Medicaid Costs and Coverage

Figuring out what Medicaid covers and does not cover can be a concern for any beneficiary. Understanding your Medicaid coverage and the costs you might incur can help you plan your finances.

While there is a long list of benefits provided by all state Medicaid agencies, each state can also choose whether to offer additional services. You always need to confirm with your state agency as to whether or not your services are covered.

How much does Medicaid cost? Well, that depends. Some recipients will receive all medical services covered by Medicaid free, while others might need to pay a small fee. Any Medicaid cost is designed to be minimal as to not dissuade any beneficiary from receiving treatments. Preventative care is especially helpful in long-term health care, so ensuring that the costs of preventative care are covered or minimal ensures that more Medicaid beneficiaries pursue those regular services.

What does Medicaid cover?

Medicaid coverage includes a list of mandatory benefits outlined by the Centers for Medicare and Medicaid Services (CMS) that oversees the program on a national level. While there are different types of Medicaid insurance, the mandatory benefits must include all of the following medical services:

  • Inpatient and outpatient hospital services
  • EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services
  • Nursing Facility Services and home health services
  • Physician services
  • Rural health clinic services and federally-qualified health center services
  • Laboratory and X-ray services
  • Family planning, Nurse Midwife, and Certified Pediatric and Family Nurse Practitioner services
  • Freestanding Birth Center services (when licensed or otherwise recognized by the state)
  • Tobacco cessation counseling for pregnant women

Additionally, Medicaid coverage includes transportation to medical care, too. These mandatory benefits are offered by every state Medicaid agency, regardless of its status in having accepted the Medicaid expansion. Some states also choose to offer more services to their resident Medicaid beneficiaries.

Related Article: Becoming a Medicaid Beneficiary

The optional Medicaid benefits will vary and your specific enrollment might not include all of them. However, the following is a list of potential optional benefits covered by Medicaid:

  • Prescription Drugs
  • Physical and occupational therapy
  • Speech, hearing and language disorder services
  • Respiratory care services
  • Podiatry services
  • Optometry services and eyeglasses
  • Dental services and dentures
  • Prosthetics
  • Chiropractic services
  • Hospice care

Your Medicaid coverage may or may not include all or some of the above optional benefits. Always be sure to confirm with your state Medicaid agency as to whether or not certain services are included. You should also always make sure to ask about Medicaid acceptance when you are booking an appointment with any new medical provider.

Optional covered Medicaid services include more mental health services now than ever before. In fact, Medicaid is the single largest payer of mental health services in the entire country. If you are in need of mental health care, be sure to confirm with your state Medicaid agency regarding your options. There are particular services that might be available near you, but be sure to confirm costs and coverage first before you book an appointment.

What does Medicaid not cover?

When figuring out what Medicaid does not cover, the easiest solution is to look through the list of benefits that are covered to see if what you need is included or not. The list of mandatory covered Medicaid services above is comprehensive, so if your service is not listed it might not be covered. However, you must remember to confirm with your own state Medicaid agency.

Each state can choose which optional Medicaid coverage to offer to beneficiaries, so you will want to check on any particular services you need before making any appointments. When in doubt, always ask your state agency for confirmation and clarification. You should also make sure to clarify any conditions of your potential coverage, such as the frequency of appointments you can make for screenings like dental or vision, or even for regular physician’s appointments. Certain types of services might be covered, but only up to a certain amount or a certain number of visits per year.

Also, confirm any potential Medicaid costs involved and make sure you understand which providers accept your Medicaid insurance. You should also double-check the year that your state Medicaid agency uses, since some use a calendar year, which is January through December, while others might have a fiscal year that differs. For example, a state’s Medicaid coverage year might be July 1st through June 30th. Be sure to confirm when you receive your benefits and always stay updated on any changes to your coverage.

Generally, Medicaid coverage does not include cosmetic procedures or other appointments or procedures that are not deemed to be medically necessary. Each state can determine its own parameters for what is considered to be medically necessary or not, though, so be sure to confirm with both your medical providers and with your state Medicaid agency before booking anything.

Is Medicaid free?

How much is Medicaid? That is a common question among potential beneficiaries. Medicaid coverage varies based on your eligibility and on your state Medicaid agency’s specific programs. Some Medicaid recipients will not pay anything at all, while others might be required to pay a small co-payment when medical services are received. Generally, Medicaid beneficiaries do not need to pay any monthly fees to maintain health care coverage, while private insurance holders do.

There is no Medicaid fee schedule like there is for the Medicare program, but rather you will have to confirm with your state Medicaid agency regarding any fees associated with any medical services you need. Always be sure to confirm with your state agency for any new services you might need and then also make sure to confirm with the medical provider regarding any fees that might be charged. If your state has a list of Medicaid providers, you should ask for a copy for your own reference whenever you need new medical services.

Related Article: What is Medicaid?

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