Federal statute and regulations mandate the coverage of certain populations and benefits in Medicaid and define the optional populations and services states may cover. States make policy decisions regarding their program’s parameters within these federal requirements to meet their specific needs and priorities. This issue brief describes the mandatory and optional eligibility pathways in Medicaid and the distinction between mandatory and optional benefits.
MACPAC examined enrollment and spending for mandatory and optional individuals and services using data from the Transformed Medicaid Statistical Information System (T-MSIS) and CMS-64 net financial management report for fiscal year (FY) 2023. In FY 2023, most spending and enrollment in Medicaid was for mandatory populations and benefits. Mandatory eligibility groups accounted for the majority of Medicaid enrollment.