Medicaid Coverage

Medicaid Coverage Is Available

The Medicaid program provides many benefits for its enrollees. The government-funded program allows for low-income families and other households that meet specific eligibility requirements to receive health care coverage for a variety of different medical situations. The coverage does vary from state to state because each state administers its own Medicaid program. However, federal law requires that certain mandatory benefits be covered no matter what state the resident is in.

About Medicaid

Medicaid is a program that is funded by both the state governments and the federal U.S. government. Each state establishes and administers its own Medicaid programs, and each determines the type of benefits, the amount of coverage and the scope of services provided as well. However, it is important to understand that although each state has its own prerogative regarding how the program is administered, the program must abide by certain broad federal regulations.

Mandatory vs. Optional Benefits

Part of the broad federal regulations are mandatory benefits. These benefits have been decided on by the federal government and must be covered by each program administered by each state. All states must provide coverage for the benefits deemed mandatory. Additionally, the federal government has also put forth certain optional benefits that states may choose to cover but are not required to provide to Medicaid enrollees. Learn more about these services in the sections below.

Medicaid Benefits

Included in the list of benefits that are considered mandatory in regards to Medicaid coverage are inpatient hospital services, outpatient hospital services, physician services and more. This means that almost all visits to a hospital or physician’s office, depending on what the visit is for, are covered by Medicaid health insurance. In addition to those mandatory services, beneficiaries can also expect to have certain home health services or nursing facility services covered as well. Expectant parents can also utilize nurse midwife services and freestanding birth center services as long as the birth center is licensed or recognized by the state. It is critical that anyone who is applying to receive Medicaid coverage or anyone who is currently a beneficiary of Medicaid fully understands the benefits that they are entitled coverage for. Understanding the benefits beforehand allows for less confusion and promotes households utilizing the available services.

Although there are a number of essential health benefits that must be covered by Medicaid, there are also many benefits that are considered optional and do not have to be covered in any state. Each state determines which optional benefits to provide to their Medicaid beneficiaries, and the benefits vary greatly from state to state. Just as it is very important to be aware of the benefits that are guaranteed to be covered by Medicaid in every state, it is also important for everyone to understand which optional benefits states do and do not provide coverage for.

Among the benefits that are considered optional are prescription drugs, clinic services and optometry services. Also, it is not required by federal regulation for any physical therapy or occupational therapy treatments to be covered by Medicaid unless the state decides to cover it. Some states in the U.S. will cover services including hospice, chiropractic treatment and inpatient psychiatric services for individuals younger than 21, though those benefits are not mandatory. It is crucial that beneficiaries research the health service coverage in the state they reside in so that they know which services will be covered by their Medicaid plan before they attempt to receive treatment requiring these services, as this could require them to pay the full cost of the service out of pocket.

Dental services are included in the optional list of benefits, and states are not required to provide dental work to adult beneficiaries. Currently, due to the flexibility provided regarding dental benefits, less than half of states provide comprehensive dental care, though emergency dental care is provided to most adult beneficiaries. However, Medicaid does require that dental services be provided to children. These services must provide, at a minimum, pain relief and infection relief, restoration of damaged teeth and general maintenance of dental health. The requirement for this type of coverage is enforced by the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.

The EPSDT also requires that all services that are determined to be medically necessary be performed. The conditions that are deemed medically necessary are determined by each individual state. The EPSDT also states that if a condition is found during a screening and that condition requires treatment deemed medically necessary, the state must provide the resources needed to treat that condition, whether or not the services are included in that state’s Medicaid program plan. Vision services, screening services, hearing services, treatment and other necessary health care services are also required to be provided whether or not the service is covered by the state’s Medicaid plan. Those services will only be provided if the condition is deemed a medical necessity, as determined on a case-by-case basis.

It is crucial to understand that states can impose copayments, co-insurance, deductibles and similar other charges on most of the benefits covered by Medicaid, including both inpatient and outpatient services. The amounts charged will also vary depending on the income of the beneficiary. Because each state varies on what amounts it charges, it is important for all beneficiaries to be very aware of the out-of-pocket expenses policy in their state before seeking treatment. Out-of-pocket costs cannot be required for a few different services, including emergency services, family planning services, preventative services for children and more. In addition, children, institutionalized adults and those who are terminally ill are also excluded from out-of-pocket costs.

Due to the high level of variability between each of the states in the U.S. regarding Medicaid benefits, it is important for applicants and beneficiaries to gain as much information as possible about the policies and coverage options in their state. Being knowledgeable about the benefits offered will greatly reduce mistakes from being made and will help families to know what services to seek based on what is covered. Although many services are covered because they are deemed mandatory by federal law, there are many optional services that are not required coverage. Doing research on the specifics in the state the beneficiary resides in will ensure he or she gets the most out of his or her Medicaid program coverage.

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