Medicaid Eligibility

Am I Eligible For Medicaid?

Medicaid eligibility is an interesting mixture of factors. You must fall into one of the "groups" serviced by Medicaid in order to be eligible. Ultimately this means that if you do not fall into one of the groups you cannot get help through Medicaid.

Medicaid Eligibility Groups

Each state may have additional financial and non-financial requirements for being eligible for Medicaid but in general to be eligible you must belong to one of these groups:

  • Group I: People who receive assistance through a cash assistance program of one kind or another. This group is called SSI, which stands for Supplemental Security Income. People included in this group are either old, blind and/or mentally oand physically disabled.
  • Group II: Families with dependent children who have need. This group is referred to as AFDC or Aid to Families with Dependent Children. Pregnant women with incomes 133% below the federal poverty line (FPL) and children younger than 18 who are 100% below the FPL and their families are eligible for Medicaid.

Many Medicare Recipients May Be "Dual Eligible"

Dual eligibility means that you qualify for both Medicare and Medicaid. When this happens a recipient can have almost all of their medical expenses covered under one program or the other. For example, Medicaid can be used to help pay for Medicare Part A and Part B premiums. In addition, Medicaid may cover services like dental care and home-health care services not covered by Medicare.

Other Eligibility Factors for Medicaid

The main groups that are served under Medicaid include pregnant women, Children who are under 21, people who are old, blind and disabled and families with children. In all cases these groups of people also have to satisfy additional financial and non-financial requirements to receive Medicaid payments.

Medicaid eligibility is further determined by:

  • State residency
  • US citizenship or alien status
  • SSN
  • Proof of Identity
  • Proof of Income and Assets
  • Further State requirements
  • Must agree to the assignment of your medical rights
  • Special rules apply to special groups including institutionalized people, disabled children who are still living at home, and other unique situations.

States Have Mandatory and Optional Groups under Federal Rules

States have mandatory groups that they must offer help to. Mandatory groups include families with children who have limited incomes, SSI recipients and babies up to one year born to women that are Medicaid-eligible who remain in the home with the mother. Low-income children, children in foster or adoption care and low-income Medicare beneficiaries are also Mandatory Medicaid Groups.

Optional Eligibility groups include some SSI payment recipients, institutionalized or working disabled with relatively high incomes. The "medically needy" can sometime qualify immediately but will be required to "spend down" to qualify for Medicaid assistance. The idea behind this program is to provide additional help for recurring bills for 1-6 months to people who would otherwise not qualify for Medicaid. "Medically needy" can also refer to full time students under the age of 19. Certain pregnant women, ill infants and blind persons may also qualify under the Optional provision.