The Medicaid Eligibility Game

Medicaid is jointly administered by the Centers for Medicare and Medicaid Services (CMS) and individual state Medicaid agencies. CMS is an agency within the Department Health and Human Services (HHS), which in turn is overseen by the President. CMS sets program parameters, provides policy guidance, and approves waivers excusing states from certain requirement. CMS issues guidance on eligibility, enrollment, medical assistance, coverage, provider participation, provider payments, cost-sharing, and a host of other policy issues related to the program.

In turn, each state creates a uniform, state-wide medical assistance program that is embodied in a federally-approved state plan. The state agencies are free to make choices within the parameters set by the federal government, often through waivers or creative programming.

There are two overarching buckets of eligibility: pre-ACA (Historical) criteria and post-ACA (Expansion) criteria. The post-ACA criteria only applies to the population that became eligible as a result of the ACA in the states that chose to expand Medicaid after the Supreme Court determined that states could not be coerced into expanding their Medicaid programs as expansively dictated by the ACA. The pre-ACA criteria still applies in states that did not expand Medicaid.

Historical Criteria (must meet all five criteria to quality for Medicaid)

  • Category: pregnant women, children, individuals with disabilities, elderly, parent with child in the home
  • Income: Varies by state, but typically 100% of the federal poverty level (FPL)
  • Resources: Items like cars and homes must be valued under a certain amount, usually between $1,000-$3,000
  • Residency in the state one is applying for Medicaid
  • Legal resident of the U.S.

Expansion Criteria (no more categories, purely income based)

  • Adults under 65 without dependent children with income below 133% FPL
  • Elderly and individuals with disabilities
  • Children under 6 and pregnant women living below 133% FPL
  • Children ages 6-19 living below 100% FPL

Medicaid eligibility was significantly altered in 2010 when the ACA expanded eligibility from those living below 100% FPL to 133% FPL with no other requirements. It’s hard to fully paint the picture of just how much the program has changed in the intervening years. Not only has this been consequential for low-income childless adults, it has expanded eligibility for young adults under 26 and former foster youth. The ACA has offered previously unprecedented opportunities for Medicaid to respond to disaster relief, public health emergencies, and school programs. Perhaps most importantly, the ACA precipitated a cultural shift in the way the public perceives Medicaid.  What was once a stigmatized extension of welfare is now the championing provider of the basic right to health services.

Image from Kaiser Family Foundation (recently updated).

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