C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER C—MEDICAL ASSISTANCE PROGRAMS › PART 435—ELIGIBILITY IN THE STATES, DISTRICT OF COLUMBIA, THE NORTHERN MARIANA ISLANDS, AND AMERICAN SAMOA › Subpart B—Mandatory Coverage

42 C.F.R. § 435.119

Coverage for individuals age 19 or older and under age 65 at or below 133 percent FPL

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Link to an amendment published at 91 FR 33469, June 3, 2026.

(a) Basis. This section implements section 1902(a)(10)(A)(i)(VIII) of the Act.

(b) Eligibility. Effective January 1, 2014, the agency must provide Medicaid to individuals who:

(1) Are age 19 or older and under age 65;

(2) Are not pregnant;

(3) Are not entitled to or enrolled for Medicare benefits under part A or B of title XVIII of the Act;

(4) Are not otherwise eligible for and enrolled for mandatory coverage under a State's Medicaid State plan in accordance with subpart B of this part; and

(5) Have household income that is at or below 133 percent FPL for the applicable family size.

(c) Coverage for dependent children. (1) A State may not provide Medicaid under this section to a parent or other caretaker relative living with a dependent child if the child is under the age specified in paragraph (c)(2) of this section, unless such child is receiving benefits under Medicaid, the Children's Health Insurance Program under subchapter D of this chapter, or otherwise is enrolled in minimum essential coverage as defined in § 435.4 of this part.

(2) For the purpose of paragraph (c)(1) of this section, the age specified is under age 19, unless the State had elected as of March 23, 2010 to provide Medicaid to individuals under age 20 or 21 under § 435.222 of this part, in which case the age specified is such higher age.

[58 FR 48614, Sept. 17, 1993, as amended at 77 FR 17205, Mar. 23, 2012; 78 FR 42302, July 15, 2013]
Notes of Decisions
Cited in 3 cases (1 in the last 5 years), 2019–2024 · leading case: S. Burda v. DHS (Pa. Commw. Ct. 2019).
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S. Burda v. DHS (Pa. Commw. Ct. 2019). “13 of the MA Handbook (Children Ages 1-5); 42 C.F.R. §435.119 . As a result, Daughter was disqualified from receiving MA benefits.”
Jeremy Cady & Ryan Johnson v. Missouri Sec'y of State John Ashcroft, & Heidi Miller & Laura Dominik (Mo. Ct. App. 2020). “Section 1396a(a)(10)(A)(i)(VIII) and as set forth in 42 C.F.R. 435.119, and who have income at or below one hundred thirty-three percent of the federal poverty level plus five percent of the applicable family size as determined under 42 U.”
In Re Appeal of T.D. (Vt. 2024). “15, 2017, GCR 16-095); see also 42 C.F.R. § 435.119 (b)(3). Because petitioner was already enrolled in Medicare, the Board concluded, she was not eligible for MCA.”
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