poverty level. more recently, many states have authorized financial requirements that will make it more difficult for working-poor adults to access coverage. in wisconsin, nearly a quarter of medicaid patients were dropped after the state government imposed premiums of 3% of household income. a survey in minnesota found that more than half of those covered by medicaid were unable to obtain prescription medications because of co-payments. the deficit reduction act of 2005 (dra) requires anyone seeking medicaid to produce documents to prove that he is a united states citizen or resident alien. an exception is made for emergency medicaid where payments are allowed for the pregnant and disabled regardless of immigration status. special rules exist for those living in a nursing home and disabled children living at home. supplemental security income beneficiaries once someone is approved as a beneficiary in the supplemental security income program, they may automatically be eligible for medicaid coverage (depending on the laws of the state they reside in). five year "look-back" the dra has created a five-year "look-back period". this means that any transfers without fair market value (gifts of any kind) made by the medicaid applicant during the preceding five years are penalizable. the penalty is determined by dividing the average monthly cost of nursing home care in the area or state into the amount of assets gifted. therefore, if a person gifted $60,000 and the average monthly cost of a nursing home was $6,000, one would divide $6000 into $60,000 and come up with 10. 10 represents the number of months the applicant would not be eligible for medicaid. all transfers made during the five-year look-back period are totaled, and the applicant is penalized based on that amount after having already dropped below the medicaid asset limit. this means that after dropping below the asset level ($2,000 limit in most states), the medicaid applicant will be ineligible for a period of time. the penalty period does not begin until the person is eligible for medicaid. elders who gift or transfer assets can be caught in the situation of having no money but still not being eligible for medicaid. immigration status legal permanent residents (lprs) with a substantial work history (defined as 40 quarters of social security covered earnings) or military connection are eligible for the full range of major federal means-tested benefit programs, including medicaid (medi-cal). lprs entering after august 22, 1996, are barred from medicaid for five years, after which their coverage becomes a state option, and states have the option to cover lprs who are children or who are pregnant during the first five years. noncitizen ssi recipients are eligible for (and required to be covered under) medicaid. refugees and asylees are eligible for medicaid for seven years after arrival; after this term, they may be eligible at state option. nonimmigrants and unauthorized aliens are not eligible for most federal benefits, regardless of whether they are means tested, with notable exceptions for emergency services (e.g., medicaid for emergency medical care), but states have the option to cover nonimmigrant and unauthorized aliens who are pregnant or who are children, and can meet the definition of "lawfully residing" in the united states. special rules apply to several limited noncitizen categories: certain "cross-border" american indians, hmong/highland laotians, parolees and conditional entrants, and cases of abuse. aliens outside the united states who seek to obtain visas at u.s. consulates overseas or admission at u.s. ports of entry are generally denied entry if they are deemed "likely at any time to become a public charge". aliens within the united states who seek to adjust their status to that of lawful permanent resident (lpr), or who entered the united states without inspection, are also generally subject to exclusion and deportation on public charge grounds. similarly, lprs and other aliens who have been admitted to the united states are removable if they become a public charge within five years after the date of their entry due to causes that preexisted their entry. a 1999 policy letter from immigration officials defined "public charge" and identified which benefits are considered in public charge determinations, and the policy letter underlies current regulations and other guidance on the public charge grounds of inadmissibility and deportability. collectively, the various sources addressing the meaning of public charge have historically suggested that an alien's receipt of public benefits, per se, is unlikely to result in the alien being deemed to be removable on public charge grounds. children and schip a child may be eligible for medicaid regardless of the eligibility status of his parents. thus, a child may be covered by medicaid based on his individual status even if his parents are not eligible. similarly, if a child lives with someone other than a parent, he may still be eligible based on its individual status. one-third of children and over half (59%) of low-income children are insured through medicaid or schip. the insurance provides them with access to preventive and primary services which are used at a much higher rate than for the uninsured, but still below the utilization of privately insured patients. as of 2014, rate of uninsured children was reduced to 6% (5 million children remain uninsured). hiv medicaid provided the largest portion of federal money spent on health care for people living with hiv/aids until the implementation of medicare part d, when the cost of prescription drugs for those eligible for both medicare and medicaid was shifted to medicare. unless low income people who are hiv positive meet some other eligibility category, they are not eligible for medicaid assistance unless they can qualify under the "disabled" category to receive medicaid assistance — for example, if they progress to aids (t-cell count drops below 200). the medicaid eligibility policy differs from journal of the american medical association (jama) guidelines, which recommend therapy for all patients with t-cell counts of 350 or less and even certain patients with a higher t-cell count. due to the high costs associated with hiv medications, many patients are not able to begin antiretroviral treatment without medicaid help. it is estimated that more than half of people living with aids in the united states receive medicaid payments. two other programs that provide financial assistance to people living with hiv/aids are the social security disability insurance (ssdi) and the supplemental security income programs. utilization during 2003–2012, the share of hospital stays billed to medicaid increased by 2.5%, or 0.8 million stays. as of 2019, medicaid paid for half of all births in the united states. medicaid super utilizers (defined as medicaid patients with four or more admissions in one year) account for more hospital stays (5.9 vs.1.3 stays), longer lengths of stay (6.1 vs. 4.5 days), and higher hospital costs per stay ($11,766 vs. $9,032). medicaid super-utilizers were more likely than other medicaid patients to be male and to be aged 45–64 years. common conditions among super-utilizers include mood disorders and psychiatric disorders, as well as diabetes, cancer treatment, sickle cell anemia, sepsis, congestive heart failure, chronic obstructive pulmonary disease, and complications of devices, implants, and grafts. budget and financing medicaid spending as part of total u.s. healthcare spending (public and private). percent of gross domestic product (gdp). congressional budget office chart. unlike medicare, which is solely a federal program, medicaid is a joint federal-state program. each state administers its own medicaid system that must conform to federal guidelines for the state to receive federal matching funds. financing of medicaid in the american samoa, puerto rico, guam, and the u.s. virgin islands is instead implemented through a block grant. the federal government matches state funding according to the federal medical assistance percentages. the wealthiest states only receive a federal match of 50% while poorer states receive a larger match. medicaid funding has become a major budgetary issue for many states over the last few years, with states, on average, spending 16.8% of state general funds on the program. if the federal match expenditure is also counted, the program, on average, takes up 22% of each state's budget. some 43 million americans were enrolled in 2004 (19.7 million of them children) at a total cost of $295 billion. in 2008, medicaid provided health coverage and services to approximately 49 million low-income children, pregnant women, elderly people, and disabled people. federal medicaid outlays were estimated to be $204 billion in 2008. in 2011, there were 7.6 million hospital stays billed to medicaid, representing 15.6% (approximately $60.2 billion) of total aggregate inpatient hospital costs in the united states. at $8,000, the mean cost per stay billed to medicaid was $2,000 less than the average cost for all stays. medicaid does not pay benefits to individuals directly; medicaid sends benefit payments to health care providers. in some states medicaid beneficiaries are required to pay a small fee (co-payment) for medical services. medicaid is limited by federal law to the coverage of "medically necessary services". since the medicaid program was established in 1965, "states have been permitted to recover from the estates of deceased medicaid recipients who were over age 65 when they received benefits and who had no surviving spouse, minor child, or adult disabled child". in 1993, congress enacted the omnibus budget reconciliation act of 1993, which required states to attempt to recoup "the expense of long-term care and related costs for deceased medicaid recipients 55 or older." the act allowed states to recover other medicaid expenses for deceased medicaid recipients 55 or older, at each state's choice. however, states were prohibited from estate recovery when "there is a surviving spouse, a child under the age of 21 or a child of any age who is blind or disabled". the act also carved out other exceptions for adult children who have served as caretakers in the homes of the deceased, property owned jointly by siblings, and income-producing property, such as farms". each state now maintains a medicaid estate recovery program, although the sum of money collected significantly varies from state to state, "depending on how the state structures its program and how vigorously it pursues collections." on november 25, 2008, a new federal rule was passed that allows states to charge premiums and higher co-payments to medicaid participants. this rule enabled states to take in greater revenues, limiting financial losses associated with the program. estimates figure that states will save $1.1 billion while the federal government will save nearly $1.4 billion. however, this meant that the burden of financial responsibility would be placed on 13 million medicaid recipients who faced a $1.3 billion increase in co-payments over 5 years. the major concern is that this rule will create a disincentive for low-income people to seek healthcare. it is possible that this will force only the sickest participants to pay the increased premiums and it is unclear what long-term effect this will have on the program. a 2019 study found that medicaid expansion in michigan had net positive fiscal effects for the state. effects a 2019 review by kaiser family foundation of 324 studies on medicaid expansion concluded that "expansion is linked to gains in coverage; improvements in access, financial security, and some measures of health status/outcomes; and economic benefits for states and providers." a 2021 study found that medicaid expansion as part of the affordable care act led to a substantial reduction in mortality, primarily driven by reductions in disease-related deaths. a 2018 study in the journal of political economy found that upon its introduction, medicaid reduced infant and child mortality in the 1960s and 1970s. the decline in the mortality rate for nonwhite children was particularly steep. a 2018 study in the american journal of public health found that the infant mortality rate declined in states that had medicaid expansions (as part of the affordable care act) whereas the rate rose in states that declined medicaid expansion. a 2020 jama study found that medicaid expansion under the aca was associated with reduced incidence of advanced-stage breast cancer, indicating that medicaid accessibility led to early detection of breast cancer and higher survival rates. a 2020 study found no evidence that medicaid expansion adversely affected the quality of health care given to medicare recipients. a 2018 study found that medicaid expansions in new york, arizona, and maine in the early 2000s caused a 6% decline in the mortality rate: "hiv-related mortality (affected