The Medicaid gap is a term used to describe the gap between state Medicaid eligibility, and Marketplace subsidy eligibility, in state’s that didn’t expand Medicaid.

How Does the Medicaid Gap Work?

Below are some quick bullet points to illustrate the “gap” between those who qualify for subsidies, and those who qualify for affordable health insurance due to Marketplace subsidies.

  • Marketplace subsidies are only offered to those making 100% – 400% of the Federal Poverty Guideline (see below).
  • If a person falls below the cut-off, they may fall in the Medicaid Gap if: Their state didn’t expand Medicaid to at least 100% of the Federal Poverty Guidelines.
  • In some state’s Medicaid eligibility can be as low as 50% FPL and other factors such as gender and pregnancy can affect eligibility.
  • In most state’s CHIP covers most low income children, so the Medicaid gap mainly affects adults.
  • State’s that did expand, expanding Medicaid to the 138% FPL. In those state’s those making less than 138% FPL qualify for Medicaid only.

See information on state’s that expanded Medicaid.

Federal Poverty Guidelines Medicaid Gap

The table below illustrates the Medicaid gap by showing a simplified version of the 2016 Federal Poverty Level Guidelines used to determine marketplace tax credit and Medicaid eligibility. The numbers are slightly higher each year. Check out the Federal Poverty Guideline Page for current guidelines.

Families making less than the amounts below (100% FPL) don’t have access to Marketplace cost assistance. Instead, they have to rely on state Medicaid rules, that in states that rejected Medicaid expansion, typically exclude single adults.

Watch a breakdown of the Medicaid Gap by John Oliver for a detailed explanation on the implications of the Medicaid gap.

Simplified 2016 FPL Guidelines for the 48 Contiguous States and DC (not Alaska and Hawaii).

Persons in household 2016 Federal
Poverty Level threshold
100% FPL
 *Medicaid eligibility is different in states that did not expand Medicaid. Federal Poverty Guidelines are different in Hawaii and Alaska.
1 $11,880
2 16,020
3 20,160
4 24,300
5 28,440
6 32,580
7 36,730
8 40,890

NOTE: If your family contained more than 8 people, add $4,160 for each additional person. Note that Hawaii and Alaska use different guidelines. (Additional amounts are unchanged from 2015).

In state’s that expanded Medicaid, all families making under the amounts below (138% FPL) have access to free or low cost coverage under Medicaid.

Simplified 2016 Medicaid Guidelines for the 48 Contiguous States and DC (not Alaska and Hawaii)

Persons in household 2016 Federal
Poverty Level threshold
138% FPL
 *Medicaid eligibility is different in states that did not expand Medicaid. Federal Poverty Guidelines are different in Hawaii and Alaska.
1 $16,242
2 $21,983
3 $27,724
4 $33,465
5 $39,205
6 $44,946
7 $50,687
8 $56,428

NOTE: If your family contained more than 8 people, add $4,160 for each additional person. Note that Hawaii and Alaska use different guidelines. (Additional amounts are unchanged from 2015).