Medicaid Eligibility and Long-Term Services

For Medicaid to cover the cost of long-term services:

An individual must meet the criteria for Medicaid eligibility in his or her state of residence. That means applicants have to fall into one of the categories of people that Medicaid covers and meet financial eligibility criteria for that category. Medicaid doesn’t cover all low-income people, only certain groups, such as children, pregnant women, seniors, and people with disabilities.
The state must offer long-term services to people in the individual’s eligibility category. Long-term services are offered as a benefit only to people who fall into certain eligibility categories, such as seniors or people with disabilities.
A person must meet the state’s requirements for needing long-term services based on an assessment of his or her level of need for assistance.

This section provides an overview of general Medicaid eligibility, focusing on the eligibility categories that are the most important ways individuals gain access to Medicaid long-term care coverage.

Eligibility for Medicaid:
To be eligible for Medicaid, individuals must fall into one of the categories of people that the Medicaid program in their state covers and meet the financial eligibility criteria (e.g., income and asset limits) for that category. There are some categories of people that states are required to cover in Medicaid programs. These are referred to as "mandatory" and "categorically eligible" groups. There are other groups to whom states may extend Medicaid eligibility. These are referred to as "optional" eligibility categories. Optional eligibility categories are important avenues for individuals to gain access to coverage for long-term services. Financial eligibility requirements vary by state and by the eligibility category a person falls into. Medicaid eligibility is limited to American citizens and certain lawfully residing immigrants.

See Groups that States Must Cover and Optional Groups that States Can Cover to learn more about Medicaid eligibility, particularly the eligibility categories that are important for people who need long-term services. For full information about Medicaid eligibility, check out our Medicaid section.

Medicaid Eligibility and Coverage for Long-Term Services:
Being eligible for Medicaid is only one step in receiving coverage for long-term services. Long-term services are not an available service for every eligibility category, because some states do not extend long-term services coverage to all optional eligibility categories. For example, in many states, people can be eligible for Medicaid if they have high medical expenses. This category is called "medically needy." Not all states cover the cost of long-term services for people in the "medically needy" eligibility category.

The individual also has to meet the state’s tests for needing long-term services. This is based on an evaluation of an individual's clinical or functional needs. Different services have different requirements. For example, an individual has to have a very high level of need to receive nursing facility care, but he or she could receive home health care at a lower level of need. This is discussed in greater detail in the section on Long-Term Services that Medicaid Covers.

Health Reform Note:
Health reform significantly expands Medicaid eligibility for people under 65. This change goes into effect in 2014. However, health reform does not change the eligibility of the following groups of people who qualify for Medicaid:

Those who are eligible for Medicaid based on their eligibility for other types of assistance, such as Supplemental Security Income (SSI);
Those who are eligible for Medicaid because they live in a long-term care institution or meet the criteria for needing institutional care;
Those who are classified as medically needy; and
Those who are over 65.

Most people who qualify for Medicaid and need long-term services fall into one of the eligibility categories that is not affected by health reform. For more information on how health reform changes general Medicaid eligibility, see the Medicaid and Health Reform Central sections of our website.

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