Some states are expanding their Medicaid programs. Others haven’t. Your health coverage options depend on your state, your income and household size, and other factors.
How Medicaid expansion works
The Affordable Care Act provides states with additional federal funding to expand their Medicaid programs to cover adults under 65 with income up to 133% of the federal poverty level. (Because of the way this is calculated, it’s effectively 138% of the federal poverty level.) Children (18 and under) are eligible up to that income level or higher in all states.
This means that in states that have expanded Medicaid, free or low-cost health coverage is available to people with incomes below a certain level regardless of disability, family status, financial resources, and other factors that are usually taken into account in Medicaid eligibility decisions.
- First, find out if your state is expanding Medicaid.
The following states are expanding their Medicaid programs. If your state is on this list, learn what this means for you:
- District of Columbia
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Dakota
- Rhode Island
- West Virginia
The following states have not decided to expand their Medicaid programs. If your state is on this list, learn what this means for you:
- North Carolina
- South Carolina
- South Dakota
If your state is expanding Medicaid
If your state is expanding Medicaid, your options depend on your income and household size.
When you fill out a Marketplace application, you’ll find out if you’re eligible for Medicaid or a private insurance plan.
If your state hasn’t expanded Medicaid
If you live in a state that hasn’t expanded its Medicaid program and you have limited income, you may not have many options for health coverage. It will depend on where your income falls.
- If your income is more than 100% of the federal poverty level -- $11,670 a year as a single person or about $23,850 for a family of 4 -- you will be able to buy a private health insurance plan in the Marketplace and may qualify for premium tax credits and other savings based on your household size and income.
- If you make less than about $11,670 a year as a single person or about $23,850 for a family of 4, you won’t qualify for lower costs for private insurance based on your income. You may be eligible for Medicaid, even without the expansion, based on your state’s existing rules. But if you aren’t, you won’t qualify for either of the affordability options under the health care law.
Apply for Medicaid, even if your state hasn't expanded coverage
Even if your state hasn't expanded Medicaid, you should apply for coverage to see if you qualify.
Each state has coverage options that could work for you - particularly if you have children, are pregnant, or have a disability.
Remember, you can apply for Medicaid and CHIP at any time, all year long. There’s no limited enrollment period for either program.
- If my state isn’t expanding Medicaid and my income is below the federal poverty level, why can’t I get savings on Marketplace insurance?
When the health care law was passed, it required states to provide Medicaid coverage for adults between ages 18 and 65 with incomes up to 133% of the federal poverty level, regardless of their age, family status, or health.
- The law also provides premium tax credits for people with incomes between 100% and 400% of the federal poverty level to buy private insurance plans in the Marketplace.
- The U.S. Supreme Court later ruled that the Medicaid expansion is voluntary with states. As a result, some states haven’t expanded their Medicaid programs.
- Many adults in those states with incomes below 100% of the federal poverty level fall into a gap. Their incomes are too high to qualify for Medicaid under their state’s current rules. But their incomes fall below the law’s cutoff for savings on private coverage in the Marketplace.
- Under the law, the federal government pays states all of the costs for newly eligible people for the first three years. It will pay no less than 90% of the costs in the future.
- States are continuing to make coverage decisions. They could expand Medicaid in the future.
- How can I get health care if I fall into the coverage gap?
The health care law has expanded funding to community health centers, which provide primary care for millions of Americans. These centers provide services on a sliding scale based on your income. Find a community health center near you.
- If my state isn’t expanding Medicaid and I don’t qualify for Medicaid coverage, do I have to pay a fee?
Under the law, most people must have health coverage or pay a fee. But you won’t have to pay this fee if all of the following apply:
- You live in a state that isn’t expanding Medicaid
- You would qualify for Medicaid if the state did expand Medicaid
- You don’t qualify for Medicaid under the state's current rules or for lower costs on a private insurance plan in the Marketplace because of where your income falls
This is called an exemption. You can get an exemption when you apply for coverage in the Marketplace.