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.

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.

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).

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

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.

Generally, in determining the Medicaid eligiblity of individuals who seek Medicaid on the basis of being 65 years old or older, or having blindness or a disability ("ABD" individuals), section 1902(r)(2)(A) of the Act requires that State Medicaid programs use the SSI program's eligibility methodologies (financial and blindness/disability-related). However, section 1902(f) of the Act permits States to use methodologies more restrictive than the SSI program's, subject to certain conditions. (These states are referred to as "209(b)" States, after the subsection 209(b) of the Social Security Act Amendments of 1972, Pub. L. No. 92-603, that enacted section 1902(f) of the Act.) The 209(b) states use at least one eligibility criterion more restrictive than the SSI program. States that elected this option may not use more restrictive standards than those in effect under their State Medicaid plans as of January 1, 1972, and must permit ABD applicants to reduce their countable income by deducting their incurred medical expenses (to "spend down") their income.

Medicaid spenddown is an important concept not only to the 209(b) States but also to all States with medically needy programs. Spenddown applies to individuals who have too much income to qualify under the State's income limits. When an individual has too much countable income to qualify for Medicaid, the State Medicaid agency (in States that provide coverage to the medically needy) looks at the individual's incurred medical expenses during a budget period (1 to 6 months). In some cases, the State can also look at some anticipated expenses, such as the cost of health insurance. The State then takes incurred costs for medical services covered under the State's Medicaid plan during the budget period and deducts them from the individual's countable income until the individual meets the State's income limit. The medical expenses used to reduce the individual's income to the eligibility standard are the responsibility of the individual, i.e., to qualify for Medicaid.

At present, there are eight 209(b) States. They are:

States that use the SSI eligibility criteria for Medicaid may make their own Medicaid determinations or ask SSA to do it. States known as SSI Criteria States make their own determinations for SSI recipients. At present, the Commonwealth of the Northern Mariana Islands (NMI) and eight States are SSI Criteria States.

The SSI Criteria States are:

When SSA makes a Medicaid determination

When a State requests SSA to make Medicaid eligibility determinations, the State completes a 1634 agreement with us. (See SI 01730.005 for SSA and State agreements under Section 1634.) Named for the authorizing section in the Act, the 1634 agreement specifies the State and SSA's responsibilities. Currently, the District of Columbia and the 34 States not mentioned in SI 01715.010A.1. or SI 01715.010A.2. have 1634 agreements. In these 1634 States, we make Medicaid eligibility decisions for individuals receiving SSI payments and federally-administered SSPs and who meet certain U.S. citizenship or immigration status (SI 01715.001).

When SSA does not make a Medicaid determination

SSA refers SSI claimants and recipients to the State if they may not be eligible for Medicaid coverage due to not meeting certain U.S. citizenship/immigration status requirements (SI 01715.001), but may include lawfully residing children under age 21 and/or pregnant women that are eligible for Medicaid coverage under a State's election. SSA also refers to the State those SSI claimants that do not meet the Medicaid-only factors (e.g., refusal to assign their rights to third party medical payments; refusal to provide third party liability information; or having a Medicaid trust). SSA does not determine Medicaid ineligibility; 1634 States make their own ineligibility determinations for Medicaid, and are responsible for all Medicaid ineligibility notices.

In SSI denials, we refer ineligible SSI claimants to the State.

Notification

In 1634 States, SSA tells SSI-Medicaid eligibles in the SSI award notice that they will hear from their State about Medicaid shortly. The State issues Medicaid denial notices.