Under the ACA, states had the option to expand Medicaid to cover nearly all low-income adults ages 19–64 — but not all states took it. In expansion states, a low income alone is typically enough to qualify: a 51-year-old single adult with no children, no disability, and no income would generally be Medicaid-eligible in states like California, New York, or Michigan. In non-expansion states like Texas, low income is not enough — a client must fit a specific category such as disability (approved, not just pending), SSI receipt, pregnancy, being a parent or caretaker of a minor child, or being 65+. This creates a coverage gap: adults earning below 100% FPL who don’t meet a categorical requirement are ineligible for Medicaid and ineligible for marketplace premium tax credits (APTC requires income at or above 100% FPL). However, if a Texas client has a reasonable good-faith expectation of reaching 100% FPL during the year — for example, a disability applicant who anticipates approval and back-pay, or a client expecting to begin work — they may qualify for marketplace APTC based on projected income; document your basis carefully. Filter and search below to find expansion status and income limits for each of your 23 licensed states.

MAGI-based income thresholds for ACA expansion adults (19–64) and children's programs. SSI rules apply for elderly/disabled eligibility.

Match your lead to a category first, then check their state section below.

In all 15 expanded states, any adult 19–64 at or below 138% FPL qualifies — no categorical requirement. Watch for waiver nuances in IN, and Basic Health Programs in MN and NY.

These states did not adopt full ACA expansion. Adults without dependents or a qualifying disability are often entirely ineligible. The coverage gap (below 100% FPL, no Medicaid, no marketplace subsidy) is a real risk in AL, FL, SC, and TX.

Always screen Medicare leads for dual-eligible programs — available in all 23 states. QMB/SLMB programs alone can save clients $1,800–$2,000+ per year in Part B premiums.

Use during ACA calls to determine the correct path for each client situation.

• Always verify current FPL limits and state-specific rules at Medicaid.gov or the state Medicaid agency directly — guidelines update annually each February/March.
• Never enroll a client in marketplace coverage if they are Medicaid-eligible — this creates premium tax credit reconciliation problems at tax time and compliance risk for you as the agent.
• Document your Medicaid eligibility screening on every ACA call. If you referred a client to Medicaid rather than enrolling in a marketplace plan, note it clearly in the client file.
• In coverage gap states (AL, FL, SC, TX, and most of GA) do not promise a marketplace subsidy before verifying the client's income is at or above 100% FPL.
• For dual-eligible Medicare clients, ensure their D-SNP enrollment aligns with their state Medicaid eligibility status to prevent disenrollment mid-year.
• Indiana (HIP 2.0) and Wisconsin (BadgerCare) have nuanced waiver-specific rules — when in doubt, direct clients to the state Medicaid agency for final eligibility determination.
• Income methodology may differ: marketplace uses projected annual MAGI; some states use current monthly income for Medicaid. Clarify with the state when income is near a threshold.
• North Carolina expanded in December 2023 and is still in active enrollment growth — treat NC leads with expanded-state awareness and always screen for Medicaid before marketplace.

Work through these questions in order during live calls to route each client correctly.