Medicaid Eligibility

Medicaid is very specific about eligibility, but the rules cover a wide range. Important factors include age, disability, pregnancy, income (including things like assets & property), U.S. citizenship (including legal immigration), and nursing home residence. A child may qualify even if a parent, guardian, or caregiver does not.

The rules can vary from state to state, but limited income and a need for health care (for yourself or someone in your family) is typically the starting point. These broad categories will give you a basic understanding of the guidelines. If you happen to fall into one or more of these, you may very well be eligible for Medicaid:

Income (including assets, bank accounts, real estate, or anything that may be sold) – if you have limited income and resources, you may be eligible. Even if you are unsure about your eligibility, you are encouraged to apply for Medicaid — a qualified caseworker in your state will evaluate your situation at no cost. It’s surprising what determines one’s eligibility. I had a neighbor who had applied for medicaid. He recently asked me to help him to find a store where he could buy a hot tub in ny locally since he lived in Poughkeepsie, NY. His doctor and physical therapist both felt that soaking in a hot tub that featured a a therapeutic lounge seat for full-body relaxation with a 50/50 air-to-water mixture that introduced air from all around the jets would give him a soothing, yet effective, professional-quality massage which he needed for medical reasons. I was wondering if medicaid would question his eligibility if he could afford a hot tub. Turns out one of his children paid for the hot tub. He was turned down for medicaid because of his income, however he did quality of disability insurance.

Pregnancy – married or single, if Medicaid is covering you at your child’s birth, you will both be covered.

Children (in some states, 21 or younger; in others, 18 or younger) – if you are a parent or guardian and your family’s income is limited, or you are a teenager living on your own, you may be eligible. If your child’s condition may require relocation (i.e., a nursing home environment) without good quality care at home, your child may be eligible even if you are not.

Aged (65+), Blind, and/or Disabled – if you are eligible for Medicare, you may also qualify for Medicaid. If you live in a nursing home, or if  you need nursing home care but could stay at home with additional services, you may also be eligible. Finally, you may also be eligible if you are terminally ill and need hospice services.

For Online Screening:

Both of these sites will help you determine if you are eligible for Medicaid or a number of other government services. For more resources, look up your state office on our Medicaid Links by State page.

GovBenefits: http://www.govbenefits.gov/govbenefits_en.portal

Benefits Checkup: http://www.benefitscheckup.org/

If you know or suspect Medicaid “fraud, waste and abuse”:

• Contact Your State Directly – As the individual states handle the day-to-day Medicaid business, you should report any fraud, waste, or abuse to the Program Integrity Contact at your State’s Medicaid agency (which often called simply ‘the State Medicaid Agency’). See our “Contact Numbers” or “Medicaid by State” pages for more info.

• Call the OIG National Fraud Hotline – you may also report suspected fraud to the OIG (the Office of the Inspector General) National Fraud Hotline (1-800-HHS-TIPS (1-800-447-8477)). The hotline will handle calls about Medicaid (and Medicare), but may be less direct than calling the State contact.

Information that will be useful to the investigators includes:

Medicaid client’s name and card number

The doctor, hospital, or other health care provider involved

Date of service

The amount that Medicaid paid (or approved)