Medicaid Eligibility Basics: Who Qualifies and Why Rules Differ So Much by State

Medicaid can be a lifeline for people who need health coverage but can’t afford private insurance. At the same time, figuring out who actually qualifies for Medicaid can feel confusing—especially when you discover that the rules aren’t exactly the same in every state.

This guide from HowToGetAssistance.org explains Medicaid eligibility in plain English, why it varies by state, and what you can do to check your own situation through official channels. HowToGetAssistance.org is not a government agency, application site, or benefits office—we’re here to help you understand the basics so you can take next steps with your state’s official Medicaid office.

What Is Medicaid, In Simple Terms?

Medicaid is a public health coverage program that helps people with low incomes and limited resources pay for medical care. It is:

• Funded by both federal and state governments
• Run by each state (and sometimes counties), under federal rules
• Usually free or low-cost to the enrollee

Depending on your state and your situation, Medicaid may cover:

• Doctor visits and preventive care
• Hospital stays and emergency care
• Prescription medications
• Mental health and substance use treatment
• Pregnancy and postpartum care
• Long-term care services (like nursing homes or home health)
• Some transportation to medical appointments

The specific services, co-pays, and income rules vary by state, but all Medicaid programs are meant to help people who would struggle to afford health coverage otherwise.

Why Medicaid Eligibility Varies by State

Medicaid is a federal–state partnership. That means:

• The federal government sets some basic rules, like certain groups that must be covered.
• States decide many of the details, like:
  • Exact income limits
  • Assets rules (for certain groups)
  • Which optional groups to cover
  • Extra services beyond the federal minimums

This is why two people with similar income and family size might qualify in one state but not in another.

Common reasons eligibility differs by state include:

• Whether the state chose to expand Medicaid to more low‑income adults
• Different income limits for children, parents, pregnant people, and older adults
• Different rules for disability-based Medicaid and long‑term care
• County-based administration in some states (county agencies run the program locally)

Because of this variation, the only reliable way to know if you qualify is to:

• Contact your state Medicaid agency or
• Use your state’s official benefits portal to check and apply

Who Typically Qualifies for Medicaid?

While details vary, most states focus on these broad groups:

1. Low‑Income Children and Teens

Most states cover:

• Children under 19 in families with income below a set limit
• Infants and very young children often have higher income limits than teenagers

In practice, children qualify at higher incomes than adults in many states, because federal rules strongly protect kids’ coverage.

2. Pregnant People

Medicaid commonly covers pregnant individuals with incomes higher than the limits for other adults. Coverage often includes:

• Prenatal care
• Labor and delivery
• Postpartum care (for a set period after the pregnancy, which varies by state)

Many states have separate income rules just for pregnancy-related Medicaid.

3. Parents and Caregivers of Minor Children

Some states cover low‑income parents or caregivers of children under 18, but:

• Income limits for this group can be lower than for children
• In some states, coverage for parents is only available if the state has expanded Medicaid or if income is well below the poverty line

4. Low‑Income Adults (Medicaid Expansion States)

Under federal law, states may choose to expand Medicaid to cover more adults. In Medicaid expansion states, many adults qualify if they:

• Are between 19 and 64
• Have low income (the exact dollar amount depends on family size and federal poverty levels)
• Are U.S. citizens or certain qualifying non-citizens, and
• Meet state residency rules

In non‑expansion states, low‑income adults without children often do not qualify unless they are elderly, pregnant, or have a qualifying disability.

5. Older Adults (65+)

Many people aged 65 or older qualify for both:

• Medicare (a federal insurance program, usually based on work history), and
• Medicaid (based on financial need)

Medicaid can help older adults by:

• Covering Medicare premiums or cost-sharing
• Paying for services Medicare may not cover, such as long-term nursing home care, when financial criteria are met

6. People With Disabilities or Blindness

People who are blind, have certain disabilities, or are unable to work may qualify based on:

• A disability determination (often through Social Security), and
• Strict income and resource limits

Disability-based Medicaid rules are often complex and can differ sharply by state, especially for:

• People receiving Supplemental Security Income (SSI)
• People applying for Medicaid on the basis of disability alone
• Long-term care or home- and community-based services

Why Income Limits Aren’t the Same Everywhere

Each state decides how “low-income” is defined for its Medicaid groups, within federal guidelines. Common features:

• Income is usually compared to the Federal Poverty Level (FPL), which changes annually.
• States choose what percentage of FPL qualifies for different groups (children, pregnant people, adults, older adults, people with disabilities).
• Some states also look at resources or assets (like savings, property, and certain vehicles) for specific categories, especially:
  • Older adults
  • People with disabilities
  • People seeking long-term care (like nursing facilities)

Because of this flexibility:

• A parent may qualify in one state at a certain income, but not in another.
• A single adult with no children may be covered in one state (if expansion was adopted), but not eligible at all in another.

To get accurate numbers for your situation, you usually need to:

• Look at the income charts on your state’s official Medicaid website, or
• Speak with your local Medicaid office or county human services department

Key Factors That Affect Medicaid Eligibility

Most state Medicaid agencies look at some combination of:

• Income: Wages, self-employment, unemployment benefits, certain Social Security payments, etc.
• Household size: Who is counted in your family unit can change your income limit.
• Age: Children, adults, and older adults may have different program categories.
• Disability status: Whether you are considered disabled under Social Security or state rules.
• Pregnancy status: Pregnant people are often evaluated under special, more generous rules.
• Citizenship/immigration status:
  • U.S. citizens usually qualify if they meet income and other criteria.
  • Some lawfully present immigrants qualify for full benefits; others may only qualify for emergency Medicaid or state‑only programs.
• Residency: You usually must live in the state where you apply and intend to remain there.
• Assets/resources (for some groups): Cash, bank accounts, some property, and investments can matter, especially for:
  • Long-term care coverage
  • People 65+
  • People with disabilities

Common Types of Medicaid Categories (At a Glance)

Below is a simplified comparison of some common groups. Exact rules vary by state.

*Asset rules differ a lot by state and program type. Always check with your state Medicaid office.

How To Check If You Might Qualify

Because the rules vary, a helpful approach is:

1. Identify your main category
   Are you applying as:

   • A parent or caregiver?
   • A child or teen?
   • Pregnant?
   • An adult without children?
   • Someone with a disability?
   • Age 65 or older?

2. Review income and household information
   Know:

   • Who lives with you and whom you support financially
   • Your gross monthly income from all sources
   • If anyone in your household already has Medicaid, Medicare, or other coverage

3. Use your state’s official tools
   Most states offer:

   • An online screening tool that asks simple questions and gives a “likely eligible” or “unlikely eligible” message
   • A customer call center or local office where you can ask about your situation

4. Ask questions before you apply
   You can call:

   • Your state Medicaid agency
   • A local county human services office
   • A community health center or local navigator/assistor program

While these tools can’t guarantee approval, they help you decide whether an official application is worth pursuing.

Documents Commonly Needed for a Medicaid Application

Each state sets its own documentation requirements, but people are often asked to show:

Proof of identity

• State ID or driver’s license
• Passport
• Other government-issued photo ID

Proof of U.S. citizenship or immigration status (if applicable)

• U.S. birth certificate
• U.S. passport
• Permanent Resident Card (green card)
• Other DHS/immigration documents

Proof of residency

• Lease or rental agreement
• Utility bill with your name and address
• Official mail such as a tax notice or benefits letter

Proof of income

• Recent pay stubs
• Self-employment records
• Unemployment benefit letters
• Social Security benefit letters
• Pension statements

Household information

• Social Security numbers (or document numbers, if applicable) for people applying
• Birth certificates for children, when required

Assets/resources (if your category requires it)

• Bank statements
• Statements for retirement accounts or investments
• Life insurance with cash value
• Property tax bills or deeds (if you own property other than your home)

👍 Tip: When you’re unsure what to bring, you can call your local Medicaid office and ask what documents are typically requested in your situation.

Where and How to Apply for Medicaid

You cannot apply for Medicaid through HowToGetAssistance.org. Applications must go through official government channels. Depending on your state, you may be able to apply:

1. Online

Most states now offer an official benefits portal where you can:

• Create an account
• Fill out a Medicaid application
• Upload documents
• Receive messages from the agency

To find the right portal, search for:

• Your state name + “official Medicaid application”
• Your state name + “health and human services benefits portal”

Make sure the website clearly identifies itself as a state or county government site (look for .gov or a clearly stated official agency name).

2. By Phone

Some states allow you to:

• Apply over the phone with a caseworker or call center representative, or
• Request that a paper application be mailed to you

You can usually find the phone number by checking your state Medicaid agency website or calling a statewide 2‑1‑1 information line, which often refers callers to the correct office.

3. In Person

Many areas have:

• County human services or social services offices
• Department of Health or Department of Human Services locations

At these offices, you can typically:

• Pick up and drop off paper applications
• Ask questions about documents
• Sometimes get in-person help filling out forms

Because office structures vary, it’s usually smart to call ahead or check online for hours and whether appointments are required.

4. By Mail or Fax

Some states still accept:

• Completed paper application forms mailed to a central processing center or local office
• Forms and documents sent by fax

Instructions are usually available on your state Medicaid website or application forms.

What Happens After You Apply

While timelines and procedures aren’t identical across the country, applicants often go through these steps:

1. Application received
   The agency logs your application. You may get:

   • A case number
   • A confirmation letter or electronic notice

2. Review and request for more information (if needed)
   A caseworker may:

   • Review your forms
   • Ask for missing documents or clarification
   • Set a deadline for you to provide additional information

3. Eligibility decision
   Once the agency has enough information, they decide if you qualify. You should receive:

   • A written decision notice by mail or through your online account
   • An explanation of:
     • Whether you’re approved or denied
     • Your coverage start date
     • Any next steps

4. Enrollment and coverage start
   If approved, the notice may explain:

   • When your coverage begins (sometimes it can be retroactive to cover recent medical bills, depending on state rules)
   • How to select or change a managed care plan, if your state uses those

If you do not hear back in the timeframe stated in your application materials, you can:

• Call your state Medicaid hotline
• Contact your local office with your name, date of birth, and any case or application number to ask for a status update

Common Reasons Applications Are Delayed or Denied

People are often surprised by delays or denials. Common issues include:

• Missing documents

  • Not providing pay stubs, proof of residency, or other requested information by the deadline.

• Incomplete applications

  • Leaving key questions blank or not listing all household members as required.

• Income above the limit

  • Earning more than your state’s income rules allow for your category.

• Mismatch in information

  • Differences between what’s on the application and what is reported to other agencies (e.g., wages or Social Security).

• Not meeting category rules

  • For example, in a non‑expansion state, a low‑income adult without children may not fit into any covered category even if income is very low.

If you receive a denial letter, it should say why and explain how to request an appeal if you disagree.

How Medicaid Appeals and Fair Hearings Typically Work

If you think a decision about your Medicaid eligibility is wrong, you usually have the right to request an appeal or fair hearing.

While procedures vary, the process often includes:

1. Carefully reading your notice
   It typically explains:

   • The reason for the decision
   • Your deadline to appeal
   • Instructions on how to file (mail, online, or in person)

2. Filing an appeal on time
   You may need to:

   • Write a short statement saying you disagree with the decision, or
   • Fill out an appeal form included with your notice

3. Preparing for the hearing
   You can:

   • Collect documents that support your case (pay stubs, letters, medical information if relevant, etc.)
   • Ask a legal aid organization, disability rights group, or advocate if they can help you understand the process

4. Attending the hearing
   Hearings can be:

   • In person
   • By phone or video, depending on your state

   An impartial hearing officer usually listens to both you and the agency and then issues a decision.

If you are interested in appealing, it is important to act quickly, because appeal deadlines are often strict.

If You Don’t Qualify for Medicaid: Other Options to Explore

If you’re told you aren’t eligible for Medicaid, there may be other possibilities:

• Children’s Health Insurance Program (CHIP)

  • Some children who don’t qualify for Medicaid may qualify for CHIP, a related program for kids with slightly higher family incomes.
  • Your state Medicaid or health department website usually explains how to apply.

• Marketplace health plans with subsidies

  • If your income is too high for Medicaid (or you’re in a state where adults without children aren’t covered), you may be able to buy coverage through a federal or state health insurance marketplace.
  • Depending on your income, there may be financial help with premiums and cost-sharing.

• Community health centers and sliding-fee clinics

  • Federally Qualified Health Centers (FQHCs) and other clinics may offer care with fees based on your income.
  • You can usually locate these by searching for “community health center” along with your city or county.

• State or local health programs

  • Some states or counties have special programs for:
    • Emergency medical services
    • Specific conditions (like HIV care)
    • Prescription assistance

• Hospital financial assistance (charity care)

  • Many hospitals have programs to reduce or forgive bills for patients with low income, even if they don’t have Medicaid.

For help sorting through options, you can contact:

• Your state health department
• A local community health center
• A 2‑1‑1 information and referral line, where available

How To Make Sure You’re Using Official Medicaid Channels (And Avoid Scams)

Because Medicaid helps people with limited means, it can unfortunately attract scams. To protect yourself:

Signs you’re on an official channel:

• The website or office clearly identifies a state or county agency (for example, a Department of Human Services, Social Services, or Health).
• Web addresses often end in “.gov” (not always, but this is common for state sites).
• Phone numbers and addresses are listed on official state government pages or in official publications.

Red flags:

• A site that asks you to pay a fee to “apply faster” or “guarantee approval” for Medicaid.
• Unsolicited calls or messages asking for your Social Security number, bank details, or payment to “unlock benefits.”
• People claiming to be from Medicaid who contact you through personal messages on social media.

Ways to verify you’re in the right place:

• Call your state Medicaid hotline (number found through your state government website or 2‑1‑1).
• Ask a local clinic, hospital billing department, or social services office to confirm the correct application website or address.
• Check that any paper forms or letters list a recognizable state or county agency name and official mailing address.

Remember: HowToGetAssistance.org cannot process Medicaid applications or check your case status. All enrollment steps must go through official state or county agencies.

Understanding Medicaid eligibility is often the first step toward getting coverage. Once you know which category you might fit into, what documents to gather, and how your state’s rules work, you can approach your state Medicaid agency or local office more confidently and ask specific, informed questions about your situation.