DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

CENTER FOR MEDICAID AND STATE OPERATIONS

Medicaid At-a-Glance

2005

A Medicaid Information Source

■ The Medicaid Program

■ Key Eligibility Groups

■ Mandatory State Plan Services

■ State Chart

• Optional Medicaid Plan Services

• Federal/State Matching Rates for Services

■ Federal Poverty Guidelines
THE MEDICAID PROGRAM

KEY ELIGIBILITY GROUPS

CATEGORICALLY NEEDY

MEDICALLY NEEDY

1

The medically needy have too much money (and in some

cases resources like savings) to be eligible as categorically

needy. If a state has a medically needy program, it must

include pregnant women through a 60-day postpartum

period, children under age 18, certain newborns for one

year, and certain protected blind persons.

The Medicaid Program provides medical benefits to

groups of low-income people, some who may have no

medical insurance or inadequate medical insurance.

Although the Federal government establishes general

guidelines for the program, the Medicaid program requirements are actually established by each State. Whether or not a person is

eligible for Medicaid will depend on the State where he or she lives.

States are required to include certain types of individuals

or eligibility groups under their Medicaid plans and they

may include others. States’ eligibility groups will be

considered one of the following: categorically needy,

medically needy, or special groups. Following are brief

descriptions of some of the key eligibility groups included under States’

plans. These descriptions do not include all groups. Contact your state

for more information on all Medicaid groups in your state. (For more

information, see http://www.cms.hhs.gov/medicaid/eligibility or

http://www.cms.hhs.gov/medicaid/whoiseligible.asp).

■ Families who meet states’ Aid to Families with 

Dependent Children (AFDC) eligibility requirements 

in effect on July 16, 1996.

■ Pregnant women and children under age 6 whose 

family income is at or below 133 % of the Federal poverty level.

■ Children ages 6 to 19 with family income up to 100% of the 

Federal poverty level.

■ Caretakers (relatives or legal guardians who take care of children 

under age 18 (or 19 if still in high school)).

■ Supplemental Security Income (SSI) recipients (or, in certain 

states, aged, blind, and disabled people who meet requirements 

that are more restrictive than those of the SSI program). 

■ Individuals and couples who are living in medical institutions and

who have monthly income up to 300% of the SSI income 

standard (Federal benefit rate). 
SPECIAL GROUPS

2

States may also, at the State’s option, provide Medicaid to: 

■ Children under age 21, 20, 19, or under age 19 who are full-time 

students. If a state doesn’t want to cover all of these children, it can

limit eligibility to reasonable groups of these children.

■ Caretaker relatives (relatives or legal guardians who live with and 

take care of children).

■ Aged persons (age 65 and older).

■ Blind persons (blindness is determined using the SSI program 

standards or state standards).

■ Disabled persons (disability is determined using the SSI program 

standards or state standards).

■ Persons who would be eligible if not enrolled in a health 

maintenance organization.

States that have medically needy programs:

Arkansas Hawaii Maine Nebraska Pennsylvania Vermont

California Illinois Maryland New Hampshire Puerto Rico Virginia

Connecticut Iowa Massachusetts New Jersey Rhode Island Washington

Dist. of Columbia Kansas Michigan New York Tennessee West Virginia

Florida Kentucky Minnesota North Carolina Texas* Wisconsin

Georgia Louisiana Montana North Dakota Utah

*The medically needy program in Texas covers only the “mandatory" medically needy groups. It does not

cover the aged, blind and disabled.

■ Medicare Beneficiaries—Medicaid pays Medicare premiums,

deductibles and coinsurance for Qualified Medicare

Beneficiaries (QMB)—individuals whose income is at or

below 100% of the Federal poverty level and whose

resources are at or below twice the standard allowed under

SSI. There are additional groups for whom Medicare related expenses are

paid by Medicaid—Medicare beneficiaries with income greater than

100% but less than 135% of the Federal poverty level.

■ Qualified Working Disabled Individuals—Medicaid can pay

Medicare Part A premiums for certain disabled individuals who

lose Medicare coverage because of work. These individuals have

income below 200% of the Federal poverty level and resources

that are no more than twice the standard allowed under SSI. 

■ States may also improve access to employment, training, and

placement of people with disabilities who want to work through

expanded Medicaid eligibility. Eligibility can be extended to

working disabled people between ages 16 and 65 who have

income and resources greater than that allowed under the SSI

program. States can extend eligibility even more to include

working individuals who become ineligible for the group described

above because their medical conditions improve. States may

require such individuals to share in the cost of their medical care.

■ There are two eligibility groups related to specific medical

conditions that states may include under their Medicaid plans. One

is a time-limited eligibility group for women who have breast or

cervical cancer; the other is for people with tuberculosis (TB) who
STATE CHILDREN’S HEALTH

INSURANCE PROGRAMS

3

are uninsured. Women with breast or cervical cancer receive all plan

services; TB patients receive only services related to the treatment of

TB. The charts below identify the states that include these groups

under their Medicaid plans.

States including people with TB:

California Minnesota Oklahoma Rhode Island Wisconsin

Dist. of Columbia New York Puerto Rico Utah Wyoming

Louisiana

States including women with breast or cervical cancer:

Alabama Florida Louisiana Nebraska Ohio Texas

Alaska Georgia Maine Nevada Oklahoma Utah

Arizona Hawaii Maryland New Hampshire Oregon Vermont

Arkansas Idaho Massachusetts New Jersey Pennsylvania Virginia

California Illinois Michigan New Mexico Rhode Island Washington

Colorado Indiana Minnesota New York South Carolina West Virginia

Connecticut Iowa Mississippi North Carolina South Dakota Wisconsin

Delaware Kansas Missouri North Dakota Tennessee Wyoming

Dist. of Columbia Kentucky Montana

1115 medicaid waivers:

■ Some states have also expanded eligibility under Medicaid waivers. Often

the expanded eligibility is only for people who enroll in managed care.

States with 1115 statewide, expanded eligibility waivers:

Alabama Dist. of Columbia Maryland New Jersey Tennessee

Alaska Florida Massachusetts New Mexico Utah

Arizona Hawaii Michigan New York Virginia

Arkansas Idaho Minnesota Oregon Vermont

California Illinois Mississippi Rhode Island Washington

Colorado Maine Missouri South Carolina Wisconsin

Delaware

Note: States also enroll beneficiaries in managed care through 1915(b) waivers. Only two states, Alaska and

Wyoming, do not include managed care in their Medicaid program.

long term care:

■ All states provide community Long Term Care services for

individuals who are Medicaid eligible and qualify for institutional

care. Most states use eligibility requirements for such individuals

that are more liberal than those normally used in the community.

To find out more about Medicaid in your State call the toll free

number for your State. A list of toll free numbers can be reached through

the CMS website, http://www.cms.hhs.gov/medicaid/consumer.asp.

Find out more about Medicare by calling 1-800-MEDICARE or

going to http://www.medicare.gov.

In addition to a state’s Medicaid program, states have a

health insurance program for children up to age 19, known

as the State Children’s Health Insurance Program (SCHIP).

In some states the SCHIP is part of the state’s Medicaid

program, in some states it is separate, and in some states it

is a combination of both types of programs. These programs are for

children whose parents have too much money to be eligible for Medicaid,

but not enough to buy private insurance. Most states offer this insurance

coverage to children in families whose income is at or below 200% of

the Federal poverty level. However, because states have different income

eligibility requirements, you need to find out about the program in your
4

state. Not all the insurance programs provide the same benefits, but they

all include shots (immunizations) and care for healthy babies and

children at no cost. Families may have to pay a premium or a small

amount (co-payment) for other services depending on their income.

While states call their child health insurance programs by different

names, you should be able to find out about the program in your state

by asking for the State Children’s Health Insurance Program or calling

1-877-KIDS NOW (1-877-543-7669).

For more detailed SCHIP information see the following websites:

http://cms.hhs.gov/schip and http://www.insurekidsnow.gov.

MANDATORY STATE PLAN SERVICES

services for categorically needy

eligibility groups:

Medicaid eligibility groups classified as categorically

needy are entitled to the following services unless waived

under section 1115 of the Medicaid law. These service

entitlements do not apply to the SCHIP programs. 

■ Inpatient hospital (excluding inpatient services in institutions for

mental disease).

■ Outpatient hospital including Federally Qualified Health Centers 

(FQHCs) and if permitted under state law, rural health clinic and 

other ambulatory services provided by a rural health clinic which 

are otherwise included under states’ plans.

■ Other laboratory and x-ray.

■ Certified pediatric and family nurse practitioners (when licensed to 

practice under state law).

■ Nursing facility services for beneficiaries age 21 and older.

■ Early and periodic screening, diagnosis, and treatment (EPSDT) for 

children under age 21.*

■ Family planning services and supplies.

■ Physicians’ services. 

■ Medical and surgical services of a dentist.

■ Home health services for beneficiaries who are entitled to nursing 

facility services under the state’s Medicaid plan.

• Intermittent or part-time nursing services provided by home 

health agency or by a registered nurse when there is no home 

health agency in the area.

• Home health aides.

• Medical supplies and appliances for use in the home.

■ Nurse mid-wife services. 

■ Pregnancy related services and service for other conditions that 

might complicate pregnancy.

■ 60 days postpartum pregnancy related services.

*Under the EPSDT program, states are required to provide all medically necessary services. This includes

services that would otherwise be optional services. If an optional service is only available through the

EPSDT program, it will not appear on this chart.
5

STATE PLAN

(See below)

services for medically needy eligibility groups:

States must provide at least the following services when the medically

needy are included under the Medicaid plans:

■ Prenatal and delivery services. 

■ Post partum pregnancy related services for beneficiaries under age 

18 and who are entitled to institutional and ambulatory services 

defined in a state’s plan.

■ Home health services to beneficiaries who are entitled to receive 

nursing facility services under the state’s Medicaid plan. 

States may include any other services described under Medicaid

law subject to any limits based on comparability of services. States

may provide different services to different groups of medically needy.

For example, States may opt to provide specific services for

beneficiaries under age 21 and/or over age 65 in institutions for

mental disease and/or intermediate care facilities for the mentally

retarded if included as medically needy. However, unless there is a

waiver, the services provided to a particular group must be available

to everyone within that group. The chart does not reflect different

services for the different medically needy sub-groups—only that at

least one group gets the service.

optional medicaid state plan services:

The services reflected on this chart are only the optional

state plan services that states have elected to include under

their plans and managed care waivers as of March 31,

2005. (See http://www.cms.hhs.gov/medicaid/stateplans,

http://www.cms.hhs.gov/medicaid/managedcare or call the state’s

Medicaid agency for up-to-date information.) The eligibility groups that

are entitled to each service are identified. The chart does not include

services provided under the SCHIP programs or additional non-plan

services that may be provided through waiver programs or managed care

organizations. The chart also does not reflect the services that states are

required to provide. A description of those services and the services for

the optional medically needy eligibility groups are described above.

The chart identifies limits on services, but it doesn’t reflect what type

of limit is imposed. Generally, these limits are on the number of visits,

days a service may be provided or items of services like prescriptions that

may be filled in a specified time. It is important to note that states may,

under waiver authority, also be imposing additional limits on sub-groups

of the eligibility categories listed.

federal/state matching rates for services:

The Medicaid program is funded through Federal and state funds.

States have different Federal matching rates to fund the services

provided under their Medicaid programs. The Federal matching rates

for each state for Federal fiscal years 2005 and 2006 are reflected on

the chart.
6

FEDERAL POVERTY LEVEL CHARTS

The 2005 Federal Poverty Level Charts were used by state

Medicaid agencies in developing their eligibility criteria

for various Medicaid groups for the period covered by this

Medicaid At-a-Glance chart. In some cases the law

requires states to use a percentage of the Federal poverty

level as the income threshold while other states have elected to use

percentages of the Federal poverty level for their eligibility criteria.
7

M

 OCN = Optional Categorically Needy Groups Only MN = Medically Needy Only (Any Medically Needy Group)

 ACN = All Categorically Needy X AP = Additional Populations added through 1115 Waivers

2005 

FMAP

2006 

FMAP

70.83 69.51 Alabama + +

57.58 50.16 Alaska + 

67.45 66.98 Arizona + +   + 

74.75 73.77 Arkansas + + +  + 

50.00 50.00 California + + + + + 

50.00 50.00 Colorado     + 

50.00 50.00 Connecticut + 

50.38 50.09 Delaware + + + 

70.00 70.00 D.C. + + + 

58.90 58.89 Florida + + + +  + 

60.44 60.60 Georgia + + +  + 

58.47 58.81 Hawaii + + + 

70.62 69.91 Idaho + + + 

50.00 50.00 Illinois + + +  

62.78 62.98 Indiana + + + + + + 

63.55 63.61 Iowa + + + + 

61.01 60.41 Kansas + + + + 

69.60 69.26 Kentucky  + + 

71.04 69.79 Louisiana + + + 

64.89 62.90 Maine + + + + + + 

50.00 50.00 Maryland + + + + + + 

50.00 50.00 Massachusetts + + + + 

56.71 56.59 Michigan + + + + 

50.00 50.00 Minnesota + + + +  + 

77.08 76.00 Mississippi + + + + 

61.15 61.93 Missouri + + + 

71.90 70.54 Montana + + + + + 

59.64 59.68 Nebraska + + + + + + 

55.90 54.76 Nevada + + + + 

50.00 50.00 New Hampshire + + + + + 

50.00 50.00 New Jersey + + + + 

74.30 71.15 New Mexico + + + + 

50.00 50.00 New York + + + 

63.63 63.49 North Carolina + + + + + + 

67.49 65.85 North Dakota +  +    

59.68 59.88 Ohio + + + + + + 

70.18 67.91 Oklahoma +   

61.12 61.57 Oregon + + + + + +X+

53.84 55.05 Pennsylvania + + + + + 

55.38 54.45 Rhode Island + + 

69.89 69.32 South Carolina + + + + 

66.03 65.07 South Dakota + + + + 

64.81 63.99 Tennessee      

60.87 60.66 Texas + 

72.14 70.76 Utah + + + + + 

60.11 58.49 Vermont + + + 

50.00 50.00 Virginia + + + 

50.00 50.00 Washington + + + + 

74.65 72.99 West Virginia +  +   + 

58.32 57.65 Wisconsin + + + + + + 

57.90 54.23 Wyoming + + 

Totals: 27 44 49 34 31 27 

Totals = Total number of States and District of Columbia that provide the service to one or more categories of eligibles

50.00 50.00 Puerto Rico + + + +

50.00 50.00 Virgin Islands +

Note: Only Mandatory Services are required for American Samoa, Guam, and N. Mariana Islands.

Note: All services provided by Puerto Rico are provided by Managed Care.

Other Licensed Practitioners

OptometristsPsychologistsPrivate Duty NursingNurse Anesthetist

Chiropractors

Podiatrists
8

MEDICAID SER

+



+

+

+

+

+

+

+

+

+

+



+

+

+

+

+



+

+

+

+

+

+

+

+

+

+

+

+

+

+



+

+

+

+

+

+



+

+

+

+





+

+

49

Physician Directed

Clinic Services

 ALL = All Eligibility Groups that States Covers A combination of symbols like the following  + means that the stat

 + Limits = Limit of some type on the service services to all eligibility groups, but places limits on all the categorical

STATES

AL

AK + + + + + + + +

AZ + + + +  + +

AR + + + + + + +

CA + + + + + + + +

CO + + + + + + +

CT + + + + +

DE   

DC + + + + + + + +

FL + + + + + +

GA + + + + + + +

HI + + + + + + + +

ID + + + + + + +

IL + + + + + + + +

IN + + + + + + + +

IA + + + + + + + +

KS + + + + + + + +

KY + + + + + + + +

LA + + +

ME + + + + + + + +

MD + + + + + + + +

MA + + + + + + +

MI + + + + +

MN + + + + + + + +

MS + + + + + + + +

MO + + + + +

MT + + + + + + + +

NE + + + + + + + +

NV + + + + + + + +

NH + + + + + + + +

NJ + + + + + + + +

NM + + + + + + + +

NY     + + + +

NC + + + + + + + +

ND + + + + + + + +

OH + + + + + + + +

OK +

OR + + + + + + + +

PA + + + + + + + +

RI + + + + +

SC + + + + + + +

SD + + + + + + +

TN     +   

TX + + +

UT + + + + + + + +

VT + + + + ++ + + +

VA + + + + + + + +

WA + + + + + + + +

WV    + +   

WI + + + + + + + +

WY + + + + + + + +

-- 49 48 49 44 44 43 40 40

PR + +  

VI +

Therapies for Speech

Hearing and Language

Disorders

DentalPhysical Therapy

Occupational Therapy

Home Health Therapies

Speech and Language

Audiology Services

PhysicalOccupational
9

RVICES STATE

e provides the ( )1 = Delaware, Indiana, New York, North Dakota, Puerto Rico and

y needy groups. Inpatient hospital services only provided to beneficiaries age 65 and o

STATES

AL + +

AK + + + + +

AZ + + + +  + +

AR + + + +

CA + + + + +

CO + + +

CT + + + + + + +

DE + + + + +

DC + + + + + +

FL + + + + + +

GA + + + + + + +

HI + + + + +  

ID + + + + +

IL + + + + + + +

IN + + + + + + +

IA + + + +

KS + + + +

KY + + + + + +

LA + + +

ME + + + + + + +

MD + + + + + + +

MA + +   

MI + + + +

MN + + + + + + +

MS + + + + + +

MO + + + +

MT + + + + + + +

NE + + + + +

NV + + + + + + +

NH + + + + + +

NJ + + + + +  +

NM + + + +

NY + + + + + + +

NC + + + + + + +

ND + +  +   +

OH + + + + + + +

OK + + + +

OR + + + +  + +

PA + + + + + + +

RI + + + + +

SC +X+ + + +

SD + + + + +

TN  +  + 

TX +

UT + + + + + + +

VT + + + +

VA + + + + + +

WA + + + + + +

WV   +   

WI + + + +   

WY + +

-- 51 35 49 43 33 33 36

PR +

VI + +

Screening Services

Diagnostic Services

Preventive Services

MEDICAID OPTIONAL SERVICES STATE PLAN CH

Prescribed Drugs

Dentures

Eyeglasses

Prosthetic Devices

d Wyoming: 

lder in institutions for mental disease. 

STATES

AL + + 

AK + 

AZ   

AR + 

CA + + 

CO + + 

CT + 

DE + + 

DC + 

FL + + 

GA + 

HI + + 

ID + + 

IL + + 

IN + + 

IA + 

KS + 

KY + 

LA + 

ME + + 

MD + + 

MA  

MI + + 

MN + + 

MS + 

MO + 

MT + 

NE + 

NV + 

NH + + 

NJ + 

NM + 

NY + 

NC + 

ND +  

OH + + 

OK + + 

OR + 

PA + 

RI + + 

SC + 

SD + + 

TN +  

TX + 

UT + + 

VT + + (

VA + + 

WA + + 

WV  + 

WI + + 

WY + + 

-- 46 33 

PR 

VI

Mental Health Rehab. /Stablization

Services 

Inpatient Hospital/ Nursing

Rehabilitative

RT

Other
10

E PLAN CHART

( )2 = Idaho and South Dakota: Skilled nursing facility services only 

ntal disease. provided to beneficiaries age 65 and older in institutions for mental dis

+ + + + + +

+ + + + + 

   + +

  + + 

+ + + + + +

+ +  + + +

+ + + + +

+ ()

1  +

+ + + + +

+ + + + + 

+ + +

+ + + +

+ (+)

2 + + + + +

+  +  +

+ (+)

1 + + +

 + + + +

+ + + + + +

+ ++ + +

+ + + + + +

+    + + +

+ + + + + +

   + + + +

+ + + + + +

+ + + + + +

+ + + +

+ + + + + +

+ + + + +

+ + + + + +

+ + + + +

+ + + + + +

+ + + + +

+ + + +

()

1   + + 

()

3 + + + + +

 ()

1   + + +

+ + + + +

+ + +  + + +

+ +X+ +X+ + + +

+   + + +

+ + + + + +

+ + + +

+ ()

2  + + +

     

+ + +

+ + + + + +

+ ()

3  ++ ++ +

+   + +

+   + + +

+   +  

+ +   + +

+ (+)

1  +

33 43 51 46 36 48 25

(+)

1 

Targeted Case

Management

Primary Care Case

Management

Personal Care Services

Intermediate Care

Facility Services for MR

es Case Management

Inpatient Hospital/ NursingFacility/ICF Services 65 andOlder in IMD

ative

Inpatient Psychiatric

Services Under Age 21

Other

( )3 = North Caro

sease. services only prov

STATES

AL + 

AK  + 

AZ +  

AR + 

CA + 

CO  

CT 

DE + 

DC + 

FL + + 

GA + 

HI + + 

ID + 

IL + + 

IN + 

IA + 

KS + 

KY + 

LA + 

ME  

MD + 

MA X+ 

MI + + 

MN + 

MS + 

MO + 

MT + 

NE + 

NV + + 

NH 

NJ + 

NM + 

NY + 

NC  + 

ND  

OH + + 

OK 

OR + 

PA + + 

RI + 

SC + 

SD  

TN   

TX + + 

UT + 

VT  

VA  

WA   

WV   

WI + + 

WY  

-- 48 16 

PR 

VI + 

Source

Respiratory Care for

Ventilator Dependent

Hospice Care
11

T

Publication No. CMS-11024-05

Use 410-786-1905 to fax requests for additional copies.

( )3 = North Carolina and Vermont: Inpatient hospital and intermediate care facility

services only provided to beneficiaries age 65 and older in institutions for mental disease.

+ + +

 + + +

+   +   

+ + + + +

+ + + + +

 + +   +

 + 

+ 

+ +  +

+ +  + + + +

+ + + +

+ + + +  +

+ + + +

+ +  + +  

+ + + + 

+ + + ++

+  + + + +

+ + + +

+ + + +

 + 

+  + + +

X+ + + + 

+ + + + + + +

+  + + + +

+ + + +

+  + + +

+ + + + +

+ + + + +

+ + + +

+ + +

+ + + + +

+ + + +

+ + + + + 

 + + +

 +   +

+ +  + + + + 

+ +

+ + +   +

+ + + + + +

+ + +

+  + + +

 +   +

    

+ +  + + + + +

+ + +  +

 ++ ++ +

  +   

   + + 

    

+ + + + + +  

 +  + +

48 16 22 12 49 50 35 25

+

+ +

Source: Approved Medicaid state plans and waivers as of March 31, 2005.

Other

Medical or Remedial

Respiratory Care for

Ventilator Dependent

Critical Access HospitalReligious (Non-Medical)

Health Care InstitutionNursing FacilityServices Under Age 21

Emergency Hospital

Services in NonMedicare Participating

PACE (All Inclusive

Care for the Elderly)

Care Services

Transportation Services

(Not Administrative)

Hospice Care