What Do I Need To Get Medicaid Coverage?

To get Medicaid coverage, you will need to share documents showing your Social Security number (SSN), proof of citizenship, the amount you spend on housing and more. Medicaid is a government-sponsored health insurance program that offers cheap or free coverage to needy populations, including low-income people, pregnant women, people with disabilities and senior citizens.

Keep reading to learn more about how Medicaid works, including what health care benefits it covers and how you can qualify.

Key Takeaways Medicaid is a program funded jointly by the federal government and state governments to provide low-cost or no-cost health care coverage for people who are poor, pregnant, elderly or disabled. Since Medicaid is operated by individual state governments, coverages and eligibility standards can vary from state to state. Children in lower-income families who aren’t eligible for Medicaid may instead qualify for coverage through CHIP. CHIP and Medicaid enrollment are open year-round. When applying for Medicaid, you may need to share information like your name and age, SSN, citizenship or immigration status, income, housing information and insurance information.

What Is Medicaid?

Medicaid is a government-funded program that covers medical care and related expenses at little to no cost, primarily for low-income individuals and other vulnerable populations. It is a partnership between the federal government and state governments, with each state running its own Medicaid program while adhering to federal guidelines. As a result, eligibility requirements and covered services may vary by state.^[1]

Similarly, funding for Medicaid is split between the federal government and each state government. In general, the federal government covers between 50% and 83% of the costs to operate Medicaid in any given state, depending on the state’s income per capita. The exact percentage of Medicaid spending covered for each state — known as the Federal Medical Assistance Percentage (FMAP) — is updated every year.^[2]

Medicaid is the largest medical insurance provider in the United States, insuring nearly 80 million people in conjunction with the Children’s Health Insurance Program (CHIP).^[3]

When Was Medicaid Introduced?

Although the idea of a national health insurance plan had been floated by President Harry Truman as early as the 1940s, Medicaid was not formally established until President Lyndon B. Johnson signed the Social Security Amendments of 1965 into law on July 30, 1965. This legislation also led to the creation of Medicare.^[4]

How Does Medicaid Work?

If you are eligible for both Medicaid and another type of health plan, Medicaid is required to be the payer of last resort.^[5] For example, if you are on both Medicare and Medicaid and you receive a health care service that is covered by both programs, your Medicare coverage will likely pay for the service. However, your Medicaid coverage may step in if you receive a service that isn’t covered by the Medicare program.

While Medicaid may directly pay for your medical care, many state Medicaid programs partner with private insurance companies to manage and pay out claims. In addition, if you are eligible for Medicaid but haven’t yet enrolled, the program may reimburse you for treatments you received up to three months prior to enrolling.^[1]

One of the major benefits of Medicaid is that it offers year-round enrollment, meaning you can sign up at any time as long as you are eligible. This distinguishes Medicaid from private Health Insurance Marketplace coverage, which you can only purchase during the open enrollment period — which lasts from Nov. 1 to Jan. 15 each year in most states.^[6]

Who Qualifies for Medicaid?

Medicaid eligibility requirements differ from state to state, but coverage is generally available to low-income children and parents, pregnant women, seniors, people who receive Supplemental Security Income (SSI) and disabled individuals.^[3] Throughout most of the country, adults can qualify for Medicaid if their income is less than or equal to 138% of the federal poverty level (FPL).^[7]

For households in the majority of states, 138% of the FPL comes out to $21,597 per year for the first family member plus an additional $7,590 for each subsequent member. For example, if your household consists of two parents and three children, then you will likely be eligible for Medicaid with an annual household income below $51,957.^[8]

Depending on your state, you may be able to qualify for Medicaid at a higher income level if you are considered medically needy. However, you will still need to cover your own medical costs out of pocket until you have spent enough to exceed the “spend-down” amount your state requires for medically needy Medicaid applicants. Regardless of how you qualify, you must generally be a U.S. citizen or permanent resident and live in the state where you receive Medicaid coverage to access your benefits.^[3]

Changes to Medicaid can happen quickly — both at the state and federal levels — so keep yourself informed of all recent eligibility updates, especially those pertaining to work requirements.

CHIP

The Children’s Health Insurance Program (CHIP) primarily provides cheap or free health coverage for children ages 18 and under whose families have a relatively low household income but aren’t eligible for Medicaid. Depending on the state, children may be able to qualify for CHIP with a household income that is anywhere from 170% to 400% of the FPL.^[9]

CHIP coverage may also extend to pregnant women who otherwise lack access to affordable health insurance. In some states, low-income women may qualify for prenatal and pregnancy-related care coverage through CHIP even if they do not meet the typical citizenship or immigration requirements.^[9] Like Medicaid, CHIP enrollment is open for eligible individuals throughout the entire year.^[6]

What Does Medicaid Cover?

States have some leeway in deciding what health care services their Medicaid plans will cover. However, federal law requires Medicaid to cover the following benefits in every state:^[10]

Transportation to medical care	Inpatient hospital services and outpatient hospital services
Rural health clinic services	Federally qualified health center services
Lab and X-ray services	Nursing facility services
Early and periodic screening, diagnostic and treatment (EPSDT) services	Family planning services
Tobacco cessation counseling for pregnant women	Physician services
Home health services	Nurse midwife services
Certified pediatric and family nurse practitioner services	Freestanding birth center services (if licensed or otherwise recognized by the state)
Medication-assisted treatment for substance use disorders	Routine costs of items and services needed by Medicaid patients in qualifying clinical trials

Additionally, Medicaid plans in every state include prescription drug coverage, even though it is not officially a mandatory benefit.^[11] Meanwhile, the following services are optional benefits, meaning each state can choose whether to cover them:^[10]

Other licensed practitioner services	Private duty nursing services
Clinic services	Dental services
Physical therapy	Occupational therapy
Speech, hearing and language disorder services	Dentures
Prosthetics	Eyeglasses
Other diagnostic, screening, preventive and rehabilitative services	Services for seniors in institutions for mental diseases
Services for people with intellectual disabilities in intermediate care facilities	Inpatient psychiatric services for people under the age of 21
Hospice care	Case management (including primary care case management)
Tuberculosis-related services	Respiratory care for ventilator-dependent individuals
Personal care services	Primary and secondary medical strategies, treatment and services for individuals with sickle cell disease
Certified community behavioral health services	Home and community-based services (HCBS)
Self-directed personal assistance services	Community First Choice attendant services
Medical assistance for eligible individuals in eligible institutions for mental diseases	Alternative benefits specifically tailored to the needs of a given state
Health home care for Medicaid enrollees with chronic conditions	Religious nonmedical health care institution services
Emergency services at a hospital that isn’t approved by Medicare	Critical access hospital services

What Isn't Covered?

Medicaid commonly excludes coverage for services like the following:^[12]

Cosmetic surgery	Nonprescription drugs and health supplements
Experimental treatments	Elective abortions
Personal comfort benefits (e.g., private hospital rooms)	Disability-related home modifications (e.g., wheelchair ramps)
Herbal and homeopathic therapies

In addition, Medicaid typically doesn’t cover care you receive outside of the country, and it may also limit coverage for treatments you receive in a different state. For example, North Carolina’s Medicaid program generally excludes coverage for out-of-state services unless Medicaid beneficiaries receive them within 40 miles of the North Carolina border in Georgia, South Carolina, Tennessee or Virginia.^[13]

Does Medicaid Cover Home and Community-Based Services (HCBS)?

HCBS coverage is an optional Medicaid benefit, but every state Medicaid program offers some degree of coverage for home health care.[10][14] Examples of HCBS care include the following:[15]

Skilled nursing care	Occupational, physical and speech therapy
Dietary management conducted by a registered dietitian	Pharmacy services
Durable medical equipment	Case management
Personal care	Caregiver and client training
Health promotion and disease prevention	Hospice care
Senior center and adult daycare services	Congregate meal programs
Home-delivered meal programs	Assistance with dressing, bathing, toileting, eating or transferring
Transportation and access	Home repairs and modifications
Home safety assessments	Homemaker and chore services
Information and referral services	Financial services
Legal services	Telephone reassurance

How To Apply for Medicaid

You can apply for Medicaid online through your state’s Medicaid agency or the federal Marketplace website at HealthCare.gov. Be prepared to share the following information when you apply:^[16]

• Name and date of birth
• SSN
• What you spend monthly on rent, mortgage payments or utilities
• Proof of citizenship or immigration status
• Proof of income
• What other government benefits you receive
• Whether you already have a health plan or are eligible for group health insurance through your employer