Medicaid and Cancer: Who Qualifies and What It Covers

This page is for people with cancer, and their families, who want to know whether Medicaid can help pay for care. It explains how Medicaid works, the different ways to qualify, what it covers, and where to get help applying.

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. 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. The FPL is the federal poverty level. Medicaid.gov says states "were given the option to extend eligibility to adults with income at or below 133% of the FPL." Not every state has used that option, so the income limit for adults depends on your state.

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." They do this 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. States may offer Medicaid to 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. Ask your state whether it offers this group and what its rules are.

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. Ask your state Medicaid office what drugs it covers and what rules apply, such as approval before a prescription is filled.

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

• Rides to appointments. Medicaid.gov lists an "assurance of transportation" so people can reach covered services. Ask your state or plan whether rides are available and how to book them.
• 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. HealthCare.gov lists 1-800-318-2596 for questions. If you may qualify, the Marketplace sends your details to your state agency, and the state contacts you.

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 may be able to help you apply. Ask the billing office who to see.

Outside the hospital, NCI's Cancer Information Service at 1-800-4-CANCER can point you to other sources of help with costs. Your state Medicaid office can answer questions about your own case.