What Does Medicaid Cover?

What is Medicaid? What does Medicaid cover? Read this article to find out.

Established in 1965, Medicaid is a public insurance program that offers health coverage to families that have a low income and other people, including kids, parents, pregnant women, senior citizens, and individuals with disabilities. Moreover, it is subsidized mutually by the federal government and the states. Each state works its own Medicaid program in accordance with the rules set up by the government. Since the government rules are extensive, states have a lot of adaptability in planning and controlling their programs. Accordingly, Medicaid qualification and advantages can and frequently fluctuate from one state to another.


As of November 2020, Medicaid has provided insurance for more than 72 million Americans from birth through to 65 years of age and more. Given the extent of its coverage base, it’s not shocking that the framework is extraordinarily perplexing, and the guidelines might be confusing in case you’re considering nursing home placement and are simultaneously exploring significant long-term care choices.


Furthermore, Medicaid is an incredible option for senior citizens. It gives broad and extensive coverage as an independent item, and it works together in a coordinated manner with Medicare to assist older adults in dealing with their medical services and long-term care costs. In many states, it permits seniors to get services that are covered. This typically happens in a setting that they decide, and not simply in private institutions. Moreover, in any case, it’s difficult to understand how the program functions, what it covers, and who qualifies, particularly since prerequisites fluctuate by state and contrast on the basis of a candidate’s clinical requirements and monetary circumstances.


In this article, we’ll clarify Medicaid in essential terms to assist you with understanding the program, find out about qualification necessities and see what does Medicaid cover. We will likely leave you with a strong comprehension of what Medicaid is and how it can help you or a friend or family member.

Table of contents

What is Medicaid?

Understanding Medicaid?

How does Medicaid work?

What does Medicaid cover?

What does Medicaid not cover?

Does Medicaid cover dental care?

Who is eligible for Medicaid?

How to apply for Medicaid?

Is Medicaid free?

How much does Medicaid cost?

How did the Affordable Care Act change Medicaid?

How effective is Medicaid?


What is Medicaid?

Medicaid is a term that alludes to the public health care coverage program that gives medical insurance to families with a low income and people in the United States. The program is mutually financed by the national government and individual states. In addition to this, Medicaid operates at the state level which implies that coverage and management fluctuate significantly from one state to another.


Remember that Medicaid is just accessible to people and families who meet certain income-based measures. In 2013, the Affordable Care Act expanded Medicaid eligibility criteria to adults acquiring up to 138% of the Federal Poverty Level (FPL). This is valid in many states, despite the fact that income limits can fluctuate. States with the maximum Medicaid enrollment include:


  • California (10,860,126)
  • New York (5,863,440)
  • Texas (4,034,937)
  • Georgia (3,805,520)
  • Pennsylvania (2,980,867)


Perhaps the most befuddling thing about this system is that there isn’t just one kind of Medicaid. Most states have a few Medicaid programs that aim at certain populaces. Notwithstanding customary Medicaid, which provides services to adults with low incomes, there’s a poverty-level program for the Blind, Aged, or Disabled.


In addition to this, Institutional Medicaid is one of the more important programs for older adults. It is a significant source of long-term care financing. This program covers over 60% of the country’s nursing home occupants. Moreover, Medicaid also pays for over half of long-term care claims. Thus, making this program a significant fraction of the federal budget, together with the medical care industry and the country’s economy.


Furthermore, Medicaid pays for the care given in nursing homes. This is significant in light of the fact that it just pays for 100 days of skilled nursing for every coverage period. It additionally provides coverage for in-home care and personal help through Home-and Community-Based Services waivers. These additional items permit states to offer extra advantages, insofar as they’re compliant with the government rules.

Understanding Medicaid

Approved by President Lyndon B. Johnson and Title XIX of the Social Security Act, Medicaid was endorsed into law in 1965. It is a government-supported insurance program for people of all ages who do not have enough assets or earn enough salary to cover medical services. All things considered, it provides coverage for their PCP visits, hospital stays, long-term clinical care, custodial care, and other health-related expenses.


Individual states select who is eligible for coverage, the sort of coverage, and the way toward paying health care workers and clinics. That is on the grounds that each state is liable to oversee and regulate its own Medicaid program. The federal government matches state spending and the matching rate changes according to the state you are in from about a legal minimum of 50% to a maximum of 83%. Even though all states take part in Medicare, they are not required to do so.


The program is the biggest source of financing medical services for those with a low income in the U.S. In 2019, the entire Medicaid spending was almost $613.5 billion, representing 16% of the country’s medical care bill. The federal government took care of 64.5% of the bill while individual states paid 35.6%. Moreover, Medicaid commonly provides coverage to the accompanying groups:


  • Adults over the age of 65
  • People with disabilities
  • Pregnant women
  • Low-income children and their parents


In addition to this, Medicaid qualification was extended to incorporate adults who were younger than 65 years old, given that their salaries fell under 133% of the federal poverty level, according to the Patient Protection and Affordable Care Act. Moreover, kids represent 38% of enrollees with about 18% of the entire expense. By correlation, individuals with disabilities represent 14% of enrollees with about 36% of the complete expenses.

How does Medicaid work?

Let us assume that you need the Medicaid benefits, such as long-term care waivers, the initial step is to apply for coverage. You can finish this procedure through either the Healthcare Marketplace or your state’s Medicaid office. Furthermore, applications are normally prepared by the Department of Human Services or a similar division.


Remember that in order to fit the bill for Medicaid, you should meet certain monetary and clinical qualification prerequisites. Moreover, there are asset and salary limits, and for certain advantages, candidates should get a nursing facility level of care (NFLOC), as found out by evaluating their health and capacity to perform ordinary errands.


Since Medicaid is for people who have restricted assets and broad clinical requirements, by and large, there are no expenses or deductibles. In any case, a few states have share-of-cost prerequisites that are normally dependent on your salary. Moreover, together with long-term services and support, you’ll also get primary and emergency clinical care when your coverage is set up. In certain states, Medicaid is directed by the federal authorities, and different states have managed care associations that are regulated by private back up plans. This sort of coverage gives you admittance to Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) networks that will be recognizable in the event that you’ve had different kinds of insurance.


A pleasant aspect concerning Medicaid is that in case you’re a dual enrollee, it can deal with your Medicare copays or coinsurance. In addition to this, it also deals with any other charges that aren’t your main insurance organization does not take care of. Medicaid may likewise pay for physician recommended meds that aren’t covered by your Part D prescription drug coverage or Advantage Plan. As per the government Medicaid guidelines, this sort of coverage is discretionary. However, all states offer it, and it practically covers all FDA-endorsed prescriptions, which the program buys at cost, because of discounts and unique concurrences with drug stores.

What does Medicaid cover?

Medicaid covers a ton of similar clinical benefits that a customary health care coverage plan would. Hospital care and visits to the doctor are paid for with low or no copays for both adults and children. Although states decide their own Medicaid benefits, they are needed to cover certain services. Health care services that Medicaid provides coverage for are:


  • Emergency care.
  • Preventive-care services for children.
  • Family planning.
  • Pregnancy-related services, including help in quitting tobacco.
  • Several other services for children under 18 years of age, except if they are in higher-earning households.


The Medicaid benefits given below are needed in all states. However, they may come with a copay, on the basis of where you live:


  • Physician visits.
  • Inpatient and outpatient hospital services.
  • Selected preventive care known as EPSDT: early and periodic screening, diagnostic, and treatment services.
  • Laboratory tests.
  • Home health services.
  • Rural health clinics.
  • X-rays.
  • Nurse midwife and freestanding birth center services.
  • Nursing facility care.
  • Certified pediatric and family nurse practitioners.
  • Transportation to medical care.


In some cases, your primary care physician should demonstrate to the state that your care is essential to get Medicaid to pay. This is classified as “prior authorization,” and it’s a strategy utilized by a wide range of health insurance organizations to diminish inefficient spending on specific administrations.


All states offer dental advantages to kids under Medicaid, and most states also do this for adults. As per a June 2015 government report, Medicaid programs in 27 states offer preventive dental administrations for adults and 26 states cover remedial services like cavity fillings. In addition to this, 19 states only cover emergency dental care for adults with Medicaid. Most states pay for eye tests and glasses.

What does Medicaid not cover?

Despite the fact that Medicaid will pay for certain administrations that aren’t covered by Medicare, the program has some coverage rejections. Most things that aren’t covered can be categorized as one of four classes:


  • The particular service or test isn’t covered
  • The services are unreasonable or medically unnecessary
  • Providers were reimbursed through another program
  • Charges were improperly bundled or billed through another allowance


Medicaid will not pay for clinical consideration given outside of the United States, unless in certain travel-related circumstances or when an unfamiliar hospital is nearer than your local hospital. Furthermore, Medicaid won’t pay for:


  • Free health screenings or devices that are given away
  • Durable medical equipment replaced through a warranty
  • Health care services provided by another government agency
  • Personal comfort items, such as TVs and beautician services
  • Cosmetic surgery and any resulting complications

Does Medicaid cover dental care?

Dental administrations are a necessary help for most Medicaid-qualified people younger than 21, as a necessary segment of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) advantage.

Individuals below 21 years of age

EPSDT is Medicaid’s extensive child healthcare program. The program’s emphasis is on early diagnosis, prevention, and therapy of ailments. EPSDT is an obligatory help needed to be given under a state’s Medicaid program.


Moreover, dental services should be given at intermissions that satisfy sensible guidelines of the dental practice. This should be in compliance with what the state has decided after meeting with perceived dental associations engaged with youngster wellbeing, and at such different spans, as demonstrated by clinical need, to decide the presence of a speculated ailment or condition. Administrations should incorporate at the very least, pain relief and curing diseases, restoration of teeth, and support of dental wellbeing. Dental administrations may not be restricted to emergency services for EPSDT beneficiaries.


Oral screening might be essential for an actual test. However, it doesn’t fill in for a dental assessment performed by a dental specialist because of an immediate referral to a dental specialist. An immediate dental reference is needed for each kid as per the periodicity plan set by the state. The Centers for Medicare and Medicaid Services doesn’t further state what dental services should be given. In any case, EPSDT necessitates that all services covered under the Medicaid program should be given to EPSDT recipients if it is clinically fundamental. Under the Medicaid program, the state decides clinical needs.


In the event that a condition requiring treatment is found during a screening, the state should offer the vital types of assistance to treat that condition, regardless of whether such administrations are remembered for the state’s Medicaid plan.

Individuals who are 21 years old and more

States might choose to offer dental types of assistance to their adult populace that is qualified for Medicaid or, choose not to offer dental types of assistance by any means, as a feature of its Medicaid program. While most states essentially give emergency dental services for adults, less than 50% of the states give extensive dental consideration. There are no base prerequisites for adult dental coverage.

Who is eligible for Medicaid?

Medicaid is a program where any individual who meets the qualification rules has an option to join up with Medicaid coverage. It likewise implies that states have ensured government monetary help for part of the expense of their Medicaid programs. To get government subsidizing, states should cover certain “compulsory” populaces:


  • children through age 18 in families with income below 138 percent of the federal poverty line ($29,974 for a family of three in 2020);
  • people who are pregnant and have income below 138 percent of the poverty line;
  • certain parents or caretakers with very low income; and
  • most seniors and people with disabilities who receive cash assistance through the Supplemental Security Income (SSI) program.


States may likewise get government Medicaid assets to cover “discretionary” populaces. These consist of individuals in the groups recorded earlier whose salary surpasses the cutoff points for “compulsory” coverage; seniors and individuals with disabilities not getting SSI and with a salary under the poverty line; “clinically needy” individuals, and others with higher pay who need long-term administrations and supports; and — because of the Affordable Care Act (ACA) — non-impaired adults with a salary that falls below 138% of the poverty line, including those without kids. The ACA was planned to stretch out coverage to every such adult, however, a 2012 Supreme Court choice gave states the decision of whether they wanted to extend their projects or not.


Moreover, not all individuals with low livelihoods are qualified for Medicaid. In the 15 states that have not executed the ACA Medicaid extension (as of April 2020), adults who are more than 21 years old are for the most part ineligible for Medicaid regardless of how low their wages are except if they are pregnant, really focusing on kids, old, or have a disability. Furthermore, in the run-of-the-mill non-development state, even guardians are ineligible if their pay surpasses only 42% of the poverty line ($9,122 for a group of three).


In addition to this, many individuals who are not U.S. residents are ineligible for Medicaid in spite of having a legitimate immigration status. This group incorporates individuals with temporary insured status whom the national government has permitted to live in the country for helpful reasons and individuals allowed brief authorization to go to the United States for study purposes, travel, or work. Additionally, permanent legal inhabitants (frequently alluded to as green card holders) can’t try out Medicaid for the initial five years, regardless of whether they meet all qualification necessities or not.

How to apply for Medicaid?

You can apply for Medicaid whenever you want to. This means that you don’t need to wait for an open enlistment period. In the event that you think clinical costs might qualify you for Medicaid, you can apply to discover. In addition to this, you can also apply for Medicaid regardless of whether you presently have health care coverage or not. Remember that you will not be punished for exchanging plans outside of open enlistment. On the off chance that you do presently have insurance and are considered qualified for Medicaid, ensure that you stop your current wellbeing plan. If you think you earn more money than what is required to meet all requirements for Medicaid, yet your salary is close to the qualification levels, there are three valid justifications to apply in any case:


  • You may still gain coverage if you have a lot of medical bills.
  • If you have children, your application doubles as a CHIP application for them.
  • Your state’s Medicaid office can help find other health insurance solutions for you.


You can apply for Medicaid either through the Affordable Care Act marketplace or with the help of your state’s Medicaid office. Moreover, after you have applied, you will get more information on what to expect and how to use your Medicaid advantages.

Is Medicaid free?

Indeed, Medicaid is normally free. In spite of the fact that states are allowed to require a portion of the expense, there are typically no charges, deductibles, or copays with Medicaid since this program is proposed for low-income families and people with extremely high hospital expenses. Cost-sharing might be needed for some higher-income target groups, and you might have cash-based costs while asking for certain medications from famous brands. On the off chance that you fit the bill for Medicare, Medicaid might even get some abundance charges.

How much does Medicaid cost?

Each state has the choice of setting expenses, deductibles, and cash-based expenses for some Medicaid recipients. Higher workers with Medicaid, which means those with earnings at or above 150% of the poverty level, may pay more for the accompanying wellbeing administrations:


  • For solutions, states might charge coinsurance of 20% of each medication’s expense to support the utilization of cheaper medications.
  • On the off chance that individuals in this group utilize the emergency center in a non-crisis circumstance, they could likewise be charged to the maximum for care. For this situation, the medical clinic’s doctors should decide if the visit was a crisis.


Some higher workers could likewise pay little month-to-month expenses for Medicaid. For instance, kids in California with families procuring 160% to 266% of the federal poverty level compensate for a month-to-month premium of $13 per child. Working individuals with disabilities in California can procure up to 250% of the federal poverty level and still get full-scope Medi-Cal by paying a low month-to-month premium dependent on countable pay.

How did the Affordable Care Act change Medicaid?

Medicaid assumes a considerably more significant part in giving insurance to low-income Americans because of the Affordable Care Act. As noticed, the ACA gives coverage to the poor and adults with a low salary by extending qualification for Medicaid to 138 percent of the poverty line. As of April 2020, 35 states in addition to the District of Columbia have executed the Medicaid extension to serve poor and low-pay adults. Moreover, by 2029, 14 million more adults with a low income will have tried out Medicaid and accessed reasonable far-reaching health coverage because of the ACA.


The expansion is an excellent monetary arrangement for states. In the wake of getting all expansion costs for the initial three years, the federal government presently pays 90% of development costs on a lasting premise. Also, by enormously decreasing the quantity of uninsured, the expansion will save states and regions generous aggregates on uncompensated care for the uninsured. Moreover, a few of the expansion states have additionally experienced savings in mental health programs, criminal equity frameworks, and other spending regions.

How effective Is Medicaid?

Medicaid is extremely successful in giving health care coverage to the poor and needy. Since the ACA’s significant coverage expansions produced results in 2014, Medicaid has assisted with decreasing the quantity of uninsured from 45 million to 29 million. In the event that Medicaid didn’t exist, the greater part of Medicaid enrollees would be uninsured. This is on the grounds that private health care coverage is for the most part impossible for Medicaid recipients: some low-pay workers don’t approach coverage for themselves and their families through their positions and can’t stand to buy coverage in the individual market.


Medicaid is likewise successful in further enhancing access to care, supporting monetary dependability among low-pay families, and further developing health results. Probably the clearest proof comes from the ACA expansion of Medicaid coverage to adults with a low salary, which gives a new “normal test,” allowing analysts to look at results in states that did and did not embrace the development.


Medicaid coverage likewise has long-term benefits for kids. Children with Medicaid improve in school and miss fewer school days because of sickness or injury, research shows. They are likewise bound to complete secondary school, go to school, and graduate from school; they procure more like adults, and they experience fewer trauma center visits and hospitalizations.


Now that you have read this article, you know all about what does Medicaid cover. Medicaid gives a wide degree of health care coverage, including visits to the doctor, clinic costs, nursing home care, home medical care, and so forth. Medicaid additionally takes care of long haul care costs, both in a nursing home and at-home consideration. Moreover, prescription drugs are not covered by Medicaid. However, in case you’re qualified for Medicaid, the program might pay the charge for Medicare Part D, the Medicare prescription drug plan.

Tony Bennett

Tony Bennett

Tony Benett makes his living in the insurance industry by teaching and consulting. He is also recognized by the legal profession as an expert on insurance coverages. His insurance experience includes having worked at the company level, owned an independent general agency and having worked for an insurance association. He has received various certificates over the past few years and helps his clients and readers by giving them a realistic outlook on what they can expect to achieve within their set targets. At Insurance Noon, he is known for his in-depth analysis and attention to details with accuracy. He has been published as one of the most referred agents by his peers in the insurance community. Tony loves the outdoors and most sport events. His passion other than providing excellent advice is playing golf.

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