Mandatory Federal Benefits
According to Quality Medicaid Care, Medicaid is required by federal law to pay for inpatient and outpatient hospital services, including transportation to medical care when needed. The insurer will also pay for federally qualified health centers and rural health clinic services, along with lab and X-ray services. In addition, early and periodic screening, diagnostic, and treatment services are covered, as are nursing facility services.Men and women wanting to control the number of children they have benefit from the required family planning services, and women who are pregnant and smoke can receive tobacco cessation counseling to benefit their health and the health of the unborn child. Physician, home health, nurse midwife, and certified pediatric and family nurse practitioner services are mandatory under federal law, and a woman can use a licensed freestanding birth center service if she chooses. Medication-assisted treatment is a benefit for anyone covered by Medicaid, and the program pays for routine patient costs for beneficiaries taking part in qualifying clinical trials.
Medicaid is a joint federal and state program that provides healthcare coverage to eligible low-income individuals and families. This guide will help you understand the essential components of Medicaid services, including the mandatory federal benefits and the additional benefits that states may provide.
The federal government requires all states participating in Medicaid to provide certain mandatory benefits to eligible beneficiaries. These core services ensure that individuals have access to necessary healthcare services. They include:
- Inpatient Hospital Services: Care provided when admitted to a hospital, including surgeries and overnight stays.
- Outpatient Hospital Services: Medical services provided at a hospital that don’t require an overnight stay, such as same-day surgeries and emergency care.
- Physician Services: Visits to doctors and specialists for diagnosis, treatment, and preventive care.
- Rural Health Clinic Services: Primary care and preventive services provided in rural areas to increase accessibility.
- Federally Qualified Health Center (FQHC) Services: Comprehensive health services, including preventive care, provided by community-based clinics.
- Laboratory and X-ray Services: Diagnostic tests necessary for diagnosing and treating medical conditions.
- Nursing Facility Services: Long-term care services for individuals aged 21 and older requiring assistance with daily activities and medical needs.
- Home Health Services: Care provided at home, such as nursing, therapy services, and medical equipment for eligible beneficiaries.
- Pediatric and Family Nurse Practitioner Services: Primary and specialty care for children and families provided by nurse practitioners.
- Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services: Comprehensive healthcare services for individuals under 21, including check-ups, vaccinations, and necessary treatments to address identified issues.
- Transportation to Medical Care: Non-emergency transportation services to access medical appointments and treatments.
These mandatory services are designed to provide essential healthcare access, ensuring that Medicaid beneficiaries receive necessary medical attention regardless of where they live in the United States.
Many state programs offer coverage for speech, hearing, and language disorder services and other diagnostic, screening, preventative, or rehabilitative services. Ask if the program will help with the cost of prescription drugs and prosthetics, which can be costly for the individual. Other services that might be covered include help for men and women 65 and older in an Institution for Mental Disease. Hospice and case management are other services many state Medicaid programs cover.
A state program may extend this coverage to services provided for intellectually disabled men and women in an intermediate care facility or children under 21 in need of inpatient psychiatric care. Personal care and respiratory care for men and women who depend on a ventilator may also be covered. Ask the state Medicaid office if the Community First Choice Option and home and community-based services are included in the benefits.
People might assume they know what is covered and what isn't, only to receive a bill for services and wonder how they will pay it. One way to navigate the system is to work with a Medicaid advisor. They help clients determine what coverage they have and what items are excluded based on the mandatory federal benefits and benefits offered by the state. With their help, a person can get the services they need without worrying about a bill that must be paid. The peace of mind they receive when they have this information is priceless.
State Benefits
States may choose to offer other benefits under their Medicaid plans. Participants in this program should check with their Medicaid provider to learn what is and is not covered. Licensed practitioner and private duty nursing services might be covered along with clinic services. Ask about dental and denture coverage; anyone who wears glasses might find the program will pay for them. A person can also receive physical or occupational therapy and cover the visits under the healthcare insurance program.Many state programs offer coverage for speech, hearing, and language disorder services and other diagnostic, screening, preventative, or rehabilitative services. Ask if the program will help with the cost of prescription drugs and prosthetics, which can be costly for the individual. Other services that might be covered include help for men and women 65 and older in an Institution for Mental Disease. Hospice and case management are other services many state Medicaid programs cover.
A state program may extend this coverage to services provided for intellectually disabled men and women in an intermediate care facility or children under 21 in need of inpatient psychiatric care. Personal care and respiratory care for men and women who depend on a ventilator may also be covered. Ask the state Medicaid office if the Community First Choice Option and home and community-based services are included in the benefits.
People might assume they know what is covered and what isn't, only to receive a bill for services and wonder how they will pay it. One way to navigate the system is to work with a Medicaid advisor. They help clients determine what coverage they have and what items are excluded based on the mandatory federal benefits and benefits offered by the state. With their help, a person can get the services they need without worrying about a bill that must be paid. The peace of mind they receive when they have this information is priceless.
In addition to the mandatory benefits, states have the flexibility to offer additional services through Medicaid. These optional services vary by state and may include:
- Prescription Drugs: Medication coverage for beneficiaries, including generics and some brand-name drugs.
- Physical Therapy: Rehabilitation services to help individuals recover from injuries or manage chronic conditions.
- Occupational Therapy: Therapy services designed to help individuals gain or regain skills necessary for daily living and work.
- Speech, Hearing, and Language Disorder Services: Therapy and treatment for individuals with communication disorders or hearing impairments.
- Dental Services: Preventive, diagnostic, and treatment services for oral health, including routine check-ups and emergency care.
- Vision Services: Coverage for eye exams, glasses, and treatment of vision impairments.
- Chiropractic Services: Care related to the spine and musculoskeletal system.
- Personal Care Services: Assistance with daily living activities for individuals who need help at home, such as bathing, dressing, and meal preparation.
- Case Management Services: Coordination of care for individuals with complex health needs, such as those with chronic illnesses or disabilities.
- Hospice Services: End-of-life care and support for individuals and their families.
- Prosthetics and Durable Medical Equipment: Coverage for medically necessary devices, such as wheelchairs, crutches, and prosthetics.
- Mental Health and Substance Abuse Treatment: Access to behavioral health services, including counseling and addiction treatment programs.
States can choose which optional services to provide based on their population’s needs and budget. It’s important to check with your state’s Medicaid office to learn more about the services available to you.
Navigating Medicaid Services
Understanding Medicaid’s mandatory and optional benefits can help you make informed decisions about your healthcare. Here are some tips to ensure quality care:
- Check Eligibility Requirements: Medicaid eligibility varies by state, so be sure to verify if you qualify based on your income, family size, and medical needs.
- Know Your Benefits: Familiarize yourself with both federal and state-specific benefits available to you. Ask your state Medicaid office for detailed information.
- Select a Primary Care Provider (PCP): Your PCP will be your main point of contact for healthcare services and can refer you to specialists when necessary.
- Ask Questions: Don’t hesitate to ask about services and benefits, including coverage for prescriptions, mental health, or transportation assistance.
- Review Your State’s Medicaid Handbook: Each state provides a Medicaid handbook detailing available services, eligibility, and provider networks. This resource can be invaluable for understanding your rights and benefits.
Medicaid services offer essential support to millions of Americans, providing access to healthcare that promotes better quality of life. By knowing your benefits and understanding how the program works, you can make the most of the coverage and services available to you.
