Medicaid is a medical assistance program administered by the state and funded through a state-federal partnership. It provides health care to almost 60 million uninsured, low-income individuals and reimburses providers – safety net institutions and other health care providers – at set rates for services provided to Medicaid recipients and hospitals with a disproportionate share of uninsured patients.
While state participation in Medicaid is voluntary, all 50 states currently participate. By opting into the program, states must comply with certain federal requirements, including coverage for certain categories of people, known as “mandatory” eligibles, and services, known as “mandatory services.” They must also meet certain federal provider rate requirements. States do have flexibility in how they design and implement their programs, as states can set provider rates above the federal standard and can choose to extend eligibility to “optional eligibility groups” and offer “optional services.”
Eligibility for Medicaid can vary from state to state, particularly the income level for eligibility; however, certain groups are required to be covered. These are known as “mandatory eligibility groups” and, with a few caveats, include:
- Pregnant women;
- Very low-income parents;
- Blind persons;
- Disabled persons
Income eligibility levels for the mandatory eligible population also vary by group.
Optional eligibility groups include:
- SSI eligibles between the mandatory income eligibility level and 100% of the FPL
- Nursing home residents with income falling between SSI level and 300% of the FPL
- Children, parents, pregnant women who fall between the mandatory income eligibility level and a cap set by the state
- Disabled persons who work and whose income level disqualifies them from SSI benefits
- Medically needy persons requiring institutional care who exceed the SSI income eligibility levels
For states that have expanded Medicaid eligibility pursuant to the Affordable Care Act (ACA), parents and other adults must be covered up to 133% of the federal poverty level (FPL) (138% including the 5% adjusted according to the new MAGI rules)
The types of services covered from state-to-state will also vary in type, amount, duration and scope; however, every state must cover the following “mandatory” services:
- Physicians’ services
- Hospital services (inpatient and outpatient)
- Laboratory and x-ray services
- Early and periodic screening, diagnostic, and treatment (EPSDT) services for (recipients under 21 years)
- Federally-qualified health center (FQHC) and rural health clinic (RHC) services
- Family planning services and supplies
- Pediatric and family nurse practitioner services
- Nurse midwife services
- Nursing facility services (recipients 21 and older)
- Home health care for persons eligible for nursing facility services
- Transportation services
Optional services include, but are not limited to, such things as prescription drug coverage, clinic services, dental services, durable medical equipment, eyeglasses, intermediate care facilities for individuals with developmental disabilities (ICF/DD), home and community based services. A state Medicaid program typically covers many of the optional services expressly mentioned here; however, states still have the option to not cover them. Thus, not every state’s Medicaid program may look the same or offer the same types of coverage.
Children’s Health Insurance Program (CHIP)
The Children’s Health Insurance Program (CHIP) is a medical assistance program providing health care coverage to an estimated eight (8) million low-income children up to age 19 whose family income is too high to qualify for Medicaid, but too low to afford private insurance. Some states extend their eligibility to include parents and pregnant women.
Like Medicaid, CHIP is administered by the state and funded through a state-federal partnership. The amount of federal match varies from state-to-state. In 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) was signed into law. In addition to continuing the CHIP program, CHIPRA increased funding to allow for improvements to the program, including outreach to those children who are eligible yet are not enrolled. Furthermore, Congress increased the amount of federal match to incentivize states to expand their coverage. The Affordable Care Act (ACA) extended the CHIP program through 2019 and also increased federal funding above what was previously awarded through CHIPRA.
Each state and the District of Columbia, administers their own program with broad guidance from CMS. States have three options in administering their program:
- Through Medicaid expansion (seven states, DC and five territories)
- Establish separate Child Health Insurance Program (17 states)
- Some combination of the two approaches (26 states)
States have flexibility in setting the income eligibility criteria, with 46 states and the District of Columbia covering children up to 200% of the federal poverty level (FPL). Review a complete listing of current state income eligibility.
CHIPRA also authorized states to create an eligibility category for pregnant women, but not all states opted to provide coverage through their CHIP. Some states opted to use alternative public programs instead. Use the following links to see the federal guidance regarding changes to CHIP eligibility under:
The types of benefits covered from state-to-state vary based on how the program is designed (see design options above) and also vary in type, amount, duration and scope. All states are required to provide the following:
- Routine check-ups
- Doctor visits
- Dental and vision care
- Inpatient and outpatient hospital care
- Laboratory and X-ray services
- Emergency services
States may opt to provide additional benefits so you will need to contact your state to determine the complete list. Learn about the CHIP benefit design, including dental, and the accompanying federal guidance.
Get more information about optional and mandatory services.
It is important to note that every state’s CHIP may not look the same or offer the same types of coverage. In addition, the out-of-pocket costs including enrollment fees, premiums, deductibles, coinsurance and copayments, also vary but are limited to 5% of the family’s annual income.
To determine whether your child may be eligible for CHIP, contact:
The information on this page is provided for informational purposes only and is not intended to provide advice about your eligibility for any program or any particular insurance product for you or your family. If you have questions about whether you qualify for Medicaid or your children qualify for CHIP, you should contact your state’s Medicaid program or Marketplace (www.healthcare.gov), a licensed/certified Navigator, In-Person Assister, or Application Counselor in your state, or your Marketplace Call Center.