What Does Medicaid Not Cover?

21 Services Medicaid Doesn’t Cover

Under the Medicaid program, US states are required to cover mandatory benefits and can choose whether to cover optional benefits. Benefits must be sufficient in amount, duration, and scope to reasonably achieve their purpose.

Medicaid benefits must be consistent across the state. Subscribers must also be free to choose from the list of healthcare providers or accomplished care programs in Medicaid.

The extent of coverage (scope and quantity) varies by state. For instance, a state can cap the number of annual inpatient clinic days subscribers can receive. In contrast, another state may opt to have unlimited 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 a major public health insurance program in the United States for low-income individuals and families. 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. Without this program, many Medicaid enrollees would not have access to affordable health care. Medicaid pays for various health services, meaning enrollees don’t pay out-of-pocket for most health services.

Medicaid spending accounts for nearly a fifth of all personal health care spending in the US. This provides adequate financing for hospices, community health centers, nursing homes, clinics, hospitals, and healthcare professionals.

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. Medicaid applications are typically processed by the state’s Medicaid agency or the Department of Human Services.

You must meet specific medical and financial qualification requirements to qualify for Medicaid. In addition, there are revenue and asset restrictions.

For some benefits, applicants must meet a nursing facility level of care determined by a functional needs assessment.

Since Medicaid is meant for persons with low incomes or widespread medical needs, there are usually no payments or deductibles.

However, some States include share-of-cost, typically based on your salary. Once your coverage has been confirmed, you can also access primary and alternative medical care and long-term services.

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 encountered 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.

Prescription drug coverage is an optional Medicaid benefit, but all states currently provide it. It covers most 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:

  1. Kids from low-income households
  2. Kids in foster care
  3. Persons with disabilities
  4. Pregnant women with small incomes
  5. Senior citizens with small incomes
  6. 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 Services Are 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:

  1. Services deemed by the peer review organization, DHS, Dental, or Optometric specialist are not clinically essential.
  2. Services provided by direct relatives or members of the beneficiary’s home.
  3. Home remedies, nutritional supplements, vitamins, alcoholic beverages, and over-the-counter medication are prohibited unless a physician has approved them.
  4. Missed appointments.
  5. Custodial care.
  6. Medical supplies and gear for patients in a nursing establishment, such as a swing bed.
  7. Health services for persons over 21 years and under 65 in public and state hospitals or mental health institutions.
  8. Health services that aren’t outlined by the beneficiary’s medical record.
  9. The US DHHS (Department of Health and Human Services) or any other federal agency deems services, procedures, or medications to be in their trial phase.
  10. Medications that the federal government deems to be less than adequate (desi drugs).
  11. Cosmetic surgery is intended for beautification, such as liposuction, tummy tucks, and body contouring surgeries, rather than for repairs following an accidental injury. See also Cosmetic Surgery Grants
  12. Surgeries for embryo implantation.
  13. Surgeries for sterilization reversal.
  14. Postmortems (autopsies).
  15. Reports are needed for legal purposes or other 3rd party insurance coverage.
  16. Recordkeeping, logging, or documents related to providing a covered service.
  17. Counseling services, vocational training, or educational activities.
  18. Self-help devices, protective outwear, and exercise gear.
  19. Payment is required to reserve beds in nursing facilities such as ICR/MR or swing beds unless it is a specific provision by the department.
  20. Payment is for a private ward in a primary care or nursing facility.
  21. Computers or computer peripheral devices except for assistive communication gear.

Final Thought

Medicaid provides all-inclusive medical coverage for millions of Americans across all the states, most 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.

See Also

Does Medicaid Cover Cataract Surgery

Does Medicaid Cover Braces

Does Medicare Cover Hearing Aids

Current Version
September 1, 2021
Written By
Shubham Grover
April 14, 2024
Updated By
Andrea Morales G.

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