Medical Programs - General Information

Program Summary

What happens to you or a family member when you need medical attention?

The Nevada Department of Health and Human Services offers medical assistance through a number of programs for individuals and families. Some of this coverage is free to you, and some requires a fee. The services provided may include doctor visits, prescriptions, dental care, eye exams/glasses, etc. and therapies, to name a few.

There are several Medicaid related programs for which DWSS determines eligibility. These programs include:

Family Medical Coverage: for low-income individuals, families, children, and specialized households.

Nevada Check Up: low-cost, comprehensive health care coverage to low income, uninsured children (birth through 18) who are not covered by private insurance or Medicaid.

Medical Assistance to Aged, Blind and Disabled (MAABD): for low-income individuals eligible for Supplemental Security Income from Social Security, residents of Nursing and other long-term care facilities, institutionalized individuals, disabled children, and Home and Community-Based waivers.

Medicare Beneficiaries: for individuals eligible for Medicare that may qualify for partial Medicaid coverage of premiums, co-insurance, and deductibles.

Hospital Presumptive Eligibility: allows qualified hospitals to determine certain individuals presumptively eligible for Medicaid services based on preliminary information.

Family Medical Coverage

Health coverage to low-income adults and children with income up to 138% if the federal Poverty Level. Eligibility is determined by DWSS on an individual basis. Emergency medical assistance on a month-by-month basis for undocumented non-citizens, or to qualified non-citizens not covered by an eligible category. These applicants must meet all other eligibility requirements except for citizenship. A pregnant woman eligible for Medicaid in any month of her pregnancy remains eligible for her entire pregnancy and postpartum period(up to 60 days after giving birth). Newborn children may remain eligible for Medicaid for one year, if their mother was eligible for Medicaid at the time of their birth. The newborn child must continue to reside with the mother in Nevada. Health coverage is available up to three (3) months prior to the application month if an eligible household member received medical services during this time. Eligibility is determined on a month-by-month basis. Medicaid may continue for up to twelve months for parents or other caretaker relatives who were eligible and enrolled in Family Medical Coverage in at least 3 out of 6 months immediately preceding the month eligibility is lost due to the increased income from employment. Health coverage for individuals, under age 26, who were in foster care in Nevada at the age of 18 and enrolled in Medicaid while in foster care. Health coverage for women who are under age 65, are uninsured or underinsured, not eligible under any other Medicaid eligibility group, and who have been screened for breast and cervical cancer by the CDC, and are found to need treatment for either breast or cervical cancer. Certain child welfare cases involving children for whom a public agency is assuming full or partial financial responsibility.

Nevada Check Up

The Mission of the Nevada Check Up program is to provide low-cost, comprehensive health care coverage to low income, uninsured children (birth through 18) who are not covered by private insurance or Medicaid while:

promoting health care coverage for children;
encouraging individual responsibility; and
working with public and private health care providers and community advocates for children.

The NCU program began providing services to Nevada's children on October 1, 1998.

Premiums are charged quarterly for participation in Nevada Check Up. Premiums are either $25, $50 or $80, based on gross income, and are charged per family (not per child). Quarterly premiums are due the first day of each January/April/July/October. American Indians who are members of federally recognized Tribes and Alaska Natives are exempt from premiums.

Medical Assistance to the Aged, Blind & Disabled (MAABD)

This program provides medical services and individuals may qualify by being eligible for a means-tested public assistance program (i.e., Supplemental Security Income [SSI]). Individuals may be eligible for medical coverage for up to three months of medical coverage prior to the month of application if they apply for or would be eligible in one of the listed categories.

The eligible categories for individuals include:

Supplemental Security Income (SSI) recipients;
Employed individuals, age 16 through 64 with disabilities with combined net earned and unearned income up to 250% of the federal poverty level (Health Insurance for Work Advancement);
Nursing facility residents with gross monthly income up to 300% of the SSI payment level (State Institutional Cases);
Certain individuals who have lost SSI eligibility, but would still be eligible if some of their income were disregarded (Public Law Cases);
Disabled children who require medical facility care, but can appropriately be cared for at home;
Aged or physically disabled individuals who require medical facility care, but can appropriately be cared for at home and aged individuals who have been residing in nursing facilities who can appropriately be cared for in adult group care facilities (Home and Community-Based Waivers); and
Ineligible non-citizens who do not meet citizenship eligibility criteria and have emergency medical services may qualify for some limited Medicaid coverage.

Medicare Beneficiaries

Individuals eligible for Medicare may also qualify for benefits from the Medicare Beneficiaries program. Coverage provided by this program is different than other Medicaid groups as it does not provide the full scope of medical benefits. The categories described below may be eligible for Medicare Beneficiaries coverage:

Qualified Medicare Beneficiaries (QMBs) are Medicare recipients with income at or below 100% of the federal poverty level. Medicaid pays for their Medicare premiums, co-insurance and deductibles on Medicare covered services. Eligibility begins the month following the month the decision is made.

Special Low Income Medicare Beneficiaries (SLMBs) are Medicare recipients with income between 100% - 120% of the federal poverty level. Medicaid pays the Medicare Part B medical insurance premium. Eligibility begins with the application month with three (3) months of prior medical coverage available.

Qualifying Individuals 1 (QI-1s) are Medicare recipients with income of at least 120%, but less than 135% of the federal poverty level. Medicaid pays the Medicare Part B medical insurance premium. Eligibility begins with the application month with three (3) months of prior medical coverage available. However, this program is 100% federally funded and ends if the state allocation is used.

Qualified Disabled Working Individuals (QDWIs) are Medicare recipients with income less than 200% of the federal poverty level. Medicaid pays the Medicare Part A hospital premium, only.

Hospital Presumptive Eligibility

Hospital Presumptive Eligibility, or HPE, allows qualified hospitals to determine certain individuals “presumptively eligible” for Medicaid based on preliminary information obtained by the hospital. Individuals determined eligible for HPE receive Medicaid benefits for a one-time temporary period, up to 60 days, provided they meet all eligibility criteria.
A Qualified Hospital participates as a provider under the State Medicaid Program and agrees to make presumptive eligibility determinations consistent with state policies and procedures outlined in both the Division of Health Care Financing and Policy (DHCFP) Medicaid Services Manual (MSM), and the Division of Welfare and Supportive Services (DWSS) Medicaid Assistance Manual (MAM). Check with your hospital to see if they signed up to process HPE applications.

The purpose of HPE is to provide a streamlined process for individuals to get access to immediate coverage while promoting continued Medicaid enrollment through an application with DWSS.
HPE may provide coverage to certain individuals, including:
- Children up to age 18
- Parents or Caretaker Relatives who live with their children
- Pregnant Women
- Adults with no Children (Expanded Medicaid)
- Youth Who Aged-Out of Foster Care at age 18