What Does Medicaid Not Cover? – Overview
Under the Medicaid program, US states are forced to cover mandatory benefits and they decide whether or not to cover optional benefits. Benefits must be equal to the quantity, interval, and range of the subscribers (the compatibility rule).
Benefits must also be similar across a state (the state wideness rule). The subscribers must also be given the freedom to pick from the list of healthcare providers or accomplished care programs partaking in Medicaid.
The extent of coverage (scope and quantity) varies by state. For instance, a state can cap the number of inpatient clinic days a subscriber can receive per annum. In contrast, another state may opt to have an unlimited number of inpatient clinic days.
For kids, EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) provisions cap the extent to which states can use criteria other than a necessity for included benefits. For adults, states cap the range of a covered benefit by stating the necessity criterion, length and quantity.
What is Medicaid?
Medicaid is America’s number one public health insurance plan which helps persons or families with low incomes. It also provides much-needed help to persons who need long-term care. Medicaid covers 1 in 5 Americans, including many who have complex and expensive needs.
Medicaid is the main source of long-term care insurance for Americans. The vast majority of Medicaid subscribers don’t have access to affordable health. Medicaid pays for a wide variety of health services which means enrollees don’t pay for most health services out-of-pocket.
Medicaid payouts account for virtually a fifth of all personal healthcare expenditures in the US. This provides adequate financing for hospices, community health centers, nursing homes, clinics, hospitals, and professions in the healthcare sector.
How Does Medicaid Work?
If you want to enjoy Medicaid’s benefits, including health care waivers, start by applying for coverage. You can conclude this process in your State’s Medicaid office. All applications usually are handled by the DHS (Department of Human Services) or a similar agency.
To qualify for Medicaid, you must meet specific medical and financial qualification requirements. In addition, there are revenue and asset restrictions.
For some benefits, candidates must have an NFLOC (nursing facility level of care) as determined by a practical needs assessment that rates their well-being and their ability to perform everyday tasks.
Since Medicaid is meant for persons with low incomes and or widespread medical needs, there are no payments or deductibles in most cases.
However, some States include share-of-cost, which is typically based on your salary. Once your coverage has been confirmed, you’ll have access to primary and alternative medical care and long-term services as well.
In some states, Medicaid is provided by the State government, and in others, Medicaid is provided by care organizations that private firms handle.
This kind of coverage gives you access to PPO (Preferred Provider Organization) or HMO (Health Maintenance Organization) networks which you’ll have come across if you’ve had private insurance before.
One of the best things about Medicaid is that if you’re a dual subscriber (Medicare and Medicaid), your Medicare copayments and coinsurance will be taken care of, as well as any expenses that aren’t settled by your primary insurance.
Medicaid can also pay for prescription medications not paid for by your Medicare Advantage plan.
According to federal Medicaid laws, this kind of coverage is optional. Still, all states should offer it, and it pays for nearly all FDA-approved drugs, which the plan buys at a discount thanks to special agreements and rebates with pharmacies across the US.
Who qualifies for Medicaid coverage?
Medicaid plans are meant for certain groups of people, such as:
- Kids from low-income households
- Kids in foster care
- Persons with disabilities
- Pregnant women with small incomes
- Senior citizens with small incomes
- Parents or guardians with small incomes
Note that states can decide to expand Medicaid eligibility to other groups of people, for instance, persons with low incomes who may or may not have families.
Which Are the Services Not Covered Under Medicaid’s Program?
There are services and items that Medicaid doesn’t pay for. However, if the service or item is deemed necessary by your primary care physician, then Medicaid will pay for it. Some of the items and services that Medicaid does not cover include:
- Services that have been deemed by the peer review organization, DHS, Dental, or Optometric specialist not to be clinically essential.
- Services that are provided by direct relatives or members of the beneficiary’s home.
- Home remedies, nutritional supplements, vitamins, alcoholic beverages, or over-the-counter medication except if a physician approved the items.
- Missed appointments.
- Custodial care.
- Medical supplies and gear for a patient in a nursing establishment such as a swing bed.
- Health services for persons over 21 years and under 65 years in public and state hospitals or even mental health institutions.
- Health services that aren’t outlined by the beneficiary’s medical record.
- Services, procedures, or medications are deemed to be in their trial phase by the US DHHS (Department of Health and Human Services) or any other federal agency.
- Medications that the federal government deems to be less than adequate (desi drugs).
- Cosmetic surgery is intended for beautification purposes rather than repairs following an accidental injury. See also Cosmetic Surgery Grants
- Surgeries for embryo implantation.
- Surgeries for sterilization reversal.
- Postmortems (autopsies).
- Reports needed for legal purposes or other 3rd party insurance covers.
- Recordkeeping, logging, or documents related to the provision of a covered service.
- Counseling services, vocational training, or educational activities.
- Self-help devices, protective outwear, and exercise gear.
- Payment to reserve beds in nursing facilities such as ICR/MR or swing beds unless its a specific provision by the department.
- Payment for a private ward in primary care or nursing facility.
- Computers or computer peripheral devices except for assistive communication gear.
Medicaid provides all-inclusive medical coverage for millions of Americans across all the states, most of whom are working families.
Despite their small incomes, Medicaid recipients can access healthcare rates similar to those offered to others in private insurance.
As illustrated above, there are some services Medicaid won’t cover because of limits by federal and state laws.
I am a dedicated healthcare researcher and an enthusiast specializing in medical grants, medical education and research. Through my articles, I aim to empower healthcare professionals and researchers with valuable insights and resources to navigate these critical aspects effectively.