What Is Medicaid and Who May Be Eligible?

Medicaid is the United States' largest public health insurance program, jointly funded by federal and state governments, and administered by individual states under broad federal guidelines set by the Centers for Medicare & Medicaid Services (CMS). If you are uninsured or underinsured and have a low to moderate household income, Medicaid may be one of the most significant programs available to help you access medical care — including doctor visits, hospital stays, prescription drugs, mental health services, and preventive care. Eligibility rules, covered benefits, and application processes differ by state, which is why understanding the federal framework first gives you a critical foundation.

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Key Takeaways - Medicaid covers more than 80 million Americans — but eligibility rules, income limits, and covered services vary significantly by state. - In states that expanded Medicaid under the ACA, adults with household incomes at or below 138% FPL may be eligible regardless of parental status. - CHIP extends coverage to children in families who earn too much for Medicaid but may struggle to afford private insurance. - Medicaid enrollment is open year-round — no waiting for an open enrollment period. - Required documents typically include proof of identity, residency, income, and household size.

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How Medicaid Is Structured: Federal Rules, State Flexibility

Medicaid is authorized under Title XIX of the Social Security Act. The federal government sets minimum eligibility and benefit standards, then matches state spending through a formula called the Federal Medical Assistance Percentage (FMAP). States receive between 50% and 83% of their Medicaid costs reimbursed by the federal government, depending on the state's per-capita income. In exchange, states must cover certain mandatory populations and services — but they also have significant flexibility to expand coverage beyond those minimums.

This structure means that where you live has an enormous impact on what Medicaid may cover and who may be eligible. Two households with identical incomes in different states can have very different access to Medicaid.

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Who May Be Eligible for Medicaid?

Mandatory Eligibility Groups

Federal law requires states to cover certain groups. These include:

  • Low-income children — Generally, children in families with incomes up to 133% FPL must be covered under Medicaid. Many states cover children at significantly higher thresholds through CHIP.
  • Pregnant individuals — States must cover pregnant people with incomes up to 133% FPL for pregnancy-related services. Many states have extended this to 185% FPL or higher, and some have extended postpartum coverage to 12 months.
  • Parents and caretaker relatives — Coverage thresholds vary widely by state and are often lower than for children.
  • Seniors and people with disabilities — Individuals who receive Supplemental Security Income (SSI) are generally automatically eligible for Medicaid in most states.
  • Individuals needing long-term care — Medicaid is the primary payer for nursing home and home- and community-based services for low-income seniors and people with disabilities.

The ACA Medicaid Expansion

The Affordable Care Act of 2010 created an optional Medicaid expansion allowing states to cover all adults — with or without children — with household incomes at or below 138% of the Federal Poverty Level. As of 2025, 41 states and the District of Columbia have adopted this expansion. If you live in an expansion state and your income falls at or below 138% FPL, you may be eligible for Medicaid regardless of whether you have dependent children.

If you live in a non-expansion state, eligibility for adults without dependent children may be extremely limited or nonexistent under Medicaid. In those states, the ACA Marketplace may be your primary alternative for subsidized coverage.

Children's Health Insurance Program (CHIP)

CHIP, authorized under Title XXI of the Social Security Act and administered by the Centers for Medicare & Medicaid Services alongside Medicaid, covers children in families who earn too much to qualify for Medicaid but may not be able to afford private insurance. Income thresholds for CHIP vary by state but typically range from 200% to 300% FPL, and some states have set thresholds even higher. In most states, CHIP coverage is free or available for a very low monthly premium.

CHIP also covers pregnant individuals in some states through what is called the "unborn child" option or a separate CHIP program for pregnant women.

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What Services May Medicaid Cover?

Federal law requires states to cover a set of mandatory benefits under Medicaid. These include:

  • Inpatient and outpatient hospital services
  • Physician services
  • Laboratory and X-ray services
  • Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services for children under 21
  • Family planning services and supplies
  • Federally Qualified Health Center (FQHC) and Rural Health Clinic services
  • Nursing facility services for adults
  • Home health services

States may also offer optional benefits such as prescription drug coverage (now nearly universal), dental services, vision care, physical therapy, and behavioral health services. Benefit amounts vary by household size and income, and specific covered services vary by state.

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How to Apply for Medicaid

Step 1: Gather Your Documents

Before applying, collect the following:

  • Proof of identity: Driver's license, state ID, passport, or birth certificate
  • Proof of residency: Utility bill, lease agreement, or official mail with your current address
  • Proof of income: Recent pay stubs (last 30 days), employer letter, tax returns, or documentation of other income sources (Social Security, child support, etc.)
  • Proof of household size: Birth certificates for children, documentation of who lives in your home
  • Social Security numbers for all household members applying
  • Immigration documentation if applicable (lawful permanent residents and certain other immigration statuses may be eligible)

Step 2: Choose Your Application Method

You can apply for Medicaid through several channels:

  • Your state Medicaid agency: Every state has a dedicated Medicaid agency. You can find your state's agency through Medicaid.gov or Benefits.gov.
  • HealthCare.gov: If you apply for ACA Marketplace coverage and appear eligible for Medicaid, your application will be transferred to your state Medicaid agency automatically.
  • In person: Many states allow applications at local Department of Social Services or Health and Human Services offices.
  • By phone or mail: Most state agencies accept applications by phone or paper form.

Step 3: Understand the Timeline

States are generally required to process Medicaid applications within 45 days (or 90 days for disability-related applications). Some states have faster processing times. If approved, coverage may be retroactive to the first day of the month you applied, or in some cases up to three months prior if you had qualifying medical expenses.

Medicaid enrollment is open year-round. Unlike ACA Marketplace plans, there is no annual open enrollment window. You can apply at any time — especially important if you've recently lost a job, had a baby, or experienced another life change that affected your income or household size.

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If You Don't Qualify for Medicaid: Other Options to Explore

If your income is above the Medicaid threshold but you still cannot afford private insurance, several other programs may be available:

  • ACA Premium Tax Credits: Households with incomes between 100% and 400% FPL (and in some cases above 400% FPL under current law) may be eligible for subsidies to reduce Marketplace plan premiums.
  • Federally Qualified Health Centers (FQHCs): These community health centers provide primary and preventive care on a sliding-fee scale based on income, regardless of insurance status. Find one at findahealthcenter.hrsa.gov.
  • Prescription Assistance Programs: Many pharmaceutical manufacturers offer Patient Assistance Programs (PAPs) for people who cannot afford their medications. NeedyMeds.org and RxAssist.org are free directories of these programs.
  • Ryan White HIV/AIDS Program: For individuals living with HIV, this federal program funds a range of medical and support services.

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People Also Ask

Q: Does Medicaid cover dental and vision care? A: Dental and vision coverage under Medicaid is mandatory for children through the EPSDT benefit but optional for adults. Many states do offer some adult dental and vision coverage, though the scope varies widely. Contact your state Medicaid agency directly to confirm what adult dental and vision services may be available in your state.

Q: Can I have Medicaid and private insurance at the same time? A: Yes. If you have employer-sponsored or private insurance and also meet Medicaid eligibility criteria, you may be enrolled in both. In this situation, your private insurance typically pays first and Medicaid may cover remaining costs as a secondary payer. This is sometimes called "dual coverage" and can significantly reduce out-of-pocket expenses.

Q: What happens to my Medicaid if my income increases? A: If your income rises above your state's Medicaid eligibility threshold, you may lose Medicaid coverage. States are required to conduct annual eligibility redeterminations. If you lose Medicaid, this qualifies as a Special Enrollment Period for ACA Marketplace plans, giving you 60 days to enroll in a Marketplace plan, which may come with premium tax credits depending on your income.

Q: Are immigrants eligible for Medicaid? A: Eligibility for immigrants depends on immigration status, length of U.S. residency, and state policy. Lawful Permanent Residents who have been in the U.S. for at least five years are generally eligible for full Medicaid benefits if they meet income criteria. Some states have chosen to use state funds to cover immigrants during the five-year waiting period. Undocumented immigrants are generally not eligible for full Medicaid but may receive emergency Medicaid services.

Q: How is CHIP different from Medicaid for children? A: Both programs cover children, but CHIP targets families with incomes too high for Medicaid but who may not afford private insurance — typically between 133% and 300% FPL, depending on the state. CHIP may have small premiums or cost-sharing, while Medicaid for children is generally free. In many states, both programs are administered together and children are seamlessly enrolled in whichever program fits their family's income.

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Last reviewed: May 2026