What are the eligibility requirements for Medicaid?

One of the biggest concerns, when we grow up and are responsible for ourselves or our families, is not being able to cover the expenses generated by health care. As impossible as it sounds, having health insurance that fits our budget is something that can and should be done by everyone. Several affordable health plans allow us to get quality health care; one of those options is Medicaid. In this article, you will find information about its eligibility requirements.

First of all, Medicaid is the government program that provides health care coverage to over 70 million people, thus becoming the largest provider of this service in our country.

Obtaining these benefits is not that difficult, read on and find out how to acquire them.

Medicaid Coverage

Medicaid is a medical assistance program for people who cannot afford private health insurance due to low income or other special conditions such as a disability or being over 65 years of age. Complying with the requirements for Medicaid is almost always classified as “challenging”, but the truth is that if you are well informed, you can increase your chances of being accepted into the program of your choice.

This program has the particularity of receiving federal funds while being administered by local state governments, making it a “joint federal and state program”. The state offices operate receiving the applications and attending to the requirements of the individuals and families who are already affiliated with Medicaid.

In principle, it was a program aimed at people with disabilities, over 65 years of age, qualified children, people who receive Supplemental Security Income (SSI), low-income families, and pregnant women, since they are part of the “mandatory eligibility groups”.

Federal law establishes which groups of people must be included in the “mandatory eligibility groups,” that is, those who irrevocably meet the program’s eligibility requirements and should receive benefits. In this document, you can check which these groups are.

However, in 2010, through The Affordable Care Act, the government extended the requirements for Medicaid, thus allowing people who initially could not apply to this program, now have the opportunity to do so. For example, the earnings of adults who want benefits were extended and may be equal to or less than 133% of the Federal Poverty Level (FPL).

Eligibility Criteria

A very common question we ask ourselves when applying for this type of program is: what is the primary qualification for receiving Medicaid benefits? And the truth is that many web portals state that the amount of your income is decisive for your application to be approved, but even if you meet this requirement but lack the others, your application is likely to be rejected.

The requirements for Medicaid can vary depending on 2 conditions: 1) whether they are financial requirements or not and 2) terms related to the program to which you wish to apply.

Financial requirements

These are some of the most controversial requirements due to their importance when the state Medicaid office estimates whether or not you are accepted into the program.

The level of income that you or your family have will decisively influence whether your application is accepted. For The Children’s Health Insurance Program (CHIP), parents, pregnant women, and adults, income-based eligibility will be determined based on the MAGI method.

Modified Adjusted Gross Income (MAGI) is your adjusted gross income plus exempt or excluded income and certain deductions (excluded foreign income, nontaxable interest, rental losses, taxable Social Security payments…). If you click here, you can estimate your MAGI with the automatic calculator.

Now, there are certain groups of people who are exempt from using the MAGI method to calculate their income. This does not mean that the amount of their income will not be evaluated as a requirement to obtaining Medicaid; they simply do not use this method. This is the case of people with disabilities, those over 65 years of age, or people with blindness. Their income level is also decisive but it will be calculated based on the methodologies used for the Supplemental Security Income program (SSI).

The same happens with the Medicaid Saving Programs, people who wish to opt for this program must calculate their income using the SSI method. The information on how to do this is available on the official page of the Social Security Administration so that you can consult it whenever you want.

On the other hand, there is an exception to this principle of verifying income level as part of the Medicaid requirements. This is the case of young adults who meet the requirements of a former foster care recipient, children whose adoption is regulated under Title IV-E of the Social Security Act, and those whose coverage could be based on their participation in another program (for example, the program for treatment and prevention of breast and cervical cancer, or the Supplemental Security Income). This group of people is automatically eligible for Medicaid regardless of their income level.

State Medicaid offices will evaluate your income level and compare it with the established limits. Generally, these limits are based on the FPL of the state where you reside; therefore we recommend you to check the official Medicaid pages of your state to know the limits. On this page, you can check if you are eligible (only based on your income).

Non-financial requirements

In addition to the financial requirements, applicants for the different Medicaid programs must comply with the following:

  1. Be a US citizen or foreigner with a legally established residence.
  2. Be a resident of the state where you apply.
  3. Meet the age requirements (in cases such as CHIP, 65 years or older…).
  4. Being pregnant (in the case of CHIP for low-income pregnant women).

🡺READ MORE: What are the income limits for Medicaid?

How To Apply And The Needed Documentation

On repeated occasions, applications are rejected due to a lack of information or documentation necessary to verify compliance with the requirements for Medicaid.

It is for this reason that we list the essential documents that you must have when making your application.

  • Your medical history to prove your disability.
  • Birth certificate or a government-issued ID (driver’s license).
  • Some proof of your citizenship or legal residence.
  • Documentation showing your assets and income.
  • Birth certificates of your children and marriage certificate (if applicable).
  • Utility bills, rent payment receipts, copies of your lease, or any documents that prove where you live.

This is the essential documentation so, you have a general guide about what you might need when applying. Likewise, we invite you to consult with your State Medicaid Agency for more detailed information. Remember that the requirements vary depending on the state.

Now, once you have collected all your documentation, you can apply online by creating an account on the Health Insurance Marketplace page or through your state Medicaid Agency.

HealthCare.gov website to apply for Medicaid

And here, you will find the contact information for the state agencies.

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