Medicaid works differently in every state. Select your state above to personalize this page. Then learn your MCO, your card, your benefits, and what to do when something is denied.
Personalize this page
Select your state
Medicaid varies by state. Set your state once and we will show your specific program name, phone, and rules throughout this page.
Pick a topic below. Open one to see specific situations. Open a situation to see plain steps. Stop at any depth that answers your question. Or search across all of it.
Cards and enrollment · Just enrolled
Five things to do this week
Medicaid coverage starts the day your application is approved, but using it well requires a few setup steps. Here is the order most people should take.
1
Find out which managed care plan you were assigned
Most states auto-assign new enrollees to a managed care organization (MCO). Your enrollment letter or member portal will tell you. You usually have 30 to 90 days to switch to a different plan if you want to.
2
Look up your providers in your MCO's directory
Your existing doctors may or may not be in your MCO's network. Check before scheduling. If they are not, you can either switch doctors or switch MCOs while your window is open.
3
Pick up your member card or print it from the portal
You will receive a Medicaid card from your state and (if applicable) a separate MCO card. Carry both. Some states have moved to digital-only cards on the member portal.
4
Set up your state Medicaid online account
Almost every state has a portal where you can view your coverage, find providers, see claim status, and report changes. Set this up while you have time.
5
Identify your renewal date
Medicaid coverage is reviewed every 12 months. Most coverage losses happen because someone missed their renewal paperwork. Mark the date now and watch for mail.
A SHIP counselor can walk through this with you, free
Even though SHIP focuses on Medicare, many counselors also help with Medicaid setup. shiphelp.org or call 877-839-2675.
Medicaid does not always go by the name "Medicaid." Most states have given their program a brand name, and using the right one matters. When you call a doctor and ask "do you take Medicaid?", you may get a different answer than if you used your state's specific name.
There are good reasons states rebrand. A state-specific name can reduce stigma, distinguish managed care plans from traditional fee-for-service Medicaid, and signal that the program is locally administered. The downside is that providers, billers, and even other Medicaid recipients may use the brand name and the federal name interchangeably or inconsistently. The practical effect is that you should always know both: the federal program (Medicaid) and your state's specific brand. Use the state name first when calling providers, since that's usually how they have you in their system.
Pick your state above to see your program name and contact information. Otherwise, the section below shows generic Medicaid information.
Your state's program name
In your state, Medicaid is called your state Medicaid program. Use this name when scheduling appointments, asking providers about coverage, and on any forms that ask which insurance you have.
Your state Medicaid agency phone
For questions about your enrollment, eligibility, benefits, or to find out which managed care plan you're assigned to: your state Medicaid hotline. Have your member ID handy when you call.
Your state Medicaid agency website
For applications, member portals, provider directories, and benefit details specific to your state: your state Medicaid website.
Expansion status
Your statehas expanded or has not expanded Medicaid under the Affordable Care Act. This affects who qualifies: in expansion states, adults with income up to 138% of the federal poverty level qualify regardless of disability or family status. In non-expansion states, eligibility for adults is limited to specific categories like disability, pregnancy, or caretakers of minor children.
About 75% of Medicaid enrollees nationwide get their coverage through a private managed care organization (MCO) that contracts with the state. Most are auto-assigned. Knowing your MCO matters because your network, prior authorizations, and customer service all run through them.
What an MCO is
A private health insurance company contracted by your state to manage your Medicaid coverage. The state pays them a fixed amount per member per month. The MCO is responsible for your care network, prior authorizations, and most member services.
How auto-assignment works
When your application is approved, the state assigns you to an MCO based on factors like geographic area, your existing doctors if they can identify any, family member assignments, or simply rotation. You receive a notice telling you which MCO you were assigned to.
You can usually switch MCOs
Most states give you a 30 to 90 day window to switch to a different MCO without needing a reason. After the window closes, you typically can only switch during an annual open enrollment period or with a qualifying event.
How to compare MCOs
Look at provider networks (do your doctors take that MCO?), prescription drug formularies (are your medications covered?), prior authorization rules, customer service ratings, and any extra benefits like dental, vision, or wellness programs.
Fee-for-service Medicaid
A minority of enrollees, mostly those with the most complex needs (dual eligibles, certain disabilities, certain long-term care recipients), are in fee-for-service Medicaid where the state pays providers directly. There is no MCO. The state is your point of contact.
Cards and enrollment · Your card
Your member card
You may have one card or two depending on your state and whether you are in managed care.
Your state Medicaid card
Issued by your state Medicaid agency. Shows your name, member ID, and effective date. Carry this even if you have an MCO card. Some providers verify eligibility through this number.
Your MCO card
If you are in managed care, your MCO sends you a separate card. Shows your MCO's logo, your member ID with that MCO, the customer service phone number, and pharmacy benefit information. Use this card at appointments and pharmacies.
Lost or stolen card
Call your MCO's member services for a replacement MCO card. For a replacement state card, contact your state Medicaid agency. Most states allow you to print a temporary card from their online portal while you wait.
Mobile member card
Most MCOs and many states now offer a mobile app or web-based digital card. Some providers prefer the digital version because it shows real-time eligibility status.
Cards and enrollment · Before you go
Before your first visit
A few minutes of preparation prevents the most common Medicaid billing problems and care delays.
1
Confirm the provider takes your specific MCO
Call the office and ask: "Are you in-network for [your MCO name]?" Not "do you take Medicaid?" Those are different questions. Online directories can be months out of date.
2
Bring all your cards
Your state Medicaid card, your MCO card, and any other coverage cards (Medicare if dual eligible, Part D if applicable). Providers often need to see all of them.
3
Bring a current medication list
Names, doses, frequencies. Helpful for any appointment, but particularly important on Medicaid where formularies can shift between MCOs.
4
Know whether you need a referral
On most managed care plans, seeing a specialist requires a referral from your primary care provider. Get the referral before scheduling the specialist visit, not after.
Doctors and networks · Finding a provider
Finding a doctor
Finding a Medicaid provider works differently depending on whether you are in managed care or fee-for-service. The starting point is also different by state.
1
If you have an MCO, start with the MCO's directory
Your MCO has an online provider directory and a member services phone line. Both should show real-time network status. Use the MCO's tools first because they are the authoritative source for what is in-network.
2
Verify by calling the office directly
Online directories can lag. Call the office and ask: "Are you currently in-network for [your specific MCO name]?" and "Are you accepting new Medicaid patients?"
3
If you are in fee-for-service, use your state directory
Most state Medicaid agencies have a "find a provider" tool on their website. The state pays providers directly, so any Medicaid-enrolled provider in your area can see you.
4
When you cannot find a doctor, try a Federally Qualified Health Center
FQHCs accept all patients regardless of insurance or ability to pay. Costs are based on a sliding scale. Find one at findahealthcenter.hrsa.gov.
Doctors and networks · Network status
In-network and out-of-network
On managed care, going to an out-of-network provider can mean the visit is not covered at all. Knowing your network is one of the most consequential things on Medicaid.
In-network
A provider who has signed a contract with your specific MCO. Visits are covered with little or no out-of-pocket cost. The provider bills the MCO directly.
Out-of-network
A provider who has not signed a contract with your MCO. Most non-emergency visits are not covered. The provider can sometimes balance-bill you for the full charge.
Emergency care exception
Federal Medicaid law requires emergency care to be covered regardless of network. If you have a real emergency, go to the nearest ER. The hospital cannot refuse you.
Out-of-area travel
Most MCO networks are limited to your service area. Care while traveling is generally not covered except for emergencies. Plan ahead if you need routine care while traveling.
What to do if a needed specialist is not in-network
Ask your MCO for a network exception or out-of-network authorization. If your MCO's network does not include a specialist you medically need, federal law requires them to provide access at in-network cost-sharing.
Doctors and networks · Authorizations
Referrals and prior authorization
Most Medicaid managed care plans require referrals before specialist visits and prior authorization before certain services. Getting these right prevents denials.
Referrals
Permission from your primary care provider (PCP) to see a specialist. Required by most MCOs. Without one, the specialist visit may not be covered. Schedule with your PCP first to get the referral.
Prior authorization
Permission from your MCO to receive a specific service. Required for things like hospital admissions, advanced imaging (MRI, CT), durable medical equipment, certain medications, and some procedures. The provider's billing staff submits the request.
How long approval takes
Standard requests must be decided within 14 days under federal Medicaid managed care rules. Expedited requests for urgent care must be decided within 72 hours. Some states have shorter timelines.
If prior authorization is denied
You have the right to appeal. The denial notice includes the appeal process and the deadline. See the Denials and Appeals section for the full process.
Doctors and networks · Getting there
Medical transportation
Federal Medicaid law requires every state to cover non-emergency medical transportation (NEMT) for enrollees who have no other way to get to medical appointments. This benefit is significantly underused.
What NEMT covers
Rides to and from covered medical appointments when you have no other way to get there. Includes rides to specialist visits, dialysis, mental health appointments, and pharmacies.
How to request a ride
Call your MCO's transportation phone line (on your member card) or your state's NEMT broker. In most states, you must call at least 2 to 3 business days in advance. Same-day rides are generally for urgent care only.
What is provided
Depending on your medical need, this might be a public transit pass, a taxi, a wheelchair-accessible van, or a non-emergency ambulance. The least costly appropriate option is provided.
Mileage reimbursement
In some states, you can be reimbursed for driving yourself or having a friend or family member drive you. Ask your state agency or MCO about this option.
Doctors and networks · Safety net
Federally Qualified Health Centers
FQHCs are community health centers that receive federal funding to provide care regardless of insurance status or ability to pay. They serve everyone, but they are particularly important for Medicaid enrollees because every FQHC accepts every state's Medicaid.
What FQHCs are
Federally funded health centers serving medically underserved areas or populations. They include community health centers, migrant health centers, health care for the homeless programs, and public housing primary care centers. About 1,400 organizations operating around 14,000 sites nationwide.
What they offer
Primary care, preventive services, mental health, substance use treatment, dental in many cases, and pharmacy. Many also offer transportation, translation, and case management.
Cost on Medicaid
No copays, no deductibles, no out-of-pocket cost for any covered service.
Cost without insurance
Sliding fee scale based on family size and income. No one is turned away for inability to pay.
Federal Medicaid law requires every state to cover certain services. These benefits cannot vary by state. Whether you are in Texas, Vermont, or Hawaii, your Medicaid covers all of these.
Inpatient and outpatient hospital services
Both emergency and scheduled hospital care.
Physician services
Visits to medical doctors for medical reasons.
Lab and X-ray services
Diagnostic testing as ordered by a provider.
Family planning services and supplies
Birth control, counseling, related services.
Federally Qualified Health Center and Rural Health Clinic services
Care from these federally designated providers.
Nurse midwife and certified pediatric and family nurse practitioner services
Care from advanced practice nurses.
Nursing facility services for adults 21 and older
Skilled nursing facility care when medically necessary.
Home health services for those eligible for nursing facility care
Skilled home-based care as alternative to facility.
EPSDT for those under 21
Early and Periodic Screening, Diagnostic, and Treatment for children. Comprehensive child health services.
Transportation to medical care
Non-emergency medical transportation when needed.
Tobacco cessation counseling for pregnant women
Support to quit smoking during pregnancy.
Coverage and benefits · State choices
State optional benefits
Federal law sets a floor of services that every state must cover. Beyond that floor is a long list of services states can choose to cover. This is where Medicaid varies most across the country, and where most coverage surprises happen.
The federal government and your state share the cost of Medicaid. To get federal matching dollars, your state has to cover certain mandatory services (hospital, doctor visits, lab work, nursing home care, and a handful of others). Beyond that, each state legislature decides which of about thirty-three optional categories to also cover. Some states are generous; others cover the bare minimum. Your benefits are not just a function of the program, they are a function of the state you live in. The same person could move across a state line and lose adult dental coverage entirely, or gain hearing aid coverage they did not have before.
For older adults, three categories matter most: adult dental, hearing aids, and vision/glasses. These are the most likely to be partially covered, capped, or excluded entirely. They are also the services people most often need and find missing when they go to use them. Always check your state's specific coverage before assuming a service is included, especially for these three.
Pick your state above for a direct link to your state's benefit list. Otherwise, the snapshot below shows the typical 2026 pattern across states.
For the specific list of optional benefits your state has chosen to cover, see your state Medicaid website or call your state Medicaid hotline. The categories below tell you what to ask about.
Prescription drugs
Technically optional under federal law, but every state covers prescriptions because Medicaid would be untenable without them. The variation is in how: which specific drugs are on the formulary, what tier they sit on, and whether prior authorization or step therapy is required. Always check your specific medications against your plan's formulary.
Adult dental
The biggest variation. Roughly half of states cover comprehensive adult dental (cleanings, fillings, dentures, extractions). The other half cover only emergency dental (acute pain, infection) or nothing at all for adults. Children's dental is federally mandated, so this is specifically an adult issue. If your state does not cover what you need, dental schools and federally qualified health centers often offer sliding-scale care.
Adult vision
About two-thirds of states cover routine eye exams for adults. Coverage of glasses is more limited; many states cover them only after cataract surgery or for specific conditions. If glasses are not covered, look for vouchers from Lions Clubs International or local vision charities, and check eyeglass discount programs available through Medicaid health plans.
Hearing aids
Historically excluded by most states for adults, this is changing. As of 2026, a growing number of states have added partial hearing aid coverage, often with annual or per-ear caps in the $500 to $2,500 range. Check your state's specific benefit; if not covered, the over-the-counter hearing aid market (legalized in 2022) now offers reasonable options starting around $200 to $500 per pair.
Physical, occupational, and speech therapy
Generally covered by most states when medically necessary, but with significant variation in visit limits. Some states cap therapies at 20 to 30 visits per year per type. If you need more, your provider can request additional visits with documentation; an appeal is possible if denied.
Mental health and substance use treatment
All states cover these to some degree, both because they are partially mandatory under federal mental health parity laws and because Medicaid is the largest payer of behavioral health in the U.S. The variation is in which specific services (e.g., intensive outpatient, residential treatment) are available and the size of the provider network.
Durable medical equipment
Wheelchairs, walkers, hospital beds, oxygen, CPAP machines, and similar are covered in most states. Most require prior authorization, especially for higher-cost items. If denied, your provider can submit medical necessity documentation; appeals are common and often successful when properly supported.
Personal care services in your home
Help with daily activities like bathing, dressing, and meal preparation. Coverage varies dramatically. Some states cover this generously through their state plan; others limit it severely or only cover it through HCBS waivers with wait lists. This is one of the most consequential gaps for older adults aging in place.
Hospice care
All states have the option to cover hospice and most do. End-of-life comfort care, family bereavement support, and pain management are typically included.
Adult day care
Daytime care and supervision in a community setting, valuable for older adults whose family caregivers work during the day. Limited state plan coverage; more often available through HCBS waivers.
Every state covers prescription drugs as part of its Medicaid program, but how it is delivered varies. Most enrollees get prescriptions through their MCO; others get them directly through the state.
Formulary
The list of drugs covered by your plan. State Medicaid programs and MCOs each maintain their own formulary. Your specific medications may or may not be on it.
Preferred Drug Lists
Within a formulary, drugs are tiered. Preferred drugs require no prior authorization. Non-preferred drugs require prior authorization or step therapy.
Step therapy
You may be required to try a lower-cost drug first before a higher-cost drug is approved. Your prescriber can request an exception when medically necessary.
Copay structure
Federal rules limit Medicaid copays. For most enrollees, the maximum is $4 for preferred generic drugs and $8 for preferred brand-name drugs. Some states and some categories of enrollees have $0 copay.
340B and pharmacy networks
MCOs negotiate networks with pharmacies. Most major chain pharmacies and independent pharmacies participate. Mail order is often available.
Brand vs generic
Substitution to generic is usually required unless your prescriber writes "dispense as written" with documented medical necessity.
Coverage and benefits · LTSS
Long-term services and supports
Medicaid is the largest payer of long-term care in the United States. It covers nursing home care, and through home and community-based waivers, it covers care that lets people stay in their homes.
Nursing facility care
Federally mandated. Every state Medicaid program covers nursing home care for those who need it and qualify financially. Includes room, board, skilled nursing, therapy, and personal care.
Eligibility for nursing facility coverage
Two tests must be met: financial (low income and limited assets) and functional (you need the level of care a nursing facility provides). Asset limits and income rules vary by state.
Spend-down
In many states, you can qualify by spending excess income on medical expenses each month, "spending down" to the eligibility level. The mechanics are state-specific.
Look-back period
States review the past 5 years of asset transfers. Gifts or transfers below market value can trigger a penalty period of ineligibility. An elder law attorney can help structure assets legally before need becomes urgent.
Spousal protections
When one spouse needs nursing facility care and the other does not, federal law protects a portion of assets and income for the at-home spouse (the "community spouse").
Estate recovery
After a Medicaid recipient dies, states are required to seek recovery from the estate for long-term care costs paid. Rules vary by state. There are hardship exceptions.
Long-term care planning takes years
Asset and income planning for Medicaid is significantly more effective when done in advance. An elder law attorney can advise on legal strategies.
Coverage and benefits · Home and community
Home and community-based waivers
Most older adults prefer to stay in their homes rather than move to a facility. Home and Community-Based Services (HCBS) waivers let states use Medicaid funds to pay for care at home, in assisted living, or in adult day programs instead of nursing homes.
What HCBS waivers cover
Personal care assistance (help with bathing, dressing, eating), home health aide services, adult day care, respite care for family caregivers, home modifications, assistive technology, transportation, and case management.
How they work
Each state designs its own waiver programs and applies for federal approval. Slot availability is limited; many states have wait lists.
Eligibility
Same financial eligibility as nursing facility Medicaid, plus a determination that you would otherwise need nursing facility level of care if not for these services.
Wait lists
Many states have wait lists for HCBS waiver slots, sometimes years long. Apply as early as possible if you anticipate needing services.
1915(c) versus 1915(i)
Most HCBS waivers are 1915(c) waivers. Some states also offer 1915(i) state plan services that do not require institutional level of care.
PACE programs
The Program of All-Inclusive Care for the Elderly serves dual eligibles 55+ who would otherwise need nursing home care. Combines Medicare and Medicaid funding into one comprehensive program.
Apply for HCBS even if you do not need it yet
If you anticipate needing services, getting on the wait list early is important. Wait list time can exceed years in some states.
Coverage and benefits · Gaps
Coverage gaps to know
Medicaid covers a lot, but not everything. The gaps below are the most common surprises. Knowing them in advance lets you plan: confirm coverage before scheduling, set up backup options for non-covered services, and avoid the bills that come from assuming something is covered when it is not.
Medicaid coverage gaps fall into two categories: federal exclusions (services no Medicaid program covers anywhere) and state choices (services your specific state does not cover, even though some other state might). The federal exclusions below are firm. The state choices vary, and your specific state's benefit list will tell you which apply to you.
Out-of-network non-emergency care
If you're in a managed care plan (MCO) and you see a provider who's not in your MCO's network, the visit will not be covered for non-emergency care. The exception is true emergencies, which are covered anywhere in the U.S. To verify a provider is in-network, call your MCO's member services line (number on the back of your member card) before scheduling. Do not rely on online directories alone, they often lag months behind.
Adult dental, vision, and hearing in many states
These are state-optional. Children's versions are federally mandated, but adult coverage varies. Roughly half of states cover comprehensive adult dental; the rest cover only emergency dental or nothing. Adult vision tends to be covered for exams but limited for glasses. Hearing aids are excluded by most states for adults, though a growing number have begun adding partial coverage with annual caps. Check your state's benefit list, or for the deepest detail, see our state-specific coverage page.
Cosmetic procedures
Federal exclusion. Procedures that are purely cosmetic (not medically necessary) are not covered by any Medicaid program. The line gets fuzzy for procedures that are reconstructive after illness, injury, or congenital conditions, those can be covered with proper medical documentation. If a procedure has both cosmetic and medical components, your provider can help frame the medical necessity in the prior authorization request.
Care outside the United States
Federal exclusion. Medicaid does not cover any care delivered outside the U.S., even in emergencies. If you travel internationally, plan for travel insurance separately. The few exceptions involve emergency care in a U.S. territory or near a Canadian/Mexican border crossing where the closest hospital is in the other country, and these are case-by-case.
Experimental and investigational treatments
Treatments that are not yet considered standard of care, or are part of a clinical trial, are generally not covered. The boundary between "standard" and "experimental" shifts as evidence accumulates. If a treatment was denied as experimental, ask your provider about the medical literature supporting it, an appeal with strong evidence sometimes succeeds. Also ask whether the trial itself covers treatment costs (many do).
Care provided before your eligibility date
Bills from before your Medicaid eligibility started are generally not covered, even if you would have been eligible at the time. The exception is retroactive coverage: most states will cover medical expenses for the 3 months before your application, if you would have qualified during that period. You have to specifically request retroactive coverage when applying or shortly after, your caseworker can confirm.
Long-term services in some non-expansion states
Long-term care (nursing home, in-home care) is federally mandatory, but eligibility for adults under 65 without disabilities is much narrower in non-expansion states. If you're under 65 in a non-expansion state and you need long-term care, eligibility may require establishing a disability claim first, which adds time. Plan ahead.
Verify before, not after
Most coverage surprises happen because patients assumed a service was covered. A 5-minute call to your MCO before any non-routine visit, prescription, or procedure prevents almost all of them. The number is on the back of your member card.
Most Medicaid services are no-cost. If you receive a bill from a provider for a Medicaid-covered service, it usually means something went wrong with billing, not that you owe the money.
1
Confirm the visit was for a Medicaid-covered service
If the service is covered by Medicaid and you saw an in-network provider, you should not be billed beyond any small copay your state allows.
2
Verify your Medicaid was active on the date of service
Sometimes bills arrive because the provider did not have your current eligibility on file. Call the provider with your Medicaid information and ask them to rebill.
3
If billed for an out-of-network visit, contact your MCO
If your MCO directed you to an out-of-network provider, or if no in-network provider was available, the visit should still be covered. The MCO can resolve this with the provider.
4
If a provider continues to bill you for a covered service, file a complaint
It is illegal in most circumstances for a Medicaid provider to balance-bill an enrolled patient. Contact your state Medicaid agency to file a complaint.
Do not pay before investigating
Once you pay, recovering money is much harder than preventing payment. If something looks wrong, call before paying.
Bills and cost-sharing · Premium states
States with premiums
A handful of states charge a small monthly Medicaid premium to certain enrollees, generally those with higher incomes within Medicaid limits or in expansion populations. The amounts are limited by federal law.
Federal premium limits
Federal law caps Medicaid premiums. For most enrollees, premiums cannot exceed 5% of family income on a quarterly basis. Most states either charge nothing or charge well below the cap.
States that charge premiums for some enrollees
States including Indiana, Michigan, Wisconsin, and Iowa charge small premiums to certain populations, particularly higher-income expansion enrollees. The specific amounts and populations vary year to year.
Consequences of not paying
In some states, missing premium payments can result in disenrollment from coverage. The rules vary. Contact your state agency to set up a payment plan if you are struggling.
Premium assistance
If your premium causes financial hardship, your state may have a hardship exception or sliding scale. Ask.
Bills and cost-sharing · Copays
Copay rules
Federal Medicaid law allows states to charge small copays for some services. The amounts are very limited, and many enrollees are exempt entirely.
Maximum copay amounts
Federal limits cap most Medicaid copays at small amounts. Common maximums: $4 for preferred generic drugs, $8 for non-preferred or brand-name drugs, $4 for non-emergency use of the ER, and small amounts for inpatient stays. Higher copays apply only to certain higher-income groups.
Who is exempt from copays
Children under 18, pregnant women (for pregnancy-related services), people in nursing facilities or HCBS, people receiving hospice, and many emergency services. Federally Qualified Health Centers also cannot collect copays for many services.
Total cost-sharing cap
Federal law caps total Medicaid out-of-pocket spending at 5% of family income on a quarterly basis. Once you reach this limit, you should not be charged more. Track your copays and notify your MCO when you reach the cap.
Cannot deny care for inability to pay
For most populations, providers cannot refuse to provide a covered service because you cannot pay the copay. They can still bill you for it later.
Bills and cost-sharing · Errors
A bill looks wrong
Provider billing errors are common in Medicaid. Most resolve with a single phone call.
You were billed for a covered service
Call the provider's billing department. Confirm they have your current Medicaid information and ask them to rebill. If they refuse, contact your MCO or state Medicaid agency.
You were balance-billed
A Medicaid provider cannot bill you for the difference between their charge and what Medicaid paid. This is illegal in almost all circumstances. Report to your state Medicaid agency.
Wrong amount on a permitted copay
If a copay was charged at more than the federal limit, request a refund. Federal limits are small and easy to look up.
A service you never received
This may be Medicaid fraud. Report to your state's Medicaid Fraud Control Unit. Find yours at oig.hhs.gov.
Bills and cost-sharing · Spend-down
Spend-down programs
In many states, people whose income is above the standard Medicaid eligibility limit can still qualify by "spending down" to the level through medical expenses. This is sometimes called the "Medically Needy" program.
How spend-down works
You report your income and your medical expenses to your state Medicaid agency for a defined period (typically 1 to 6 months). When your medical expenses bring your effective income below the eligibility threshold, you qualify for that period.
What counts as medical expenses
Doctor bills, hospital bills, prescription drug costs, durable medical equipment, dental and vision care, transportation to medical care, health insurance premiums, and certain other expenses. Rules vary by state.
Documentation
You generally need to keep receipts and bills as proof. Some states require you to submit them; others use an honor system with verification.
States with spend-down
About 33 states plus DC have a Medically Needy program. The remaining states do not, which means people above the income limit cannot qualify even with high medical expenses.
How to apply
Through your state Medicaid agency. Ask specifically about the Medically Needy program or spend-down option.
Denials and appeals · Service denied
A service was denied
Medicaid denial appeals are protected by federal law. You have the right to a fair hearing before an impartial reviewer, and in many cases, you can keep receiving the service while you appeal.
1
Find the denial notice and read why
The notice must tell you what was denied, why, and how to appeal. Common denial reasons: not medically necessary, not a covered service, prior authorization not obtained, lacks documentation.
2
Note the appeal deadline
Federal law gives you at least 90 days to appeal. Some states have shorter MCO appeal timelines (typically 60 days for the internal MCO appeal).
3
Decide if you want to keep the service while appealing
If the denial is for a service you were already receiving, you can usually request "continuation of benefits" if you appeal within 10 days of the notice. Be aware: if you lose the appeal, you may have to repay the cost.
4
File the appeal in writing, by the deadline
For managed care, file the internal MCO appeal first. If the MCO upholds the denial, you can then request a state fair hearing. Keep copies of everything.
Two-step process under managed care
In most states, MCO enrollees must first complete the MCO's internal appeal before requesting a state fair hearing. Each step has its own deadline.
Denials and appeals · Coverage during appeal
Continuation of benefits
If you are already receiving a service and Medicaid (or your MCO) decides to reduce, suspend, or terminate it, you may be able to keep receiving it during your appeal. This is one of the most important Medicaid rights.
When continuation is available
For services you were already authorized to receive that are being reduced, suspended, or terminated. Not for newly requested services that were denied.
How to request it
You must request continuation of benefits before the action takes effect. Most states require the request within 10 days of the notice date. Filing the appeal alone may not trigger continuation; specifically request continuation of benefits in writing.
What you must agree to
If you lose the appeal, you may have to repay the state for services you received during the appeal. Read the waiver carefully before signing.
Who decides quickly
For "expedited" appeals (cases where waiting could seriously harm you), federal law requires a decision within 72 hours.
Denials and appeals · Prior authorization
Prior authorization in Medicaid
Like Medicare Advantage plans, most Medicaid managed care plans require prior authorization for certain services. The federal rules are stricter than for Medicare Advantage in some respects.
When prior authorization is required
Hospital admissions, advanced imaging, certain surgeries, durable medical equipment, certain medications, and out-of-network care. Each MCO publishes its prior authorization list.
Who submits the request
Your provider's billing or referral staff. You generally do not submit it yourself, but you can ask whether it has been submitted and follow up.
Federal timing rules
Standard requests must be decided within 14 days. Expedited requests (urgent) must be decided within 72 hours. Some states have shorter timelines.
Notice requirements
If denied, the MCO must send a written notice explaining the reason, your right to appeal, and how to request continuation of benefits.
Auto-authorization
If the MCO does not respond within the required timeframe, the request is automatically considered approved.
Denials and appeals · Fair hearing
The fair hearing process
A state fair hearing is your final administrative appeal. An impartial state hearing officer (sometimes an Administrative Law Judge) reviews your case.
Where it happens
In person, by phone, or by video, depending on your state and your preference. You do not have to attend in person.
What you can do
Present documents, call witnesses (your doctor in particular is valuable), and explain why the decision was wrong. You can have a representative such as a family member, friend, or attorney with you.
Free legal help
Legal aid organizations in most areas provide free representation for Medicaid hearings. Contact your local legal aid (legal services corporation) or a SHIP counselor for referrals.
How long it takes
Federal law requires a decision within 90 days of when you requested the hearing.
After the hearing
You receive a written decision. If you lose, you can usually pursue further appeals through state court. The fair hearing decision will explain your options.
Denials and appeals · The two-step process
MCO appeal vs state hearing
Under Medicaid managed care, appeals usually run in two stages: first within the MCO, then to the state. Knowing the difference matters because the deadlines and processes are different.
Step one: MCO internal appeal
Filed with your MCO. Typically required before you can request a state hearing. The MCO must decide within 30 days for standard appeals, 72 hours for expedited.
Step two: State fair hearing
Filed with your state Medicaid agency, typically only after the MCO has decided on your internal appeal. An impartial state hearing officer reviews. Federal law requires a decision within 90 days.
Exception: dismissal or no decision
If the MCO dismisses your appeal or fails to decide within the required timeframe, you can usually request a state hearing without completing the MCO appeal.
Combined deadlines
Each step has its own deadline. You must request the MCO appeal within typically 60 days of the original denial. After the MCO decision, you typically have 120 days to request the state hearing. These vary by state.
What if both deny?
Depending on your state, you may have further administrative review or judicial review through state courts. The state hearing decision will explain your options.
Renewals and changes · The annual renewal
Annual redetermination
Every Medicaid enrollee must renew coverage at least once a year. The redetermination is the single biggest reason people lose Medicaid coverage. It is also the easiest problem to prevent.
1
Watch for the renewal notice
Your state will mail you a renewal notice 30 to 60 days before your coverage expires. The notice tells you what to do. Some states require you to fill out a form; others can renew you automatically using existing data.
2
Update your address with your state agency
A huge portion of coverage losses happen because the renewal notice was mailed to an outdated address. Update your address as soon as you move. Most state agencies have an online portal or phone line for this.
3
Respond by the deadline
Even if you think nothing has changed, you must respond. If you do not, your coverage will end. The exact deadline is on the notice, typically 30 days from the date mailed.
4
If your income or household has changed, report accurately
The renewal asks for current information. If your income increased, you may no longer qualify for the same level of coverage but may qualify for a different program. Report accurately and the agency will route you appropriately.
5
Use a navigator if it is confusing
Federally funded navigators are trained to help with Medicaid applications and renewals at no cost. Find one at localhelp.healthcare.gov.
Set a reminder for your renewal date now
Knowing your renewal date in advance is the single most powerful thing you can do to protect your coverage. Find it on your member portal or by calling your state agency.
Renewals and changes · Mid-year changes
Reporting changes
You are required to report certain changes to your state Medicaid agency within 10 days of when they happen. Reporting late, or not at all, can cost you coverage or trigger overpayment recovery.
Income changes
A new job, raise, change in hours, loss of work, or change in self-employment income. Even small changes should be reported.
Household changes
Marriage, divorce, birth or adoption of a child, a household member moving in or out, or a death in the household.
Address changes
A move within your state. A move to a different state usually means your coverage ends and you must apply in your new state.
Other coverage changes
Starting Medicare, getting employer insurance, or getting other coverage. This affects how Medicaid coordinates with your other coverage.
How to report
Most states have an online portal for reporting changes. You can also call your state Medicaid agency (your state hotline) or the state agency directly. Keep a record of when and how you reported.
What happens after you report
The state recalculates your eligibility. You may stay on the same coverage, move to a different program, or be disenrolled. You will receive a written notice explaining the result.
Renewals and changes · Moving states
Moving to a new state
Medicaid does not transfer between states. Your coverage ends in the state you leave and you must apply for Medicaid in the new state. Planning the timing carefully prevents gaps in coverage.
1
Notify your old state Medicaid agency
Tell them you are moving and provide the date. Your coverage in the old state will end at the end of the month you leave (in most states).
2
Apply in the new state as soon as you can
You can usually apply before you move, with coverage starting once you establish residence. Each state has slightly different rules about establishing residency.
3
Be prepared for a gap
Even with careful planning, there is often a brief gap in coverage. Avoid scheduled procedures during the transition month.
4
Bring your medical records
Request copies before you leave. Establishing care with new providers in your new state is easier with records in hand.
5
Re-establish managed care assignment
In your new state, you may be auto-assigned to a new MCO. You will have a window to switch if you prefer a different one.
Different states have very different Medicaid
Eligibility rules, covered benefits, copays, and provider networks all change. The Medicaid you had may be very different from what you get in the new state.
Renewals and changes · Lost coverage
I lost my coverage
If your Medicaid coverage ended, you have several options depending on why it ended and how recently. Acting quickly preserves the most options.
If you missed your renewal
In many states, if you submit your renewal paperwork within 90 days of losing coverage, you can be reinstated retroactively without a new application. Call your state agency immediately.
If your income increased
You may qualify for the Marketplace with subsidies. Losing Medicaid coverage triggers a 60-day Special Enrollment Period to enroll in a Marketplace plan. Apply at healthcare.gov.
If you have a child who lost coverage
Your child may still qualify for CHIP (Children's Health Insurance Program), which has higher income limits than Medicaid for adults. Apply through your state Medicaid agency.
Transitional Medical Assistance
If you lost Medicaid because of increased earnings from work, federal law provides transitional Medicaid coverage for up to 12 months. Ask your state agency about TMA when you report income changes.
If you believe coverage ended in error
You have the right to appeal. The notice of termination explains the appeal process. File the appeal quickly to potentially preserve coverage during the appeal.
Renewals and changes · Becoming dual eligible
Becoming dual eligible
When you become eligible for Medicare while still on Medicaid, your coverage situation changes significantly. Medicare becomes your primary insurance and Medicaid wraps around it.
When this happens
Most commonly when you turn 65 while on Medicaid, or when you complete the 24-month Medicare waiting period after qualifying for Social Security Disability.
Medicare becomes your primary coverage
Doctors and hospitals bill Medicare first. Medicaid pays second for any remaining cost-sharing.
Medicaid covers your Medicare cost-sharing
For most dual eligibles (specifically Qualified Medicare Beneficiaries, or QMBs), Medicaid pays your Medicare premiums, deductibles, and coinsurance. You should pay nothing for Medicare-covered services.
You qualify for Extra Help automatically
Dual eligibility automatically qualifies you for the Part D Low Income Subsidy (Extra Help), which dramatically reduces your prescription drug costs.
Special enrollment for D-SNP plans
Dual eligibles can switch into Dual Special Needs Plans (D-SNPs) that coordinate Medicare and Medicaid in one plan, with one set of benefits and one card.
Continue your Medicaid renewals
Becoming dual eligible does not end your Medicaid renewal obligations. You still must renew your Medicaid coverage annually.
Help · Talk to someone
There are real people who help, free
You do not have to figure Medicaid out alone. Federally funded navigators, free legal aid, and your state's Medicaid agency all help at no cost. None of them sell anything.
First call · Application help
Healthcare.gov navigator
Free, federally trained navigators help with Medicaid and Marketplace applications and renewals.
Crossover questions that do not fit neatly under one topic. Tap any question to see the answer.
Medicaid is a joint federal-state program. Each state runs its own version, and many states have given their program a unique brand name. Medi-Cal in California, MassHealth in Massachusetts, TennCare in Tennessee, AHCCCS in Arizona, and so on.
The federal government sets minimum standards. States can build above the floor with optional benefits and broader eligibility. So your state's Medicaid is genuinely different from the next state's, even though both are "Medicaid."
When you call a doctor, ask about your state-specific program by name. They may take your state's plan but not other states' plans.
Eligibility depends on income, household size, age, disability status, and your state. The federal rules set minimums; states can be more generous.
In the 40 expansion states + DC: Adults under 65 with income up to 138% of the federal poverty level (about $22,025 a year for a single adult in 2026) qualify based on income alone.
In the 10 non-expansion states: Eligibility is much more limited for adults without children. Most states still cover children, pregnant women, parents with very low income, the elderly, and people with disabilities.
The fastest way to find out is to apply. Apply through your state Medicaid agency or through healthcare.gov, which routes Medicaid applications to your state.
Medicaid is the federal-state program for low-income people of all ages. Eligibility depends on income and other factors.
Medicare is the federal program for people 65 and older and certain people with disabilities. Eligibility is age- and work-history-based, not income-based.
CHIP (Children's Health Insurance Program) covers children whose families earn too much for Medicaid but cannot afford private insurance. Income limits are higher than Medicaid for kids.
People who qualify for both Medicare and Medicaid are called "dual eligible." Medicare pays first; Medicaid pays second.
Medicaid does not transfer. Coverage in your old state ends and you must apply in your new state. Each state has its own eligibility rules, covered benefits, and managed care plans.
Steps: notify your old state Medicaid agency you are moving and provide the date. Apply in your new state as soon as you have established residency. There is often a brief gap in coverage during the transition.
Medical records do not transfer automatically. Request copies from your providers before you leave.
Most states deliver Medicaid through private managed care organizations (MCOs) rather than directly. About 75% of Medicaid enrollees nationwide are in managed care.
The state contracts with MCOs to manage your coverage. The MCO is responsible for your network, prior authorizations, customer service, and most day-to-day administration. The state pays the MCO a fixed amount per member per month.
You usually have a 30 to 90 day window after enrollment to switch MCOs if you want a different one. After that, you can typically only switch during annual open enrollment.
This is one of the most feared and misunderstood Medicaid issues. The short answer: while you are alive, generally no. After death, in some circumstances, yes through estate recovery.
While you are alive: Your home is exempt from Medicaid's asset test in most circumstances. You can own a home and qualify for Medicaid.
After death: Federal law requires states to seek recovery from the estates of Medicaid recipients who received long-term care services. The state can place a lien on the home or seek payment from the estate. Rules and exceptions vary by state.
Spousal and other protections: No recovery while a surviving spouse is alive, while a child under 21 lives in the home, or while a disabled child lives there. Hardship exceptions exist.
Asset planning years in advance, with an elder law attorney, can structure your assets legally to minimize estate recovery exposure.
Yes. You can authorize another person to act on your behalf in several ways.
Authorized representative: You complete a form with your state Medicaid agency naming someone (a family member, friend, navigator, or attorney) to receive notices and act on your behalf.
Power of attorney: A legal document, typically prepared with an attorney, that gives broader decision-making authority. Required for certain financial matters.
Caregiver assistance: Many state agencies allow a caregiver to call on your behalf with proper verification, even without formal documentation.
"Dual eligible" means you have both Medicare and Medicaid. About 12 million Americans are dual eligible.
How payment works: Medicare pays first for any service Medicare covers. Medicaid pays second for cost-sharing and for services Medicare does not cover.
What Medicaid covers as the wraparound: Medicare premiums (Part B and often Part A), Medicare deductibles and coinsurance, and Medicaid-covered benefits not covered by Medicare (most importantly, long-term care).
Extra Help is automatic: Dual eligibility automatically qualifies you for the Part D Low Income Subsidy (Extra Help), reducing prescription drug costs significantly.
D-SNPs: Special Medicare Advantage plans for dual eligibles coordinate both programs in one plan with one card.
Yes. Medicaid enrollees are targeted by several common scams.
Fake "renewal" calls or texts asking for personal information, Medicaid ID, or banking details. Your state agency communicates by mail or through the official member portal. Hang up on suspicious calls.
Fake equipment offers promising free braces, scooters, or genetic testing in exchange for your Medicaid number. Hang up.
Door-to-door enrollment "help" pressuring you to switch MCOs or apply for a particular product. Legitimate enrollment help comes through navigators, not door-to-door visits.
Report suspected fraud to your state's Medicaid Fraud Control Unit at oig.hhs.gov.
Work requirements arrive January 1, 2027 for Medicaid expansion enrollees in many states under the 2025 Reconciliation Law. Specifics depend on state implementation. Watch for state-specific notices.
Mississippi expansion debate continues. The Mississippi Health Care Security and Promotion Act of 2026 was filed in January.
Continuous eligibility for children in some states means children under 6 can stay enrolled regardless of income changes.
Postpartum coverage has been extended to 12 months in most states.
HCBS waiver expansions continue in many states as people prefer home-based to facility-based care.
For the most current state-specific changes, check your state Medicaid agency website or KFF's Medicaid tracker.
Data sources & methodology
Federal Medicaid data
Centers for Medicare & Medicaid Services (medicaid.gov · cms.gov) · Social Security Act Title XIX · 42 CFR Parts 430, 431, 435, 438, 440, 441, 447 · KFF State Health Facts · Medicaid Managed Care Final Rule (CMS-2439-F).
2026 figures and policy
Federal Poverty Level updated annually by HHS · Medicaid expansion status tracked by KFF (40 states + DC as of 2026) · 2025 Reconciliation Law: Medicaid Work Requirements (effective January 2027). State-specific eligibility and benefits vary; verify with your state agency.
Free, unbiased help: Healthcare.gov navigators (localhelp.healthcare.gov) · Eldercare Locator (eldercare.acl.gov · 800-677-1116) · Legal Services Corporation (lsc.gov) · Your state Medicaid agency (medicaid.gov state contacts).
