The Advocate's Guide to
the Medicaid Program


The Advocate's Guide to Medicaid

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A Template for State Advocates to Use

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The Guide describes the basic federal requirements on which individual state Medicaid programs are based. State programs vary significantly, particularly with regard to eligibility and service design and coverage. Thus, state advocates could benefit from their own state Guide. State templates are based on the national Guide’s organization, and include the headings, text and footnotes with cues and spacing for the insertion of state law, regulations, and case citations.  Click here for the template.



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

© 2011 National Health Law Program

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