Medicaid Income Eligibility Limits for Adults as a Percent of the Federal Poverty Level

Income Limits for Medicaid and CHIP Programs

Medicaid is a government-sponsored program that is offered in all 50 states. Qualifications for Medicaid is based upon income and family size. Having a high income that is above the Medicaid limits means that there are higher chances you may not be eligible for Medicaid coverage. However, there are some things that you can do to increase your chances of getting Medicaid coverage despite your high income. One significant process that has proved to work is being on the Medicaid spend-down program. Due to the Affordable Care Act, a number of states expanded their qualifications to allow more people to receive coverage. Medicaid provides healthcare for low-income people, families, and children. Depending on where a person lives, some receive coverage for all adults below a specific income level.

What is the Medicaid Spend-Down Program?

The Medicaid spend-down program is a program that allows you to deduct medical expenses from your income so that you can meet the Medicaid limit for coverage. These medical expenses are those that are not covered by any insurance, and you have to pay for them out of pocket. If the medical expenses significantly reduce your income to below the limit that is accepted for Medicaid coverage you will be eligible for Medicaid. It is also known as Medical need program and is mostly for people that are blind, disabled and aged. If you want to get on the Medicaid spend down program, it is essential that you contact the Medicaid office in your state to know of the rules. You may be living in a state that does not offer it, so do your research first.

What Is Spend-Down?

The spend down amount is the difference between your Medicaid limit and your income for eligibility. It is usually determined over a period depending on the state. For instance, in some states, it may be up to 6 months. In other states, you may be required to submit the monthly expenditure in the form of receipts and bills while in others you have to pay a premium to Medicaid monthly. It is essential that you know where to apply for the Medicaid before applying.

Organizations Involved

Some of the organizations that you can benefit from include Special Needs Trusts, Miller Trusts, and Supplemental Needs Trusts. These are the organizations that can help you become Medicaid-eligible when your income is higher than the Medicaid limit. If you are not sure where to apply for the spend down the program, you can look into these three and identify what is available in your state. Know how they work as well as they are organizations that you can benefit from.

Medicaid Buy-in Program

There is the Medicaid Buy-in Program that is for people with disabilities with high income and assets. The Buy-in program is where you pay a premium to be eligible to receive Medicaid. Different states have different guidelines, and it is, therefore, important to know where to apply before doing so.

Apply For Your Medicaid Spend-Down Program 

You will only have the Medicaid spend down coverage for each period that you can meet your amount through your medical expenses. This means that if you do not have any medical expenses to pay in a certain month, you will not receive any Medicaid coverage. Once you meet the spend down expenses again, you will be eligible for Medicaid. But if you want to qualify for Medicaid in-patient hospital coverage, you may need to apply for Medicaid spend-down for a number of periods. If you are aged and would like nursing home care, you may use the Medicaid spend-down program to have it covered. You will automatically get Extra Help for the 1st month for meeting the spend-down amount until the year comes to an end. This will still be active regardless of meeting the spend down amount in other periods.


As mentioned earlier there are some organizations that you can benefit from when applying for the Medicaid spend-down program. Trusts, for example, are organizations that you can use to apply for Medicaid coverage. How these trusts work is that you put a certain portion of your income or asset in the trust and they will not count it as income. This ensures that you are able to meet your spend-down amount and can get Medicaid coverage at a high expense.

New To Medicare?

If you are new to Medicaid coverage, the following are some of the five things you need to know about Medicaid:

  • Medicaid is financed by the federal and state government jointly
  • Medicaid coverage costs lower than private insurance: the cost of having private insurance is higher than getting medical coverage. This is because the costs for private insurance are higher in terms of the premiums that have to be paid. On the other hand, getting Medicaid is cheaper because of the low rates of pay. The coverage for Medicaid is even more as compared to private insurance where the more you pay, the more coverage that you get.
  • Medicaid has better health care access: research and survey conducted have shown that individuals with Medicaid have better access to quality health care and they are able to get it on time. People that are uninsured have difficulties getting better health care which causes deterioration in their health. It is, therefore, better to get Medicaid if you want to have better health care.
  • Medicaid is able to cover other services out of what is required by Medicaid law: getting Medicaid is of great benefit to you because you are able to get other services such as prescription drugs, eyeglasses and physical therapy. Its benefits are endless and can help you greatly in the end to receive quality health care.
  • Medicaid has evolved: ever since it was first introduced in 1965, Medicaid has evolved over the years to offer better coverage services and at lower costs. People that are disabled, aged and also pregnant women are now able to access Medicaid coverage at lower costs. Medicaid coverage is still evolving, and much more states have it now.


Medicaid coverage is available in all states for persons below a specific income level. This is dependent upon family size, family structure, or disability status. In states that have expanded Medicaid coverage due to the Affordable Care Act, people can qualify for Medicaid based on income alone. Therefore, if a person’s income is below 13% of federal poverty, he/she will qualify. Each state has coverage options particularly for families with young children or women who are pregnant.


Once a person has been approved to receive Medicaid services, he/she will receive an enrollment card. To determine what type of coverage you receive, the best thing to do is contact member services to ensure your health services are covered. When you make an appointment with a healthcare provider, it is important to ensure that they accept Medicare services. If you do not, you may be required to pay for services out of pocket if they do not accept Medicaid. Check local Medicaid websites to find doctors that accept Medicaid to ensure your services will be covered.

Dental Coverage

Dental coverage is a required component of Medicaid. Those who are under 21 are eligible for bi-annual dental screenings and necessary treatments. It is necessary that people engage in regular screenings to determine the existence of serious conditions. These services must include treatment of infections, pain, teeth restoration, and general maintenance. If further treatment is necessary, the state is required to provide the services necessary to fix and prevent further problems even if the services are not a part of the Medicaid plan. For adults over the age of 21, each state may choose whether or not to provide dental services as part of the Medicaid plan. Most states provide emergency dental services for those adults covered under Medicaid, but only about half provide comprehensive dental care. Check with your current state to see what is and is not covered regarding dental services.

Emergency Services

During an emergency situation, go to the nearest hospital for treatment. The law requires that a hospital treat a patient in an emergency situation despite payment of services. Medicaid provides emergency ambulance services by provider’s licenses by the state. For Medicaid to cover ambulance transportation, the patient must be taken in a vehicle that has been inspected and licensed by the state. If non-emergency transportation is necessary, a doctor’s recommendation must first be given before Medicaid will cover the service.


The Children‘s Health Insurance Program provides benefits to children through Medicaid and other programs. Children, who are eligible, are covered up through age 19 if the family’s income is too high to qualify for Medicaid. Each state sets its own terms for CHIP regarding income eligibility. 46 states will cover children up to or over 200% of the federal poverty level and 24 states will cover up to 250% of the poverty level. Dental services are available through a Medicaid expansion program under Chip and are required to prevent disease and promote proper oral health. Age-appropriate vaccines are also covered under CHIP and are a required component for those enrolled in the CHIP plan. Contact your state office to determine if your children are eligible for coverage under the CHIP plan.


Medicaid coverage is an effective coverage that ensures each American citizen has access to quality healthcare. If you have a high income, you can follow the above steps to receive Medicaid coverage in your state. Just check the eligibility requirements for it.

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