Optional Eligibility Groups that States Can Cover
States have the option of extending Medicaid coverage to other groups. Listed below are groups that states have the option to cover, which provide important avenues for people to get coverage for long-term services. For information on other optional groups, see the Medicaid section of our website.
- Seniors and people with disabilities who have incomes that exceed the Supplemental Security Income (SSI) level but are below 100 percent of poverty.
- Certain working disabled people with a family income no higher than 250 percent of poverty who would be eligible for SSI if they did not work.
- Individuals who live in institutions such as nursing homes or intermediate care facilities who have incomes up to 300 percent of SSI (states can have lower qualifying income levels).
- People who qualify as medically needy. These are individuals who are in one of the Medicaid eligibility categories and have high medical expenses, but their income or assets place them above Medicaid eligibility. Under the "medically needy option," an individual's incurred medical expenses can be deducted from his or her income to determine eligibility as medically needy. This is referred to as "spending down" to Medicaid eligibility. States establish separate income and asset criteria for this category. Currently, 34 states have a medically needy option that is available to seniors and people with disabilities.
- People who meet income and functional eligibility criteria for 1915i home- and community-based care. 1915i is an optional program in Medicaid. In states that offer this option, the state can extend Medicaid eligibility up to 150 percent of poverty for individuals who meet the clinical/functional eligibility criteria for the state's 1915i program.
- Individuals who meet the state's SSI income eligibility criteria, are eligible for nursing facility care based on an assessment of their clinical/functional needs, are living in the community, and meet criteria for home- and community-based care provided through a state waiver program. These waivers create special programs that allow states to extend Medicaid coverage for individuals living in the community who would normally be covered only if they were living in an institution.
- Some children with severe disabilities whose families have incomes above the Medicaid eligibility level. These children are covered through what are referred to as "Katie Beckett" programs. These are optional programs that allow states to cover dependent children who meet the Social Security Administration's definition of having a disability, require a level of care that is typically provided in an institution, can be cared for safely at home at a lower cost to Medicaid, do not have assets in their own name above the state standard for a child living in an institution to have Medicaid coverage, and whose parents' income is too high for Medicaid eligibility but insufficient to pay for the child's care at home.
