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Guidelines for Medicaid

Medicaid is a medical assistance program administered jointly by state and federal governments. It has been in existence since 1965. Each state has an agency that is responsible for regulating, administering and approving applications for Medicaid; these programs may differ slightly from state to state. Although state agencies are responsible for Medicaid, the federal government sets minimum guidelines to which all states must adhere.

  1. Mandatory Eligibility Guidelines

    • Under federal law, states must provide Medicaid coverage to individuals who are receiving federally assisted income maintenance payments. As of 2010, examples of these "mandatory eligibility" groups include recipients of Supplemental Security Income (SSI), limited income families who have children and meet state requirements, recipients of adoption assistance or foster care, and certain individuals who are receiving Medicare. In addition, Medicaid covers infants born to a Medicaid-eligible mother for the first year of their lives. Medicaid also covers children under the age of six, and pregnant women with a family income at or below 133 percent of the federal poverty level.

    Optional Eligibility Guidelines

    • Federal law also gives states the option to provide Medicaid benefits for "categorically needy" groups. States will receive federal matching funds for approved groups, including targeted low-income children, institutionalized individuals with limited resources and income, and recipients of state supplementary payments. Individuals who are elderly, disabled or blind may also qualify, provided their income is below the federal poverty level. Children under the age of 21 who meet the resources and income guidelines of the Aid to Families with Dependent Children program can also qualify for Medicaid, as of 2010. Finally, uninsured low-income women who have had screening and diagnosis through a Breast Cancer and Cervical Cancer Early Detection Program will qualify if they need treatment for cervical or breast cancer.

    Spousal Impoverishment

    • Medicaid also has provisions in place for the prevention of spousal impoverishment, which include assistance for individuals who are in need of a nursing facility or medical institution. To qualify, the patient must remain in the facility for at least 30 days. The couple's combined countable resources determine eligibility, regardless of which person owns the items. Countable resources exclude the home, household goods, burial funds and an automobile. Individual state guidelines then determine whether the applicant is eligible, based on the difference between the state's allowed Protective Resource Amount and the combined countable resources.

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