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View all in Financial Management
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* Upper Payment Limit FAQs
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* Medicaid Administrative Claiming
* LTC Ombudsman Programs
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* State Budget & Expenditure Reporting for Medicaid and CHIP
* Expenditure Reports MBES/CBES
* CMS-64 FFCRA and CAA Increased FMAP Expenditure Data
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* State Option to Provide Qualifying Community-Based Mobile Crisis
Intervention Services
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* Early and Periodic Screening, Diagnostic, and Treatment
* Vision and Hearing Screening Services for Children and Adolescents
* Lead Screening
* Hospice Benefits
* Mandatory & Optional Medicaid Benefits
* Prevention
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* Assurance of Transportation
* Reentry Services for Incarcerated Individuals
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View all in Prescription Drugs
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* Person-Centered Hospital Discharge Model
* Person-Centered Planning Grants
* State Profile Tool Grant
* Balancing Long Term Services & Supports
* Integrating Care
* Employment Initiatives
* Institutional Long Term Care
* Money Follows the Person
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* Alternatives to Psychiatric Residential Treatment Facilities
Demonstration
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1. Home
2. Medicaid
3. Eligibility Policy
ELIGIBILITY POLICY
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RELATED RESOURCES
* Medicaid Medical Support Requirements and Implementation Strategies Slide
Deck
* Coverage of Youth Formerly in Foster Care in Medicaid (Section 1002(a) of the
SUPPORT Act) (SHO #22-003) (Slide Deck)
* Map: States that have Extended Postpartum Coverage
* Health Coverage Options for Certain Ukrainian Nationals
* State Flexibilities to Determine Financial Eligibility for Individuals in
Need of HCBS
* SHO: Medicaid Eligibility for COFA Migrants
* Updated Fact Sheet: Health Coverage Options for Afghan Evacuees
* Extension of Medicaid for COFA Migrants: State Implementation, Short-term
Workarounds and Outreach Strategies Slide Deck
* Medicaid and CHIP Disaster Relief MAGI-Based Verification Plan Addendum
* Medicaid Eligibility Quality Control
* Minimum Essential Coverage
* Eligibility and Family Size – QMBs and SLMBs
* Verification Plan Template
* Verification Plan Template Instructions
* Reasonable Compatibility Scenarios
Medicaid is a joint federal and state program that, together with the Children’s
Health Insurance Program (CHIP), provides health coverage to over 77.9
million Americans, including children, pregnant women, parents, seniors, and
individuals with disabilities. Medicaid is the single largest source of health
coverage in the United States.
To participate in Medicaid, federal law requires states to cover certain groups
of individuals. Low-income families, qualified pregnant women and children, and
individuals receiving Supplemental Security Income (SSI) are examples
of mandatory eligibility groups. States have additional options for coverage and
may choose to cover other groups, such as individuals receiving home and
community-based services and children in foster care who are not otherwise
eligible.
The Affordable Care Act of 2010 created the opportunity for states to expand
Medicaid to cover nearly all low-income Americans under age 65. Eligibility for
children was extended to at least 133% of the federal poverty level (FPL) in
every state (most states cover children to higher income levels), and states
were given the option to extend eligibility to adults with income at or below
133% of the FPL. Most states have chosen to expand coverage to adults, and those
that have not yet expanded may choose to do so at any time. See if your state
has expanded Medicaid coverage to low-income adults.
DETERMINING ELIGIBILITY FOR MEDICAID
FINANCIAL ELIGIBILITY
The Affordable Care Act established a new methodology for determining income
eligibility for Medicaid, which is based on Modified Adjusted Gross Income
(MAGI). MAGI is used to determine financial eligibility for Medicaid, CHIP, and
premium tax credits and cost sharing reductions available through the health
insurance marketplace. By using one set of income counting rules and a single
application across programs, the Affordable Care Act made it easier for people
to apply and enroll in the appropriate program.
MAGI is the basis for determining Medicaid income eligibility for most children,
pregnant women, parents, and adults. The MAGI-based methodology considers
taxable income and tax filing relationships to determine financial eligibility
for Medicaid. MAGI replaced the former process for calculating Medicaid
eligibility, which was based on the methodologies of the Aid to Families with
Dependent Children program that ended in 1996. The MAGI-based methodology does
not allow for income disregards that vary by state or by eligibility group and
does not allow for an asset or resource test.
Some individuals are exempt from the MAGI-based income counting rules, including
those whose eligibility is based on blindness, disability, or age (65 and
older). Medicaid eligibility for individuals 65 and older or who have blindness
or a disability is generally determined using the income methodologies of the
SSI program administered by the Social Security Administration (some states,
known as 209(b) states, use certain more restrictive eligibility criteria than
SSI, but still largely apply SSI methodologies). Eligibility for the Medicare
Savings Programs, through which Medicaid pays Medicare premiums, deductibles,
and/or coinsurance costs for beneficiaries eligible for both programs (often
referred to as dual eligibles) is determined using SSI methodologies..
Certain Medicaid eligibility groups do not require a determination of income by
the Medicaid agency. This coverage may be based on enrollment in another
program, such as SSI or the breast and cervical cancer treatment and prevention
program. Children for whom an adoption assistance agreement is in effect under
title IV-E of the Social Security Act are automatically eligible. Young adults
who meet the requirements for eligibility as a former foster care recipient are
also eligible at any income level.
NON-FINANCIAL ELIGIBILITY
To be eligible for Medicaid, individuals must also meet certain non-financial
eligibility criteria. Medicaid beneficiaries generally must be residents of the
state in which they are receiving Medicaid. They must be either citizens of the
United States or certain qualified non-citizens, such as lawful permanent
residents. In addition, some eligibility groups are limited by age, or by
pregnancy or parenting status.
EFFECTIVE DATE OF COVERAGE
Once an individual is determined eligible for Medicaid, coverage is effective
either on the date of application or the first day of the month of application.
Benefits also may be covered retroactively for up to three months prior to the
month of application, if the individual would have been eligible during that
period had he or she applied. Coverage generally stops at the end of the month
in which a person no longer meets the requirements for eligibility.
MEDICALLY NEEDY
States have the option to establish a “medically needy program” for individuals
with significant health needs whose income is too high to otherwise qualify for
Medicaid under other eligibility groups. Medically needy individuals can still
become eligible by “spending down” the amount of income that is above a state's
medically needy income standard. Individuals spend down by incurring expenses
for medical and remedial care for which they do not have health insurance. Once
an individual’s incurred expenses exceed the difference between the individual’s
income and the state’s medically needy income level (the “spenddown” amount),
the person can be eligible for Medicaid. The Medicaid program then pays the cost
of services that exceeds the expenses the individual had to incur to become
eligible.
In addition to states with medically needy programs, 209(b) states also must
allow a spenddown to the income eligibility levels eligibility groups based on
blindness, disability, or age (65 and older), even if the state also has a
medically needy program. Thirty-six states and the District of Columbia use
spenddown programs, either as medically needy programs or as 209(b) states.
APPEALS
States must provide individuals the opportunity to request a fair hearing
regarding a denial, an action taken by the state agency that he or she believes
was erroneous, or if the state has not acted with reasonable promptness. States
have options for how to structure their appeals processes. Appeals may be
conducted by the Medicaid agency or delegated to the Exchange or Exchange
Appeals Entity (for appeals of denials of eligibility for individuals whose
income is determined based on MAGI). Appeals also may be delegated to another
state agency, if a state obtains approval from CMS under the Intergovernmental
Cooperation Act of 1968.
CIB: Coordination Between HHS Appeals Entity and Medicaid and CHIP Agencies –
Assessment States
This Informational Bulletin discusses federal requirements and provides
technical assistance related to coordination of appeals among insurance
affordability programs in states that have elected for the Federally-Facilitated
Exchange (FFE) to assess eligibility for Medicaid and CHIP (“assessment
states”).
Appendix 1: States treating decisions of HHS Appeals Entity as assessments of
eligibility provides three scenarios to illustrate the specific steps that
assessment states must take upon receiving an Electronic File Transfer from the
Department of Health and Human Services (HHS) Appeals Entity if the state has
opted to treat decisions of the HHS Appeals Entity as an assessment of Medicaid
or CHIP eligibility. See operational flows for the scenarios:
* Scenario 1
* Scenario 2
* Scenario 3
Appendix 2: States treating decisions of HHS Appeals Entity as determinations of
eligibility provides three scenarios to illustrate the specific steps that
assessment states must take upon receiving an Electronic File Transfer from the
HHS Appeals Entity if the state has opted to accept decisions of the HHS Appeals
Entity as a final determination of Medicaid or CHIP eligibility. See operational
flows for the scenarios:
* Scenario 1
* Scenario 2
* Scenario 3
RELATED TOPICS
Spousal Impoverishment: Protects the spouse of a Medicaid applicant or
beneficiary who needs coverage for long-term services and supports (LTSS), in
either an institution or a home or other community-based setting, from becoming
impoverished in order for the spouse in need of LTSS to attain Medicaid coverage
for such services.
Treatment of Trusts: When an individual, his or her spouse, or anyone acting on
the individual's behalf establishes a trust using at least some of the
individual's funds, that trust can be considered available to the individual for
determining eligibility for Medicaid.
Transfers of Assets for Less Than Fair Market Value: Medicaid beneficiaries who
need LTSS will be denied LTSS coverage if they have transferred assets for less
than fair market value during the five-year period preceding their Medicaid
application. This rule applies when individuals (or their spouses) who need LTSS
in a long-term care facility or wish to receive home and community-based waiver
services have transferred, sold, or gifted assets for less than they are worth.
Estate Recovery: State Medicaid programs must recover from a Medicaid enrollee's
estate the cost of certain benefits paid on behalf of the enrollee, including
nursing facility services, home and community-based services, and related
hospital and prescription drug services. State Medicaid programs may recover for
other Medicaid benefits, except for Medicare cost-sharing benefits paid on
behalf of Medicare Savings Program beneficiaries.
Third Party Liability: Third Party Liability refers to third parties who have a
legal obligation to pay for part or all the cost of medical services provided to
a Medicaid beneficiary. Examples are other programs such as Medicare, or other
health insurance the individual may have that covers at least some of the cost
of the medical service. If a third party has such an obligation, Medicaid will
only pay for that portion.
Waivers and Demonstrations: States can apply to CMS for waivers to provide
Medicaid to populations beyond those traditionally covered under the state plan.
Some states have additional state-only programs to provide medical assistance
for certain low-income people who do not qualify for Medicaid. No federal funds
are provided for state-only programs.
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