Medicaid - Eligibility Criteria, Federal Poverty Level Guidelines & Claim Submission

Eligibility Criteria:

To be eligible for Medicaid, an individual must be a U.S. citizen or a permanent legal resident for at least five continuous years and also meet at least one of the following Medicaid eligibility criteria:

• An individual must be a resident of the state in which he/she is receiving Medicaid.

• An individual with income below the poverty level is defined by each state.

• An individual can also be eligible for Medicaid if his/her income is above the poverty level but his/her family income is below the poverty level defined by the states.

• An individual who is blind or disabled.

• Pregnant women with income up to 133 percent of the federal poverty level.

Federal Poverty Level Guidelines:

• In states that have chosen to expand their Medicaid programs, all individuals with income up to 138 percent of the federal poverty level (FPL) will qualify for coverage.

• There are 12 states that have not chosen to expand their Medicaid programs/ Those states are - Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin and Wyoming.

• 2021 Federal Poverty Level guidelines for the 48 contiguous states and the District of Columbia:

• 2021 Federal Poverty Level guidelines for Alaska:

• 2021 Federal Poverty Level guidelines for Hawaii:

Claim Submission:

• When the patient has multiple insurances then Medicaid would be the last payer to bill. You can also determine it by checking the eligibility of the insurance.

• When the patient has only Medicaid insurance as primary and no other insurance then Medicaid must be billed as primary.