Medicaid is a joint federal and state program that provides health coverage to millions of Americans, including low-income adults, children, pregnant women, elderly adults, and people with disabilities. Unlike Medicare, which is federally administered, Medicaid eligibility and benefits vary significantly from state to state. Understanding how Medicaid works in your state is essential to accessing the healthcare support you may be entitled to.
This guide breaks down Medicaid eligibility and benefits, explaining how state-by-state variations can impact your access to care.
What Is Medicaid?
Medicaid is a needs-based health insurance program established under the Social Security Act of 1965. It is funded jointly by the federal government and the states but administered by state governments, which means every state runs its own version of Medicaid with unique rules and coverage options.
The program is designed to assist:
- Low-income individuals and families
- Pregnant women
- Children and teens
- Elderly people
- People with disabilities
General Medicaid Eligibility Requirements
While each state sets its own eligibility guidelines, the federal government establishes certain mandatory groups that states must cover. Basic requirements across all states include:
- Income Level: Your income must fall below certain thresholds, often based on the Federal Poverty Level (FPL).
- Citizenship/Residency: Must be a U.S. citizen or qualified non-citizen and resident of the state you’re applying in.
- Categorical Eligibility: Must belong to a qualifying category (pregnant, child, disabled, etc.).
Federal Minimum Eligibility Standards (as of 2025):
| Group | Income Limit (% of FPL) |
|---|---|
| Children (0–18) | Up to 138% |
| Pregnant Women | 138% to 200% (varies) |
| Adults under 65 (in expanded states) | Up to 138% |
| Aged, Blind, Disabled | Income/resource tested |
Medicaid Expansion Under the ACA
The Affordable Care Act (ACA) allowed states to expand Medicaid to cover non-disabled adults without dependents earning up to 138% of the FPL. As of 2025, 40 states and Washington D.C. have adopted Medicaid expansion, while others have not.
States That Have Expanded Medicaid (examples):
- California
- New York
- Illinois
- Michigan
- Ohio
- Washington
- Oregon
States That Have Not Expanded Medicaid (examples):
- Texas
- Florida
- Mississippi
- Alabama
- Georgia
In non-expansion states, many low-income adults fall into a “coverage gap”—earning too much to qualify for Medicaid, but too little to afford private insurance or receive subsidies.
State-by-State Medicaid Variations
While Medicaid must meet federal guidelines, states have the authority to:
- Set their own income limits
- Determine benefits packages
- Impose premiums or cost-sharing
- Manage enrollment systems
Below is a sample overview of how Medicaid eligibility and benefits vary in key states.
California (Medi-Cal)
- Expansion State: Yes
- Eligibility: Adults under 65 with income up to 138% FPL
- Benefits: Comprehensive, including dental and vision
- Special Notes: Covers undocumented youth under age 26 and adults over 50
Texas
- Expansion State: No
- Eligibility: Extremely limited; parents must earn less than 17% of FPL
- Benefits: Basic coverage; limited optional benefits
- Special Notes: Adults without children usually not eligible
New York
- Expansion State: Yes
- Eligibility: Broad; includes low-income adults and special populations
- Benefits: Full scope benefits, including mental health and dental
- Special Notes: Robust mental health and substance use disorder programs
Florida
- Expansion State: No
- Eligibility: Very restricted for adults; higher thresholds for children
- Benefits: Basic, with optional services varying by plan
- Special Notes: One of the largest uninsured populations in the country
Ohio
- Expansion State: Yes
- Eligibility: Adults up to 138% FPL
- Benefits: Includes mental health, substance use treatment
- Special Notes: Uses managed care for most beneficiaries
What Does Medicaid Cover?
Mandatory Federal Benefits:
All states must provide these core services:
- Inpatient and outpatient hospital services
- Physician services
- Laboratory and X-ray services
- Home health care
- Nursing facility services
- Family planning
- Early and periodic screening, diagnostic, and treatment (EPSDT) for children
Optional Benefits (Vary by State):
- Dental and vision care
- Prescription drugs
- Physical therapy
- Chiropractic services
- Podiatry
- Speech and hearing services
Managed Care vs. Fee-for-Service
Many states now offer Medicaid through Managed Care Organizations (MCOs), which provide comprehensive services under contract. Others still use fee-for-service models, where the state reimburses providers directly.
How to Apply for Medicaid
Application Methods:
- Online: Through your state Medicaid website or HealthCare.gov
- In Person: Local Department of Human Services office
- By Phone or Mail
Documents You May Need:
- Proof of income (pay stubs, tax returns)
- Social Security number
- Proof of residency
- Immigration documentation (if applicable)
Enrollment Tip: Medicaid applications are accepted year-round, unlike marketplace health plans which have open enrollment periods.
Special Medicaid Programs by State
Many states offer unique Medicaid programs, such as:
- Home and Community-Based Services (HCBS) Waivers for long-term care outside of nursing homes.
- Medicaid Buy-In Programs for working people with disabilities.
- Dual-Eligibility Programs for people eligible for both Medicaid and Medicare.
- CHIP (Children’s Health Insurance Program): Often operates alongside Medicaid to cover children in families earning too much to qualify for regular Medicaid.
How to Check Your Eligibility
Use the tools below to check state-specific eligibility:
- Medicaid.gov State Overviews
- Healthcare.gov Eligibility Checker
- State Medicaid agency websites
Recent Changes and Future Outlook
States are constantly adjusting Medicaid rules, especially in the wake of public health emergencies and budget constraints. As of 2025:
- Several states are pursuing work requirements, though most are blocked in court.
- Telehealth expansion continues to be supported across many state Medicaid programs.
- Medicaid unwinding of pandemic-era continuous coverage has begun, meaning beneficiaries may need to reapply or verify eligibility.
Conclusion
Medicaid is a lifeline for millions of Americans, but understanding eligibility and benefits requires a clear look at your state’s specific rules and programs. Whether you’re a single adult in California or a parent in Texas, the services you qualify for—and how you apply—can vary widely.
Knowing your rights, tracking your income level, and staying updated with your state’s Medicaid agency are essential steps in ensuring you or your loved ones get the coverage you need.