Who Qualifies for Medicaid? A Comprehensive Guide

March 3, 2025

senior Caucasian woman having blood test performed by female doctor

*Updated November 14th, 2025

If you’re struggling to afford healthcare, Medicaid may offer the coverage you need. This joint federal-state health insurance program provides essential medical assistance and health coverage—from doctor visits to long-term care—for millions of low-income individuals and families. However, Medicaid eligibility rules differ by state, making it important to understand whether you may be eligible. This guide breaks down eligibility for Medicaid, how to apply for Medicaid, and what to do if your income is too high for Medicaid.

What Is Medicaid?

Medicaid is a state and federal health insurance program designed to assist low-income individuals and families who might otherwise struggle to afford medical services. Administered by state agencies with oversight from the Department of Health and Human Services, Medicaid provides states with federal funding to operate their own Medicaid programs while following federal guidelines. Because states have flexibility, Medicaid policies and eligibility groups vary nationwide.

Key Benefits of Medicaid

Medicaid coverage includes a wide range of medical services, such as:

  • Doctor visits and preventive care

  • Emergency room care

  • Prescription medications

  • Mental health treatment

  • Prenatal and maternity care for a pregnant woman

  • Pediatric services

  • Home health and nursing facility care

  • Long-term care support

  • Transportation to medical appointments in some states

For many individuals—especially those with disabilities, chronic conditions, or ongoing care needs—Medicaid provides crucial free or low-cost health care that may not be available through a private insurance plan.

Medicaid vs. Medicare: Key Differences

Although Medicaid and Medicare are both government-supported programs, they serve different purposes.

Feature Medicaid Medicare
Eligibility Based on income level, age, disability, or family status Primarily available to individuals age 65+ or disabled
Income-Based? Yes, based on your countable income No
Coverage Broad healthcare and long-term care benefits Hospital, medical, and drug coverage
Cost Typically free or low-cost Premiums, copays, deductibles

Some people are dual eligible, meaning they qualify for both Medicaid and Medicare, which helps reduce medical costs by covering Medicare premiums and deductibles.

Who Is Eligible for Medicaid?

Your Medicaid eligibility depends on several factors, including income limit, household size, age, medical needs, and citizenship or eligible immigration status. While many states have expanded Medicaid under the Affordable Care Act (ACA), others still use more restrictive criteria.

Income-Based Eligibility

Income is one of the most important factors in determining whether you may be eligible for Medicaid. States use the Federal Poverty Level (FPL) and Modified Adjusted Gross Income (MAGI) to determine financial eligibility.

Adults below a certain income—typically up to 138% of the FPL in states that have expanded their Medicaid programs—may qualify.

Medicaid income limits vary, but are often based on:

  • Household size

  • Monthly income

  • Whether you apply as a parent, adult, senior, or disabled person

Most applicants are not subject to asset tests, but individuals seeking long-term care must meet medically needy income level standards.

Categorical Eligibility

Beyond income requirements, certain groups are automatically or more easily determined eligible for Medicaid.

1. Low-Income Children

Children may qualify through Medicaid or CHIP (the Children’s Health Insurance Program), which provides low-cost health coverage.

2. Pregnant Women

A pregnant woman may be eligible if her income meets the state’s threshold. Coverage often continues postpartum.

3. Parents & Caretaker Relatives

Low-income parents and caretaker relatives may be eligible depending on state standards.

4. Seniors (Age 65+)

Adults age 65 and older may qualify if they meet income and asset limits. Medicaid often helps cover long-term care.

5. Individuals With Disabilities

People receiving Supplemental Security Income are usually automatically eligible. States may expand Medicaid to cover individuals with certain disabilities.

6. Individuals in Foster Care or Former Foster Care

Young adults previously in foster care may be eligible for extended Medicaid coverage until age 26.

7. Adults in Expansion States

In states that expanded Medicaid, low-income adults qualify strictly based on income, regardless of disability or family status.

Special Medicaid Programs

Medically Needy / Spend-Down Medicaid

If your income is too high for Medicaid, you may still qualify for Medicaid by “spending down” your income on medical bills.

Medicare Savings Programs

These programs help low-income seniors pay Medicare premiums.

Medicaid Buy-In

Some states allow working individuals with disabilities to buy into Medicaid services.

Medicaid Eligibility by State

Each state sets its own Medicaid eligibility criteria, income limits, and benefits. State Medicaid agencies determine how income, assets, and medical needs are evaluated.

Key differences include:

  • Whether the state expanded Medicaid

  • The income limit for each eligibility group

  • Availability of programs like medically needy coverage

  • Rules for foster care and former foster care adults

To determine your eligibility:

  • Visit your state Medicaid agency website

  • Use the health insurance marketplace eligibility tool

  • Contact your state’s health and human services department

  • Ask whether anyone in your household qualifies or your household qualifies for Medicaid

Medicaid Eligibility for Immigrants

Immigration status affects whether you are eligible for Medicaid or may be eligible for limited emergency Medicaid.

  • Eligible immigration status (e.g., lawful permanent residents after 5 years)

  • Refugees and asylees: generally eligible

  • Undocumented immigrants: only limited Medicaid for emergencies

How to Apply for Medicaid and CHIP

To apply for Medicaid and CHIP, follow these steps:

  1. Check your state’s Medicaid eligibility rules.

  2. Gather documents (proof of income, household size, identity, and citizenship).

  3. Complete a Medicaid application online, by phone, by mail, or in person.

  4. Your state Medicaid agency will review your information.

  5. You’ll receive a notice saying whether you were determined eligible for Medicaid.

If your income level or family size changes, notify the agency—eligibility is determined based on income and other factors at the time of application.

What If You Don’t Qualify for Medicaid?

If your income is too high for Medicaid or you don’t meet categorical requirements, you still have options:

• Children’s Health Insurance Program

CHIP provides low-cost health coverage for children in families who earn too much for Medicaid.

• Affordable Care Act Plans

The health insurance marketplace offers subsidized plans based on income.

• Local and Community Programs

Community clinics, nonprofit health centers, and county health and human services programs provide free or low-cost health services.

• Employer or Private Insurance

If available, employer-sponsored or private insurance plans may offer alternative options.

Final Thoughts

Medicaid helps millions of Americans access free or low-cost health coverage, but navigating Medicaid eligibility rules can be challenging. Because Medicaid programs must follow federal guidelines while allowing states flexibility, it’s important to check your local rules and income limits.

If you may be eligible, take time to apply for Medicaid, understand what your state Medicaid program covers, and confirm that your chosen provider accepts Medicaid. And if you don’t qualify, you still have pathways to affordable health insurance.