SSA - POMS: SI 01715.001 - Medicaid and the Aged, Blind and Disabled

A. Introduction

The importance of Medicaid to Supplemental Security Income (SSI) beneficiaries cannot be overemphasized. In most states, eligibility for SSI may automatically qualify an individual for Medicaid. This connection between SSI and Medicaid is a significant feature of the SSI program for beneficiaries. See SI 01715.001C.2 for changes in availability of federal financial participation for Medicaid coverage effective October 1, 2026, which may affect Medicaid eligibility for certain noncitizen SSI recipients.

Each State requests approval of its Medicaid Plan from the Centers for Medicare & Medicaid Services (CMS). Although the State Medicaid Plans differ, they all provide medical coverage for at least some SSI beneficiaries in all 50 States, the District of Columbia and the Commonwealth of the Northern Mariana Islands (NMI). See SI 1715.010A for more information about SSI and Medicaid eligibility in each State.

NOTE: The following addresses parts of Medicaid that affect the aged, blind and disabled. For the most part, it leaves out those parts of Medicaid that affect families with dependent children.

B. Background

Title XIX of the Social Security Act (the Act), known as Medicaid in most States (some States have State-specific Medicaid program names such as Medi-Cal in California; in Arizona, it is called AHCCS, the Arizona Health Care Cost Containment System), establishes a joint state-federal partnership in which federal financial participation is provided for each State's medical assistance program. The Federal government pays 50 percent of Medicaid administrative costs and between 50 and 83 percent of program costs following a statutory formula.

The Medicaid statute requires coverage of mandatory groups and gives States the option to provide Medicaid to various other groups.

C. Policy

1. Statutory Groupings

In general, the Medicaid statute divides State plan coverage into three separate groupings:

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The mandatory groups; i.e., individuals who must be covered by any State that has a Medicaid program (sometimes referred to as the mandatory categorically needy);
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The optional groups (sometimes referred to as the categorically needy); and
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Other coverage groups, such as the medically needy and individuals covered under a waiver.

See SI 01715.005 for additional information on these groups.

2. Eligibility - General

To be potentially eligible for any Medicaid coverage, an individual must meet specific categorical requirements such as being aged, blind or disabled, a child under 19 (or up to 21, at state option), a pregnant woman, or parent/caretaker relative. Individuals who do not belong to a covered category cannot get Medicaid.

Medicaid is a joint, Federal-State program under title XIX of the Social Security Act. There are other types of medical assistance programs that are not jointly-funded under title XIX of the Act. Those are not Medicaid.

EXAMPLE:A State may provide medical assistance to individuals who receive general assistance who are not eligible for SSI. Information about medical assistance which is not Medicaid may be available to the field office (FO) from materials issued by the regional office (RO) or local sources. FOs refer individuals for all types of medical assistance that may be available, not just Medicaid.

Under section 71109 of P.L. 119-21, effective October 1, 2026, with limited exceptions, federal financial participation may only be provided for Medicaid coverage to a person who meets certain U.S. citizenship or immigration status criteria (see section 1903(v)(5) of the Social Security Act, 42 USC 1396(v)(5). In general, an individual must be:

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a resident of one of the 50 States, the District of Columbia, or a territory of the United States; and
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either—
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  a citizen or national of the United States;
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  an alien lawfully admitted for permanent residence (LPR, commonly referred to as a green card holder);
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  an alien who has been granted the status of Cuban-Haitian entrant; or
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  an individual who lawfully resides in the United States in accordance with a Compact of Free Association (CFA or COFA), i.e., a citizen of the Federated States of Micronesia (FSM), the Republic of the Marshall Islands (RMI) or the Republic of Palau (RP).

NOTE:

The federal financial participation limitation does not apply to Medicaid coverage for care and services necessary to treat an emergency medical condition or a state's election to provide Medicaid coverage to lawfully residing children under age 21 and/or pregnant women.

See SI 01715.010A.3 for more information regarding when SSA makes a Medicaid determination and when SSA refers the case to the State.

3. Retroactivity

Rules through December 31, 2026 - The Medicaid statute requires retroactive coverage of covered medical expenses for up to 3 months before the Medicaid application if the individual would have been eligible at that time.

Rules effective January 1, 2027 - Changes to statute under section 71112 of P.L. 119-21 require that, effective January 1, 2027, the retroactive eligibility period for individuals determined eligible for SSI or SSP, and who would have met Medicaid eligibility criteria during the retroactive period, will be limited to two months prior to the month of application.

Retroactivity is very important. (Instructions for situations in which the individual dies while the application is pending are located in SI 01730.015.) In the 1634 States, the SSI application also serves as the Medicaid application. See SI 01715.010A.3 for more information about 1634 States.

NOTE: Retroactivity does not apply to Qualified Medicare Beneficiaries (QMBs), a group discussed in SI 01715.005 A.5.

D. References

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SI 00601.009 Application Effective Date
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SI 01715.005 Medicaid Groups
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SI 01715.010 Medicaid and the Supplemental Security Income (SSI) Program
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SI 01730.015 Disability Determinations for Deceased Claimants to Establish Medicaid Eligibility

Social Security

Program Operations Manual System (POMS)

SI 01715.001 Medicaid and the Aged, Blind and Disabled