Medicaid Basics: Eligibility and Coverage

Answers to frequently asked questions about Medicaid eligibility, coverage, and denials.

By , J.D. · University of Virginia School of Law
Updated by Bethany K. Laurence, Attorney · UC Law San Francisco

Medicaid is a program that provides very low-cost or free health care to some adults and children with limited incomes. It's funded by the federal government and the states. But each state manages its own Medicaid program.

Some states have given the Medicaid program a different name. For example, California's Medicaid program is called Medi-Cal, and the Medicaid program in Massachusetts is called MassHealth.

Can I Qualify for Medicaid?

Each state has its own eligibility rules for Medicaid, but some standard features exist. In any state, you must first financially qualify for the Medicaid program and then medically qualify for specific Medicaid services. (The state must deem the services "medically necessary," or the state Medicaid program won't pay for them.)

What Income Qualifies for Medicaid?

You must generally have a low income and very few assets to qualify for Medicaid. However, not everyone with a low income and few assets qualifies for the program. Eligibility for Medicaid varies, but in many states, it's based at least in part on whether:

  • you're disabled
  • you're pregnant or have certain cancers
  • you have minor children, or
  • you're over age 65.

Disability. If you have disabilities, you'll still have to meet your state's income and asset requirements. But in most states, you'll automatically qualify for Medicaid if you receive Supplemental Security Income (SSI) disability benefits.

Women. Pregnant women who meet the income and asset requirements will qualify for Medicaid. And children are automatically covered for one year after they're born to mothers receiving Medicaid. Many states provide coverage to pregnant women with higher income and assets than is typically allowed for Medicaid eligibility.

Women with breast or cervical cancer can obtain treatment through a special Medicaid program for those diseases. Many states offer this coverage to women at higher income levels, too.

Adults with children. Most states offer Medicaid to low-income adults with children, although there's no uniform income standard for that coverage. In addition, most states expanded their Medicaid programs under the federal Affordable Care Act. In states that opted into the "Medicaid expansion," adults under 65 with incomes at or below 133% of the poverty level (about $20,000 for an individual) can qualify for Medicaid, even if they don't have children and aren't pregnant or disabled.

Medically needy. About three-quarters of the states also allow those who don't fit under Medicaid's traditional income and resource guidelines but are "medically needy" to qualify for Medicaid. You're considered medically needy if your medical expenses are so high that they would reduce your income or assets to eligible levels. Learn more in our article on Medicaid's medically needy program.

Children with higher income. Children in households with incomes too high to qualify for Medicaid but not high enough to afford private insurance might be covered by their state's Children's Health Insurance Program (CHIP). Each state has its own rules about who can qualify for CHIP, with most states' eligibility guidelines falling between 200% and 400% of the federal poverty level. In 2024, that's around $62,000 to $125,000 per year for a family of four—more if you live in Alaska or Hawaii.

What Is Medically Necessary for Medicaid?

Medicaid recipients must show that the particular service they want Medicaid to pay for is medically necessary. The medical necessity requirement is intended to prevent Medicaid from paying for elective treatments and procedures. Many states give the opinion of the treating physician a good deal of weight in deciding whether to approve a service.

There's no federal definition of medical necessity; each state has defined the term for its Medicaid program. For example, Florida limits patients to the least expensive treatment that's effective.

Other common restrictions that are part of many states' definitions of medical necessity include:

  • bans on experimental treatments
  • requirements that treatments provide a significant benefit to the patient, and
  • bans on treatments used primarily for the patient's or doctor's convenience.

Other states define medical necessity more broadly. For example, California's Medi-Cal program defines a treatment as medically necessary when it's reasonable and necessary to do the following:

  • prevent significant illness or disability
  • relieve severe pain, or
  • save someone's life.

Regardless of the state where you live, if your doctor doesn't think the treatment is medically necessary, Medicaid isn't likely to agree to pay for it.

Do I Have to Be a Citizen to Get Medicaid?

You must be a U.S. citizen or a lawful permanent resident to receive Medicaid. And you'll need to show proof of your citizenship or immigration status and your identity to qualify.

But there's an exception to the citizenship requirement for people with emergency medical conditions, including pregnant women in labor. Specific coverage can vary from state to state, as each state can define "emergency medical conditions" as it chooses.

Some states offer more Medicaid coverage to non-citizens than other states. For example, some states, like California, offer coverage of prenatal expenses (non-emergency care for pregnant women) regardless of citizenship or immigration status, through the Medi-Cal Access Program.

What Services Does Medicaid Pay For?

Each state can determine what services its Medicaid program will pay for, but some services must be covered under federal law. Mandatory covered services include the following:

  • inpatient and outpatient hospital bills
  • prescriptions
  • lab fees
  • long-term care services
  • transportation to and from medical care, and
  • vision and dental care for children.

In addition to the mandatory covered services, some states have chosen to provide Medicaid coverage for things like:

  • glasses
  • hearing aids
  • physical therapy
  • mental health services, and
  • hospice care.

Even though Medicaid might cover these services, Medicaid recipients sometimes have trouble getting certain services because no providers in their area accept Medicaid. For example, in many rural areas, there are no dentists who accept Medicaid, so children receiving Medicaid might not have access to dental care.

How Are Medicaid Services Provided?

Today, many Medicaid recipients get their services from managed care organizations, which are private companies that states have hired to deliver medical services according to Medicaid guidelines. Other Medicaid recipients still get "fee-for-service" Medicaid—meaning that the state pays the Medicaid recipient's health care provider directly.

No matter your state, Medicaid is supposed to provide affordable health care for those with low incomes. So, medical services provided through Medicaid have an extremely low cost or sometimes are free.

How to Apply for Medicaid

You can apply for Medicaid through the health insurance marketplace in your state (or or by contacting your state's Medicaid agency directly. Find the website and contact information for your state's Medicaid agency using the map at

What If Your Application for Medicaid Is Denied?

You have a right to appeal if your Medicaid application is denied for any reason. The deadlines and procedures for appealing should be described in your written denial notice from your state's Medicaid office. For more information, see Nolo's article on appealing a Medicaid denial.

Many legal aid offices provide free legal assistance for applicants denied Medicaid. Contact information for your local legal aid office can be found at the Legal Services Corporation's website.

Updated March 22, 2024

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