What is Section 1619(b)?

A federal protection that lets certain SSI recipients keep Medicaid after SSI cash benefits stop due to work, if disability continues, Medicaid is needed for work, and earnings stay under the state’s annual threshold.

How do IRWE and BWE help me keep benefits?

IRWE let you deduct disability-related work costs from earnings for SSI. BWE, for blind SSI recipients, exclude any earned income used for work-enabling expenses. Both can lower countable income and support continued Medicaid via SSI rules.

What is the Medicaid Buy-In for workers with disabilities?

A state option that allows working adults with disabilities to enroll in Medicaid with higher income and asset limits, often paying a sliding-scale premium. It’s useful when earnings are too high for SSI-linked Medicaid.

What does “300% of SSI” mean in HCBS programs?

Many states allow income up to three times the SSI Federal Benefit Rate for people who meet an institutional level of care and receive long-term services at home or in facilities. This creates a higher income cap than standard Medicaid.

Do MAGI Medicaid rules use IRWE/BWE deductions?

No. MAGI uses tax-based income with a 5% FPL disregard and no asset test. It does not apply SSI-style IRWE/BWE deductions.

Does getting employer insurance disqualify me from Medicaid?

Not necessarily. Many states operate HIPP programs that can pay your employer plan premium when it’s cost-effective, with Medicaid acting as secondary coverage.

Do ABLE accounts affect Medicaid eligibility?

ABLE accounts get favorable treatment. Up to $100,000 is disregarded for SSI resources, and Medicaid programs follow federal guidance on disregarding certain ABLE contributions and distributions.

Medicaid & Work: 2025 Guide For Disabled Adults

Q: Will I lose Medicaid if I start working?

Not automatically. SSI recipients may keep Medicaid under Section 1619(b) up to a state-specific earnings threshold. Others can qualify through Medicaid Buy-In, MAGI adult Medicaid, medically needy spenddown, or HCBS pathways.

Short answer: Working does not automatically end Medicaid. Many disabled adults can keep coverage through SSI-linked Medicaid (1619(b)), Medicaid Buy-In, MAGI pathways, medically needy spenddown, or HCBS rules that allow income up to 300% of SSI. The right door depends on your program and state. Social Security Medicaid+2Medicaid+2 KFF

Does work make you lose Medicaid? (the quick answer)

Usually no, if you use the correct pathway:

On SSI? If earnings stop your SSI cash payment, Section 1619(b) can keep your Medicaid as long as your state threshold isn’t exceeded, you still meet disability rules, and you need Medicaid to work. Each state has a yearly dollar threshold (SSA updates it annually). Social Security+1
Not on SSI? Many states offer a Medicaid Buy-In for workers with disabilities—higher income and asset limits (often with a sliding-scale premium). Medicaid
In expansion states? You might qualify under MAGI rules (no asset test; 5% FPL disregard) up to ~138% FPL for adults—separate from disability pathways. Medicaid+1
Higher medical costs? Medically needy/spenddown lets you subtract incurred medical expenses to qualify when income is too high. Medicaid
Need long-term services? Many states allow up to 300% of SSI income for people meeting an institutional level of care at home or in facilities (HCBS special income rule). KFF

Bottom line: Earnings ≠ automatic loss of Medicaid. The path you use changes how income/assets are counted.

The five doors to Medicaid while you work

SSI-linked Medicaid with Section 1619(b) (keep Medicaid after SSI cash stops)

If you lose SSI cash due to earnings but still meet SSA disability rules, 1619(b) lets you keep Medicaid up to your state’s threshold (SSA publishes these annually; amounts vary widely). If earnings later drop, SSI payments can restart without a new application. Social Security+2Social Security+2

How it counts earnings: SSI rules: first $20 (general) + $65 (earned) disregarded, then ½ of the rest is countable; IRWE and BWE can lower countable earnings further. Social Security+1
Why it matters: You keep Medicaid while advancing at work—as long as you stay under the 1619(b) threshold for your state and still need Medicaid. Social Security

Source: SSA—“Continued Medicaid Eligibility (1619(b))” & 2025 state thresholds, last checked: Sept 9, 2025. Social Security+1

Bottom line: If you’re on SSI, 1619(b) is the default safety net to work and keep Medicaid.

Medicaid Buy-In for Workers with Disabilities (MBI-WD)

Most states offer a Buy-In category so people with disabilities can work with higher earnings and still get Medicaid, often paying a small premium. Authority originated in the BBA of 1997 and Ticket to Work (1999); states design specifics (income/asset limits; premium tables). Medicaid+1

Who uses it: Workers with disabilities over SSI limits or who aren’t on SSI/SSDI.
Typical limits: Many states set income up to 200–250% FPL (or more) and higher asset caps; recent state filings (e.g., NY, 2025) detail income 250% FPL and liberal resource rules (e.g., retirement accounts disregarded). Medicaid
Where it exists: KFF’s 2025 dataset shows wide Buy-In adoption across states. KFF

Source: Medicaid.gov—Employment Initiatives / Buy-In, KFF 2025 state adoption; NY 1115 filing, last checked: Sept 9, 2025. Medicaid+1 KFF

Bottom line: If 1619(b) won’t work or you’re not on SSI, ask your state about “Working Disabled/Buy-In” eligibility.

MAGI Adult Medicaid (in expansion states)

If your state expanded Medicaid, low-income adults (including disabled adults who don’t want to test disability) can qualify under MAGI rules: no asset test, no variable disregards (just the 5% FPL “across-the-board” disregard), based on taxable income. Earnings from work are counted like on your tax return. Medicaid+1

Heads-up: MAGI is different from SSI-related Medicaid. It does not use IRWE/BWE or SSI-style half-earnings rules. Medicaid

Source: Medicaid.gov—Eligibility Policy & MAGI FAQs, last checked: Sept 9, 2025. Medicaid+1

Bottom line: In expansion states, MAGI Medicaid can be a simple, asset-free path while you work—if your income stays within limits.

Medically Needy / Spenddown

If income is too high for standard Medicaid but you have large medical bills, the medically needy option (in many states) lets you “spend down” income with allowed medical expenses until you meet the state’s MN income level. 209(b) states must allow spenddown for ABD groups. Medicaid+1

Source: Medicaid.gov—Eligibility Policy; CMS implementation guides, last checked: Sept 9, 2025. Medicaid+1

Bottom line: Heavy medical costs can re-open Medicaid through spenddown even when earnings rise.

HCBS / Long-Term Services pathways (the 300% of SSI rule)

For people who meet an institutional level of care (nursing-facility level), many states allow income up to 300% of the SSI Federal Benefit Rate—applied to institutional or HCBS at home (varies by state). In 2025, KFF notes widespread use of these special income pathways. KFF

Source: KFF 2025 non-MAGI eligibility levels; CMS HCBS guidance, last checked: Sept 9, 2025. KFF Medicaid

Bottom line: If you need LTSS/HCBS, the income bar is higher—often up to 300% of SSI.

SSI work incentives that can lower countable earnings

IRWE (Impairment-Related Work Expenses): Out-of-pocket costs needed to work due to your disability (e.g., equipment, attendant care, specialized transport) can be deducted from earnings in SSI calculations and when SSA evaluates SGA for SSDI. Social Security choosework.ssa.gov
BWE (Blind Work Expenses): For SSI recipients who are statutorily blind, SSA excludes any earned income used to pay for items/services that enable work (not limited to disability-related costs). Social Security
SGA context (disability determination only): 2025 SGA = $1,620/mo (non-blind) and $2,700/mo (blind). This affects disability determinations, not SSI payment amounts for current recipients. Social Security+1

Source: SSA Spotlights & Red Book 2025, last checked: Sept 9, 2025. Social Security+2Social Security+2

Bottom line: IRWE/BWE can keep countable income lower—helping you keep Medicaid through SSI paths or stay under SGA for SSDI.

State differences that matter (1634 vs 209(b); thresholds; Buy-In)

1634 states: SSI approval usually triggers Medicaid automatically.
209(b) states (CT, HI, IL, MN, MO, NH, ND, VA): Medicaid uses more restrictive ABD criteria than SSI; SSI recipients must separately qualify (states must allow spenddown). KFF Medicaid
1619(b) thresholds: State-specific and updated annually by SSA (check your state’s 2025 amount). Social Security
Buy-In adoption: Most states operate a Working Disabled/Buy-In program in 2025 (income/asset rules vary). KFF

Source: KFF (209(b), Buy-In adoption), Medicaid.gov 209(b) guidance, SSA thresholds; last checked: Sept 9, 2025. KFF+1 Medicaid Social Security

Bottom line: Your state determines how you qualify—always check your state’s rules.

Employer coverage + Medicaid: HIPP can pay your premiums

If you gain employer-sponsored insurance, many states run a Health Insurance Premium Payment (HIPP) program. When cost-effective, Medicaid can pay your ESI premium and act as secondary coverage for benefits Medicaid covers but the plan doesn’t. (Program names and rules vary by state.) Medicaid+1

Source: Medicaid.gov premium-assistance/HIPP materials & recent SPAs, last checked: Sept 9, 2025. Medicaid+1

Bottom line: Don’t drop Medicaid when you start a job—ask about HIPP.

Assets while you work: ABLE accounts help

ABLE accounts let eligible people with disabilities save for qualified disability expenses with favorable treatment: up to $100,000 is ignored for SSI resource limits (excess may suspend SSI cash but Medicaid can continue under SSI rules), and Medicaid programs must follow federal guidance on disregarding certain ABLE contributions/distributions. Social Security Medicaid

Source: SSA POMS SI 01130.740 (updated 7/8/2025); CMS SMD-17-002 (ABLE & Medicaid), last checked: Sept 9, 2025. secure.ssa.gov Medicaid

Bottom line: ABLE can protect savings while you work without costing you Medicaid.

Which path fits you — a 10-minute checklist

Are you on SSI now?
- Yes → Ask SSA about 1619(b) and confirm your state threshold; track IRWE/BWE and report wages. Social Security+2Social Security+2
Not on SSI or earnings exceed SSI rules?
- Ask your state about the Medicaid Buy-In (“Working Disabled”) option; check premium/asset rules. Medicaid
In an expansion state & under ~138% FPL?
- Consider MAGI adult Medicaid (no asset test; 5% disregard). Medicaid
High medical costs?
- Explore Medically Needy/spenddown with your state Medicaid office. Medicaid
Need LTSS/HCBS?
- Ask about the 300% of SSI pathways and HCBS eligibility. KFF
Got job-based insurance?
- Apply for HIPP so Medicaid can pay your premium and act as secondary. Medicaid
Need help deciding?
- Contact a WIPA benefits counselor (free, SSA-funded) via the Ticket to Work Find Help tool or Help Line. choosework.ssa.gov+1

Bottom line: You likely qualify through one of these doors—use WIPA to verify the best fit.

Comparison table — work & Medicaid pathways

Pathway	Who it’s for	How earnings are counted	Asset rules	Key cap/threshold	Do this next
SSI + 1619(b)	SSI recipients who lose cash due to work but still disabled	SSI formula: $20 + $65 disregards, then ½ of rest; IRWE/BWE can further reduce countable earnings	SSI asset rules (state supplements may vary)	State 1619(b) threshold (updates yearly)	Check your state threshold; report wages; track IRWE/BWE. Social Security+1
Medicaid Buy-In (MBI-WD)	Workers with disabilities over SSI limits or not on SSI	State-set; often broad—earnings allowed with premium	Often higher asset caps; some retirement funds disregarded	Frequently 200–250% FPL (varies)	Call state Medicaid about Working Disabled/Buy-In. Medicaid+1
MAGI Adult Medicaid	Low-income adults in expansion states	Taxable income; 5% FPL disregard only	No asset test	~138% FPL for adults (state specifics vary)	Use your state portal/Marketplace; choose Medicaid (MAGI). Medicaid
Medically Needy / Spenddown	People with high medical expenses	Earned income counted; medical bills offset income to reach MNIL	ABD asset rules; state verifies	MNIL varies by state/household size	Ask Medicaid about spenddown enrollment. Medicaid
HCBS / Special Income Rule	People meeting institutional level of care	ABD methodology; post-eligibility patient liability may apply	ABD asset rules; some states allow disregards	Up to 300% of SSI income (state-specific)	Ask about 1915(c)/1915(i) options and 300% SSI path. KFF
HIPP (premium assistance)	Medicaid enrollees with ESI access	N/A (not an eligibility group)	N/A	Cost-effectiveness test	Apply for HIPP; keep Medicaid as secondary. Medicaid

Sources: SSA 1619(b)/IRWE/BWE; Medicaid.gov Eligibility, Buy-In, HIPP; KFF non-MAGI/300% SSI. Last checked: Sept 9, 2025. Social Security+2Social Security+2 Medicaid+2Medicaid+2 KFF

FAQs

Will I lose Medicaid if I start working?
Not automatically. 1619(b) can preserve Medicaid for SSI recipients who work, up to a state threshold. Others may qualify through Buy-In, MAGI, medically needy, or HCBS rules. Social Security Medicaid

What is 1619(b)?
A federal rule letting certain SSI recipients keep Medicaid after SSI cash ends due to earnings, up to a state-specific dollar limit, if disability continues and Medicaid is needed to work. Social Security

How do IRWE and BWE help?
They reduce countable earnings for SSI: IRWE deducts disability-related work costs; BWE (for blind SSI recipients) excludes any earned income used for work-enabling expenses. Social Security+1

What is the Medicaid Buy-In?
A state option for workers with disabilities whose earnings would otherwise be too high. Many states allow income around 200–250% FPL (or more) and higher assets with premiums. Medicaid

What does “300% of SSI” mean?
For LTSS/HCBS, many states allow income up to 3× the SSI Federal Benefit Rate for people who meet an institutional level of care—a higher cap than regular ABD Medicaid. KFF

I got job-based insurance—should I drop Medicaid?
No. Ask about HIPP. If cost-effective, Medicaid may pay your premium and act as secondary coverage. Medicaid

Do ABLE accounts affect Medicaid?
ABLE balances get favorable treatment; up to $100k is ignored for SSI resources, and Medicaid follows federal guidance on disregarding certain contributions/distributions. Social Security Medicaid

How much can I earn and keep Medicaid under 1619(b)?
It depends on your state’s threshold (updated yearly by SSA). If your gross wages stay under your state’s amount, you can keep Medicaid after SSI cash stops, as long as you still meet disability rules and need Medicaid to work. Social Security

Can I switch from SSI-linked Medicaid to a Buy-In program if I get a raise?
Often, yes. Many states let workers with disabilities buy in to Medicaid with higher earnings (sometimes with premiums). Check your state’s Working Disabled/Buy-In rules. Medicaid

What if my state is 209(b)?
You may need to separately qualify for Medicaid even if you get SSI, but states must allow spenddown for ABD groups. Check state rules and consider Buy-In if available. KFF Medicaid

Does getting job-based insurance disqualify me from Medicaid?
No. If cost-effective, HIPP may pay your ESI premium; Medicaid can remain secondary. Medicaid

Do MAGI rules use IRWE/BWE?
No. MAGI follows tax rules (with a 5% FPL disregard) and doesn’t use SSI-style work expense deductions or asset tests. Medicaid

Can ABLE accounts help me keep Medicaid while working?
Yes. ABLE balances get favorable treatment for SSI/Medicaid, and certain contributions/distributions are disregarded per federal guidance. secure.ssa.gov Medicaid

Disclaimer

This article is educational and not legal/financial advice. Rules change and vary by state and program. Always confirm with your state Medicaid agency, SSA, and a qualified benefits counselor.

Key takeaways

Working doesn’t automatically end Medicaid. Paths include 1619(b), Buy-In, MAGI, medically needy, and HCBS 300% SSI. Social Security Medicaid KFF
Countable income can be lowered with IRWE/BWE under SSI rules. Social Security
State rules differ (e.g., 209(b) states, Buy-In specifics), so check your state. KFF
HIPP may pay your employer premium while Medicaid remains secondary. Medicaid
ABLE accounts help protect savings without losing Medicaid. secure.ssa.gov

Next steps:

Identify your pathway (SSI/1619(b), Buy-In, MAGI, Medically Needy, HCBS).
Call a WIPA counselor (free) via SSA’s Find Help tool; confirm your earnings plan and protections. choosework.ssa.gov
If you get employer coverage, apply for HIPP so Medicaid can help with premiums. Medicaid

Medicaid & Work: 2025 Guide for Disabled Adults