MedicaidA joint federal and state program that helps with medical costs for some people with limited income and resources. is a state and federal program that provides free or low-cost health insuranceA type of insurance that pays for some or all of your medical expenses.
based on your income and the size of your family.
Who is Eligible?
In general, low-income individuals and families, children, most pregnant women, and individuals who are blind or have a disabilityAny condition of the body or mind that makes it more difficult for the person with the condition to do certain activities and interact with the world around them. are eligible for MedicaidA joint federal and state program that helps with medical costs for some people with limited income and resources.. If you are age 65 or older, or have ALS (Lou Gehrig’s disease) or end-stage renal disease, you may be eligible for MedicareThe federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant). instead.
To find out if you are eligible for Medicaid, you will need to apply for it. See “Applying for Medicaid” below. Also see the Medicaid & CHIP for American Indians website.
Types of Medicaid
American Indians have a choice between MedicaidA joint federal and state program that helps with medical costs for some people with limited income and resources. Fee-for-Service or a Medicaid Managed CareA health care delivery system that combines health insurance, delivery of care, and administration. Managed Care Organizations (MCOs) are paid a set payment per member per month for these services. plan (see descriptions below). However, if you already have MedicareThe federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant). or you need long-term careServices for people who cannot do basic activities of daily living, like dressing or bathing. This includes medical and non-medical care. These services can be provided at home or in assisted living or nursing homes. Medicare and most health insurance plans do not pay for long-term care. services (such as a nursing home or in-home care), you will need to select a Managed Care plan.
- Medicaid Fee-for-Service: If you have Medicaid Fee-for-Service, it means that your healthcare providers are reimbursed by Medicaid for each service that you receive. You will be able to see any healthcare provider that accepts Medicaid Fee-for-Service.
- Medicaid Managed Care: If you have a Medicaid Managed Care plan (called Centennial CareNew Mexico’s Medicaid Managed Care program since January 2014. in New Mexico), it means that your care is paid for by a contract between the state and a Managed Care Organization (MCO) that gets a set payment per month for each member. As of January 1, 2019, Medicaid Managed Care is provided by Blue Cross/Blue Shield of New Mexico, Presbyterian Health Plan, and Western Sky Community Care (Centene Corp.). If you choose Medicaid Managed Care, you will select a plan from one of these organizations when you sign up for Medicaid. You will be able to see any healthcare provider that accepts the plan you choose.
What Medicaid Covers
MedicaidA joint federal and state program that helps with medical costs for some people with limited income and resources. plans will cover:
- Medical care received in the three months prior to your Medicaid application: You can get this coverage as long as your income was not substantially higher in the three months before you applied for Medicaid. To find out whether you qualify for this coverage, you will want to apply for it right away.
- Physical health services, including check-ups, diagnostic tests, treatment for illnesses and injuries.
- Dental care.
- Behavioral health services, meaning mental health and substance abuse services, like counseling.
- Prescription medications: If you have Medicaid, there are usually no out-of-pocketCosts for health care or prescription drugs that you must pay on your own because they are not covered by your health insurance plan. costs for medications on your health plan’s “formularyA list of prescription drugs that an insurance plan will cover. Also called a “drug list.”” (a list of medications that your health plan will pay for).
- Long-term careServices for people who cannot do basic activities of daily living, like dressing or bathing. This includes medical and non-medical care. These services can be provided at home or in assisted living or nursing homes. Medicare and most health insurance plans do not pay for long-term care.:
- Medicaid Managed CareA health care delivery system that combines health insurance, delivery of care, and administration. Managed Care Organizations (MCOs) are paid a set payment per member per month for these services. plans will cover nursing home and in-home care for low-income seniors. This benefit is not available for individuals enrolled in Medicaid Fee-for-Service.
- Institutional Care Medicaid covers nursing home care for individuals who are age 65 or older or who have a disabilityAny condition of the body or mind that makes it more difficult for the person with the condition to do certain activities and interact with the world around them. that is expected to last at least 12 months, who require a nursing home level of care, and whose income is below a certain level.
- Centennial CareNew Mexico’s Medicaid Managed Care program since January 2014. Community Benefit (formerly known as CoLTS) covers many in-home care services for individuals who are eligible for nursing home care but who can receive services at home or in an assisted livingA facility that provides care for seniors who want to stay independent but who need some help with activities of daily living, like bathing, dressing, eating, and moving around. facility. However, funding for this coverage is limited and there is usually a waiting list.
- Medical equipment: Medicaid will cover eye exams and one pair of glasses per year.
- Medicaid Fee-for-Service will cover hearing aids and other durable medical equipmentCertain equipment, like a walker, wheelchair, or hospital bed, that’s ordered by your doctor for use in the home., such as oxygen equipment, wheelchairs, or blood test strips. Medicaid Managed Care plans may also cover these things if they are “medically necessaryThis refers to care or equipment that your doctor has prescribed to treat an illness or condition.,” meaning that your doctor prescribes them to treat an illness or injury.
- Home modifications: If you require the level of care that is typically required to be in nursing home, you can get help living at home, including home modifications, from a Medicaid Managed Care program called Centennial Care Community Benefit.
- Transportation: Medicaid will cover ambulance services for emergencies. If you need emergency transportation, call 911. Medicaid also offers transportation services to help you get to and from your medically-necessary, non-emergency medical appointments. Most transportation services require you to make an appointment several days in advance and may only cover transportation to medical services that are covered by your insurance. Some Medicaid plans will reimburse you for transportation costs, including gas and bus fares, and meals and lodging if it is necessary for you to travel away from home overnight.
- Traditional healing and alternative therapies: Traditional healing for American Indians is covered by Medicaid Managed Care plans up to a certain amount, such as $100, per year. To have a traditional healer’s services covered, you may have to fill out a form certifying that you are using the reimbursement for traditional healing. Other alternative therapies, such as acupuncture, massage, naturopathy, homeopathy, or biofeedback, may be covered by some Medicaid plans.
To find out exactly what your Medicaid plan will cover, call the number on the back of your health insuranceA type of insurance that pays for some or all of your medical expenses.
card or review your Member HandbookThe handbook you receive when you sign up for a health insurance plan. It includes information on what providers are in your network, what benefits are covered, and how much they will cost. .
Applying for Medicaid
You can apply for MedicaidA joint federal and state program that helps with medical costs for some people with limited income and resources. in person or online. If you would like to apply by yourself, you can see the Medicaid website for further information.
Applying for and renewing Medicaid can be complicated and confusing, so it’s a good idea to get in-person assistance. You can get help from the Benefits Coordinator at your local IHS or Tribal clinic, or a Patient Navigator or insurance broker. In New Mexico, BeWellNM has counselors specifically for American Indians; call (855) 241-8137 or visit their office at 6403 Menaul Blvd. NE in Albuquerque.
When you apply for Medicaid, you may need to provide the following documents or information:
- Proof of age (for example: birth certificate, driver’s license, passport)
- Proof of citizenship (for example: birth certificate, passport, Tribal enrollment card, Certificate of Degree of Indian Blood)
- Proof of all your sources of income (for example: paystubs, Social SecurityA federal program that provides retirement, disability, and survivor benefits. Most Social Security benefits are based on taxes that you paid on your wages while working., Supplemental Security IncomeA monthly benefit paid by Social Security to people with limited income who are disabled, blind, or age 65 and older. These are not the same as Social Security retirement or disability benefits., Veterans benefits, any other income)
- Proof of assets (for example: bank statements)
- Proof of disabilityAny condition of the body or mind that makes it more difficult for the person with the condition to do certain activities and interact with the world around them.
- Proof of residence (for example: recent mail addressed to you, rent receipts, a copy of your mortgage)
- Proof of any other health insuranceA type of insurance that pays for some or all of your medical expenses.
(any other current health insurance cards)
You can also check online to see if you are eligible. See the Medicaid Program, Benefits Category page on the Benefits.gov website. You can also apply on the YesNM page on the New Mexico Human Services department website.
Using Medicaid and Staying Covered
Whenever you go to a healthcare provider, including the IHS, bring your insurance card with you and make sure the provider’s office knows that you have MedicaidA joint federal and state program that helps with medical costs for some people with limited income and resources. (make sure to say whether you have Medicaid Fee-for-Service or a Managed CareA health care delivery system that combines health insurance, delivery of care, and administration. Managed Care Organizations (MCOs) are paid a set payment per member per month for these services. plan). If a healthcare provider does not accept your health insuranceA type of insurance that pays for some or all of your medical expenses.
, ask them to refer you to one who does.
You must renew your Medicaid coverage every year. In the month before your renewal is due, you will receive a renewal application in the mail.
If you, your spouse, or any of your dependents experience changes to your address, income, family size, or other insurance, your eligibility for Medicaid may change. Make sure to read and keep any information you receive regarding your Medicaid in case there are changes that require your attention. Your IHS Benefits Coordinator can help you report changes or see the How to Report Changes to the Marketplace page on the Healthcare.gov website. You can also report changes by logging in to your Healthcare.gov account or by calling (800) 318-2596 or TTY (855) 889-4325.