Medicaid is a joint federal and state program that, together with the Children’s Health Insurance Program (CHIP), provides health coverage to over72.5 millionAmericans, including children, pregnant women, parents, seniors, and individuals with disabilities. Medicaid is the single largest source of health coverage in the United States.
To participate in Medicaid, federal law requires states to cover certain groups of individuals. Low-income families, qualified pregnant women and children, and individuals receiving Supplemental Security Income (SSI) are examples ofmandatory eligibility groups. States have additional options for coverage and may choose to cover other groups, such as individuals receiving home and community-based services and children in foster care who are not otherwise eligible.
The Affordable Care Act of 2010 created the opportunity for states to expand Medicaid to cover nearly all low-income Americans under age 65. Eligibility for children was extended to at least 133% of the federal poverty level (FPL) in every state (most states cover children to higher income levels), and states were given the option to extend eligibility to adults with income at or below 133% of the FPL. Most states have chosen to expand coverage to adults, and those that have not yet expanded may choose to do so at any time. See if your state has expanded Medicaid coverage to low-income adults.
Determining Eligibility for Medicaid
Financial Eligibility
The Affordable Care Act established a new methodology for determining income eligibility for Medicaid, which is based on Modified Adjusted Gross Income (MAGI). MAGI is used to determine financial eligibility for Medicaid, CHIP, and premium tax credits and cost sharing reductions available through the health insurance marketplace. By using one set of income counting rules and a single application across programs, the Affordable Care Act made it easier for people to apply and enroll in the appropriate program.
MAGI is the basis for determining Medicaid income eligibility for most children, pregnant women, parents, and adults. The MAGI-based methodology considers taxable income and tax filing relationships to determine financial eligibility for Medicaid. MAGI replaced the former process for calculating Medicaid eligibility, which was based on the methodologies of the Aid to Families with Dependent Children program that ended in 1996. The MAGI-based methodology does not allow for income disregards that vary by state or by eligibility group and does not allow for an asset or resource test.
Some individuals are exempt from the MAGI-based income counting rules, including those whose eligibility is based on blindness, disability, or age (65 and older). Medicaid eligibility for individuals 65 and older or who have blindness or a disability is generally determined using the income methodologies of the SSI program administered by the Social Security Administration (some states, known as 209(b) states, use certain more restrictive eligibility criteria than SSI, but still largely apply SSI methodologies). Eligibility for theMedicare Savings Programs, through which Medicaid pays Medicare premiums, deductibles, and/or coinsurance costs for beneficiaries eligible for both programs (often referred to asdual eligibles) is determined using SSI methodologies..
Certain Medicaid eligibility groups do not require a determination of income by the Medicaid agency. This coverage may be based on enrollment in another program, such as SSI or the breast and cervical cancer treatment and prevention program. Children for whom an adoption assistance agreement is in effect under title IV-E of the Social Security Act are automatically eligible. Young adults who meet the requirements for eligibility as a former foster care recipient are also eligible at any income level.
Non-Financial Eligibility
To be eligible for Medicaid, individuals must also meet certain non-financial eligibility criteria. Medicaid beneficiaries generally must be residents of the state in which they are receiving Medicaid. They must be either citizens of the United States or certain qualified non-citizens, such as lawful permanent residents. In addition, some eligibility groups are limited by age, or by pregnancy or parenting status.
Effective Date of Coverage
Once an individual is determined eligible for Medicaid, coverage is effective either on the date of application or the first day of the month of application. Benefits also may be covered retroactively for up to three months prior to the month of application, if the individual would have been eligible during that period had he or she applied. Coverage generally stops at the end of the month in which a person no longer meets the requirements for eligibility.
Medically Needy
States have the option to establish a “medically needy program” for individuals with significant health needs whose income is too high to otherwise qualify for Medicaid under other eligibility groups. Medically needy individuals can still become eligible by “spending down” the amount of income that is above a state's medically needy income standard. Individuals spend down by incurring expenses for medical and remedial care for which they do not have health insurance. Once an individual’s incurred expenses exceed the difference between the individual’s income and the state’s medically needy income level (the “spenddown” amount), the person can be eligible for Medicaid. The Medicaid program then pays the cost of services that exceeds the expenses the individual had to incur to become eligible.
In addition to states with medically needy programs, 209(b) states also must allow a spenddown to the income eligibility levels eligibility groups based on blindness, disability, or age (65 and older), even if the state also has a medically needy program. Thirty-six states and the District of Columbia use spenddown programs, either as medically needy programs or as 209(b) states.
Appeals
States must provide individuals the opportunity to request a fair hearing regarding a denial, an action taken by the state agency that he or she believes was erroneous, or if the state has not acted with reasonable promptness. States have options for how to structure their appeals processes.Appeals may be conducted by the Medicaid agency or delegated to the Exchange or Exchange Appeals Entity (for appeals of denials of eligibility for individuals whose income is determined based on MAGI).Appeals also may be delegated to another state agency, if a state obtains approval from CMS under the Intergovernmental Cooperation Act of 1968.
CIB: Coordination Between HHS Appeals Entity and Medicaid and CHIP Agencies – Assessment States
This Informational Bulletin discusses federal requirements and provides technical assistance related to coordination of appeals among insurance affordability programs in states that have elected for the Federally-Facilitated Exchange (FFE) to assess eligibility for Medicaid and CHIP (“assessment states”).
Appendix 1: States treating decisions of HHS Appeals Entity as assessments of eligibilityprovides three scenarios to illustrate the specific steps that assessment states must take upon receiving an Electronic File Transfer from the Department of Health and Human Services (HHS) Appeals Entity if the state has opted to treat decisions of the HHS Appeals Entity as an assessment of Medicaid or CHIP eligibility. See operational flows for the scenarios:
- Scenario 1
- Scenario 2
- Scenario 3
Appendix 2: States treating decisions of HHS Appeals Entity as determinations of eligibilityprovides three scenarios to illustrate the specific steps that assessment states must take upon receiving an Electronic File Transfer from the HHS Appeals Entity if the state has opted to accept decisions of the HHS Appeals Entity as a final determination of Medicaid or CHIP eligibility. See operational flows for the scenarios:
- Scenario 1
- Scenario 2
- Scenario 3
Related Topics
Spousal Impoverishment:Protects the spouse of a Medicaid applicant or beneficiary who needs coverage for long-term services and supports (LTSS), in either an institution or a home or other community-based setting, from becoming impoverished in order for the spouse in need of LTSS to attain Medicaid coverage for such services.
Treatment of Trusts:When an individual, his or her spouse, or anyone acting on the individual's behalf establishes a trust using at least some of the individual's funds, that trust can be considered available to the individual for determining eligibility for Medicaid.
Transfers of Assets for Less Than Fair Market Value:Medicaid beneficiaries who need LTSS will be denied LTSS coverage if they have transferred assets for less than fair market value during the five-year period preceding their Medicaid application.This rule applies when individuals (or their spouses) who need LTSS in a long-term care facility or wish to receive home and community-based waiver services have transferred, sold, or gifted assets for less than they are worth.
Estate Recovery:State Medicaid programs must recover from a Medicaid enrollee's estate the cost of certain benefits paid on behalf of the enrollee, including nursing facility services, home and community-based services, and related hospital and prescription drug services. State Medicaid programs may recover for other Medicaid benefits, except for Medicare cost-sharing benefits paid on behalf of Medicare Savings Program beneficiaries.
Third Party Liability:Third Party Liability refers to third parties who have a legal obligation to pay for part or all the cost of medical services provided to a Medicaid beneficiary. Examples are other programs such as Medicare, or other health insurance the individual may have that covers at least some of the cost of the medical service. If a third party has such an obligation, Medicaid will only pay for that portion.
Waivers and Demonstrations:States can apply to CMS for waivers to provide Medicaid to populations beyond those traditionally covered under the state plan. Some states have additional state-only programs to provide medical assistance for certain low-income people who do not qualify for Medicaid. No federal funds are provided for state-only programs.
FAQs
What is the highest income to qualify for Medicaid? ›
Income Limit in Most States
Most states — 38 and Washington, D.C. — have the same income limit of $2,523 per month for a single person for most types of Medicaid services. For a married couple, the limit increases to $5,046 in most cases.
They must have limited income, limited assets, and a medical need for care. In 2023, a single individual applying for Nursing Home Medicaid in TX must meet the following criteria: 1) Have income under $2,742 / month 2) Have assets under $2,000 3) Require the level of care provided in a nursing home facility.
What is the income limit for Medicaid in Texas 2022? ›*If the care recipient has gross countable income greater than $2,523, he or she will be deemed ineligible for Medicaid benefits.
Can adults qualify for Medicaid in Texas? ›Adults with disabilities who qualify will get Medicaid for the Elderly and People with Disabilities. If you have a disability and work, you might be able to get the Medicaid Buy-In for Adults program.
Is Medicaid free? ›Medicaid is a joint federal and state program that provides free or low-cost health coverage to millions of Americans, including some low-income people, families and children, pregnant women, the elderly, and people with disabilities.
What are the disadvantages of Medicaid? ›Disadvantages of Medicaid
They will have a decreased financial ability to opt for elective treatments, and they may not be able to pay for top brand drugs or other medical aids. Another financial concern is that medical practices cannot charge a fee when Medicaid patients miss appointments.
| Income Limit | Asset Limit | |
|---|---|---|
| Institutional / Nursing Home Medicaid | $2,349 / month | $2,000 |
| Medicaid Waivers / Home and Community Based Services | $2,349 / month | $2,000 |
| Regular Medicaid / Aged Blind and Disabled | $783 / month | $2,000 |
The amount of money you earn before taxes each month must be less than $2,453. The amount of money you have, such as cash, banks and retirement accounts (countable assets) must be no more than $2,000.
How long does it take to get Medicaid approved in Texas? ›Make a decision within 45 days on applications from applicants under age 65 who have had disability established based on the Social Security Administration criteria for RSDI Title II or SSI Title XVI disability.
Can you own a home and still qualify for Medicaid in Texas? ›For property to be considered a home for Medicaid eligibility purposes, the person or spouse must consider the property to be their home and: have ownership interest in the property; and. reside in the property while having ownership interest.
What is the max income for food stamps in Texas? ›
| Family size | Maximum monthly income |
|---|---|
| Family size 3 | Maximum monthly income $ 3,167 |
| Family size 4 | Maximum monthly income $ 3,816 |
| Family size 5 | Maximum monthly income $ 4,465 |
| Family size For each additional person, add: | Maximum monthly income $ 649 |
To get Medicaid or CHIP, a child must be age 18 and younger (in some cases children with disabilities age 19 and 20 can get Medicaid).
Is there free health insurance in Texas? ›Texas Medicaid
Medicaid is a program that provides free or low-cost healthcare coverage to people by the combined efforts of the state and federal governments.
...
STAR Kids
- Aetna.
- Amerigroup.
- Blue Cross and Blue Shield of Texas.
- Children's Medical Center.
- Community First Health Plans.
- Cook's Children Health Plan.
- Driscoll Health.
- Superior Health Plan.
Mandatory benefits include services including inpatient and outpatient hospital services, physician services, laboratory and x-ray services, and home health services, among others. Optional benefits include services including prescription drugs, case management, physical therapy, and occupational therapy.
How Much Is Medicare a month? ›In 2023, the premium is either $278 or $506 each month, depending on how long you or your spouse worked and paid Medicare taxes. You also have to sign up for Part B to buy Part A. If you don't buy Part A when you're first eligible for Medicare (usually when you turn 65), you might pay a penalty.
How does Medicaid work? ›Medicaid does not provide health care directly. The large majority of Medicaid beneficiaries are covered through private managed care plans. For others, state Medicaid programs pay hospitals, doctors, nursing homes, and other health care providers for covered services that they deliver to eligible patients.
Which state has the best Medicaid program? ›This means Medicaid will cover preventative services such as check-ups, cleanings, x-rays and sealants. It also covers restorative services such as fillings, crowns, root canals, oral surgery and emergency procedures. In other words, dental services for children and young adults cannot be limited to emergency services.
How do people feel about Medicaid? ›#1 Public Holds Favorable Views Of Medicaid
A majority of Democrats (85%), independents (76%), and Republicans (65%) view the program favorably.
Do you have to pay back Medicaid in Texas? ›
If you received Medicaid long-term services and supports, the state of Texas has the right to ask for money back from your estate after you die. In some cases, the state may not ask for anything back, and the state will never ask for more money back than it paid for your services.
Does Medicaid check your bank account Texas? ›While Medicaid agencies do not have independent access to a Medicaid recipient's financial statements, Medicaid does an annual update to make sure a Medicaid recipient still meets the financial eligibility requirements. Furthermore, a Medicaid agency can ask for bank statements at any time, not just on an annual basis.
How far back does Medicaid look at assets in Texas? ›Under pre-DRA transfer of assets policy, the look-back period is 36 months (or 60 months) from the later of the date of: institutionalization, or. Medicaid application.
How do I protect my assets from Medicaid in Texas? ›Medicaid Asset Protection Trusts (MAPT) can be a valuable planning strategy to meet Medicaid's asset limit when an applicant has excess assets. This type of trust enables someone who would otherwise be ineligible for Medicaid to become Medicaid eligible and receive the care they require be at home or in a nursing home.
Is there a waiting list for Medicaid in Texas? ›There are 156,161 people waiting for home and community based waiver services in Texas. The waiting list in Texas is called an "Interest List".
How long do you have to live in Texas for Medicaid? ›The Medicaid applicant must be either a U.S. citizen or an alien with qualified alien status. Additionally, the applicant must be a resident of Texas. There is no length of residence requirement. The applicant merely needs to reside in Texas and intend to remain or return to Texas.
What is 5 year lookback Medicaid Texas? ›In order to be eligible for Medicaid, one cannot have assets greater than the limit. Texas has a look back period of 5 years with a penalty for people who sell assets below fair market price, transfer assets to others, or give money and property away.
What assets are exempt from Medicare? ›Other exempt assets include pre-paid burial and funeral expenses, an automobile, term life insurance, life insurance policies with a combined cash value limited to $1,500, household furnishings / appliances, and personal items, such as clothing and engagement / wedding rings.
Can I get food stamps if I make $1,800 a month? ›With all this in mind, if your gross income minus deductions is less than $1,133 for an individual or $1,526 for a home with two people, you can qualify for SNAP benefits. That means if you have a net income of $1,800 or more and have three or more people in your household, you can collect SNAP benefits.
What bills count for food stamps Texas? ›SNAP counts cash income from all sources, including earned income (before payroll taxes are deducted) and unearned income, such as cash assistance, Social Security, unemployment insurance, and child support.
Can a single person get food stamps in Texas? ›
SNAP assistance is available to qualifying families, elderly people, and single adults. Applicants must reside in Texas, and must apply in the county in which they reside.
Does Medicaid cover surgery? ›When it comes to surgical procedures, both Medicare and Medicaid provide coverage for many medically necessary surgical services received under inpatient and outpatient treatment. However, coverage terms can vary depending on the type of surgery being performed, where it is performed, and your specific circumstances.
Can you have Medicare and Medicaid at the same time in Texas? ›Beginning April 1, 2015, the Texas Health and Human Services Commission has offered a way to serve adults who are eligible for both Medicare and Medicaid, known as dual-eligible individuals.
How to get health insurance in Texas with no job? ›If you're unemployed you may be able to get an affordable health insurance plan through the Marketplace, with savings based on your income and household size. You may also qualify for free or low-cost coverage through Medicaid or the Children's Health Insurance Program (CHIP).
What happens if you don't pay a hospital bill in Texas? ›Medical debt can be sent to a collections agency like any other debt. However, if it is owed to a non-profit hospital, they may be required to provide financial assistance to you before it is sent to collections.
What if I don't have health insurance in Texas? ›If you do not have health insurance, you can contact your local community health center for assistance. To find one near you, use this directory found on the Texas Association of Community Health Centers website.
Is Texas Star the same as Medicaid? ›STAR+PLUS is a Texas Medicaid managed care program for adults who have disabilities or are age 65 or older. Adults in STAR+PLUS get Medicaid health-care and long-term services and support through a health plan that they choose.
Who does Texas Medicaid cover? ›Most people who have Medicaid in Texas get their coverage through the STAR managed care program. STAR covers low-income children, pregnant women and families. STAR members get their services through health plans they choose.