Medicaid is considered an entitlement program for the individuals who qualify, meaning that states must provide services to eligible individuals or risk losing federal Medicaid funding. So who qualifies for Medicaid?
To qualify for Medicaid, individuals must:
- Be a citizen of the United States or a qualified non-citizen;
- Be a resident of the state where they are applying for Medicaid benefits;
- Meet the income and asset thresholds for their eligibility pathway in their state; and
- Meet any other criteria specific to the population.
Some eligibility criteria are specific to the population covered. For example, children in foster care and people who qualify for Supplemental Security Insurance disability benefits are automatically eligible for Medicaid. People who receive long-term services and supports may also need to demonstrate that they need more intensive and ongoing care to receive certain services.
There are dozens of unique eligibility pathways for individuals to receive Medicaid benefits. States are required to cover some populations and eligibility pathways and may choose to cover others:
|Mandatory Eligibility Groups
||Optional Eligibility Groups
- Children and infants
- Children and youth involved in the child welfare system
- Pregnant women
- Parents and caretaker relatives
- Adults ages 65 and older
- Children and adults with disabilities, including SSI recipients
- Qualified non-citizens, including refugees and asylees
- Other non-citizens (emergency services only)
- Non-disabled, childless adults (expansion group)
- Medically needy individuals (individuals with high medical expenses and incomes above traditional eligibility thresholds)
- Family planning group
- Breast or cervical cancer group
- Colorectal cancer group
- Mandatory eligibility groups above minimum income, asset or other eligibility restrictions that otherwise apply
While most beneficiaries are eligible to receive all the services provided by the state Medicaid program, the package of Medicaid benefits varies based on the eligibility pathway and may not include the full scope of covered benefits. For example, some eligibility pathways only cover the costs of premiums, deductibles or other cost sharing and do not cover health care services. Similarly, people who are eligible for the family planning group are only eligible to receive certain family planning services and may not be eligible for other health services covered by the Medicaid program.
In recent years, over 20% of the United States population had Medicaid or CHIP coverage. The percentage of people covered by Medicaid ranges from approximately 10% to 30% of the population in each state. Across states, Medicaid is often the single largest source of health coverage for certain populations, including pregnant women, children, and people with disabilities. As such, Medicaid is a key policy lever for states to address health coverage and outcomes for certain populations.