Major Medicaid and CHIP eligibility pathways and state implementation status in the post-ACA era that impact AYAs with blood cancers
| Population . | Program . | Pathway . | Number of states adopted . | Specific eligibility criteria . |
|---|---|---|---|---|
| YAs (aged 19-39 years) | Medicaid | MAGI in Medicaid expansion states | 41a (as of Apr 2024) | Based on FPL: Medicaid expansion states cover nonelderly adults with income up to 138% FPL.b |
| MAGI in nonexpansion states | 10a (as of Apr 2024) | Eligibility is based on FPL and varies by state.b For example: • Georgia: up to 31% FPL for parents and 0% FPL for other adults • Texas: up to 16% FPL for parents and 0% FPL for other adults | ||
| Non-MAGI: working people with disabilitiesc | 48d (as of Jul 2022) | Cover working people with disabilities whose income and/or assets exceed the limits for other eligibility pathways, which is an optional pathway with eligibility limits varying by state. For example: • Connecticut: up to 552% FPL (or $6250 monthly income) and assets up to $10 000 for an individual | ||
| Non-MAGI: seniors and people with disabilities up to 100% FPLc | 28e (as of Jun 2024) | Cover seniors and people with disabilities, whose income exceeds the SSI limit but generally is up to 100% FPL, and states can choose to apply an asset limit. This pathway is optional to states, with eligibility limits varying by state. For example: • Georgia: up to 74% FPL and assets up to $2000 for an individual • South Carolina: up to 100% FPL and assets up to $8400 for an individual | ||
| AYAs (aged 15-39 years) | Medicaid | Non-MAGI: SSI enrolleesc | All states (mandatory pathway) | Cover people who receive federal SSI benefits. This is the only non-MAGI pathway that states must include in their Medicaid programs. Eligibility is based on income and asset limit and on an impaired ability to work at a substantial gainful level as a result of old age or disability. The maximum SSI federal benefit rate is 74% FPL, but the effective SSI income limit may be higher than 74% FPL in some states. The maximum asset limit is $2000 for an individual and $3000 for a couple. |
| Non-MAGI: Section 1915 (I) HCBS for individuals at risk of institutional carec,f | 5d,g (as of Jul 2022) | Cover people who are not eligible through another pathway and who meet the Section 1915 (I) financial and functional eligibility criteria and are at risk of institutional care. This pathway is optional to states, with eligibility limits varying by state. For example: • Indiana: adults with behavioral health needs and with income up to 150% FPL • Maryland: children with mental illness and with income up to 150% FPL | ||
| Non-MAGI: “Medically needy” populationsc,h | 34e (as of Jun 2024) | Cover pregnant women, children, parents, seniors, or individuals with disabilities who have limited income and vary by state. This includes persons who spend down by incurring medical expenses so that, after medical expenses, their income falls below a state-established medically needy income limit. | ||
| Adolescents (15-18 years) | Medicaid | Non-MAGI: “Katie Beckett” children, a Medicaid waiver program that covers children who have long-term disabilities or complex medical needs to receive Medicaid coverage at home, regardless of household incomec | 43e (as of Jun 2024) | Cover children up to age 19 with significant disabilities living at home, regardless of household income. These children must meet the SSI medical disability criteria or otherwise qualify for an institutional level of care according to functional eligibility criteria set by the state. Katie Beckett income limits are generally 300% of SSI ($2523 per month in 2022), with a $2000 asset limit, considering only the child's own income and assets. |
| Non-MAGI: Family Opportunity Act children with disabilitiesc | 8d (as of Jul 2022) | Cover children (ages 0-18) with disabilities living at home. These children must meet SSI medical disability criteria, with family income up to 300% FPL. Assets are not considered for eligibility determination. Distinction from Katie Becket pathway: the FOA option considers household income (not just the child's own income) and only requires SSI medical disability criteria (not requiring an institutional level of care). | ||
| Non-MAGI: foster care children or former foster care youthi | All states (mandatory pathway) | Foster care children: typically qualify for Medicaid regardless of income while they are in the foster system. Former foster care youth: individuals who age out of foster care are eligible for Medicaid until age 26, regardless of their income. | ||
| MAGI: state- and age-specific income eligibility limits for Medicaid based on income | All states (mandatory pathway) | Income thresholds are based on FPL and vary by state.h For example: • Hawaii: Medicaid up to 191% FPL (ages 0-1), 139% FPL (ages 1-5), 133% FPL (ages 6-18) • Washington: Medicaid up to 215% FPL (ages 0-18) • Georgia: Medicaid up to 210% FPL (ages 0-1), 154% FPL (ages 1-5), 138% FPL (age 6-18) | ||
| CHIP | MAGI: CHIP as an expansion of Medicaid | 11j (as of Jun 2024) | Income thresholds are based on FPL and vary by state.h For example: • Hawaii: CHIP 191%-313% FPL (ages 0-1), 139%-313% FPL (ages 1-5), 133%-313% FPL (ages 6-18) | |
| MAGI: CHIP as a separate program from Medicaid | 2j (as of Jun 2024) | Income thresholds are based on FPL and vary by state.h For example: • Washington: CHIP up to 317% FPL (ages 0-18) | ||
| MAGI: a combination of both approaches | 38j (as of Jun 2024) | Income thresholds are based on FPL and vary by state.h For example: • Georgia: CHIP up to 252% FPL (ages 0-18) |
| Population . | Program . | Pathway . | Number of states adopted . | Specific eligibility criteria . |
|---|---|---|---|---|
| YAs (aged 19-39 years) | Medicaid | MAGI in Medicaid expansion states | 41a (as of Apr 2024) | Based on FPL: Medicaid expansion states cover nonelderly adults with income up to 138% FPL.b |
| MAGI in nonexpansion states | 10a (as of Apr 2024) | Eligibility is based on FPL and varies by state.b For example: • Georgia: up to 31% FPL for parents and 0% FPL for other adults • Texas: up to 16% FPL for parents and 0% FPL for other adults | ||
| Non-MAGI: working people with disabilitiesc | 48d (as of Jul 2022) | Cover working people with disabilities whose income and/or assets exceed the limits for other eligibility pathways, which is an optional pathway with eligibility limits varying by state. For example: • Connecticut: up to 552% FPL (or $6250 monthly income) and assets up to $10 000 for an individual | ||
| Non-MAGI: seniors and people with disabilities up to 100% FPLc | 28e (as of Jun 2024) | Cover seniors and people with disabilities, whose income exceeds the SSI limit but generally is up to 100% FPL, and states can choose to apply an asset limit. This pathway is optional to states, with eligibility limits varying by state. For example: • Georgia: up to 74% FPL and assets up to $2000 for an individual • South Carolina: up to 100% FPL and assets up to $8400 for an individual | ||
| AYAs (aged 15-39 years) | Medicaid | Non-MAGI: SSI enrolleesc | All states (mandatory pathway) | Cover people who receive federal SSI benefits. This is the only non-MAGI pathway that states must include in their Medicaid programs. Eligibility is based on income and asset limit and on an impaired ability to work at a substantial gainful level as a result of old age or disability. The maximum SSI federal benefit rate is 74% FPL, but the effective SSI income limit may be higher than 74% FPL in some states. The maximum asset limit is $2000 for an individual and $3000 for a couple. |
| Non-MAGI: Section 1915 (I) HCBS for individuals at risk of institutional carec,f | 5d,g (as of Jul 2022) | Cover people who are not eligible through another pathway and who meet the Section 1915 (I) financial and functional eligibility criteria and are at risk of institutional care. This pathway is optional to states, with eligibility limits varying by state. For example: • Indiana: adults with behavioral health needs and with income up to 150% FPL • Maryland: children with mental illness and with income up to 150% FPL | ||
| Non-MAGI: “Medically needy” populationsc,h | 34e (as of Jun 2024) | Cover pregnant women, children, parents, seniors, or individuals with disabilities who have limited income and vary by state. This includes persons who spend down by incurring medical expenses so that, after medical expenses, their income falls below a state-established medically needy income limit. | ||
| Adolescents (15-18 years) | Medicaid | Non-MAGI: “Katie Beckett” children, a Medicaid waiver program that covers children who have long-term disabilities or complex medical needs to receive Medicaid coverage at home, regardless of household incomec | 43e (as of Jun 2024) | Cover children up to age 19 with significant disabilities living at home, regardless of household income. These children must meet the SSI medical disability criteria or otherwise qualify for an institutional level of care according to functional eligibility criteria set by the state. Katie Beckett income limits are generally 300% of SSI ($2523 per month in 2022), with a $2000 asset limit, considering only the child's own income and assets. |
| Non-MAGI: Family Opportunity Act children with disabilitiesc | 8d (as of Jul 2022) | Cover children (ages 0-18) with disabilities living at home. These children must meet SSI medical disability criteria, with family income up to 300% FPL. Assets are not considered for eligibility determination. Distinction from Katie Becket pathway: the FOA option considers household income (not just the child's own income) and only requires SSI medical disability criteria (not requiring an institutional level of care). | ||
| Non-MAGI: foster care children or former foster care youthi | All states (mandatory pathway) | Foster care children: typically qualify for Medicaid regardless of income while they are in the foster system. Former foster care youth: individuals who age out of foster care are eligible for Medicaid until age 26, regardless of their income. | ||
| MAGI: state- and age-specific income eligibility limits for Medicaid based on income | All states (mandatory pathway) | Income thresholds are based on FPL and vary by state.h For example: • Hawaii: Medicaid up to 191% FPL (ages 0-1), 139% FPL (ages 1-5), 133% FPL (ages 6-18) • Washington: Medicaid up to 215% FPL (ages 0-18) • Georgia: Medicaid up to 210% FPL (ages 0-1), 154% FPL (ages 1-5), 138% FPL (age 6-18) | ||
| CHIP | MAGI: CHIP as an expansion of Medicaid | 11j (as of Jun 2024) | Income thresholds are based on FPL and vary by state.h For example: • Hawaii: CHIP 191%-313% FPL (ages 0-1), 139%-313% FPL (ages 1-5), 133%-313% FPL (ages 6-18) | |
| MAGI: CHIP as a separate program from Medicaid | 2j (as of Jun 2024) | Income thresholds are based on FPL and vary by state.h For example: • Washington: CHIP up to 317% FPL (ages 0-18) | ||
| MAGI: a combination of both approaches | 38j (as of Jun 2024) | Income thresholds are based on FPL and vary by state.h For example: • Georgia: CHIP up to 252% FPL (ages 0-18) |
Data publicly available online from https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/
Data publicly available online from KFF, https://www.kff.org/affordable-care-act/state-indicator/medicaid-income-eligibility-limits-for-adults-as-a-percent-of-the-federal-poverty-level.
Data publicly available online from KFF, https://www.kff.org/report-section/medicaid-financial-eligibility-in-pathways-based-on-old-age-or-disability-in-2022-findings-from-a-50-state-survey-appendix/.
Data publicly available online from KFF, https://www.kff.org/medicaid/issue-brief/medicaid-financial-eligibility-in-pathways-based-on-old-age-or-disability-in-2022-findings-from-a-50-state-survey/.
Data publicly available online from KFF, https://www.kff.org/other/state-indicator/state-adoption-of-major-optional-pathways-to-full-medicaid-eligibility-based-on-old-age-or-disability.
Section 1915(i) of the Social Security Act is a Medicaid provision that allows states to offer HCBS to individuals as an alternative to institutional care. Eligibility criteria for these services are usually based on functional need rather than requiring individuals to qualify for an institutional level of care, which broadens access to services for those with disabilities or chronic conditions. States have flexibility in setting eligibility criteria and determining the services offered, such as day care, personal care, and habilitation to support independent living in communities.
This number reflects states electing Section 1915 (i) as an independent eligibility pathway. Other states may use Section 1915 (i) to provide HCBS to people who are eligible for Medicaid through another pathway.
The “medically needy” or “spend-down” pathways allow individuals with income above the typical Medicaid limits to become eligible by incurring medical expenses that effectively reduce their income. Individuals must spend down their income by incurring medical costs equal to the difference between their income and the state's Medicaid income limit. Once they meet this spend-down amount, they qualify for full Medicaid benefits for the remainder of that period. Expenses that qualify for “spend-down” include medical bills for doctor visits, hospital costs, and prescription drugs. While not all states offer this program, it provides a crucial safety net for populations like AYAs with blood cancers facing high cancer treatment costs relative to their income.
HCBS, home and community-based services; YA, young adults.