How To Qualify for Medicaid

Eligibility for Medicaid Explained

Medicaid is a combined federal and state initiative that offers low-cost medical care to qualified people. The objective is to promote the health of persons who may otherwise go without medical treatment for themselves and their children. Although the federal government requires coverage for some categories of persons, each state may determine its particular criteria.

To qualify for Medicaid, you must fulfill the required income and resource requirements. Various types of individuals may qualify for Medicaid, and there are varied income restrictions for each. Limitations may also extend to the quantity of resources you hold (think land, automobiles, and bank accounts) (think land, cars, and bank accounts). The number of persons living in your home also counts.

Read more about Medicaid, what it covers, who is eligible, Medicaid rules, and how to appeal Medicaid refusal.

Important Takeaways
  • The federal government compels states participating in Medicaid to cover certain obligatory qualifying categories, including low-income families, eligible pregnant women, and children.
  • States with extended Medicaid systems may cover all low-income adults under 65 years of age.
  • If your income is too high to qualify for Medicaid, you may spend down the amount over your state’s income criteria and become eligible for coverage.
  • Anybody denied Medicaid coverage has a right to obtain a fair hearing from their state Medicaid agency.

What Does Medicaid Cover?

Medicaid is a combined state and federal program that provides health care coverage to qualified people. Anybody who satisfies the qualifying conditions has a right to enroll in Medicaid coverage. While each state has its own Medicaid program, the federal government lays requirements that all states must obey. Depending on the federal requirements, states administer their Medicaid programs to best serve the qualified citizens.

States may chose to offer more services than authorized by the federal government and may extend coverage to a greater population.

Federal law dictates that states offer certain services, known as mandated benefits, under Medicaid. Governments also may give extra benefits and services, known as optional benefits. The chart below displays some of the necessary 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 patients via commercial managed-care plans.

Since Medicaid is a jointly financed program, the federal government pays states for a specific amount of its program spending, known as the Federal Medical Assistance Percentage (FMAP) (FMAP). States should be able to cover their part of Medicaid costs for the services offered under their respective programs.

Medicaid and Medicare are frequently used interchangeably but don’t offer identical coverage. Medicaid is a combined state-federal program serving low-income persons of any age, while Medicare is a federal program that mainly covers those older than 65 years old, regardless of their income, and also includes dialysis patients and younger handicapped people. Medicaid may differ from state to state, while Medicare is the same throughout the U.S. 

Who Is Eligible for Medicaid?

Medicaid offers low-cost health coverage to qualified persons in diverse groupings. Individuals who fulfill the qualifying standards have a right to Medicaid coverage. Typically, your eligibility for Medicaid hinges on one or a combination of the following factors:

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

While Medicaid mainly focuses on low-income populations, several states operate extended Medicaid programs to cover all persons below particular income criteria.

While there are various qualifying conditions, you might qualify based on your income alone if your state has extended its Medicaid program.

Financial Eligibility Criterion

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

  • Adjusted gross income
  • Untaxed overseas income
  • Non-taxable Social Security payments
  • Tax-exempt interest

When the marketplace analyzes your household’s income, the dollar amount is translated to a percentage of the federal poverty level (FPL) to assess eligibility for each program. This system is the foundation for establishing financial eligibility for most individuals, children, parents, and pregnant women seeking for Medicaid.

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

  • Young people who were previously foster-care recipients.
  • Children whose care is supported by the Department of Children and Family Services.
  • Anybody engaged in a program such as Social Security Supplemental Security Income (SSI) payments or the Breast and Cervical Cancer Prevention and Treatment Program.

Assets held by the members of your home may also be considered in establishing your eligibility for Medicaid. Examples of resources may include cash, bank accounts, bonds, equities, vacant real estate, certain vehicles, and some trusts. Certain assets, such as the house you live in, some automobiles, and your furnishings don’t count.

Applicants for various Medicaid programs also must report or examine all possible 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 standards can impact your eligibility for Medicaid. Some of the basic conditions you must fulfill to qualify for Medicaid include: 63

  • Immigration or citizenship status: You must be either a U.S. citizen or an eligible qualified immigrant accepted for permanent residence.
  • Residency: You must be a resident of the state for whose Medicaid program you’re seeking.
  • Age: You must fulfill the program’s age restrictions.
  • Social Security number: The legislation demands a Social Security number or evidence of application from anybody seeking for Medicaid.
  • Pregnancy or parenting status

You must also fulfill specific medical criteria to qualify for some Medicaid service categories, often following an examination of your medical condition. The evaluation may include analyze your medical records and other data relating to your health condition.

State Increased Medicaid Eligibility

As of August 2021, 38 states (including the District of Columbia) have extended Medicaid to cover all low-income people whose family incomes are below a defined level.

7 If your state has extended Medicaid, you are eligible for coverage based on your income alone. Generally, your family income shouldn’t exceed 138% of the federal poverty limit.

In Idaho, for instance, the monthly income restrictions for expanded Medicaid vary from $1,482 for one person to $5,136 for a family with eight members. The income limit is $523 for each extra member beyond eight. Visit this page to discover 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 help with a Marketplace plan. States offer alternative coverage choices if you’re pregnant, have children, or live with a handicap.

How To ‘Spend Down’ To Satisfy Medicaid Criteria

If your income or assets exceed your state’s Medicaid income level, your state may operate a spend-down program that enables you qualify for coverage by spending the money over your program restrictions. You may spend down by spending fees for medical and rehabilitative treatment for which you have no health insurance coverage.

Spend-down works like an insurance deductible. You pay medical care expenditures up to a set amount for a given base period, generally three or six consecutive months.

After the incurred medical expenditures surpass the difference between your income and your state’s Medicaid income limit, as part of the spend-down, Medicaid payments will be approved for all or part of the base period. States with a medically needy program must also enable spend-down for blind, elderly, and crippled persons who don’t fulfill the Medicaid eligibility standards.

Appealing for Denial of Coverage

You’ll start getting the proper Medicaid services if you fulfill all the conditions and are declared financially eligible. If you don’t fulfill all the qualifying conditions, you will be advised of your right to a fair hearing. States shall allow persons who believe they should be eligible the ability to appeal the denial of coverage, either on the grounds that a mistake was made or that the state failed to act fast.

The structure of the appeals procedure differs across states. The Medicaid agency may conduct the appeals procedure or else delegate it. Another state agency may undertake the appeal receiving clearance from the Centers for Medicare & Medicaid Services (CMS) (CMS).

Commonly Asked Questions (FAQs)

How frequently is Medicaid eligibility determined?

Medicaid eligibility is assessed once every 12 months. You might lose benefits throughout the renewal procedure for failing to submit the proper papers.

How can I verify my eligibility for Medicaid?

You may verify your eligibility for Medicaid in two ways:

  • Accessing your state’s Medicaid website or calling your state’s Medicaid office.
  • Via the health insurance marketplace. You’ll discover what programs you and your family qualify for.

What is the age for Medicaid availability?

Medicaid is normally offered to all low-income U.S. residents younger than 65 years of age. You may also apply if you’re 65 years or older, crippled, or blind and have little income and assets.