Medicaid, known in Michigan as Medical Assistance (MA), provides crucial health insurance coverage for individuals and families with limited income. Within Michigan, there are two primary Medicaid programs: Traditional Medicaid (TM) and the Healthy Michigan Plan (HMP). Launched in 2014 as a component of the Affordable Care Act, HMP expanded access to health care for many Michigan residents. Once enrolled in either TM or HMP, beneficiaries gain access to health coverage that functions similarly to other health insurance plans, assisting with medical expenses and promoting access to care.
Navigating Michigan Medicaid Programs: Traditional Medicaid (TM) and Healthy Michigan Plan (HMP)
Determining eligibility for Michigan Medicaid, whether TM or HMP, involves meeting specific criteria established by the Michigan Department of Health and Human Services (MDHHS). These requirements encompass both financial aspects, primarily income limitations, and non-financial factors such as residency and citizenship status. Eligibility can also be determined based on age, disability, or blindness. The MDHHS carefully evaluates each application to ascertain if an applicant qualifies for Medicaid benefits.
While both HMP and TM share fundamental eligibility requirements, including Michigan residency and income below a defined threshold, key distinctions exist. Traditional Medicaid incorporates an asset limit, whereas the Healthy Michigan Plan does not. Furthermore, TM is structured into various categories or sub-programs, necessitating applicants to fit into one of these categories to qualify. HMP, conversely, does not have such categorical divisions, often making it easier to qualify for.
However, it’s important to note that certain population groups are specifically directed towards Traditional Medicaid and are not eligible for the Healthy Michigan Plan. These groups include:
- Minor children
- Pregnant women
- Individuals aged 65 or older
- People who are eligible for or receiving Medicare
These specific groups typically fall under designated categories within Traditional Medicaid. Consequently, if they satisfy the broader eligibility criteria for Medicaid, they will generally be enrolled in Traditional Medicaid rather than the Healthy Michigan Plan.
Exploring Traditional Medicaid (TM) Categories
Traditional Medicaid (TM) categories are organized into two main groups, Group 1 and Group 2, each with distinct income requirements. Group 1 programs are designed for individuals with net incomes at or below a specified limit. Net income is calculated as countable income minus allowable deductions.
Group 2 programs also operate with a net income limit. However, a significant feature of Group 2 programs is that eligibility can still be achieved even if an applicant’s income exceeds the standard limit. This is because Group 2 programs take into account an applicant’s medical expenses when determining eligibility. Some Group 2 programs may also incorporate a deductible or “spend-down.” A deductible represents the amount of healthcare costs an individual must pay out-of-pocket before their Medicaid benefits commence. For instance, with a $100 deductible, the beneficiary is responsible for the initial $100 of their healthcare expenses before Medicaid coverage begins.
For detailed information on the specific categories within Michigan’s Traditional Medicaid program, please refer to the “Health Care Programs Eligibility” page on the official MDHHS website. This resource provides comprehensive details on each category and their respective eligibility criteria.
Medicaid Eligibility Linked to Supplemental Security Income (SSI)
Individuals receiving Supplemental Security Income (SSI) benefits may automatically qualify for Traditional Medicaid. This automatic eligibility applies if two conditions are met:
- The individual is a resident of Michigan.
- The individual agrees to cooperate with third-party resource liability requirements.
A third-party resource refers to any entity, person, or program that is or could be responsible for covering some or all of an individual’s medical expenses.
Even if an individual does not receive SSI, they may still be eligible for either the Healthy Michigan Plan or Traditional Medicaid based on factors like age, disability, or blindness. For personalized guidance and to explore these pathways to eligibility, reaching out to the Michigan Medicare/Medicaid Assistance Program (MMAP) is recommended. MMAP offers free, statewide counseling services dedicated to assisting individuals with their health care questions and concerns.
Furthermore, local legal services offices can provide free legal assistance and advice regarding Medicaid eligibility. The Guide to Legal Help can help locate a legal services office in your vicinity. While they may not offer direct representation in all cases, they can provide valuable advice and support.
Another helpful resource is a local Federally Qualified Health Center (FQHC). FQHCs are community-based healthcare providers that receive funding from the Health Resources & Services Administration (HRSA). They often employ patient advocates who can answer questions about Medicaid programs and eligibility. Use the locator tool to find an FQHC near you.
Income and Asset Limits for Michigan Medicaid
Both the Healthy Michigan Plan and each category within Traditional Medicaid have established income limits. Additionally, certain Traditional Medicaid categories also include asset limits. These limits vary depending on the specific program. It’s important to reiterate that the Healthy Michigan Plan does not have any asset limits.
Understanding Income for Medicaid Eligibility
Income is defined as money received by an applicant. The MDHHS will assess income from various sources, including:
- Wages from employment, encompassing both traditional employment and self-employment.
- Child support payments.
- Disability benefits.
- Unemployment benefits.
It is important to note that MDHHS may not count all received money as income. For example, SSI benefits received are typically not counted as income for Medicaid eligibility purposes.
Understanding Assets for Medicaid Eligibility
Assets are defined as items owned by an individual. Examples of assets include:
- Cash on hand and in bank accounts.
- Personal property, such as vehicles and valuable collections.
- Real property, which includes land and any structures on it.
- Financial assets such as investments, retirement accounts, life insurance policies (depending on type and cash value), and trusts.
It is crucial to know that there are no asset limits for Traditional Medicaid categories designed for eligible children, pregnant women, and certain families with minor children. However, most other Traditional Medicaid categories do have asset limits. As previously mentioned, the Healthy Michigan Plan has no asset limits.
For in-depth information on specific income and asset limits for various Michigan Medicaid programs, please consult the article “Income and Asset Limits for Medicaid.”
Additional Eligibility Requirements for Michigan Medicaid
Beyond income and asset limitations, several other requirements must be met to qualify for Traditional Medicaid or the Healthy Michigan Plan. Depending on individual circumstances, applicants must:
- Be a resident of the state of Michigan.
- Possess a Social Security number or actively work with MDHHS to obtain one.
- Be a U.S. citizen or an immigrant holding a specific qualified immigration status.
- Be willing to report specific information to MDHHS as required.
- Apply for any other state or federal benefits for which they might be eligible.
Michigan Residency Explained
Establishing Michigan residency simply means living within the state of Michigan. Temporary absences from the state, such as for vacation or seasonal travel, do not jeopardize residency status as long as the individual intends to return to Michigan. For instance, spending winter months in a warmer climate does not negate Michigan residency if the individual plans to return to their Michigan home.
Individuals experiencing homelessness are still eligible to apply for and receive Traditional Medicaid or the Healthy Michigan Plan. Lacking a permanent address does not disqualify an individual from being considered a Michigan resident for Medicaid purposes. Medicaid eligibility will not be denied solely based on homelessness. For further clarification and assistance, individuals experiencing homelessness can contact MMAP or local legal services offices. FQHCs are also valuable resources for answering questions about Medicaid eligibility and providing support.
Citizenship and Immigration Status Requirements
To be eligible for Traditional Medicaid or the Healthy Michigan Plan, applicants must be either a U.S. citizen or hold a specific qualified immigration status. The term “qualified alien” encompasses various immigration statuses that may qualify an individual for Medicaid, such as:
- Lawfully Admitted Permanent Residents (LPRs), commonly known as green card holders.
- Asylees, individuals granted asylum in the U.S.
- Refugees, individuals admitted to the U.S. as refugees.
For detailed information regarding specific immigration statuses and their implications for Medicaid eligibility, contacting MMAP or consulting with immigration lawyers and legal services lawyers through the Guide to Legal Help is recommended. FQHCs can also provide assistance with Medicaid questions related to immigration status.
It’s important to note that emergency medical services are available to all individuals regardless of citizenship or immigration status.
Reporting Information to MDHHS
Maintaining eligibility for and receiving ongoing benefits from Traditional Medicaid or the Healthy Michigan Plan requires reporting certain information to MDHHS. Examples of reportable information include:
- Changes in income and assets.
- Paternity of children and child support information.
- Details regarding third-party resources that may be liable for medical expenses.
A “good cause exemption” exists for the child support cooperation requirement in cases where an applicant is a survivor of domestic violence.
Freedom to Work: Medicaid for Working Individuals with Disabilities
Michigan’s “Freedom to Work” law enables individuals with disabilities to receive Traditional Medicaid coverage while employed. To qualify under this provision, individuals must meet all of the following criteria:
- Be classified as disabled according to Social Security Administration (SSA) standards.
- Be currently employed.
- Be between the ages of 16 and 64.
- Fulfill the general “Other Eligibility Requirements” outlined earlier.
This program also has income and asset limits. Individuals with substantial work income may be required to pay a premium, a monthly payment for their Medicaid coverage. The premium amount typically increases with higher income levels. For further information and personalized guidance, contact MMAP, local legal services offices, or FQHCs.
Medicaid Eligibility for Disabled Adult Children (DAC)
Certain disabled adult children (DAC) may be eligible for Traditional Medicaid if they meet specific criteria. Eligibility for DAC Medicaid requires that the individual:
- Be at least 18 years of age.
- Have previously received SSI benefits but ceased receiving them due to becoming eligible for Disabled Adult Child Retirement, Survivors, and Disability Insurance (RSDI) benefits.
- Would still be eligible for SSI if not for the RSDI benefits.
To explore eligibility for DAC Medicaid and for assistance with the application process, individuals can contact MMAP, local legal services offices, or FQHCs.
Applying for Michigan Medicaid: A Step-by-Step Guide
To initiate the application process for either Traditional Medicaid or the Healthy Michigan Plan, an application must be submitted to the MDHHS. The most efficient method for applying is online through the MI Bridges Portal. Applying online provides immediate proof of application submission. Applications can also be submitted in person at a local MDHHS office. MDHHS offices are obligated to provide paper application forms upon request. Alternatively, an application form can be printed, completed, and brought to an MDHHS office.
Assistance from a friend or family member in completing the application is permissible. For individuals with reading or writing difficulties, MDHHS is required to provide assistance; it’s essential to inform them of the need for help. Some MDHHS offices provide computer stations for online application submission through the MI Bridges Portal, with staff assistance available.
During the application process, applicants will need to verify key information by providing documentation. This may include documents like birth certificates, Social Security cards, state ID cards, driver’s licenses, or passports. Documents verifying income and expenses, such as recent pay stubs and bank statements (less than 30 days old), may also be required.
Submitting an application implies a legal attestation that all provided information is truthful and complete to the best of the applicant’s knowledge. If any question is unclear, seeking clarification is always preferable to guessing.
For applicants with limited English proficiency, MDHHS is mandated to provide interpreter services. It’s crucial to inform MDHHS of the need for an interpreter or assistance with understanding English documents. Applicants have the right to bring their own interpreter if preferred. The Medicaid application is also available in Spanish and Arabic. Online applications can be completed with assistance from someone who can help with language interpretation.
In most cases, MDHHS has a 45-day timeframe to process applications and make a decision. If a disability determination is required as part of the application, the processing timeframe extends to 90 days. For pregnant applicants, MDHHS is required to make a decision within 15 days.
Accessing and Maintaining Michigan Medicaid Coverage (HMP/TM)
Upon approval for Traditional Medicaid or the Healthy Michigan Plan, recipients will receive an eligibility letter outlining their coverage details and an enrollment card. Questions regarding coverage can be directed to member services using the contact number provided in the eligibility letter or on the back of the enrollment card.
To ensure healthcare providers and pharmacies accept Medicaid coverage, it’s advisable to contact their offices directly to confirm. Provider directories are also often available on the respective program’s website.
Avoiding Billing Issues with Michigan Medicaid
To prevent billing complications, always verify that healthcare providers accept the specific Medicaid coverage (TM or HMP) before receiving services or obtaining medications. It is also crucial to promptly inform providers of any changes in personal information or insurance details.
Reporting Changes to Maintain Medicaid Eligibility
It is mandatory to report any changes in household size, income, or assets to MDHHS. These changes must be reported within 10 days of their occurrence. Failure to report changes in a timely manner can lead to benefit reduction or termination. The most efficient and reliable method for reporting changes is through the MI Bridges online portal. Alternatively, changes can be reported by calling MI Bridges at 888-642-7434 or by using DHS Form-2240.
It is best practice to report changes in writing and retain copies of emails, faxes, or letters as proof of timely reporting. If a reported change results in an unfavorable action, such as loss of coverage or an increased deductible, beneficiaries have the right to request a hearing. The Do-It-Yourself MDHHS Hearing Request tool can assist in completing and submitting a hearing request. Always retain a copy of the request for personal records.
Requesting a Hearing for Medicaid Decisions
If MDHHS takes an action or makes a decision that is disagreed with, such as denial, termination, or reduction of benefits, a hearing can be requested. The Do-It-Yourself MDHHS Hearing Request tool simplifies the process of completing the hearing request form. Make sure to keep a copy of the completed form for your records.
Hearing requests can be submitted by fax, mail, or in person. If faxing, retain the fax confirmation. If mailing, consider using certified mail for proof of delivery. Address the request to the “Hearing Coordinator,” not the caseworker. For in-person submissions, sign the office lobby log book (if available) and photograph the signature as record. Alternatively, request a date-stamped copy of the submitted form as proof of receipt.
To ensure continued Medicaid coverage while awaiting a hearing decision, it is crucial to request the hearing before the effective action date specified on the MDHHS notice. The effective date for Medicaid actions is invariably the first day of the month. Federal law mandates that coverage continue if a hearing is requested before the effective action date.
While older MDHHS policies stipulated a 10-day deadline for hearing requests, this policy has been revised, although system updates may not fully reflect this change. If facing issues related to this outdated 10-day notice, seeking assistance from a local legal services office is recommended.
Outcomes of a Successful Hearing
If a hearing is won, MDHHS will cover any outstanding medical bills incurred during periods of lapsed coverage. Reimbursement for out-of-pocket medical expenses paid during periods of denied coverage may also be possible. However, pursuing reimbursement can be complex, and consulting with a lawyer for assistance is advisable. The Guide to Legal Help can help locate lawyers or legal services offices in your area.
