Eligibility Requirements for Medicaid

Medicaid eligibility is primarily based upon your total household income, with several other factors also taken into consideration. Medicaid qualifications are determined on a state level under guidelines set by the federal government.

Medicaid is run as a joint federal-state program, so you will have to confirm the exact eligibility requirements and application processes for your specific state of residence to be sure you comply with all of the requirements.

Knowing who qualifies for Medicaid can also make the program more transparent so that all Citizens understand what it takes to get this type of assistance. The Medicaid income limits are determined according to the Federal Poverty Level (FPL). If a household’s total income is less than a certain percentage of that FPL, then the individual or family might qualify for Medicaid assistance. There are other eligibility factors considered as well, so be sure to review each category below to ensure you meet the basic requirements and qualifications before you submit an application for assistance.

Who qualifies for Medicaid?

The Medicaid requirements can vary state by state, since each state operates its own Medicaid program under the basic federal government outline. The Center for Medicare and Medicaid Services (CMS) oversees the national Medicaid program and its local implementation. However, the qualifications for Medicaid can be individually set by your state of residence. Note that you must apply in the state where you live full-time, so be sure you have proof of your residential address for your application.

Related Article: How to Apply to Medicaid

Medicaid income eligibility is the primary factor in determining program qualifications. In some states, the Medicaid expansion has made income the sole eligibility factor considered. In states that have not accepted and implemented the Medicaid expansion, other factors will still determine eligibility. In all states, the following factors can contribute to your qualifications:

  • Income
  • Household size
  • Disability status
  • Family status
  • Citizenship and residency

The Medicaid age requirements are also a factor in determining overall eligibility for the program. Understand Medicaid and Medicare are two different programs. Medicare is available to certain citizens aged 65 years and older. Medicaid age eligibility, on the other hand, is not a factor since this assistance is available to low-income individuals of all ages, depending on the state where you live. Some low-income seniors qualify for both Medicare and Medicaid, but Medicaid only pays for services once Medicare and any other insurance programs have paid first.

How to Qualify for Medicaid

To qualify for Medicaid, individuals must also meet certain non-financial eligibility criteria. Medicaid requirements generally include that you must be a resident of the state where you apply and receive benefits. You must also either be a citizen of the United States or a qualified non-citizen, such as a lawful permanent resident. Other Medicaid eligibility factors include your age and your pregnancy or parenting status. Understand how pregnant women can take advantage of Medicaid to become more informed about health care options for your growing family.

If you meet the eligibility requirements for Medicaid, you will receive health care coverage either on the date that you apply or on the first day of the month when you apply. Your benefits might also be covered retroactively for up to three months prior to the month when you submitted your application. That is based upon your qualifications during that time period.

Medicaid eligibility is extended legally to certain groups, including low-income families, qualified pregnant women and children, and individuals receiving Supplemental Security Income (SSI). States have the option to offer coverage to additional groups, which might include residents who receive home and community-based services or children in foster care.

Medicaid income limits are not the only factor to consider. If you meet any of the following conditions, you might qualify for Medicaid:

  • If you are pregnant.
  • If you are the parent or guardian of a child who is younger than 19 years of age and your household income is low.
  • If your child requires nursing home care or an in-home nurse.
  • If you are 65 years of age or older.
  • If you are blind or disabled.
  • If you are terminally ill and require hospice services.
  • If you are leaving welfare and need health care coverage.

Medicaid Income Limits by State

Each state decides on its own eligibility for the Medicaid program and each state has chosen whether or not to accept the new rules under the Medicaid expansion. Therefore, each state has its own income limits set according to whether or not it operates under the new expanded rules.

Medicaid income limits by state vary because of the optional expansion of the program. Under the Medicaid expansion, states that have accepted and implemented it allow any low-income individual to apply based solely on income. In states where the expanded rules have not been accepted, other factors apply and can influence the eligibility of a low-income individual or family.

Related Article: Medical Help Program

Medicaid income requirements are set against the Federal Poverty Level (FPL), but they still vary by state. If your state of residence has accepted and implemented the Medicaid expansion, then your eligibility will be determined by your income. If your total household Modified Adjusted Gross Income (MAGI) is 133 percent of the FPL or below, then you will qualify for assistance. This is regardless of your age, family status or health.

Unfortunately, Medicaid qualifications in states that have not expanded the program can complicate your situation if you fall into a gap. This gap includes adults in those states with incomes below 100% of the FPL who do not qualify for Medicaid based on disability, age or other factors. That means that your income is too high to receive Medicaid in your state, but that your income is too low to receive any savings on a private health insurance plan through the Healthcare Marketplace.

Other Income Requirements for Medicaid

If you qualify for Medicaid based on blindness, disability or age, then you do not need to comply with the MAGI income requirements. Instead, your eligibility based on income will be determined according to the Social Security Administration (SSA) standards. Note that, when calculating your MAGI as a percentage of the FPL, you will receive a five percent buffer. This means that your MAGI can actually be up to 138 percent of the FPL to still make you eligible to receive Medicaid assistance in states that have expanded the program.

Also note that, if you qualify for Medicaid, you will not be eligible to receive any savings on a Healthcare.gov Marketplace insurance plan. If you opt to purchase a plan instead of receiving Medicaid, then you must pay full price for that plan.

Related Article: Medicaid Costs and Coverage

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