Can I get Medicaid? Who qualifies in your state, and how it differs from Medicare

What is Medicaid, and what does it pay for?

Medicaid pays doctors, clinics and hospitals for the care of the people it covers; it does not send you money. Each state runs its own program under federal rules and can give it its own name. States must provide the mandatory benefits under federal law and may add optional ones. Medicaid.gov: Mandatory & optional Medicaid benefits

Most people in Medicaid pay little or nothing. Today states may charge small premiums and cost sharing to some enrollees, and total out-of-pocket costs for a family cannot exceed 5 percent of its income. CMCS Informational Bulletin, November 18, 2025

Who qualifies for Medicaid

You qualify if you fit a group your state covers, your income is under that group's line, you live in the state, and you are a U.S. citizen or have an eligible immigration status. HealthCare.gov: Getting Medicaid & CHIP

• Adults 19 to 64 (the expansion group). In an expansion state, adults 19 to 64 who are not pregnant and not on Medicare qualify with household income at or below 133 percent of the poverty line for their family size. A 5-point disregard makes the working line 138%.42 C.F.R. §§ 435.119(b), 435.603(d)(4)
• Children. Every state covers children through 18 at least up to 133 percent of the poverty line, and many go much higher, often with CHIP for children above the Medicaid line.42 C.F.R. § 435.118(c)
• Pregnant women. Every state covers pregnant women at least up to 133 percent of the poverty line; most states go higher.42 C.F.R. § 435.116
• Parents and caretaker relatives. Covered up to the state's own line, which is very low in most states that have not expanded (12% of the poverty line in Texas).CMS state levels
• 65 or older, blind or disabled. These groups are generally judged by the SSI program's income rules rather than MAGI, and they can face an asset test. For those income rules, see SSI.Medicaid.gov: Eligibility policy
• Medically needy (some states). Some states let people whose income is too high spend down: medical bills they owe count until their income is under the state's medically needy standard.Medicaid.gov: Eligibility policy

Medicaid income limits for 2026: 138% of the poverty line

The expansion line is 133 percent of the poverty line, plus a disregard of 5 percentage points, so the working line is 138%. Here it is in dollars from HHS's 2026 poverty guidelines, published in the Federal Register on January 15, 2026: the 2026 guideline is $15,960 a year for one person in the 48 states and DC, plus $5,680 for each additional person; Alaska $19,950 plus $7,100; Hawaii $18,360 plus $6,530. HHS ASPE 2026 poverty guidelines · 42 C.F.R. § 435.603(d)(4)

The monthly figures are HHS's own 138% chart for 2026. States move to the new guidelines on their own schedule, and many count monthly income against these lines.

How income is counted (MAGI). For children, pregnant women, parents and adults under 65, states count modified adjusted gross income, the tax-return income figure, for the household you are in for taxes. The MAGI method does not allow an asset or resource test, so savings and a car do not count for these groups. Medicaid.gov: Eligibility policy · 42 C.F.R. § 435.603

The coverage gap. In a state that has not expanded, an adult under 100% of the poverty line who is not a parent, pregnant, disabled or 65 can fall into a gap: too poor for help with a Marketplace plan and not covered by Medicaid. HealthCare.gov still says to apply. HealthCare.gov: Medicaid expansion & what it means for you

Medicaid by state: who has expanded, and each state's lines

Each state's levels as a percentage of the poverty line, from CMS's table of state decisions as of December 1, 2023 (the latest that CMS publishes). CMS lists them before the 5-point disregard: 133% for adults is 138% in practice. ($) means the state sets dollar amounts by household size and CMS converted them. District of Columbia covers adults up to 210%; Minnesota and New York cover adults from 133% up to 200% through a Basic Health Program.

Medicare vs Medicaid: what is the difference?

Sources: Medicare.gov: Get started with Medicare; Medicare costs · CMS fact sheet, November 14, 2025 · 42 C.F.R. § 406.12(d)(1) · SSA: Medicare · HealthCare.gov

Both Medicare and Medicaid: dual eligibility and the Medicare Savings Programs

If you have Medicare and a low income, your state's Medicaid program can pay your Medicare costs through one of the 4 Medicare Savings Programs, and full Medicaid can add services Medicare does not cover. The largest is the Qualified Medicare Beneficiary (QMB) program: it pays Part A premiums (if you do not have premium-free Part A), Part B premiums, deductibles, coinsurance and copayments. Medicare.gov: Medicare Savings Programs

• Income limits are slightly higher in Alaska and Hawaii, and states may count less income or fewer resources, so apply even if you are a little over.
• With QMB, Medicare providers are not allowed to bill you for services and items Medicare covers. You also get Extra Help with drugs and pay no more than $12.65 in 2026 for each covered drug.
• Apply through your state Medicaid agency.

How to apply for Medicaid

1. 1Apply any time of year. Fill out an application through the Marketplace at HealthCare.gov (1-800-318-2596, TTY 1-855-889-4325), which sends it to your state agency, or apply directly with your state Medicaid agency. Apply even if your state has not expanded Medicaid.
2. 2List your tax household. Medicaid counts income for your tax household: you and the people you expect to claim as tax dependents, and a spouse you live with. 42 C.F.R. § 435.603(f)
3. 3Gather proof. Identity and citizenship or immigration papers, Social Security numbers, recent pay stubs or your last tax return, and any other income. The checklist below ticks them off.
4. 4Wait for the decision. The state must decide within 45 days, or 90 days if you apply on the basis of disability. 42 C.F.R. § 435.912(c)(3)
5. 5Coverage can reach back. Today Medicaid can be made effective up to the third month before the month you apply, for care you got while eligible. For applications made on or after January 1, 2027, it reaches back one month for the expansion group and two months for everyone else. 42 C.F.R. § 435.915(a) · Public Law 119-21 § 71112

What changes in 2027: the work requirement and 6-month renewals

Public Law 119-21, signed on July 4, 2025 (CMS calls it the Working Families Tax Cut legislation), changes Medicaid for the expansion group. The dates below are from CMS's own guidance.

• Work requirement from January 1, 2027. States must require adults 19 to 64 in the expansion group to show community engagement for a month: a combined minimum of 80 hours of work, community service or a work program, or enrollment in school at least half-time, among other ways. New applicants show 1 to 3 months before they apply; enrollees show it between renewals.Public Law 119-21 § 71119 · CMCS bulletin
• Who is excluded. Among others: parents and caretakers of a child under 14 or of a disabled person, pregnant and postpartum women, people who are medically frail (blind or disabled, with a substance use disorder, a disabling mental disorder, a disability that limits daily activities, or a serious or complex medical condition), veterans with a total disability rating, former foster youth, and people meeting SNAP or TANF work rules.Public Law 119-21 § 71119
• 30 days to fix it. If the state cannot confirm compliance from its own data, it must send a notice and give you 30 calendar days to show compliance or that the rule does not apply, and check every other way you might qualify.42 C.F.R. § 435.912(e)(3) · CMCS bulletin
• Renewals every 6 months. For most adults in the expansion group, states must redetermine eligibility once every 6 months for renewals scheduled on or after January 1, 2027. Everyone else renews every 12 months.Public Law 119-21 § 71107 · SMD 26-001 · 42 C.F.R. § 435.916(a)
• Copays from October 1, 2028. Expansion adults with income above 100% of the poverty line will owe cost sharing on some care, up to $35 for any service; primary care, behavioral health and community health center services are exempt, and the 5 percent family cap stays.Public Law 119-21 § 71120

Denied or cut off? Ask for a fair hearing

• Up to 90 days to ask. Your state must give you a reasonable time, not more than 90 days from the date the notice was mailed, to request a fair hearing. Your notice states the exact deadline.42 C.F.R. § 431.221(d)
• Keep coverage while you appeal. If you ask for a hearing before the date the state's action takes effect, the state may not end or reduce your services until the hearing decision, with narrow exceptions. If the state wins, it can try to recover what was paid.42 C.F.R. § 431.230

Free help: legal aid and bar referral services. If your Medicaid depends on a disability finding by Social Security, see how to appeal a disability denial.

Nursing homes, long-term care and estate recovery

Medicaid is the main payer for long-term care, but nursing-home and home-care Medicaid use the rules for people 65 or older or disabled, with asset limits and a look-back at gifts; this page does not cover them. One rule to know before you plan: for people 55 or older, states must seek recovery from the estate for nursing facility services, home and community-based services and related hospital and drug costs, and may not recover while a spouse, a child under 21, or a blind or disabled child survives. Medicaid.gov: Estate recovery

Planning a home or an estate: see transfer on death deeds, living trusts and probate.

Getting help

Legal aid offices help with Medicaid denials, terminations and fair hearings, usually at no cost if your income is low.

Common questions

Official sources

1. CMS / Medicaid.gov: Medicaid, CHIP and BHP eligibility levels by state (state decisions as of December 1, 2023; adults 133%, notes 4, 5, 7, 9, 11; 5% FPL disregard) medicaid.gov
2. HHS ASPE: 2026 poverty guidelines ($15,960 + $5,680; Alaska $19,950 + $7,100; Hawaii $18,360 + $6,530) aspe.hhs.gov
3. HHS ASPE: detailed 2026 poverty guidelines with percentages, dollars per year and per month (the 138% column) aspe.hhs.gov
4. Federal Register, January 15, 2026 (2026-00755): Annual update of the HHS poverty guidelines (PDF) govinfo.gov
5. 42 C.F.R. § 435.119: adults 19 to 64 at or below 133 percent FPL ecfr.gov
6. 42 C.F.R. § 435.603: MAGI-based income; (d)(4) the 5-percentage-point disregard ecfr.gov
7. 42 C.F.R. § 435.118: infants and children under 19 (minimum 133 percent FPL) ecfr.gov
8. 42 C.F.R. § 435.116: pregnant women (minimum 133 percent FPL) ecfr.gov
9. 42 C.F.R. § 435.912: timely decisions (45 days; 90 days on the basis of disability; 30-day community engagement notice) ecfr.gov
10. 42 C.F.R. § 435.915: effective date (up to the third month before the application) ecfr.gov
11. 42 C.F.R. § 435.916: renewals once every 12 months ecfr.gov
12. 42 C.F.R. § 431.221: request for a fair hearing (up to 90 days from the notice) ecfr.gov
13. 42 C.F.R. § 431.230: services continue when the hearing is requested before the date of action ecfr.gov
14. 42 C.F.R. § 406.12: Medicare Part A for disability beneficiaries begins with the 25th month ecfr.gov
15. CMCS Informational Bulletin, November 18, 2025: Medicaid and CHIP provisions of Public Law 119-21 (§§ 71107, 71109, 71112, 71119, 71120; cost-sharing cap 5 percent) medicaid.gov
16. CMS State Medicaid Director Letter SMD 26-001 (March 6, 2026): 6-month eligibility redeterminations for the adult group from January 1, 2027 medicaid.gov
17. Medicaid.gov: Community engagement (section 71119), beginning January 1, 2027 medicaid.gov
18. Medicaid.gov: Mandatory & optional Medicaid benefits medicaid.gov
19. Medicaid.gov: Eligibility policy (MAGI, no asset test; SSI methods for 65+, blind, disabled; medically needy; retroactive coverage) medicaid.gov
20. Medicaid.gov: Estate recovery (age 55 or older; no recovery while a spouse, a child under 21 or a blind or disabled child survives) medicaid.gov
21. Medicaid.gov: Contact us (questions go to your state Medicaid agency) medicaid.gov
22. HealthCare.gov: Getting Medicaid & CHIP (apply any time of year; work requirement warning from January 1, 2027) healthcare.gov
23. HealthCare.gov: Medicaid expansion & what it means for you (133%, effectively 138%; the coverage gap) healthcare.gov
24. HealthCare.gov: Contact us (1-800-318-2596, TTY 1-855-889-4325) healthcare.gov
25. Medicare.gov: Get started with Medicare (65 or older; disability, ESRD, ALS) medicare.gov
26. Medicare.gov: Medicare costs (Part A $311 or $565; Part B deductible $283) medicare.gov
27. CMS fact sheet, November 14, 2025: 2026 Medicare Parts A & B premiums and deductibles (Part B $202.90) cms.gov
28. Medicare.gov: Medicare Savings Programs (QMB 2026: $1,350 / $1,824 a month; $9,950 / $14,910; $12.65 per drug) medicare.gov
29. Social Security: Medicare (sign up for Part A and Part B through Social Security; 3 enrollment periods) ssa.gov

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