Medicaid and CHIP Overview

This job aid provides information and guidance for Navigators and certified application
counselors (collectively, assisters) on helping consumers learn about and apply for Medicaid
and the Children’s Health Insurance Program (CHIP).

Overview.......................................................................................................................................2
Eligibility........................................................................................................................................2
Applying for Medicaid and CHIP ...................................................................................................3
Medicaid Adult Expansion ............................................................................................................4
Medicaid and CHIP and Marketplace Coverage ...........................................................................6
Medicaid and CHIP Enrollees and Special Enrollment Periods ....................................................7
Medicaid and CHIP for Pregnant Women .....................................................................................8
Medicaid Coverage Gap ...............................................................................................................8
Medically Needy Medicaid ..........................................................................................................10
Medicaid and CHIP Eligibility and Immigration Status ................................................................10
Lawfully Residing Children and Pregnant Women ......................................................................11
Tips for Enrolling Consumers in Medicaid or CHIP .....................................................................12
Scenario .....................................................................................................................................13
Additional Resources ..................................................................................................................14
Appendix A: State Medicaid & CHIP Information ........................................................................15

March 2022.This document is intended only as a summary of legal requirements and to provide operational information and does not itself
create any legal rights or obligations. All legal requirements are fully stated in the applicable statutes and regulations. The contents of this
document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a
contract. This document is intended only to provide clarity to the public regarding existing requirements under the law. This material was printed,
published, or produced and disseminated at U.S. taxpayer expense.
Overview
Medicaid and the Children’s Health Insurance Program (CHIP) are state-administered health
coverage programs funded by the Federal Government and the states that provide
comprehensive coverage for over 81 million consumers.
 Medicaid is a state-administered health coverage program that provides free or low-cost
health coverage to some low-income people, families and children, pregnant women, the
elderly, and people with disabilities.
 CHIP is a state-administered health insurance program that provides health insurance
coverage for low-income children (and, in some states, low-income pregnant women)
whose household income is too high to qualify for Medicaid but too little to afford
Marketplace coverage.

 States establish and administer their own Medicaid and CHIP programs and determine
the type, amount, duration, and scope of services, within federal guidelines.

 Medicaid benefits for children under the age of 21 must include the full range of medically
necessary services. Medicaid benefits for adults may vary but generally must be
comprehensive in scope.
 CHIP must provide, at a minimum, well-baby and well-child care, dental coverage,
behavioral health care, and vaccines.
Most Medicaid and CHIP coverage qualifies as minimum essential coverage (MEC). However,
some forms of Medicaid that cover limited benefits aren’t considered MEC. Some limited types
of Medicaid only pay for certain services, such as family planning, emergency care, tuberculosis
services, and coronavirus disease 2019 (COVID-19) testing and treatment. For more
information on which Medicaid programs are considered MEC, visit HealthCare.gov/medicaid-
limited-benefits.
Consumers who are determined eligible for or are enrolled in coverage through Medicaid or
CHIP that counts as MEC are ineligible for advance payments of the premium tax credit (APTC)
for themselves and for income-based cost-sharing reductions (CSRs) to help pay for the cost of
their Marketplace coverage. If they are enrolled in both Medicaid or CHIP and Marketplace
coverage with APTC/CSRs, the consumer should visit HealthCare.gov/medicaid-chip/cancelling-
marketplace-plan or contact the Marketplace Call Center at 1-800-318-2596 for instructions on
how to end their Marketplace coverage with APTC/CSRs.

Eligibility
Medicaid and CHIP eligibility depends on several factors, including:
 A consumer’s income level;
  Modified adjusted gross income (MAGI) is used to determine most consumers’
financial eligibility for Medicaid and CHIP. MAGI is the consumer’s adjusted gross
income plus any non-taxable Social Security, tax-exempt interest, or untaxed
foreign income they might have. For example, earned wages and unemployment
benefits are counted in the MAGI calculation, but income from child support and
student loans is not. There are some differences in the MAGI calculation for
Medicaid/CHIP than for the Marketplace.
 A consumer may be required to provide documentation to their state Medicaid or
CHIP agency in order to verify their income, and their application may be
suspended (no Medicaid or CHIP benefits) until they do so. Their state Medicaid or
CHIP agency will inform them of what information to provide.
 The number of people in their household;
 Household composition and family size are important to calculate MAGI and
determine Medicaid and CHIP eligibility. Household size generally includes tax
filers and tax dependents in the household, but sometimes different family
members are included in a consumer’s Medicaid and CHIP household size, such
as when determining Medicaid and CHIP eligibility for someone who doesn’t file a
tax return and is not claimed as a tax dependent.
 The consumer’s age, pregnancy status, and whether the consumer has a disability;
 The state in which they live; and
 Their U.S. citizenship, U.S. national status, or immigration status.

Applying for Medicaid and CHIP

Consumers can apply and receive eligibility results for Medicaid and CHIP in two main ways:
1. Through their state's website.
 Consumers can find their state Medicaid and CHIP program names at
HealthCare.gov/medicaid-chip-program-names and in Appendix A. They can also
choose their state in the drop-down menu at HealthCare.gov/medicaid-chip, which
will direct them to their state’s Medicaid/CHIP agency website. They can apply
through the agency website to find out if they qualify for Medicaid or CHIP.
Consumers can also apply by phone, mail, in person, or through other commonly
available electronic means.
 If they qualify, Medicaid/CHIP coverage can begin immediately and may be
effective retroactively.
2. By filling out a Marketplace application.
  After submitting a completed application for Marketplace coverage with financial
assistance, the Marketplace will evaluate eligibility results for both Marketplace
coverage with financial assistance and Medicaid or CHIP coverage. If anyone in
the household is or may be eligible for Medicaid or CHIP or requests a full/non-
MAGI determination of Medicaid/CHIP eligibility by the state Medicaid/CHIP
agency, the Marketplace will send the consumer’s information to the state
Medicaid or CHIP agency for a final eligibility determination and/or enrollment, as
applicable.
 The state Medicaid or CHIP agency will notify consumers about any next steps to
finalize an eligibility determination and/or enroll in Medicaid or CHIP coverage, as
applicable.

Medicaid Adult Expansion

Under the Affordable Care Act (ACA), states have the opportunity to expand Medicaid to low-
income adults under the age of 65 with income at or below 138 percent of the federal poverty
level (FPL). Exhibit 1 provides information on income eligibility for Medicaid for expansion states
in the continental United States. Note: Consumers may still qualify for Medicaid even if their
specific scenario is not demonstrated in Exhibit 1, as their eligibility depends on their specific
circumstances.
Exhibit 1 – Income Thresholds for Medicaid Eligibility in the Medicaid Adult Group by Income and Household Size, 2022

Income at or below 138% of the FPL 1

Number of People in the If a consumer’s income is at or below 138% of the FPL and
Household their state has expanded Medicaid coverage to the adult
group, they may qualify for Medicaid.
1 $18,754
2 $25,268
3 $31,781
4 $38,295
5 $44,809
6 $51,322

Consumers in states that have not expanded Medicaid coverage to the adult group for
households with income below 100 percent of the FPL ($13,590 for a household of one, with an
increase of $4,270 for each additional person) may not qualify for either income-based Medicaid
or financial assistance for a Marketplace plan. Assisters should help consumers in this situation
understand that they may still qualify for Medicaid under their current state rules. For more
information, refer to Medicaid Coverage Gap below.
Assisters should understand that consumers who are lawfully present permanent residents are
eligible for Medicaid. In general, lawfully present immigrants must have a “qualified” immigration
status to be eligible for Medicaid or CHIP, and many, including most lawful permanent residents
or “green card” holders, must wait five years after obtaining qualified status before they may
enroll. Some immigrants with qualified status, such as refugees and asylees, do not have to wait
five years before enrolling. Some immigrants, such as those with temporary protected status,
are lawfully present but do not have a qualified status and are not eligible to enroll in Medicaid
or CHIP regardless of their length of time in the country.

Out-of-pocket Costs
Within limits, states can impose copayments, coinsurance, deductibles, and other similar
charges on most Medicaid-covered benefits. All out-of-pocket charges are based on the specific
state’s defined payment amount for that service. Out-of-pocket amounts vary depending on a
Medicaid beneficiary’s income. Certain groups, including children, individuals receiving hospice
care, and individuals residing in an institution, are exempt from cost sharing. Refer to your state
agency for details about Medicaid out-of-pocket costs. Cost sharing can never exceed five
percent of a household’s income. Exhibit 2 presents the maximum allowable out-of-pocket costs

1These amounts are 2022 guidelines, and poverty guidelines and income amounts are different for Alaska and
Hawaii. For more information, visit Aspe.HHS.gov/poverty-guidelines.
that beneficiaries at different income levels can expect to pay for certain Medicaid-covered
services (unless the state is operating with a waiver of cost-sharing limitations granted by the
Centers for Medicare & Medicaid Services). However, states have more flexibility around cost
sharing for higher-income children enrolled in CHIP.
Exhibit 2 – Maximum Allowable Copayments Determined by Eligible Population’s Household Income

Services and Supplies <100% of the FPL 101-150% of the FPL >150% of the FPL
10% of the cost the 20% of the cost the
Inpatient Hospital $91.60
agency pays agency pays
10% of the cost the 20% of the cost the
Outpatient Services $4.90
agency pays agency pays
Non-emergency use of No limit*
the Emergency $9.80 $9.80 *Must remain within the
Department 5% aggregate family cap
Preferred Drugs $4.90 $4.90 $4.90
20% of the cost the
Non-preferred Drugs $9.80 $9.80
agency pays

Medicaid and CHIP and Marketplace Coverage

If consumers are determined eligible for Medicaid or CHIP, they are not eligible to receive APTC
or CSRs through the Marketplace, even if they choose to decline Medicaid or CHIP coverage.
Consumers should immediately end Marketplace coverage with premium tax credits or other
cost savings for anyone in their household who is determined eligible for or already enrolled in
Medicaid or CHIP that counts as MEC. If dually enrolled consumers do not end their
Marketplace coverage with financial assistance, they will have to pay full cost for that coverage.
Throughout the coverage year, the Marketplace conducts periodic data matching (PDM) to
periodically check whether consumers are dually enrolled in Marketplace insurance with APTC
and Medicaid or CHIP. In accordance with guidance from the Internal Revenue Service (IRS), if
a Marketplace makes a determination or assessment that an individual is ineligible for Medicaid
or CHIP and eligible for APTC when the individual enrolls in Marketplace coverage, the
individual is treated as not eligible for Medicaid or CHIP for purposes of the premium tax credit
while they are enrolled in Marketplace coverage for that year. For more information on PDM,
refer to Medicaid & CHIP PDM FAQs at Marketplace.cms.gov/technical-assistance-
resources/medicaid-chip-periodic-data-matching-faq.pdf.
Consumers with limited Medicaid coverage should consider filling out an application through the
Health Insurance Marketplace®2 to find out if they qualify for comprehensive coverage through

2 Health Insurance Marketplace® is a registered service mark of the U.S. Department of Health & Human Services.
Medicaid, CHIP, or a Marketplace insurance plan with savings based on their income. When
consumers with limited Medicaid coverage fill out a Marketplace application, they should
indicate that they want to find out if they can get help paying for coverage, and they should not
check the box indicating they have Medicaid. Instead, if otherwise accurate, consumers should
check “Other” to indicate that they have other limited benefit coverage or they don’t have other
coverage at all. If otherwise eligible, most consumers with income that’s at least 100 percent of
the FPL can purchase a qualified health plan (QHP) through the Marketplace and be eligible for
help lowering the costs of coverage.

Medicaid and CHIP Enrollees and Special Enrollment Periods

There are several different Special Enrollment Period (SEP) types related to Medicaid and CHIP
loss and denials:
 Consumers who lose Medicaid or CHIP coverage (including pregnancy-related coverage
and medically needy coverage or aging out of CHIP coverage) can qualify for an SEP
due to their loss of coverage. They can access this SEP by applying at the Marketplace
and attesting to their loss of coverage.

 Consumers may qualify for an SEP if they applied for coverage at the Marketplace or
through their state Medicaid/CHIP agency during the Marketplace Open Enrollment
Period (OEP) and the state Medicaid or CHIP agency determines them ineligible for
Medicaid/CHIP after the OEP ended. They can access this SEP by submitting a
HealthCare.gov application and attesting to their Medicaid/CHIP denial.

This SEP is also available to consumers who apply for coverage through the Marketplace
after an SEP qualifying event, are assessed potentially eligible for Medicaid/CHIP, and
are determined Medicaid/CHIP ineligible more than 60 days after their original SEP
qualifying event.

 Consumers may qualify for an SEP if they become newly eligible for help paying for
Marketplace coverage because they moved to a different state and/or experienced a
change in income and they were previously both of these:
 Ineligible for Medicaid coverage because they lived in a state that hadn’t expanded
Medicaid.
 Ineligible for help paying for coverage because their household income was below
100 percent of the FPL.
They can access this SEP by calling the Marketplace Call Center and explaining their
situation. Once the Call Center confirms that they’re APTC eligible, the consumer’s
application will be escalated to a review team that will determine their SEP eligibility. After
 a determination is made, the Marketplace will send a notification to the consumer via
mail.
Consumers may visit HealthCare.gov/screener and answer a few questions to find out if they
may qualify for an SEP to enroll in or change plans. To receive a determination, consumers
should submit an application on HealthCare.gov. Consumers may also call the Marketplace Call
Center at 1-800-318-2596 (TTY: 1-855-889-4325) to enroll by phone and verify their SEP
eligibility. If consumers qualify for an SEP, they generally have 60 days after their SEP
qualifying event to newly select or change their Marketplace coverage. Note: Consumers
enrolling in Marketplace coverage for the first time may need to submit documents to prove they
qualify for an SEP. For more information about SEPs, visit HealthCare.gov/coverage-outside-
open-enrollment/special-enrollment-period. Consumers changing plans through an SEP may be
limited to choosing a new plan from their current plan category. For more information, visit
HealthCare.gov/coverage-outside-open-enrollment/changing-plans.

Medicaid and CHIP for Pregnant Women

Medicaid pays for nearly half of all births in the United States. With Medicaid coverage, pregnant
women get help paying for care related to pregnancy, labor, and delivery as well as postpartum
care for at least 60 days after birth, regardless of any change in household income. Babies born
to pregnant women who are receiving Medicaid on the date of delivery are automatically eligible
for Medicaid (known as "deemed newborns"). Medicaid eligibility continues until the child’s first
birthday, and citizenship documentation is not required.
Pregnant women who are receiving Medicaid on the date their pregnancy ends continue their
Medicaid coverage for a postpartum period that lasts for 60 days after the end of the pregnancy
and through the end of the month in which the 60-day period ends. After the postpartum period
ends, they may lose Medicaid eligibility. The American Rescue Plan Act of 2021, enacted March
11, 2021, gives states the option to extend Medicaid coverage for pregnant women beyond the
required 60-day postpartum period through the end of the month in which a 12-month
postpartum period ends. If adopted for Medicaid, the extended postpartum coverage election
applies automatically to a separate CHIP in the state for children who are pregnant and
pregnant women, as applicable. This state option begins on April 1, 2022, and is currently
authorized for five years from that date. Learn more about providing health coverage to lawfully
residing children and pregnant women in 2107(e)(1)(N) of the Social Security Act and SHO# 10-
006. For a list of states providing Medicaid and CHIP coverage to lawfully residing children
and/or pregnant women, visit Medicaid.gov/medicaid/enrollment-strategies/medicaid-and-chip-
coverage-lawfully-residing-children-pregnant-women.

Medicaid Coverage Gap

In states that have not expanded Medicaid to the adult group, many adults with incomes below
100 percent of the FPL are in what is known as a coverage gap. Their incomes are too high to
qualify for Medicaid under their state’s current rules and too low to qualify for help paying for
Marketplace coverage. Some consumers in the coverage gap include adults with no dependent
children or parents of dependent children whose household income is above the state’s
threshold for parents but below 100 percent of the FPL. Consumers in the coverage gap may:
 Fill out a Marketplace application. Each state has coverage options that could work for
the consumer, particularly if they have children, are pregnant, or have a disability. Also,
when they provide more detailed income information, they may qualify for help paying for
Marketplace coverage.
 Purchase Catastrophic coverage, which is available for people under 30 and people of
any age with a hardship exemption. Catastrophic plans usually have lower monthly
premiums than comprehensive plans but only cover certain preventive services and
worst-case scenarios, like serious accidents or illnesses. For more information, visit
HealthCare.gov/choose-a-plan/catastrophic-health-plans.
 Obtain health care services at federally qualified community health centers. These
centers provide services on a sliding scale based on the individual’s income. To find a
community health center near the consumer, visit HealthCare.gov/community-health-
centers.
 Explore the availability of pharmaceutical assistance programs. Some pharmaceutical
companies offer assistance programs that provide financial assistance or free products to
low-income individuals for the drugs they manufacture. To help consumers find out if
assistance is available for the medications they take, visit Medicare.gov/pharmaceutical-
assistance-program.
 Find out about other coverage options, including short-term, limited-duration insurance.
 Short-term, limited-duration insurance (STLDI) plans are generally not required to
comply with ACA provisions that apply to individual health coverage plans. STLDI
plans may not include coverage of essential health benefits and might also have
lifetime and/or annual dollar limits on health benefits. If STLDI coverage expires or
a consumer loses eligibility for this coverage, they may have to wait until an OEP
to get other health insurance coverage. They will not be eligible for an SEP to get
Marketplace coverage.

 For more resources, please refer to the Resources for the Uninsured webinar at
Marketplace.cms.gov/technical-assistance-resources/connecting-uninsured-to-health-
care-resources.pdf and the Health Coverage Options for the Uninsured fact sheet at
Marketplace.cms.gov/technical-assistance-resources/health-coverage-options-for-
uninsured.pdf.
Medically Needy Medicaid
States have the option to establish a “medically needy program” for individuals with significant
health needs whose income is too high to otherwise qualify for Medicaid under other eligibility
groups. Medically needy individuals can still become eligible for Medicaid by “spending down”
the amount of income that is above their state's medically needy income standard.
 Individuals spend down by incurring expenses for medical and remedial care for which
they do not have health insurance.
 Once an individual’s incurred expenses exceed the difference between the individual’s
income and the state’s medically needy income level (the “spend-down” amount), the
person can be eligible for Medicaid.
 The Medicaid program then pays the cost of services that exceeds the expenses the
individual had to incur to become eligible. They are not considered covered by MEC until
Medicaid begins paying the cost of their care.
 Some consumers who have medically needy coverage that consists of a
comprehensive state plan benefit and who do not have a spend-down requirement
may qualify for an SEP to enroll in a QHP through the Marketplace if they lose
their Medicaid medically needy coverage. Consumers in this situation should
answer “yes” to the Marketplace application question that asks if they recently lost
health coverage, and consumers should not attest to currently having Medicaid.
 Some states have elected to provide a less robust benefit to medically needy
consumers, and this coverage is not considered MEC. These individuals can
qualify for Marketplace coverage with APTC even though they also are eligible for
Medicaid medically needy coverage. However, they will not qualify for an SEP for
loss of Medicaid coverage if their medically needy coverage ends. Individuals with
spend-down coverage will also not qualify for an SEP.
A consumer does not have to accept medically needy Medicaid coverage and can instead elect
to enroll in a QHP through the Marketplace with financial assistance, if otherwise eligible. These
consumers should not attest that they have Medicaid on their Marketplace application.

Medicaid and CHIP Eligibility and Immigration Status

Qualified Non-citizens
Immigrants who are “qualified non-citizens” are generally eligible for Medicaid and CHIP
coverage if they meet their state’s other eligibility requirements, such as income and residency
rules.
In order to enroll in full Medicaid benefits or CHIP coverage, many qualified non-citizens, such
as many lawful permanent residents (LPRs, or “green card holders”), have a five-year waiting
period. 3 This means they must wait five years after receiving "qualified" immigration status
before they can be eligible for full Medicaid benefits and CHIP coverage, if they otherwise meet
all of the eligibility requirements in the state. For qualified non-citizens who have not met the
five-year waiting period or do not have satisfactory immigration status are only eligible for the
treatment of an emergency medical condition under Medicaid, if they otherwise meet all of the
other eligibility requirements in the state. 4 There are exceptions. For example, refugees and
asylees don’t have to wait five years to receive full Medicaid. 5 Exhibit 3 lists some Medicaid- and
CHIP- eligible qualified non-citizens who do and do not have a five-year waiting period. For
more information, visit HealthCare.gov/immigrants/lawfully-present-immigrants and
Macpac.gov/subtopic/noncitizens.
Exhibit 3 - Qualified Non-citizens Eligible for Medicaid and CHIP

Qualified Non-citizens With Five-year Waiting Qualified Non-citizens Without Five-year Waiting
Period Requirement Period Requirement

 Lawful Permanent Residents (LPR/Green Card  Refugees

Holder)  Asylees
 Paroled into the U.S. for at least one year  COFA migrants (applies to Medicaid and CHIP
 Conditional entrant granted before 1980 in states that have elected to cover children
 Battered non-citizens, spouses, children, or under 21 and/or pregnant women in CHIP under
parents the CHIPRA 214 option)
 Individuals with a pending application for a  Deportation is being withheld
victim of trafficking visa  Cuban and Haitian entrants
 Amerasians
 Active-duty military servicemembers, veterans,
and their spouses and dependent children
 Victims of trafficking and the individual’s spouse,
child, sibling, or parent
 LPRs who adjust from refugee, asylee, or some
other exempt qualified non-citizen status

Lawfully Residing Children and Pregnant Women

States have the option to cover all lawfully residing children under age 21 and/or pregnant
women in Medicaid or CHIP, including during the five-year waiting period. A child or pregnant
woman is lawfully residing for the purposes of Medicaid or CHIP eligibility if they’re lawfully
present and otherwise eligible for Medicaid or CHIP in the state of application. To find out if a

3 8 U.S.C. § 1613
4 8 U.S.C. § 1613; 42 C.F.R. § 435.406
5 8 U.S.C. 1612(b)
particular state has this option in place, visit Medicaid.gov/medicaid/outreach-and-
enrollment/lawfully-residing.

Emergency Care
Medicaid provides payment for treatment of an emergency medical condition for people who
meet all Medicaid eligibility criteria in the state (such as income and state residency) but are
ineligible for full Medicaid benefits if they don’t have a satisfactory immigration status.

Marketplace Savings
Lawfully present immigrants who have an estimated household income less than 100 percent of
the FPL and are not eligible for Medicaid due to their immigration status may be eligible for
APTC and CSRs for QHPs through the Marketplace if they meet all other eligibility
requirements. They may attest to their Medicaid denial on the Marketplace application, which
will help the Marketplace determine whether they are eligible for APTC and CSRs to help with
the costs of Marketplace coverage and covered services. By answering the question, “Was
[Person’s name] found not eligible for [state Medicaid program name] or [state CHIP program
Fname] based on their immigration status since [current year minus 5 years]?” as applicable,
consumers can enroll in Marketplace coverage with financial assistance if they are otherwise
eligible. More information about lawfully present immigrants’ eligibility for Medicaid and other
coverage options is available at HealthCare.gov/immigrants/lawfully-present-immigrants.

Tips for Enrolling Consumers in Medicaid or CHIP

Consumers can apply for and, if found eligible, enroll in Medicaid or CHIP at any time during the
year using the streamlined Marketplace application available at HealthCare.gov. The following
tips will help ensure that consumers receive accurate eligibility determinations and are able to
enroll in Medicaid, CHIP, or Marketplace coverage for which they are eligible.
 Instruct consumers to provide accurate income information, and inform them that the
Marketplace will check trusted data sources to verify their application data.
 Depending on their state’s rules and other factors, consumers will receive either
an eligibility determination or assessment notice from the Marketplace. Consumers
who are potentially eligible for Medicaid or CHIP may need to provide documents
to their state Medicaid or CHIP agency to verify application information and may
not be determined eligible for coverage until complying. Their state Medicaid or
CHIP agency will inform them of what information to provide and other important
details, as applicable.
 If the Marketplace cannot verify a consumer’s information and the applicant
appears potentially eligible for Marketplace coverage (with or without APTC and/or
 CSRs), the Marketplace will generate a data matching issue, and the consumer
will have 90 days to resolve the inconsistency.
 Help all members of a potentially mixed eligibility household who are seeking coverage to
apply for and enroll in coverage, as applicable. Different members of a household may be
eligible for different forms of health coverage. For example, an applicant may be eligible
for financial assistance through the Marketplace, the applicant’s child may be eligible for
CHIP, and the applicant’s spouse may be eligible for Medicaid due to disability.
 Explain to consumers how to file an appeal (sometimes referred to as a “fair hearing”) for
a Medicaid or CHIP eligibility denial. Appeal requests can be filed with the state Medicaid
agency or the Marketplace Appeals Entity (if the state in which the consumer resides has
delegated authority to the Marketplace Appeals Entity for appeals). Detailed information
about how to file an appeal and the options the consumer has regarding who will make
an appeal determination is included in the eligibility determination notice.
 If the state agency decides someone in a consumer’s household isn’t eligible for
Medicaid or CHIP, the consumer will get a notice from the state agency explaining this. In
most cases, the state will send the consumer’s information to the Marketplace. The
Marketplace will send a notice to the consumer explaining how to submit an application
for a private insurance plan and help paying for it.

Scenario
Medicaid Eligibility and Coverage Options in a Non-expansion State
Michael is a 29-year-old U.S. citizen who earns $11,000 per year. He lives in a state that has
not expanded Medicaid. He worries that a QHP through the Marketplace will be too expensive,
and he wants to better understand his coverage options. When assisting Michael to find health
coverage options, consider the following:
 Michael should submit a Marketplace application to determine his eligibility and indicate
on his application that he wants to find out if he can get help paying for coverage.
Household size, disability status, and other factors could make a difference in his
eligibility for Medicaid, even if his state has not expanded Medicaid to low-income, non-
elderly adults.
 Based on his income, Michael is not eligible for Medicaid under the adult group
(sometimes called the Medicaid expansion group) because his state has not expanded
Medicaid. If his state had expanded Medicaid, he would be income eligible under the
adult group. Because Michael earns less than 100 percent of the FPL ($13,590 per year
for a household size of one) and is a U.S. citizen, he does not qualify for financial
assistance to help with the costs of Marketplace coverage.
  Michael can receive health services at a federally qualified community health center or
the emergency room if he needs care in a hospital.
 Michael can purchase Catastrophic coverage without applying for a hardship exemption
since he is under 30 years old.

Additional Resources
For more information visit:
 Medicaid.gov
 InsureKidsNow.gov
 HealthCare.gov: Getting Medicaid & CHIP Coverage
 Medicaid and CHIP Eligibility
Appendix A: State Medicaid & CHIP Information
The Affordable Care Act promotes the coordination of state Medicaid and CHIP programs with the Health
Insurance Marketplaces. Each state must still have a single state agency to administer or supervise the
administration of the Medicaid program. As an assister, consumers may ask you questions regarding
specific Medicaid or CHIP eligibility requirements in their states. You may also encounter consumers who
have been assessed or determined eligible for Medicaid or CHIP by the Marketplace or referred to the
state Medicaid/CHIP agency for other reasons and require assistance with their application/enrollment.
Please refer consumers to these websites and agencies to help them find the information and assistance
they need.
Medicaid Program Medicaid Program CHIP Program CHIP Program
State
Name Website Name Website
Alabama Alabama Medicaid Medicaid.alabama.gov ALL Kids Adph.org/allkids
Agency
Alaska Alaska Medicaid Dhss.alaska.gov/dpa/p Denali KidCare Dhss.alaska.gov/dhcs/
ages/medicaid Pages/ denalikidcare
Arizona Arizona Health Azahcccs.gov AHCCCS KidsCare Azahcccs.gov/Member
Care Cost s/GetCovered/Categori
Containment es/KidsCare
System (AHCCCS)
Arkansas Arkansas Medicaid Medicaid.mmis.arkans ARKids First! Arkidsfirst.com
as.gov
California Medi-Cal Dhcs.ca.gov/services/ Medi-Cal Insurekidsnow.gov/cov
medi-cal erage/ca/index.html
Colorado Colorado Medicaid Colorado.gov/pacific/h Health First Colorado.gov/hcpf/chil
cpf/ colorado-medicaid Colorado d-health-plan-plus
Connecticut Connecticut Ct.gov/hh HUSKY Health Ct.gov/hh
Medicaid
Delaware Delaware Medical Dhss.delaware.gov/dh Delaware Healthy Dhss.delaware.gov/dss
Assistance ss/dmma/medicaid Children Program /dhcp
Program
District of DC Medical Dhcf.dc.gov/service/dc DC Healthy Dhcf.dc.gov/service/dc-
Columbia Assistance -healthy- families Families healthy-families
Administration
Florida Florida Medicaid Myflfamilies.com/servi Florida KidCare Floridakidcare.org
ce- programs/access-
florida-food-medical-
assistance-
cash/medicaid
Georgia Georgia Medical Medicaid.georgia.gov PeachCare for Kids Dch.georgia.gov/peach
Assistance care-kids
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State
Name Website Name Website
Hawaii Hawaii Medicaid Humanservices.hawaii My Medical Humanservices.hawaii.
.gov/mqd Benefits gov
Idaho Idaho Medicaid Healthandwelfare.idah Idaho Health Plan Healthandwelfare.idah
Program o.gov/Me for Children o.gov
dical/Medicaid
Illinois Illinois Medical Illinois.gov/hfs All Kids Illinois.gov/hfs/Medical
Assistance Programs/AllKids
Indiana Indiana Medicaid Medicaid/members Hoosier Healthwise In.gov/medicaid/memb
ers
Iowa Iowa Medical Dhs.iowa.gov/iahealthl Hawk-I Dhs.iowa.gov/hawki
Assistance ink
Kansas KanCare Kdhe.ks.gov/183/Kan KanCare Kdhe.ks.gov/183/KanC
Care-Medicaid are-Medicaid
Kentucky Kentucky Medicaid Chfs.ky.gov/agencies KCHIP Kidshealth.ky.gov
Louisiana Louisiana Medicaid Ldh.la.gov LaCHIP Ldh.la.gov
Maine MaineCare Maine.gov/dhhs/maine Cub Care Maine.gov/dhhs/oms/m
care ainecare-
options/children
Maryland Maryland Medicaid Health.maryland.gov/ Maryland Health.maryland.gov/m
Program mmcp/pages/home.as Children’s Health mcp/chp/pages/home.a
px Connection spx
Program (MCHP)
Massachusetts MassHealth Mass.gov/topics/mass MassHealth Mass.gov/topics/massh
health ealth
Michigan Michigan Medicaid Michigan.gov/mdhhs MIChild Michigan.gov/mdhhs
Minnesota Minnesota Medical Mn.gov/dhs/people- Medical Assistance Insurekidsnow.gov/cov
Assistance we- (MA) erage/mn
serve/adults/health-
care/health-care-
programs/programs-
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Mississippi Mississippi Medicaid.ms.gov Mississippi Health Insurekidsnow.gov/cov
Medicaid Benefits CHIP erage/ms
Missouri MO HealthNet Mydss.mo.gov/healthc MO HealthNet for Mydss.mo.gov/healthc
are Kids are/mohealthnet-for-
kids
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State
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Montana Montana Medicaid Dphhs.mt.gov/Montan Healthy Montana Dphhs.mt.gov/HMK/ind
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Nebraska Nebraska Medicaid Dhhs.ne.gov/Pages/M Nebraska CHIP Dhhs.ne.gov/Pages/Me

edicaid-and-Long- dicaid-Eligibility
Term-Care
Nevada Nevada Medicaid Nevadahealthlink.com Nevada Check Up Nevadahealthlink.com/
start-here/about-the-
aca/medicaid
New New Hampshire Dhhs.nh.gov/ombp/me Expanded Dhhs.nh.gov/dfa/medic
Hampshire Medicaid dicaid Children’s Medicaid al/children
New Jersey New Jersey State.nj.us/humanserv NJ Family Care Njfamilycare.org
Medicaid ices/dmahs/clients/me
dicaid
New Mexico New Mexico Hsd.state.nm.us/Looki Centennial Care Benefits.gov/benefit/13
Medicaid ngForAssistance/cent 19
ennial-care-overview
New York New York Medicaid Health.ny.gov/health_ Child Health Plus Health.ny.gov/health_c
care/medicaid are/child_health_plus
North Carolina North Carolina Medicaid.ncdhhs.gov/ NC Health Choice Medicaid.ncdhhs.gov/
Medicaid medicaid for Children medicaid
North Dakota North Dakota Nd.gov/dhs/services/m Healthy Steps Nd.gov/dhs/services/m
Medicaid edicalserv/medicaid edicalserv/chip
Ohio Ohio Medicaid Medicaid.ohio.gov Healthy Start Medicaid.ohio.gov/FO
R-
OHIOANS/Programs/C
hildren-Families-and-
Women
Oklahoma SoonerCare Okdhs.org/services/he SoonerCare Okdhs.org/services/he
alth/Pages/soonercare alth/Pages/soonercare
Oregon Oregon Health Plan Oregon.gov/oha/HSD/ Oregon Health Plan Oregon.gov/oha/HSD/
OHP OHP
Pennsylvania Pennsylvania Dhs.pa.gov/Services/A Pennsylvania CHIP Chipcoverspakids.com
Medical Assistance ssistance/Pages/Medi
cal-Assistance
Rhode Island Rhode Island Healthyrhode.ri.gov RiteCare Eohhs.ri.gov/Consume
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State
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South Carolina Healthy Scdhhs.gov/Getting- Partners for Scdhhs.gov/eligibility-
Connections Started Healthy Children groups/partners-
healthy-children-phc
South Dakota South Dakota Dss.sd.gov/medicaid South Dakota CHIP Dss.sd.gov/medicaid
Medicaid
Tennessee TennCare Tn.gov/tenncare Cover Kids Tn.gov/content/tn/cove
rkids/coverkids
Texas Texas Medicaid HHS.texas.gov/service Texas CHIP HHS.texas.gov/service
s/health/medicaid-chip s/health/medicaid-chip
Utah Utah Medicaid Medicaid.utah.gov Utah CHIP Chip.health.utah.gov
Vermont Green Mountain Dvha.vermont.gov/me Dr. Dynasaur Med.uvm.edu/vchip/ho
Care mbers me
Virginia Virginia Medical Commonhelp.virginia. Family Access to Coverva.org/famis
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Washington Medicaid State Hca.wa.gov/health- Apple Health Hca.wa.gov/health-
Plan care-services- care-services-
supports/apple-health- supports/apple-health-
medicaid-coverage medicaid-coverage
West Virginia Mountain Health Dhhr.wv.gov/bms West Virginia CHIP Chip.wv.gov
Choices
Wisconsin Wisconsin Dhs.wisconsin.gov/ba BadgerCare Plus Dhs.wisconsin.gov/bad
Medicaid dgercareplus gercareplus
Wyoming EqualityCare Health.wyo.gov/health Kid Care CHIP Health.wyo.gov/healthc
carefin/apply arefin/chip