The Medicaid program continues to be a lifeline for millions of Americans in 2025. Whether you’re a child, pregnant woman, senior, or someone living with a disability, Medicaid is there to help cover healthcare costs that might otherwise be out of reach. As healthcare expenses continue to rise, knowing how this program works has never been more important.
This guide will walk you through everything from eligibility and income limits to what services are covered and how to apply for coverage.
Overview
Medicaid is a joint federal and state health insurance program designed for low-income individuals and families. It differs from Medicare, which is mainly for seniors. Thanks to the Affordable Care Act, Medicaid expanded in 38 states, making it accessible to more people under 65 with limited income.
In 2025, Medicaid covers doctor visits, hospital care, prescriptions, mental health services, and more. It’s especially important for those who are uninsured or unable to afford private health insurance.
Eligibility
Eligibility for Medicaid depends on a mix of factors—income, household size, age, and disability status. Each state runs its own Medicaid program, so rules vary.
Income Limits (2025)
In states that expanded Medicaid, adults qualify with income up to 138% of the Federal Poverty Level (FPL). Here’s what that looks like:
| Household Size | Income Limit (138% FPL) |
|---|---|
| 1 person | $20,120 |
| 4 people | $41,400 |
In non-expansion states, eligibility is more limited and often restricted to specific groups.
Groups Covered
- Children: Medicaid typically covers children up to age 18, often with higher income limits.
- Pregnant Women: Coverage is available up to 138%–200% FPL depending on the state.
- Seniors (65+): Seniors with low income may qualify, especially for nursing care and help with Medicare premiums.
- People with Disabilities: Coverage includes long-term services, and some states offer Buy-In programs to let people work and keep benefits.
Immigration Status
To qualify, you must be a U.S. citizen or lawful permanent resident. Some non-citizens may qualify after a five-year wait, though pregnant women and children may be exempt.
Coverage
Medicaid covers a wide range of essential services. Some are mandatory in all states, while others are optional and vary.
Mandatory Benefits
- Hospital services
- Doctor visits
- Maternity and newborn care
- Prescription drugs
- Mental health and substance use treatment
- Lab tests and X-rays
- Long-term care and nursing home services
Optional Benefits
- Dental care
- Vision exams and glasses
- Non-emergency transportation
- Home-based support services
Applying
You can apply online, in person, by phone, or by mail. Here’s how to do it:
- Check Eligibility: Use your state’s Medicaid site or HealthCare.gov.
- Gather Documents: You’ll need proof of income, SSNs, ID, and possibly medical documents.
- Apply: Submit your application using the method that’s easiest for you.
- Wait for Approval: This can take 30–45 days.
- Get Coverage: Once approved, you’ll get a Medicaid card and instructions for using your benefits.
Managed Care vs. FFS
Many states use Managed Care, where private insurers handle Medicaid coverage. You pick from a network of doctors, and your care is coordinated.
In Fee-for-Service (FFS), you see providers who accept Medicaid and the program pays per visit or treatment.
Dual Eligibility
Some people qualify for both Medicare and Medicaid. These “dual eligibles” often get help with Medicare premiums, deductibles, and co-pays—leading to better overall coverage and less out-of-pocket expense.
Other Programs
CHIP (Children’s Health Insurance Program) is closely related to Medicaid and covers kids whose families earn too much for Medicaid but still need help. It includes checkups, dental visits, and emergency care.
Common Mistakes to Avoid
- Leaving out documents
- Not reporting changes in income
- Misunderstanding eligibility rules in your state
Medicaid Expansion Impact
Thanks to Medicaid expansion, more low-income adults now have access to care. It’s led to fewer hospital bills, more preventive care, and better health outcomes. But not all states expanded, so check your state’s policies.
FAQs
Who qualifies for Medicaid in 2025?
Eligibility is based on income, age, disability, and state rules.
What is 138% of FPL for 2025?
Roughly $20,120/year for an individual, $41,400 for a family of 4.
What does Medicaid cover?
Covers doctor visits, hospital care, prescriptions, and more.
How do I apply for Medicaid?
Apply online, by phone, in person, or by mail via your state.
What is Medicaid expansion?
It allows more low-income adults to qualify for coverage.
