An Overview of Medicaid Eligibility and Benefits

Covering more than 64.5 million Americans, Medicaid is the largest health insurance provider in the United States.   The program, created under the Social Security Act Amendments of 1965, is available to low-income individuals in the fifty states, the District of Columbia, and U.S. territories. It is a collaboration between federal and state governments to provide coverage for basic health care.

Understanding how it works can help you to make the most of its benefits.

What Medicaid Covers

Medicaid does not necessarily cover everything, but it covers a lot. The federal government requires that certain services be offered to all Medicaid beneficiaries.

These mandatory services include the following:

• Care provided in community health centers and rural health clinics
• Care provided in nursing facilities for people 21 years of age and older
• Care provided by physicians, nurse midwives, and nurse practitioners
• Early and periodic screening, diagnostic, and treatment (EPSDT) services
• Family planning services and supplies
• Home health care for people eligible for nursing facility services
• Laboratory and imaging services
• Transportation for medical reasons

However, each state has the option to expand on those services—and they often do. These optional services may include but are not limited to:

• Case management
• Dental care (including dentures)
• Durable medical equipment
• Hospice care
• Mental health services
• Prescription medications
• Prosthetic devices
• Rehabilitation services (including physical therapy and occupational therapy)
• Telemedicine
• Vision care (including eyeglasses)

Who Can Get Medicaid?

Many people with low incomes would be unable to afford health insurance without government assistance. This is where Medicaid comes into play. The U.S. Department of Health and Human Services (HHS) determines the federal poverty level (FPL) every year, and these values are used to set the eligibility standards for Medicaid.

All states cover certain categories of people, including low-income families, children, pregnant women, the elderly, and people with disabilities. The federal government sets the standard, but individual states can choose to expand coverage beyond these limits, such as to all individuals below a certain income level. States can increase income thresholds to include more people. You can learn more information about what your state program covers on the Medicaid.gov website.

Impact of the Affordable Care Act

The Affordable Care Act (ACA or Obamacare), enacted in 2010, had a significant impact on Medicaid eligibility, as it is what offered Medicaid Expansion to states.   In exchange for federal funding, states agreed to expand Medicaid coverage to anyone with incomes up to 133% of the FPL, regardless of other factors. (Childless individuals would no longer be excluded from coverage.) The remaining states continue to follow the traditional Medicaid eligibility guidelines.

Immigration Status and Eligibility

Being an American citizen assures that you can get Medicaid coverage as long as the other requirements are also met. The same cannot be said for those with immigrant status.

Qualified non-citizens are generally eligible for Medicaid once they meet state requirements for income and length of residency. Often, the residency requirement is five years after attaining lawful permanent residency (green card) status.  

There are exceptions for refugees and those granted asylum, currently or before becoming lawful permanent residents (green card holders).

Immigrants who have entered the country illegally may be eligible for emergency services only, not the full Medicaid benefit.

Medicaid vs. Medicare

Both of these healthcare programs are regulated by the CMS, but there are a lot of differences between them.

• State run
• Offers care to the elderly and those with disabilities
• Offers care to low-income individuals of all ages, regardless health status
• Provides long-term nursing home care to its beneficiaries

• Federally run
• Offers care to the elderly and those with disabilities
• Limits nursing home care to short-term recovery after a hospital stay

More than 8 million people are eligible for both Medicaid and Medicare. These people are referred to as dual eligible. Medicaid helps them to pay for services that Medicare doesn't cover.

How to Enroll in Medicaid

Signing up for Medicaid can be done easily online at Medicaid.gov. Alternatively, you can contact your local Medicaid office to apply by phone or to schedule an in-person appointment. If you are eligible, you will want to sign up as soon as possible to make the most of the benefits.

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.

1. U.S. Centers for Medicare & Medicaid Services. June 2019 Medicaid & CHIP Enrollment Data Highlights.
2. U.S. Centers for Medicare & Medicaid Services. Mandatory & Optional Medicaid Benefits.
3. U.S. Centers for Medicare & Medicaid Services. Affordable Care Act Provisions.
4. U.S. Centers for Medicare & Medicaid Services. Coverage for Lawfully Present Immigrants.

• Kaiser Family Foundation. Medicaid - A Primer: Key Information on the Nation’s Health Coverage Program for Low-Income People. Updated March 1, 2013.
• U.S. Centers for Medicare & Medicaid Services. Medicaid and CHIP Application, Eligibility Determination, and Enrollment Data.
• U.S. Department of Health and Human Services. Poverty Guidelines. Updated January 17, 2020.

By Tanya Feke, MD
Dr. Feke is a board-certified family physician, patient advocate and best-selling author of "Medicare Essentials: A Physician Insider Explains the Fine Print."