We are headed into the year the Affordable Care Act (“Obamacare”) rolls out its best known feature – the health insurance exchanges. These will be online marketplaces where folks without employer-sponsored health insurance will be able to buy individual policies for themselves with help from the federal government if they qualify (see www.bitly.com/exchanges-story).

Some will qualify for Medicaid, the health insurance program for people with the lowest incomes, and that’s the topic of this article. Created by Congress in 1965 as part of Title XIX of the Social Security Act, Medicaid is co-funded by the federal government and each state. States administer the program and set guidelines for eligibility and services within federal mandates. Some states have more generous coverage than others.

Even though Medicaid was supposed to be for poor people, it historically didn’t cover every kind of poor person. It mostly covered families with children, elderly people and disabled people. If you didn’t have children and weren’t elderly or disabled, you probably couldn’t get Medicaid coverage (although each state has its own rules). However, that’s changing, and the changes might be of big interest for musicians who need health care.

Under the new health care law, Medicaid is being expanded to include adults with no children who aren’t disabled and aren’t elderly. To qualify, you’ll need to make no more than 133 percent of the Federal Poverty Guidelines. In 2013, this means an annual income of no more than $15,281.

However, if you’re a news junkie, you might remember that this Medicaid expansion was one area in which the Supreme Court ruled against the implementation of the law. Under the ruling, states can choose not to expand their Medicaid coverage under the law. Fourteen states have announced they will not expand and three more are leaning away from it. Connecticut and New Jersey are expanding and New York’s Governor Cuomo claims the state is already mostly in line with expansion but has stopped short of embracing full expansion for now.

So what does Medicaid cover? Federally mandated services include hospitalization, prenatal care, childhood vaccines, nursing facilities for people 21 and older, family planning, X-rays and screenings, some mental health care, and home health care for people eligible for nursing services. The Hyde Amendment (no relation to this author) prohibits federal funding for abortion unless the mother’s life is threatened by the pregnancy, so if this service is covered by Medicaid, it is done so with state funds. This is the case in Connecticut, New Jersey and New York, as well as 12 other states.

States may opt to include other services. New York, New Jersey and Connecticut all cover optometrists, dentists, prescription drugs for non-Medicare eligibles, prosthetic devices, preventive services and nursing facilities for people under 21. New Jersey also covers chiropractic, podiatry and hospice care.

New York covers certain drugs excluded from the Medicare Part D program (see my previous article on Medicare, which you can read at www.bitly.com/medicare-story). These include certain antipsychotics, antidepressants, anti-retrovirals used in AIDS treatment, and anti-rejection drugs used after organ transplants. These are covered by a Medicaid wraparound policy. New York’s Preferred Drug Program makes it possible to get Medicaid-covered drugs without prior authorization from the state by using drugs on the preferred drug list. The drugs listed above used to be exempt from the prior approval requirement if they were not on the list. That is no longer the case and the prior approval is now required. The most up-to-date list can be found at www.bitly.com/drugs-list.

There is some important fine print with Medicaid. In New York, if you receive services on or after your 55th birthday or if you become permanently institutionalized, Medicaid may try to recover its costs from your estate after you die. A Local 802 member told me that his parents transferred the deed to their house to him 15 years before either of them needed services. This protected the property from being claimed by Medicaid after this member’s mother passed away.

In New Jersey, eligibility for Medicaid is determined at the county level. Any child born to a woman on Medicaid is eligible for a full year as long as the child lives with the mother, regardless of changes in the mother’s status.

If a person qualifies for both Medicaid and Medicare, the costs of Medicare Part D and Medicare Part B can be covered by Medicaid. But Medicaid will not cover prescriptions except in states like New York, which covers some drugs excluded from Medicare. Usually Medicaid patients are automatically enrolled in a Medicare Part D program when they turn 65.

A persistent problem with Medicaid in general is getting providers to accept it. The reason for this is that Medicaid almost always reimburses at a level lower than Medicare and private health insurance. This is scheduled to change for primary care physicians under the new health care law. Doctors should soon eventually see parity in reimbursement between the two government programs. But specialists like orthopedists may not see an increase.

The consequences for this can be serious. If someone on Medicaid comes to an emergency room, the hospital is only required by law to “stabilize” the person, not “treat” the person. If, for example, a broken bone is not set correctly in a timely manner, the result can be a serious deformation.

In summary, although Medicaid is supposed to be discounted health care for poor people, it is confusing. Rules and requirements vary state to state and you can be given misleading information. This will become more complicated when the state exchanges roll out in 2014.

If you think you or a loved one may be eligible for Medicaid, start by calling the Musicians’ Assistance Program at (212) 397-4802. Beginning in 2014, there will be community-based organizations (called “Navigators”) that will be available to help people figure out the new health insurance exchanges as well as Medicare and Medicaid. The Actors’ Fund is currently seeking status as a navigator. Meanwhile, its Artists Health Insurance Resource Center is a great place to look for options. (Start at www.ActorsFund.org.)

Finally, a request: I am interested in hearing about other musicians’ experiences and stories as they search for health insurance, whether it’s with the Local 802 plan, Medicare, Medicaid, private insurance, or no insurance at all. If you care to share your experiences with me, I will add them to my research. I hope the results will ultimately help musicians. Of course, I will respect your confidence and privacy. E-mail me at earmar4@verizon.net.

A health insurance option for families who don’t qualify for Medicaid

Families with incomes too high for Medicaid can qualify for Children’s Health Insurance Program (CHIP). This is health insurance for children up to age 19 whose parents do not have coverage for them. Families qualify with incomes up to $45,000 a year for a family of four, or just under 200 percent of the Federal Poverty Guidelines. This program offers coverage to children at low cost to their families. This program is run in New York under Child Health Plus. In New Jersey the program is called NJ Family Care. In Connecticut the program is called Husky B and is premium-free for a family of four with an annual income of up to $55,342. To find out more about CHIP, call the Local 802 Musicians’ Assistance Program at (212) 387-4802 or e-mail MAP@Local802afm.org.

If you don’t have health care as a musician, you’ve got some options. The first thing you should do is call the Local 802 Organizing Department at (212) 245-4802. Ask about putting more of your gigs under union contracts, so you can qualify for the union’s health plan. If this just doesn’t work for you, call the union’s Musicians’ Assistance Program at (212) 397-4802 and ask about your health insurance options as an artist. If you’re 65 or older, you probably qualify for Medicare. See www.bitly.com/medicare-story for more.

There’s at least one more program you should know about, and that’s the topic of this article: Medicaid. As a musician, is this a viable choice for you? If you want to learn more, call the Musicians’ Assistance Program at (212) 397-4802. Our trained social worker can start the ball rolling for you.

Martha Hyde is a multi-woodwind player who performs on Broadway. A member of Local 802, she is also a trustee on the Local 802 Health Benefits Fund.