Since 2013 I have worked exclusively in Medicare insurance.  Many people will ask me, however, ‘What is Medicaid?’  Some of my clients are on both Medicare and Medicaid.  Those situations are more complex because you are dealing with two government agencies and a different setup in terms of insurance.

what is medicaid coverage

To help clients, I call Nebraska Medicaid or Access Nebraska frequently.  During our initial meeting, I determine if prospective clients are eligible for Medicaid and LIS (Low Income Subsidy) through the EXTRA HELP Program.  Medicaid and LIS are all based upon total income and assets.

Medicare & Medicaid do not require insurance agents to elp with Medicaid and LIS nor compensate agents for the work, but for those who qualify, the extra support is tremendous.  I love to help clients get Medicaid and LIS when they qualify.

On top of figuring out how Medicare works, those who qualify for Medicaid, have an additional challenge as to how to apply for Medicaid.  Each state has its own unique approach.  But the big questions I hear are: what is Medicaid, where did it come from, what does it cover, how do I qualify, how do I apply for Medicaid, and why doesn’t it help me at my income level?  Medicaid has a story, like Medicare.

What Is the Story of Medicaid?

The story of Medicaid began when Congress established Medicaid as part of Medicare in the Social Security Act of 1965 Title XIX.  Individual states administer the federal program.  The federal and state governments jointly fund Medicaid.  The federal government sets the minimum standards for Medicaid, such as eligibility and coverage benefits, but the states implement and administer the plan.  The state implements plans with a certain level of its own discretion.

For example, the state may expand eligibility to a wider group.  It may also add additional benefits.  Of course, the state will primarily bear the funding burden for those additional members and benefits.  As it stands, the federal government covers fifty percent of the cost, except for states with lower per capita costs.  The federal government may pay up to eighty percent.  As it stands today, Medicaid covers 1 in 5 Americans. That’s a lot!

Does Medicare cover home health care

Medicaid & Long Term Care

The benefits covered include inpatient and outpatient acute care services, but what many may not be aware of is that the federal government is also involved in long-term care.  As a matter of fact, the federal government is the largest provider of long-term care coverage through Medicaid.

Reform & Leverage

In 1986 constituents complained to their representatives in Congress that nursing home facilities were treating loved ones poorly and not giving them adequate care.  Congress commissioned the Institute of Medicine (IOM) to study nursing home care in the nation.  IOM discovered widespread abuse, neglect, and inadequate care.  The study resulted in sweeping reforms that became law in the Nursing Home Reform Act in the Omnibus Budget Reconciliation Act of 1987.

Patient Bill of Rights

The legislation’s goal was to ensure nursing home residents received quality care to enable them to maintain their “highest practicable” physical, mental, and psychosocial well-being.  Congress mandated essential health benefits.  Part of the legislation created a “Bill of Rights” for residences.  You may have seen that bill displayed in some long-term care facilities when you visited.

  • The right to freedom from abuse, mistreatment, and neglect;
  • The right to freedom from physical restraints;
  • The right to privacy;
  • The right to accommodation of medical, physical, psychological, and social needs;
  • The right to be treated with dignity;
  • The right to communicate freely;
  • The right to participate in the review of one’s care plan, and to be fully informed in advance about any changes in care, treatment, or change of status in the facility;
  • The right to voice grievances without discrimination or reprisal.
what is medicaid insurance
Patient Bill of Rights

Because the federal government pays so much money to long-term care facilities, the industry quickly complied.

Monitoring Care For Medicaid Beneficiaries

There is over 1.6 million elderly and disabled receiving care in over 11,000 institutions.  Nursing homes must be certified to receive Medicare and Medicaid reimbursements.  The law requires states to perform inspections of facilities and surveys of residents annually and conduct investigations of complaints.  They are the primary enforcer of Medicaid.

Medicare Nebraska

CMS Means Business

When violations are found, remedies and penalties may be imposed.  Everything from the closure of the facility, monetary and criminal penalties, to the retraining of staff depending on the severity and widespread nature of the problem. You can check out the star rating for nursing homes at this link on

Medicaid Is Not Perfect

The major challenge for nursing homes is they may become dependent upon federal and state funding for their operations.  For those institutions with a large Medicaid population, the reimbursement is 75—80 percent of what private insurance residents pay.  Maintaining a facility at the level that Medicaid requires with inadequate funding may result in a bare-bones operation.  It can also result in slipping out of compliance with the federal guidelines.

Deficit Reduction Act of 2005 (DRA) attempts to address the issues of inadequate funding.  Nursing home residents who are on Medicaid can no longer be evicted without due process.  Nursing home workers undergo background checks and standardized levels of training.  Those convicted of abusing residents are placed on a national register of workers who have abused nursing home patients.

Creative Legislation

Another idea in DRA is a provision for states to partner with private long-term care insurance companies.  The rules allow for the amount of LTC policy, such as $250,000, to be used to protect an equal amount of the person’s assets.  Instead of spending down a person’s assets to nothing so he/she can then go on Medicaid, an equal amount of assets would be protected if a person purchased nursing home insurance.

Medicaid Planning Techniques

DRA legislation enacted prohibitions again “Medicaid planning” techniques.  Some attorneys and financial planners were devising ways to move assets out of a person’s estate so that Medicaid and the state would not make claims against nursing care costs after the person passed.  They would also transfer assets to family members to reduce the individual’s net worth and more quickly impoverish the person to make them a county ward. 

Clawback provisions and penalties going back some time as far as five years to discourage persons from moving or hiding assets were enacted.

ObamacareObamacare and Medicaid

The next big change to Medicaid came with the Patient Protection and Affordability Act of 2010 (ACA), a.k.a. Obamacare.  The Affordable Care Act (ACA) required states to expand Medicaid to all citizens under 65 with incomes less than 138 percent of the federal poverty guideline.  The federal government guaranteed funds for the first three years.

The U.S. Supreme Court ruled that provision of the ACA was unconstitutional because of its coercive nature to the states.  The Medicaid expansion, however, remained intact but was left to the states to implement.

Nebraska implemented the ACA Medicaid provision in October of 2020 after state Initiative 427 was affirmed by the voters.  Nebraska partners with private insurance companies to add managed care plans.

Not Enough

A major challenge for Medicaid is still reimbursement.  Because the Medicaid reimbursement is so low, nursing homes, doctors, and other healthcare facilities are less enthusiastic about taking on more or even any Medicaid recipients.  In 2012, CMS adjusted the payment amounts for primary care physicians, so they were paid and for Medicare beneficiaries as for Medicaid recipients.  Doctor surveys, however, give the same consistent feedback that lower Medicaid reimbursements diminish access to medical providers.

Nebraska Medicaid

Initiative 427

The Nebraska Medicaid program currently provides coverage to approximately 240,000 Nebraskans, with expenditures totaling $2,117,730.000 in 2018. Nebraska voters passed Initiative 427 in the November 2018 election that expanded Medicaid coverage to eligible able-bodied adults ages 19-64 who earn up to 138 percent of the federal poverty level. That is about $17,000 per year for a single adult. Governor Pete Ricketts’s administration is tasked with implementing the voter’s approved Medicaid expansion. The Nebraska Department of Health and Humana Services director, Matthew Van Patton, contacted CMS (Center for Medicare & Medicaid Services) to receive support for the state Medicaid program that enlarges Medicaid in Nebraska. This was part of provisions in the Patient Protection and Affordable Care Act (ACA), a.k.a. Obamacare. The name of the Nebraska Medicaid change is the Heritage Health Adult (HHA) expansion program.

Heritage Health Adultnebraska medicaid phone number

The Heritage Health Adult is designed to improve population health. Many of the individuals in the 19-64 population had not obtained health coverage in the past. That age group of excluded from Medicaid. Their income was too high, or employers did not offer group health coverage. This has hurt those individuals as well as our community as a whole. We see that with the high numbers of lower-income and minorities contracting COVID. One of the program’s goals is to improve the health of the overall Nebraska community by providing health coverage to the uninsured.

apply for nebraska medicaidBasic & Prime Medicaid

The program is a tiered system divided into two benefit tiers–Basic and Prime. The essential Medicaid services are like it sounds. It will consist of a robust package of services available to those low-income individuals who qualify. The Prime tier is designed for those who more actively engage in the program through wellness and personal responsibility engagement activities. Those who engage will qualify for prime coverage, such as dental, vision, and over-the-counter drugs. Providing health care in this manner is designed to help reduce per-capita costs.

Medically Frail

Many people eligible for expansion will have particular health needs that may be barriers to improving health. These people can be designated “Medically Frail” and will receive Prime benefits. Visit the Medically Frail web page for more information about the process.

 Nebraska Medicaid Changes Show Up in Managed Care Plannebraska medicaid expansion

Nebraska’s Medicaid managed care program, Heritage Health, combines Nebraska Medicaid’s physical health, behavioral health, and pharmacy programs into a single comprehensive and coordinated program for the state’s Medicaid and Children’s Health Insurance Program (CHIP) enrollees. Heritage Health members enroll in one of three statewide health plans to receive their health care benefits. Nebraska Total CareWellCareUnited Healthcare Community Plan. The private companies manage the care of the Medicaid beneficiaries on behalf of the state of Nebraska’s Medicaid system. These are managed care plan forms.

Many times clients who are on Medicare will call about Medicaid. We have many clients who are on both Medicare and Medicaid. Some of those clients qualify for the special needs plans that coordinate the two and give some very generous additional benefits. However, the Nebraska Medicaid changes that Initiative 427 caused do not affect people on Medicare and Medicaid. The program expansion is just for those between the ages of 19-64 and not on Medicare. We still get phone calls, however, asking whether they qualify. If you wish to check and see if you may qualify for Medicaid or other programs that the Nebraska Department of Health and Human Services provides, please call 402-595-2850.





What Our Clients Are Saying About Omaha Insurance Solutions

Tom & Cheryl O.

Cheryl and I would like to express our appreciation for guiding us through the retirement and Medicare process. In the two meetings we had, you were so patient with our lack of understanding and many questions. Your creative grasp of terminology, technology, multiple market options, and the sheer scope of the process, made our experience so relaxed and enjoyable. We feel like we got the BEST financial options for our specific circumstances. Thanks for such a magnificent outcome!!! You helped us “take the bull by the horns!!”

Kent C.

I had so much Medicare junk mail. Chris made it simple. He put all the different plans up on the big screen. He made it understandable and easy to select.

Vickie A.

Chris did everything right. He answered all my questions when I asked them. He took away my anxiety over going on Medicare.