Step 1 of 2: Medical profile   Gender Date of birth Height Weight Smoker? Applicant* M F / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Spouse -- M F / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children 0  1 2 3 4 5 6         Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Currently Insured?* Yes No Have conditions?* yes   no Please specify  Take medications?* yes   no Please specify  Step 2 of 2: Tell us about yourself First Name* Last Name* Address* City* State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip* Day Phone* Evening Phone* Contact Time* Morning Afternoon Evening Email* By submitting this form, you agree to be legally bound to, and abide by, the Privacy Policy.

MEDICAID

Having its origins in 1965, Medicaid is a Federal program that offers health care coverage for select low-income families. Title XIX of the Social Security Act is a Federal/State sponsored program that is designed to pay medical costs for certain designated families who happen to have low incomes/resources with which to pay for it themselves. So who is eligible for Medicaid? Eligibility includes people who are aged, blind, or disabled, along with certain people in families with dependent children. Although a Federal program, Medicaid is run by the states, which means that each state determines who is eligible and the range of health services offered.

It is a common misconception that Medicaid is a program that is designed to cover all poor persons. Medicaid DOES NOT offer paid medical assistance to every single poor person. Those eligible to receive medical assistance must be a part of one of the groups designated in the following list:

BASIS OF ELIGIBILITY:

• Individuals who meet the requirements for the Aid to Families with Dependent Children (AFDC) program
• Children under age 6 whose family income is at or below 133 percent of the Federal poverty level
• Pregnant women whose family income is below 133 percent of the FPL
• Supplemental Security Income (SSI) recipients in most States
• Recipients of adoption or foster care assistance
• Special protected groups (typically individuals who lose their cash assistance due to earnings from work or from increased Social Security benefits, but who may keep Medicaid for a period of time)
• All children born after September 30, 1983 under age 19, in families with incomes at or below the FPL

SCOPE OF SERVICES:

• Inpatient hospital services
• Outpatient hospital services
• Prenatal care
• Vaccines for children
• Physician services
• Nursing facility services for persons aged 21 or older
• Family planning services and supplies
• Rural health clinic services
• Home health care for persons eligible for skilled-nursing service
• Laboratory and x-ray services
• Pediatric and family nurse practitioner services
• Nurse-midwife services
• Early and periodic screening, diagnostic, and treatment services for children under age 21

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