While Medicaid eligibility is income-based, some people may qualify for Medicaid based on age, availability of financial resources or healthcare needs.
There are five main criteria of Medicaid eligibility:
- Categorical eligibility — children, parents or caregivers with children, people with disabilities and seniors.
- Income eligibility — each eligibility category has a different income threshold.
- Resource eligibility — people with disabilities and seniors with limited income and savings.
- Immigration status — you must be a legal resident of the U.S. to receive Medicaid benefits.
- Residency — you must have established residency in the state where you are requesting Medicaid benefits.
Two main groups that are eligible for Medicaid
Healthy, but with low incomes:
- Childen
- Pregnant women
- Some seniors
People with disabilities or chronic conditions & have low incomes:
- People with disabilities
- Some seniors
What is the Federal Poverty Level?
The Federal Poverty Level (FPL) accounts for the minimum amount of gross income that a family needs for food, clothing, transportation, shelter and other necessities. The calculation is used to determine eligibility in multiple federal assistance programs. It is recalculated every year.
2020 Federal Poverty Guidelines for the contiguous 48 states
| People in Household | Poverty Guideline |
|---|---|
| 1 | $12,760 |
| 2 | $17,240 |
| 3 | $21,720 |
| 4 | $26,200 |
| 5 | $30,680 |
| 6 | $35,160 |
| 7 | $39,640 |
| 8 | $44,120 |
| For families/households with more than 8 persons, add $4,480 for each additional person. | |
Each group of people eligible for Medicaid must meet certain FPL eligibility thresholds.
- Children between 6 and 18 are eligible for Medicaid if their family makes less than 138% of the FPL. If there are three people living in their house the total yearly income would have to be less than $29,974 to qualify for Medicaid.
- Pregnant women are eligible for Medicaid if their family makes less than 138% of the FPL. If the pregnant woman already had a child, her household size would be 2 people and she would need to make less than $23,791 per year to qualify for Medicaid.
- Low-income working adults with no children are eligible for Medicaid if their state has expanded eligibility under the Affordable Care Act. In most states, these low-income adults need to make less than 138% FPL or $17,226 per year if they are the only person in their household.
Source: https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines
Examples of Medicaid Eligibility
- Medicaid
- Pregnant Woman
- Medicaid Expansion
- Activities of Daily Living (ADLs)
- Dually Eligible
Medicaid – Children of low-income families
JJ is 10 years old and lives in Louisiana with his father and 8-year-old brother. This means there are three people in his household. His mother recently died after battling cancer. His dad is employed as a maintenance worker for a local property management company.
JJ’s dad earns $26,635/year.
JJ and his brother are covered under Medicaid because his dad earns less than $30,288/year.
Pregnant Woman
Tanya is a recently single mother with one child who lives in Texas. She is pregnant and works full-time as a restaurant hostess making the federal minimum wage of $7.25 per hour. She works full-time and earns just over $15,000 a year. Because she has a child, her household size is 2 people.
Her child qualifies for Medicaid because she earns less than 138% of the Federal Poverty Level or $25,365 per year for a 2 person household.
At this time Tanya also receives Temporary Assistance for Needy Families (TANF). TANF is a time-limited benefit program that helps parents or caregivers. Each state determines what benefits are available for those who qualify. In Texas, Tanya can receive a cash benefit to help with things like housing and childcare.
Since Tanya needs to earn less than $33,820 per year to qualify for Medicaid as a pregnant woman, she is also currently covered. However, once her child is born she will not qualify for Medicaid as a caregiver parent in Texas since she makes more than $3,626 per year, or 17% of the Federal Poverty Level with a household size of 3, and will no longer have health care coverage. Each state sets the Medicaid eligibility level for parents and caregivers of children and that level is approved by the federal government.
If Tanya’s state expanded Medicaid, she would qualify for Medicaid after giving birth since she makes less than $29,435 per year with a 3 person household.
Medicaid Expansion
After working as an administrative assistant at the same company for more than 25 years, Lisa was part of a large lay off due to downsizing. She is currently working at a local grocery store while she is looking for another office position.
She earns the federal minimum wage of $7.25 per hour. She works an average of 35 hours a week, earning just over $1,000 a month.
Lisa qualifies for Medicaid after her state expanded Medicaid eligibility to low-income working adults and she makes less than $17,236 per year.
Example of person needing help with ADLs
Susan is an 80-year-old woman who was living on her own until she fell and broke a hip. Her doctor determined that she should move to a nursing home to recover from surgery. Susan was already on Medicaid due to her low income and small amount of assets and on Medicare because she is over 65 years old.
After recovering from her hip fracture, she was assessed to determine if she needed help with activities of daily living (ADLs). The assessment showed that she needed help dressing, walking from one place to another, using the bathroom and showering. She also needed help remembering to take her medications and eat three meals a day.
Based on the ADL assessment, Susan’s doctors and family agreed that she could no longer live at home and would need to be moved into a nursing facility for her safety.
Dually Eligible
Rebecca is a 35-year-old woman who survived a serious car accident as a child, leaving her with physical and cognitive disabilities. Despite her disabilities, including the requirement to use a wheelchair, Rebecca lives independently with the help of Supplemental Security Income (SSI).
Rebecca has a part-time job at a local manufacturing facility. She earns $13 per hour, equaling roughly $15,600 a year.
Rebecca is a Dual Eligible because she qualifies for coverage under both Medicare and Medicaid. She qualifies for Medicare because she’s permanently disabled and receives disability benefits. She qualifies for Medicaid because she earns less than $4,249 per month.
Gary's Story
Gary Sullivan was a highly driven professional - until his muscular dystrophy prevented him from continuing to work. Find out how Medicaid acts as a safety net for individuals experiencing unexpected life changes.
Donald's Story
Medicaid supports individuals like Donald Boone who need long-term support, including those who have an intellectual or developmental disability (I/DD). Through home- and community-based services, these individuals can gain independence and improve their health outcomes. This not only helps them stay out of care facilities, but it helps them live fuller lives.
This video explores how The Employment & Community First CHOICES program in Tennessee helps individuals with I/DD live more independently. With services to help them find, train for and keep a job, the program helps participants stay healthier, learn new skills, meet new people and build self-confidence through working.
Jennifer's Story
For members like Jennifer, who was born with spinal muscular atrophy, health care is a daily necessity. But as a college math teacher and advocate for individuals with intellectual and developmental disabilities (I/DD), Jennifer requires care that is both tailored to her needs and her lifestyle. Through integrated care, Jennifer has a team to support her health needs, including a designated case manager and a streamlined process for requesting transportation to appointments. See how care integration has helped keep her out of the emergency room and nursing home settings and made daily independence possible.
