Medicaid is a program jointly funded by the federal government and the states to provide health insurance coverage to low-income Americans. Medicaid eligibility is determined based on income level, and adults, children, pregnant women, the elderly and people with disabilities all can become Medicaid recipients.

Right now in the United States, Medicaid covers one in every four children, 21 percent of low-income adults, and 60 percent of all nursing home residents. Without Medicaid, 50 million Americans would be without any form of health insurance coverage.

Each state sets up and administers their own Medicaid program and determines the scope of services provided based on a broad set of federal guidelines. Federal law requires that all Medicaid programs cover a certain set of “mandatory benefits.” These benefits include inpatient and outpatient hospital services, nursing facility services, home health services, physician services, and laboratory and x-ray services. Also mandatory are family planning services, nurse midwife services, certified pediatric and family nurse practitioner services, freestanding birth center services (when already licensed and recognized by the state), and smoking cessation counseling for pregnant women. Medicaid also covers what’s known as EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services.

Mandatory Medicaid Benefits

Inpatient hospital services

Outpatient hospital services

EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services

Nursing Facility Services

Home health services

Physician services

Rural health clinic services

Federally qualified health center services

Laboratory and X-ray services

Family planning services

Nurse Midwife services

Certified Pediatric and Family Nurse Practitioner services

Freestanding Birth Center services (when licensed or otherwise recognized by the state)

Transportation to medical care

Tobacco cessation counseling for pregnant women

There are also a number of optional benefits which states can choose to include in their Medicaid programs. These include things like prescription drug coverage, physical and occupational therapy, speech and language disorder services, podiatry services, optometry services, and dental services. (Prescription drug coverage is currently offered in the Medicaid programs of all 50 states even though it is optional.)

In order to be eligible for Medicaid, you must be a U.S. citizen or qualified non-citizen (for example, a green card holder, refugee.) In some cases, qualified non-citizens must wait 5 years after receiving “qualified” immigration status before they are eligible for Medicaid, though there are some exceptions - for example, you may be eligible immediately if you were a refugee or asylee.

Federal law requires that states provide certain groups of individuals with Medicaid health insurance coverage. These are what’s known as mandatory eligibility groups, and they include groups like low-income families and qualified pregnant women and children. States then have additional options about who else they might cover, including those receiving home- and community-based services and children in foster care who are not otherwise eligible.

The Affordable Care Act (ACA) allowed states to choose to expand their Medicaid programs to cover low-income adults. Whether or not you qualify for Medicaid, and what the income limits are, depends on whether your state expanded Medicaid and whether you meet any other criteria (for example, if you are pregnant, are parenting a child under the age of 19, or have a disability.).

So far, 38 states and DC have chosen to cover otherwise ineligible adults through their Medicaid programs, known as Medicaid expansion. In most of these states, adults under the age of 65 making less than 138% of the Federal Poverty Level can qualify for Medicaid (different eligibility requirements apply to adults 65 and older, who may be eligible for Medicare). That's $18,754 for an individual and $38,295 for a family of four. In the 13 states that have chosen not to expand their Medicaid programs, adults usually do not qualify for Medicaid unless they meet additional conditions.

The following states have expanded Medicaid, meaning that adults under the age of 65 making less than 138% of the Federal Poverty Level can qualify:

• Alaska
• Arizona
• Arkansas
• California
• Colorado
• Connecticut
• Delaware
• District of Columbia
• Hawaii
• Idaho
• Illinois
• Indiana
• Iowa
• Kentucky
• Louisiana
• Maine
• Maryland
• Massachusetts
• Michigan
• Minnesota
• Missouri
• Montana
• Nebraska
• Nevada
• New Hampshire
• New Jersey
• New Mexico
• New York
• North Dakota
• Ohio
• Oklahoma
• Oregon
• Pennsylvania
• Rhode Island
• Utah
• Vermont
• Virginia
• Washington
• West Virginia

The following states have NOT expanded Medicaid, meaning that adults do not qualify for Medicaid unless they meet specific conditions:

• Alabama
• Florida
• Georgia
• Kansas
• Mississippi
• North Carolina
• South Carolina
• South Dakota
• Tennessee
• Texas
• Wisconsin
• Wyoming

The ACA also established a new system for determining income eligibility for most groups of people who qualify for Medicaid, like children, pregnant women, and adults. Now, states use what is known as Modified Adjusted Gross Income (MAGI). MAGI takes into consideration all taxable income and tax filing relationships to determine eligibility not just for Medicaid, but also for premium tax credits and cost sharing reductions available through the health insurance Marketplace. MAGI does account for the kinds of deductions you would take on your income taxes, such as Social Security benefits, individual retirement contributions and tax-exempt interest. As a result, MAGI ends up looking very close to what most people would see as their adjusted taxable income on their tax return.

However, Medicaid and the Marketplace have different rules for household composition. While the Marketplace only looks at your tax household, Medicaid also takes into consideration who you live with and your familial relationships. This is why the application may ask additional questions about your household and family aside from who you claim on your taxes.

Foster care children (including former foster care children up to 26 years old who were on Medicaid on their 18th birthday), institutionalized individuals in adult homes run by the Local Department of Social Services or the Office of Minority Health, and Medicare beneficiaries earning less than 100 percent of the Federal Poverty Level do not use MAGI to determine their eligibility for Medicaid, but instead are eligible based on these circumstances. Other non-MAGI eligible people are those enrolled in the AIDS Health Insurance Program, COBRA, Medicaid for the Working Disabled, Medicaid Cancer Treatment Program, Medicare Savings Program, Social Security Disability Insurance, and Social Security Insurance.

The first step is to find out if you qualify for Medicaid. This is an easy and straightforward process and usually only takes a few minutes. This will let you know if you qualify for Medicaid based on your income, where you live, and whether your state has opted into Medicaid expansion. You can get started by selecting “Apply Now” at the top or bottom of this page.

If you’re eligible, you can start your Medicaid application. Once you’re finished, your app will be submitted to your state’s Medicaid agency. They will review your information and send you an official letter of determination within a few weeks. However, if you don't hear from them, we always recommend giving them a call.

Once you submit your application, you will also get access to a free and secure HealthSherpa account. Inside your account you can review suggested follow-up steps to make sure the application process is successful. For example, reminders to submit any required documents or to call your state’s Medicaid agency.

If your eligibility is approved you will be given instructions on how to choose your new health insurance plan!

Once enrolled, you'll want to be sure report changes as soon as they happen. These changes may include income or household size. This can change your eligibility and may qualify you for a Marketplace plan. You can access your application in your HealthSherpa dashboard to report these changes. We also encourage you to reach out to your state medicaid and / or CHIP office.

If you don’t qualify for Medicaid based on income alone, you still might be eligible and can continue to apply, especially if you are pregnant, have children, or have a disability. You can apply for Medicaid at any time, and don’t have to wait for the Marketplace’s annual Open Enrollment to do so.

To apply for Medicaid, you’ll need to have some basic documentation to prove your income, citizenship, and place of residence. First, you will need a valid Social Security Number (SSN). Then you’ll need proof of age, in the form of a birth certificate or driver’s license. Next, you’ll need proof of income (like paystubs, W-2 forms, or wage and tax statements). You should also have on hand policy numbers for any health insurance plans you currently have and information about any job-provided health insurance that might be available to you and your family, if applicable.

If you do not have all of these documents on hand, you can still apply, but your state agency may ask for additional documentation after receiving your application.

If you are eligible for Medicaid under a non-MAGI group - for example, you are over the age of 65 or have a disability - you should also have proof of assets (i.e. bank statements) and proof of residence (like a copy of your lease or mortgage, rent receipts, or any recent mail addressed to you at your current address). If you’re applying for Medicaid because you believe you are eligible as a result of a disability, you will also need some form of documentation to prove your disability.

The Medicaid agency typically has 45 days to process your application once submitted, and up to 90 days if you believe you are eligible because of a disability. However, it may take more time than this if your state’s Medicaid agency does not have all the documentation it needs to assess your eligibility when you first apply.

Keep in mind that if the Medicaid agency thinks you are being non-cooperative in providing information needed to assess your eligibility, they can deny your application. Should this happen, you’ll have to begin the whole process again, even if you now have all the documentation you need. That means it’s best to make sure you have all the information you need on-hand before you apply. The sooner your application is reviewed, the sooner your coverage can begin.

If you are deemed eligible for Medicaid, you will receive a letter from your state agency with the date of eligibility and the amount you must contribute each month towards the cost of your coverage and care. Your state Medicaid agency will review your eligibility status each year to make sure you still qualify, so be sure to keep all relevant information you may need about your income and assets on hand so you can be best prepared to ensure continuous coverage.

It is especially important to keep your contact information (mailing address, phone number, email address) up to date with your state Medicaid agency. They may contact you for information when reviewing your eligibility status and can end your coverage if you do not respond. In this case, you may have to start the application process over again.

As a result of the Affordable Care Act (ACA), some states have expanded their Medicaid programs to cover more people by raising the income limits for Medicaid eligibility. Regardless of where you live, you can still apply for Medicaid and may qualify depending on your income, household size, whether you have a disability, and your family status.

However, in states that have expanded Medicaid coverage, you can qualify based on your income alone. If you are in a state with an expanded Medicaid program, you may be eligible for coverage if your combined household income is at 138% of the Federal Poverty Level (FPL). Medicaid expansion covers all families and individuals below this income level in states with expanded coverage. Medicaid expansion provides coverage for many Americans who previously fell into what’s known as the “Medicaid coverage gap.” These individuals often struggle to maintain the kind of work that would otherwise provide health insurance benefits or the kind of salary that would make buying Marketplace insurance affordable. And yet many still do not qualify for Medicaid solely based on their disability. Expanding Medicaid did just what it sounds like, making more people eligible for the program who wouldn’t be otherwise and thus ensuring more Americans get affordable health insurance coverage.

As a result of the Affordable Care Act, states that choose to expand their Medicaid programs receive additional federal funding to do so. And research has shown that expanding Medicaid significantly reduces the financial strain felt by low-income Americans, while also increasing their healthcare use, resulting in overall better health. States that expanded Medicaid also saw decreased rates of delayed care and decreased mortality rates among their citizens.

Both Medicaid and Medicare helps people pay for health coverage and care. However, Medicaid is for low-income people while Medicare is primarily for those over the age of 65 or younger folks with disabilities.

Medicaid serves low-income people of all ages by providing health insurance at minimum cost, ensuring that those in the program pay nothing to very little for any healthcare costs they may have. It is a program jointly funded by the federal government and each state, and is administered by each states’ own Medicaid office. Programs and benefits can vary by state, but eligibility is generally based on income relative to a certain percentage of the Federal Poverty line.

Medicare is an insurance program mainly for people over the age of 65 of any income level, and people with certain disabilities, that is paid for by a trust that enrollees pay into throughout their adult lives. Enrollees pay small deductibles to help off-set costs, but on the whole, this federal program pays for medical costs out of these pre-funded trusts, keeping healthcare costs low for people later in life. Medicare programs are essentially the same, no matter where in the United States you live.

CHIP, or the Children’s Health Insurance Program, provides low-cost health insurance to children up to age 19 whose families earn too much to qualify for Medicaid in their state, but do not earn enough to be able to afford private insurance. In some places, CHIP also covers pregnant women. Every state runs and offers a CHIP insurance program for children.

Every state runs their own CHIP program, and has different guidelines on CHIP eligibility. You can apply for CHIP at any time, not just during the annual Open Enrollment Period for the health insurance Marketplace. In 15 states, children may have to be uninsured for up to 90 days before becoming eligible to enroll in CHIP.

CHIP benefits vary slightly by state, but all CHIP programs must provide comprehensive coverage. That means CHIP health insurance covers:

• Routine check-ups
• Immunizations
• Doctor visits
• Prescriptions
• Dental and vision care
• Inpatient and outpatient hospital care
• Laboratory and X-ray services
• Emergency services

Any child up to age 19 who is uninsured but whose family earns too much to qualify for Medicaid might be eligible for CHIP. Each state has different guidelines in terms of income eligibility and eligibility standards. But if you or one of your children is under 19 and uninsured and health insurance coverage seems too expensive to afford, you should go ahead and apply.

You can apply for CHIP by filling out an application on the health insurance Marketplace through HealthSherpa. To get started, select “Apply Now" at the top or bottom of this page. If it looks like someone in your household may qualify for CHIP, you will be contacted directly by your state agency about enrollment.

All routine preventive care services, like annual “well child” check-ups and dental visits, are free under CHIP though you may pay a small co-pay for other kinds of services. Every state’s CHIP program is slightly different, and some states may charge a monthly premium for CHIP insurance. While costs vary by state, they generally won’t exceed more than a total of 5% of a family’s combined annual income.

Though often run through a state’s Medicaid program, CHIP is its own health insurance program. It is designed to specifically cover children in families who earn too much to qualify for Medicaid but cannot otherwise afford or access private insurance.

Typically, you won’t qualify for CHIP if you already have access to health insurance. However, if the amount you’re paying towards your coverage is more than 10% of your family's gross income you may be eligible and it is worth applying.

All CHIP programs, regardless of where you live, ensure no- to low-cost comprehensive coverage, including all check-ups, doctor’s visits, hospital care, emergency care and prescription. It is always better to have health insurance coverage so you can access the healthcare you need when you need it, and this is especially important for growing children.