“Medicaid categorical eligibility criteria are the characteristics that define the population qualifying for Medicaid coverage under a particular eligibility pathway; in other words, the nonfinancial requirements that an individual must meet to be considered eligible under an eligibility group. Medicaid covers several broad coverage groups, including children, pregnant women, adults, individuals with disabilities, and individuals 65 years of age and older (i.e., aged). There are a number of distinct Medicaid eligibility pathways within each of these broad coverage groups.

“Historically, Medicaid eligibility was limited to poor families with dependent children who received cash assistance under the former Aid to Families with Dependent Children (AFDC) program, as well as poor aged, blind, or disabled individuals who received cash assistance under the Supplemental Security Income (SSI) program. Medicaid eligibility rules reflected these historical program linkages both in terms of the categories of individuals who were served and in that the financial eligibility rules were generally based on the most closely related social program for the group involved (e.g., AFDC program rules for low-income families with dependent children and pregnant women, and SSI program rules for aged, blind, or disabled).¹⁵ Over time, Medicaid eligibility has expanded to allow states to extend Medicaid coverage to individuals beyond those who were eligible based on receipt of cash assistance, including the most recent addition of the ACA Medicaid expansion population (i.e., nonelderly adults with income up to 133% of FPL [Federal Poverty Level]).¹⁶ Medicaid’s financial eligibility rules also have been modified over time for certain groups.¹⁷

“If a state participates in Medicaid, the following are examples of eligibility groups that must be provided Medicaid coverage:

“• certain low-income families, including parents, that meet the financial requirements of the former AFDC cash assistance program;

“• pregnant women with annual income at or below 133% of FPL;

“• children with family income at or below 133% of FPL;

“• aged, blind, or disabled individuals who receive cash assistance under the SSI program;¹⁸

“• children receiving foster care, adoption assistance, or kinship guardianship assistance under SSA Title IV–E;

“• certain former foster care youth;¹⁹

“• individuals eligible for the Qualified Medicare Beneficiary program;²⁰ and

“• certain groups of legal permanent resident immigrants.²¹

“Examples of eligibility groups to which states may provide Medicaid include the following:

“• pregnant women with annual income between 133% and 185% of FPL;

“• infants with family income between 133% and 185% of FPL;

“• certain individuals who require institutional care and have incomes up to 300% of the SSI federal benefit rate;

“• certain medically needy individuals (e.g., children, pregnant women, aged, blind, or disabled) who are otherwise eligible for Medicaid but who have incomes too high to qualify and spend down their income on medical care;²² and

“• nonelderly adults with income at or below 133% of FPL (i.e., the ACA Medicaid expansion).²³

“Some individuals who are eligible for Medicaid are also eligible for Medicare. Individuals enrolled in both Medicaid and Medicare are referred to as dual-eligible individuals.”

Source: U.S. Congressional Research Service. Medicaid: An Overview (R43357; June 24, 2019). https://crsreports.congress.gov/product/pdf/R/R43357