Medicaid: The Basics

Applicants can enroll through the Marketplace or their state agency, and if denied, they have the right to appeal within state‑specific deadlines.

Medicaid helps ensure that low-income adults and children can access long-term care and healthcare services, leading to better health outcomes for more people. Individual states and the federal government jointly administer Medicaid through cost-sharing.

The following article highlights the basics of Medicaid, including eligibility, coverage, and how to apply for benefits.

Understanding Medicaid processes, appeals, and eligibility can be overwhelming and confusing. But legal help is available. Talk to a healthcare attorney in your state for targeted legal advice.

Medicaid Basics

The U.S. Department of Health and Human Services (HHS) jointly administers this medical assistance program with individual states and through the Centers for Medicare and Medicaid Services (CMS).

As of April 2026, the total number of Medicaid enrollees exceeds 66 million. States receive federal funding to administer Medicaid, and they can tailor their Medicaid programs to achieve their long-term healthcare goals. Since states administer Medicaid, each state can set its eligibility requirements.

States must follow CMS regulations in tailoring their programs. States can apply for CMS waivers to try out new programs.

Medicaid Expansion

President Barack Obama signed the Patient Protection and Affordable Care Act (ACA) into law in 2010. The intent of the ACA includes expanding health care coverage for low-income adults. The ACA does this by subsidizing health insurance premiums. Another way is through the Medicaid Expansion.

Before the ACA, some low-income adults could not qualify for Medicaid because their incomes were too high. They earned too much money to qualify for medical assistance but not enough to afford insurance premiums. In states with expanded Medicaid, low-income adults can qualify if their incomes are at or below 133% of the federal poverty level.

Medicaid Eligibility

The primary factor determining Medicaid eligibility is income level. The second eligibility factor is citizenship. Only U.S. citizens or lawful permanent residents can enroll in Medicaid.

Medicaid waives this requirement for people with emergency medical conditions, including pregnant women in labor. Some states also offer non-emergency prenatal coverage for pregnant women regardless of immigration status.

Children from families with incomes above the Medicaid coverage threshold may be eligible for health care benefits through the Children’s Health Insurance Program (CHIP).

Medicaid coverage, processes, and eligibility rules vary by state. Find local legal help.

Financial Eligibility for Medicaid

For Medicaid eligibility income purposes, states use a household’s modified adjusted gross income (MAGI). MAGI is the adjusted gross income plus any of the following:

• Untaxed foreign income
• Social Security benefits
• Tax-exempt interest

Income-based eligibility is a percentage of the federal poverty level (FPL).

State Criteria for Medicaid Eligibility

Each state has different criteria for Medicaid eligibility, often grouped by age, such as children, pregnant women, and adults. State eligibility criteria include residency in the state.

For example, in Florida, infants up to one year old are eligible if their family’s income is below 206% of FPL. Eligibility for adults is limited to those with a family income near 100% of the FPL. Those with a family income below 138 percent of FPL in expanded Medicaid qualify for Medicaid.

Exemptions From Income-Based Eligibility Requirements

Some people are exempt from income-based eligibility requirements. These persons include:

• The blind
• People with certain disabilities
• Those 65 or older

The federal Supplemental Security Income (SSI) eligibility criteria program applies to these persons.

Other populations eligible for exemption include the following:

• Those in the breast and cervical cancer treatment and prevention program
• Children covered by an adoption assistance agreement under Title IV-E of the Social Security Act
• Former foster care recipients (young adults)

Medically Needy Programs

Most states participate in needy programs to cover people with very high medical expenses and incomes. Often, their income is too high to otherwise qualify for health coverage. These programs allow patients to spend down the income above the state’s medically needy income standard. Once they meet the criteria, Medicaid will provide coverage.

Medicaid Benefits and Coverage

Although Medicaid covers essential health services, it has its limits, depending on where you live. Although the list of covered health benefits varies by state, federal law mandates a certain baseline of coverage, including the following:

• Preventative care like cancer screening
• Inpatient and outpatient hospital services
• Community-based services, such as rural health clinic services
• Laboratory services
• Transportation to medical care
• Nursing facilities, including nursing home care
• Intermediate care facilities, including mental health facilities

Optional Health Benefits

Health benefits that your state’s Medicaid program may or may not offer include the following:

• Prescription drugs
• Physical therapy
• Dental care
• Eyeglasses
• Prosthetics
• Respiratory care

Medicaid Enrollment and Appeals

You may enroll in Medicaid (or CHIP) through the Health Insurance Marketplace or your state’s Medicaid website. If you apply for coverage through the marketplace and the data shows that anyone in your family is eligible, the marketplace will forward your information to your state agency.

If the agency denies your application, you can appeal the decision. The state Medicaid agency must give you written notice of the denial (“notice of action”) explaining the following:

• Reason for denial
• The specific rule that supports the denial
• Information about how to appeal

Deadlines for requesting an appeal vary by state but are at most 90 days from the date the agency mails the denial. If you’re already receiving benefits, you’ll want to file your appeal within ten days to avoid a disruption of coverage.

Get Legal Help With Medicaid

You or your loved one can apply for Medicaid online or in person with little trouble. If the agency denies your application and you believe the denial was in error, you may need help appealing the decision. A local attorney can help you with your application or appeal. Legal help is available.