Medicaid Financial Eligibility

Prior to the enactment of the Affordable Care Act (ACA) in 2010, United States citizens could be eligible for Medicaid coverage in the state in which they resided if they were members of a specific category (e.g., children, parents of dependent children, pregnant people, etc.) and if their income and combined assets fell within a range determined by the state. The ACA amended this eligibility standard by removing the specific categories and establishing a nationwide minimum income eligibility level at 138% of the federal poverty level (FPL) for all states operating Medicaid programs. In 2023, 138% of the FPL for an individual was $20,120.² This policy is referred to as Medicaid “expansion.”

In 2012, however, the Supreme Court found the ACA’s establishment of a national minimum income eligibility level to be unconstitutional, leaving the decision of whether to expand Medicaid to individual states.³ Since that decision, most states have chosen to expand Medicaid to a minimum eligibility level of 138% of the FPL and provide Medicaid coverage for childless adults, who had prior to the ACA been ineligible for coverage. In these states, expansion has resulted in fewer uninsured Americans and allowed many people with rare diseases to obtain vital health care coverage. Unfortunately, as of December 2023, 10 states have not opted to expand Medicaid, depriving millions of uninsured or underinsured Americans access to quality, affordable health care coverage.⁴

Children’s Health Insurance Program (CHIP)

Like Medicaid, CHIP is a joint venture between the federal government and state governments in which states can opt to cover children whose families earn incomes above current Medicaid eligibility levels.
Each state determines its upper income limits for CHIP eligibility, resulting in regional variability. The national average of the upper income limit is 255% of the FPL.⁵ As of August 2023, almost 7 million children were enrolled in CHIP.⁶

2023 Update on Eligibility Requirements

In December 2023, North Carolina became the latest state to expand their state’s Medicaid program.⁷ In August 2022, Georgia, a non-expansion state, was given permission by a federal judge to move forward with their “Georgia Pathways” program, offering Medicaid coverage to an estimated 50,000 Georgia residents.⁸ While this increase in Medicaid eligibility has caused Georgia’s grade in this section to improve, a full expansion of Medicaid would have covered an additional estimated 450,000 Georgians. Georgia is requiring beneficiaries to comply with harmful policies, including a work requirement, in order to maintain coverage. NORD is concerned with this policy decision and opposes programs that implement barriers that would limit a person’s ability to receive quality, accessible health care. For more information on this issue please visit NORD’s Protecting Patients in State Medicaid Programs” section of the Report Card

Medicaid Unwinding

Throughout the COVID-19 pandemic, states were required to continue providing Medicaid services to existing beneficiaries in exchange for increased federal funding. In March 2023, this continuous enrollment provision was terminated and, as a result, states around the country are re-evaluating whether individuals currently covered by Medicaid should retain their coverage moving forward. Each state has implemented a different process for determining continued eligibility. Per KFF, at least 11 million people have been disenrolled as of November 27, 2023.⁹ NORD is deeply concerned about the extent of coverage losses. Although a state’s procedures related to Medicaid unwinding is not graded as a part of this year’s State Report Card, NORD continues to monitor the situation closely.

Notes on Methodology Changes

This year, the final grade states received are based on an average grade from each of the four reviewed categories: Eligibility for Childless Adults, Eligibility for Parents of a Dependent Child, Eligibility for a Pregnant Person, and Eligibility for Children. Within the Eligibility for Children category, the grade was derived from an average of the four subcategories: Medicaid eligibility for ages 0-1, 1-5, 6-18 and Separate CHIP for children aged 0-18. Although the upper income limits of CHIP programs are often greater than the upper income limits of Medicaid programs, there is a significant difference in the benefits conferred which necessitates an independent category.

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1. 1. August 2023 Medicaid & CHIP Enrollment Data Highlights. Centers for Medicare & Medicaid Services. https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html
   2. Department of Health and Human Services. 2023 Poverty Guidelines: 48 Contiguous States (all states except Alaska and Hawaii). https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines
   3. National Federation of Independent Business, et al. v. Sebelius, Secretary of Health and Human Services, et al. (2012, Jun 27). Legal Information Institute. https://www.law.cornell.edu/wex/national_federation_of_independent_business_v._sebelius_(2012)
   4. Status of State Medicaid Expansion Decisions: Interactive Map. (2023, Oct. 24). KFF. https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/
   5. Medicaid and CHIP Income Eligibility Limits for Children as a Percent of the Federal Poverty Level. (2023, Jan. 1). KFF. https://www.kff.org/health-reform/state-indicator/medicaid-and-chip-income-eligibility-limits-for-children-as-a-percent-of-the-federal-poverty-level/
   6. August 2023 Medicaid & CHIP Enrollment Data Highlights. Centers for Medicare & Medicaid Services. https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html
   7. Medicaid expansion to begin in North Carolina as governor lets budget bill become law. (2023, Sept. 22) PBS. https://www.pbs.org/newshour/politics/medicaid-expansion-to-begin-in-north-carolina-as-governor-lets-budget-bill-become-law
   8. Miller, A. & Whitehead, S. (2022, Nov. 18). Path Cleared for Georgia to Launch Work Requirements for Medicaid. Kaiser Health News. https://khn.org/news/article/georgia-medicaid-pathways-kemp/
   9. Medicaid Enrollment and Unwinding Tracker. (2023, Nov. 27). KFF https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-and-unwinding-tracker/

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Grading Methodology

To evaluate eligibility standards, NORD graded states on each of the following categories:

1. Eligibility for Parents of Dependent Children: NORD analyzed the income level (% of federal poverty level, or FPL) at which states allow parents of dependent children to enroll in Medicaid. States where eligibility was set at 138% of FPL or greater received an A. States where eligibility was set between 100% to 137% of FPL received a B. States where eligibility was set between 90% to 99% of FPL received a C. States where eligibility was set at 89% of the FPL or less received a D. States with no coverage for this group received an F.
2. Eligibility for Childless Adults: NORD assessed whether states have expanded their Medicaid program, thereby allowing for childless adults to become eligible. States where eligibility was set at 138% of FPL or greater received an A. States where eligibility was set between 100% to 137% of FPL received a B. States where eligibility was set between 90% to 99% of FPL received a C. States where eligibility was set at 89% of the FPL or less received a D. States with no coverage for this group received an F.
3. Eligibility for Pregnant Women: NORD assessed state financial eligibility requirements for pregnant women to enroll in Medicaid. States where eligibility was set at 220% of FPL or greater received an A. States where eligibility was set between 190% to 219% of FPL received a B. States where eligibility was set between 150% to 189% of FPL received a C. States where eligibility was set at 149% of the FPL or less received a D. States with no coverage for this group received an F.
4. Eligibility for Children (Including CHIP-Funded Eligibility): NORD assessed state financial eligibility requirements for children ages 0-18. States where eligibility for Medicaid or CHIP was set at 300% of FPL or greater received an A. States where eligibility was set between 195% to 299% of FPL received a B. States where eligibility was set between 150% to 194% of FPL received a C. States where eligibility was set at 149% of the FPL or less received a D. States with no coverage for this group received an F.

 

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