WHAT IS MEDICAID?Medicaid is a State and Federal medical assistance program that pays medical bills for eligible, needy persons. All payments are made directly to the providers of medical and other health care services. The Medicaid-eligible person does not pay the health care provider for services. The only exception is a patient in a Medicaid approved nursing home who may be required to contribute part of his or her income toward the cost of care.
Managed Care – All Medicaid recipients will be asked to choose a managed care provider. Those who have no preference will be assigned. The managed care providers in Somerset County are: Amerigroup, United Healthcare, Horizon NJ Health, Wellcare and Aetna Better Health of NJ. All recipients medical needs will be met through the managed care provider.
WHAT SERVICES DOES MEDICAID COVER?Medicaid pays for:
- Physician services in the office, clinic or other medical facility;
- A special program for children, known as Early Periodic Screening, Diagnosis and Treatment or EPSDT;
- Prescribed drugs from a pharmacy;
- Hospital, inpatient and outpatient care;
- Home health care, nursing home care, and medical day care as planned by your doctor;
- Clinic services including family planning and rehabilitation services, such as physical, speech language, or occupational therapy as prescribed by your doctor;
- Mental health services in a doctor’s office or approved mental health clinic;
- X-ray and laboratory service;
- Ambulance and invalid coach service as prescribed by your doctor;
- Medical supplies and equipment;
transportation to and from Medicaid approved health care services when it is not otherwise available;
- Personal care assistant services.
WHAT MEDICAID PROGRAMS ARE AVAILABLE THROUGH THE SOMERSET COUNTY BOARD OF SOCIAL SERVICES?
TANF Related Medicaid – Most recipients of a TANF money grant are eligible to receive Medicaid. Persons who are eligible for a TANF grant may elect to receive Medicaid only. Persons who are no longer eligible for a money grant due to the receipt of earned income, unemployment or state disability payments or child support may receive extended Medicaid benefits for an additional 4-24 months.
Medicaid Special – Children up to age 21 – all children under the age of 21 may be eligible for Medicaid benefits depending upon their living arrangements, income and resources.
New Jersey Care for Pregnant Women and Children – Pregnant women may receive Medicaid benefits until 60 days after the end of their pregnancy. The newborn is covered for the first year. Children born after 9/30/83 may also be covered under this program. The income level is set by the current Federal Poverty Level. There are no resource limitations for this program.
NJ KidCare – Children whose family income is under 350% of the poverty level and who have not reached age 19 can be covered under this program.
ACA Medicaid-Available to any individual that is income eligible and does not receive Medicare benefits.
PROGRAMS FOR THE ELDERLY AND DISABLED
Medicaid in the Community – Individuals who are disabled or over 65 who have lost their SSI eligibility due to Social Security payment increases may be eligible to receive Medicaid benefits in the community. Also eligible are persons who would otherwise be entitled to an SSI money payment but who do not wish to apply.
New Jersey Care for Elderly and Disabled – Elderly and disabled persons whose income is below the present Federal Poverty Level may be eligible for the total Medicaid coverage under this program, depending upon the amount of their resources and their living arrangement.
Nursing Home Program – Persons in need of long term care in a nursing home may be eligible for Medicaid depending upon their income and resources. However, income limits for this program are considerably higher than those for Medicaid in the community. Eligible persons may have to contribute their monthly income (less a personal needs allowance) toward the payment of the nursing home costs.
NJ Workability – Individuals with permanent disabilities who are between age 16 and 65 and are working may be eligible for Medicaid under this program. Earnings may be as high as 250% of the Federal Poverty Limit (over $45,000 per year) and countable assets may be up to $20,000. A person’s own Social Security benefit is disregarded, but any other unearned income may not exceed the Federal Poverty Limit.
LIMITED BENEFIT PROGRAMS
Medically Needy Program - This program provides limited coverage to persons who are disabled or over 65, pregnant women, and children under 21. This program does not pay for inpatient hospital costs except for pregnant women. It does not pay for prescription costs for the elderly and disabled. The income limit for pregnant women and children is higher than that for TANF. The income limit for the elderly and disabled is less than that for SSI. The resource limits are comparatively high. Persons who have large out of pocket medical expenses who are ineligible for any other Medicaid program may apply for this one as there is a spend down provision in addition to the income limitation.
WHAT IF I HAVE MEDICARE?
If you are 65 or over or disabled, you could be eligible for both Medicaid and Medicare. As a supplement to Medicare, Medicaid will pay for certain services and items not covered by Medicare, and also provides necessary medical care when your Medicare benefits are exhausted. Medicaid will also pay the Part B medical premium. You must use your Medicare benefits first before Medicaid will pay for your health care services.
WHAT IF I HAVE OTHER HEALTH INSURANCE?
If you have other health insurance, you must give this information when you apply for assistance. Federal and State laws require all other sources of payment for medical care to be used before Medicaid will pay a bill. Some examples of other sources are: Blue Cross, Worker’s Compensation, and third party insurance benefits resulting from an automobile accident or other injury. As a condition of eligibility for Medicaid benefits, a person must permit the Medicaid Program to use these sources of payment before Medicaid will pay for medical or health care services.
WILL I HAVE A MEDICAID CARD?
Yes, you will receive a Medicaid card. You will also receive an identification card from your HMO.
HOW DOES THE PROGRAM WORK?
Those persons in Managed Care and HMO’s will go to the primary doctor assigned to them. This doctor will make referrals as needed. Other participants may go to any participating doctor or provider for treatment or service. If you do not know where to go for health service, call the Medical Assistance Customer Center at 732-863-4400 for the name of providers in your area.
HOW DO I APPLY FOR MEDICAID IN SOMERSET COUNTY?
You may apply for the Medicaid by applying on-line at: www.njhelps.org
Persons may apply for most Medicaid Programs at any one of the three offices of the Somerset County Board of Social Services.
Persons wishing to apply for Adult Related Medicaid Programs may apply at the Somerville office. It is best to call for an appointment. If a person is too ill or disabled to come for an office visit, a home visit will be arranged or an authorized representative may be able to apply on the applicant’s behalf.