Medicaid Basics: Who Qualifies and How to Apply

Eligibility depends primarily on your income and household size, though other factors apply:

• Income: In states that expanded Medicaid under the ACA, adults earning up to 138% of the federal poverty level (about $20,120/year for one person in 2024) generally qualify. • Children and pregnant women often qualify at higher income levels than adults. • People with disabilities or who receive Supplemental Security Income (SSI) typically qualify in all states. • Non-expansion states: About a dozen states did not expand Medicaid, meaning lower-income adults without children may not qualify. Check your state's specific rules.

Citizenship status also affects eligibility. U.S. citizens and many lawfully present immigrants qualify. Undocumented immigrants generally do not qualify for full Medicaid, though emergency Medicaid may be available.

Federal law requires states to cover certain mandatory benefits, including:

• Inpatient and outpatient hospital services • Physician services and nurse practitioner visits • Laboratory and X-ray services • Nursing facility services for adults • Home health services • Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services for children

Most states also cover dental, vision, prescription drugs, mental health services, and substance use treatment, though the scope varies. Some states offer additional optional benefits like physical therapy or personal care services.

You can apply for Medicaid at any time — unlike ACA Marketplace plans, there is no limited enrollment period. If you qualify today, you can apply today.

Ways to apply: 1. Online at healthcare.gov (the application will route you to Medicaid if you qualify) 2. Directly through your state's Medicaid agency website 3. In person at a local Department of Social Services or Medicaid office 4. By phone through your state's Medicaid helpline

You will typically need: proof of identity, proof of income (recent pay stubs or tax returns), Social Security numbers for household members, and proof of citizenship or immigration status.

CHIP (Children's Health Insurance Program) covers children in families who earn too much for Medicaid but cannot afford private insurance. CHIP covers routine doctor visits, immunizations, prescriptions, dental, and vision.

Income limits for CHIP are higher than Medicaid — in most states, children in families earning up to 200–300% of the federal poverty level may qualify. Like Medicaid, CHIP enrollment is open year-round with low or no cost.

If your income falls near the Medicaid limit, compare both options:

• Medicaid: Free or very low cost. No monthly premium in most cases. Best for people with low or no income. • ACA Marketplace: Has monthly premiums (reduced by subsidies). More provider network flexibility in some areas. May be better if you have a specific doctor or hospital you need access to.

If your income fluctuates during the year, report changes to your state Medicaid office — you may gain or lose eligibility, and switching between Medicaid and a Marketplace plan is possible mid-year with a qualifying life event.