Medicaid expansion is a provision of the Affordable Care Act that lets states open Medicaid to nearly all adults under 65 with household incomes at or below 138 percent of the federal poverty level. Forty-one states and the District of Columbia have adopted it; ten states have not. In 2026 the income cutoff works out to roughly $21,600 a year for a single adult and about $35,630 for a family of three. The federal government pays 90 percent of the cost of covering the expansion group, and states pay the remaining 10 percent.
Who Qualifies Under Expansion
Before the ACA, Medicaid mostly reached specific categories of low-income people: children, pregnant women, parents with very low incomes, seniors, and people with disabilities. Childless adults generally could not qualify at any income, and the median eligibility threshold for parents was just 64 percent of the federal poverty level.1Center on Budget and Policy Priorities. Medicaid Expansion Frequently Asked Questions
Expansion replaces those categorical rules for adults 18 to 64 with a single income test. If your household income is at or below 138 percent of the federal poverty level, you qualify. The statute sets the number at 133 percent, but a mandatory five-percent income disregard raises the effective threshold to 138 percent.2HealthCare.gov. Medicaid Expansion and You Income is measured using modified adjusted gross income, a standardized calculation that replaced the older patchwork of state-specific rules.3MACPAC. Medicaid Expansion
Under expansion, whether you have children, whether you have a disability, and your age within the 18-to-64 range no longer matter. A single adult working a low-wage job with no dependents can qualify on income alone.
Why Some States Have Expansion and Others Don’t
The ACA originally required every state that participates in Medicaid to adopt expansion or lose its entire federal Medicaid funding. In June 2012, the Supreme Court struck down that penalty in National Federation of Independent Business v. Sebelius, holding that the threat amounted to unconstitutional coercion of the states.4Justia. National Federation of Independent Business v. Sebelius, 567 U.S. 519 The expansion itself survived, but the federal government could no longer force states to take it. That turned expansion into a state-by-state choice.
Which States Have Expanded
The ten states that have not adopted expansion are Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming. Many of the expansion states adopted on the first available date in January 2014. Others came later, often through ballot initiatives: Maine in 2017, Idaho and Nebraska in 2018, Oklahoma in 2020, Missouri in 2021, and South Dakota in 2022.5KFF. State Activity Around Expanding Medicaid Under the ACA North Carolina is the most recent, launching its expansion on December 1, 2023.6North Carolina Department of Health and Human Services. North Carolina Expands Medicaid
Two holdout states offer something adjacent but narrower. Wisconsin covers adults up to 100 percent of the poverty level under a longstanding waiver, but it hasn’t adopted the ACA expansion and doesn’t get the enhanced federal match. Georgia’s Pathways to Coverage waiver covers adults up to 100 percent of poverty only if they complete 80 hours a month of work or related activities.7National Conference of State Legislatures. Medicaid Expansion
The Coverage Gap in Non-Expansion States
The ACA was written assuming every state would expand, so it made marketplace premium subsidies available only to people at or above 100 percent of the poverty level. In states that didn’t expand, adults who earn too much for their state’s traditional Medicaid but too little for marketplace subsidies fall into a coverage gap with no affordable option. About 1.4 million uninsured adults are currently in it.8KFF. How Many Uninsured Are in the Coverage Gap
The gap is heavily southern: 97 percent of affected people live in the South, with Texas accounting for 42 percent, Florida 19 percent, and Georgia 14 percent.8KFF. How Many Uninsured Are in the Coverage Gap Traditional Medicaid income limits in these states can be very low. In Alabama, a family of three qualifies only if income is at or below 18 percent of the poverty level, about $4,678 a year. Most people in the coverage gap are working, often in service or construction jobs without employer-sponsored insurance.9Stateline. In the 10 States That Didn’t Expand Medicaid, 1.6M Can’t Afford Health Insurance
What Expansion Coverage Includes
Adults enrolled through expansion get coverage through what Medicaid calls an Alternative Benefit Plan, modeled on commercial insurance rather than the traditional Medicaid benefit package. These plans must cover the ten essential health benefit categories the ACA requires: ambulatory care, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder treatment, prescription drugs, rehabilitative and habilitative services, lab work, preventive and wellness care, and pediatric services including dental and vision.10MACPAC. Alternative Benefits Packages
States have flexibility in how they build the plan, and Alternative Benefit Plans may cover fewer optional benefits than traditional Medicaid. Adult dental, for example, isn’t required. People considered medically frail or with special health care needs are exempt from mandatory enrollment in these plans and can receive the full traditional Medicaid benefit package instead.11Medicaid.gov. Alternative Benefit Plan Coverage
How to Apply
In expansion states, there’s no limited enrollment window. Applications are accepted year-round. The most common route is HealthCare.gov, which uses your income and household information to determine whether you qualify for Medicaid, CHIP, or marketplace subsidies.2HealthCare.gov. Medicaid Expansion and You Many states also take applications through their own online portals, by phone, by mail, or in person at local social services offices. Processing generally takes up to 45 days, or up to 90 days when a disability determination is involved.
If you live in a state that hasn’t expanded, it’s still worth applying through the marketplace. The application can identify whether you qualify for traditional Medicaid based on pregnancy, disability, or dependent children, and whether your income makes you eligible for marketplace subsidies.2HealthCare.gov. Medicaid Expansion and You People who don’t qualify for either program can seek care at community health centers, which charge on a sliding scale based on income.
What Changes Under the 2025 Reconciliation Law
The budget reconciliation law signed on July 4, 2025 adds new requirements for the expansion population that will take effect in the coming years.12KFF. Tracking the Medicaid Provisions in the 2025 Budget Bill
Starting January 1, 2027, expansion enrollees ages 19 to 64 will have to document at least 80 hours a month of work, job training, education, or community service to keep coverage. States will check compliance at application and at least every six months. People who can’t demonstrate compliance after a 30-day notice face disenrollment, and they’re also barred from marketplace premium tax credits.13KFF. A Closer Look at the Work Requirement Provisions in the 2025 Federal Budget Reconciliation Law Exemptions cover several groups, including parents and caretakers of children under 14, people who are medically frail, pregnant and postpartum individuals, veterans with total disability ratings, former foster youth under 26, and people in substance use disorder treatment.14Center for Health Care Strategies. A Summary of National Medicaid Work Requirements
Also on January 1, 2027, states must redetermine expansion enrollees’ eligibility every six months instead of annually.15Georgetown University Center for Children and Families. Medicaid and CHIP Cuts in the House-Passed Reconciliation Bill Explained
Beginning October 1, 2028, states will have to charge copays of up to $35 per service to expansion enrollees with incomes above the poverty level. Primary care, mental health, substance use disorder treatment, and federally qualified health center services are exempt from those copays.16Justice in Aging. Budget Reconciliation and Low-Income Older Adults
The Congressional Budget Office estimated the law’s Medicaid and CHIP provisions would reduce federal spending by $863 billion over ten years and increase the uninsured population by 7.8 million by 2034. Counting interactions with the ACA marketplace, CBO put the total increase in uninsured people at 10.9 million.15Georgetown University Center for Children and Families. Medicaid and CHIP Cuts in the House-Passed Reconciliation Bill Explained
Trigger Laws and the 90 Percent Match
The 90 percent federal match is what makes expansion affordable for states. Twelve states have “trigger laws” that would automatically end or force reconsideration of their expansion programs if that match rate drops. Nine of them, Arizona, Arkansas, Illinois, Indiana, Montana, New Hampshire, North Carolina, Utah, and Virginia, require termination if the federal share falls below 90 percent (below 80 percent in Arizona). Three more, Idaho, Iowa, and New Mexico, require legislative review rather than automatic termination.17Center for American Progress. How Federal Funding Cuts Could Unravel Medicaid Expansion in 12 States If those triggers activated, more than 3.6 million residents in those states could lose Medicaid coverage.
If the enhanced match were eliminated outright, the Urban Institute has projected that states would collectively face a $44.3 billion annual funding gap to maintain expansion. If states dropped expansion instead, Medicaid enrollment could fall by 15.9 million people, and the uninsured population could grow by 10.8 million.18Urban Institute. Reducing Federal Support for Medicaid Expansion Would Shift Costs to States and Coverage Losses