The Medicaid Maze: A Survivor’s Guide to Family Income Limits and Eligibility in 2025

In a Nutshell: Your Quick Guide to the Medicaid Maze

For those in the thick of it, needing answers now, here is the bare-bones truth of what you need to know.

• The Official Charts Are a Starting Point, Not the Answer. The simple income charts you find online are based on the Federal Poverty Level (FPL). Your eligibility is NOT based on your raw income, but on your Modified Adjusted Gross Income (MAGI) as a percentage of the FPL. For 2025, 100% of the FPL for a single person is $15,650, and for a family of four, it’s $32,150.¹ But this is just the beginning.
• There Are Two Different Systems: MAGI vs. Non-MAGI. Your path to eligibility depends on who you are.

• MAGI Medicaid: For most children, pregnant women, parents, and adults under 65 in expansion states. This system is based on tax rules and, crucially, has no asset test.³ Your savings account or car value do not matter.
• Non-MAGI Medicaid: For individuals eligible due to age (65+), blindness, or disability. This system has different income rules and has a very strict asset test—often as low as $2,000 for an individual.⁵

• Your State Is Everything. Whether your state expanded Medicaid under the Affordable Care Act (ACA) is the single most important factor for adults under 65. In expansion states, you can qualify with an income up to 138% of the FPL. In the 10 non-expansion states, eligibility for adults is extremely limited, creating a “coverage gap” where you can be too poor for help.⁶
• Income Is Not What You Think It Is. For Medicaid, “income” includes things you might not expect. For example, your pre-tax 401(k) contributions and even your non-taxable Social Security benefits are counted.⁸ However, things like child support and Supplemental Security Income (SSI) are not.¹⁰
• Application Mistakes Are Common and Costly. The application process is a minefield. Common errors like waiting too long to file, guessing on forms, gifting money within five years of needing long-term care, or misreporting “lumpy” self-employment income can lead to denial and months of lost coverage.¹¹

This guide will walk you through every one of these points in detail.

It’s a complex journey, but with the right map, you can navigate it.

Section I: My Wake-Up Call: Why the Official Charts Are a Trap

I’ll never forget the call from the McHenry family.

On paper, it seemed straightforward.

I had pulled up the standard government chart for Medicaid income limits, a neat grid of household sizes and dollar amounts.

A quick glance at their income, and my heart sank.

They looked to be clearly over the limit.

I almost told them not to bother, to save themselves the heartache of a guaranteed denial.

Thank God I didn’t.

What unfolded over the next few weeks was a descent into a bureaucratic nightmare that revealed the dangerous lie at the heart of the Medicaid system: the illusion of simplicity.

The McHenry’s weren’t just dealing with one clear rejection.

They were caught in a whirlwind of conflicting notices from the state of Florida.

One form said their sick 5-year-old son, Ryder, who was undergoing chemotherapy, had been denied coverage.

Another notice, arriving almost simultaneously, said the family’s coverage would continue for another year.

A third letter declared that the parents and their older son made too much money and would be cut off in less than two weeks.¹⁴

After hours on hold, disconnected calls, and conversations with caseworkers who couldn’t explain the discrepancies, the truth began to emerge.

The state’s automated system appeared to be erroneously counting Ryder’s cancer-related disability payments as family income, artificially inflating their earnings and pushing them over the eligibility cliff.¹⁴

They were trapped in a system that was not just confusing, but actively working against them, armed with incorrect data and opaque rules.

That case was my wake-up call.

It taught me that the clean, simple charts published on government websites are a trap.

They present Medicaid eligibility as a simple two-variable equation: your income and your family size.

This is dangerously misleading.

The real system is a sprawling, chaotic ecosystem governed by a dizzying interplay of federal tax law, state-level political decisions, and labyrinthine administrative procedures.

The very agencies that are supposed to help often publish conflicting information.

A person trying to plan for their family’s future can find one set of “Federal Poverty Level” guidelines on the U.S. Courts website ¹⁵, another on a form for immigration sponsorship ¹⁶, and yet another from the Department of Health and Human Services (HHS).²

Using the wrong official-looking chart can lead you to make devastating financial decisions based on a false premise, only to be denied without ever understanding why.

This experience forced me to develop a new way of seeing the problem.

I realized you can’t navigate a river by only looking at a map of the ocean.

To truly understand Medicaid, you have to see it as a giant watershed.

The Federal Poverty Level (FPL) is the “sea level” of this entire system—the baseline measurement.

But your actual eligibility, your real-world fate, depends entirely on which “river” you’re in: the modern MAGI system or the legacy Non-MAGI system.

It depends on the powerful “currents” of your state’s specific rules, most importantly whether it expanded Medicaid.

And it depends on learning to spot and navigate the treacherous “dams and waterfalls”—the application pitfalls, documentation requirements, and eligibility cliffs that can wreck even the most deserving applicants.

This guide is the map to that watershed.

It’s the report I wish I’d had for the McHenry family.

It’s for every person staring at a denial letter they don’t understand, or for anyone too intimidated by the complexity to even start.

Section II: The “Sea Level” of Eligibility: Understanding the Federal Poverty Level (FPL)

Before we can navigate the complex river systems of Medicaid, we must first understand the fundamental benchmark against which all eligibility is measured: the Federal Poverty Level, or FPL.

Think of it as the “sea level” of the entire benefits landscape.

It is a set of income thresholds, updated annually by the Department of Health and Human Services (HHS) to account for inflation, that are used to determine eligibility for a vast array of federal programs, including Medicaid, the Children’s Health Insurance Program (CHIP), and subsidies on the Affordable Care Act (ACA) Marketplace.¹

While these numbers are the foundation, it is critical to understand that they are a reference point, not a direct income test.

You will almost never see a Medicaid rule that says, “You must earn less than $32,150.” Instead, the rules are written in percentages, such as, “You must have an income at or below 138% of the FPL”.¹

This is a crucial distinction.

The FPL is the yardstick; your eligibility is the measurement.

The 2025 Federal Poverty Level Numbers

To begin, let’s establish the baseline.

The following table consolidates the 2025 FPL guidelines for the 48 contiguous states and the District of Columbia at the most common percentages used for health programs.

This single, comprehensive table can serve as your primary reference, helping you avoid the confusion of using different, limited charts from various government agencies.¹⁵

Table 1: 2025 Federal Poverty Level (FPL) Guidelines (48 Contiguous States & D.C.)

Household Size	100% (Annual)	138% (Annual)	150% (Annual)	200% (Annual)	100% (Monthly)	138% (Monthly)
1	$15,650	$21,597	$23,475	$31,300	$1,304	$1,800
2	$21,150	$29,187	$31,725	$42,300	$1,763	$2,432
3	$26,650	$36,777	$39,975	$53,300	$2,221	$3,065
4	$32,150	$44,367	$48,225	$64,300	$2,679	$3,697
5	$37,650	$51,957	$56,475	$75,300	$3,138	$4,330
6	$43,150	$59,547	$64,725	$86,300	$3,596	$4,962
7	$48,650	$67,137	$72,975	$97,300	$4,054	$5,595
8	$54,150	$74,727	$81,225	$108,300	$4,513	$6,227
For each additional person, add:	$5,500	$7,590	$8,250	$11,000	$458	$633

Source: Synthesized from HHS, Healthcare.gov, and other federal sources.¹

Monthly figures are rounded for clarity.

Important Caveats: Alaska and Hawaii

Due to a significantly higher cost of living, Alaska and Hawaii have their own, higher FPL guidelines.

It is essential to use the correct chart if you reside in one of these states.

• 2025 FPL for Alaska (100%): $19,550 for an individual; $40,190 for a family of four.²
• 2025 FPL for Hawaii (100%): $17,990 for an individual; $36,980 for a family of four.²

The FPL Is Not Your Income Limit

This is the most critical lesson of this section.

Staring at the “100% (Annual)” column and thinking “I make more than that, so I’m not eligible” is the single biggest mistake an applicant can make.

These numbers mean nothing in isolation.

Your eligibility is determined by comparing your specific household income, calculated using a complex methodology called Modified Adjusted Gross Income (MAGI), to a specific percentage of the FPL set by your state for your specific eligibility group (e.g., pregnant woman, child, or adult).

The rest of this guide is dedicated to demystifying that exact process.

The FPL is just sea level; now we need to find your river.

Section III: The Two Great Rivers: Are You in the MAGI or Non-MAGI System?

One of the most profound and least understood aspects of the Medicaid system is that it is not one system at all.

It is two separate, parallel systems that operate under fundamentally different rules.

The Affordable Care Act (ACA) sought to standardize and simplify things by creating a new methodology based on federal income tax concepts, known as Modified Adjusted Gross Income (MAGI).⁴

This became the default for most applicants.

However, Congress specifically exempted certain vulnerable populations from this new system, leaving them in the legacy system governed by older, more complex rules.

Therefore, the first and most important question you must answer is: which river am I in? The answer determines everything that follows, from how your income is counted to whether the value of your car or savings account matters at all.

The MAGI River (The Modern System)

This is the main channel for Medicaid eligibility today.

If you are in one of the following groups, you are almost certainly in the MAGI river ³:

• Children aged 18 and under
• Pregnant women
• Parents and caretaker relatives of minor children
• Adults ages 19-64 without disabilities in states that have expanded Medicaid

The defining characteristics of the MAGI system are revolutionary for a public benefits program:

1. Based on Tax Concepts: It determines your household size and income based on how you file your federal income taxes.³ It’s about filers, spouses, and dependents, not just who lives under your roof.
2. No Asset Test: This is a monumental and often misunderstood feature. For MAGI Medicaid, the amount of money you have in savings, the value of your car, or the equity in your home is completely irrelevant.³ You can have a million dollars in the bank and still qualify for MAGI Medicaid if your
   income for the year is below the limit. This fact alone runs counter to decades of public perception about “welfare” programs and is a source of immense confusion. Many people who would be eligible never apply because they incorrectly believe their modest savings disqualify them.²²

The Non-MAGI River (The Legacy System)

This is the older, narrower, and more treacherous channel.

It is reserved for individuals whose eligibility is based on their status, not just their income.

You are in the Non-MAGI river if you are seeking eligibility because you are ³:

• Age 65 or older
• Determined to be blind by the Social Security Administration (SSA)
• Determined to be disabled by the SSA (e.g., receiving SSI or SSDI)

The rules of this river are entirely different and far stricter:

1. Based on SSI Rules: Income is counted using methodologies from the Supplemental Security Income (SSI) program, which can be more complex and less intuitive than tax rules.⁴
2. Includes a Strict Asset Test: This is the critical difference. Unlike MAGI, the Non-MAGI system imposes a severe limit on “countable assets.” In most states, an individual cannot have more than $2,000 in countable resources to their name. For a couple, the limit is often just $3,000.⁵ This includes cash, bank accounts, stocks, bonds, and property that isn’t your primary home.

The System’s Split Personality

This division creates a split personality within Medicaid that is a primary driver of confusion.

Advice that is perfectly correct for a 40-year-old parent applying under MAGI rules can be financially catastrophic for a 70-year-old applying for long-term care under Non-MAGI rules.

Imagine a daughter helping her 40-year-old sister (a single mother) apply for Medicaid.

She learns correctly that her sister’s used car and $5,000 in emergency savings don’t matter.

A few years later, she tries to help her 75-year-old father apply for nursing home care.

Assuming the rules are the same, she doesn’t advise him to do anything about his $20,000 in savings.

His application is swiftly denied for being over the asset limit.

The advice failed not because it was wrong, but because it was applied to the wrong river.

Public forums and even some official websites often fail to clearly delineate between these two systems, lumping all the rules together and creating a minefield for applicants.²¹

To navigate successfully, you must first identify your channel.

The rest of your journey depends on it.

Section IV: Navigating the MAGI River: Income, Households, and Hidden Traps

For the majority of families and individuals seeking coverage, the journey to Medicaid eligibility flows through the MAGI river.

While this modern system is intended to be simpler—by tying eligibility to familiar tax concepts and eliminating the dreaded asset test—it contains its own set of rapids and hidden currents.

Successfully navigating it requires a precise understanding of two key concepts: what the government considers “income” and who it considers to be in your “household.”

Part A: Calculating Your Modified Adjusted Gross Income (MAGI)

Your MAGI is the single most important number in your application.

It is not a line item on your tax return; it’s a specific calculation used for health care programs.²³

The formula is straightforward in theory:

Adjusted Gross Income (AGI) (from Form 1040, Line 11)

+ Untaxed Foreign Income

+ Non-Taxable Social Security Benefits

+ Tax-Exempt Interest

= Modified Adjusted Gross Income (MAGI) 10

The complexity lies in the details of what counts as income in the first place.

The following checklist provides a definitive guide.

Table 2: The Ultimate MAGI Checklist: Countable vs. Non-Countable Income

Count This Income	Do NOT Count This Income
Wages, salaries, tips, bonuses 10	Supplemental Security Income (SSI) 23
Net income from self-employment (profit after expenses) 10	Child support payments received 8
Unemployment compensation 10	Gifts and inheritances 8
Social Security Disability Income (SSDI) 9	Proceeds from loans (student, home, bank) 10
All Social Security benefits (both taxable and non-taxable portions) 9	Veterans’ disability payments 10
Retirement income (pensions, IRA/401(k) withdrawals) 10	Worker’s compensation 10
Capital gains 10	Federal tax credits (like the Child Tax Credit) 10
Alimony received (for divorce agreements before Jan 1, 2019) 10	TANF (welfare) benefits 21
Rental or royalty income (net) 10	Foster care payments 21
Tax-exempt interest 24	Scholarships/grants used for tuition & fees 8

Source: Synthesized from Healthcare.gov, HHS, and state training materials.⁸

This checklist reveals several non-obvious traps for the unwary.

The Pre-Tax Contribution Trap: Many people try to lower their taxable income by contributing to pre-tax retirement accounts like a 401(k) or using a flexible spending account (FSA).

While this reduces the income on your W-2, Medicaid’s MAGI rules are different.

Those pre-tax salary deferrals are added back in and counted as income.⁸

A family might diligently save for retirement, see their take-home pay decrease, and believe they now qualify for Medicaid, only to be denied.

The system’s definition of income defies the logic of personal finance, creating a devastating trap for those trying to do the right thing.

The Self-Employment Quagmire: For gig workers, freelancers, and small business owners, income is rarely stable.

Medicaid eligibility is based on your projected annual net income, which can feel like pure guesswork.²⁵

This creates a notorious problem on the Healthcare.gov application portal.

The site asks for your

“current monthly income.” If you are a freelancer who had a slow month and honestly report $0, the system may automatically shunt you into a bureaucratic loop, determining you are eligible for Medicaid based on that single month’s income, even if your annual income is hundreds of thousands of dollars.¹³

The hard-won wisdom from those who have survived this process is clear: do not report your actual, fluctuating monthly income.

Instead, project your best estimate for your total annual net income (after business expenses), divide it by 12, and report that average as your “current monthly income” on the application.¹³

While it may feel inaccurate for any given month, it is the only reliable way to reflect your true annual financial picture and avoid being incorrectly flagged for Medicaid.

Part B: Defining Your MAGI Household

Just as “income” has a specific definition, so does “household.” For MAGI Medicaid, your household is not defined by who you live with, but by who you file taxes with.³

This is another fundamental concept that causes immense confusion.

There are three basic scenarios:

1. You are a Tax Filer (and not claimed as a dependent): Your household consists of you, your spouse (if you file a joint tax return), and anyone you claim as a tax dependent.⁸
2. You are a Tax Dependent: Your household is the same household as the tax filer who claims you. So, if your parents claim you, your household for Medicaid purposes is your parents’ household, including their income.⁸ There are complex exceptions to this rule, for example, if a child is claimed by a non-custodial parent.
3. You are a Non-Filer (and not claimed as a dependent): Your household consists of you, your spouse (if you live together), and your biological, adopted, or step-children who live with you.⁸

This tax-based approach leads to bizarre and counterintuitive outcomes that can make or break an application.

The “Tax Dependent” Rule Creates Bizarre Outcomes: Consider a 20-year-old college student who lives at home with their parents.

The student has a part-time job and earns $8,000 a year, well below the Medicaid limit.

The parents have a high income and are not eligible.

Is the student eligible?

The answer has nothing to do with where the student lives or how much they earn.

It depends entirely on a single checkbox on the parents’ Form 1040.

• Scenario A: The parents claim the student as a tax dependent. For Medicaid purposes, the student’s household is the parents’ household. Their high income is attributed to the student, making the student ineligible.²⁸
• Scenario B: The parents do not claim the student as a tax dependent. The student is now considered their own household of one. With an income of only $8,000, they are well below the 138% FPL threshold ($21,597 in 2025) and are eligible for Medicaid in an expansion state.¹

The family’s decision on how to file their taxes—a choice that might save them a few thousand dollars in tax credits—can determine whether their child has health insurance.

This is a powerful, non-obvious lever that families can use to secure coverage, but only if they know it exists.

The system is a maze of interconnected rules where a decision in one domain (taxes) has profound and often unseen consequences in another (health care).

Section V: Navigating the Non-MAGI River: The World of Assets and Look-Backs

For seniors and individuals with disabilities, the path to Medicaid is a different river entirely—one with much stricter rules and more dangerous obstacles.

This is the world of Non-MAGI Medicaid, where it’s not just your income that matters, but every dollar you have saved.

Forgetting this distinction is one of the most common and costly mistakes a family can make.

It’s Not Just Income, It’s Assets

The single most important feature of the Non-MAGI system is the asset test.

Unlike the MAGI system, where savings are irrelevant, this legacy pathway imposes a strict limit on “countable resources”.⁵

While the exact rules vary by state, the limits are typically punishingly low.

Table 3: State-by-State Income & Asset Limits for Non-MAGI Medicaid (Aged, Blind, & Disabled)

This table provides an overview of the monthly income and, crucially, the asset limits for “Regular” (non-institutional) Medicaid for the Aged, Blind, and Disabled (ABD) population.

Note how income limits vary wildly, but the asset limit is consistently low across most states.

State	Single Income Limit (Monthly)	Couple Income Limit (Monthly)	Single Asset Limit	Couple Asset Limit
Alabama	$987	$1,470	$2,000	$3,000
Arizona	$1,305	$1,763	$2,000	$3,000
California	$1,801	$2,433	No Asset Limit (as of 1/1/24)	No Asset Limit (as of 1/1/24)
Florida	$1,149	$1,522	$2,000	$3,000
Georgia	$967	$1,450	$2,000	$3,000
Illinois	$1,304	$1,762	$17,500	$17,500
Kentucky	$235	$291	$2,000	$3,000
New York	$1,800	$2,433	$31,175	$42,312
Ohio	$967	$1,450	$2,000	$3,000
Pennsylvania	$989	$1,483	$2,000*	$3,000*
Texas	$967	$1,450	$2,000	$3,000

*Source: Synthesized from the comprehensive state-by-state chart in.⁴⁵

Data is for Regular/ABD Medicaid and is subject to change.

Pennsylvania’s asset limit can be higher ($8,000) in some circumstances.

California eliminated its asset test for all Medicaid programs.

This table highlights the brutal reality of the Non-MAGI system.

In most of the country, a senior with more than $2,000 in their life savings is considered too “rich” for Medicaid.

This forces many into the difficult and emotionally fraught process of “spending down” their assets to qualify for care they desperately need.

The 5-Year Look-Back Period: The Biggest Trap of All

To prevent people from simply giving away their assets to family members to meet the low limit, Medicaid implemented the 5-Year Look-Back Period.

This is arguably the single most dangerous trap in the entire system.

When an individual applies for long-term care Medicaid (such as for a nursing home), the state agency will scrutinize every financial transaction they have made for the five years (60 months) prior to the application date.¹²

Any transfer of assets—cash, property, investments—for less than fair market value during this window is flagged as a potential violation.

If a violation is found, Medicaid does not deny the application outright.

Instead, it imposes a penalty period, a length of time during which the applicant is ineligible for benefits, even if they are otherwise qualified.²⁹

The length of the penalty is calculated by dividing the value of the improper transfer by the average monthly cost of nursing home care in that state.

For example, gifting $60,000 in a state where the average cost of care is $10,000 per month would result in a six-month penalty period, during which the family would be responsible for the full cost of care.

This rule ensnares well-meaning families constantly.

Consider the real-world story of Madeleine, who was helping her mother, Agnes, apply for Medicaid.³¹

Madeleine had been her mother’s caregiver for years and would regularly withdraw cash from her mother’s account to reimburse herself for groceries, mileage, and other expenses.

When the Medicaid agency demanded five years of bank statements, they flagged these withdrawals, totaling around $30,000, as improper gifts.

Without meticulous records proving every penny was a legitimate reimbursement, Agnes faced a devastating penalty period.

What seemed like a sensible family arrangement became a potential financial catastrophe under Medicaid’s unblinking gaze.

This reveals another systemic conflict: the clash between tax law and Medicaid law.

The IRS allows individuals to make substantial tax-free gifts each year (e.g., $18,000 in 2024).³²

Many financial advisors and families believe this makes such gifts safe.

It does not.

For Medicaid’s purposes, that $18,000 gift is a sanctionable transfer that will trigger a penalty.¹²

The government’s own programs operate under conflicting rules, creating a perfect trap for citizens who are trying to follow the law as they understand it.

Section VI: Charting the Currents: The State Expansion Divide and the Coverage Gap

Beyond the fundamental divide between the MAGI and Non-MAGI rivers, the single most powerful force determining your Medicaid journey is the political current of your home state.

An applicant’s fate is often sealed by their zip code, due to a pivotal policy decision at the heart of the Affordable Care Act (ACA).

The ACA Medicaid Expansion Explained

The ACA was designed to dramatically reduce the number of uninsured Americans by expanding Medicaid to a new population: non-disabled adults with incomes below the poverty line who were previously ineligible.

The law invited states to expand their programs to cover nearly all adults with household incomes at or below 138% of the Federal Poverty Level.⁴

To encourage this, the federal government offered to pay a vastly increased share of the costs for this newly eligible group—initially 100%, and settling at 90% long-term.⁶

However, a 2012 Supreme Court ruling made this expansion optional for states.³³

This decision effectively split the country into two different Americas when it comes to health care for low-income adults.

The Two Americas of Medicaid

As of 2025, the map is a patchwork of access and denial.

41 states (including Washington d+.C.) have adopted the expansion, while 10 states have not.⁶

Table 4: Medicaid Expansion Status by State (as of 2025)

Adopted & Implemented Expansion (41 States)

Not Adopted (10 States)

Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Dakota, Utah, Vermont, Virginia, Washington, West Virginia

Alabama, Florida, Georgia*, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin*, Wyoming

Source: Synthesized from KFF, Healthinsurance.org, and Wikipedia data.⁶

*Georgia has implemented a partial expansion with a work requirement, covering adults only up to 100% FPL.

Wisconsin has not formally adopted the ACA expansion but covers adults up to 100% FPL through a state-specific waiver, so it has no coverage gap.

This map is the most important piece of contextual information for any adult under 65 applying for Medicaid.

It immediately determines the basic landscape of your eligibility.

The Coverage Gap: A Policy-Made Black Hole

In states that did not expand Medicaid, a cruel and paradoxical situation was created: the coverage gap.

The ACA was written with the assumption that all states would expand.

Therefore, it only provides subsidies for people to buy private insurance on the Marketplace if their income is between 100% and 400% of the FPL.¹⁸

The law assumed that anyone with an income below 100% FPL would be covered by Medicaid.

In non-expansion states, this assumption is false.

Their traditional Medicaid eligibility levels for parents are often extremely low (e.g., just 16% of FPL in Texas, or about $354/month for a family of three), and they offer no coverage at all for adults without dependent children, regardless of how low their income Is.⁷

This creates the gap: millions of adults who earn too much to qualify for their state’s restrictive Medicaid program, but too little to qualify for financial help to buy a plan on the ACA Marketplace.¹

They are left with no affordable health insurance options.

As of 2023, an estimated 1.4 million people are trapped in this gap.⁷

A deep look at this population reveals a stark picture:

• Geographically Concentrated: 97% of people in the gap live in the South. Texas alone accounts for 42% of the total, with Florida (19%) and Georgia (14%) making up another third.⁷
• Working Poor: The majority are in low-wage jobs. The most common occupations are cashiers, cooks, construction laborers, and retail salespeople.⁷
• Disproportionately People of Color: While 44% of all adults in non-expansion states are people of color, they make up 60% of those in the coverage gap, highlighting the deep racial disparities embedded in these policy choices.⁷

This gap is not an accident or an oversight; it is a direct and foreseeable consequence of state-level political decisions to reject federal funding and refuse expansion.

Furthermore, the system’s stability is not guaranteed even in expansion states.

At least nine states, including Arizona, Arkansas, Indiana, and North Carolina, have passed “trigger laws” that could automatically end or roll back their Medicaid expansion if the federal funding share drops below the enhanced 90% rate.⁶

This makes coverage for millions of people vulnerable to future federal budget negotiations, revealing a precariousness that most enrollees are completely unaware of.

A political debate in Washington d+.C.

could, with the stroke of a pen, eliminate their health care without any action from their state legislature.

Section VII: Avoiding the Waterfalls: A Tactical Guide to the Application Gauntlet

Understanding the grand structure of the Medicaid watershed—the FPL sea level, the MAGI and Non-MAGI rivers, and the state expansion currents—is the strategic part of the journey.

But strategy alone won’t get you to your destination.

You must also master the tactics of the application process itself, a gauntlet filled with hidden waterfalls that can sink your application.

The following is a tactical guide built from the painful experiences of countless families and the hard-won wisdom of legal experts.

These are the most common pitfalls and, more importantly, how to avoid them.

Table 5: The Top 10 Application Pitfalls and How to Avoid Them

Pitfall	The Problem	The Solution
1. Waiting Too Long to File	You believe you need all documentation before applying. This delays your “effective date,” potentially costing you months of retroactive coverage for medical bills already incurred.11	File Immediately. As soon as the need for care arises, submit the application with the minimum required information (name, address, signature). This establishes your place in line. You can provide the detailed verifications later.11
2. Guessing on the Application	You’re unsure about an old bank account or a potential benefit, so you guess. If you’re wrong, you may be forced to prove a negative—that the account doesn’t exist—which can be impossible and lead to denial.11	Never Guess. If you do not have definitive proof (e.g., a bank statement), leave the section blank or state “unknown.” It is better to respond to a specific request for information from the agency than to create a problem you cannot solve.11
3. Misunderstanding Gross vs. Net Income	You look at your take-home pay (net income) and believe you are under the limit. Medicaid, however, uses your gross, pre-tax income, including deductions for things like health insurance or 401(k) contributions.32	Always Calculate Using Gross Income. Before you even begin, calculate your income the way Medicaid does. Add up all earnings before any deductions are taken out. This gives you a realistic picture of your eligibility.32
4. The 5-Year Look-Back Violation	You gift money to your children or sell a property for a low price, thinking it’s a normal family transaction. For long-term care Medicaid, any transfer for less than fair market value in the last 5 years triggers a penalty period of ineligibility.12	Stop All Gifting. If long-term care is a possibility within the next five years, do not transfer any assets without consulting an elder law attorney. The rules are unforgiving and counterintuitive.12
5. Failing to Respond to Notices	The agency sends a request for more information with a tight deadline. You miss the deadline because you’re waiting on a document, or you ignore it. This can lead to an automatic denial for “failure to cooperate”.40	Calendar Every Deadline. Respond to every request, even if it’s just to say, “I have received your request and am working on obtaining the document. I request a 10-day extension.” Never let a deadline pass in silence.11
6. Relying on Verbal Communication	You have a helpful conversation with a caseworker on the phone who tells you what to do. There is no record of this conversation, and if a different caseworker handles your file later, that advice is meaningless.11	Create a Paper Trail. After every phone call or in-person meeting, send a brief, polite email or letter to the caseworker summarizing the conversation: “Per our conversation today, I understand I need to provide X, and you will do Y.” This documents the exchange.11
7. The “Lumpy” Income Trap	You are self-employed with fluctuating income. You honestly report a low-income month on the Healthcare.gov application and get incorrectly shunted into a Medicaid denial/referral loop that can take months to fix.13	Annualize Your Income. Project your annual net income as best you can, divide by 12, and report that monthly average on the application. This provides a more accurate picture for the system and avoids the “low-income month” glitch.13
8. The “Tax Dependent” Trap	A family fails to realize that claiming a young adult (e.g., a 19-22 year old student) as a tax dependent makes them ineligible for Medicaid by tying them to the parents’ higher income.8	Analyze the Tax Situation. Understand that the decision to claim a dependent has massive health insurance implications. In some cases, forgoing a tax dependency can be the key to securing coverage for that family member. It’s a trade-off that must be considered consciously.
9. Incomplete Documentation	You submit the application but are missing key financial statements or proof of income. The back-and-forth process of requests and submissions delays a decision by weeks or months.29	Prepare a Complete Package. Before you file, use a checklist to gather all required documents: several months of bank statements for all accounts, proof of all income sources, life insurance policies, property deeds, etc. Submit as much as you can with the initial application.40
10. Not Getting Expert Help	The case is complex (e.g., a Non-MAGI application for long-term care with assets to spend down), but you try to handle it alone to save money. A single mistake can cost tens of thousands of dollars in uncovered nursing home bills.42	Know When to Call a Professional. For simple MAGI cases, you can often apply on your own. For any case involving assets, trusts, property, or long-term care (the Non-MAGI river), hiring an experienced elder law attorney is not a luxury; it is essential risk management.39

Section VIII: Conclusion: Becoming Your Own Best Advocate

We have traveled the entire Medicaid watershed, from the FPL sea level to the distinct MAGI and Non-MAGI rivers.

We’ve charted the powerful state expansion currents that create a nation of haves and have-nots, and we’ve mapped the treacherous application waterfalls that can sink even the most careful navigator.

The journey is undeniably complex, and if you feel overwhelmed or frustrated, you are not alone.

It is crucial to understand that this complexity is a feature of the system, not a personal failing.

You are not struggling because you aren’t smart enough or organized enough.

You are struggling because you are trying to navigate a system pieced together over decades, with conflicting rules, political tripwires, and bureaucratic inertia.⁵

The story of Tonya Moore in Arkansas, who was kicked off Medicaid because the state used her daughter’s income from jobs she no longer had, is not a story of personal error; it is a story of systemic failure.¹⁴

But knowledge is power.

By understanding the underlying structure of this maze, you transform from a passive victim of the bureaucracy into an active, empowered advocate for yourself and your family.

When you know to ask, “Am I in the MAGI or Non-MAGI river?” you can immediately filter out 90% of the irrelevant and confusing advice you will encounter.

When you understand the brutal math of the 5-year look-back, you can protect your family from making a catastrophic financial mistake.

When you know that the “lumpy income” question on the federal website is a known trap, you can answer it in a way that avoids months of bureaucratic purgatory.

The system may be a maze, but it is not entirely random.

It has rules.

It has patterns.

It has pressure points.

This guide was designed to give you the map to those rules and patterns.

It cannot make the journey simple, but it can make it navigable.

By arming yourself with this knowledge, you become your own best advocate, capable of asking the right questions, anticipating the pitfalls, and charting a course through the turbulent waters to the safe harbor of the coverage you and your family deserve.

Works cited

1. Federal Poverty Level (FPL) – Glossary | HealthCare.gov, accessed August 13, 2025, https://www.healthcare.gov/glossary/federal-poverty-level-fpl/
2. Annual Update of the HHS Poverty Guidelines – Federal Register, accessed August 13, 2025, https://www.federalregister.gov/documents/2025/01/17/2025-01377/annual-update-of-the-hhs-poverty-guidelines
3. Medicaid – MAGI Medicaid vs. Non-MAGI Medicaid – Benefits Plus Learning Center, accessed August 13, 2025, https://benefitsplus.cssny.org/pbm/health-programs/medicaid/magi-medicaid-vs-non-magi-medicaid
4. Eligibility Policy | Medicaid, accessed August 13, 2025, https://www.medicaid.gov/medicaid/eligibility-policy
5. Should You Prepare a Medicaid Application Yourself? | Shepherd Elder Law, accessed August 13, 2025, https://shepherdelderlaw.com/should-you-prepare-a-medicaid-application-yourself-2/
6. Status of State Medicaid Expansion Decisions – KFF, accessed August 13, 2025, https://www.kff.org/status-of-state-medicaid-expansion-decisions/
7. How Many Uninsured Are in the Coverage Gap and How Many Could be Eligible if All States Adopted the Medicaid Expansion? | KFF, accessed August 13, 2025, https://www.kff.org/medicaid/issue-brief/how-many-uninsured-are-in-the-coverage-gap-and-how-many-could-be-eligible-if-all-states-adopted-the-medicaid-expansion/
8. MAGI – NC Medicaid, accessed August 13, 2025, https://medicaid.ncdhhs.gov/documents/county/magi-hh-and-income-training-0814/download
9. Module 2: Apple Health Modified Adjusted Gross Income (MAGI) – Washington State Health Care Authority, accessed August 13, 2025, https://www.hca.wa.gov/assets/free-or-low-cost/module-2-apple-health-modified-adjusted-gross-income.pdf
10. What’s included as income | HealthCare.gov, accessed August 13, 2025, https://www.healthcare.gov/income-and-household-information/income/
11. Common Medicaid Application Mistakes – Stotler Hayes Group, accessed August 13, 2025, https://stotlerhayes.com/common-medicaid-application-mistakes/
12. Top 10 Florida Medicaid Application Mistakes – Elder Needs Law, accessed August 13, 2025, https://www.elderneedslaw.com/top-10-florida-medicaid-application-mistakes
13. Beware the Medicaid eligibility check trap when applying on healthcare.gov! – Reddit, accessed August 13, 2025, https://www.reddit.com/r/financialindependence/comments/1lhyww6/beware_the_medicaid_eligibility_check_trap_when/
14. ‘I’m trying not to go into panic.’ Review of millions of Medicaid … – PBS, accessed August 13, 2025, https://www.pbs.org/newshour/health/im-trying-not-to-go-into-panic-review-of-millions-of-medicaid-enrollees-plagued-by-error-and-confusion
15. 150% of the HHS Poverty Guidelines for 2025 – United States Courts, accessed August 13, 2025, https://www.uscourts.gov/sites/default/files/2025-01/ifp-monthly-poverty-guidelines-2025.pdf
16. I-864P | 2025 HHS Poverty Guidelines for Affidavit of Support – USCIS, accessed August 13, 2025, https://www.uscis.gov/i-864p
17. 2025 Federal Poverty Guidelines – ProJusticeMN.org, accessed August 13, 2025, https://www.projusticemn.org/resource/item.8233-Federal_Poverty_Guidelines/
18. Federal Poverty Level 2025: Medicaid Income Limits & Guidelines – Jarvis Law Office, accessed August 13, 2025, https://jarvisfirm.com/federal-poverty-level-2025-medicaid-income-limits-guidelines/
19. Federal Poverty Guidelines / Levels for 2025 & Their Relevance to Medicaid Eligibility, accessed August 13, 2025, https://www.medicaidplanningassistance.org/federal-poverty-guidelines/
20. 2025 Poverty Guidelines: 48 Contiguous States (all states except Alaska and Hawaii) – HHS ASPE, accessed August 13, 2025, https://aspe.hhs.gov/sites/default/files/documents/dd73d4f00d8a819d10b2fdb70d254f7b/detailed-guidelines-2025.pdf
21. Medicaid / ​Medical Assistance General Eligibility Requirements – Commonwealth of Pennsylvania, accessed August 13, 2025, https://www.pa.gov/agencies/dhs/resources/medicaid/medicaid-general-eligibility
22. kicked off Medicaid due to asset limit($20,000)… will Markertplace allow him to buy insurance with $1200 monthly income? : r/HealthInsurance – Reddit, accessed August 13, 2025, https://www.reddit.com/r/HealthInsurance/comments/1lq96uk/kicked_off_medicaid_due_to_asset_limit20000_will/
23. Modified Adjusted Gross Income (MAGI) – Glossary | HealthCare.gov, accessed August 13, 2025, https://www.healthcare.gov/glossary/modified-adjusted-gross-income-magi/
24. www.healthcare.gov, accessed August 13, 2025, https://www.healthcare.gov/glossary/modified-adjusted-gross-income-magi/#:~:text=MAGI%20is%20adjusted%20gross%20income,Supplemental%20Security%20Income%20(SSI).
25. Reporting Self-Employment Income to the Marketplace | HealthCare.gov, accessed August 13, 2025, https://www.healthcare.gov/self-employed/income/
26. Medicaid income eligibility question : r/HealthInsurance – Reddit, accessed August 13, 2025, https://www.reddit.com/r/HealthInsurance/comments/9sq8qp/medicaid_income_eligibility_question/
27. Medicaid Household Rules – Beyond the Basics, accessed August 13, 2025, https://www.healthreformbeyondthebasics.org/reference-guide-medicaid-household-rules/
28. confused on why i have medicaid : r/HealthInsurance – Reddit, accessed August 13, 2025, https://www.reddit.com/r/HealthInsurance/comments/1l9x1ry/confused_on_why_i_have_medicaid/
29. What to Do When Denied Medicaid: Appeals, Reversals & Re-Applying, accessed August 13, 2025, https://www.medicaidplanningassistance.org/denied-medicaid/
30. How to Avoid Common Medicaid Application Mistakes – Regency Health Care, accessed August 13, 2025, https://www.regencyhcs.com/blog/how-to-avoid-common-medicaid-application-mistakes
31. Medicaid Transfer Penalty: Avoid This Costly Mistake – Mason Law, PC, accessed August 13, 2025, https://masonlawpc.com/avoid-costly-medicaid-mistake/
32. 20 Common Mistakes When Completing A Nursing Home Medicaid …, accessed August 13, 2025, https://dallaselderlawyer.com/common-mistakes-medicaid-application-eligibility-dallas/
33. Medicaid expansion, eligibility, enrollment and benefits in your state – Healthinsurance.org, accessed August 13, 2025, https://www.healthinsurance.org/medicaid/
34. Status of State Medicaid Expansion Decisions, accessed August 13, 2025, https://www.tdmr.org/status-of-state-medicaid-expansion-decisions/
35. What is Medicaid expansion? – Healthinsurance.org, accessed August 13, 2025, https://www.healthinsurance.org/glossary/medicaid-expansion/
36. Medicaid coverage gap – Wikipedia, accessed August 13, 2025, https://en.wikipedia.org/wiki/Medicaid_coverage_gap
37. 9 States Poised To End Coverage for Millions if Trump Cuts Medicaid Funding, accessed August 13, 2025, https://kffhealthnews.org/news/article/medicaid-expansion-funding-trigger-laws-9-states-trump-administration/
38. The Top Eight Mistakes People Make With Medicaid – Elder Law, accessed August 13, 2025, https://www.floridaelder.com/the-top-eight-mistakes-people-make-with-medicaid/
39. Avoid these mistakes when applying for Medicaid – Stefans Law Group PC, accessed August 13, 2025, https://www.stefanslawgroup.com/blog/2022/01/avoid-these-mistakes-when-applying-for-medicaid/
40. 10 Common Medicaid Denial Reasons – Senior Planning Services, accessed August 13, 2025, https://www.seniorplanning.com/resources/medicaid-denial-reasons/
41. Really confused on how to calculate “Income for the month” on healthcare.gov application : r/HealthInsurance – Reddit, accessed August 13, 2025, https://www.reddit.com/r/HealthInsurance/comments/1e9fhn4/really_confused_on_how_to_calculate_income_for/
42. Buyer Beware: Choose Your Medicaid Application Support Wisely, accessed August 13, 2025, https://www.czepigalaw.com/blog/choose-wisely/
43. Should you prepare a Medicaid application yourself, or get help?, accessed August 13, 2025, https://www.varalaw.com/should-you-prepare-a-medicaid-application-yourself-or-get-help/
44. Barriers to Medicaid Enrollment: Who Is at Risk? – PMC – PubMed Central, accessed August 13, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC1449169/
45. Medicaid Eligibility Income Chart by State (Updated July 2025), accessed August 13, 2025, https://www.medicaidplanningassistance.org/medicaid-eligibility-income-chart/