Like far too many older adults in America, 75-year old Mr. T struggled to get by. His fixed limited income didn’t even cover his monthly housing or medical expenses—let alone his other basic needs like food, heat, and medicine.

Then he learned that he might qualify for Medicaid as a senior, and everything changed. With help from Elder Law of Michigan—one of NCOA’s 90 Benefits Enrollment Centers (BECs) across the United States—Mr. T successfully applied for the program. This freed up more of his budget for other basic necessities, and now he feels “much less stressed” about paying his bills on time.

“I just can’t say enough how thankful I am!” he said.

If you can relate to Mr. T’s situation, you’re not alone. You may even have wondered about Medicaid eligibility yourself. It’s true that the rules can be complicated to navigate. But NCOA and our network of BECs are here to help. Keep reading to learn the different ways seniors can qualify for Medicaid and where to get more answers in your state.

Do seniors get Medicare or Medicaid?

In some cases, they get both.

If you’re age 65 or over, you likely are eligible for Medicare—a federal health insurance program that covers a wide range of services to keep you healthy as you age. (While the minimum enrollment age is generally 65, the program also covers younger people with certain disabilities.)

Medicare isn’t free, however, and many people with low incomes can’t afford its out-of-pocket costs. That’s where Medicaid comes in.

“You can think of Medicaid as a bridge that closes the gap between your budget and Medicare’s costs and benefits,” explained Jen Teague, Director of Health Coverage and Benefits at NCOA. “Medicaid can help you pay for your Medicare premiums, and it also covers certain services that Medicare doesn’t—including the long-term care that many older adults may eventually need.”

People who have both Medicare and Medicaid coverage are called “dual-eligible.” Roughly 12.5 million Americans fall into this category.¹ Could you be one of them?

How does a senior qualify for Medicaid?

Because Medicaid is jointly funded by the U.S. government and individual states, eligibility rules depend on where you live.

However, there are certain universal requirements that every applicant must meet. To qualify for Medicaid benefits you must, at a minimum:²

•    Be a U.S. citizen or eligible non-citizen
•    Live in the state where you are applying
•    Have an income at or below 138% of the federal poverty level

Then, your eligibility is based on one or more of these factors:³

•    Age
•    Income level
•    Household size
•    Disability status

Let’s take a closer look.

Two pathways to Medicaid coverage for seniors

The federal government requires that people who meet specific guidelines must automatically be eligible for Medicaid (it’s mandatory). Beyond that, each state can decide whether and how to extend coverage to other groups (it’s optional).

“There’s even a little flexibility in how states interpret mandatory coverage,” Teague said. “For that reason, if you think you might qualify for Medicaid based on one or more of the pathways below, you should contact your state Medicaid agency to confirm.”

Here are the ways that dually eligible seniors might qualify for Medicaid.⁴

Pathway 1: Mandatory coverage

You receive Supplemental Security Income (SSI)⁵
If you get monthly financial assistance through SSI, you are automatically eligible for Medicaid.

You are enrolled in a Medicare Savings Program (MSP)
If you qualify for an MSP based on your income, you are eligible for partial Medicaid benefits. One thing to note: because MSPs themselves are funded by Medicaid, your state may have specific rules about how you qualify under this category.

Pathway 2: Optional coverage

Your income is very low
If your income is at or below 100% of the federal poverty level ($1,255 per month for an individual or $1,703 for a couple in 2024), you may qualify for Medicaid in your state. It is important to note that federal poverty levels are higher in Alaska and Hawaii.

You are considered medically needy
You may have heard of “Medicaid spend-down.” Essentially, that’s how people whose incomes are otherwise too high to qualify for Medicaid might become eligible for benefits. The intent is to provide crucial support for those whose health care expenses exceed their ability to pay. For example, many older adults who require long-term care face steep bills that quickly overwhelm their income, savings, and other financial assets; hence, they are considered medically needy.

As of 2022, 34 U.S. states offered the medically needy pathway to Medicaid eligibility.⁶  But the rules around spend-down are complicated and the potential pitfalls deep, Teague warned. “You will want to consult with a qualified elder law attorney, estate planner, or other knowledgeable, trusted professional who can advise you on the process and whether or not it makes financial sense for you and/or your spouse,” she said.

You have specific functional limitations
If you live with certain disabilities that require long term services and support (LTSS), you may qualify for Medicaid under the “special income rule.” This rule broadens eligibility to people who earn up to 300% of Supplemental Security Income.⁷ In 2024, that’s $3,765 per month for an individual and $5,110 per month for a couple.

Each state defines the level of care you would need in order to qualify for the special income rule, and you might also need to undergo a functional assessment as part of your eligibility determination. Check with your Medicaid office to learn more.

Your state implemented a Section 1115 waiver
This provision allows individual states to expand access to Medicaid (among other things) in ways that go above and beyond what the federal government mandates.⁸ As of June 2023, most states had implemented at least one Section 1115 waiver.⁸ Most often, these waivers are meant to test out new approaches to the Medicaid program and therefore aren’t permanent. It’s best to contact your Medicaid agency to learn about specific waivers in your state and whether they apply to you.

Should I apply for Medicaid? And what would I get with Medicaid benefits?

If you think you might qualify, you owe it to yourself to find out. Roughly 1 in 4 people enrolled in Medicaid is an older adult or someone living with a disability.⁸ That means you would join millions of other Americans whose health and well-being is better thanks to improved access to care.

In addition to routine and acute health care services, Medicaid covers institutional and community-based long-term care. Depending on where you live, it also may offer additional benefits that Medicare does not, such as vision, hearing, and dental coverage.

Ready? Learn how to apply for Medicaid here.

Sources

1.  Kaiser Family Foundation. Medicare. A Profile of Medicare-Medicaid Enrollees (Dual Eligibles). Jan. 31, 2023. Found on the internet at https://www.kff.org/medicare/issue-brief/a-profile-of-medicare-medicaid-enrollees-dual-eligibles/

2.  Medicaid.gov. Medicaid Eligibility. Found on the internet at https://www.medicaid.gov/medicaid/eligibility/index.html

3. USA.gov. How to Apply for Medicaid and CHIP. December 6, 2023. Found on the internet at https://www.usa.gov/medicaid-chip-insurance

4. Medicaid and CHIP Payment and Access Commission. Dually Eligible Beneficiaries. Found on the internet at https://www.macpac.gov/subtopic/dually-eligible-beneficiaries-eligibility/

5. Social Security Administration. Understanding Supplemental Security Income (SSI) Benefits – 2023 Edition. Found on the internet at https://www.ssa.gov/ssi/text-benefits-ussi.htm

6. KFF. Medicaid Eligibility Through the Medically Needy Pathway. Found on the internet at https://www.kff.org/other/state-indicator/medicaid-eligibility-through-the-medically-needy-pathway/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

7. MaryBeth Musumeci et al. “Medicaid Financial Eligibility in Pathways Based on Old Age or Disability in 2022: Findings from a 50-State Survey.” July 11, 2022. Found on the internet at https://www.kff.org/report-section/medicaid-financial-eligibility-in-pathways-based-on-old-age-or-disability-in-2022-findings-from-a-50-state-survey-appendix/

8. Robin Rudowitz et al. “10 Things to Know About Medicaid.” June 30,2023. KFF. Found on the internet at https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid/