How Does Medicaid Decide If You Qualify?

Jul 14

3 min read

Confused about who qualifies for Medicaid? Learn how Medicaid determines eligibility, what factors they consider, and how to know if you still meet the requirements in 2025.

Medicaid Isn’t Guaranteed — You Have to Qualify Every Year

Millions of Americans depend on Medicaid for affordable healthcare. But unlike traditional insurance, Medicaid isn’t something you can just “set and forget.”

You have to qualify — and stay qualified — based on specific rules.

Let’s break down how Medicaid determines your eligibility, what could cause you to lose it, and what to do if you no longer qualify.

🧾 1. Medicaid Is Based on Income — Not Just Need

At its core, Medicaid is a needs-based program. That means it primarily serves:

Low-income individuals and families
Children and pregnant women
People with disabilities
Seniors who need long-term care

But the main thing Medicaid looks at?Your household income.

This is measured against the Federal Poverty Level (FPL) — which changes every year.

💵 2025 Federal Poverty Level Examples (Lower 48 States):

Household Size	138% FPL (Typical Limit for Adults)
1 person	$20,783/year
2 people	$28,208/year
3 people	$35,633/year
4 people	$43,058/year

⚠️ These numbers vary by state and by category (e.g., kids can qualify with higher income).Florida uses these guidelines — but doesn’t offer full Medicaid expansion.

🧮 2. What Counts as Income?

Medicaid counts your Modified Adjusted Gross Income (MAGI). This includes:

Wages
Self-employment income
Unemployment benefits
Social Security (some types)
Certain tax-exempt income

It doesn’t include:

Child support
Veteran’s benefits
TANF or SNAP (food stamps)

🧠 Many people lose coverage simply because their income increased slightly — or they forgot to report changes.

📋 3. They Also Look at Household Size

Your income is compared to the FPL based on how many people are in your household — not just who you live with, but who you file taxes with.

For example:

A single parent with 2 kids = household of 3
A married couple with no kids = household of 2

Get this wrong on your redetermination paperwork, and you could be denied even if you’re eligible.

🔄 4. Redetermination Happens Every Year (Sometimes More Often)

States require Medicaid recipients to renew their eligibility — often every 12 months.This process is called redetermination.

You'll be asked to confirm:

Current income
Household size
Mailing address
Other insurance coverage

Miss a notice, forget to reply, or send incomplete info, and your coverage may be canceled automatically.

🛡️ What If You No Longer Qualify?

If your income goes up or you age out of the program, you may still be eligible for affordable health insurance through the ACA Marketplace.

In fact, many former Medicaid recipients qualify for:

$0 or low-cost plans
Help paying deductibles and copays
Broader provider networks

💬 I help people transition from Medicaid to ACA plans every day. It’s fast, free, and there’s no pressure.

✅ Need Help Checking Your Eligibility?

At SentiumHealth, I can help you:

Understand your Medicaid status
Review your income and household correctly
Apply for ACA coverage if you’re no longer eligible
Avoid gaps in care during the transition

📞 Get Help Now — Before You Lose Coverage

📱 Call or text: 407-815-5238💬 Chat live: SentiumHealth.com

🗣️ Real Client Story

"I didn’t realize my new job pushed me over the Medicaid income limit. SentiumHealth helped me get a $30/month ACA plan that kept me covered."— Erica, Miami FL