Coverage

What Does Medicaid Cover and Not Cover?

Medicaid coverage can vary by state, but there are certain things that are required by law to be covered everywhere, and some benefits that Medicaid typically does not cover in most states. In this Medicaid review, we outline the typical benefits covered and not by Medicaid.

Medicaid provides coverage for a wide range of health care services to low-income individuals. But there are some things that Medicaid does not cover. 

Medicaid is not required to provide coverage for private nursing or for caregiving services provided by a household member. Things like bandages, adult diapers and other disposables are also not usually covered, and neither is cosmetic surgery or other elective procedures.

Additionally, Medicaid will not cover anything that is not FDA-approved or any alternative medicine. 

Medicaid coverage can vary a bit from state to state, so a service or item that is covered in one state may not be covered in another. Optional benefits that may or may not be covered depending on the state include:

  • Prescription drugs (although technically an optional benefit, every state Medicaid program provides at least some prescription drug coverage)
  • Physical and occupational therapy
  • Dental and eye care for adults
  • Hospice
  • Chiropractic care
  • Prosthetics 
  • Podiatry services
  • Respiratory care
  • Speech, hearing and language disorder services 

Again, coverage rules vary by state. If you would like to know if Medicaid will cover a particular service or item, contact your state Medicaid program for assistance. 

Does Medicaid cover all expenses?

Medicaid generally covers all expenses for covered care, but there may be circumstances in which small monthly premiums, deductibles or copayments are required. These include people with incomes above a certain amount in some states or when non-emergency services are administered in an emergency room.

Higher-risk groups such as children and pregnant women are typically exempt from any expenses 

What services are required to be covered by Medicaid?

While each state may tailor its own Medicaid benefits, there are some mandatory Medicaid benefits that are required to be covered in every state. These include:

  • Inpatient and outpatient hospital services
  • Physician services
  • Laboratory and x-ray services
  • Home health care
  • Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
  • Nursing Facility Services
  • Rural health clinic care
  • Federally qualified health center services
  • Family planning services
  • Nurse midwife services
  • Certified Pediatric and Family Nurse Practitioner services
  • Freestanding Birth Center services (when licensed or otherwise recognized by the state)
  • Transportation to medical care
  • Tobacco cessation counseling for pregnant women 

Medicaid is also required to cover the following services for children:

  • Dental care
  • Physical therapy
  • Eye care and eyeglasses
  • Hearing care and hearing aids
  • Podiatry services
  • Prosthetic devices
  • Mental health care
  • Hospice care
  • Some assisted living services

What are the disadvantages of Medicaid?

The list of services not covered by Medicaid is not the only downside to the program. Some other disadvantages of Medicaid include:

  • Eligibility differs by state, so you may not qualify where you live but otherwise would if you lived in a different state.

  • Benefits can change year to year based on budget cuts and other legislation.

  • Options for providers may be limited and quality of care can be sometimes diminished.

Why did I get denied for Medicaid?

There’s a multitude of reasons why someone may get denied for Medicaid coverage. Aside from not meeting the financial or demographic requirements, some common reasons for a denied Medicaid application include:

  • Incomplete application or documents
  • Failure to respond to a request within a timely manner
  • Late filing
  • Disability not proven or otherwise not medically qualified 

Don’t forget that mistakes can be made on behalf of Medicaid, and you have a right to appeal Medicaid’s decision concerning your coverage. Contact your state Medicaid program for instructions about how to appeal a decision if you are denied benefits. 

Can you have Medicaid and Medicare at the same time?

Yes, some beneficiaries are eligible for both Medicaid and Medicare. Depending on where you live and your eligibility, you may be able to enroll in a special type of Medicare Advantage plan called a Dual-eligible Medicare Special Needs Plan (D-SNP).

A D-SNP can offer benefits that Original Medicare (Parts A and B) don’t cover, such as dental, hearing, vision and more. All D-SNP plans are required to cover prescription drugs.

To learn more about these special types of plans and to find out if any are available where you live, you can compare plans online or call to speak with a licensed insurance agent.

Find a $0 premium Medicare Advantage plan today.

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1-800-557-6059

Christian

About the author

Christian Worstell is a licensed insurance agent and a Senior Staff Writer for MedicareAdvantage.com. He is passionate about helping people navigate the complexities of Medicare and understand their coverage options.

His work has been featured in outlets such as Vox, MSN, and The Washington Post, and he is a frequent contributor to health care and finance blogs.

Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism. He currently lives in Raleigh, NC.

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