Do I Qualify for Medicaid – A Guide for Answering All Your Queries Right
Millions of Americans, including certain low-income people, families and children, pregnant women, the elderly, and persons with disabilities, benefit from Medicaid and the Children's Health Insurance Program (CHIP).
Medicaid is a federal-state-funded health-insurance program for low-income and low-income families in the United States. Medicaid eligibility varies based on where you live because states finance and operate their programs cooperatively. Medicaid eligibility is determined in part by the applicant’s income, age, handicap, pregnancy, household size, and function in the home. According to Medicaid.gov, nearly 74 million Americans are currently registered in their state’s Medicaid and Children’s Health Insurance Programs (CHIP).
Who can get Medicaid?
- Depending on your income, household size, disability, family status, and other characteristics, you may be eligible for Medicaid in any state. However, if your state has expanded Medicaid coverage, you may be able to qualify solely based on your income.
- Enter the size of your family and your location. We’ll tell you who qualifies for Medicaid, if your state has expanded Medicaid, and if you qualify solely based on your income.
- You can create an account and apply for Medicaid through the Marketplace if you believe you are eligible. We’ll send your information to your state agency if it appears that anyone in your home qualifies for Medicaid or CHIP. They’ll get in touch with you about enrolling. You can submit your application at any time of the year.
- If you don’t qualify for Medicaid, we’ll let you know if you’re eligible for financial assistance to purchase a Marketplace health plan. (However, unless you qualify for a Special Enrollment Period, you will not be able to enroll.)
Do I qualify for Medicaid?
Medicaid covers some low-income individuals, families, children, pregnant women, the elderly, and persons with disabilities for free or at a reduced cost. Many states have expanded their Medicaid programs to cover everyone who earns less than a set amount. Your eligibility for Medicaid is largely determined by whether your state has extended its program.
What if I’m turned down by Medicaid?
- For the 2018 plan year, you might be able to purchase a private health plan on the Marketplace instead. You may be eligible for a premium tax credit and out-of-pocket cost savings based on your income.
- You still have options if you don’t qualify for Marketplace or Medicaid savings.
How to qualify for Medicaid
Medicaid is a government-run healthcare program that is available in almost every state. However, if you earn between 100 and 200 percent of the federal poverty level (FPL) and are pregnant, old, disabled, a parent/caretaker, or a child, there is almost certainly a program for you. And, depending on whether your state expanded Medicaid under Obamacare, there may be a program for you if your income is less than 133 percent of the federal poverty level. The federal poverty guidelines for 2019 (except Alaska and Hawaii, which have higher guidelines) are as follows:
In 2019, Alaska’s federal poverty line ranges from $15,600 (for one person) to $54,310 (for two individuals) (for eight people). Hawaii’s federal poverty level ranges from $14,380 (for one person) to $49,940 (for two individuals) (for eight people).
How Medicaid eligibility is determined
Your modified adjusted gross income (MAGI), which is your taxable income plus certain deductions, determines your income eligibility. Non-taxable Social Security benefits, individual retirement contributions, and tax-exempt interest are among the deductions available. Most people’s MAGI is the same as or very similar to their adjusted taxable income, which may be found on their tax returns. The size of your household increases your specific income requirements in dollars.
Our list focuses on the key adult programs in each state. The majority are restricted to state residents, U.S. citizens, permanent residents, or legal immigrants (exceptions are specified).
How to apply for Medicaid
If you qualify for Medicaid, you can apply at any time of year through your state’s Medicaid website or the federal health insurance marketplace, HealthCare.gov. If you apply for Medicaid through Healthcare.gov and it appears that you are eligible, the federal government will tell your state agency, who will contact you about enrollment. In most cases, states also allow you to print paper applications that you can mail, fax, or return to your local government office.
You will almost certainly need to present documentation that you meet your state’s requirements to finish your Medicaid application. This documentation could include the following:
- As proof of age and citizenship, bring your birth certificate or driver’s license.
- Proof of income should be provided in the form of recent pay stubs or tax filings.
- Bank statement photocopies
- A lease, utility bill summaries, or a copy of your mortgage could all be used as proof of address.
- Medical records will be used as proof of incapacity.
Your Medicaid application has 45 days to be processed by the state. If their eligibility is based on a handicap, they have 90 days to apply (disability can result in a permanent loss of income). To help guard against such a decline, Policygenius can help you compare disability insurance coverage. If you don’t qualify for Medicaid, Healthcare.gov may be able to help you find subsidized health insurance.
Only specific life events, including getting married or having a child, allow you to apply for a marketplace health care plan outside of open enrollment, which runs from November 1 to December 15 each year.
How Medicaid works
Medicaid was established in 1965 to provide health insurance to Americans who were unable to work. Participation in the program is entirely voluntary. States are not required to participate, yet they all do. To get federal funding, participating states must meet certain criteria outlined by the Center for Medicare and Medicaid Treatments, but they also have a lot of say over who is eligible and what services are covered.
President Barack Obama’s healthcare bill standardized Medicaid eligibility rules, allowing anybody earning up to 133 percent of the federal poverty level to enroll. The Supreme Court, however, contested and overturned that provision. States might choose to expand Medicaid, but they were no longer required to do so. Thirty-five states (plus D.C.) did, while 15 did not. Since the Trump administration stated that states would be able to implement work requirements for low-income and needy Americans receiving Medicaid, eligibility has varied by state.
To put it another way, determining whether you qualify for Medicaid is significantly more difficult than before. Here’s our state-by-state Medicaid guide, which we’ll keep up to current when new laws are enacted.
How to qualify for Medicaid: Tips and eligibility requirements
You must apply for Medicaid coverage if you require long-term care and are unable to pay for either the essential treatment or any sort of insurance or annuity protection. This programme, which provides managed care, is for those who are handicapped or over the age of 65 and have income and assets that fall below specific federal and state standards.
Qualifying for Medicaid can be difficult, but pertinent steps help you determine if you are eligible and increase your chances of receiving coverage.
Learn about Medicaid asset limits and eligibility requirements
As of January 2021, if you are married and your spouse is still able to live independently, they are eligible to keep 50% (or 100% in some areas) of your joint assets up to a limit of $130,380. Generally, your single or joint income cannot exceed 138 percent of the federal poverty level, however, some states have higher limits.
In almost all circumstances, you will also need to show that you are disabled through medical documentation. However, there are certain exceptions (such as women with breast or cervical cancer or anyone diagnosed with tuberculosis). You must also be a U.S. citizen or hold a green card, as well as show proof of residency in the state. Though there are certain exceptions to these rules, such as people who have been victims of human trafficking or who are categorized as “medically needy” by Medicaid.
1. Start the spend-down process
You will need to minimize your estate if your assets or income exceed the state’s criteria. You can give your assets or things to your children or another responsible party you can trust to use them on your behalf if you arrange ahead of time for at least 5 years (or 30 months in California).
In some situations, depending on your state’s regulations, you may be able to set up a spend-down trust. However, there are some limitations to this structure, and any monies left in the trust after death cannot be handed on to a relative.
2. Medicaid application form
You can apply for Medicaid in a few different ways. Visit www.medicaid.gov, www.healthcare.gov, or the website of your state’s Medicaid department for further information and Medicaid application form. If you don’t have access to the internet, Medicaid provides local eligibility offices in each state where you can apply in person or over the phone.
Incomplete information on the application is one of the most prevalent reasons people are denied coverage. Gather the following documents to provide before you begin filling out an application:
- Birth certificate or driver’s license (to prove your age)
- Proof of citizenship
- Documentation of all assets and income
- Copies of your mortgage, lease, rent payment receipts, utility bills, or other documents that prove where you live
- Medical records documenting your disability
- Information about any other health insurance coverage you may have
Be sure to check with your particular state to see if they require different or additional documentation, along with the standard documents listed above.
3. Work requirements and Medicaid in 2018 and beyond
President Joseph Biden started undoing the previous administration’s efforts to design and execute new eligibility standards for those without children or disabilities in April 2021. These rules would have permitted states to deny Medicaid coverage to childless adults who aren’t disabled, don’t work, or participate in volunteer or employment-related programs. 1617 Because the laws had been declared unlawful by federal courts, even states that had gotten permission have not implemented employment requirements as of April 2021. 16
President Biden’s 2021 American Rescue Plan includes increased matching federal funding as an incentive to urge states to expand Medicaid.
Work requirements in the Medicaid programs of Arizona, Arkansas, Indiana, Michigan, New Hampshire, Ohio, South Carolina, Utah, and Wisconsin have now been canceled by the US Department of Health and Human Services. After gaining initial approval, Kentucky and Nebraska withdrew their proposals for work requirements.
During the previous administration, at least 15 states requested for or gained approval to impose work requirements, according to the Pew Charitable Trusts.
According to the independent Center on Budget and Policy Priorities, Arkansas removed over 18,000 Medicaid recipients off the rolls in 2018 because they did not meet new eligibility rules.
4. Get some expert help
You may want to contact two professionals before or during the Medicaid application process to assist you to improve your chances of gaining coverage. The first expert is an attorney who specializes in elder law and is well-versed in your state’s Medicaid legislation. The other person is a financial expert who can help you set up a Medicaid trust or take other steps to reduce your debt.
Does the federal poverty level vary from one state to another?
Thirty-nine states and Washington, D.C., have accepted federal funding to expand Medicaid under the ACA. Missouri voters approved Medicaid expansion that was slated to take effect in mid-2021, but implementation has been suspended after GOP lawmakers refused to provide funding.
The bottom line
Qualifying for Medicaid is a difficult procedure, and it isn’t getting any easier with state-by-state adjustments. To increase your chances of acceptance, seek as much assistance as possible from a financial counselor and a knowledgeable elder care attorney before you begin this process.
Also, be prepared to plan ahead and significantly lower the size of your permissible estate through a giving or donation program in order to fulfill your state’s standards.
Even if your income does not qualify you for Medicaid, you should still apply. If you have children, are pregnant, or have a disability, you may be eligible for your state’s program. You can apply for Medicaid at any time of year because there are no Open Enrollment Periods for Medicaid or CHIP.
Note: Medicaid & CHIP program names vary. Learn what they’re called in your state.
10 things to know about Medicaid: Setting the facts straight
- Medicaid is the nation’s public health insurance program for people with low income
Medicaid is a government-run healthcare program for low-income persons in the United States. One out of every five Americans is covered by Medicaid, which includes many people with complicated and expensive healthcare needs. The program is the primary source of long-term care insurance in the United States. The great majority of Medicaid recipients do not have other inexpensive health insurance options. Medicaid covers a wide range of health treatments and keeps out-of-pocket payments to a minimum. Medicaid accounts for almost a fifth of all personal healthcare spending in the United States, funding hospitals, community health centers, physicians, nursing homes, and health-care-related professions.
- Medicaid is structured as a federal-state partnership
States run Medicaid programs within federal guidelines and have discretion over who is covered, what services are covered, how healthcare is delivered, and how physicians and hospitals are paid.
The Medicaid entitlement is predicated on two guarantees: first, that all Americans who fulfill Medicaid eligibility requirements would be covered, and second, that states will receive federal matching funds for qualified services delivered to eligible enrollees without a cap. A formula in the law determines the match rate for most Medicaid members, which must be at least 50% and includes a larger federal match rate for poorer states.
- Medicaid coverage has evolved over time
Medicaid eligibility for parents, children, the poor aged, blind, and individuals with disabilities was related to cash assistance (either Aid to Families with Dependent Children (AFDC) or federal Supplemental Security Income (SSI) commencing in 1972) under the original 1965 Medicaid law. States may choose to provide coverage at income levels higher than those eligible for financial assistance.
Congress has gradually increased federal minimum requirements and provided states with more coverage alternatives, particularly for children, pregnant women, and individuals with disabilities. Congress also mandated that Medicaid assist low-income Medicare recipients with premiums and cost-sharing, as well as allowing states to offer a “buy-in” option to Medicaid for working people with disabilities.
Medicaid expansions have led to record decreases in the number of children without coverage, as well as substantial reductions in the number of adults without coverage in states that have adopted the Affordable Care Act’s Medicaid expansion. Many Medicaid adults work, but few have access to job coverage and had no affordable options prior to the Affordable Care Act.
- Medicaid covers 1 in 5 Americans and serves diverse populations
Medicaid serves as a high-risk pool for the commercial insurance market, providing health and long-term care to millions of America’s poorest and most vulnerable citizens. Medicaid served nearly 75 million low-income Americans in the fiscal year 2017. As of February 2019, 37 states had agreed to expand Medicaid. According to data from FY 2017 (when fewer states had authorized the expansion), 12.6 million people were added to the expansion group.
Children make up more than four out of every ten Medicaid enrollees (43 percent), while the elderly and individuals with disabilities make up around one out of every four registrants.
Medicaid covers nearly half of all births in a typical state; 83 percent of poor children; 48 percent of children with special health care needs and 45 percent of nonelderly adults with disabilities (such as physical disabilities, developmental disabilities such as autism, traumatic brain injury, serious mental illness, and Alzheimer’s disease); and nearly six out of ten nursing home residents.
- Medicaid covers a broad range of health and long-term care services
Medicaid covers a wide range of services in order to meet the different needs of the people it helps.
Due to the limited ability of Medicaid and CHIP enrollees to pay out-of-pocket costs due to their low incomes, federal rules prohibit states from charging premiums in Medicaid for beneficiaries with incomes below 150 percent of the federal poverty level (FPL), prohibit or limit cost-sharing for certain populations and services, and limit total out-of-pocket costs to no more than 5% of family income. Some states have received waivers that let them charge more premiums and cost-sharing than the federal guidelines allow. Many of these waivers are aimed at expanding adults, but some also apply to people who qualify through standard routes.
- Most Medicaid enrollees get care through privately managed care plans
Over two-thirds of Medicaid recipients are enrolled in private managed care plans that contract with states to provide comprehensive treatments, while the other clients are treated on a fee-for-service basis.
Medicaid covers a range of long-term services and supports for people with intellectual disabilities, from home and community-based services (HCBS) that allow people to live independently in their own homes or in other community settings to institutional care in nursing homes (NFs) and intermediate care facilities (ICF-IDs). In FY 2016, HCBS accounted for 57% of overall Medicaid LTSS spending, while institutional LTSS accounted for 43%. This is a significant change from 1995 when institutional settings accounted for 82 percent of national Medicaid LTSS spending.
- Medicaid facilitates access to care
Medicaid beneficiaries have considerably greater access to care than the uninsured, according to a substantial body of evidence, and are less likely to postpone or forego essential care due to cost. Furthermore, Medicaid members’ rates of access to care and satisfaction with care are comparable to those of persons with private insurance.
The expansion of Medicaid to low-income pregnant women and children has resulted in significant reductions in newborn and child mortality in the United States. Medicaid eligibility throughout childhood is linked to lower teen mortality, greater long-term educational achievement, reduced disability, and lower rates of hospitalization and emergency department visits later in life, according to a growing body of research.
Second-order fiscal effects, such as greater tax collections due to better incomes in adulthood, are also included. Adult Medicaid expansions are linked to increased access to care, improved self-reported health, and lower mortality among adults, according to research.
- Medicaid is jointly financed by states and the federal government
Medicaid is a federal-state partnership that is funded equally by the federal government and the states. Medicaid spending is matched by the federal government. The guaranteed availability of federal Medicaid matching payments relieves state fiscal strains when enrollment grows during recessions. Although federal matching rates do not automatically react to economic swings, Congress has temporarily increased them twice to enhance state assistance during downturns.
In the fiscal year 2017, federal and state Medicaid spending totaled $577 billion. After Social Security and Medicare, Medicaid is the third-largest domestic program in the federal budget, accounting for 9.5 percent of government spending in FY 2017. After elementary and secondary education, Medicaid was the second-largest item in state budgets in 2017.
- Medicaid spending is concentrated on the elderly and people with disabilities
Seniors and individuals with disabilities make up one out of every four Medicaid recipients, yet they account for about two-thirds of all spending, indicating high per-enrollee expenses for both acute and long-term care. Because Medicare coverage is limited and there are few inexpensive options in the private insurance market, Medicaid is the principal payer for institutional and community-based long-term services and support.
The highest-cost 5% of Medicaid members account for more than half of the program’s spending. Medicaid, on the other hand, is less expensive per enrollee than commercial insurance, owing to lower Medicaid payment rates for providers. Adult Medicaid users’ average health care expenses would be more than 25% higher if they had job-based coverage instead, according to analysis.
Medicaid spending per enrollee has been expanding at a slower rate than commercial insurance rates and other healthcare benchmarks.
- The majority of the public holds favorable views of Medicaid
According to public opinion polls, Medicaid enjoys widespread support. Seven out of ten Americans claim they’ve ever dealt with Medicaid, with three out of ten saying they’ve ever been insured. Majorities of people, regardless of political affiliation, think Medicaid is a good program that is working effectively.
Furthermore, polls suggest that few Americans support cuts to federal Medicaid financing. Medicaid has substantial support among individuals who are disproportionately covered by Medicaid, such as children with special health care needs, seniors, and those with disabilities, in addition to broad-based support.
Millions of Americans, the majority of whom are working families, benefit from Medicaid’s comprehensive coverage and financial safety. Medicaid enrollees get access to care at rates equivalent to those of those with private insurance, despite their modest income. Medicaid serves millions of elderly and persons of all ages with disabilities, both in nursing facilities and in the community, in addition to acute health care.
Medicaid helps to support the private insurance market by acting as a high-risk pool,
offering coverage to many uninsured people who were previously unable to obtain coverage through the private, mostly employment-based health insurance system due to low income, bad health, or disability. Medicaid also helps low-income Medicare members pay for premiums and copayments, as well as providing long-term treatments and supports not covered by Medicare.