Where Are States Today? Medicaid and CHIP Eligibility Levels for Adults, Children, and Pregnant Women
This fact sheet provides an overview of eligibility levels for parents, other non-disabled adults, children, and pregnant women in Medicaid and CHIP. The data are based on eligibility levels reported by states as of January 2015, updated to reflect state Medicaid expansion decisions as of April 2015. The findings highlight Medicaid’s expanded role for low-income adults under the Affordable Care Act (ACA) and its continued role as a primary source of coverage for children and pregnant women. State-specific data is available in Tables 1-3.
As of April 2015, 29 states set Medicaid income eligibility levels for parents and other adults to at least 138% FPL, reflecting their adoption of the ACA Medicaid expansion (Figures 1 and 2, Table 1). As enacted, the ACA expanded Medicaid eligibility to adults with incomes at or below 138% of the federal poverty level (FPL) ($27.724 for a family of three in 2015), although this provision was effectively made a state option by the Supreme Court’s 2012 ruling on the constitutionality of the ACA. As of April 2015, eligibility levels for parents and other adults are at or above 138% FPL in the 29 states that have adopted the Medicaid expansion. Two expansion states extend Medicaid eligibility for parents and/or other adults above the ACA minimum levels (DC at 221% FPL for parents and 215% for other adults and CT at 201% FPL for parents).
In the 22 states that have not adopted the Medicaid expansion, the median eligibility limit for parents is 44% FPL, and, with only one exception, childless adults are ineligible for Medicaid (Figure 3). A total of 13 states limit parent eligibility to less than half of the poverty level, and only four of the non-expansion states (AK, ME, TN, and WI) cover parents at or above the poverty level. Wisconsin is the only non-expansion state that provides full Medicaid coverage to any childless adults, although eligibility at 100% FPL remains below the expansion level.1 In the other non-expansion states, parents and other adults with incomes above Medicaid eligibility limits but below poverty fall into a coverage gap; they are ineligible for Medicaid and do not qualify for the premium tax credits for Marketplace coverage, which are not available to those with incomes below 100% FPL.2
Medicaid and CHIP coverage for children and pregnant women remains considerably higher than adult coverage across all states. More than half of states (28 states) cover children with family incomes at or above 250% FPL, with 19 extending coverage to 300% FPL or higher (Figure 4, Table 2 -2A). Only two states (ID and ND) limit children’s eligibility to below 200% FPL. Underlying these upper limits, eligibility levels reflect the ACA’s new minimum Medicaid eligibility level of 138% FPL for children of all ages, which resulted in the shift of older children (ages 6 up to 19) with incomes between 100% and 138% FPL from CHIP to Medicaid in some states as of January 2014. With the exception of Arizona, CHIP enrollment is open in all states. The ACA established protections that prohibit states from applying any restrictions in eligibility or enrollment for children through September 2019. Most states extend coverage to pregnant women beyond federal minimums through Medicaid and CHIP. Prior to the ACA, states were required to cover pregnant women in Medicaid to at least 133% FPL. As of January 2015, nearly two-thirds of states (33) cover pregnant women at or above 200% FPL, including eleven states that cover pregnant women with family incomes at or above 250% FPL in Medicaid and CHIP (Figure 5, Table 3-3A).
In sum, as expected, Medicaid’s role has increased for low-income adults in the 29 states that have adopted the Medicaid expansion. However, eligibility levels for adults remain low in states that have not adopted at this time, resulting in gaps in coverage. Although full federal financing for the expansion begins to phase down in 2016 to 90%, there is no deadline by which states must adopt the Medicaid expansion to low-income adults and debate continues in several states. Medicaid and CHIP remain primary sources of coverage for low-income children and pregnant women and the ACA protects eligibility levels for children through 2019.
Oklahoma and Utah provide more limited coverage to some childless adults under Section 1115 waiver authority.
For more information, see: R. Garfield, et al., “The Coverage Gap: Uninsured Poor Adults in State that Do Not Expand Medicaid – An Update,” Kaiser Family Foundation, November 2014.
also of interest
- A Closer Look at the Impact of State Decisions Not to Expand Medicaid on Coverage for Uninsured Adults
- A Historical Review of How States Have Responded to the Availability of Federal Funds for Health Coverage
- Modern Era Medicaid: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP as of January 2015