"MAGI" Medicaid Eligibility under the Affordable Care Act - Rules for Most People Under age 65 Without Medicare

Medicaid eligibility rules changed significantly on January 1, 2014 for some New Yorkers as a result of the Affordable Care Act’s eligibility expansion and streamlining provisions. The expansion only applies to a population called the "MAGI" population. Generally, the new rules do NOT apply to people over age 65 or who have Medicare at any age. There are limited exceptions to this. Various resources are available to explain the new rules and benefits:

CMS - the Centers for Medicare & Medicaid Services, a Federal Agency

• Affordable Care Act overview: a primer November 2013
• Household composition and income eligibility detailed rules November 2013
• MAGI 2.0: Building MAGI Knowledge
  • Part 1: Household Composition July 2016
  • Part 2: Income Counting  Dec. 11, 2020
• Federal requirements and state flexibilities for verifying eligibility criteria May 2012
• 12-month continuous eligibility for children/youth under 19 years old:
  • Medicaid.gov page titled Continuous Eligibility for Medicaid and CHIP Coverage
  • State Health Official (SHO) Letter, SHO #25-001, Section 5112 Requirement for all States to Provide Continuous Eligibility to Children in Medicaid and CHIP under the Consolidated Appropriations Act, 2023 (January 15, 2025) 
  • NOTE:  GIS 26 MA/10 - Discontinuance of Continuous Coverage for MAGI Adults and Children from Birth to age Six (PDF) - adults no longer have 12 months of continuous coverage, and children no longer have continuous coverage from birth to age six.  But children under age 19 still have 12 months of continuous coverage

National Health Law Program (NHeLP)

• NHeLP Advocates Guide to MAGI (updated 2018) (This August 2018 update addresses changes to MAGI under the Republican tax plan enacted last year, as well as recently passed legislation affecting MAGI-based calculations, including:

  • New tax filing threshold now set at $12,000 for individuals, which will lower total household income for some who claim tax dependents (this will lead to more people being eligible for Medicaid, Cost Sharing Reductions, and more generous Premium Tax Credits);

  • New rules for prorating lottery winnings in Medicaid instead of counting them as lump sum income;

  • New income exclusions for payments made under parent-mentor programs and for those participating in clinical trials

• Link to  NHELP WEBINAR On MAGI Budgeting Jan. 7, 2014

• MAGI Household Quick Reference Guide

• Q&A: When Differences Between Marketplace and Medicaid MAGI Result in Ineligibility for Either Program

• Fact Sheet: IRS Updated Guidance on Home and Community Based Services and Excluding Difficulty of Care Payments from Gross Income

NYS Dept. of Health (NYSDOH)

• Links to State directives on the new rules and procedures

• NYSOH page titled Changes to Medicaid Coverage, explaining Medicaid Work Requirements and the ending of the 12 months of continuous coverage for adults over age 19 in Medicaid

Health Care for All New York coalition

Click here for an interactive Marketplace eligibility questionnaire, designed to help enrollment assistors and consumers better assess their potential eligibility for Marketplace coverage based on immigration status, age and income. This tool was created jointly by the Children's Defense Fund - New York, the Empire Justice Center, and the Community Service Society through their work in the Health Care for All New York coalition.

This questionnaire is not an official assessment of eligibility. To receive an official determination of eligibility contact the New York State of Health Marketplace at http://www.nystateofhealth.ny.gov or 1-855-355-5777. You can also reach out to a NYSOH Assistor via the Find Local Help page on NYSOH, which allows you to filter by zip code, county, and preferred language, among other criteria.

Empire Justice Center (EJC)

This training, Medicaid in 2014: Understanding MAGI & the Marketplace, covers the following topics, with case examples to help illustrate how the rules apply to our clients:

• The new MAGI (Modified Adjusted Gross Income) income levels and budgeting rules for Medicaid;
• Qualified Health Plans and the types of benefits these plans will provide;
• Eligibility for assistance with affording the new qualified health plans - Advance Premium Tax Credits and Cost Sharing Reductions; and
• The new online process for applying for all of these forms of assistance. 

• Trilby de Jung, Former Senior Attorney at Empire Justice is the presenter for the bulk of the slides.  The last seven slides are presented by Lisa Ball, attorney and certified navigator, with LAW-NY.  For a video recording of the webinar visit http://www.empirejustice.org/training-center/

• Also see description of April 2013 NYS Budget changes implementing the ACA in NYS

• Empire Justice Center Reports on Immigrant Access to Health Care in NY's Health Insurance Exchange

The Legal Aid Society (LAS)

• Training materials by the Legal Aid Society

• MAGI budgeting - More Legal Aid Society materials

Community Service Society (CSS)

• The Community Service Society Benefits Plus Learning Center chapter on MAGI Medicaid

New York Legal Assistance Group (NYLAG)

• PowerPoint by NYLAG on MAGI Budgeting