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What Medicaid Covers

Other Requirements for Medicaid Coverage

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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.


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