Who Qualifies for Medicaid? A Comprehensive Guide

March 3, 2025

senior Caucasian woman having blood test performed by female doctor

If you’re struggling to afford healthcare, Medicaid may offer the coverage you need. This joint federal-state program provides essential medical services—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 qualify. This guide breaks down Medicaid requirements, the application process, and alternative options if you don’t qualify.

What is Medicaid?

Medicaid is a public health insurance program designed to assist low-income individuals and families who might otherwise struggle to afford medical care. Established in 1965 under Title XIX of the Social Security Act, Medicaid provides states with federal funding to administer their own healthcare programs while following federal guidelines. States have the flexibility to determine eligibility criteria, covered benefits, and administrative processes, leading to variations in Medicaid programs across the country.

Key Benefits of Medicaid

Medicaid covers a broad range of healthcare services, including:

  • Doctor visits and preventive care
  • Emergency room visits and hospital stays
  • Prescription drugs
  • Mental health and substance use disorder treatment
  • Prenatal and maternity care
  • Pediatric services, including immunizations and well-child visits
  • Home health and nursing home care
  • Durable medical equipment and assistive devices
  • Transportation to medical appointments (in some states)

For many enrollees—particularly those with chronic conditions, disabilities, or requiring long-term care—Medicaid is an essential source of coverage, providing benefits that may not be available through private insurance.

Medicaid vs. Medicare: Key Differences

Although Medicaid and Medicare are both government-administered healthcare programs, they serve distinct populations and have different eligibility requirements.

Feature Medicaid Medicare
Eligibility Low-income individuals, families, children, pregnant women, seniors, and individuals with disabilities Individuals aged 65+ and some younger individuals with disabilities
Income-Based? Yes, income and assets determine eligibility No, eligibility is based primarily on age or disability
Coverage Scope Comprehensive, including hospital care, doctor visits, long-term care, and additional non-traditional services Primarily hospital care (Part A) and medical services (Part B), with optional prescription drug coverage (Part D)
Cost to Beneficiaries Low or no cost for most services (varies by state) Monthly premiums, deductibles, and copayments required

While Medicare serves older adults and certain disabled individuals, Medicaid provides need-based healthcare coverage. Some individuals qualify for dual eligibility, meaning they receive benefits from both Medicaid and Medicare, which can help reduce out-of-pocket costs by covering Medicare premiums, deductibles, and copayments.

Who Qualifies for Medicaid?

Medicaid is a joint federal and state program that provides health coverage to low-income individuals, families, seniors, and people with disabilities. Eligibility depends on income level, household size, and categorical qualifications. While some states have expanded Medicaid under the Affordable Care Act (ACA), others maintain more restrictive eligibility criteria.

Income-Based Eligibility

One of the primary determinants of Medicaid eligibility is household income relative to the Federal Poverty Level (FPL). The FPL is updated annually and varies by household size. In states that have expanded Medicaid, adults with incomes up to 138% of the FPL may qualify.

Medicaid Income Limits for 2024

Household Size 100% FPL 138% FPL (Medicaid Expansion)
1 Person $15,060 $20,783
2 People $20,440 $28,207
3 People $25,820 $35,630
4 People $31,200 $43,054
Each Additional Person +$5,380 +$7,424

(Income thresholds may vary slightly in Alaska and Hawaii.)

  • Expansion states: Adults aged 19-64 with incomes up to 138% of the FPL qualify for Medicaid.
  • Non-expansion states: Medicaid is typically limited to low-income parents, pregnant women, children, seniors, and disabled individuals.

Medicaid eligibility calculations use Modified Adjusted Gross Income (MAGI), which considers taxable income and deductions. Most applicants are not subject to asset limits, but exceptions apply to seniors and those seeking long-term care benefits.

Categorical Eligibility

In addition to income limits, Medicaid provides coverage for specific groups of people, many of whom qualify regardless of Medicaid expansion.

1. Low-Income Children

  • Medicaid and the Children’s Health Insurance Program (CHIP) cover children in families with incomes up to 200% of the FPL in most states.

2. Pregnant Women

  • Many states offer Medicaid to pregnant individuals with incomes between 138% and 200% of the FPL.
  • Coverage typically extends 60 days postpartum, though some states have expanded it to 12 months.

3. Parents and Caretaker Relatives

  • Some states allow low-income parents or legal guardians of minor children to qualify.
  • Eligibility thresholds vary, especially in non-expansion states.

4. Seniors (Aged 65 and Older)

  • Seniors may qualify if they meet income and asset limits.
  • Medicaid offers long-term care benefits for eligible seniors, covering nursing home care and home-based services.

5. Individuals with Disabilities

  • People with disabilities may qualify if they receive Supplemental Security Income (SSI) or meet state-specific disability criteria.
  • Medicaid covers services like personal care assistance, assistive devices, and long-term care.

6. Individuals Receiving Supplemental Security Income (SSI)

  • SSI recipients are automatically eligible for Medicaid in most states.
  • Some states require a separate Medicaid application but grant automatic approval.

7. Adults in Medicaid Expansion States

  • In expansion states, low-income adults qualify regardless of disability, family status, or medical conditions.

Special Considerations for Medicaid Qualification

Medically Needy Programs (Spend-Down Medicaid)

Some individuals earn too much to qualify for Medicaid but have high medical expenses. In states with a Medically Needy Program, they can “spend down” excess income on medical costs to become eligible.

Dual Eligibility: Medicaid & Medicare

Low-income seniors and individuals with disabilities may qualify for both Medicaid and Medicare, known as dual eligibility. Medicaid helps cover Medicare premiums, deductibles, and out-of-pocket costs.

Medicaid Eligibility by State

Medicaid is a federal-state partnership, meaning each state sets its own eligibility criteria within federal guidelines. States can adjust income limits, expand coverage, or implement special programs.

Key State-Level Differences

  1. Medicaid Expansion: As of 2024, 40 states and Washington, D.C. have expanded Medicaid under the ACA.
  2. Income Limits: Some states offer higher thresholds for specific groups like children and pregnant women.
  3. Medically Needy Programs: Certain states allow individuals to qualify by spending down their income on medical expenses.
  4. Medicaid Buy-In Programs: Some states offer Medicaid coverage to working adults with disabilities who exceed income limits.

States That Expanded Medicaid

Expansion States (40 + D.C.): California, Colorado, Connecticut, Illinois, Massachusetts, Michigan, Minnesota, New York, Ohio, Oregon, Pennsylvania, Virginia, Washington, and others.

Non-Expansion States (10): Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming.

(Note: Wisconsin provides limited Medicaid expansion up to 100% of the FPL.)

How to Check Your Medicaid Eligibility

Since Medicaid rules vary, check your state’s specific guidelines:

  • Visit the State Medicaid Website (Medicaid.gov provides links to each state’s program).
  • Use Healthcare.gov’s Eligibility Tool to assess your eligibility.
  • Contact Your State’s Medicaid Office for personalized assistance.
  • Apply Online Through Your State’s Medicaid Portal.

Medicaid Eligibility for Immigrants and Non-Citizens

  • Lawful Permanent Residents (Green Card Holders): Eligible after five years of legal U.S. residence (some states waive the wait for pregnant women and children).
  • Refugees and Asylees: Automatically eligible.
  • DACA Recipients & Undocumented Immigrants: Generally not eligible, except for emergency Medicaid in life-threatening situations.

How to Apply for Medicaid

  1. Check eligibility through your state Medicaid website.
  2. Gather required documents (proof of income, residency, identity, citizenship status).
  3. Apply online, in person, by phone, or by mail.
  4. Wait for processing (usually within 45 days; disability applications may take longer).
  5. Receive approval or denial notice.

What to Do If You Don’t Qualify for Medicaid

If you don’t qualify, consider these alternatives:

  1. Affordable Care Act (ACA) Plans: Subsidized health insurance for those earning 100%-400% of the FPL (Healthcare.gov).
  2. CHIP (Children’s Health Insurance Program): Low-cost coverage for children in families that earn too much for Medicaid (InsureKidsNow.gov).
  3. State and Local Healthcare Assistance: Free or low-cost medical services at community health centers.
  4. Short-Term Health Insurance: Temporary coverage for those between jobs.
  5. Charity Care Programs: Nonprofit hospitals offer financial assistance based on need.
  6. Employer-Sponsored Insurance: Check if your employer offers health benefits.

Final Thoughts

Medicaid helps millions of Americans get the healthcare they need, but qualifying isn’t always straightforward. Each state has its own rules, income limits, and coverage guidelines, so it’s important to check official sources for the most accurate and up-to-date information.

If you don’t qualify, there are still other ways to get affordable healthcare. The ACA marketplace offers subsidized insurance plans, CHIP provides coverage for children in lower-income families, and many states have local assistance programs. Medicaid isn’t the only path to coverage, and exploring all available options can help you find the right solution for your situation.