Financial eligibility for most categories of Medicaid and the Children’s Health Insurance Program (CHIP) is determined using a tax-based measure of income called modified adjusted gross income (MAGI). The MAGI methodology includes rules prescribing who must be included in a household when determining eligibility. The following FAQ explains MAGI and the rules for determining Medicaid and CHIP households under MAGI.
MAGI is a methodology used to determine income for the purposes of Medicaid or CHIP eligibility. It is based on tax definitions of income and household. MAGI rules for determining what income to count when determining Medicaid, CHIP, and premium tax credit eligibility are mostly aligned. The rules determining who is in a household and whose income to count, however, can vary significantly. Also, under MAGI rules, an individual or family’s assets do not count in determining eligibility. (For more information on what income counts under MAGI rules, see Key Facts: Income Definitions for Marketplace and Medicaid Coverage.)
All states must use the MAGI rules regardless of the decision to expand Medicaid. However, MAGI rules apply only to certain categories of Medicaid eligibility. These include parents and caregiver relatives, children, pregnant women, and the adult expansion group. States’ previous rules for determining income and households continue to apply to the elderly, disabled, and children in foster care.
Medicaid and CHIP households are determined based on a person’s family and tax relationships as well as their living arrangements. How people file taxes and who is in their tax unit doesn’t always determine who is in their Medicaid household, but it determines which Medicaid household rules apply in defining the household. Premium tax credit household rules, on the other hand, are based purely on tax relationships.
The most important difference between Medicaid and premium tax credit households is that for Medicaid, household size and composition are determined separately for each member of the household, but for the premium tax credit, members of a tax unit are always treated as a household. This means that for Medicaid, household size may differ for family members even when they are in the same tax filing household. Thus, it is possible that for Medicaid, a family of three filing its taxes together may have two members with a household size of three and the third member of the family may be a household of one. For the premium tax credit, each member of a household that files its taxes together will have the same household size. (For more information on determining household size for the premium tax credit, see Key Facts: Determining Household Size for the Premium Tax Credit.)
Another important difference is Medicaid provides states with several options that affect how they define households when determining Medicaid eligibility. However, because the premium tax credit is a federal benefit, the rules are established at the federal level and are consistent across states.
Medicaid determines an individual’s household based on their plan to file a tax return, regardless of whether or not he or she actual files a return at the end of the year. Medicaid also does not require people to file a federal income tax return in previous years.
For each individual applying for coverage, Medicaid looks at whether they plan to be:
People’s intended tax filing status determines which Medicaid household rules apply in making the household determination. Figure 1 summarizes the Medicaid household rules and Figure 2 shows how to apply these rules. (For more information, see Reference Guide: Medicaid Household Rules.)
| FIGURE 1: MAGI Rules for Determining Medicaid and CHIP Households | ||
| FIGURE 2: How to Determine An Individual’s Medicaid Household | ||
For tax filers claiming their own exemption and who can’t be claimed as a tax dependent, the household includes the tax filer, the spouse filing jointly, and everyone whom the tax filer claims as a tax dependent.
For tax dependents, the household is the same as the tax filer claiming the individual as a tax dependent. However, there are three exceptions to this rule, when the rule for non-filers is applied:
For individuals who neither file a tax return nor are claimed as a tax dependent, the household rules differ based on whether the individual is an adult or a minor:
In addition to the general rules for determining household size, some rules apply in all situations:
States have flexibility in how they implement the MAGI rules in two areas. First, in some instances the Medicaid household rules applied may depend on whether an individual is under 19 years old or not. Where the rules indicate an age limit, states have the option to extend that age limit to 21 if the individual is a full-time student. Second, for individuals whose household includes a pregnant person (but are not pregnant themselves), states can count the pregnant person as one, two, or one plus the number of children they are expecting.
Generally, no. Married couples who live together are always considered to be in each other’s household regardless of how they file taxes.
However, married couples who don’t live together and who file taxes separately will be considered as separate households.
As long as both parents file taxes, non-married parents living in the same household would still use the rule for tax filers to determine each parent’s Medicaid household. This means their household includes themselves and anyone claimed as a dependent on their tax return.
However, a child under 19 living with non-married parents and being claimed as a tax dependent by one of the parents, would fall into the non-filer rule. Therefore, the child’s household size for Medicaid would include himself, both parents, and any siblings living with the child. For example:
| TABLE 1: Example of Determining Households for Non-Married Parents | |||||||
| Filing Status | Counted in Household | Household Size | Medicaid Rule Applied | ||||
| Dan | Jen | Drew | Mary | ||||
| Dan | Tax filer | X | 1 | Tax filer rule | |||
| Jen | Tax filer | X | X | X | 3 | Tax filer rule | |
| Drew | Tax dependent | X | X | X | X | 4 | Non-filer rule (exception) |
| Mary | Tax dependent | X | X | X | X | 4 | Non-filer rule (exception) |
The household of an individual who is at least 19 years old and is claimed as a tax dependent by his parents is always the same as the household of the parents claiming him. This is true even if the individual was much older, say 35 years old. For example, under some circumstances parents can claim their child who is 35 years old as a qualifying relative on their tax return. In this scenario, Medicaid would use the tax dependent rule for determining the household of this individual, which means his household would be the same as the household of his parent (the tax filer) claiming him as a dependent. The following examples illustrate how the Medicaid rules would be applied:
No. This exception also applies to minors claimed as a tax dependent by someone other than their parent. Anytime an individual — regardless of age — is claimed as a tax dependent by someone other than their parents, the non-filer rules apply in determining that individual’s household. For example:
Health Reform: Beyond the Basics is a project of the Center on Budget and Policy Priorities designed to provide training and resources that explain health coverage available through Medicaid, CHIP, and the Marketplace. It is aimed at navigators, advocates, state and local officials and others who help consumers get and keep their health coverage.