Medicaid and Cancer: Who Qualifies and What It Covers

Medicaid is a joint federal and state health coverage program. Washington sets a floor of rules and pays a share of the bill. Your state builds its own program on top of that floor and runs the day-to-day. That is why the honest answer to "does Medicaid cover this?" always starts with "which state are you in?"

For people who qualify, Medicaid is comprehensive coverage, not a discount card. There are usually no premiums and only nominal cost sharing. And it can start before the day you applied.

People give up on Medicaid because they compared their pay to one income number and stopped. There are at least four separate pathways. Cancer patients qualify through all of them.

1. MAGI income (most adults under 65). Modified adjusted gross income looks at taxable income and tax filing relationships. On this pathway your savings, your house and your car are not counted at all. Medicaid.gov says states "were given the option to extend eligibility to adults with income at or below 133% of the FPL," and that most states have chosen to expand. In a state that did not expand, an adult with no dependent children may be turned down at a much lower income, or at any income.

2. Age, blindness or disability. Are you 65 or older, blind, or living with a qualifying disability? Then you are assessed under older rules that count resources as well as income. People who receive Supplemental Security Income are a group every state must cover.

3. Medically needy, or spend-down. Medicaid.gov says medically needy individuals "can still become eligible by 'spending down' the amount of income that is above a state's medically needy income standard" by incurring expenses for care they have no insurance for. Cancer generates exactly those expenses. Not every state runs a medically needy program, so ask yours by name.

4. The breast and cervical cancer group. This is a distinct eligibility category. It covers people under 65 who were screened through the CDC's National Breast and Cervical Cancer Early Detection Program, need treatment, and have no other creditable coverage. There is no income or resource test on this pathway.

Ask a caseworker to check you against all four. Do not let one screen-out end the conversation.

Federal rules require every state program to include a set of mandatory benefits. The ones that matter most during treatment are inpatient and outpatient hospital services, physician services, and laboratory and X-ray services. In practice that covers surgery, hospital admissions, oncologist visits, imaging and pathology.

Other benefits are optional for states, and prescription drugs are the big one. Every state currently offers a drug benefit. But the formulary, the prior authorisation rules and any small copay are set by your state. If you are in a Medicaid managed care plan, that plan sets them too.

Two coverage areas are worth naming out loud, because people do not know to ask:

• Rides to appointments. Federal regulations require state Medicaid agencies to "assure necessary transportation for clients to and from providers." Ask your plan how to book non-emergency medical transportation, and how far ahead.
• Retroactive coverage. Benefits may be covered "for up to three months prior to the month of application, if the individual would have been eligible during that period." Ask which months apply to you before you pay any old bill.

Skip the general search results. Go to Medicaid.gov's state directory, titled "Where can people get help with Medicaid and CHIP." It lists every state agency with its own phone number and enrollment portal. That is the only place that will give you your state's real income limit, its managed care plans, and its application.

You can apply on any day of the year. There is no enrollment window for Medicaid. Apply directly to the state, or fill out one application at HealthCare.gov. That line is 1-800-318-2596, TTY 1-855-889-4325, open 24 hours a day except holidays. It forwards your details to the state if you may qualify.

Having Medicare does not shut you out. People who qualify for both are "dually eligible." Medicare pays first for covered services, and Medicaid pays last, after Medicare and any other insurance.

Medicaid may also pick up your Medicare premiums, deductibles and coinsurance through a Medicare Savings Program. And people with full Medicaid get Extra Help with Part D drug costs automatically.

Your hospital's financial counselor or oncology social worker can file a Medicaid application on your behalf. They do it every week.

Outside the hospital, two organizations help free. Patient Advocate Foundation at (800) 532-5274 provides case management on coverage problems. Triage Cancer at 424-258-4628 publishes state-by-state guides to how these rules actually work where you live.