Medicaid covers more Americans than any other single health program, and yet the most common question about it has no single answer. Whether you qualify depends on which state you live in, how your household is counted, and which eligibility category you fall into. The good news: the rules are knowable, and checking costs you nothing.
The one number that matters most: 138 percent
In the 40 states plus Washington, D.C. that adopted Medicaid expansion, adults under 65 qualify based on income alone if their household income is at or below 138 percent of the federal poverty level. No asset test, no disability requirement, no dependent children required.
Under the 2025 federal poverty guidelines, 138 percent works out to roughly $21,597 a year for a single adult and about $44,367 for a family of four. The 2026 guidelines are typically published in late January and nudge those numbers up slightly, so treat these as close estimates and check current figures through medicaid.gov or your state agency.
Rough monthly equivalents under the 2025 guidelines:
- Household of 1: about $1,800 per month
- Household of 2: about $2,433 per month
- Household of 3: about $3,067 per month
- Household of 4: about $3,697 per month
How Medicaid counts your income (it is not your gross pay)
For most non-elderly applicants, states use MAGI: modified adjusted gross income, borrowed from the tax code. A few practical consequences follow from that.
- Pre-tax deductions like 401(k) contributions and most health premiums withheld from your paycheck reduce countable income.
- Child support you receive does not count. Child support you pay is not deducted.
- SSI payments do not count. Unemployment benefits generally do.
- Your "household" is basically your tax filing unit, which is why a 22-year-old claimed as a dependent is usually counted with their parents.
This is why people who assume they earn too much are sometimes wrong. A $25-an-hour worker with heavy retirement withholding and a spouse at home can land under the line. Run the real numbers before you self-reject.
Categories with higher income limits
The 138 percent figure applies to non-disabled adults. Other groups qualify at substantially higher incomes, and this is where most of the missed enrollment happens.
Children and CHIP
Children qualify for Medicaid or the Children's Health Insurance Program at much higher household incomes; many states cover kids in families earning 200 to 300 percent of the poverty level, and some go higher. Even if the parents earn too much for their own coverage, the kids are frequently eligible. Details live at healthcare.gov.
Pregnant women
Most states cover pregnancy at higher income thresholds, commonly around 200 percent of poverty or more, and federal law now lets states extend postpartum coverage for 12 months after birth. Most states have taken that option.
Seniors and people with disabilities
Applicants 65 and older or with disabilities are assessed under older, non-MAGI rules that usually include an asset test alongside income limits. These pathways include coverage for long-term care, where "spend-down" rules and a five-year look-back on asset transfers apply. If a nursing home is in the picture, talk to your state Medicaid office or a legal-aid elder law program before moving money around; well-intentioned gifts to family members within the look-back window can trigger penalty periods.
What Medicaid actually covers once you are in
Federal law requires every state program to cover the heavy items: hospital care (inpatient and outpatient), physician services, lab work and X-rays, nursing facility care, home health, and — for anyone under 21 — the sweeping EPSDT benefit that includes comprehensive dental, vision, and hearing care for children. Most states add optional benefits on top: prescription drugs (every state covers them in practice), physical therapy, eyeglasses, and some level of adult dental.
Cost-sharing is minimal by design. Premiums are rare, copays where they exist are nominal — a few dollars — and federal rules cap total cost-sharing for a household. For most enrollees, Medicaid is the most protective insurance card in the country. The trade-off is provider participation: not every physician accepts Medicaid, so part of using the coverage well is asking "do you take my state's Medicaid, and which managed care plan?" when booking. Most states now deliver Medicaid through private managed care organizations, which means after approval you may pick among two or four plans with different provider networks. Pick based on whether your current doctors and nearest hospital are in-network, not on the gift card a plan dangles for enrolling.
The ten states without expansion
In the states that never adopted expansion — including Texas, Florida, and Georgia — non-disabled adults without dependent children generally cannot get Medicaid at any income level, and parents qualify only at very low incomes, sometimes under 20 percent of the poverty line. This creates the coverage gap: people who earn too much for Medicaid but too little for marketplace subsidies, which historically begin at 100 percent of poverty. If you are in that gap, check whether your income lands just above 100 percent of poverty, because then marketplace premium tax credits may apply, and look into community health centers, which treat patients regardless of coverage on a sliding fee scale.
How to apply, and what to have ready
You can apply any day of the year — Medicaid has no open enrollment season. Three routes:
- Directly through your state Medicaid agency, online, by phone, or on paper.
- Through HealthCare.gov, which forwards applications to your state when you appear Medicaid-eligible.
- In person at many hospitals, clinics, and county assistance offices, which often have certified application counselors.
Have on hand: proof of identity, Social Security numbers for applicants, recent pay stubs or self-employment records, and immigration documents if applicable. States must generally decide within 45 days, or 90 days when a disability determination is involved.
One development to watch: federal legislation enacted in 2025 directs states to add work and community-engagement requirements — generally 80 hours a month of work, training, education, or volunteering — for many expansion-population adults, with implementation rolling out on a state-by-state schedule. Exemptions are expected for parents of young children, people who are medically frail, and several other groups, but the paperwork burden will be real. If you are an expansion adult, expect new reporting requirements in your state sometime between now and early 2027, and treat any mail about "community engagement" as urgent rather than junk.
Renewals, denials, and appeals
Medicaid eligibility is redetermined at least yearly, and since the pandemic-era continuous coverage rules ended, states have been aggressive about paperwork-based terminations. A large share of people removed from the rolls lost coverage for missing a form, not for earning too much. Open every envelope from your state agency, keep your address current, and respond by the deadline even if you think the request is redundant.
If you are denied and believe the math is wrong, you have the right to a fair hearing; the denial notice tells you how to request one, and deadlines are short, often 30 to 90 days. In our experience reading state eligibility manuals, a meaningful slice of denials trace to income being counted for the wrong household members, which is exactly the kind of error a hearing can fix.
While you wait, or if you do not qualify
Medicaid coverage can be retroactive up to three months in many states if you were eligible during those months, so ask about retroactive coverage if you have recent medical bills. If your income is modestly above the limit, price a subsidized marketplace plan before assuming you are stuck. And if your budget is tight across the board, programs like SNAP use similar income concepts; our walkthrough on applying for SNAP shows how the pieces fit together. Start with your state agency's screening tool — twenty minutes there beats a month of guessing.
