • You are age 65 or older.

  • You are legally blind.

  • You have a disability (defined as the inability to engage in any substantial gainful activity by reason of a medically determinable physical or mental impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than 12 months).

  • You need nursing home care.

In Georgia, if you are age 65 or older, blind, or have a disability, you can apply for Supplemental Security Income (SSI) by contacting your local Social Security office. If you are approved for supplemental income, you will automatically receive Medicaid.

Medicaid Exemptions As it relates to the income threshold to qualify for Medicaid, “there are some exemptions you need to keep in mind when making your initial eligibility determination, the most important of which is Georgia’s home exemption” says Tuggle.

In Georgia, as of 2018, your home and any household goods contained in the home are exempt from being considered for the purposes of qualifying for Medicaid. Additionally, Georgia will not count a car as part of your resources, regardless of its value.

And there are ways to keep your exemptions even when you are struggling to pay your mortgage or no longer live in the home as your primary residence. These ownership issues can be complex, and it is best to work with an experience legal team to determine the best steps for you.

What Does Medicaid Cover?

In general, people who participate in Medicaid are provided, with limitations and parameters, coverage for the following:

  • Doctor and / or nurse office visits

  • Prescription drugs

  • Inpatient and outpatient hospital services

  • Nursing facilities

  • Medical equipment and supplies

  • Home health services

  • Hospice

“Medicaid also provides dental, vision and hearing coverage for children who qualify,” adds Tuggle. “Adults are not afforded the same coverage, but adults may be covered for preventative dental services such as fillings and oral surgery, if said procedure is deemed to be an emergency”

What's Not Covered?

The following services are not covered by Medicaid:

  • Any service that is not medically necessary

  • Private duty nursing

  • Medical services and care given by a responsible relative or member of your household

  • Cosmetic surgery

  • Experimental items and chiropractic services, among others.

The biggest thing to remember as it relates to coverage is simple, “If you aren’t sure what is covered, call your Medicaid provider, and they will be happy to help determine whether the service you wish to undergo is covered by Medicaid,” Tuggle says.

Additionally, Tuggle recommends “that you always check with your treating physician to make sure they accept Medicaid. Even if Medicaid is willing to cover a procedure, many doctors health care providers won’t accept Medicaid, and aren’t required by law to do so. With that being said, your Medicaid provider should have a list of doctors who accept Medicaid in your area.”

Do I Need a Lawyer to Apply for Medicaid?

There are several issues which may require you to hire legal counsel to guide you through Georgia’s arduous Medicaid application process. First and foremost, the application is lengthy, full of legal jargon, and any minor error may cause your application to be denied, further delaying necessary medical treatment. For these reasons, Tuggle strongly advises seeking legal counsel if you to need to receive approval for Medicaid coverage in the near future.

“No matter what potential issues may lie in wait for you while applying for Medicare or Medicaid, it will always be in your best interest to seek the advice of legal counsel as soon as possible, because waiting until the last minute may lead to irreversible error on the part of the applicant,” says Tuggle.

The experienced attorneys at Whitehurst, Blackburn & Warren are well-versed in this subset of Georgia law. To get started today and schedule your free, no obligation consultation, contact us at (229) 226-2161.

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