Medicaid Eligibility, Waivers & Long-Term Care

Who Qualifies for Medicaid: The Basic Framework

Each state decides Medicaid eligibility rules. States follow federal guidelines, but they set their own income and asset limits. One state may cover someone who doesn't qualify in another state. This means two people with the same income might qualify for Medicaid in one place but not another.

Medicaid covers several groups of people:

• MAGI-based groups (Modified Adjusted Gross Income) — mostly working-age people and families. These are evaluated using income calculations similar to tax returns.
• Non-MAGI groups (aged, blind, disabled) — mostly seniors and people with disabilities. These groups often have more complex rules about assets and income.

Income and asset limits change from state to state and by group. The exact dollar amounts change every year and differ by state, so we don't list specific numbers here. Instead, we explain how eligibility works. We also direct you to current official figures from your state.

MAGI-Based Eligibility Pathways

Most Medicaid members are in MAGI-based groups. Eligibility is decided using a simplified income calculation. It's roughly based on federal tax returns.

Children

Medicaid covers children in low-income families. The income limits are different in each state. Many states cover children whose families earn more than the federal poverty line. See CHIP (Children's Health Insurance Program) for coverage that bridges the gap between Medicaid and private insurance.

Pregnant People and Postpartum Individuals

Pregnant people and those after delivery are eligible based on income levels set by each state. These income limits are often higher than for other adults. Coverage usually includes prenatal care, delivery, and care after delivery.

Parents and Caretakers

Parents and caretakers may qualify for Medicaid. But their income limits are usually lower than limits for children. Eligibility rules vary by state.

ACA Expansion Adults

The Affordable Care Act (ACA) lets states expand Medicaid to adults without children. As of 2024, most but not all states have chosen to expand. In states that expanded, adults without children can qualify. In states that haven't expanded, this pathway is not available. Check your state's Medicaid program to see if it expanded.

Non-MAGI Eligibility Pathways

Non-MAGI groups are mostly seniors and people with disabilities. They have more complex rules about both income and assets (resources are things you own, like money or property).

Aged, Blind, and Disabled (SSI-Related)

People age 65 and older, legally blind, or receiving disability payments often qualify for Medicaid. In many states, SSI (Supplemental Security Income) recipients automatically qualify. For Medicaid, you must meet both income limits and asset limits. Assets include bank accounts, property, and vehicles. Each state sets its own asset limits, which are often higher than income limits.

Working People with Disabilities

Some states have work incentive programs. These let people with disabilities keep Medicaid even when they earn more. The rules are different in each state.

Understanding State Variation in Medicaid Expansion

After the ACA, states made different choices about Medicaid expansion:

• Expansion states expanded Medicaid to adults without children. These adults typically earn up to about 138% of the federal poverty line.
• Non-expansion states did not expand Medicaid. They limit adult coverage to narrower groups, mostly parents and caregivers of children.

This creates coverage gaps in non-expansion states. Working-age adults with no children can't get Medicaid there. States can change this choice over time. To learn your state's current policy, visit State Medicaid Directory or Medicaid.gov.

Medicaid Eligibility Pathways at a Glance

Long-Term Care and Medicaid

Medicare covers short-term medical needs. Medicaid pays for long-term custodial care. This is help with daily activities like bathing, dressing, eating, and toileting, in a nursing facility or at home. Medicare covers only short nursing home stays. But Medicaid can cover much longer care in facilities or at home.

Institutional Medicaid: Nursing Facilities

Medicaid pays for long-term nursing facility (SNF) care when medical needs are met. To qualify, residents must spend down their assets to the Medicaid limit in their state. Once they reach that limit, Medicaid covers the full cost. Most private insurance does not.

Home and Community-Based Services (HCBS) Waivers

Many seniors and people with disabilities prefer to get services at home or in the community rather than move to a nursing facility. States offer Home and Community-Based Services (HCBS) waivers under Section 1915(c). These waivers let Medicaid pay for in-home help, adult day programs, assisted living, and other support services. They often cost less than institutional care and offer better quality of life.

HCBS waivers are optional. Each state designs its own programs with different services and eligibility rules. Some have long waiting lists. To learn about HCBS in your state, contact your state Medicaid office or visit State Medicaid Directory.

Demonstration Waivers and Program Flexibility

States can also operate Section 1115 demonstration waivers. These give states more flexibility in how to deliver Medicaid. They may include special programs for specific groups or new service delivery models. Your state's details are available from your state Medicaid office.

Asset Limits, Spend-Down, and Medicaid Eligibility for Long-Term Care

MAGI-based groups focus on income. But non-MAGI groups—especially seniors and disabled people seeking institutional care—must also meet asset limits. Assets include bank accounts, vehicles, investments, and property.

What Counts as an Asset?

Most financial resources count toward your asset limit. But some items are exempt (don't count). These typically include your primary home (up to a state set value), one vehicle, and some personal items. Your home usually doesn't count if a spouse or dependent child lives there.

The Spend-Down Process

To qualify for Medicaid long-term care, you may need to spend down (lower) your assets to the Medicaid limit. You can spend money on medical bills, burial costs, and personal expenses. The spend-down limit is different in each state.

Planning Ahead

Spend-down rules are complex and different in each state. Many families consult with an elder law attorney or financial advisor. Be careful: improper transfers or gifts of assets can cause Medicaid waiting periods ("look-back" penalties). Expert guidance is important.

Medicaid Estate Recovery

When Medicaid pays for long-term care for someone age 55 or older, the state may seek recovery (repayment) of those costs from their estate after death. This usually happens through sale of the home. But recovery may not happen if a surviving spouse, minor child, disabled child, or sibling lives in the home and helped maintain it. Rules are different in each state.

This is why estate and long-term care planning with an attorney is recommended for older adults and families.

Dual Eligible: Medicare and Medicaid Together

Some people qualify for both Medicare and Medicaid. You can be dual eligible if you are 65+, have disability payments, and low income. With both programs, you get coverage from each. Medicaid often pays for services Medicare doesn't cover, like long-term care and extended nursing home stays.

Dual eligible people have special enrollment options. You may qualify for specialized coverage models. See Dual Eligible: Medicare and Medicaid for more.

Keeping Your Coverage: Redeterminations and Renewals

Your Medicaid coverage is not permanent. States regularly check if you still qualify. A redetermination can happen because of:

• A change in income, household size, or family status
• A regular renewal period set by your state (typically annual)
• You reporting a change to your state Medicaid office

To keep coverage, report changes quickly and respond to renewal notices. Missing a deadline or not responding can cause you to lose coverage, even if you still qualify. See Enrollment & Deadlines and Life Changes & Medicaid for details on how to report changes and renew coverage.

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