- Open enrollment
-
-
-
Guides to open enrollment
Read our guides to Medicare and Marketplace open enrollment for 2027
-
Medicare open enrollment
- Navigating Medicare open enrollment
- Guía inscripción abierta de Medicare
-
Marketplace open enrollment
- What to know about Marketplace open enrollment
-
-
- Medicaid
-
-
-
Your guide to Medicaid
Learn how Medicaid works, from benefits and eligibility to meeting work requirements
-
-
- Clinical trials
-
-
-
Learn about clinical trials
Understand how clinical trials work, how researchers plan for safety, and how to join a trial
-
-
- Resources
-
-
-
Resources for patients and providers
Explore our practical resources for navigating clinical trials, understanding Medicaid, and much more
-
-
Glossary: Medicaid terms to know
This glossary explains common Medicaid words in clear, everyday language.
Terms listed alphabetically
The number of hours certain adults may need to complete through approved activities during the required month. Activities may be combined to reach 80 hours.
A person may also meet the requirement by earning at least the federal minimum wage multiplied by 80 hours during the month. People who qualify for an exemption do not have to complete or report these hours.
Everyday tasks people need to do to care for themselves. Examples include eating, bathing, dressing, walking, using the bathroom and moving safely from one place to another. Difficulty completing these activities may be considered when Medicaid decides whether someone is medically frail.
A Medicaid eligibility group for certain adults ages 19 through 64 who qualify mainly based on their income. States may use a different name for this group.
Beginning in 2027, people in this group will generally have their Medicaid eligibility reviewed every six months. Some may also be subject to the community engagement requirement unless they qualify for an exemption.
A request asking Medicaid or a Medicaid health plan to review a decision you believe is wrong. You may be able to appeal if your application is denied, your coverage ends or a service is reduced or denied.
A legal term for a person who may be subject to the new Medicaid community engagement requirement. It generally refers to certain adults ages 19 through 64 who receive coverage through the adult expansion group or a similar Medicaid waiver program.
Not every adult Medicaid member is an applicable individual.
The form and information you submit when asking for Medicaid coverage. Depending on your state, you may be able to apply online, by telephone, by mail or in person.
A person you give permission to help with your Medicaid application, renewal, notices or appeal. This may be a family member, caregiver, attorney, advocate or another trusted person.
A person who regularly provides care or support to a child or another person who needs help because of a disability or health condition.
Under the new community engagement rules, certain parents, guardians and family caregivers of a child age 13 or younger or a person with a disability may be exempt. Your state will determine what information is needed.
The federal agency that oversees Medicaid, Medicare and the Children’s Health Insurance Program. States must follow federal Medicaid requirements, but each state operates its own program.
Low-cost or free health coverage for eligible children and, in some states, pregnant people whose household income is too high for Medicaid. CHIP rules and program names vary by state.
A new Medicaid eligibility requirement that may apply to certain adults beginning January 1, 2027, or earlier in some states. It is also called a work requirement.
A person who is subject to the rule may need to complete at least 80 hours a month through work, an approved work program, community service or a combination of these activities. Enrollment in an educational program at least half-time may also meet the requirement.
People who qualify for an exemption do not have to meet the requirement.
Unpaid work is performed through an organization or program that serves the community. Certain community service hours may count toward the community engagement requirement. Your state will explain which activities and organizations qualify.
A period during which a person can generally remain covered without having eligibility reviewed again, even if certain circumstances change. Continuous eligibility rules depend on a person’s age, eligibility group and state.
A set amount you may pay when you receive a covered service or medication. For example, you might pay a small copay for a prescription. Many Medicaid members and services are protected from copayments.
States can impose copayments, coinsurance, and deductibles on most Medicaid-covered services. However, these charges are generally limited to nominal amounts to ensure that essential healthcare remains accessible.
The portion of healthcare costs that a person may have to pay. Cost sharing can include copayments, coinsurance, deductibles or premiums. Medicaid limits how much eligible members may be charged.
When a person’s Medicaid coverage ends. This may also be called termination or closure of coverage.
Before ending coverage, the state generally must send a written notice explaining the reason, the effective date and the person’s appeal rights.
A person who has both Medicare and Medicaid. Medicaid may help eligible people pay certain Medicare premiums and out-of-pocket costs.
A school, college, career education or technical training program. Under the community engagement requirement, being enrolled at least half-time in an approved educational program may meet the monthly requirement.
The school or program generally determines what counts as half-time.
The rules used to decide whether a person qualifies for Medicaid. Eligibility can be based on income, household size, age, pregnancy, disability, caregiving status and other factors.
Rules differ by state and eligibility group.
A category used to determine which Medicaid rules apply to a person. Examples include children, pregnant people, parents, older adults, people with disabilities and adults in the Medicaid expansion group.
People in the same household who are on Medicaid may belong to different eligibility groups and may have different renewal dates.
Medicaid coverage for emergency medical conditions for certain people who meet state income and residency rules but do not qualify for full Medicaid because of their immigration status. The services covered and application process vary by state.
A renewal completed using information the state already has from reliable data sources. It may also be called an automatic renewal.
When the state has enough information to confirm that you remain eligible, you may not need to return a renewal form. When the state needs more information, it must send you a renewal form and give you time to respond.Medicaid coverage for emergency medical conditions for certain people who meet state income and residency rules but do not qualify for full Medicaid because of their immigration status. The services covered and application process vary by state.
A rule that allows a person to avoid a requirement because of their circumstances.
People who may be exempt from the community engagement requirement include certain caregivers, pregnant or postpartum people, people who are medically frail, American Indians and Alaska Natives, former foster youth, some veterans and people participating in certain treatment programs.
A formal review of a Medicaid decision by the state. You can request a fair hearing when you believe Medicaid incorrectly denied or ended your coverage or made another incorrect eligibility decision.
Your notice should explain how to request a hearing and the deadline for doing so.
An income measure updated each year by the federal government. States compare a household’s income with the federal poverty level when determining eligibility for Medicaid, CHIP and other programs.
A way Medicaid pays healthcare professionals and facilities separately for each covered service they provide. In other Medicaid programs, services may be provided through a managed care plan.
A reason a state may accept for why someone could not meet a requirement, submit information or complete an action by a deadline. States may define good cause differently.
Read your notice or contact your state Medicaid agency to learn whether good cause applies to your situation.
A temporary exception that may allow someone to be treated as meeting the community engagement requirement during difficult circumstances.
A state may choose to offer hardship exceptions for situations such as hospitalization, nursing facility care, a federally declared disaster, high local unemployment or extended travel for necessary medical care. Hardship exceptions are different from ongoing exemptions.
The people Medicaid includes when reviewing your application and income. A Medicaid household is not always the same as everyone who lives in your home. Tax relationships, marriage and family relationships may affect who is counted.
The process Medicaid uses to confirm a person’s income. The state may use tax records, wage databases, employer information, pay stubs or other reliable sources.
Under the new community engagement rules, states must first try to use reliable information they already have before asking a person to provide additional documents.
Help for people who communicate in a language other than English. This can include a qualified interpreter, translated forms or translated notices.
When required, language assistance must be accurate, timely and provided at no cost. Do not feel that you must use a child, family member or friend as your interpreter.
A health plan that contracts with the state to provide Medicaid services. The plan may have its own provider network, member services department, drug list and prior authorization rules.
Your Medicaid program and managed care plan may have different responsibilities, so check your notice or member card to determine whom to contact.
Financial help that lowers the monthly cost of a health plan purchased through the Health Insurance Marketplace as part of the Affordable Care Act.
Under the new federal Medicaid rules, a person who would otherwise qualify for Medicaid but loses eligibility only because they did not meet the community engagement requirement generally will not qualify for a Marketplace premium tax credit. Seek assistance before your Medicaid coverage ends.
A public health coverage program jointly funded by the federal government and the states. Medicaid provides coverage to eligible people with limited income, including children, pregnant people, parents, older adults and people with disabilities.
Each state operates its own Medicaid program and may use a different program name.
A state option created by the Affordable Care Act that allows more adults with limited income to qualify for Medicaid. States that have expanded Medicaid generally cover an adult expansion group. Eligibility and program names vary.
A Medicaid term describing a person with serious health, behavioral health or functional needs that significantly affect their ability to meet certain program requirements.
This may include a person who:
- Is blind or has a disability
- Has a substance use disorder
- Has a disabling mental health condition
- Has a physical, intellectual or developmental disability that significantly limits daily activities
- Has a serious or complex medical condition
A person who is medically frail may be exempt from the new community engagement requirement. The state will determine how people request and document this status.
Being classified as medically frail is an eligibility protection. It is not a judgment about a person’s strength, independence or value.
A healthcare service, treatment, medication or supply needed to diagnose or treat a health condition and consistent with accepted medical standards.
Medically needy or spend-down program
An optional Medicaid pathway for certain people whose income is above the usual Medicaid limit but who have significant medical expenses.
A person may qualify after medical expenses reduce their countable income to the state’s required level. Not every state offers the same spend-down options.
Different words used to describe a person who has Medicaid coverage. Your state or health plan may use any of these terms.
A letter, email or electronic message from Medicaid or a Medicaid health plan. A notice may request information or explain a decision about your coverage or services.
Read every notice and respond by the stated deadline. Contact Medicaid immediately if you need the notice in another language or accessible format.
A notice explaining that the state could not confirm that a person met the community engagement requirement or qualified for an exemption.
The state must give the person 30 calendar days to provide information showing that they met the requirement or that the requirement did not apply to them. Medicaid coverage must generally continue during this 30-day response period.
Medicaid coverage available after a pregnancy ends. People who are pregnant or covered during their state’s postpartum period are exempt from the community engagement requirement.
An amount a person pays regularly to keep health coverage. Most Medicaid members do not pay a premium, but certain states and eligibility groups may require one.
Approval that may be required from Medicaid or a Medicaid health plan before a service, treatment, medication or medical item is provided.
Prior authorization does not always guarantee that the full cost will be covered.
A government term for some people who are not U.S. citizens but have an immigration status that may allow them to get Medicaid. This can include some green card holders and people with certain other lawful immigration statuses. You must also meet your state’s rules, such as income and residency requirements. Some people may have to wait five years, but exceptions may apply.
Starting October 1, 2026, federal funding for full Medicaid and CHIP coverage will be limited to fewer immigration groups. This may affect some people who are currently covered. Different rules may apply to children, pregnant people, emergency care and health programs paid for by a state.
Being called a qualified noncitizen does not always mean you qualify for full Medicaid. Do not assume you are ineligible. Read any notice you receive and contact your state Medicaid office or a trusted enrollment assister for help.
An activity that may count toward the community engagement requirement. Examples include employment, community service, an approved work program or a combination of approved activities.
Enrollment in an educational program at least half-time may also satisfy the requirement. States will provide instructions about which activities qualify and how they will be verified.
Submitting a new Medicaid application after coverage has ended or an earlier application was denied.
A person who loses Medicaid for not meeting the community engagement requirement may reapply at any time. The state will review whether the person currently meets the requirement or qualifies for an exemption.
A change or type of assistance that helps a person with a disability access Medicaid information or complete a Medicaid process.
Examples may include materials in Braille or large print, relay or TTY services, help communicating or another accessible way to complete forms. Ask the state Medicaid agency or health plan for the accommodation you need.
Another word for an eligibility review. The state reviews current information to decide whether a person still qualifies for Medicaid.
A redetermination may happen during a scheduled renewal or after the state receives information about a change in income, household size or another eligibility factor.
The process Medicaid uses to confirm that a person still qualifies for coverage.
Beginning in 2027, people in the adult expansion group will generally have their eligibility renewed every six months instead of every 12 months. Other Medicaid members may remain on a different renewal schedule.
Providing information, or allowing the state to use available data, to confirm that an eligibility requirement has been met.
For community engagement, the state may use payroll, education, job training, community service or Medicaid healthcare data before asking the person to submit additional proof.
Medicaid coverage that may pay eligible medical bills from before the month a person applied.
For applications submitted on or after January 1, 2027, federal law will limit the maximum retroactive period to:
- One month before the application month for people in the adult expansion group
- Two months before the application month for most other Medicaid eligibility groups
Apply as soon as possible when you believe you may qualify.
A person whose work or income changes based on the season, such as agricultural, tourism or holiday employment.
Under the community engagement rules, a state may review a seasonal worker’s average monthly income over the previous six months when determining whether the requirement was met. Medicaid coverage that may pay eligible medical bills from before the month a person applied.
Permission from the federal government allowing a state to test certain changes to its Medicaid program. A waiver may affect eligibility, covered services, delivery of care or other program rules.
Because waivers are state-specific, rules may differ from one state to another.
A significant health condition that may require ongoing, specialized or intensive care. A serious or complex condition may be considered when deciding whether a person is medically frail or qualifies for a temporary hardship exception.
A diagnosis alone may not automatically result in an exemption. Ask your state what information or medical documentation is required.
A federal legal term for someone who is not subject to the community engagement requirement during a particular month.
Federal materials also commonly describe these individuals as exempt. Examples may include certain caregivers, people who are medically frail, pregnant or postpartum people, American Indians and Alaska Natives and former foster youth.
The state office responsible for determining Medicaid eligibility and operating the Medicaid program. The agency may have a different name in each state.
Contact your state agency to update your address, check an application, complete a renewal, report a change or request an appeal.
A program that helps eligible households buy food. It is sometimes called food assistance or food stamps.
Under the new Medicaid rules, certain people who meet SNAP work rules may also be treated as meeting the Medicaid community engagement requirement.
A state-run program that may provide temporary cash assistance and employment-related services to eligible families.
Certain people who meet their state’s TANF work requirements may also be treated as meeting the Medicaid community engagement requirement.
The ending of Medicaid coverage. It may also be called disenrollment or closure.
A termination notice should explain why coverage is ending, when it will end and how to appeal.
An approved program that helps people prepare for, obtain or maintain employment. Examples may include job training, employment placement or workforce development activities.
Approved work program hours may count toward the community engagement requirement.
Find a clinical trial
Our TrialFinder site makes it easy to search for clinical trials based on your condition and location.
Call us for help
Our CareLine case managers can answer your questions about clinical trials. Call:
1-855-329-5969
Find patient support
Learn more about the services and programs offered by Patient Advocate Foundation to support patients.