To cover more low-income Americans, the Affordable Care Act (ACA) expanded Medicaid eligibility. Adults aged 64 or younger with incomes that do not exceed 138% of the federal poverty level (FPL) are now eligible for Medicaid in most states. Still, the expansion has not been implemented by every state. Although the Affordable Care Act is a federal act calling for changes to Medicaid eligibility guidelines nationwide, some states are still not participating. The Supreme Court has ruled that a state may not be forced or required to expand its Medicaid programs. As a result, each state has been able to decide whether it will participate in the expansion.
What Qualifications Do All States Consider for Medicaid Eligibility?
In every state, you may be eligible for Medicaid based on:
- Size of household
- Family status
Additional factors may also be considered. The specific guidelines for eligibility may differ by state.
What Are the Medicaid Qualifications in States with Expanded Medicaid Eligibility?
Only one factor is considered for inclusion in expanded Medicaid coverage: income. If the income for your household is below the designated level, which is 138% of the federal poverty threshold, you are eligible for expanded Medicaid.
What Is the Coverage Gap in States That Have Refused Medicaid Expansion?
If your income is below 100% of the federal poverty standard and you don’t qualify for Medicaid based on the current guidelines in your state, you may fall within a coverage gap. Your income may not be high enough to save through a Marketplace plan, and without the expansion, it may not be low enough to meet the eligibility requirements for Medicaid.
In states that have chosen not to expand Medicaid, a gap in coverage is leaving over two million people ineligible for affordable health care coverage. In these states, the percentage of those uninsured who are living below the poverty level is greater than twice the percentage in states that have expanded Medicaid. The high numbers are not due to an issue with ACA. Instead, they are due to the choices of state governments. If a state is interested in closing the Medicaid coverage gap for its low-income citizens, it can decide to accept the Medicaid expansion funding from the federal government whenever it chooses.
Initially, when the Medicaid expansion first became available, only the District of Columbia and 26 states offered the expansive eligibility. However, in 2021, the expansion was offered in D.C. and 38 states. The states with expanded Medicaid include:
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Dakota
- Rhode Island
- West Virginia
Where Does the Funding for Medicaid Expansion Originate?
A small amount of the funding for Medicaid expansion comes from the individual participating states, but most of the funding comes from the federal government. When the expansion first became available in 2014, the federal government covered the entire cost for those who were newly eligible under the new guidelines. The federal government continued to fully cover the cost through 2016. However, over time, the states have begun to cover a portion of the expansion expenses. In 2020, the states were expected to pay 10% of the cost. This expectation continues to be the state’s responsibility moving forward.
If a state chooses not to offer the Medicaid expansion, the federal government only gives them the usual amount of funding instead of the enhanced funding for eligibility expansion. It’s important to note that the federal government doesn’t offer expansion funding if a state does not completely expand its Medicaid eligibility.
How Many New Beneficiaries Became Eligible for Medicaid Through the Expansion?
A 2019 poll indicates that approximately 10 million new enrollees became eligible based on the expansion of Medicaid’s guidelines for eligibility. However, the actual number of enrollees was quite a bit higher due to the COVID-19 pandemic. In 2021, 14.8 million people who enrolled in Medicaid were eligible due to the expansion. Additionally, four million enrollees who already met the pre-expansion eligibility requirements had enrolled mainly due to the enrollment help they received through outreach efforts.
Which States Have Refused the Medicaid Eligibility Expansion?
There are 12 states that have not fully embraced the Medicaid expansion. Within these states, there has been a continual debate because the governor and/or the legislature have been in opposition to receiving federal funds for Medicaid expansion.
States that have not fully accepted the expansion of Medicaid eligibility include:
- North Carolina
- South Carolina
- South Dakota
Should You Apply for Marketplace Coverage if Your State Has Not Expanded Its Medicaid Coverage?
If you live in a state that has not agreed to expand Medicaid and you believe your income is less than the income level needed to be eligible for a Marketplace insurance plan, you should apply to the Marketplace.
How Can You Get the Healthcare You Need if You Are Not Eligible for Medicaid or the Marketplace?
If you do not qualify for Medicaid or the Marketplace, you can still receive healthcare services. Here are a few options that may be available:
- Community health care: Many community medical care centers, which receive increased funding through the health care law, offer income-based services.
- Catastrophic health plan: Anyone under the age of 30 may enroll in a Catastrophic health plan. At the age of 30 or older, you may still be eligible for a Catastrophic plan if you claim an exemption.
- Marketplace plan with advance payment of the premium tax credit: If your annual income changes to 100-400% of the federal poverty level, you can enroll in the Marketplace plan with advance payment of the premium tax credit. Once your income is beyond 400% of the poverty threshold, you may still be eligible for savings.
- Health Coverage Under the Affordable Care Act: Enrollment Trends and State Estimates, HHS.