Who are eligiblie to Medicaid and eligibility criteria of Medicaid

General Medicaid Eligibility

This section describes who grants eligibility, what constitutes Medicaid eligibility, and what identification recipients must provide.

3.1.1 Granting Eligibility

Medicaid eligibility is determined by policies established by and through the following agencies:

• Department of Human Resources
• Social Security Administration
• Alabama Medicaid

Names of eligible individuals and pertinent information are forwarded to Medicaid who, in turn, makes the information available to HP. Any questions concerning general or specific cases should be directed in writing to Medicaid or the appropriate certifying agency.

3.1.2 Eligibility Criteria

A person may be eligible for medical assistance through Medicaid if the following conditions are met:
• The applicant must be eligible for medical assistance for the date the service is provided. Services cannot be paid under the Medicaid program if they are provided to the recipient before the effective
date of his or her eligibility for Medicaid, or after the effective date of his or her termination of eligibility.

Having an application in process for Medicaid eligibility is not a guarantee that the applicant will
become eligible.

• The service must be a benefit covered by Medicaid, determined medically necessary (exceptions are preventive family planning and EPSDT screenings) by the Medicaid program, and performed by an approved
provider of the service.

• Applicants may be awarded retroactive eligibility to cover a time period prior to the application and award for eligibility. When applicants are awarded eligibility, they receive an award notice that includes the effective
dates of coverage. The notice indicates whether retroactive eligibility has been awarded. Providers may contact the HP Provider Assistance Center at 1(800) 688-7989 to verify retroactive eligibility dates.

Medicaid does not guarantee future eligibility. Providers should not assume future eligibility based on current eligibility. Providers who do not verify eligibility prior to providing a service risk claim denial due to ineligibility.


Based on eligibility criteria, recipients may be eligible for full Medicaid benefits, or for certain services only. A recipient’s age, health care requirements, and place of residence may further define his or her
eligibility for Medicaid programs or services. Additionally, a recipient’s history of Medicaid benefits may render him or her eligible or ineligible for specific programs or services. For these reasons, it is very important that the providers verify recipient eligibility and ensure they understand all aspects of the eligibility response.
Please refer to Section 3.3, Understanding the Eligibility Response, for more information.


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