What is Medicaid | Everything You Need to Know About

What Does Medicaid Cover

Medicaid is a government-backed health insurance program designed for low-income families. It is a jointly funded Federal-State program offering benefits not typically covered by Medicare.

People with Medicaid insurance pay little or nothing to get all healthcare services. Everything you need to know about Medicaid health insurance, its eligibility, and the application process is given in this article.

Just take me to the Medicaid Coverage List

How Do States Determine Eligibility Criteria for Medicaid

Medicaid Health Insurance is a joint health insurance program with the federal and state governments. While Medicaid is a federal-state program, each state administers its program within federal guidelines, leading to variations in coverage and eligibility criteria across states. Health insurance helps people with low-income families who have limited resources to get access to healthcare services.

Medicaid was first launched in the 1960s and became legal in 1965. People often get confused between Medicaid and Medicare. Medicare is a different healthcare program designed for the elderly and disabled.

Since it’s a joint program of state and federal government, state governments receive funds from the federal government to distribute their services to eligible people. It is the largest healthcare program in the US.

Is Medicaid available for all

The Medicaid Program is not available for all US citizens. The program serves a specific group of people. The group of people who can apply for the Medicaid Health Insurance program is listed below:

• Low-income parents or caretaker relatives
• Children from low-income families
• Pregnant women in low-income households
• Low-income senior citizens (aged 65+)
• Children in foster care, and individuals with disabilities

Medicaid eligibility is determined both by federal guidelines and state-specific regulations. The program is available to certain low-income individuals and families, with eligibility criteria varying by state. The state government can expand coverage or restrict eligibility as it decides, within federal guidelines.

How do you get Medicaid Services

Medicaid payment models include Fee-for-Service, where providers are paid for each service; Managed Care, where organizations receive a fixed monthly payment per enrollee; and Alternative Payment Models, which may combine both aspects to encourage efficiency and quality of care. Here’s detailed information about the different ways in which one can get Medicaid Services.

1. Fee for Service

In this system, Medicaid providers are paid for the services offered to Medicaid enrollees. The fees for different healthcare services are based on the government’s maximum price per unit.

2. Alternative Payment Models

Under rate-based (alternative) payment models, providers receive pre-set payment rates (for example, a fixed amount per service bundle or time period) instead of billing per individual procedure. Providers can be reimbursed on different schedules (daily, monthly, quarterly, or annually) under these models, as determined by Medicaid program rules.

3. Managed Care

Managed Care providers through Medicaid are provided monthly capitation payments for each enrolled member.

What types of Services are Covered Under Medicaid

Mandatory benefits under Medicaid include, but are not limited to:

• hospital services,
• nursing facility services,
• home health services,
• physician services,
• rural health clinic services,
• family planning services.

States also have the option to cover additional services under Medicaid. In addition, you can get many other optional services through Medicaid Health Insurance. When a state offers optional services, they are often provided at little or no cost to Medicaid enrollees.

How to Apply for Medicaid

There are multiple ways you can apply for Medicaid health insurance. Individuals can apply for Medicaid through their state’s Medicaid agency or through the Health Insurance Marketplace. The application process can vary by state but generally involves submitting proof of income, residency, and other eligibility criteria. Or you can do the same online with the help of their website at Healthcare.gov.

The application process for Medicaid is simple. Anyone can do so by following three simple steps.

1. Fill out an application form with the details and personal information given.
2. A review of your financial condition to check your eligibility, as this program is for low-income families only.
3. A review of any other eligibility criteria (such as disability status, if applicable).

After completing these three steps, wait for the final decision notice, which may come by mail, phone, or email.

You can apply in person at a local Medicaid office. Just visit a local Medicaid or social services office and request the application form to register for the Medicaid program. The authorized person will help you fill out the application process and with all the other help you might need throughout the process.

On the other hand, you can visit the official website to get more information about the Medicaid program and, depending on your state, apply for it.

While applying for the Medicaid Application, you might need the following documents.

Make sure you have all the documents listed below in your hands to complete the application process faster.

• Proof of identification
• Proof of residency
• Social Security Number
• Proof of income
• Alien or immigration documents
• Bank statements, life insurance, property tax statements
• Proof of citizenship

You can get more information about the application process by visiting their official website.

Who is eligible for Medicaid Health Insurance

The eligibility criteria for each state are different. However, everyone must meet the criteria to complete the application process.

Applicants must be residents of the state where they apply for Medicaid. Eligibility criteria include being a low-income adult, child, pregnant woman, elderly adult, or a person with a disability, but specific eligibility thresholds vary by state.

Here’s the category of people who can apply for Medicaid Health Insurance.

• Eligible low-income adults
• Children
• Pregnant women
• People with disabilities

What Medicaid Usually Covers

Medicaid typically covers a broad range of essential health services for those who qualify. While specific benefits can vary by state, core services mandated by federal law are included in every Medicaid program. medicaid.gov medicaid.gov. In addition, most states opt to provide many optional benefits as well kff.org . Below is an overview of what Medicaid usually covers:

Hospital & Doctor Services: All state Medicaid programs cover inpatient and outpatient hospital care, as well as visits to primary care doctors and specialists. This includes hospital stays, emergency services, surgeries, and regular doctor check-ups goodrx.com. Medicaid enrollees receive medically necessary treatments from physicians, with the program footing the bill

Preventive & Child Healthcare: Medicaid emphasizes preventive care. Enrollees have access to immunizations, screenings, and routine preventive services at little to no cost. Children and adolescents get especially comprehensive coverage through EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) services, which ensure individuals under 21 receive all medically necessary care (from well-child exams and vaccinations to dental and vision care). kff.org In fact, Medicaid covers nearly half of all U.S. births and insures millions of children, reflecting its broad support for maternal and pediatric health.

Long-Term Care & Home Health: Unlike most private insurance, Medicaid is a primary payer for long-term care. It covers services in nursing facilities and may also fund in-home care or assisted living support for those who qualify. Many states offer Home and Community-Based Services (HCBS) waiver programs, allowing elderly or disabled enrollees to receive care at home or in community settings instead of institutions. Medicaid’s coverage of long-term services and supports (LTSS) is crucial, the program pays for over 60% of long-term care nationwide.

Prescription Drugs: Although classified as an “optional” benefit, all 50 states and D.C. cover outpatient prescription medications for Medicaid beneficiaries. grantsformedical.com. Medicaid plans include comprehensive drug formularies that encompass most FDA-approved drugs, from antibiotics and insulin to chronic condition medications. These prescriptions are provided either free or with a nominal co-pay, making medications affordable for low-income patients.

Mental Health & Substance Use Treatment: Medicaid provides robust coverage for behavioral health services. This means therapy sessions, mental health counseling, inpatient and outpatient substance use disorder treatment, and often psychiatric medications are covered, with specifics varying by state. All states must cover certain inpatient psychiatric care for those under 21, and many states also offer community-based mental health services. Medicaid has become a key source of care for mental health and addiction treatment, ensuring that such services are available to enrollees who need them.

Transportation to Medical Appointments: Uniquely, Medicaid usually covers non-emergency medical transportation (NEMT) for those who lack other means to get to healthcare appointments goodrx.com . This benefit can include reimbursement for mileage, rideshare services, or van programs that take patients to doctor’s offices, dialysis centers, pharmacies, and other medical facilities. Medicaid’s transportation assistance removes a common barrier to care, helping enrollees keep up with treatments and check-ups that they might otherwise miss due to lack of transport

What Medicaid Rarely Covers (Despite Claims)

Medicaid is generous in covering medically necessary treatments, but there are common misconceptions about services it will pay for. Some services are rarely, if ever, covered by Medicaid – even if you might hear claims to the contrary. If a service goes beyond essential healthcare or is deemed not medically necessary, Medicaid funding is usually off the table. Here are several things Medicaid almost never covers:

• Cosmetic or Elective Procedures: Medicaid will not pay for purely cosmetic surgeries or procedures done for aesthetic reasons. Nearly all elective cosmetic surgeries (e.g. tummy tucks, face lifts, cosmetic dental work) are excluded by Medicaid policy. Only in very rare cases – when a procedure that might be cosmetic (such as breast reconstruction after a mastectomy or surgery to correct a deformity from an accident) is medically necessary, might it be considered for coverage. Bottom line: if the primary purpose is cosmetic enhancement, Medicaid won’t cover it.
• Fertility Treatments: Infertility services and advanced reproductive treatments are almost never covered by Medicaid. This means procedures like in vitro fertilization (IVF), intrauterine insemination, fertility medications, or the costs of surrogacy are typically excluded. A few states have narrow exceptions (for example, New York Medicaid may cover certain fertility-preservation medications, and Illinois Medicaid covers egg or sperm preservation for specific medical conditions). However, by and large, Medicaid does not fund IVF or similar fertility treatments, considering them elective. Individuals seeking fertility services usually must look to other means or private insurance riders, as Medicaid won’t pick up the tab in most cases.
• Over-the-Counter Drugs and Alternative Therapies: Medicaid generally does not cover OTC medications, vitamins, or supplements, even if recommended by a doctor blogs.cornell.edu . For instance, non-prescription pain relievers, cold medicine, or herbal supplements would be out-of-pocket expenses. Likewise, alternative treatments lacking solid medical consensus, think homeopathic remedies, most herbal treatments, or naturopathic care – are not part of standard Medicaid benefits. Some complementary therapies like chiropractic adjustments or acupuncture might be covered in certain states under strict conditions (often only when a physician deems them medically necessary and they are provided by a licensed practitioner). But as a rule, if a treatment isn’t part of conventional evidence-based medicine, Medicaid will rarely cover it.
• Routine Adult Dental and Vision Services: Unlike children on Medicaid (who get comprehensive dental and vision care through EPSDT), adult beneficiaries often have limited or no coverage for routine dental and vision. Medicaid’s dental coverage for adults is optional and varies widely by state. Some states provide preventive and restorative dental care for adults on Medicaid, but others only cover emergencies or none at all. The same goes for vision: eyeglasses and routine eye exams for adults are not guaranteed (many states cover one pair of glasses after cataract surgery, for example, but won’t cover elective vision correction or new prescriptions annually). Always check your state’s policy, but be aware that claims of “free dental/vision for all Medicaid adults” are generally false. In reality, adult dental/vision benefits under Medicaid are limited and, in some states, virtually non-existent.
• Personal Comfort or Conveniences: Medicaid won’t cover services or upgrades that are mainly for personal comfort rather than medical necessity. For example, requests for a private hospital room, a special in-room television or phone service charge, or a “luxury” upgrade at a nursing facility will be denied as they aren’t medically required. Medicaid will pay for a semiprivate room in a hospital or nursing home, but if you choose to upgrade to a private suite, that cost difference is on you. Similarly, Medicaid doesn’t pay for things like hospital meal upgrades or concierge services. The program’s funds are strictly for healthcare essentials, anything optional or “nice to have” is outside Medicaid’s scope.

Services That Almost Always Get Denied

Even when you’re enrolled in Medicaid, certain types of requests and claims are virtually always denied by the program. Medicaid, like any insurer, has medical necessity rules and coverage limits. If a proposed service, item, or drug falls outside those rules, the claim will be rejected. Here are some scenarios where Medicaid will almost invariably say “no”:

• Experimental or Unapproved Treatments: Medicaid will not pay for treatments that are deemed experimental, investigational, or not FDA-approved. If a procedure or drug is still in clinical trial status or lacks solid evidence of effectiveness, it’s almost certain Medicaid won’t cover it. For example, a cutting-edge therapy that hasn’t passed FDA approval, or an off-label drug use that hasn’t been proven effective, will be declined. Medicaid funds are reserved for treatments that are established as safe and effective; anything considered “test” or “experimental” is nearly always denied.
• Services Lacking Medical Necessity: Any service that your Medicaid plan determines is not medically necessary will get denied grantsformedical.com . This can be a broad category – essentially, if your doctor cannot document that a service or item is required for your health, Medicaid won’t pay. Common examples include: frequent services without evidence of need, duplicate tests, or procedures that don’t fit your diagnosis. Medicaid requires proper documentation in your medical record to justify each service. If it’s not in the record or not aligned with accepted medical guidelines, the claim will be rejected. Always ensure your healthcare provider provides justification to Medicaid for any unusual or extensive services you need.
• Exceeding Coverage Limits: Medicaid plans often have quantity limits or frequency caps on certain services. For instance, a state Medicaid program might allow only a certain number of physical therapy sessions per year, a maximum number of inpatient hospital days, or a limit on how often a particular test can be done. If you try to get more of a service than your plan allows, those extra claims will almost always be denied unless you obtain prior authorization. For example, if your state caps adult dental cleanings at one per year, a second cleaning will be out-of-pocket. Or if there’s a 30-day limit per year on inpatient rehab and you need day 31, Medicaid typically won’t cover that day. It is possible to request exceptions or an override in some cases, but without that special approval, going beyond Medicaid’s set coverage scope results in denial.
• Medications or Equipment Not on the Approved List: Medicaid, like other insurers, uses formularies and approved equipment lists. If you submit a prescription for a drug that’s not on your state’s formulary (preferred drug list) or a brand-name medication when a generic is available, Medicaid may deny it or require prior authorization. The same goes for medical equipment and supplies: Medicaid covers many items (wheelchairs, diabetic supplies, etc.), but only certain models or price points. A claim for a higher-end or non-standard device might be refused if a cheaper medically equivalent option exists. In short, requests for non-covered drugs or deluxe medical gear will be turned down unless your provider can justify that no covered alternative works for you. Always consult your plan’s covered drug and equipment list; if it’s not on there, expect a denial or a paperwork battle to get approval.
• Non-Medical Expenses or Missed Appointments: Medicaid will not pay for anything that isn’t a health service. This includes things like fees for missed appointments, charges for copying medical records, or services purely for third-party requests (such as elective medical reports for legal cases). For example, if you miss a doctor’s appointment and the office tries to charge a no-show fee, that fee is your responsibility, Medicaid won’t cover it. Similarly, home modifications (like installing ramps or air conditioning) aren’t covered by standard Medicaid, unless you’re on a special waiver that specifically includes those for medical reasons blogs.cornell.edu. The guiding principle is that Medicaid only pays for direct care and medically necessary services. Any peripheral costs or non-healthcare expenses will be denied.

If You’re Looking For Cash Assistance, Stop Here

Medicaid is health insurance, not a cash grant. It does not provide money for rent, food, utilities, or other living expenses. Instead, Medicaid pays doctors, hospitals, pharmacies, and other providers directly for covered healthcare services you receive. If you need help with non-medical expenses or direct financial aid, programs like SNAP, TANF, or SSI are more appropriate. Medicaid’s role is limited to healthcare coverage — not income support or cash assistance.

Medicaid Coverage List

Final Words:

Medicaid is a government-backed health insurance program. Medicaid provides plenty of benefits to enrollees compared to the ones with private health insurance policies. The lower payment rates, no-cost healthcare services, and many other benefits make this program quite efficient for the needy.

Medicaid is designed to provide medical assistance to low-income individuals and families, ensuring access to essential healthcare services for those who qualify under state and federal guidelines. Check your eligibility criteria, get more information about the Medicaid program through your state’s Medicaid office or website, and apply for it to get its benefits. Medicaid is a must-have program for low-income families.

See Also

What Does Medicaid Not Cover

Alternatives to Medicaid

What is Emergency Medicaid