Licensed Insurance Agents: 888-323-1149 TTY: 711
Mon - Fri, 8am - 8pm ET

Medicaid Eligibility and Enrollment: Getting Help with Medicare Costs

The Medicaid program provides financial assistance with health costs for low-income people, including pregnant women, children, disabled people, and older adults. Medicaid eligibility is limited to United States citizens and lawfully present residents who meet federal and state income and residency requirements.

Medicare beneficiaries with limited incomes may also be eligible for the Medicaid program. These individuals can get help paying for Medicare out-of-pocket expenses, such as deductibles, premiums, copayments, and coinsurance.

Note that health care under Medicaid is not necessarily completely free of charge. There may be costs to you, such as copayments; details may vary by state.

State Medicaid eligibility

The federal government partially funds the program and provides minimum requirements for Medicaid income eligibility. However, each state determines Medicaid eligibility for its residents. The state requirements can vary depending on your income and situation.

Most states determine Medicaid eligibility by income and family size with respect to the Federal Poverty Level (FPL).The federal minimum eligibility standard is 133% of the FPL in 2016. State Medicaid programs can expand coverage beyond this level, so Medicaid income eligibility may vary by state. You might qualify in your state even if you don’t meet the federal minimum requirement.

Even if you’re not sure whether you qualify, you might want to apply for Medicaid in your state if you cannot afford health insurance and have limited resources. Medicaid income eligibility determinations will be made by a qualified caseworker in your state. Approvals are based on information you provide including personal status (whether you fit into one of the qualifying categories); your annual income; and your financial resources. Other circumstances that impact your ability to afford health care may also be taken into account.

Some population groups are required under federal law to be covered by state Medicaid programs, although states may cover additional groups. In general, the Medicaid program targets certain low-income populations such as pregnant women, the disabled, the elderly, children, and the “medically needy.” Check with your state’s Medicaid program for specific eligibility criteria.

The Affordable Care Act expanded Medicaid coverage to include low-income adults who weren’t eligible based on other criteria; for example, childless adults and those not eligible for Medicare. Previously, these low-income individuals needed a waiver to be covered by state Medicaid programs. You must meet the federal minimum income standard, but some states may have more generous eligibility criteria. The government has streamlined the application review process to help you get this assistance in a timely manner.

If you have a low income and you don’t fit into the above categories, you may want to contact your state Medicaid office to see if you are eligible.

Medicaid eligibility for children

Medicaid and the Children’s Health Insurance Program (CHIP) provide free or low-cost health coverage to uninsured children, including doctor visits, vaccinations, dental and vision care, emergency care, and preventive services. Hospital care (inpatient and outpatient) and laboratory services are covered as well.

Generally, Medicaid covers:

  • Children and teenagers from birth up to age 19
  • Young adults who have aged out of foster care, until age 26, with no income restrictions
  • Children of public employees (in some states)

If you’re a teenager living on your own, your state may allow you to apply on your own behalf, or an adult may apply for you. Age limits may be different depending on your state’s rules. Some states cover children up to age 21 in certain situations. Medicaid income eligibility is generally based on family income and the number of people in your household. Nearly every state has expanded Medicaid coverage for children beyond the federal minimum, so check with your state Medicaid program to see if you are eligible.

The child’s immigration and residency status determines Medicaid eligibility, not the parents’. That means if the parents are not U.S. citizens while the child is a citizen or legal resident, Medicaid may cover the child, even if the parents are not eligible.

For more information on Medicaid eligibility requirements for children and to apply:

Note that if you have one or more children enrolled in CHIP, you might qualify for Medicaid if you meet income requirements or other eligibility criteria.

Medicaid eligibility for pregnant women and infants

If you are pregnant and have a low income or no income, you may want to apply for Medicaid as soon as possible. Medicaid covers prenatal health care throughout the pregnancy, labor, and delivery, and for an additional 60 days postpartum. Your child automatically qualifies if she or he is born while you’re on Medicaid.

If you are eligible for Medicaid based on pregnancy, your benefits continue until the end of the month in which the 60th day following the birth falls. This is regardless of changes in income that might otherwise affect eligibility status. Your Medicaid benefits may continue longer, if you still qualify for the program.

Medicaid eligibility for disabled adults

If you qualify for Medicaid because of a disability, the government will cover a wide range of health-care services and, in some cases, long-term services and supports (such as psychiatric care), depending on your situation.  This category includes working individuals or those able to work.

Typically, those who receive Supplemental Security Income (SSI) benefits are automatically eligible for Medicaid benefits as well. However, some states have additional criteria for Medicaid eligibility. This might include requiring applicants to prove their disability hinders them from performing “substantial gainful activity,” in addition to meeting income and asset requirements. Check with your state’s Medicaid program for specific requirements.

Medicaid eligibility for Medicare beneficiaries (dual-eligibles)

Limited-income people who have Medicare Part A and/or Part B may qualify for help with health-care costs and additional health benefits through Medicaid. Those who are eligible for both Medicaid and Medicare benefits are known as “dual-eligibles.”

As a dual-eligible, you may qualify for Medicaid benefits through any of four Medicare Savings Programs:

  • Qualified Medicare Beneficiary (QMB) Program
  • Specified Low-Income Medicare Beneficiary (SLMB) Program
  • Qualifying Individual (QI) Program
  • Qualified Disabled and Working Individuals (QDWI) Program

Each Medicare Savings Program has different eligibility criteria, including income and asset requirements. For more information on eligibility for these programs, visit Medicare.gov. Keep in mind that income and resource limits change annually, and availability and eligibility details may differ from state to state.

Applying for Medicaid

To apply for Medicaid, contact your state’s Medicaid program directly. Most states let you apply in person, over the phone, online, or by mailing your application. You will need to provide documentation to verify your income and resources.

You can also visit Medicaid.gov to look up the website and contact information for your state’s Medicaid program.