How to Qualify for Medicaid

The single largest source of health coverage in the United States, Medicaid is a joint federal and state program that, together with the Children’s Health Insurance Program, provides health coverage to Americans, including children, parents, pregnant women, seniors and individuals with disabilities.

Federal law requires states to cover certain groups of individuals. Low-income families, qualified pregnant women and children, and individuals receiving Supplemental Security Income (SSI) are examples of mandatory eligibility groups. Depending on where you live, states have additional options for coverage and may choose to cover other groups.

Are you eligible for Medicaid?

Based on Modified Adjusted Gross Income (MAGI), the Affordable Care Act established a new methodology for determining income eligibility for Medicaid. By using one set of income counting rules and a single application across programs, the Affordable Care Act made it easier for people to apply and enroll in the suitable program.

MAGI is the basis for determining Medicaid income eligibility for most children, pregnant women, parents, and adults. The MAGI considers taxable income and tax filing relationships to determine financial eligibility for Medicaid. The MAGI-based methodology does not allow for income disregards that vary by state or by eligibility group and does not allow for an asset or resource test.

Certain Medicaid eligibility groups do not require a determination of income by the Medicaid agency. This coverage may be based on enrollment in another program, like SSI or the breast and cervical cancer treatment and prevention program. Children for whom an adoption assistance agreement is in effect under title IV-E of the Social Security Act are automatically eligible. Young adults, who meet the requirements for eligibility as a former foster care recipient, are also eligible at any income level.

To be eligible for Medicaid, individuals must also meet certain non-financial eligibility criteria: must be residents of the state in which you are receiving Medicaid; must be United States citizens or qualified non-citizens, such as lawful permanent residents; some eligibility groups are limited by age, or by pregnancy or parenting status.

Qualifying for Medicaid

Once you are determined to be qualified for Medicaid, the start of coverage is either on the date of application or the first day of the month of application. In some cases, benefits may also be covered retroactively for up to 3 months prior to the month of application, if the you would have been eligible during that period had you applied. Coverage generally stops at the end of the month in which you no longer meets the requirements for eligibility.

Medically Needy Program

For individuals with significant health needs whose income is too high to otherwise qualify for Medicaid under other eligibility groups, States have the option to organize a “medically needy program.” Medically needy individuals can still qualify by “spending down” the amount of income that is above a particular state's medically needy income standard.

What does this mean? Individuals spend down by spending for medical and remedial care for which they do not have health insurance. Once an individual’s incurred expenses exceed the difference between the individual’s income and the state’s medically needy income level, the person can qualify for Medicaid. These excess expenses are then paid for by the Medicaid program.