Are You Eligible for Medicaid but Don't Know It?

If you're eligible for Medicaid, there's no reason to leave money on the table.

When Americans run into trouble with large medical bills, one of the first things they're advised to do is check to see if they're eligible for Medicaid. Using Medicaid coverage beats taking out a personal loan or medical credit card to pay the debt.

As of November 2022, there were 84.8 million people covered by Medicaid in the U.S. It is estimated that millions more are eligible but have not signed up or are unaware of their eligibility. Here, we outline who's eligible for Medicaid, which medical services are covered, and how to proceed if you believe you qualify.

What is Medicaid?

Medicaid is a public insurance program that provides health coverage to eligible low-income adults, children, elderly adults, pregnant women, and people with disabilities. Programs follow federal guidelines but are administered by states. Medicaid is jointly funded by states and the federal government.

What's covered?

How much coverage an individual can expect depends, in large part, on the state in which they reside. Federal guidelines are broad and give states a great deal of flexibility. Simply put, some states are far more generous than others with Medicaid benefits.

Federal law requires that states provide a particular set of mandatory benefits. It's up to individual states to determine whether they want to cover any of the optional benefits.

Mandatory benefits

• Inpatient hospital services
• Outpatient hospital services
• Physician services
• EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services
• Rural health clinic services
• Federally qualified health center services
• Nursing facility services
• Home health services
• Family planning services
• Nurse midwife services
• Certified pediatric and family nurse practitioner services
• Laboratory and X-ray services
• Freestanding birth center services (when licensed or recognized by the state)
• Tobacco cessation counseling for pregnant women
• Transportation to medical care

Optional benefits

• Prescription drugs
• Clinic services
• Occupational therapy
• Respiratory care services
• Speech, hearing, and language disorder services
• Physical therapy
• Other diagnostic, screening, preventive, and rehabilitative services
• Optometry services
• Dental services
• Dentures
• Podiatry services
• Eyeglasses
• Chiropractic services
• Prosthetics
• Other practitioner services
• Private duty nursing services
• Personal care
• Case management
• Services for individuals age 65 or older in an institution for mental disease (IMD)
• Services in an intermediate care facility for individuals with intellectual disability
• State plan home and community based services: 1915(i)
• Self-directed personal assistance services: 1915(j)
• Community First Choice Option: 1915(k)
• Tuberculosis-related services
• Inpatient psychiatric services for individuals under age 21
• Health homes for enrollees with chronic conditions: Section 1945
• Hospice care
• Other services approved by the Secretary, including services furnished in a religious, nonmedical health care institution, emergency hospital services by a non-Medicare certified hospital, and critical access hospital (CAH).

Who's eligible for Medicaid?

Classified as an "entitlement" program, anyone who meets eligibility criteria can enroll in Medicaid coverage. Here's who's eligible:

• Children through age 18 in families with an income below 138% of the federal poverty line. In 2023, 138% of the federal poverty line for a family of three is $31,781.
• People who are pregnant and have an annual income below 138% of the federal poverty line.
• Certain parents or other caretakers with very low income.
• Most seniors and people with disabilities who receive cash assistance through the Supplemental Security Income (SSI) program.

States may also receive federal funds to cover these "optional" populations:

• People with incomes that exceed the limits for mandatory coverage.
• Seniors and people with disabilities not receiving SSI, and with an income below the federal poverty line.
• Medically needy people.
• Other people with higher incomes who require long-term services and support.
• Non-disabled adults with an income below 138% of the poverty lines, including those without children.

Here's where things get tricky.

ACA Medicaid expansion

The Affordable Care Act (ACA) -- also known as Obamacare -- was signed into law in 2010. While Medicaid had been around since 1965, the ACA sought to boost the number of Americans Medicaid could help. The people Medicaid aims to help are those who are least able to come up with the cash or finance their medical care in some other way.

Currently, 39 states and the District of Columbia have adopted the Medicaid expansion of 2010. But 11 states have not. Whether you qualify for Medicaid may depend on whether you live in a state that has expanded its program.

• In all 50 states: Medicaid qualification is based on income, household size, disability, family status, and other factors specific to your state of residence.
• In 39 states and the District of Columbia: You can qualify for Medicaid based on income alone. If your household income is below 138% of the federal poverty level, you automatically qualify. The only exceptions are the few states who have set a different income limit.

These are the 11 states that have not adopted Medicaid expansion as of this writing:

1. Wyoming
2. Wisconsin
3. Kansas
4. Texas
5. Florida
6. Mississippi
7. Alabama
8. Tennessee
9. Georgia
10. South Carolina
11. North Carolina

While South Dakota has adopted Medicaid expansion, the state has yet to implement the expanded program.

State eligibility

Ultimately, all that matters is whether you're eligible in your state. Check out this resource from Medicaid.gov. It quickly links you to everything you need to know about Medicaid in your state.

To find your state, scroll down the page to the big blue map. You can either click on the outline or use the pull-down menu to locate your home state. Once your state pops up, you'll find the name of the department that oversees Medicaid, contact information, eligibility requirements, and enrollment information.

Apply for coverage

Once you know if you're eligible, apply for Medicaid directly through your state office. Or, if you'd prefer, visit HealthCare.gov to create a Health Insurance Marketplace® account and complete an application. If you decide to apply through the Marketplace, here are a few tips that will make the process easier:

• When asked if you'd like to see if you can get help paying for coverage, reply "yes."
• If it appears that someone in your household qualifies for Medicaid, the Marketplace will forward your application directly to your home state for the final decision.
• If you have any questions, contact the Marketplace Call Center at 1-800-318-2596. TTY users should call 1-855-889-4325.

If your state has not expanded Medicaid

If your annual income is below the federal poverty level but your state has not expanded Medicaid, fill out a Marketplace application anyway. Each state offers different options, and could have coverage that might work for you. This is particularly true if you are pregnant, have children, or have a disability. Do not automatically assume that you can't land coverage.

Medical costs are known to empty bank accounts. If you think you might be eligible for help paying your medical expenses, don't wait. Take steps to receive the assistance you need.