MAGI Medicaid – Eligibility

The Affordable Care Act created a new standard for Medicaid eligibility based on Modified Adjusted Gross Income (MAGI).  Most, but not all, Medicaid recipients in Rhode Island qualify under the MAGI standard.  Some applicants do not have access to Medicaid through the new MAGI standard, and their eligibility must be adjudicated under other rules.

In order to be eligible for MAGI Medicaid, the applicant:

  1. Must be categorically eligible for application of the MAGI standard;
  2. Must meet the income limits;
  3. Must be a Rhode Island resident;
  4. Must be a citizen or have other qualifying immigration status; and
  5. Must have (and provide) a valid Social Security Number.

Note that there is no resource or asset limit for MAGI Medicaid.

For information on how to apply for MAGI Medicaid, see this article.

1. Categories of Applicants Subject to MAGI

Most Rhode Islanders are eligible for Medicaid under the MAGI standard.  It is easiest to define who is not subject to the MAGI standard (known as “non-MAGI” or “ABD” applicants).  Then everyone else will be subject to the MAGI standard and be considered a “MAGI applicant.”

MAGI rules do not apply to:

  • Applicants for whom no income determination is required, such as foster children, adoption assistance, and SSI beneficiaries;  (Caution – SSI is not the same as SSD (Social Security Disability).  Disabled SSD recipients are discussed below.)
  • Individuals age 65 or over;
  • Individuals eligible for Medicare;
  • Individuals seeking long term services and supports (“LTSS”) in an institutional or home / community based setting;
  • Individuals applying for a Medicare Premium Payment Program, i.e. QMB, SLMB, and QI.
  • Individuals applying for Medicaid on the basis of age, blindness, or disability (“ABD”) or for the Medicaid FLEX spend-down program (see here for more information on both).

Disabled Social Security recipients under age 65 who are not yet eligible for Medicare, as well as individuals who are applying for SSI/SSD but have not yet been found disabled by Social Security, have choices.  The most common example of such applicants are those who have recently started receiving SSD and are still in the 24-month waiting period before gaining eligibility for Medicare.

For most, MAGI rules are best.  But some may want to receive Medicaid on grounds of age, disability, or blindness (“ABD”).  Some factors to consider:

  • Income limits are higher under MAGI, and there are no resource or asset limits.  ABD Medicaid does have resource/asset limits.
  • There is no retroactive coverage with MAGI.  If an individual has incurred large medical bills in the three months prior to applying for Medicaid, it may be possible to have those bills paid through ABD Medicaid.
  • Low income individuals with pending SSI applications, who have not yet been found disabled, may need cash assistance while they are awaiting a decision from Social Security.  To be eligible for cash, the must be found disabled and eligible in the ABD category of Medicaid.
  • ABD Medicaid includes coverage for long term services and supports (LTSS), while MAGI Medicaid does not.  ABD recipients may also be eligible to “spend down” into Medicaid through the FLEX program.

Basically all other Rhode Islanders can apply as MAGI applicants.

Example 1
David and his wife Jessica are each under 65, disabled, and receiving SSD.  David started receiving benefits recently and is not yet eligible for Medicare.  Jessica has been disabled for five years and is already receiving Medicare.
→ David can decide whether to apply for MAGI or ABD Medicaid benefits.  See the discussion above the the considerations relevant to that decision.  Once his waiting period for Medicare is over and he becomes eligible, he can no longer receive MAGI Medicaid benefits.  Jessica is not eligible for MAGI Medicaid benefits because she is eligible for Medicare already.  She can only apply under ABD rules.

2. Income Limits

The State further divides MAGI applicants into four categories.  The income limit for the applicant depends on their category:

MAGI Medicaid Income Limits by Category (FPL)

CategoryIncome Limit (FPL)
Parents (of children up to 18, or 19 if full-time students)138%
Children (under 19)266%
Pregnant Women258%
Other Adults138%

Those income limits calculate as follows:

MAGI Medicaid Annual Income Limits (2015)

Household Size138% FPL
(Parents and Other Adults)
258% FPL
(Pregnant Women)
266% FPL
(Children under 19)
1$ 16,243$ 30,367$ 31,308
2$ 21,983$ 41,099$ 42,374
3$ 27,724$ 51,832$ 53,439
4$ 33,465$ 62,565$ 64,505
5$ 39206$ 73,298$ 75,571

 

MAGI Medicaid Monthly Income Limits (2015)

Household Size138% FPL
(Parents and Other Adults)
258% FPL
(Pregnant Women)
266% FPL
(Children under 19)
1$ 1,354$ 2,531$ 2,609
2$ 1,832$ 3,425$ 3,531
3$ 2,310$ 4,319$ 4,453
4$ 2,789$ 5,214$ 5,375
5$ 3,267$ 6,108$ 6,298

For more information on how the household size is counted, see MAGI Medicaid – Household Size.

For more information on how MAGI income is counted, see MAGI Medicaid – Income.

3. Rhode Island Residence

Rhode Island residency is primarily based on the intent of the applicant.  If the applicant lives in Rhode Island voluntarily and intends to reside here, then she is a Rhode Island resident.  Lack of fixed address does not preclude someone from being a resident, so homelessness is no bar to eligibility.  Anyone entering the State with a job commitment or seeking employment is also considered a resident.

Children (who may not be able to form an intent to reside anywhere), are considered resident of the State where their caretaker (with whom they live) resides.

A pregnant non-citizen may be considered a RI resident irrespective of whether her immigration status indicates that she is only here for a limited time.

These State residency rules should be extremely similar, if not identical, to the State residency rules used by HealthSource RI (see QHP – Basic Eligibility Rules).

4. Immigration Status

The list of immigration statuses that qualify an applicant to receive Medicaid vary by category of applicant.  Below is some general information by category.  For more specifics, see Medicaid Eligibility for Immigrants.

Pregnant Women – Pregnant women can be eligible for Medicaid regardless of immigration status.  Even undocumented pregnant women may qualify for Medicaid.

Children under 19 – Children must have a qualifying immigration status to be eligible, but there is no five-year waiting period.

Adults and Parents – Some non-citizens with “qualified” status, including legal permanent residents
(LPRs) with green cards, are eligible for Medicaid only following a five-year waiting period.  Other non-citizens with “qualified” status, such as refugees and asylees, are eligible for Medicaid without any five-year waiting period.

Some immigrants who are ineligible for Medicaid due to immigration status will be eligible for enrollment in a qualified health plan (QHP) through HealthSource RI (HSRI) and may be eligible for advanced premium tax credits (ATPCs) and/or cost-sharing reductions (CSRs).  See QHP – Basic Eligibility Rules for more information on what immigrants are eligible for QHPs and APTCs/CSRs.

Example 2
David and his pregnant wife Vanessa have a 5-year-old daughter Autumn.  Their annual MAGI is less than $10,000.  They all immigrated from London together last year.  Vanessa and her daughter Autumn are both undocumented, but David is a legal permanent resident (LPR) with a green card.  None of their are eligible for employer-sponsored coverage.  Who is eligible for what coverage?

→ Vanessa is undocumented, but she is pregnant.  While pregnant, she qualifies for MAGI Medicaid.
→ Autumn is also undocumented, but she is not pregnant.  As an undocumented (non-pregnant) immigrant, she is not eligible for Medicaid or for a QHP.
→ David is an LPR, but he is not eligible for Medicaid because he has been in the U.S. for less than five years.  But he is eligible for a QHP and APTCs/CSRs during the waiting period.  

5. Social Security Number

Each individual applying for Medicaid coverage (including children) must provide a valid social security number (SSN).

The only minor exception is newborns, who qualify for Medicaid immediately if born to a mother with Medicaid coverage.  But even for newborns, the mother is responsible for obtaining an SSN for the child and providing it to the State.  Failure to do so can result in sanctions against the mother, though not the child, for failure to cooperate.

The State cannot require non-applicants in an applicant’s household to provide an SSN.  The State may request the SSN of all household members to help them verify income, but the eligibility of an applicant cannot be denied due to a non-applicant’s failure to provide an SSN.

Note on Incarcerated Beneficiaries

Medicaid “suspends” the eligibility of Medicaid beneficiaries who are incarcerated in Rhode Island.  The corrections system must provide basic healthcare for inmates, and Medicaid is responsible for reimbursing costs of acute care hospital stays of 24 hours or more provided off the premises of the corrections facility.

Medicaid coverage that has been suspended due to incarceration must be reinstated promptly upon the person’s release.

More Resources:

Healthcare Rights E-News

Updates and more for Resource Hub users Join

And financial support from: