“Eligibility for Medicaid is determined by both federal and state law, whereby states set individual eligibility criteria within federal minimum standards. As a result, there is substantial variability in Medicaid eligibility across states. Therefore, the ways that an individual might qualify for Medicaid are largely reflective of state policy decisions within broad federal requirements.
“In general, individuals qualify for Medicaid coverage by meeting the requirements of a specific eligibility pathway offered by the state. Some eligibility pathways are mandatory, meaning all states with a Medicaid program must cover them; others are optional. Within this framework, states are afforded discretion in determining certain eligibility criteria for both mandatory and optional eligibility groups. In addition, states may apply to CMS for a waiver of federal law to expand health coverage beyond the mandatory and optional eligibility groups specified in federal statute (see the “Medicaid Program Waivers” section for more information).
“An eligibility pathway is the federal statutory reference(s) under SSA Title XIX that extends Medicaid coverage to one or more groups of individuals.15 Each eligibility pathway specifies the group of individuals covered by the pathway (i.e., categorical criteria), the financial requirements applicable to the group (i.e., financial criteria),16 whether the pathway is mandatory or optional, and the extent of the state’s discretion over the pathway’s requirements. Individuals in need of Medicaid-covered LTSS [Long-Term Services and Support] must demonstrate the need for long-term care by meeting state-based eligibility criteria for services, and they also may be subject to a separate set of Medicaid financial eligibility rules in order to receive LTSS coverage. All Medicaid applicants regardless of their eligibility pathway must meet federal and state requirements regarding residency, immigration status, and documentation of U.S. citizenship.17“
Source: Alison Mitchell, et al. Medicaid: An Overview. CRS R43357. Congressional Research Service: Washington, DC. Updated Feb 8, 2023, last accessed July 7, 2023.
“Often an applicant’s eligibility pathway dictates the Medicaid state plan services that a given program enrollee is entitled to (e.g., women eligible due to their pregnancy status are entitled to Medicaid pregnancy-related services). When applying to a state’s Medicaid program, an individual may be eligible for the program through more than one pathway. In this situation, an individual is generally permitted to choose the pathway that would be most beneficial in terms of the treatment of income and sometimes assets when determining Medicaid eligibility, but also in terms of the available benefits associated with each eligibility pathway.
“Medicaid eligibility determinations generally apply for 12 months before an eligibility redetermination must occur. Individuals may be retroactively eligible for Medicaid up to three months prior to the month of application, if the individual received covered services and would have been eligible had he or she applied during that period.18“
Source: Alison Mitchell, et al. Medicaid: An Overview. CRS R43357. Congressional Research Service: Washington, DC. Updated Feb 8, 2023, last accessed July 7, 2023.
World Health Systems Facts is a project of the Real Reporting Foundation. We provide reliable statistics and other data from authoritative sources regarding health systems in the US and sixteen other nations.
Page last updated July 7, 2023 by Doug McVay, Editor.
