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Medicaid Eligibility - An Overview of Medicaid Eligibility and Benefits

Understanding Your State's Medicaid Program

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Updated April 10, 2014

Medicaid Eligibility - An Overview of Medicaid Eligibility and Benefits

Health reform will expand Medicaid eligibility.

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Medicaid Eligibility - What Is Medicaid?

On July 30, 1965, President Lyndon Johnson signed into law an amendment to the Social Security Act that created the Medicaid program.

Medicaid is an insurance program for low-income and needy people that provides health-related coverage for children, many seniors, and/or people who are blind or have other disabilities. The program is jointly funded by the Federal government, all fifty states, and the District of Columbia.

Each state runs its own Medicaid program, and a federal agency known as the Centers for Medicare and Medicaid Services (CMS) monitors the programs in each state and sets standards for how the programs are managed and financed.

A Dr. Mike Medcaid fact: More than 58 million Americans (about 20% of the population) are enrolled in a Medicaid program.

Some states have named their Medicaid program including, for example, "Medi-Cal" in California, "MassHealth" in Massachusetts, "Oregon Health Plan" in Oregon, and "TennCare" in Tennessee.

Who Is Eligible for Medicaid?

Federal Requirements
The federal government requires each state to cover certain mandatory groups of people in the Medicaid program. These categories include children, pregnant women, very low-income parents, the elderly, and people who are blind or disabled.

Eligibility among these categories of people varies by income. For example:

  • Children under age six with family incomes up to 133% of the federal poverty level
  • Children ages 6-19 with family incomes up to 100% of the federal poverty level
  • Pregnant women with family incomes up to 133% of the federal poverty level
A Dr. Mike definition: Federal Poverty Level - At the beginning of each year, the federal government releases an “official” income level for poverty. This amount is the minimum yearly income that an individual or family needs to be able to provide for basic needs such as food and housing. The actual dollar amount changes each year and varies based on the number of people in a family. The Federal Poverty Level is used to determine someone’s eligibility for government programs such as Medicaid.

Health Reform and Medicaid

If you or your children are currently enrolled in the Medicaid program in your state, it is unlikely that you will notice any changes in your benefits or where you receive care due to the passage of the Patient Protection and Affordable Care Act (health reform) in March 2010.

In some states, the health reform law will expand Medicaid eligibility to include all Americans under age 65 with incomes up to 133% of the federal poverty level. This would include children, pregnant women, parents, and adults without dependent children. To pay for this expansion, the federal government will provide your state with additional Medicaid funds starting in 2014.

The federal government will also provide funds for increase payments to primary care doctors, including family physicians, internal medicine physicians, or pediatricians. This may make it easier for you and other people enrolled in Medicaid to find a primary care doctor.

State Options
Your state has the option to increase the federal income limits to allow more people to qualify for Medicaid. This includes low income children, parents, and pregnant women whose family income is above the federal cutoff levels. Your state can set whatever income limit it considers appropriate.

For example: In New York, children under age one year and pregnant women are eligible for New York’s Medicaid program with family incomes up to 200% of the federal poverty level (instead of the federal cutoff of 133%).

The states can also enhance eligibility for some nursing home residents, people with disabilities who work and have incomes above the federal limit, and medically needy people who require institutional care and have incomes that are too high to qualify for Social Security Insurance.

However, federal law prevents states from making anyone eligible for Medicaid. For example, the states cannot offer Medicaid coverage to adults who don’t have children living with them and who are not disabled or elderly no matter how poor they are. States can apply to the federal government for a waiver to allow enrollment in special programs.

What Are the Medicaid Benefits?

Federal Requirements
The federal government requires each state to cover certain health-related benefits. These are known as mandatory benefits and include:

  • physician, nurse midwife, and nurse practitioner services
  • laboratory and x-ray services
  • ipatient and outpatient hospital services
  • early and periodic screening, diagnostic, and treatment (EPSDT) services for children, teens, and young adults under age 21
  • family planning services and supplies
  • services provided in community health centers and rural health clinics
  • nursing facility services for people age 21 and older

State Options
Your state can provide coverage for additional health-related services that are approved by the federal government. These so-called “optional” services may include:

  • prescription drugs
  • dental care
  • eye glasses and vision care
  • mental health services
  • home health services
  • case management
  • rehabilitation services such as physical therapy
  • hospice care

To make sure that your child receives these services, your state must make you aware of the EPSDT program available, as well as provide transportation and, if you request, help with scheduling appointments.

Where Can I Find Information About My State’s Medicaid Program?

Since each state and the District of Columbia offer different Medicaid-related services and programs, it is important for you to understand what your state’s eligibility requirements are and what you can expect if are eligible.

The website of the National Association of State Medicaid Directors has an interactive map that will connect you to the site of your state’s Medicaid office.

If you are interested in a detailed list of the benefits offered by each state, the website of the Kaiser Family Foundation has information about the benefits covered, copayments, and those services that may be limited in some way or require permission to use.

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