Services

Medicaid covers a broad spectrum of medical care  -- including long term "custodial" care such as in a nursing home.

Some services must be included by each state. In addition to these minimum services, there are additional benefits which a state may include. These benefits vary from state to state.

Medicaid covers prescription drugs. It can also cover private health insurance premiums.

To find out if a service is covered in your state, see: http://medicaidbenefits.kff.org/

If the service is covered, in order for you to obtain the treatment through Medicaid, each of the following is required:

• A doctor's prescription is required, 
• The health care provider must participate in Medicaid. The provider cannot require that you pay any money, except possibly a small co-payment.
• Treatment must be "medically necessary"

Location

Medicaid only provides limited coverage out-of-state.

Medicaid does not provide any coverage out of the country.

• Required Coverages   
  
• Services That States May Cover  
• Other Requirements for Medicaid Coverage  
• Medicaid Pays Health Insurance Premiums  
• Medicaid And Prescription Drugs  
  
• Medicaid And Travel
• Medicaid And Children

Edited by Thomas P. McCormack
Editor, Medicaid Watch and Independent Consultant
Washington, D.C.

As you might imagine with respect to a plan that is administered by the state where you live, there can be problems with obtaining medical care outside the state. Each state has its own rules about out-of-state medical treatment, so check with your own state's Medicaid administrator before traveling out-of-state.

Generally, only the following are covered in another state:

• Charges related to a life-threatening emergency.
• Charges incurred when your health would be endangered in the absence of immediate medical care -- if a provider agrees to your state's provider enrollment contract.
• Charges pre-approved by Medicaid, such as treatment at a specialized out-of-state clinic.
• Charges along state borders where residents routinely seek treatment across the state line and for which Medicaid has made arrangements to cover this care.

Out-of-country coverage is never covered.

Edited by Thomas P. McCormack
Editor, Medicaid Watch and Independent Consultant
Washington, D.C.

The federal government requires at a minimum that the following services must be provided without charge if they are medically necessary:

• Inpatient and out-patient hospital services.
• Physician services.
• Nursing facility services for people age 21 or older.
• Home health care for people eligible for nursing facility services. (Home health aides.) 
• Family planning services and supplies.
• Clinic treatment.
• Laboratory and x-ray services.
• Federally-qualified health center services and any other ambulatory services offered by a federally-qualified health center that are otherwise covered under the State plan.
• Early and periodic screening, diagnosis, and treatment services for people under age 21. .

States have the option of covering additional services including:

• Prescription coverage (which is provided in all states)
  • The following states limit the number of prescriptions: Alabama, Arkansas, Georgia, Kentucky, Louisiana, Mississippi, NOrth Carolina, Oklahoma, South Carolina, Tennessee, Texas and West Virginia).
• Second opinions
• Optometrist services and eyeglasses.
  • Eye exams.
    • Must be covered in all states for children.
    • Are covered in most states.
  • Eyeglasses:
    • Must be covered in all states for children.
    • Are covered all states except Delaware, Kentucky, Louisiana, Mississippi and Tennessee.
    • The eyeglasses which are covered are the inexpensive variety. Contact lenses are generally not covered.
• Transportation to and from a medical facility where medical care is provided, by ambulance if required. (Covered in all states except Maryland).
• Physical therapy. (Covered in all states except  Colorado, Delaware, Louisiana, Missouri, North Carolina, Oklahoma, Pennsylvania, Rhode Island and Tennessee).
• Prosthetic devices. (Covered in all states except North Carolina)
• Dental services.
  • All states must cover children's dental care.
  • Most states do not cover adult dental care. Those that do genearlly restrict dental coverage. For example, basic dental care may be covered, but not orthodonture, root canal or crowns.
  • The private Doral Dental firm has listings of many (but not all) Medicaid- and SCHIP-participating dentists in many (but not all) states and localities. Call 800.417.7140 or go to www.doralusa.com
• Dentures.
  • All states must cover children's dentures.
  • Most states cover adult dentures.
• Funeral expenses.
• Travel to and from the health care site.

There are other optional services that states may cover. Coverage varies widely from state to state. These optional services include chiropractic care, podiatry, preventive care, inpatient and outpatient rehabilatative center services, adult hearing aids, physical, speech and occupational therapy, and any other medical or rehabilitative servivce recognized and allowed under state law. 

To learn about the benefits in your state, see the Kaiser Family Foundation's web site:  www.kff.org/medicaid/benefits/index.jsp?CFID=19068006&CFTOKEN=10261818   

If you need eyeglasses, a hearing aid or dental services and they're not covered in your state, see: Eyeglasses, Hearing Aids And Dental Services

There is more to Medicaid coverage than the patient being covered under Medicaid and the service being a covered service. To be eligible for reimbursement by Medicaid each of the following must also occur:

In general, a doctor must prescribe the treatment.

For example, in the great majority of states Medicaid will pay for a prescription drug prescribed by a doctor, but will not cover the same or equivalent medication sold over-the-counter even though it would be cheaper. (Some states do cover over-the-counter drugs and first aid items whether or not prescribed by a doctor.)

Only services of a Medicaid-participating provider are covered.

All providers must be approved by Medicaid and must agree to accept the Medicaid payment as payment in full (except for small Medicaid-authorized co-payments).

Check with your state Medicaid agency, local disease specific nonprofit organization, or your medical network for names of doctors and other providers that accept Medicaid.

Treatment must be "medically necessary."

Medicaid plans rely heavily on the preauthorization process to assure coverage for procedures prior to delivery.

All hospital confinements, other high cost charges such as MRI exams, and treatment by ancillary providers such as home health agencies, chiropractors, or nurses, must be preauthorized before the service can be delivered. Usually this is handled between Medicaid and your doctor or hospital

No payment by you to providers.

Generally, Medicaid participating providers are prohibited from collecting any payment from you to supplement what the provider receives from Medicaid. For people who are Medically Needy, there may be a small co-pay for some services, a small monthly premium, and/or a small, one-time-only fee for enrollment into Medicaid.

Although it is an "optional" coverage under federal law, all 50 states plus the District of Columbia include prescription drug coverage in their Medicaid plans.

States are permitted to impose limits and restrictions on the prescription benefit within limited guidelines. Some of the restrictions used by various states include:

• Prescription Limits. Some states limit the number of prescriptions a recipient can obtain with either a monthly or annual cap (see the list above). A few, but not all, states with such limits allow exceptions, such as for life-threatening illnesses or for certain classes of drugs, such as HIV/AIDS drug cocktails. Generally, states cannot offer prescription drugs to people who are eligible for both Medicare and Medicaid. People with such dual eligiblity must get their drugs from Medicare Part D plans. States can (and some do) cover certain narrow classes of drugs excluded by Medicare Part D. If they are willing to do so without federal matching, all states can offer any drugs they desire to people who are also eligible for Medicare.
• Copayments.
• Some states require a copayment of from $.50 to $5.00 per prescription. These copayments are often waived for certain groups of Medicaid recipients.
• Copayments are prohibited for recipients under 18 years old, pregnant women, and residents of certain institutions.
• Note: federal regulations prohibit denying access to medications or other medical servivces because of a recipient's inability to pay the copayment.
• Drug Formularies.
• A formulary is a list of medications that will be covered under a health plan. Many, but not all, states have Medicaid formularies.
• Each state must have an appeal/exception mechanism for obtaining medically necessary medications that are not on the formulary.

The federal government also permits states to refuse or limit coverage for certain types of drugs. These include:

• Anorexia, weight loss, or weight gain drugs.
• Fertility drugs.
• Medications for cosmetic or hair growth purposes.
• Vitamins and minerals.
• Drugs for smoking cessation.
• Cough and cold symptom medications.
• Nonprescription drugs.

For details about the Medicaid prescription plan in your state, you can check: www.kff.org/medicaid/benefits/service.jsp?gr=off&nt=on&so=0&tg=0&yr=3&cat=5&sv=32

NOTE: Pharmacists or their assistants are required to offer prescription medicine counseling to Medicaid patients and to review their medicine usage. Mail-order pharmacies must provide toll-free telephone service. The offer to counsel must include all important aspects of the medicine, such as its description, dosage form, length of treatment, special directions, common severe side effects, interactions and their avoidance or remedy, storage, the way to handle a missed dose, and techniques for self-monitoring treatment, such as blood testing by diabetics.

All states have programs to pay private health insurance premiums. If you have private insurance and qualify for Medicaid's insurance premium payment program, it is an excellent way to continue with the same medical care you have been receiving but without having to continue to pay your health insurance premiums.

Cost Effective: State Medicaid health insurance premium payment programs (HIPPs) must be cost effective so they typically require proof that it would be cheaper for Medicaid to pay your health insurance premium than to be sole payer of your medical bills if you lost the coverage. Usually, as part of the application process, you must show that the insurance company is routinely paying more in claims than the amount of your insurance premiums. In some states the requirement is the the insurance company routinely pay as much as double the premiums.

Health Insurance Plans Which Are Covered: Most states will pay any health insurance premium provided the plan is broad enough to be cost effective from Medicaid's point-of-view. This includes individual health plans, group plans, even COBRA employer group extended coverage and "post-group" further extended coverage. The primary exception is that some states will not pay the premiums of their state's high risk health plan pool. To learn more about high risk plans, see: How To Obtain Health Insurance.

Check with your state's Medicaid program for the details and requirements of your state's HIPP program.