Medicaid: Who Qualifies and How to Apply

Medicaid is the largest health insurance program in the United States, covering over 80 million people and providing comprehensive coverage at little or no cost to eligible enrollees. Despite its scale and the breadth of benefits it provides, it is also one of the most misunderstood programs, with eligibility criteria that vary significantly by state, category, and circumstances in ways that confuse potential enrollees.

Many people who would qualify for Medicaid are not enrolled, either because they believe they are not eligible, because they do not understand how to apply, or because the stigma associated with public assistance programs creates an unnecessary barrier to accessing benefits they are legally entitled to. The financial and health consequences of going uninsured when Medicaid coverage is available are real and significant.

This guide explains who qualifies for Medicaid under current federal and state rules, how to apply, what the program covers, and what rights enrollees have within the Medicaid system.

Who Qualifies: Expanded and Traditional Medicaid

The ACA expanded Medicaid eligibility to cover most adults with incomes at or below 138 percent of the federal poverty level in states that chose to adopt the expansion. As of 2024, 40 states and the District of Columbia have expanded Medicaid. In expansion states, virtually any adult under 65 whose income falls at or below this threshold qualifies, regardless of disability status, pregnancy, or household composition.

In the 10 states that have not expanded Medicaid, traditional eligibility rules apply. These rules are more restrictive and generally require that the applicant fall into a specific category in addition to meeting income requirements: children, pregnant women, parents of minor children, elderly individuals, and people with qualifying disabilities. Non-disabled working-age adults without dependent children often do not qualify for Medicaid in non-expansion states regardless of income.

Children are eligible for Medicaid or the Children's Health Insurance Program, which extends coverage to children in families with somewhat higher incomes than Medicaid's threshold, in all states. Children's eligibility thresholds are typically significantly higher than adult thresholds, and all children in families below 200 percent of the federal poverty level or higher in most states qualify for either Medicaid or CHIP.

How to Apply for Medicaid

Medicaid applications are submitted to your state's Medicaid agency, which may be operated under the name of the state's health department, department of social services, or another state agency. Applications can be submitted online, by phone, in person, or by mail depending on the state.

The ACA Marketplace application at healthcare.gov screens for Medicaid eligibility automatically. If you apply for Marketplace coverage and your income falls below the Medicaid threshold, the system will transfer your application to your state Medicaid agency rather than enrolling you in a Marketplace plan. This makes the Marketplace application a useful starting point even if you suspect you might qualify for Medicaid.

Documentation typically required for a Medicaid application includes proof of identity, proof of income, proof of state residency, Social Security numbers for all applicants, and immigration documentation if applicable. If you are self-employed, documentation of business income and expenses is needed. Some states have simplified the documentation requirements through streamlined eligibility verification using federal data.

What Medicaid Covers

Medicaid provides comprehensive health coverage that in many cases is more complete than private insurance at a fraction of the cost. Federal law requires that all state Medicaid programs cover physician services, hospital care, laboratory and radiology services, family planning services and supplies, home health services, and for children, Early and Periodic Screening, Diagnostic, and Treatment services which are more comprehensive than typical adult preventive benefits.

Most states also cover dental care, vision care, prescription drugs, mental health and substance use disorder services, and long-term care at the federal minimum standard or better. The specific benefits and cost-sharing requirements vary by state within the federal minimum standards.

Medicaid is also the primary payer for long-term care in the United States, covering nursing home and home and community-based services for eligible individuals who meet both medical and financial criteria. Long-term care Medicaid eligibility has separate and more complex rules than standard health coverage Medicaid.

Medicaid Managed Care and Provider Access

Most states deliver Medicaid benefits through managed care organizations, which are private health plans contracted by the state to provide coverage to Medicaid enrollees. Managed care Medicaid works similarly to private HMO plans, with a network of contracted providers and a primary care coordination model.

Provider acceptance of Medicaid is variable by market and specialty. While most primary care providers and hospitals accept Medicaid, specialist access can be more limited in some areas. Federally qualified health centers and community health centers provide comprehensive primary care services to Medicaid enrollees across the country and are an important access point for Medicaid populations.

Medicaid enrollees have the right to choose their managed care plan if multiple plans are offered in their area, to change their primary care provider within the plan's network, to receive emergency care at any facility regardless of network status, and to appeal coverage denials through the plan's and state's appeals process.

Final Thoughts

Medicaid provides comprehensive health coverage to eligible individuals at little or no cost, and accessing it is a matter of applying through the right channel with the required documentation. The eligibility rules are specific but navigable, and the benefits for those who qualify are substantial.

If you are uninsured or underinsured and believe you might qualify for Medicaid based on your income and state of residence, apply. The process takes some time and documentation but is free. Enrollment protects your health and your finances from the risks of going without coverage.

Healthcare coverage you are entitled to is coverage you should use. Apply for Medicaid if you qualify.