Who Qualifies and Who Is Covered

Most disputes about who should be on Medicaid are really disputes about a category or a number. A legislator says "able-bodied adults" and means one group. A caseworker says "MAGI" and means a way of counting income. A reporter writes "138 percent of poverty" and assumes the reader knows the dollar figure. This lesson converts each of those into something you can write on a piece of paper and check. It uses the 2026 federal poverty guidelines and DHW's January 2026 income table, which DHW last updated on April 20, 2026. Limits change each January when the poverty guideline is updated, so as of October 2026 these are the numbers in force, and the 2027 numbers will differ.

Two tests and a few gates

Every Medicaid decision is a sequence of questions. An application takes a person through them in this order, even when the form hides the order.

1. Residency. The person lives in Idaho and intends to stay.
2. Citizenship or immigration status. The person is a U.S. citizen or a qualified noncitizen who meets the program's rules.
3. Category. The person fits a covered group: child, pregnant woman, parent or caretaker relative, expansion adult, person who is aged, blind or disabled, and several narrower groups.
4. Income. The household's income is at or below the limit for that group.
5. Resources. Only some groups face a limit on savings and property, mainly the aged, blind and disabled groups and long-term care.

A person can fail in one place and pass in another. An adult with a disability and income of $1,500 a month might be refused as an expansion adult, because expansion excludes people who qualify on the basis of disability, and then qualify for Aid to the Aged, Blind and Disabled with different rules. This overlap is the reason caseworkers screen an applicant for every group, and why an applicant should describe health conditions fully on the form even when the person came in only to ask about "the expansion."

The federal poverty guideline

Income limits are expressed as a percentage of the federal poverty guideline, which the U.S. Department of Health and Human Services updates each January. The 2026 guideline for the 48 contiguous states is $15,960 for one person, $21,640 for two, $27,320 for three, $33,000 for four and $38,680 for five, with $5,680 added for each additional person. The guideline is an administrative yardstick used to set program thresholds. It is not the same as the Census Bureau's poverty measure used in statistics, and it is not a household budget. Medicaid takes the guideline and multiplies it by the percentage the group qualifies at.

Household size	100% of poverty (annual)	138% (annual)	138% (monthly, DHW 2026)
1	$15,960	$22,025	$1,836
2	$21,640	$29,863	$2,489
3	$27,320	$37,702	$3,142
4	$33,000	$45,540	$3,795
5	$38,680	$53,378	$4,449

The annual 138 percent figures come from multiplying the guideline by 1.38. The Idaho Capital Sun used $29,863 for a two-person family in its July 2026 report, which matches. DHW's monthly figures round up by a dollar in some rows: its table lists $1,836 for one person where 138 percent of $15,960 divided by 12 is $1,835.40. Use DHW's number when you are explaining the rule to an applicant, because that is the number the eligibility system uses. Use your own arithmetic when you are checking the annual claim in a news story.

How MAGI counts income

MAGI stands for modified adjusted gross income. It is the income concept in the Affordable Care Act, and it follows the tax return: take adjusted gross income, add back a few items such as tax-exempt interest, and count it for the household. Idaho applies it to children, pregnant women, parents and caretakers, and expansion adults. The federal rule is 42 CFR 435.603. In practice four features matter most to an applicant.

• It follows the tax household. Who is in your household is set by who you claim, or could claim, on a tax return, with special rules for children and for people who do not file. A child living with a parent who is not expected to file is not counted in the household income under the rule at 435.603(d)(2).
• It looks at current monthly income. Eligibility is generally based on what the household is receiving now, not last year's return. A job loss in September matters in September.
• It counts gross wages less pre-tax items. Contributions to a traditional retirement account and pre-tax health premiums reduce adjusted gross income, so they reduce MAGI.
• It leaves out some money. Child support received is not counted as income, and neither is Supplemental Security Income. A loan is not income.

The 5 percent disregard

The statute says 133 percent. The practical limit is 138 percent. Federal regulation at 42 CFR 435.603(d)(4) directs states to subtract an amount equal to 5 percentage points of the federal poverty level when they apply the income test to the eligibility group with the highest MAGI-based standard. The effect is the same as raising the limit by five points. CMS's eligibility-level table for Idaho, dated December 1, 2023, lists the expansion standard as 133 percent and says that MAGI income standards are adjusted by an amount equivalent to a 5 percent disregard. KFF's January 2026 table shows the practical result: 138 percent for parents and pregnant women. DHW's table converts that into the monthly dollars above.

Where you see it	What it says	How to read it
Idaho Code 56-267(1)	133 percent of poverty	The statutory number before the disregard
CMS eligibility-level table (Dec. 2023)	133 percent for Idaho expansion adults	The state standard, MAGI-converted
DHW expansion page and income table	Up to 138 percent; $1,836 for one person	The standard plus the disregard, in dollars
Idaho Capital Sun	138 percent; $29,863 for two	Annual dollars at 138 percent

The example shows a feature of the rules that surprises families: one household can contain people in different groups with different limits. A mother may be over the adult limit while her young children qualify for Medicaid or CHIP. The application should list every household member so the system can test each person.

Expansion adults

The expansion group is the largest piece of Idaho's adult Medicaid. DHW lists these criteria: age 19 to 64, income up to 138 percent of poverty, U.S. citizen or qualified noncitizen, Idaho resident, not disabled, not pregnant, and not eligible for Medicare or another Medicaid group. The "not disabled" line sorts people into the right group and makes no judgment about anyone's health: a person whose disability qualifies them for a different group is steered there, where the benefit package may be richer. The "not pregnant" line works the same way, because pregnancy has its own group with its own postpartum coverage.

Parents belong to this group in practice. Before 2020 Idaho covered parents only at a very low income. KFF's tables show Idaho's parent limit at 25 percent of poverty for a family of three in January 2019 and at 138 percent from January 2020. The jump is the expansion. CMS's December 2023 table still lists a separate parent and caretaker standard of 19 percent of poverty, a dollar-based figure that it converts to a percentage. That old pathway, known by its section of the Social Security Act as Section 1931, still exists for parents with extremely low income and matters for details such as which rules apply to the work requirement. Some summaries put the figure under 16 percent of poverty, while the CMS table lists 19 percent as of December 2023, so this lesson says under 20 percent and treats the exact current dollar limit as a number to confirm with DHW.

The plans

Adults are placed in one of three benefit plans, according to DHW's "About Medicaid for Adults" page.

Plan	Who it is for	Notes
Basic Plan	Adults without special health needs	Basic health, prevention and wellness benefits; rules in IDAPA 16.03.09
Enhanced Plan	Adults with a disability or special health need	All Basic benefits plus specialized ones; a doctor's referral is usually needed; rules in IDAPA 16.03.10
Medicare-Medicaid Coordinated Plan	People enrolled in both Medicare and Medicaid	All Enhanced benefits plus the option of a managed care plan that coordinates the two programs

The exact titles of the IDAPA chapters are Medicaid Basic Plan Benefits (16.03.09) and Medicaid Enhanced Plan Benefits (16.03.10). Eligibility rules live in other chapters of IDAPA 16.03, and you should check the Administrative Rules site for the chapter that matches the group you are researching before you cite it. The Laws and Rules lesson on administrative rules shows how to search and read a chapter.

Pregnant women and postpartum coverage

Idaho covers pregnant women at 138 percent of poverty, according to KFF's January 2026 table. DHW's table lists the monthly limits for pregnancy coverage beginning with a household of two, and the figures match the adult table: $2,489 for two, $3,142 for three, $3,795 for four. The unborn child counts in household size. A woman who is pregnant with her first child and has no other dependents is a household of two for this purpose. If she earns $2,400 a month in MAGI terms she is under the $2,489 limit.

The DHW pregnancy coverage page says that the program covers pregnancy and care for up to 12 months after birth for eligible women. A woman who is on Medicaid through pregnancy generally keeps coverage through that postpartum period. The work requirement that begins in 2027 excludes pregnant and postpartum women, which is one reason DHW's exclusion list starts where it does. A pregnant applicant must be a U.S. citizen or an eligible noncitizen, live in Idaho and meet the income guidelines.

Children: Medicaid and CHIP

Children get two overlapping programs: Medicaid and the Children's Health Insurance Program (CHIP). Idaho uses CHIP for children whose family income is above the Medicaid limit and below a higher line. The two sources report slightly different Medicaid percentages because of how the 5 percent disregard is shown:

Group	CMS table (Dec. 2023)	KFF (Jan. 2026)	Arithmetic
Children age 0 to 5, Medicaid	142%	147%	142 + 5 = 147
Children age 6 to 18, Medicaid	133%	138%	133 + 5 = 138
Separate CHIP	185%	190%	185 + 5 = 190

DHW's table confirms the CHIP figure in dollars: a household of two can have up to $3,427 a month, three up to $4,326, four up to $5,225 and five up to $6,125. Check one against the poverty guideline. For a household of 2, 190 percent of $21,640 is $41,116 a year, or $3,426.33 a month, which DHW rounds to $3,427. The page does not list a separate dollar table for children's Medicaid below the CHIP line. For children whose family income is in the Medicaid range the practical figures are 147 percent for ages 0 to 5 and 138 percent for ages 6 to 18, per KFF's January 2026 data.

CHIP covers children under 19. The DHW CHIP page says that families may pay a small monthly premium per enrolled child based on income, though it does not list amounts, and no amount could be verified for this lesson. Ask DHW for the current schedule before you quote a premium. There is also a program for children with serious emotional disturbance, Youth Empowerment Services, with monthly income limits in DHW's table of $5,410 for a household of two, $6,830 for three and $8,250 for four.

Aged, blind and disabled groups

The groups that serve older adults and people with disabilities follow a different logic. They use the older, non-MAGI methods of counting income and they add a resource test. The older-adult and disability pathways sit alongside the Supplemental Security Income (SSI) program, and Idaho also runs state programs of its own. DHW's January 2026 table, last updated April 20, 2026, lists the main limits.

Program	Monthly income limit	Resource limit
Aid to the Aged, Blind and Disabled (AABD cash and Medicaid)	$1,047 individual; $1,511 couple	$2,000 individual; $3,000 couple
Katie Beckett (children with disabilities, institutional level of care)	$3,002 individual	$2,000
Home and community-based services (HCBS)	$3,002 individual; $5,984 couple	$2,000 (listed per person for couples)
Long-term facility (nursing home) care	$3,002 individual; $5,984 couple	$2,000 (listed per person for couples)
Medicaid for Workers with Disabilities	Up to 500% of poverty, with a premium: $0 up to 133%, $10 from 133% to 250%, and $10 to $200 (individual) above that	$10,000 individual; $15,000 couple

The table needs three cautions. First, the $3,002 figure and its link to SSI come from DHW; no explanation of how Idaho derives it was found, so describe it as DHW's limit. Second, the resource figures are what the page prints, with a footnote about how couples are treated in long-term care, which an elder-law attorney or a legal aid advocate should explain for any specific case. Third, the Workers with Disabilities program lets someone keep working and keep coverage at much higher income, which is exactly the situation that the work requirement debate sometimes forgets. A person with a disability who works part time does not stand outside the program.

Medicare Savings Programs

Idaho also helps people who have Medicare pay for it. The Medicare Savings Programs in DHW's table are Qualified Medicare Beneficiary (QMB) at up to 100 percent of poverty with monthly income of $1,350 for an individual, Specified Low-Income Medicare Beneficiary (SLMB) at 100 to 120 percent with $1,616, and Qualifying Individual (QI) at 120 to 135 percent with $1,816. The listed resource limit is $9,950 for an individual and $14,910 for a couple. These programs often are the way a retiree on a modest Social Security benefit gets a Medicare premium paid. They do not give full Medicaid by themselves, which is a point worth making in any community presentation.

Citizenship and immigration status

Medicaid and CHIP require applicants to be U.S. citizens or to hold a qualifying immigration status. A federal change that took effect on October 1, 2026 narrows federally funded eligibility for noncitizens. According to a summary from the State Health and Value Strategies program, the groups that remain eligible include lawful permanent residents after the five-year waiting period, Cuban and Haitian entrants, and migrants from the Compact of Free Association states, with lawfully residing children and pregnant individuals available at state option. Groups that lose eligibility include refugees, asylees, victims of human trafficking and other lawfully residing noncitizens outside those categories. Because the change took effect only weeks ago, check the DHW notice and your own case before you rely on any summary. If you help immigrant families, the Idaho Legal Aid Services and DHW customer service lines are the right places to confirm individual cases.

Applying, renewing and the months before you apply

Qualifying on paper and being enrolled are separate events, and most of the practical trouble happens between them. An application goes to DHW's Division of Self-Reliance, which checks the information against its own records and against data from other sources, such as SNAP and the Department of Labor, before it asks the applicant for anything. Federal rules push states to use that data first. The applicant answers questions about household members, income, residency and citizenship, and DHW sends a written decision. The notice states the group, the decision and the date, and the date matters because appeal deadlines run from it.

Three timing rules affect who is covered in a given month. First, coverage can reach back before the application. Idaho has allowed retroactive coverage for earlier months, and DHW's expansion page says that beginning in 2027 the retroactive period shrinks to one month for expansion applicants. Other Medicaid applicants keep a longer period, two months, under the federal change. A person who waits to apply until after a hospital stay in 2027 will have less protection than a person who applied in 2026. Second, coverage is reviewed on a schedule. DHW says eligibility for expansion adults will be re-evaluated every six months, with compliance checked for each person and not for the household. At each review DHW looks for three months of qualifying activity within the six-month certification period. Third, income changes can end eligibility between reviews, and a household is expected to report them.

What the redetermination numbers can and cannot tell you

Idaho reviewed every enrollee's eligibility after pandemic-era continuous coverage ended. The Idaho Capital Sun reported in April 2026 that about 40 percent of Idahoans on Medicaid were removed during the 2024 redetermination, largely for not responding to state requests. That figure comes from a news report and should be checked against DHW and Medicaid.gov unwinding data before anyone reuses it, because "removed" can include people who were no longer eligible and people who were eligible and lost coverage over paperwork, and the two groups are different policy problems. The distinction is the reason the 2027 rules put so much weight on data matching: a person who qualifies and fails to respond is counted the same way as a person who does not qualify unless somebody looks.

Two questions to ask about any count

• Ask whether a number counts people who are eligible, people who applied, people who are enrolled this month, or people who were ever enrolled in a year.
• Ask for the reason code on any count of people who lost coverage. Procedural closures and ineligibility closures belong in separate columns.

Who is covered after January 1, 2027

The 2027 work requirement, covered in Lesson 6, applies to expansion adults 19 to 64. It sorts them into people who must show 80 hours a month of work or other activity or $580 in monthly income, people who are excluded from the requirement, and people who are exempt for a short period. DHW's expansion page lists exclusions such as pregnancy, caregiving for a young child or a person with a disability, disabling conditions, substance use treatment and incarceration. Exemptions include being under 19, being on Medicare, release from incarceration within the past three months, and hospital or nursing home stays. The federal text adds more exclusions, including American Indians and Alaska Natives, veterans with a total disability rating, people who meet SNAP or TANF work rules, and young people under 26 who aged out of the state's child welfare system. It treats people as medically frail when they have a qualifying condition and an impaired ability to function, using state-defined auditable lists, so that a diagnosis alone is not enough.

Group	Subject to the 2027 requirement?	Why
Expansion adult, 19 to 64, working 80 hours a month	Yes, and meets it	Activity counts; verified at application and every six months
Expansion adult earning at least $580 a month	Yes, and meets it	Income alternative of 80 times the $7.25 federal minimum wage
Parent of a child 13 or younger	Excluded	Federal exclusion for caretakers; DHW lists caregiving
Pregnant or postpartum woman	Excluded	Federal exclusion
Child under 19	Exempt	Requirement applies only to ages 19 to 64
Adult on Medicare	Exempt	Not an expansion adult
Person on AABD or SSI-linked Medicaid	Not in the expansion group	Covered on disability or age grounds

An enrollee whose paperwork does not match still has rights. Lesson 8 explains notices and appeals, and Lesson 6 explains the steps and the 30-day window to show compliance or an exclusion.

You now have the numbers for the groups that most Idaho readers ask about. The next lesson, Who Writes the Rules, covers which body can change each limit and how to comment on a proposed change. Before you move on, take one household you know, real or invented, and run the five-step check above on paper. The exercise takes ten minutes and will teach you more than rereading the tables.