Medicaid provides health coverage to 11 million non-elderly low-income parents, other caretaker relatives, pregnant women, and other non-disabled adults. States provide coverage to parents/caretaker relatives who are in mandatory eligibility groups and optional eligibility groups.
Eligibility levels for parents/caretaker relatives vary across the country and there is currently no federal requirement that states provide coverage to non-pregnant adults without dependent children. The Affordable Care Act creates a national minimum eligibility standard of 133% of the federal poverty level (FPL), beginning in 2014, which will include coverage of most adults under age 65 at this income level.
Parents & Caretaker Relatives
Parents/caretaker relatives in low-income families with dependent children are eligible for coverage if their income meets minimum eligibility levels established for financial and medical assistance in 1996, which averages 41% of the FPL. (1996 was the year of enactment for welfare reform, which held in place guaranteed Medicaid eligibility for those receiving AFDC benefits at that time.) Parents are also eligible for Medicaid if they are medically needy or through Transitional Medical Assistance (TMA). States have the option to cover parents with incomes above the 1996 minimum levels and many states do so as mandatory or optional Medicaid state plan coverage or as part of an 1115 waiver program.
Adults without Dependent Children
There is currently no federal requirement that states provide health coverage to adults without dependent children. These adults qualify for Medicaid coverage only if they have a disability or are age 65 or older. However, about half of states provide some coverage through federal waivers or state-funded programs for non-disabled adults who have limited incomes but do not otherwise qualify for Medicaid.
Affordable Care Act Provides Eligibility for Most Low-Income Adults
In 2014, individuals under age 65 (including parents and adults without dependent children) with incomes below 133% of the FPL ($14,500 for an individual in 2011) will become eligible for Medicaid in every state. This change ends the longstanding coverage gap for low-income adults. States can choose to expand eligibility for adults prior to 2014, and several states have already done so.
Other Eligibility Groups
Many states have what are called “medically needy programs”, which are optional for states. Individuals with significant health needs, whose income is too high to otherwise qualify for Medicaid under other eligibility groups can still become eligible by “spending down” the amount of income that is above a particular state's medically needy income standard. Individuals spend down by incurring expenses for medical and remedial care. If once those incurred expenses are subtracted from the person’s annual income and the person’s income is at or below the state’s medically needy income standard, the person can be eligible for Medicaid. The Medicaid program then pays the cost of services that exceed what the individual had to incur in the way of expenses in order to become eligible.
In addition to states with medically needy programs, states that determine Medicaid eligibility of the aged, blind, and disabled using more restrictive eligibility criteria than are used by the Supplemental Security Income (SSI) program (known as 209(b) states) also allow individuals to spend down their excess income to the state’s categorically needy income standard. 209(b) states must allow a spenddown to their categorically needy income standard even if the state also has a medically needy program.
Thirty-six states and the District of Columbia use spenddown programs, either as medically needy programs or as 209(b) states.
Breast & Cervical Cancer Prevention and Treatment Program
States can choose to provide Medicaid coverage to certain groups of women who are in need of treatment for breast and cervical cancer. Women are screened through the Centers for Disease Control and Prevention’s (CDC) National Breast and Cervical Cancer Early Detection Program.
In order for a woman to be eligible for Medicaid under this option, she must:
- Have been screened for and found to have breast or cervical cancer, including precancerous conditions, through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP)
- Be determined to need treatment for breast or cervical cancer;
- Be under age 65; and
- Be uninsured and otherwise not eligible for Medicaid.
States can choose to provide Medicaid financing for coverage of tuberculosis-related services to low-income individuals who are infected with TB. This eligibility group serves individuals who are not otherwise eligible for Medicaid based on the traditional eligibility categories.
Services available to people who are eligible under the optional TB group include the following TB-related services:
- Prescribed drugs;
- Physician's services and services (including outpatient hospital services, rural health clinic services, and federally qualified health center services);
- Laboratory and X-ray services (including those to confirm the presence of infection);
- Clinic services and federally qualified health center services;
- Case management services; and
- Services (other than room and board) designed to encourage completion of regimens of prescribed drugs by outpatients, including services to directly observe the intake of prescribed drugs.