How To Qualify for Medicaid

Qualifying for Medicaid Explained

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Medicaid is a joint federal and state collaboration that provides low-cost medical coverage to eligible individuals. The purpose is to improve the health of people who might otherwise go without medical care for themselves and their children. While the federal government mandates coverage for certain groups of individuals, each state may establish its specific requirements.

To qualify for Medicaid, you must meet the requisite income and resource limits. Different groups of people may qualify for Medicaid, and there are different income limits for each. Limits may also extend to the amount of resources you own (think land, cars, and bank accounts). The number of people living in your household also counts.

Learn more about Medicaid, what it covers, who is eligible, Medicaid requirements, and how to appeal Medicaid denial.

Key Takeaways

  • The federal government requires states participating in Medicaid to cover certain mandatory eligibility groups, including low-income families, qualified pregnant women, and children.
  • States with expanded Medicaid programs can cover all low-income people under 65 years of age.
  • If your income is too high to qualify for Medicaid, you can spend down the amount above your state’s income standard and become eligible for coverage.
  • Anyone denied Medicaid coverage has a right to request a fair hearing from their state Medicaid agency.

What Does Medicaid Cover?

Medicaid is a joint state and federal program that provides health care coverage to qualifying individuals. Anyone who meets the eligibility requirements has a right to enroll in Medicaid coverage. Although each state has its own Medicaid program, the federal government places rules that all states must follow. Based on the federal rules, states run their Medicaid programs to best serve the qualifying residents.

States can elect to provide more services than mandated by the federal government and may extend coverage to a larger population.

Federal law mandates that states provide certain benefits, known as mandatory benefits, under Medicaid. States also may provide additional benefits and services, known as optional benefits. The table below shows some of the mandatory and optional Medicaid benefits.

Mandatory Benefits Optional Benefits
In-patient hospital and physician care Clinic services
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Prescription drugs
Home health services Physical and occupational therapy
Nursing facility services Vision and dental services
Laborator and X-ray services Personal care services
Transportation to medical care Chiropractic services
Family planning services Hospice
Rural health clinic and federally qualified health center services Hearing aids
Nurse midwife services Case management
Certified pediatric and family nurse practitioner services Private-duty nursing services

Some Medicaid programs pay for health care directly, while others cover beneficiaries through private managed-care plans.

Because Medicaid is a jointly funded program, the federal government pays states for a certain portion of its program expenditures, known as the Federal Medical Assistance Percentage (FMAP). States should be able to fund their shares of Medicaid expenditures for the services available under their specific plans.

Medicaid and Medicare are often used interchangeably but don’t provide similar coverage. Medicaid is a joint state-federal program serving low-income individuals of every age, whereas Medicare is a federal program that primarily covers people older than 65 years old, regardless of their income, and also covers dialysis patients and younger disabled people. Medicaid may vary from state to state, but Medicare is the same across the U.S.

Who Is Eligible for Medicaid?

Medicaid provides low-cost health coverage to qualifying individuals in different groups. People who meet the eligibility rules have a right to Medicaid coverage. Generally, your eligibility for Medicaid depends on one or a combination of the following factors:

  • Income level
  • Age
  • Number of people living in your household
  • Whether you’re pregnant or live with a disability

Although Medicaid primarily focuses on low-income groups, many states run expanded Medicaid programs to cover all individuals below specific income levels.

Although there are several qualifying factors, you can qualify based on your income alone if your state has expanded its Medicaid program.

Financial Eligibility Criteria

Financial qualifying requirements for Medicaid are broken down into two categories: income and assets owned. Under the Affordable Care Act (ACA), eligibility for income-based Medicaid through the health insurance marketplaces is calculated based on your household’s modified adjusted gross income (MAGI). Your MAGI is the total amount of several income sources, including the following for every tax-filing member of your household:

  • Adjusted gross income
  • Untaxed foreign income
  • Non-taxable Social Security benefits
  • Tax-exempt interest

When the marketplace calculates your household’s income, the dollar amount is converted to a percentage of the federal poverty level (FPL) to determine eligibility for each program. This methodology is the basis for determining financial eligibility for most adults, children, parents, and pregnant women applying for Medicaid.

You’re exempt from MAGI-based income rules if you qualify for Medicaid based on disability, blindness, or age (older than  65 years). Other groups that are not subject to income verification include:

  • Young adults who were former foster-care recipients.
  • Children whose care is subsidized by the Department of Children and Family Services.
  • Anyone enrolled in a program such as Social Security Supplemental Security Income (SSI) payments or the Breast and Cervical Cancer Prevention and Treatment Program.

Assets owned by the members of your household may also be considered in determining your eligibility for Medicaid. Examples of resources may include cash, bank accounts, bonds, stocks, unoccupied real estate, some vehicles, and some trusts. Some assets, such as the home you live in, some vehicles, and your furniture don’t count.

Applicants for some Medicaid programs also must disclose or explore all potential sources of income, including Social Security benefits, retirement benefits, Department of Veterans Affairs (VA) benefits, unemployment or worker’s compensation, and third-party medical coverage.

Non-Financial Eligibility Criteria

Medical and other general requirements also determine your eligibility for Medicaid. Some of the general requirements you must meet to qualify for Medicaid include:

  • Immigration or citizenship status: You must be either a U.S. citizen or an eligible qualified alien admitted for permanent residence.
  • Residency: You must be a resident of the state for whose Medicaid program you’re applying.
  • Age: You must meet the program’s age requirements.
  • Social Security number: The law mandates a Social Security number or proof of application from anyone applying for Medicaid.
  • Pregnancy or parenting status

You must also satisfy some medical requirements to qualify for certain Medicaid service categories, typically after an assessment of your medical condition. The assessment may also review your medical records and other documentation related to your health condition.

State Expanded Medicaid Eligibility

As of August 2021, 38 states (plus the District of Columbia) had expanded Medicaid to cover all low-income adults whose household incomes are below a specified threshold. If your state has expanded Medicaid, you are eligible for coverage based on your income alone. Typically, your household income shouldn’t exceed 138% of the federal poverty level.

In Idaho, for instance, the monthly income limits for expanded Medicaid range from $1,482 for one member to $5,136 for a household with eight members. The income limit is $523 for each additional member beyond eight. Check this page to understand your state’s Medicaid profile.

You should still fill out a marketplace application if your state hasn’t expanded Medicaid and your income level doesn’t qualify you for financial assistance with a Marketplace plan. States have other coverage options if you’re pregnant, have children, or live with a disability.

How To ‘Spend Down’ To Meet Medicaid Requirements

If your income or assets exceed your state’s Medicaid income threshold, your state may run a spend-down program that lets you qualify for coverage by spending the income above your program limits. You can spend down by incurring expenses for medical and remedial care for which you have no health insurance coverage.

Spend-down works like an insurance deductible. You cover medical care expenses up to a specific amount for a given base period, usually three or six consecutive months.

Once the incurred medical expenses exceed the difference between your income and your state’s Medicaid income limit, as part of the spend-down, Medicaid benefits will be authorized for all or part of the base period. States with a medically needy program must also allow spend-down for blind, aged, and disabled people who don’t meet the Medicaid eligibility requirements.

Appealing for Denial of Coverage

You’ll start receiving the appropriate Medicaid services if you meet all the requirements and are deemed financially eligible. If you don’t meet all the eligibility requirements, you will be notified of your right to a fair hearing. States must provide individuals who think they should be eligible the opportunity to appeal the denial of coverage, either on the grounds that an error was made or that the state failed to act promptly.

The structure of the appeals process varies among states. The Medicaid agency may conduct the appeals process or otherwise delegate it. Another state agency may conduct the appeal following approval from the Centers for Medicare & Medicaid Services (CMS).

Frequently Asked Questions (FAQs)

How often is Medicaid eligibility determined?

Medicaid eligibility is determined once every 12 months. You could lose benefits during the renewal process for failing to submit the required paperwork.

How do I check my eligibility for Medicaid?

You can check your eligibility for Medicaid in two ways:

  • Visiting your state’s Medicaid website or contacting your state’s Medicaid office. 
  • Through the health insurance marketplace. You’ll learn what programs you and your family qualify for.

What is the age for Medicaid availability?

Medicaid is typically available to all low-income U.S. citizens younger than 65 years of age. You can also apply if you’re 65 years or older, disabled, or blind and have limited income and assets.