What Medicaid will pay for depends in part on where you live. It's designed to provide government-funded medical services to low-income households. States are charged with administering their own programs, and have some latitude in deciding whether or not to cover specific services based on general federal guidelines. However, all state Medicaid services must cover some specified procedures based on federal law.
Mandatory Benefits
Regardless of which state you live in, the following mandatory benefits must be covered:
- Inpatient and outpatient hospital services
- Early and periodic screening, diagnostic and treatment services -- designed to ensure children have comprehensive and preventive care
- Nursing facility services, in Medicare-certified nursing homes
- Home health services
- Physician services
- Rural health clinic services
- Family planning services, nurse-midwife services and freestanding birth center services when they are recognized by the state
- Certified paediatric and family nurse practitioner services
- Counseling designed to help pregnant women quit tobacco
- Laboratory and X-ray services
- Federally qualified health center services
- Transportation to medical care
Optional Benefits
Some benefits are not required by federal law, but may be offered by individual states. Among these benefits include:
- Prescription drugs
- Clinic services
- Physical therapy
- Occupational therapy
- Services designed to treat speech, hearing and language disorders
- Respiratory care services
- Diagnostic, screening, preventative and rehabilitative services not designated as mandatory, based on federal guidelines
- Dental services or dentures
- Eyeglasses
- Prosthetics
- Chiropractic services
- Private-duty nurses or hospice care
Because so many services are left to the discretion of the state, many of these optional benefits may not be available where you live. For example, in Virginia, even basic dental care is not covered. In addition, because Medicaid reimbursements to physicians are low, you may have a hard time getting treatment even for covered areas.
Specific Treatments
Many times, a patient covered by Medicaid will have to go through a specific course of treatment before major events are covered. For example, hip replacement surgery may be covered, but you'll generally have to show that the condition hasn't responded to other treatments. Your doctor will need to demonstrate that the joint replacement is a medical necessity to treat your condition.
Check With Your Doctor
It isn't always obvious what's covered by Medicaid, and even some covered services have limitations and restrictions. Other covered services may require a co-payment. Check with your medical provider beforehand to ensure a particular procedure is covered and what your cost will be. Otherwise, you may find yourself paying the entire bill out of pocket.