Medicaid is the nation’s largest health insurance program, covering more than 80 million Americans — more than Medicare, and more than any private insurer. It’s a joint federal-state program: the federal government sets minimum standards and provides funding, and each state designs and runs its own version. That’s why eligibility rules, covered services, and even the program name (MediCal in California, TennCare in Tennessee, Healthy Michigan Plan) vary from state to state.
Despite its size, Medicaid is widely misunderstood. Many people who qualify don’t apply because they assume they earn too much, that it’s only for children, or that they’d have to “pay it back.” This guide cuts through the confusion.
Who Qualifies for Medicaid
Medicaid has different eligibility rules for different groups. You don’t have to qualify in every category — just one.
Children
Most states cover children up to age 18 or 19 with household income at or below 133–200% of the federal poverty level (FPL). In some states, limits are higher — particularly where Medicaid and CHIP are coordinated. One application at Healthcare.gov or your state agency determines whether a child qualifies for Medicaid or CHIP.
Pregnant Women
Medicaid covers prenatal care, labor and delivery, and postpartum care for women who meet income limits — typically up to 133–200% FPL, with many states going higher. Coverage usually continues 60 days postpartum; some states have expanded to 12 months. Immigrant women who are lawfully present but haven’t completed the 5-year waiting period may still qualify for emergency Medicaid covering delivery.
Low-Income Adults (Medicaid Expansion)
Under the Affordable Care Act, states can expand Medicaid to cover most adults under 65 with incomes up to 138% FPL. As of 2025, 40 states and Washington, D.C. have adopted expansion. In those states, adults don’t need children, a disability, or any other qualifying factor — income is the main requirement. In the states that haven’t expanded, adults without dependent children often have no Medicaid pathway even at very low incomes.
People Who Receive SSI
In most states, people who receive Supplemental Security Income (SSI) are automatically enrolled in Medicaid. A small number of states have slightly different Medicaid rules than SSI, so if you receive SSI and are denied Medicaid, ask your state agency to explain the difference.
Elderly Adults Who Need Long-Term Care
Medicaid covers nursing home care and certain home-based long-term care for older adults who meet strict financial eligibility: typically $2,000 or less in countable assets for an individual. There’s also a five-year lookback period for asset transfers. Because Medicaid is the primary payer for long-term care in the U.S., many families consult an elder law attorney well before a care crisis to do legitimate planning.
What Medicaid Covers
Federal law requires all state Medicaid programs to cover certain mandatory services:
- Inpatient and outpatient hospital care
- Physician and surgeon services
- Laboratory and X-ray services
- Family planning services and supplies
- Federally qualified health center (FQHC) services
- Nursing facility care for qualifying adults 21 and over
- Home health services for those eligible for nursing facility care
- Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) for children under 21
States may also offer optional services — and most do, to varying degrees:
- Prescription drugs (covered by nearly all states)
- Dental care (often limited for adults; comprehensive adult dental is less common)
- Vision care and eyeglasses
- Physical, occupational, and speech therapy
- Mental health and substance use disorder treatment
- Durable medical equipment (wheelchairs, hearing aids)
- Non-emergency medical transportation
What Medicaid Generally Doesn’t Cover
- Cosmetic procedures — not covered in any state
- Most adult dental — many states cover only emergency dental extraction; full dental coverage for adults is offered in a minority of states
- Over-the-counter medications — unless specifically approved under the state plan
- Long-term custodial care above asset limits — standard Medicaid does not pay nursing home costs for people who don’t meet the long-term care Medicaid asset test; that’s a separate application with much stricter financial rules
Medicaid and Medicare: Dual Eligibles
People who qualify for both Medicaid and Medicare are called “dual eligibles.” There are approximately 12 million dual eligibles in the U.S. — typically low-income older adults or people with disabilities who have both worked enough to qualify for Medicare and meet Medicaid income limits.
For dual eligibles, Medicaid often fills the gaps Medicare doesn’t cover: it can pay Medicare Part B premiums, copays, and deductibles. The Medicare Extra Help program specifically helps dual eligibles with Part D drug costs. Medicaid also covers long-term care, dental, and vision that Medicare generally doesn’t.
How to Apply
- Healthcare.gov — start the application there; the system automatically screens for Medicaid eligibility and routes you to the right program
- Your state Medicaid agency — apply directly through your state’s portal or by phone or mail
- Community health centers and hospitals — many have certified application assisters who can help for free
Unlike marketplace insurance, there’s no annual enrollment window. If you qualify at any point — because your income drops, you have a child, or you lose other coverage — you can apply immediately. Retroactive coverage going back up to three months is sometimes available for those who were eligible before applying.
Educational only. Medicaid eligibility rules, income limits, and covered services vary by state and change annually. Confirm current details with your state Medicaid agency or at healthcare.gov.