The Basics of Medicaid Eligibility

By J.W. Carpenter , last updated July 17, 2011

Federal law currently identifies over 25 mandatory categories of Medicaid eligibility. Because individual states have some flexibility to extend coverage beyond the minimum federal requirements and to exercise various policy preferences, no two state Medicaid programs are exactly alike. Thus, the following brief introduction to Medicaid eligibility is meant to apply broadly and generally to all states. For information on the finer details of Medicaid eligibility in your state, contact your state’s Medicaid authority directly. Also see the final section of this article for important eligibility changes to be introduced in 2014.

Current Medicaid Eligibility

The more than 25 detailed categories of Medicaid eligibility can be organized into three broad categories. The first category includes low-income pregnant women, children, and families. Federal guidelines require that states grant Medicaid coverage to pregnant women and children under age six who are in families with a total income of no more than 133 percent of the Federal Poverty Level (FPL). In 2011, for example, a family of three must earn less than $25,645 to meet this requirement (See the link on this page for detailed FPL tables). Children between six years of age and 19 years of age are eligible for Medicaid if they are in families earning incomes of 100 percent or less of the FPL. Again, individual states may choose to broaden these requirements, allowing more children to be covered. Among a number of other narrowly-defined groups, all children in foster care are also eligible for Medicaid.

The second broad category of Medicaid eligibility includes the elderly and the disabled. States are required to cover any elderly or disabled individual who receives regular benefits from the Supplemental Security Income (SSI) program. The SSI program is administered by the Social Security Administration and provides cash benefits to elderly and disabled people who have little to no other income sources to provide for their basic needs. Note that certain disabled individuals who are working and ineligible for SSI benefits may be eligible for Medicaid.

The third broad category of Medicaid eligibility includes elderly individuals who have income of 200 percent of the Federal Poverty Level or less. In this category, Medicaid pays some or all of the individual’s Medicare premiums and cost-sharing requirements. There are several levels of coverage depending on the individual’s income. Those individuals earning less than 100 percent of the FPL are eligible for Medicaid payment of all Medicare Part A and Part B premiums, as well as all deductibles, coinsurance charges, and copayments. Individuals who earn between 100 percent and 135 percent of the FPL are eligible for Medicaid payment of Medicare Part B premiums.

Future Changes

A major change is slated to be made to Medicare eligibility requirements beginning in 2014. This change is a result of the Patient Protection and Affordable Care Act, signed into law in 2010.

In 2014, Medicaid eligibility will be extended to include all individuals under the age of 65 who live in families with incomes less than 138 percent of the Federal Poverty Level. Individual states are free to begin phasing in this change whenever they choose, so contact your local Medicaid authority for current eligibility requirements.

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