What is Medicaid and am I eligible for it?

If you qualify, you can apply for government-funded health insurance at any time.

Elissa

Elissa Suh

Published September 6, 2019

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KEY TAKEAWAYS

  • Low income individuals, people with disabilities, and pregnant women can get health insurance through Medicaid

  • Coverage is free or very low cost

  • Medicaid is funded by the state and federal government, but eligibility and coverage benefits are decided by each state

  • Not all medical services are covered by Medicaid, so you may have to pay some medical bills on your own

Medicaid is a public health insurance program for low-income or vulnerable Americans. It provides health coverage for little to no cost. Most people qualify for Medicaid based on income, but you can also qualify for other reasons. For example, people with disabilities, pregnant women, and the elderly can qualify.

Both the state and federal government jointly fund Medicaid, but it is the state that runs and organizes the program, so the bulk of how Medicaid works — including eligibility requirements, coverage, and costs — depends on the state. You’re eligible for Medicaid if your household income falls under the federal poverty line, but some states set higher federal poverty guidelines in order to include more people in their Medicaid programs.

If your family isn’t eligible for Medicaid because your income is too high, your children may still be eligible for the Children's Health Insurance Program (CHIP), which provides access to Medicaid as well as other free or low-cost health insurance programs.

Medicaid is different from Medicare, which has no income limits and provides free or low-cost health insurance to Americans over age 65.) Some people who receive Medicare may still rely on Medicaid to pay for services not covered by Medicare.

In this article:

What is Medicaid?

If you don’t have group health insurance through your workplace and can’t afford to buy a marketplace health plan on your own, you might be able to get coverage through Medicaid. Medicaid is free for eligible participants or provided at a very low cost — medical expenses are intended to be much more affordable than those for health plan from private insurance providers.

The exact costs that you might have to pay for Medicaid will depend on the state. In fact, most of the structure and specifics of Medicaid are determined by the state. Some Medicaid programs may even have different names, like Medi-Cal in California, or HUSKY in Connecticut.

We’ll discuss different aspects of Medicaid, but remember to read this state-by-state guide to Medicaid for more information.

What does Medicaid cover?

Medicaid patients can receive a broad range of medical care, like doctor’s office visits, hospital stays, and some forms of long-term care, like nursing home care. Some medical services are mandatory and must be provided, while other services are optional and may not be covered, depending on the state.

Mandatory Medicaid benefits

  • Inpatient and outpatient hospital services
  • Physician and home health services
  • Laboratory and X-ray services
  • Nursing facility services
  • Services at federally qualified health centers, rural health clinics, and licensed birth centers
  • Transportation to medical care
  • Comprehensive preventive care, diagnostic and treatment services for individuals under 21 (called EPSDT or Early and Periodic Screening, Diagnostic, and Treatment services)
  • Family planning
  • Nurse midwife services
  • Pediatric care and nurse practitioner services
  • Tobacco cessation programs for pregnant women

Optional Medicaid services

Medicaid programs are not required to provide the following benefits, though some states may choose to do so:

  • Prescription drug coverage
  • Dental care (except for children) and dentures
  • Eyeglasses
  • Physical and occupational therapy
  • Most specialist physician services, including podiatry, optometry, and chiropractic
  • Speech, hearing, and language disorder services
  • Hospice or private duty nursing services

Medicaid eligibility and income limits

Generally you need to have low income to qualify for Medicaid. However, even if you don’t meet the income requirement, you may still qualify based on the following:

  • Pregnancy
  • Household size
  • Household role (if you’re a caretaker, for example)
  • Disability
  • Age (Medicaid for children is often provided through CHIP)

People with disabilities

Disabled individuals who receive Supplemental Security Income (SSI) are eligible for Medicaid and may receive it automatically in many states. You might not even have to fill out a Medicaid application. As always, check with your state Medicaid office to confirm.

People with disabilities who receive Social Security Disability Insurance (SSDI) typically get health insurance through Medicare. However, if you’re in the 24-month waiting period before Medicare coverage starts, you can get health plan through Medicaid in the interim.

If you’re worried about becoming disabled and losing the ability to work, you might also consider disability insurance.

What is the income limit for Medicaid?

Under the Affordable Care Act (Obamacare), some states expanded their Medicaid program to allow coverage based solely on income. In these states, you can get Medicaid coverage if your household income is below 133% of the federal poverty level (FPL). However, because of the way the government calculates its federal poverty guidelines, the threshold is effectively 138%.

For example, for a household of two, the FPL is $16,910 per year in 2019. If your household earns $23,336 per year or less, you’ll be eligible for Medicaid.

Otherwise, each state establishes their own income eligibility restrictions. Generally, if your income is less than 100% to 300% of the federal poverty level (FPL), then you may qualify for Medicaid program in your state.

2019 federal poverty levels:

Household size48 contiguous statesAlaskaHawaii
1$12,490$15,600$14,380
2$16,910$21,130$19,460
3$21,330$26,660$24,540
4$25,750$32,190$29,620
5$30,170$37,720$34,700
6$34,590$43,250$39,780
7$39,010$48,780$44,860
8$43,430$54,310$49,940

Additionally, certain Medicaid services, like nursing homes, may have additional eligibility requirements like resource limits. This means your total assets must be valued under a certain amount — usually around $2,000. The specific limits and what assets count towards them varies by state.

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How do I apply for Medicaid?

Unlike traditional health insurance, which requires you to apply during a specified enrollment period, you can apply for Medicaid at any time. Apply on healthcare.gov or your state Medicaid website — you don’t need to wait for Open Enrollment or a Special Enrollment Period. You can get coverage this way during any time as long as you meet the eligibility requirements.

If you applied for Medicaid and got rejected, you can send in an appeal to the state Medicaid office. If you lose Medicaid coverage for any reason, then you will be given the opportunity to shop for a health plan on the Obamacare marketplace.

Learn about how to apply for Obamacare.

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