Understanding Medicaid Eligibility

In terms of health care coverage and long-term care, Medicaid is an important federal-state partnership program for seniors and people with disabilities. Qualifications for Medicaid vary by state, with overarching federal guidelines. The Kaiser Family Foundation (KFF), a nonprofit organization focusing on national health issues, recently released findings from their 2022 50-state survey on pathways for Medicaid financial eligibility based on old age or disability.

Free Health Insurance for Those Who Qualify

The study shows 8.5 million full-benefit Medicaid participants aged 65 and older and 10 million full-benefit enrollees based on their disability in 2019. Pathways to receive Medicaid where the eligibility basis is having a disability or senior status are called “non-MAGI” pathways. MAGI refers to the financial methodology (Modified Adjusted Gross Income) that applies to pathways for parents, children, and pregnant people with low incomes.

Qualifying non-MAGI populations receive free health insurance based on their family size, resources, and income, including individuals 65 or older and those on Medicare who are either disabled or blind. Non-MAGI pathways use age and disability status considerations and possibly asset limits to calculate eligibility. Most non-MAGI pathways, according to the KFF survey, are “optional results in substantial state variation.”

Expanded Options

States that participate in Medicaid must include those individuals receiving Supplemental Security Income (SSI) benefits for non-MAGI pathways. The primary non-MAGI routes to full Medicaid eligibility, expanding coverage to working people with disabilities through state options include:

• Katie Beckett children. A provision of the TEFRA Act of 1982 Katie Beckett children refers to the states’ option to extend Medicaid to severely disabled children, only counting the disabled child’s income and not including the parents’ income(s)
• Seniors and the disabled who are medically needy and have “spent down” their income by deducting incurred medical expenses
• Seniors and the disabled up to 100 percent of the 2022 federal poverty level of $1,133 monthly for an individual
• The Family Opportunity Act buy-in for significantly disabled children
• Section 1915 (i) permitting states to provide independent eligibility pathways for those with functional requirements less than an institutional level of care

The pathways for each option have different income and asset rules, making eligibility complex. A disability attorney or lawyer specializing in Medicaid can readily assess your best pathway to qualify. This KFF survey contains an appendix providing details about each of these pathways and also includes additional routes for those who also require Long Term Services & Supports (LTSS).

Where to Find Information

The KFF survey presents state-level information on the criteria for Medicaid financial eligibility and significant non-MAGI pathway adoptions as of January 2022. The data includes mandatory and optional pathways for full Medicaid eligibility and state options for expanding Medicaid financial eligibility for individuals who require long-term services and support in either community settings, nursing homes, or other institutions.

In addition, highlights of adopted state actions expanding non-MAGI financial eligibility after January 2022 are included in the survey. Also included is a brief overview of non-MAGI enrollment during the public health emergency (PHE) of COVID-19 and state plans for returning to normal eligibility and renewal policies when the COVID-19 PHE is declared over. However, states can continue policies adopted during the PHE that expand asset or income limits and eliminate or reduce premiums. The Centers for Medicare and Medicaid (CMS) guidance encourages states to retain these policy changes, expanding access to Home & Community Based Services (HCBS).

Medicaid is essential to the lives of older individuals and those with special needs or disabilities and is often their sole source of medical and LTSS coverage. State eligibility rules vary to qualify for full Medicaid, and understanding how your situation fits within the rules can be overwhelming to sort out. A disability attorney or Medicaid lawyer can help assess your best pathway to qualify for Medicaid services. For assistance, please contact our Forty Fort office or call (570) 288-1800.