Medicaid is a joint federal and state health insurance program that provides free or low-cost coverage to low-income individuals and families. Many states have expanded Medicaid under the Affordable Care Act to cover adults with household incomes up to 138% of the federal poverty level (approximately $20,783 for an individual in 2026). Enrollment and applications are handled through your state's health insurance marketplace or Medicaid office.
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Who needs medicaid?
Medicaid expansion has provided coverage to millions of Americans who previously had no affordable insurance options. If you are an adult under 65 with income at or below 138% of the federal poverty level, you likely qualify in states that have expanded Medicaid. Families with children may qualify at higher income levels, and pregnant women are often covered at higher FPL thresholds depending on your state. The program is particularly significant in areas where lower median incomes and higher rates of uninsurance historically left many residents without access to preventive care. You apply through your state's health insurance marketplace, and unlike marketplace plans, Medicaid enrollment is open year-round with no limited enrollment period. The Way Agency can help you determine whether Medicaid, a marketplace plan with subsidies, or another option is the best fit for your situation.
What does medicaid cover?
- Doctor visits and specialist care
- Hospital inpatient and outpatient services
- Prescription medications
- Mental health and substance abuse treatment
- Preventive care and immunizations
- Lab tests and X-rays
- Maternity and newborn care
- Dental services (limited for adults, comprehensive for children)
- Vision care for children
- Transportation to medical appointments (through Medicaid-arranged transport)
What medicaid does NOT cover
- Cosmetic or elective surgery
- Experimental treatments not approved by the program
- Services outside of the Medicaid provider network (except emergencies)
- Adult dental coverage is limited (basic extractions and dentures, but not comprehensive restorative work)
- Long-term care abroad or out-of-state non-emergency care (without prior approval)
- Certain over-the-counter medications
What does medicaid cost?
For most enrollees, Medicaid has zero premiums and minimal copays (typically $1 to $4 per service). There are no deductibles. Children, pregnant women, and those in certain categories pay nothing out of pocket. The coverage is comprehensive and immediate once approved. However, the application process requires income verification, and some applicants may be found eligible for marketplace plans with subsidies rather than Medicaid. The Way Agency helps people navigate the sometimes confusing line between Medicaid eligibility and marketplace plans so you end up with the coverage you actually qualify for.
Frequently asked questions
Apply online through your state's health insurance marketplace or Medicaid website, by phone, or in person at your local social services office. The application takes about 30 to 45 minutes and requires proof of income, identity, and residency. Most applications are processed within 45 days. Unlike marketplace health insurance, Medicaid enrollment is available year-round.
For adults aged 19 to 64 under Medicaid expansion, the income limit is 138% of the federal poverty level. In 2026, that is approximately $20,783 for an individual, $28,208 for a family of two, and $35,632 for a family of three. Children often qualify at higher income levels through your state's Children's Health Insurance Program (CHIP), and pregnant women may qualify at higher FPL thresholds depending on your state. Income is calculated based on Modified Adjusted Gross Income (MAGI).
Yes. If you have Medicaid and another form of insurance (such as employer coverage or Medicare), Medicaid typically serves as the secondary payer, covering costs that the other insurance does not. For Medicare recipients who also qualify for Medicaid (called dual-eligible), Medicaid may pay Medicare premiums, deductibles, and copays. This combination can eliminate virtually all out-of-pocket healthcare costs.
If your income rises above 138% FPL, you will transition off Medicaid, but you may qualify for subsidized marketplace plans through your state's exchange. Most states provide a transition period, and you will receive notice before coverage ends. The Way Agency can help you find affordable marketplace coverage during a Special Enrollment Period triggered by losing Medicaid eligibility.
Yes. Medicaid covers behavioral health services including outpatient therapy, inpatient psychiatric care, medication-assisted treatment for substance use disorders, and residential treatment. Many states have expanded Medicaid behavioral health benefits significantly in response to the opioid crisis. There is no separate deductible or copay for most mental health services.
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Related coverage to consider
- Individual Health - Individual health plans purchased through your state's health insurance marketplace or directly from carriers.
- Family Health - Covers you, your spouse, and dependent children under one policy.
- Dental, Vision & Hearing - Most health insurance plans do not include dental, vision, or hearing coverage for adults.
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Reviewed by
Sheilia Royal, Agency Principal / Licensed Agent
Licensed in KY, IN & TN | 20 years experience | Last reviewed: March 2026