What Does Medicaid Cover?

According to a recent data set released by the Brookings Institution, the American health care system can be rife with high, unexpected costs that can be especially burdensome for needy citizens. Fortunately, low-income Americans nationwide have access to free or inexpensive insurance coverage through Medicaid.

Unlike Medicare, which is a federal program, each state manages its own Medicaid program. This means that every state has varying eligibility requirements and offers different forms of coverage through Medicaid.

Generally speaking, Medicaid is available to low-income individuals, families, pregnant women, people with disabilities and seniors near the federal poverty level.

What Does Medicaid Cover?

Here is a general breakdown of care and services commonly covered by Medicaid, which are typically included in categories like mandatory coverage, preventive care services and more.

Mandatory Medicaid Coverage

While Medicaid is operated largely at the state level, there are some services that are deemed mandatory under federal law:

• Doctor visits
• Inpatient and outpatient hospital services
• Medical transportation
• Some home health aids
• Certified family nurse practitioner and pediatric care
• X-rays and laboratory tests
• Nursing facility care
• Freestanding birth centers and midwife services
• Rural health clinics
• Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT)
• Health center services meeting federal qualifications
• Family planning services

Since Medicaid is administered at the state level, there may be some variations in the availability and breadth of these services from state to state.

Preventive Services

A range of preventive services are available through Medicaid that can help low-income individuals and families avoid costly medical bills.

These services include coverage for immunizations, clinical and behavioral interventions, self-care training, screenings for common illnesses and counseling that promotes healthy living.

Many states work cooperatively to promote prevention services through a program called the Medicaid Prevention Learning Network. In this program, states work together to share data and educational opportunities that can help citizens make the most of the prevention services offered through Medicaid.

Alternative Benefit Plans

To accommodate the specific health needs of low-income citizens on a regional level, many states have enacted Alternative Benefit Plan (ABP) programs.

These benefit plans can be tailored to meet specific demographic needs, but they must also meet a few minimum benchmarks to include basic Medicaid coverage. To ensure an ABP meets Medicaid standards, for example, a state can choose to combine it with comparable benefits to those earned by state employees.

A commercial HMO offered by the largest non-Medicaid insurance provider in any state can also qualify as an ABP.

Autism

The CDC estimates one in every 36 American children is identified as falling somewhere on the autism spectrum.

In July 2014, the Centers for Medicare and Medicaid Services (CMS) updated its guidelines to clearly define what forms of autism care should be covered by Medicaid. Four categories of treatment were specified, including behavioral and communication techniques, dietary treatments, medications and complementary or alternative medicine.

Medicaid funding for these treatments is available through a variety of federal and state sources, such as the Social Security Act, Home and Community-Based Services and EPSDT services.

Dental Plans

Dental coverage under Medicaid varies by state for adults but is federally mandated for children. Pediatric dental care falls under the umbrella of EPSDT services and usually includes routine checkups and maintenance visits, restoration of teeth and treatment for pain and oral infections.

To ensure an acceptable level of care, each state must cover periodic, preventive visits with a recognized dental health provider.

Most states currently offer at least some form of emergency dental coverage for adults under Medicaid. Less than half, however, offer any form of comprehensive dental insurance coverage comparable to those available through private insurers.

Behavioral Health Services

According to CMS, Medicaid is the largest provider of behavioral health services in the country, offering coverage for a range of mental health services.

In 2008, Congress further expanded Medicaid enrollees' access to mental health services with the Mental Health Parity and Addiction Equity Act. This bill lifted some limitations on mental health coverage available through Medicaid and outlawed discriminatory practices that previously limited co-pays, coinsurance and out-of-pocket maximums associated with mental health.

Screening and Testing

As with dental coverage, the federal government requires that each state provide a range of screening and testing services for Medicaid beneficiaries under the age of 21.

These services include:

• Regular physical exams
• Development of a complete medical history
• Immunizations and lab tests such a lead toxicity
• Wellness education
• Vision screenings and coverage for glasses
• Regular dental checkups
• Hearing tests and coverage for hearing aids
• Additional testing needed as a result of any EPSDT services
• Medical care deemed necessary as a result of screening and testing

Additionally, states are required to provide accurate and timely notifications to all youth Medicaid recipients about EPSDT services. Screening and testing for adults on Medicaid varies by state.

Hospice Benefits

Hospice benefits are determined by each state’s Medicaid program, but most states offer at least some coverage.

To qualify for hospice benefits, Medicaid recipients usually need to file a formal request with a hospice agency and provide a physician’s statement affirming that the patient is terminally ill. At that time, Medicaid will suspend funding for care intended to manage or cure the condition.

A beneficiary can, however, suspend hospice benefits and resume previous Medicaid coverage should their condition improve. Many forms of hospice care may be covered, such as continuous care, routine care, inpatient respite care and general inpatient care.