Understanding how to qualify for Medicaid is essential as healthcare is a vital need that no one should be deprived of. Many Americans continue to grapple with limited insurance access and the prohibitive cost of care. The Medicaid program and the Children’s Health Insurance Program (CHIP) provide free or low-cost healthcare coverage to low-income individuals and their families.
To qualify for these programs, you’ll need to meet certain eligibility requirements, some of which vary by state. This guide will show you how to qualify for Medicaid and CHIP and give tips for those who don’t meet the eligibility requirements.
How Do I Qualify for Medicaid?
Before we take you step-by-step through how to qualify for Medicaid, let’s cover some of the basic details about the program:
Medicaid is a federal program administered locally by each U.S. state. The program was launched in 1965, then expanded with the Affordable Care Act (ACA).
Medicaid provides free or low-cost health coverage to children or adults living below the federal poverty level (FPL).
What Does Medicaid Cover?
Medicaid recipients are eligible for a range of medical services. While states offer different levels of coverage, the federal government requires all Medicaid recipients to receive the following:
- Regular check-ups and office visits
- Hospital visits
- In-patient care
- Out-patient care
- Laboratory and X-ray services
- Dental care
- Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
- Nurse and midwife services
- Long-term care
- Transportation costs
- Certified Pediatric and Family Nurse Practitioner services
- Services provided at Federally Qualified Health Centers (FQHCs)
- Assistance for pregnant women to help them stop smoking
Additionally, Medicaid provides optional (or as-needed) coverage for the following:
- Vision screenings/care
- Prescription drugs
- Physical or occupational therapy
- Speech, hearing, and language disorder treatment
- Chiropractor services
- Prosthetics
- Hospice care
Medicaid recipients may also have access to a wide range of medical specialties such as respiratory care, podiatry, and more. To see the full range, check the Medicaid benefits page.
With the main details out of the way, let’s now cover how to qualify for Medicaid, starting with the eligibility requirements for both adults and children:
How to Qualify for Medicaid: Eligibility Requirements for Adults
Medicaid is generally available to the following:
- People who are pregnant.
- Adults over the age of 65.
- Those with disabilities.
- Children.
- Adults with low income.
The federal poverty level varies according to family size. As of 2023, the FPL for individuals is $14,580[1]. To determine your family’s FPL, you can simply add $5,140 for each additional family member. Thus, the FPL range is as follows:
| For families of 2 | $19,720 |
| For families of 3 | $24,860 |
| For families of 4 | $30,000 |
| For families of 5 | $35,140 |
| For families larger than 5 | add $5,140 for each additional family member |
How to Qualify for Medicaid: Eligibility Requirements for Children
Under the affordable care act, children may qualify for Medicaid as long as the household income falls below 138% of the federal poverty level[2].
However, individual states can set their own income limits to determine eligibility. A number of states use a Modified Adjusted Gross Income (MAGI) limit, which went into effect on July 1, 2022.
States use the household MAGI and the child’s age to determine eligibility for Medicaid, CHIP, and other basic health programs. To determine your exact eligibility, search for your state on the chart provided on the Medicaid website and cross-reference your state against your child’s age.
For example, in Arizona, children under the age of 1 are eligible for Medicaid if the MAGI falls below 147% of the FPL, though the MAGI level falls to 141% for children between the ages of 6 and 18.
Expanded Eligibility by State
The above eligibility requirements apply to all states, though some states offer expanded coverage to all residents below a certain income level.
This means that if you live in one of these states and your household income is below 133% of the FPL, you qualify for Medicaid. To determine your exact eligibility requirements and costs, use the Medicaid website.
To date, 40 of the 50 U.S. states have adopted expanded Medicaid eligibility requirements. The only states that have not done so are:
- Alabama
- Florida
- Georgia
- Kansas
- Mississippi
- South Carolina
- Tennessee
- Texas
- Wisconsin
- Wyoming
The expansion in South Dakota takes effect on July 1, 2023, while North Carolina won’t officially administer the expansion until January 2024.
How to Apply for Medicaid
If you believe that you are eligible for Medicaid, you can apply in one of two ways:
- Use the Medicaid website to apply directly with your state.
- Visit HealthCare.gov to complete the application.
If you choose the latter option, you’ll be asked if you’d like assistance in paying for coverage. Simply reply yes. Your application will be reviewed and then forwarded to your state Medicaid office, which will make the final decision based on the above criteria.
How Do I Qualify for CHIP?
As the name implies, the Children’s Health Insurance Program (CHIP) is a federal program aimed at providing health coverage to children from low-income households.
Like Medicaid, CHIP is a federal program administered by the state. States are able to use federal funds to enhance Medicaid coverage, create a separate program, or use some combination of the two.
What Does CHIP Cover?
CHIP is intended to be an expansion of Medicaid benefits aimed specifically at children. As such, the program has extended benefits that cover basic children’s needs, including:
- Well-baby and well-child visits
- Dental benefits
- Assistance with behavioral health and substance use disorders
- Vaccines
Some states offer additional benefits. Check with your state to determine what additional benefits you may have access to.
How to Qualify for CHIP: Eligibility Requirements
The financial eligibility requirements for CHIP mirror those of Medicaid (see above), though the program also has additional requirements that relate directly to the children.
To be eligible for CHIP, the child must be:
- 18 years of age or younger.
- Uninsured through other health policies/programs.
- A U.S. citizen or an eligible non-citizen.
- A resident of the state they apply in.
- Eligible within the state’s income range.
You can view your state’s income range on the Medicaid website.
However, certain children are not eligible for CHIP coverage. These include:
- Children of inmates of a public institution.
- Children whose parents are institutionalized for mental disease.
- Children who are eligible under a State health benefits plan.
Otherwise, CHIP eligibility extends to all those who meet the income requirements listed above.
Can Pregnant Women Receive CHIP?
Expectant mothers are eligible for Medicaid and/or CHIP benefits, which cover prenatal care, delivery, and postpartum care.
States must cover children under age 19 under Medicaid or CHIP, and they must cover pregnant women up to at least 185% of the federal poverty level.
Once a child is born to a woman in CHIP, the child is automatically enrolled in either Medicaid or CHIP with no need for another application. They will continue to receive CHIP benefits until their first birthday, after which they may be enrolled through the application process.
What CHIP Costs
While CHIP is designed to provide affordable healthcare for children of low-income families, it is not necessarily free. The costs can vary by state. You can view state requirements and more at InsureKidsNow.gov. Some states charge copays for medical visits, while others charge a small premium for using the program.
However, the program is designed to drastically reduce healthcare costs, which means that no family will pay more than 5% of their income toward healthcare.
How to Apply for CHIP
You can apply for CHIP in two ways:
- By phone at 1-800-318-2596 (TTY: 1-855-889-4325)
- By web through the household marketplace
You can apply through the marketplace, administered by the Department of Health and Human Services, by creating an account or logging in using your current account. If you qualify for Medicaid, you may already have an account that you can use to complete an application for CHIP.
How to Qualify for Medicaid or CHIP: Finding a Provider
Although these are federal programs, each state administers Medicaid and CHIP slightly differently. For that reason, each state will maintain records of medical providers who accept these programs, which can have significance when you’re looking up information on how to qualify for Medicaid or CHIP.
If you want to find a provider in your area, contact your state Medicaid agency or the provider of your health plan.
MedlinePlus — which is also run by the Department of Health and Human Services — maintains an online directory that you can use to find providers and facilities that may accept Medicaid and/or CHIP.
Alternatives to Medicaid or CHIP
Not everyone will qualify for Medicaid or CHIP. That’s especially true if you live in one of the states that do not offer expanded eligibility requirements based on household income. If this sounds familiar, you have other options to consider.
Affordable Care Act (ACA) Subsidized Plans
This can be a great option for those who formerly qualified for Medicaid but no longer do. It allows you to receive health insurance directly through the ACA marketplace.
Once you are disqualified, a special enrollment period (SEP) opens up, which is a two-month (or 60-day) period in which you can enroll in a health insurance plan. If you miss this window, you can still receive a plan, though you’ll need to wait until open enrollment.
Discounts Through the Affordable Care Act
Everyone knows health insurance is expensive. There are ways you can reduce the premiums to more affordable rates. You may be eligible for a subsidy for ACA coverage, depending on your income level. This also varies by state, but you can select your state when you apply through the HealthCare.gov website.
Depending on your income level, you may be eligible for up to 100% off your insurance premiums. You may not qualify for full coverage, but you may still qualify for a subsidy that can make a marketplace plan significantly more affordable.
Short-Term Health Coverage Post-Medicaid
What if you lose Medicaid coverage? You can replace it with a short-term health insurance option. These plans can be purchased from most major health insurance providers and are designed to be a stopgap between your previous coverage and a more permanent plan.
Just be cautious — some short-term plans have restrictions on certain chronic conditions such as diabetes or asthma. Make sure to ask about out-of-pocket costs prior to signing up.
Bill Negotiation
If all else fails, you can always try to negotiate a lower doctor bill. For example, if you received medical treatment that your insurance won’t cover — or if you’re uninsured for any reason — you may be able to contact the medical provider and work out a payment plan or even a discount.
Medical offices would rather receive some money than no money, and they may be willing to work out a plan. Also, if you’re able to pay a large portion in cash, the provider may knock off even more from the bill.
How to Qualify for Medicaid and Get the Care You Deserve
With the high price of health care, knowing how to qualify for Medicaid and CHIP is an essential skill for those with limited incomes. Tapping into these programs can make it easier for you and your family to receive the care you need while you work toward greater financial stability.
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