Medicaid Eligibility - Qualifying for Medicaid

There are numerous Medicaid programs in each state that vary depending state laws, income and family size. Medicaid is generally available in all states to those who earn less than 100%-200% of the FPL (federal poverty level) in their state along with having a disability, pregnancy, are themselves elderly or are a caretaker of a child. In some states the guidelines for Medicaid have been expanded and now include coverage of all low-income households below a particular threshold. You can check here to find out if you qualify for Medicaid based on income alone.

To find out if you qualify for Medicaid you should first find out if your state is expanding Medicaid. This will tell you which programs will work for your current situation. Use the guide below to find out if your state has adopted expanded Medicaid.

*Note. The guide below consists of states that have/have not adopted expanded Medicaid through 2019. Some states may have adopted expanded Medicaid, though they have yet to implement the expansion.

A majority of states have chosen to expand Medicaid coverage. If your state has not done so as of now, it can chose to expand Medicaid at any time. Once you find out whether your state has expanded Medicaid or not, you can then continue on with the process of determining your eligibility.

Federal law requires all states to participate in Medicaid to a certain extent. It requires all states to offer coverage to select mandatory groups such as individuals receiving SSI (Supplemental Security Income), some pregnant women and children, and low income families. Some select states offer coverage not listed in the mandatory groups list provided in the link above.

Also note that some states may have different names for Medicaid. You can check what your state's program is called here.

The process for determining Medicaid eligibility relies on your MAGI (modified adjusted gross income). The process used to take in to account your income, net worth and assets, though after the Affordable Care Act was implemented it has changed. The majority of cases will be determined using MAGI.

When filling out an application through Marketplace you will need to have an estimate for your expected household income for the year you need Medicaid coverage, not the previous year's income. The income you will be noting here is your MAGI.

MAGI is used to determine eligibility for adults, pregnant women, children and parents. Your MAGI accounts for all of your taxable income, as well as select deductions. These deductions can include everything from your non-taxable social security benefits, retirement contributions and your tax exempt interest. For most people the number is generally very close to, if not the same as your adjusted taxable income which you can find on your tax return.

You will not be able to see your MAGI directly on your tax return. You must calculate this number yourself. For most situations the household income will include the tax filer, their spouse and any tax dependents (including those who do not need coverage). You can find out more about what is considered household income here. You can estimate your MAGI by finding out the total of the figures below:

• Your total AGI (adjusted gross income) on your most recent federal tax return. You can find this on line 7 of the 1040 IRS form.
• Excluded foreign income (if applicable).
• Tax exempt Social Security interest.
• Non Taxable Social Security Benefits - Including Tier 1 Railroad Retirement Benefits
• *Note. Your MAGI does not include (SSI) Supplemental Security Income.
• Expected changes - You must adjust your estimate for any changes you may expect. Things to consider here are expected pay raises, new job/employment changes, work schedule changes, Social Security or investment changes or gaining or losing dependents. All of these can alter your income significantly.

After taking into consideration all of the factors above, the total number you are left with will be your MAGI. You will use this number when applying for Medicaid through Marketplace or your state agency.

Some states have implemented coverage for the medically needy. This program extends Medicaid coverage to those with health needs that have income too high to qualify for the standard Medicaid program.

You may also still become eligible for the standard Medicaid by "spending-down" the amount of income that is above your state's MNIL (medically needy income limit) listed in the table below. You may "spend down" by accruing expenses for medical care for which you do not have health insurance to cover. After the accrued medical expenses become larger than your state's medically needy income level, you may then be eligible for Medicaid.

For example, if you live in a state that has the Medicaid medically needy program your state will have a spend-down time period, typically around 6 months. During that period the state will look at your income and medical expenses to see if you qualify. If you have enough medical expenses during that time to satisfy your spend-down, you may then qualify for coverage. If the spend-down limit is met, you will then be eligible for coverage for the remainder of the time period. You will have to meet the spend-down MNIL again once the time period is over.

*Note. The numbers provided in the table below are through 2019.