Medicaid is one of the largest sources of health coverage in the United States, covering over 85 million people. Unlike Medicare (which is primarily for people 65 and older), Medicaid is designed to help people with limited income afford the healthcare they need.
How Medicaid Works
Medicaid is a partnership between the federal government and individual states. The federal government sets basic guidelines, but each state runs its own Medicaid program with its own rules about eligibility and covered services.
- The federal government provides matching funds to states (at least 50% of costs)
- States set their own eligibility criteria within federal guidelines
- Each state names its program differently (like Medi-Cal in California or MassHealth in Massachusetts)
- Benefits and coverage can vary significantly from state to state
Maria earns $18,000 per year as a part-time retail worker in a Medicaid expansion state. Since her income is below 138% of the Federal Poverty Level, she qualifies for Medicaid. She pays nothing for her monthly coverage and has minimal copays (often $0-$4) for doctor visits and prescriptions. When she needed surgery, Medicaid covered the entire $25,000 hospital bill.
Who Qualifies for Medicaid?
Medicaid eligibility depends on your income, household size, and what state you live in. Generally, you may qualify if you are:
In Medicaid Expansion States (40 states + DC)
- Adults 19-64 earning up to 138% of the Federal Poverty Level (~$20,783/year for an individual)
- Children in families earning up to 200-300% FPL (varies by state)
- Pregnant women (often with higher income limits)
- Elderly adults and people with disabilities (may also qualify for Medicare)
In Non-Expansion States (10 states)
- Eligibility is much more limited
- Childless adults often don't qualify regardless of income
- Parents must have very low incomes (often below 50% FPL)
- Children and pregnant women still have broader eligibility
If you don't qualify for Medicaid, you may still qualify for subsidized coverage through the Health Insurance Marketplace. Many people fall into a "coverage gap" in non-expansion states where they earn too much for Medicaid but too little for Marketplace subsidies. Check both options with a licensed agent.
Medicaid Expansion Explained
The Affordable Care Act (ACA) gave states the option to expand Medicaid to cover more low-income adults. Here's the difference:
- Expansion states: Cover all adults under 65 earning up to 138% FPL, regardless of parental status, disability, or other factors
- Non-expansion states: Maintain stricter pre-ACA eligibility rules that often exclude childless adults entirely
As of 2024, 40 states and Washington D.C. have adopted Medicaid expansion. The remaining 10 non-expansion states are primarily in the South.
What Does Medicaid Cover?
Medicaid must cover certain "mandatory" benefits, while states can choose to offer additional "optional" benefits:
Mandatory Benefits (All States)
- Inpatient and outpatient hospital services
- Physician and nurse practitioner services
- Laboratory and X-ray services
- Home health services
- Nursing facility services
- Early and periodic screening for children (EPSDT)
- Family planning services
- Federally-qualified health center services
Common Optional Benefits (Many States)
- Prescription drugs
- Dental care
- Vision care and eyeglasses
- Mental health and substance abuse treatment
- Physical therapy and rehabilitation
- Personal care services
- Transportation to medical appointments
Medicaid Costs
One of Medicaid's biggest advantages is its low cost to enrollees:
- Premiums: Most Medicaid enrollees pay no monthly premium
- Copays: Typically $0-$4 for doctor visits and prescriptions
- Deductibles: Generally none or very low
- Out-of-pocket maximum: Federal law limits out-of-pocket costs to 5% of family income
How to Apply for Medicaid
Unlike Marketplace insurance, Medicaid has no open enrollment period. You can apply any time of year:
- Online: Through HealthCare.gov or your state's Medicaid website
- By phone: Call your state's Medicaid agency or 1-800-318-2596
- In person: At your local Department of Social Services
- With help: A licensed insurance agent can guide you through the process
What You'll Need to Apply
- Proof of income (pay stubs, tax returns)
- Proof of residency (utility bill, lease)
- Social Security numbers for household members
- Citizenship or immigration documentation
- Information about current health coverage (if any)
Not Sure If You Qualify for Medicaid?
Our licensed agents can check your eligibility and help you apply for Medicaid or find alternative coverage options if you don't qualify.
Get Free GuidanceFrequently Asked Questions
What's the difference between Medicaid and Medicare?
Medicare is a federal program primarily for people 65 and older (and some younger people with disabilities). Medicaid is a joint federal-state program for people with limited income regardless of age. Some people qualify for both and are called "dual eligible."
Can I have Medicaid and private insurance at the same time?
Yes. If you have both, your private insurance is usually billed first (primary), and Medicaid may cover remaining costs as secondary insurance. This can help reduce your out-of-pocket expenses significantly.
Does Medicaid cover long-term care?
Yes, Medicaid is the primary payer for long-term care services in the United States, including nursing home care. However, strict income and asset limits apply, and many people must "spend down" their assets to qualify for long-term care coverage.
How long does it take to get approved for Medicaid?
States must process applications within 45 days (90 days for disability-based eligibility). Many states now offer same-day or next-day approval for straightforward applications, especially for children and pregnant women.