One in five Americans receives free or low-cost health coverage through Medicaid, a joint federal and state program administered by individual states under federal guidelines. Each state has different rules about who qualifies for Medicaid and how to apply.
You can apply for Medicaid anytime and must have documented proof of eligibility, including citizenship, residence, age, income and resources, and medical expenses or disability. Eligibility redeterminations are conducted regularly. If you qualify, you can have both Medicare and Medicaid.
Medicaid is a joint federal and state health program that provides health coverage to families with low income, qualified pregnant women and children, and persons who are receiving Supplemental Security Income (SSI).
States, following federal guidelines, administer Medicaid programs and are given the option to expand Medicaid coverage. For example, states may provide Medicaid coverage to individuals who are receiving home and community-based services, children in foster care, and adults with income at or below 133% of the Federal Poverty Level (FPL). The 2021 FPL is $12,880 for individuals and $17,420 for a family of two.
To qualify for Medicaid, you must meet financial eligibility requirements and be:
Financial eligibility for Medicaid is generally based on the Modified Adjusted Gross Income (MAGI), which considers taxable income and tax filing relationships. Some individuals who are blind, disabled, or age 65 or older may financially qualify for Medicaid by using the income methodologies of the SSI program, which the Social Security Administration administers.
Persons in certain groups do not require a determination of income by Medicaid. Instead, eligibility is based on enrollment in another program. For example:
States can also establish a medically needy program for persons with significant health needs whose income is too high to qualify for Medicaid otherwise. These states let you subtract your medical expenses from your income to become eligible for Medicaid.
Some states’ Medicaid eligibility requirements are more restrictive than the SSI program. These are known as 209(b) states, and they must allow a spend down to the same income eligibility levels for groups based on disability, blindness, or age (65 or older).
Because each state has different rules about eligibility and how to apply for Medicaid, you must contact your state Medicaid program to find out if you qualify. A good place to start is to see what your state’s income and resource maximum limits are.
One in five Americans has Medicaid coverage. Those who do not qualify are:
Yes! This is known as dual eligibility, and most of your health care costs are likely covered. Medicare is typically considered to be the primary insurance (unless you also have employer group health plan coverage), and Medicaid is the payer of last resort.
Medicaid pays only after Medicare, employer group health plans, and a Medicare Supplement (Medigap) insurance have paid. Note: If you qualify for Medicaid and your income/circumstances are unlikely to change, you should not need supplemental insurance.
Medicaid helps Medicare beneficiaries with Medicare premiums and cost-sharing. Also, it provides many of them with benefits not covered by Medicare, such as help with long-term care needs, some medications, or eyeglasses.
If you, as a Medicare beneficiary, qualify for Medicaid, you are automatically eligible for Extra Help, a Medicare program to help pay for drug costs like premiums, copays, and deductibles.
Some states and health plans offer Medicare-Medicaid plans for certain people who have both Medicare and Medicaid to make it easier to get the services they need.
As with anything that is Medicaid related, contact your state agency for assistance.
If you are unsure whether or not you might qualify for Medicaid, but you think you meet the financial requirements in your state, you should apply. You might be eligible depending on your household income, family size, age, or disability.
You can apply for Medicaid through the Health Insurance Marketplace or directly with your state Medicaid agency. Many Medicaid enrollees get their Medicaid benefits through private managed care plans that contract with the state. You will be advised on how to apply once you access your state’s website, or contact your state’s agency.
Be ready to provide information on your Medicaid application as proof of your eligibility. You should expect to hear back within 45 days or longer if you are disabled. If your application is denied, you will receive instructions on how to appeal the decision along with your denial notice.
Keep good records of the documents (copies) you use to complete your application. You may need to supply them again or show updated versions when you are up for renewal/redetermination, depending on your state’s Medicaid program. Be prepared to provide these documents:
Don’t wait to apply. Unlike Medicare, there are no restrictions or open enrollment periods, so you can apply at any time. It is better to apply and be turned down than to not apply at all. Renewals and redeterminations to ensure continued eligibility will occur at least every 12 months. Some states may require more frequent redeterminations, but in any case, you need to report any change in your status as soon as possible, and within 30 days.
Once your Medicaid eligibility has been determined, your coverage is effective on either the date of the application or the first day of the month of the application. Benefits may be covered retroactively for up to three months prior to when you apply if you would have been eligible during that time frame.
Coverage will stop at the end of the month that you no longer meet the eligibility requirements.
Even though you may access your application through a state website, local county offices and agents can help you in person or on the phone.
Tammy Burns is an experienced health insurance advisor. She earned her nursing degree in 1990 from Jacksonville State University, obtained her insurance billing and coding certification in 1995, and holds a health and life insurance license in Alabama, Georgia, Iowa, Mississippi, and Tennessee. Burns is Affordable Care Act (ACA)-certified for health insurance and other ancillary, life, and annuity products. She maintains an active nursing license and practices private-duty nursing.
Burns’ background as a nurse, insurance biller and coder, and insurance consultant includes infectious disease, oncology, gynecology, phlebotomy, post operative, family medicine, geriatrics, home health, hospice, human resources, management, billing, coding, claims, fixed annuities, group and individual health and life products, and Medicare. She’s always been driven by a desire to help people, spending more than 25 years as a practicing nurse in hospitals, private doctors’ offices, home health, and hospice. As a nurse, Burns supported patients filing insurance claims with Medicare, Medicaid, and private insurance companies as well as responding to billing questions from confused patients.
Seeing firsthand how unsuspecting patients are frequently confused by an overly complex system they don’t understand led Burns to become an insurance agent and health care consultant, now helping people understand the medical system. Since becoming an insurance agent in 2013, she has worked with some of the largest and most reputable insurance carriers and agencies in the nation, and she has built a large and loyal clientele by way of her commitment to transparency and personalized service.