Title XIX of the Social Security Act, added in 1965 and codified at 42 U.S.C. ยง 1396, is the federal law that created Medicaid, the joint federal-state health insurance program that now covers more than 68 million low-income Americans, with another 7 million children covered through the closely related Children’s Health Insurance Program.1Medicaid.gov. December 2025 Medicaid and CHIP Enrollment Data Highlights2Office of the Law Revision Counsel. 42 USC 1396 – Medicaid and CHIP Payment and Access Commission Medicaid pays for routine doctor visits, hospital stays, prescription drugs, and, most significantly for older families, long-term nursing home care.
How the Federal-State Structure Works
Title XIX did not create one national Medicaid program. It created a framework in which the federal government sets minimum standards and contributes funding, and each state designs and runs its own program within those rules. Every state must cover certain groups of people and certain services to receive federal money. Beyond those floors, states have wide latitude to cover additional populations, offer extra benefits, and choose how care is delivered. That is why Medicaid rules, benefits, and application processes look different depending on where you live.
Who Qualifies for Medicaid
Required Eligibility Groups
Federal law requires every state to cover several categories of people: low-income families with children, pregnant women, children up to specified ages and income levels, people receiving Supplemental Security Income due to disability, and certain elderly individuals.3Medicaid.gov. List of Medicaid Eligibility Groups States can extend coverage to other groups and often do.4HHS.gov. Who Is Eligible for Medicaid
Income is the primary test, measured against the federal poverty level (FPL). For 2026, the FPL is $15,960 per year for a single person and $33,000 for a family of four in the 48 contiguous states.5ASPE. 2026 Poverty Guidelines Different eligibility groups use different FPL thresholds, and children are generally covered at higher income levels than adults.
The ACA Expansion for Adults
Before 2014, most states limited adult Medicaid to parents with very low incomes, and childless adults were largely shut out no matter how poor. The Affordable Care Act gave states the option to cover nearly all adults with household income up to 138% of the FPL, which for 2026 works out to about $22,025 for a single person and roughly $45,540 for a family of four.5ASPE. 2026 Poverty Guidelines As of 2025, 41 states and D.C. have adopted the expansion; 10 have not. Whether you qualify as a low-income adult without children depends heavily on which of those two groups your state falls into.
Asset Limits
Income is not always the only test. For elderly and disabled applicants seeking long-term care, states also look at countable assets. Many use the SSI resource limits as the baseline: $2,000 for an individual and $3,000 for a couple in 2026.6Social Security Administration. 2026 Cost-of-Living Adjustment Fact Sheet Your home, one vehicle, and certain other assets are usually excluded, though the specifics vary by state. The ACA expansion population and most children are evaluated under Modified Adjusted Gross Income rules that ignore assets entirely.
The Medically Needy Pathway
About 36 states and D.C. offer a “medically needy” option for people whose income is too high for standard Medicaid but who face overwhelming medical bills.7Medicaid.gov. Eligibility Policy If your medical expenses consume enough of your income to bring you below the state’s medically needy threshold, you become eligible. This spend-down pathway matters most for people who need nursing home care but earn slightly too much for regular Medicaid.
Citizenship and Immigration Status
You must be a U.S. citizen or a qualifying non-citizen to receive full Medicaid benefits. Qualifying non-citizens include lawful permanent residents, refugees, asylees, and certain trafficking victims.8Center for Medicaid and CHIP Services. Eligibility for Non-Citizens in Medicaid and CHIP Most lawful permanent residents face a five-year waiting period, though refugees and asylees are exempt, and states can cover lawfully residing pregnant women and children without any waiting period. Undocumented immigrants are not eligible for regular Medicaid, but federal law does allow coverage for emergency medical services regardless of immigration status.
What Medicaid Covers
Services Every State Must Provide
Federal law requires every state Medicaid program to cover a core set of services:9MACPAC. Mandatory and Optional Benefits
- Inpatient and outpatient hospital care
- Physician services
- Laboratory and X-ray services
- Nursing facility care for adults 21 and older
- Home health services
- Family planning services and supplies
- Nurse midwife and nurse practitioner services
- Federally qualified health center and rural health clinic services
- Non-emergency medical transportation
- Tobacco cessation counseling for pregnant women
Expanded Benefits for Children
Coverage for anyone under 21 goes well beyond the standard adult benefit. The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit requires states to provide comprehensive preventive care, including vision, dental, hearing, and developmental screenings, and then cover any medically necessary treatment those screenings uncover.10Medicaid.gov. Early and Periodic Screening, Diagnostic, and Treatment Even when a state does not normally cover a service for adults, it must cover that service for a child if a screening finds it medically necessary. Families with children on Medicaid should know this benefit exists and ask for it by name.
Optional Services States May Add
States can add dozens of optional benefits on top of the mandatory floor. The most common are prescription drugs, dental care, vision services, physical and occupational therapy, personal care services, hospice, and case management.9MACPAC. Mandatory and Optional Benefits Virtually every state covers prescription drugs even though it is technically optional. The specific mix varies from state to state, and some packages are far more generous than others.
How Medicaid Is Paid For and Delivered
The federal government reimburses a percentage of every dollar a state spends on Medicaid. That percentage, the Federal Medical Assistance Percentage (FMAP), is recalculated each year based on how a state’s per capita income compares to the national average.11MACPAC. Federal Medical Assistance Percentages and Enhanced Federal Medical Assistance Percentages by State Poorer states get a higher federal share, and by law the FMAP cannot drop below 50% or exceed 83%. For the ACA expansion population, the federal government pays an enhanced 90% share.12CMS. Increased Federal Medical Assistance Percentage Through the Affordable Care Act States cover the rest from state revenues, which is why Medicaid is one of the largest items in nearly every state budget.
Most enrollees no longer receive care through a system where the state pays doctors for each visit. Instead, states contract with private health plans called managed care organizations that receive a fixed monthly payment per enrollee and coordinate that person’s care. As of 2024, roughly 78% of all Medicaid enrollees were in managed care, spread across 42 states.
Title XIX Medicaid vs. Medicare
Medicare and Medicaid serve different populations and work in different ways.13HHS.gov. What Is the Difference Between Medicare and Medicaid Medicare is federal health insurance primarily for people 65 and older, plus some younger people with qualifying disabilities. It is funded through payroll taxes and enrollee premiums and works the same everywhere. Medicaid is a joint federal-state program for people with limited income and resources, regardless of age, and enrollees usually pay little or nothing out of pocket.
The biggest practical difference is long-term care. Medicare covers short-term skilled nursing stays after a hospitalization but does not pay for extended nursing home care. Medicaid is the primary payer for long-term nursing home stays and home-based care in the United States. That fact catches many families off guard when a parent or spouse needs ongoing care.
Millions of Americans qualify for both programs. For these dual eligibles, Medicare pays first for services both programs cover, and Medicaid fills the gaps by paying Medicare premiums, covering copayments, and funding services Medicare does not cover.14CMS. Beneficiaries Dually Eligible for Medicare and Medicaid The Qualified Medicare Beneficiary program, one of several Medicare Savings Programs run through Medicaid, covers Part A and Part B premiums along with deductibles and copayments for people who qualify.
Long-Term Care Rules That Trip Families Up
Protections for the Spouse Who Stays Home
When one spouse enters a Medicaid-funded nursing home, federal law protects the other from financial ruin. The community spouse can keep a portion of the couple’s combined assets, called the Community Spouse Resource Allowance. For 2026, the federal minimum is $32,532 and the maximum is $162,660, with each state setting its own amount within that range.15Medicaid.gov. January 2026 SSI and Spousal Impoverishment Standards16Office of the Law Revision Counsel. 42 USC 1396r-5 – Treatment of Income and Resources for Certain Institutionalized Spouses The community spouse is also entitled to a minimum monthly income, ranging in 2026 from $2,643 to $4,066 depending on the state. If the community spouse’s own income falls below that allowance, part of the institutionalized spouse’s income is redirected to make up the difference.
The Five-Year Look-Back
Medicaid does not just examine your current finances. When you apply for long-term care, the state reviews all asset transfers you made during the 60 months before your application.17Office of the Law Revision Counsel. 42 USC 1396p – Liens, Adjustments and Recoveries, and Transfers of Assets If you gave away assets or sold them for less than fair market value during that window, the state calculates a penalty period during which you are ineligible for Medicaid-covered long-term care.
The penalty period equals the total uncompensated value of the transferred assets divided by the average monthly cost of nursing home care in your state. Give away $100,000 in a state where nursing home care averages $10,000 a month, and you face 10 months of ineligibility. The penalty period does not begin until you have applied for Medicaid and would otherwise be eligible, so poor timing can leave you without coverage and without the assets you gave away. This is where most long-term care planning mistakes happen.
Estate Recovery After Death
Federal law requires every state to seek repayment from the estates of Medicaid recipients who were 55 or older when they received benefits. States can recover costs for nursing facility services, home and community-based services, and related hospital and prescription drug expenses.18Medicaid.gov. Estate Recovery Some states go further and try to recover the cost of any Medicaid-covered services.
Recovery cannot happen while the recipient’s spouse is alive, or while a child under 21 or a blind or disabled child of any age survives them.17Office of the Law Revision Counsel. 42 USC 1396p – Liens, Adjustments and Recoveries, and Transfers of Assets A home is protected when a sibling with an equity interest has lived there for at least a year before the recipient entered a facility, or when an adult child who provided care that delayed institutionalization has lived there for at least two years. States must also offer hardship waivers when recovery would cause undue hardship to surviving family members.
How to Apply
You can apply two ways. The first is directly through your state’s Medicaid agency; HealthCare.gov/medicaid-chip will point you to the right place after you select your state. The second is through the federal Health Insurance Marketplace at HealthCare.gov, where you complete an application and check for all savings programs.19CMS. Apply for Medicaid and CHIP Through the Marketplace If the Marketplace determines someone in your household may qualify, it shares your information with your state agency, which follows up. You can also call the Marketplace at 1-800-318-2596.
There is no open enrollment period for Medicaid. You can apply any time during the year, and coverage can begin as early as the month you apply, or up to three months earlier if you would have been eligible then.
If Your Application Is Denied
If your application is denied, your benefits are reduced, or a service is refused, you have a federal right to challenge that decision through a fair hearing. Every state must maintain a hearing system that meets constitutional due process standards, and the state must inform you in writing of your hearing rights at the time of any adverse decision.20eCFR. 42 CFR Part 431 Subpart E – Fair Hearings for Applicants and Beneficiaries At the hearing, you can review your case file, bring witnesses, present evidence, and cross-examine anyone testifying against your claim. You can represent yourself or have someone represent you, and you can request an expedited hearing if waiting would put your health at risk. If the state is trying to cut services you are already receiving, requesting a hearing promptly can keep those services in place while the appeal is pending.