The Advocate's Guide to
the Medicaid Program


The Advocate's Guide to Medicaid

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About the Guide




Since 1986, the Advocate's Guide to the Medicaid Program (Guide) has been the leading authoritative reference on Medicaid for a quick, convenient way to understand the program.  Advocates, policy makers, and others rely on the Guide to ensure that the Medicaid program is implemented as the law intends, and that eligible low-income people can access the services that Medicaid provides.

The fourth edition of the Guide is now updated with all of the major developments in Medicaid law through October 2012, including new guidance from the Centers for Medicare & Medicaid Services and the Supreme Court’s decision upholding the Affordable Care Act.

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The newly updated fourth edition of the Guide, in both printed and electronic editions, incorporates the Affordable Care Act (2010) and 2012 Supreme Court ruling. The Guide also covers Medicaid administration, eligibility, and services, and includes comprehensive references to sources of Medicaid law and rules, including the United States Constitution, the Medicaid Act, Medicaid regulations, federal guidance documents, and federal and state court case law.


We want to recognize those who kindly took time from their busy lives and jobs to review and comment on sections of the updated fourth edition of the Guide: Gene Coffey, Mark Regan, John Rubin, and James Sheldon. In addition, a talented and dedicated group of cite checkers tracked through the encyclopedic footnotes: Lindsey Wakely 3L, and Jeffrey Lakin 2L, of the University of North Carolina School of Law; Matthew Duble, Aimee M. Hall, Terri LaBounty, Jonathan Kopy, Rita Salamone, and Kathy Thompson of Arent Fox; Julianne Doherty and Jenny Rajkowski of Akin Gump Strauss Hauer & Feld; and Sara Brine and Sarah Kitchell of McDermont Will & Emery. Our special thanks to the firms of Arent Fox, Akin Gump, and McDermot Will for their incredibly helpful pro bono assistance. We could not have completed this effort without them.

Current and past NHeLP staffers reviewed and assisted with the preparation of the Guide: co-authors Corey Davis, Jina Dhillon, Cate Hodgetts, Abbi Coursolle, Debbie Reid, and Kim Lewis, as well as Randy Boyle, Gretchen Gaskill, Lorraine Jones, Daryl Newswanger, Patti Riippa, Davida Silverman, Romon Thomas-Brown, and Mara Youdelman. Vincent Eng, of the VENG Group, gave a terrific assist with production details for the print and on-line versions of the Guide. And, we extend our heartfelt thanks to NHeLP’s Executive Director, Emily Spitzer, who provided ongoing support, excellent feedback, and calm reassurance that we would get this done!

Finally, we thank Andy Hyman and the Robert Wood Johnson Foundation. Their financial support made this Guide possible.

Jane Perkins and Sarah Somers
National Health Law Program
Carrboro, North Carolina

February 2013



I. Introduction
II. Administration
A. Centers for Medicare & Medicaid Services
B. Single State Medicaid Agency
C. Federal Financial Participation
D. State Medicaid Plans
E. Statewideness
F. Federal Medicaid Waivers
G. Demonstration Programs and Grants
H. Managed Care Programs
I. Enrollment of Beneficiaries in Group Health Plans
J. Premium Assistance for Children
K. Long Term Care Partnership Programs
L. Oversight of Providers
M. Medicaid Advisory Committees
N. Applying for Medicaid
O. Eligibility Determinations
P. Eligibility Redeterminations
Q. Presumptive Eligibility
R. Liens and Recoveries
S. Third Party Liability, Assignment, and Cooperation
T. Notice and Hearings
U. Judicial Enforcement
III. Eligibility
A. Mandatory Categorically Needy
B. Optional Categorically Needy
C. Medically Needy
D. Financial Eligibility
E. Post-eligibility Disregards of Income and Resources
F. Spousal Impoverishment Protections
G. Retroactive Eligibility
H. Residency
I. Citizenship/Immigration Status
IV. Services
A. Mandatory Services for the Categorically Needy
B. Optional Services for the Categorically Needy
C. Services for the Medically Needy
D. Early and Periodic Screening, Diagnostic and Treatment Services
E. Benchmark Coverage
F. Medicaid and the Individuals with Disabilities Education Act
G. Transportation
H. Drug Coverage
I. Organ Transplants
J. Health Homes
K. Abortion Coverage
L. Amount, Duration, and Scope of Services and Reasonable Promptness
M. Comparability of Services
N. Utilization Controls
O. Quality of Care
P. Nursing Facility Preadmission Screening
Q. Premiums and Cost Sharing
R. Freedom of Choice
S. Medicaid as Payment in Full
T. Payments to Providers
U. Direct Payments to Beneficiaries
APPENDIX A: Social Security Act/42 U.S.C. Conversion Chart
APPENDIX B: CMS Regional Offices

A Template for State Advocates to Use

Interested in creating a Guide for your state from our template? Click here for more info.

© 2011 National Health Law Program

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