MEDICAID 15-2

Chapter 15: Medicaid Eligibility

Overview of Medicaid Eligibility

• Medicaid policies are complex and can vary significantly between states, even among those that are geographically close.

• An individual eligible for Medicaid in one state may not be eligible in another state.

• Differences also exist in the services provided between states in terms of amount, duration, and scope.

• State legislatures can change eligibility requirements throughout the year, impacting Medicaid access.

• It is crucial to note that Medicaid does not assist all individuals with low incomes; low income is just one criterion for eligibility.

Non-Financial Eligibility Criteria

• Citizenship: Must be a U.S. citizen or a non-citizen with certain qualified status (e.g., lawful permanent residents).

• Residency: An applicant must reside in the state where they wish to receive Medicaid.

• Specific Group Limits: Eligibility may further depend on factors such as age, pregnancy status, or parenting circumstances.

• Some states also offer "state-only" programs for low-income individuals who do not meet Medicaid criteria, without federal funding.

Federal Funding for Medicaid

• The federal government matches state Medicaid program funds, contingent on certain healthcare services for eligible groups, including:

  • Children

  • Individuals with disabilities

  • Persons aged 65 and older

• Each state oversees its own Medicaid program, with oversight from the Centers for Medicare and Medicaid Services (CMS) that establishes requirements for service delivery, funding, quality, and eligibility.

Financial Eligibility Determination

• Modified Adjusted Gross Income (MAGI): This is the method used to determine financial eligibility for most applicants, including children, pregnant individuals, parents, and adults.

  • MAGI takes into account taxable income and tax filing relationships.

  • It replaced the previous eligibility calculation methods that relied on the Aid to Families with Dependent Children and Temporary Assistance for Needy Families.

  • MAGI methodology does not provide for variable income disregards based on state or eligibility group and excludes any asset or resource tests.

Medicaid Eligibility Groups

• Categories of Medicaid Eligibility:

  • Medically needy

  • Special groups

Related Programs

• Children’s Health Insurance Program (CHIP)

• Programs of All-Inclusive Care for the Elderly (PACE)

• Additional factors affecting Medicaid eligibility include spousal impoverishment protection and methods of confirming eligibility.

Medicaid Application Process

Coverage Activation

• Coverage begins either on the date of application or the first day of the application month.

• Benefits may be retroactively covered for up to three months prior to the application month as long as the individual would have qualified during that time.

Termination of Coverage

• Coverage typically ends at the conclusion of the month in which the individual no longer meets the eligibility requirements.