Medicaid is a joint federal and state program that provides healthcare coverage to millions of low income households in the United States. Eligibility and benefits vary depending on the state that you live in.
Groups who often qualify for Medicaid include families and individuals with low household incomes, people with disabilities, and people who are or are planning to become pregnant.
In 2023, more than 85 million people in the United States were enrolled in Medicaid.
Though Medicaid plans differ by state, federal guidelines require Medicaid to cover health services including inpatient hospital care, hospice and nursing home care, and transportation related to healthcare.
Separate types of Medicaid are available to help cover other health needs, such as emergency care and family planning.
Understanding your eligibility for Medicaid and your covered care can be one step toward ensuring you and your family have access to the care you need.
What is Medicaid?
Medicaid is a program run by federal and state governments together to provide healthcare coverage for people who could not otherwise afford it. Eligibility varies among states but often includes households that have low incomes or resources.
Medicaid is different from Medicare, which is a federal program providing health coverage for adults over age 65 years, as well as some adults below this age who have certain disabilities or health conditions. Medicare coverage does not depend on your income.
Medicaid offers certain services that Medicare does not, such as nursing home coverage. It is possible to be dually eligible for Medicaid and Medicare, allowing you to receive benefits from both.
Medicaid covers many standard medical expenses but may require copayments or deductibles, depending on your state’s specific plan. The out-of-pocket maximums may be as low as $4 for routine appointments or up to $75 for in-hospital care.
Who is eligible for Medicaid?
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Eligibility for Medicaid depends on the state you live in. Typically, the following factors will also influence whether you are eligible:
your income
whether you are under age 18 years or over age 65 years
your family size
whether you have a disability
whether you have certain chronic health conditions
whether you are or are planning to become pregnant
Affordable Care Act expansion of Medicaid
The Affordable Care Act made changes to Medicaid to allow states to expand eligibility to more households. As a result, in many states, any adult under the age of 65 years who has an income below 138% of the federal poverty level (FPL) can qualify.
In states with this expansion, based on the FPL thresholds for 2023, any individual earning less than $20,120 per year or any family of four with an income below $41,400 per year would be eligible for Medicaid.
Once it is determined that you are eligible and you enroll in Medicaid, you will receive an enrollment card to carry with you. Show your card at your doctor’s office or pharmacy to pay for your medical costs.
You will not receive money from Medicaid. The program will pay healthcare professionals directly.
Before you receive care, check to make sure your doctor’s office or pharmacy accepts Medicaid. If you are unsure of your coverage or need information about locations that accept Medicaid, contact your local state Medicaid agency.
What does Medicaid cover?
Everyone who receives Medicaid coverage will have access to certain healthcare services, regardless of the state you live in. These can include:
routine doctor visits
in-hospital care
diagnostic tests
in-home care
hospice and nursing home care
vaccinations
routine care for children and teenagers under age 21 years, including dental, vision, and hearing exams
transportation related to healthcare, both emergency and nonemergency
You can search for your state’s Medicaid program on Healthcare.gov to learn more about your specific coverage.
If you need help covering the cost of medications, the free Optum Perks Discount Card could help you save up to 80% on prescription drugs. Follow the links on drug names for savings on that medication, or search for a specific drug here.
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There are limitations to what Medicaid covers. Medicaid coverage does not extend to:
private rooms during hospital stays
emergency care for routine treatments
certain prescription medications
drugs not approved by the Food and Drug Administration (FDA)
elective procedures, like cosmetic surgery
fertility treatments, such as in vitro fertilization
Can you use Optum Perks with Medicaid?
You cannot use the Optum Perks prescription discount program together with Medicaid or any insurance.
In some cases, though, the discounted price through Optum Perks may be lower than your Medicaid copay. You may wish to compare your options so you can fill your prescription at the most affordable price.
What’s the difference between Medicaid and Medicare?
Both Medicaid and Medicare are government-run programs that help make healthcare more accessible for millions of people in the United States.
Medicare covers most people over the age of 65 years or those with long-term health conditions or disabilities. However, to be eligible for Medicaid, you must meet certain financial and healthcare needs.
Summary
Medicaid is a federal and state program to help provide healthcare coverage to individuals and households with low incomes who may not otherwise afford care.
Each state runs its own Medicaid program, so specific eligibility and benefits vary from state to state. However, federal guidelines mandate Medicaid coverage of certain services — such as routine appointments, hospital stays, nursing home care, and children’s care — regardless of the state where you live.
To check whether you are eligible for Medicaid, you can apply through your state’s local Medicaid agency at Healthcare.gov.
Download the free Optum Perks Discount Card to save up to 80% on prescription medications.
