Mandatory & Optional Medicaid Benefits
Medicaid is a joint federal and state run program that allows all states to both establish and provide their own Medicaid programs. This means the states themselves determine the type, duration, amount and spectrum of services that they provide, though they must stay within the federal guidelines of the Medicaid program.
All states are required to provide certain Medicaid benefits under federal law. States may also chose to cover select benefits as well which are known as "optional benefits". Optional benefits vary from state to state. For instance, one state may decide to limit the amount of inpatient hospital days Medicaid covers each year, while another state may allow for an unlimited amount of inpatient days an enrollee is allowed.
You will find the mandatory and optional benefits offered by Medicaid in the guide below.
*Note. Some of these items may have been updated and/or changed by state. You can check with your individual state agency to find out what your state's optional benefits may include.
Inpatient Hospital Services
|Outpatient Hospital Services||Clinic Services|
|EPSDT: Early and Periodic Screening, Diagnostic and Treatment Services||Physical Therapy|
|Nursing Facility Services||Occupational Therapy|
|Home Health Services||Speech/Hearing Language disorder Services|
|Physician Services||Respiratory Care Services|
|Rural Health Clinic Services||Diagnostic/Screening and Preventive and Rehabilitative Services|
Federally Qualified Health Center Services
|Laboratory and X-ray Services||Optometry Services|
|Family Planning Services||Dental Services|
|Nurse Midwife Services||Dentures|
|Certified Pediatric and Family Nurse Practitioner Services||Prosthetics|
|Freestanding Birth Center Services (licensed or recognized)||Eyeglasses|
|Transportation to Medical Care||Chiropractic Services|
|Tobacco Cessation Counseling for Pregnant Women||Certain Practitioner Services|
|Private Duty Nursing Services|
|Services for Individuals 65 and older in Institution for Mental Disease|
|Services in an Intermediate Care Facility for Individuals with Intellectual Disability|
|State Plan Home and Community Based Services|
|Self Directed Personal Assistance Services|
|Community First Choice Option|
|TB Related Services|
|Inpatient Psychiatric Services for Individuals Under Age 21|
|Other Services Approved by the Secretary|
|health Homes for Enrollees with Chronic Conditions|
Can I Have Both Medicaid & Medicare Benefits?
In short, yes, you can be covered and receive benefits by both programs. Both Medicaid and Medicare are similar in that they both provide medical coverage for low income individuals and families, as well as individuals with certain medical conditions and in select scenarios. When it comes to the benefits of either program however, they differ in some ways and can both be separately beneficial to you.
If you are enrolled for coverage in both Medicaid and Medicare simultaneously, Medicare will generally cover most of your medical needs and services. Though if you have medical needs that are not covered by Medicare, you can seek to have them covered by your state's Medicaid program.
Another difference concerning out-of-pocket expenses for someone who is covered by both Medicare or Medicaid is that Medicare does not always pay the entirety of a medical bill, even if the medical service is covered as such. This means that if your Medicare Part A or Part B leaves part of your medical bill unpaid, your Medicaid may step in to cover the remainder of the medical services bill. Your Medicaid coverage my also pay for prescription drugs that are not covered by your Medicare Part D coverage.
How Long Will My Medicaid Benefits Last?
Your Medicaid benefits will be active as long as you remain eligible for Medicaid and have taken the appropriate steps to remain covered. If you have recently had a life-altering event take place that changes your finances in either direction, you should contact your state Medicaid agency within 10 days to discuss the change. They will tell you the appropriate steps to take to remain covered by Medicaid.
Medicaid & Coronavirus
Medicaid has now become a lifeline to many Americans suffering with the coronavirus and other illnesses during the pandemic. The situation has caused millions of people to file for unemployment thus ending their employment medical coverage, which then leaves them with enrolling for Medicaid coverage for the time being.
The Department of Health and Human Services has deemed coronavirus testing an essential health benefit, thus Medicaid will cover costs of testing for coverage beneficiaries that are suspected of having the virus. In order for Medicaid to cover the cost of testing, your doctor must first order it and administer the test for you.
State run Medicaid programs are allowed to rapidly expand their coverage benefits and allowances when the situation becomes overwhelming, such as with the coronavirus pandemic. States are allowed the flexibility to decide to cover the costs of treatment in non-traditional settings, such as with Telemedicine and Telehealth services. The flexibility also allows states to cover any new vaccines that become available in the future.
Medicaid has also changed a bit to account for the coronavirus outbreak and now includes coverage of the following coronavirus related items :
- Lab tests for COVID-19.
- Telehealth services for diagnosing and treating COVID-19, regular office visits, mental health counseling, and preventive health screenings.
- All medically necessary hospitalizations will be covered.
- Any future vaccine may be covered. (Individual states will have the option to provide any future vaccine with or without a co-pay under current rules.)
People who were receiving health insurance through their employer and were laid off due to the coronavirus (COVID-19) pandemic are eligible to take advantage of a Special Enrollment Period to receive health insurance under Obamacare.
Please note that not all states have the same guidelines and benefits for coverage. Check with your local Medicaid state agency to determine if you are covered for a specific situation. All states and their respective Medicaid websites are listed in the table below: