Who is Covered?

Who Is Covered By Medicaid?

Medicaid is the nation’s public health insurance program for low-income Americans, and is jointly financed by the Federal and State governments. The program finances health and long-term care services for children and adults in low-income working families and for the elderly and disabled. Individuals must meet both financial and categorical criteria to qualify and be either a U.S. citizen or have five years of legal residency.

Learn attorney secrets for protecting assets while qualifying for Medicaid!

Federal law mandates eligibility for certain groups, and states have authority to expand eligibility beyond federal minimums through waivers or amendments to their State Medicaid Plans.

States  cannot receive federal matching funds to extend Medicaid to adults under age 65 without children, unless they are pregnant or disabled. As a result, over 40% of low-income adults without children are uninsured.

According to Medicaid: An Overview of Spending on “Mandatory” vs. “Optional” Populations and Services, Kaiser Commission on Medicaid and the Uninsured (2007), there are two broad categories of Medicaid eligibility: Mandatory and Optional populations, which are described below.

Mandatory Populations include:

  • Children age six and older below 100% Federal poverty level (FPL)
  • Children under age six below 133% FPL
  • Parents below state’s Aid to Families with Dependent Children (AFDC) cutoffs from July 1996
  • Pregnant women =133% FPL
  • Elderly and disabled Supplemental Security Income (SSI) beneficiaries with income = 74% FPL
  • Certain working disabled
  • Medicare Buy-In groups (Qualified Medicare Beneficiary, Specified Low-Income Medicare Beneficiary, Qualifying Individuals)

Optional Populations can include:

  • Low-income children above 100% FPL who are not mandatory by age
  • Low-Income parents with income above state’s 1996 AFDC level
  • Pregnant women >133% FPL
  • Disabled and elderly below 100% FPL ($9,310 a year for an individual), but above SSI level
  • Nursing home residents above SSI levels, but below 300% of SSI ($1,692 a month)
  • Individuals at risk of needing nursing facility or intermediate care facilities for the mentally retarded (ICF-MR) care
  • Certain working disabled (>SSI levels)
  • Medically needy

Immigrants who have entered the U.S. illegally cannot qualify for basic Medicaid benefits, although they are eligible for Medicaid coverage for emergency medical care (if they meet all other financial and non-financial requirements). Most categories of immigrants who are legally residing in the U.S. and who meet all other financial and non-financial requirements are eligible for Medicaid coverage for emergency care, but, depending on the year in which they entered the country, they may or may not be eligible for the full range of Medicaid services.