Medicaid Eligibility, Waivers & Long-Term Care

Who Qualifies for Medicaid: The Basic Framework

Each state sets its own income and asset limits. Someone who qualifies in one state may not in another, even with the same income.

Medicaid covers several groups of people:

• MAGI-based groups — working-age people and families, evaluated by income like tax returns.
• Non-MAGI groups — seniors and people with disabilities, with more complex asset and income rules.

Income and asset limits vary by state and change yearly. We explain how eligibility works and point you to current limits from your state.

MAGI-Based Eligibility Pathways

Most Medicaid members are in MAGI-based groups. For these groups, states use one simple income test. It's roughly based on what your tax return shows.

Children

Medicaid covers children in low-income families. Income limits vary by state. See CHIP for coverage between Medicaid and private insurance.

Pregnant People and Postpartum Individuals

Pregnant people and those after delivery are eligible based on state income limits. Coverage includes prenatal care and postpartum support.

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 lets states expand Medicaid to adults without children. Most states have expanded, but not all. Check your state's program to see if it expanded.

New for this group: a federal work rule. Many expansion adults must soon show 80 hours a month of work or other activities. Many people are exempt. See Medicaid work requirements for who must comply and who is exempt.

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 65+, legally blind, or disabled often qualify. You must meet both income and asset limits. Assets include bank accounts, property, and vehicles.

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, each state chose its own path:

• 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 medical care, but not long-term custodial care — ongoing help with daily activities like bathing and dressing. Medicaid is the main program that pays for that kind of care, in facilities or at home. What Medicaid covers at home varies by state and eligibility, and it generally does not pay room and board in assisted living.

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

States offer Home and Community-Based Services (HCBS) waivers. These let Medicaid pay for in-home help, day programs, and assisted living. They often cost less than nursing homes.

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 run Section 1115 waivers. These let a state test new ways to run Medicaid. Some create special programs for certain groups. Ask your state Medicaid office what your state does.

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. Full guide: Medicaid Spend-Down and Look-Back Rules for Long-Term Care.

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. Full guide: Medicaid estate recovery — can Medicaid take my house?

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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