The Basics of Medicaid Benefits

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Medicaid has historically offered pretty decent [officially terminology, of course] coverage, in large part due to federal requirements for comprehensive coverage. Medicaid covers 39% of all children, nearly half of all births, 60% of nursing home and other long-term care expenses, more than 25% of mental health services, and more than 20% of substance abuse treatment.

Additionally, many states offer what are termed “optional” benefits, coverage of services that not required by the federal government. Optional benefits go above and beyond the mandatory benefits required to be provided in every state to every eligible individual receiving Medicaid. Optional benefits include everything from hospice care and transportation services to adult dental care and respiratory care services. The ACA required that all Medicaid plans include prescription drug and mental health/substance abuse treatment coverage as well, further expanding the kind of care a beneficiary can expect to receive under the program. Here is a more expansive look at what mandatory and optional benefits are covered by Medicaid.

Mandatory Benefits (every state):

  • Certified pediatric or family nurse practitioner services
  • EPSDT
  • Family planning services and supplies
  • Federally qualified health centers
  • Freestanding birth centers
  • Home health services
  • Inpatient hospital services
  • Lab and x-ray services
  • Non-emergency transportation to medical care
  • Nurse midwife services (in accordance with state law)
  • Nursing facility services (ages 21 and over)
  • Outpatient hospital services
  • Physician services
  • Rural health clinic services
  • Tobacco cessation counseling and pharmacotherapy for pregnant women

Optional Benefits (vary by state):

  • Community supported living arrangements
  • Chiropractic services
  • Critical access hospital services
  • Dental services
  • Dentures
  • Eyeglasses and optometry services
  • Hospice services
  • Occupational therapy services
  • Personal care services
  • Physical therapy services
  • Primary care case management services
  • Private duty nursing services
  • Prosthetic devices
  • Speech, hearing, and language disorder services
  • Tuberculosis-related services

In addition to providing these benefits, Medicaid offers important financial protections from health care costs. Most states do not charge premiums and have limited out-of-pocket costs, however some states (Indiana and Montana) have been granted waivers by CMS to implement some cost sharing measures. Four additional states (Kentucky, Maine, New Mexico, and Wisconsin) have waivers that impact cost sharing pending approval from CMS.

Check out these additional general posts to learn more about the origin of the Medicaid program, how Medicaid eligibility is determined, and how Medicaid is financed and providers are reimbursed.

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