What You Should Know About Medicaid and Diabetes

Legal Issues

What You Should Know About Medicaid and Diabetes

Medicaid is a government run health insurance program for poor and disabled people.  According to the American Diabetes Association 3.5 million people with diabetes use Medicaid for all or some of their medical care. Ongoing and preventive health care is particularly important for people with diabetes to avoid costly medical complications. Many suggested changes to Medicaid may affect the level of care received by Medicaid recipients.


Medicaid is often confused with Medicare.  Medicare applies to all elderly, regardless of income and younger poorer individuals who have disabilities.    Medicare for older individuals is not dependent on the individual being poor.  Medicaid, however,  has restrictions on the amount of assets an individual may have and/or the amount of income an individual can receive to be able to receive Medicaid assistance.  Often the distinction is made that MedicAID means “assets and income depleted.” Medicare and Medicaid together cover over half the money that is spent on  long term care in this country. 


The specific restrictions on Medicaid applicability is set by individual states.  Some states limit income and some do not. The Federal Deficit Reduction Act (DRA) of 2005 made major changes to Medicaid eligibility requirements. In response to this Federal mandate, states have been tightening up their applicability requirements. For example, many states now look back for five years when determining if an individual has been giving assets away in a way that is prohibited by Medicaid eligibility rules.  Any assets that have been given away contrary to Medicaid regulations may subject the donor to sanctions.


The Affordable Care Act (ACA) of 2010, have also had effects on Medicaid. The ACA requires states to provide certain benefits to individuals.  To be able to provide these required benefits in the current tight budget situation, states are limiting services and benefits that are not required in the ACA, imposing additional eligibility restrictions, eliminating some services and shifting clients into “managed care.”  The managed care programs are supposed to provide a person or organization to coordinate an individual’s care to provide that care in a more cost efficient manner.  However, some of these managed care plans are shortchanging individuals by considering certain helpful medical procedures as not cost efficient.


Even though a state does not have to choose Medicaid to provide health care to its citizens, if a state voluntarily chooses to provide Medicaid to its citizens, the state has an obligation to meet certain minimum legal requirements and cannot arbitrarily remove benefits they have been providing in the past.  There are several ways for a state to modify its benefit plan without violating the law but they cannot remove the benefits required by the ACA.  Benefits that are not required by the ACA are frequently the first benefits to be cut.


However, before a state can modify its benefits for an individual the state must provide due process which includes prior notice and opportunity for a hearing.  Also, under the Americans with Disabilities Act (ADA) a state may not discriminate against someone because of their disability.  Medicaid provides the benefits and the ADA requires a balancing analysis. Several states have run afoul of this requirement and courts have ordered these states to reinstate benefits that had been eliminated.


There are many court cases, some of which have not yet been decided, which address the removal of benefits from state programs as a whole and from specific individuals. One of the most powerful arguments are the anti-discrimination clauses in the ADA.  Since diabetes is frequently considered a disability under the ADA, if an individual has diabetes and faces a potential reduction in Medicaid benefits they may be able to use their disability classification as a way to prohibit the state from imposing the reduction in care. However, the individual may need to procure legal counsel to launch this defense.


If you, or someone you know, is facing reductions in Medicaid health benefits and the individual have diabetes or another disability you should contact an attorney to determine the merits of a lawsuit.  Elder law attorneys can also help individuals develop a plan to protect assets and income while allowing the individual to become eligible for Medicaid benefits.


Note: This is not legal advice.  I'm not your attorney.  Some of this information will vary in your state. This provides general information and a start in deciding what to tell your lawyer.