Discover the services that Medicaid will pay for and how to access them, empowering seniors nationwide.
April 8, 2024
To understand the services that Medicaid will pay for, it's crucial to first have a comprehensive understanding of what Medicaid is and who it serves.
Medicaid is a jointly funded federal and state program that provides comprehensive coverage of health care and long-term services and supports to more than 90 million low-income people in the United States [1].
The program covers a broad range of health and long-term care services that are often not covered by other payers. These include prescription drugs, physical therapy, eyeglasses, dental care, non-emergency medical transportation, nursing home care, and home and community-based services.
Moreover, Medicaid covers doctor visits, hospital stays, long-term medical care, custodial care, and other health-related costs for individuals with insufficient resources and income in the United States. Rather than providing health care directly to individuals, the program covers these various health care services [3].
Individuals and families that meet specific income-based criteria are eligible for Medicaid. This includes U.S. citizens, permanent residents, or legal immigrants [3].
As of September 2020, approximately 70.6 million people were covered by Medicaid. The Medicaid coverage includes adults under the age of 65 with incomes under 133% of the federal poverty level (FPL) as per the Patient Protection and Affordable Care Act. Children make up 38% of enrollees with about 18% of the total cost, while people with disabilities constitute 14% of enrollees with about 36% of total costs.
To summarize, Medicaid serves as a lifeline for many low-income individuals and families, offering them access to essential health and long-term care services. The eligibility criteria for Medicaid ensures that the program aids those who need it the most, offering them a chance to lead healthier lives.
Understanding the range of services that Medicaid will pay for is essential for individuals seeking to maximize their healthcare benefits. Medicaid offers a broad scope of coverage, encompassing both mandatory and optional benefits.
Mandatory benefits refer to the set of services that all Medicaid programs must cover. These typically include inpatient and outpatient hospital services, physician services, laboratory and x-ray services, and home health services, among others, as stated by Medicaid.gov.
Medicaid also covers services that are considered medically necessary such as doctor visits, hospital care, and prescriptions [4].
Below is a table summarizing some of the mandatory benefits provided under Medicaid:
In addition to mandatory benefits, Medicaid also provides optional benefits that states can choose to include in their Medicaid programs. These cover a wider range of services, but states have the discretion to limit the types of services covered, such as prescription medications, dental care, or physical therapy.
Optional benefits may also encompass services related to enhancing the accessibility and readability of health information, such as creating and highlighting code blocks, sharing code samples, and enabling syntax highlighting.
The following table provides an overview of some optional benefits that may be included in state Medicaid programs:
It's important for Medicaid beneficiaries to understand the extent of their coverage and the services that Medicaid will pay for, to ensure they are receiving all the benefits they are eligible for.
Medicaid's role in managing healthcare costs extends to prescription drugs. In this section, we'll delve into how Medicaid covers prescription drugs and the Medicaid Drug Rebate Program.
Prescription drugs are considered an optional benefit under federal Medicaid laws, meaning states have the discretion to include this coverage or not. However, currently, all states provide coverage for outpatient prescription drugs to all categorically eligible individuals and most other enrollees within their state Medicaid programs. Medicaid will pay for services that are medically necessary such as prescriptions, ensuring access to necessary medication for eligible individuals.
The Medicaid Drug Rebate Program is a significant aspect of Medicaid's role in prescription drugs. This program allows states to receive a rebate for each prescription dispensed to Medicaid beneficiaries. The objective of this program is to offset the cost of prescription drugs, making them more affordable for Medicaid beneficiaries.
The rebate program operates by receiving a rebate from the drug manufacturer for each unit of medication dispensed. The amount of the rebate varies depending on the type of drug and the manufacturer's pricing policies. This program helps to ensure that Medicaid beneficiaries have access to affordable medication, which is a crucial part of maintaining good health.
In summary, Medicaid plays a significant role in prescription drugs by providing coverage and managing costs through the Medicaid Drug Rebate Program. These services that Medicaid will pay for help to ensure that beneficiaries have access to the medication they need. By understanding these aspects of Medicaid, beneficiaries can make the most of the benefits available to them.
Medicaid plays a crucial role in providing healthcare access to specific populations. It offers a broad range of services, including coverage for low-income Medicare beneficiaries and services not covered by Medicare [7].
Medicaid is vital for certain populations, such as children and adults both with and without disabilities. It covers 41% of all births in the United States, nearly half of children with special health care needs, and one in six adults. It is particularly significant for Black, Hispanic, and American Indian American Native (AIAN) children and adults, covering a higher share compared to White children and adults.
Medicaid is also a lifeline for individuals with disabilities. It provides coverage for 23% of non-elderly adults with any mental illness and 40% of non-elderly adults with HIV. Medicaid is particularly essential for individuals needing long-term care services and supports, covering more than 60 percent of all nursing home residents and roughly 50 percent of costs [9].
Understanding the specific services that Medicaid will pay for, particularly for these population groups, is essential in maximizing the benefit this program provides. It is also crucial to stay informed about any changes in Medicaid coverage to ensure that eligible individuals continue to receive the healthcare services they need.
Medicaid plays a significant role in the healthcare landscape of the United States. It impacts access to care, health outcomes, and provides long-term coverage for many vulnerable populations. Understanding these impacts is crucial to fully comprehend the importance of Medicaid.
Medicaid facilitates access to care and has been associated with improved health outcomes. Research shows that Medicaid beneficiaries have better access to care than uninsured individuals. They are less likely to postpone or forgo necessary care due to cost. Moreover, Medicaid eligibility during childhood is associated with positive effects on health and improved long-term educational attainment. Expansions of Medicaid to adults are linked to increased access to care, improved health status, reduced mortality, and increased economic security.
Medicaid covers a broad range of health and long-term care services that are often not covered by other payers. These services include prescription drugs, physical therapy, eyeglasses, dental care, non-emergency medical transportation, nursing home care, and home and community-based services. Medicaid also covers behavioral health services and benefits to address social determinants of health [7].
Medicaid's coverage extends to long-term care as well. More than 60 percent of all nursing home residents are covered by Medicaid, and it accounts for roughly 50 percent of costs for long-term care services and supports.
Medicaid is particularly important for certain populations, such as children, adults with disabilities, individuals with mental illness, and adults with HIV. It also covers a significant percentage of births in the United States [7].
Overall, Medicaid's effects extend far beyond simply providing insurance coverage. It improves access to necessary healthcare services, contributes to better health outcomes, and provides long-term coverage for vulnerable populations. As a key component of the U.S. healthcare system, Medicaid plays an essential role in ensuring that millions of Americans have access to the services they need.
As one navigates the complex world of Medicaid, understanding the variations in state programs and the procedure for application becomes crucial. This section will shed light on these aspects, offering a clearer path for those seeking the services that Medicaid will pay for.
Medicaid programs can vary significantly from state to state. While they all cover a broad range of health and long-term care services, the specifics can differ based on the individual state's decisions and policies [7].
For example, Medicaid covers a variety of groups and a wide range of services, including long-term care coverage, coverage for low-income Medicare beneficiaries, and coverage for services not covered by Medicare. These services encompass prescription drugs, physical therapy, dental care, non-emergency medical transportation, and nursing home care. Medicaid also covers behavioral health services and benefits to address social determinants of health.
In addition, Medicaid covers more than 60 percent of all nursing home residents and roughly 50 percent of costs for long-term care services and supports [11].
Here's a brief overview of the common services covered:
While all states cover prescription drugs, most also cover other common optional benefits like dental care, vision services, hearing aids, and personal care services for frail seniors and people with disabilities.
Applying for Medicaid involves several steps, which can slightly vary from state to state. Generally, the process involves:
Remember, while Medicaid can be a lifesaver for many, navigating its complexities can be challenging. Therefore, don't hesitate to seek help or clarification during the application process.
[2]: https://www.kff.org/medicaid/issue-brief/medicaid-a-primer-key-information-on-the-nations-health-coverage-program-for-low-income-people/#:~:text=Medicaid%20covers%20a%20broad%20range,or%20housing.
[3]: https://www.investopedia.com/terms/m/medicaid.asp
[5]: https://www.kff.org/other/state-indicator/state-medicaid-prescription-limits/
[6]: https://www.medicaid.gov/medicaid/prescription-drugs/index.html
[7]: https://www.kff.org/mental-health/issue-brief/10-things-to-know-about-medicaid/
[8]: https://www.kff.org/medicaid/issue-brief/medicaid-a-primer-key-information-on-the-nations-health-coverage-program-for-low-income-people/#:~:text=Medicaid%20is%20an%20entitlement%2C%20which%20means%20that%20individuals%20who%20meet%20eligibility%20requirements%20are%20guaranteed%20coverage.&text=Relative%20to%20White%20children%20and,adults%20with%20disabilities%20%28Figure%204%29.
[9]: https://www.kff.org/medicaid/issue-brief/medicaid-a-primer-key-information-on-the-nations-health-coverage-program-for-low-income-people/#:~:text=Medicaid%20covers%2041%25%20of%20all,for%20nearly%20one%20in%20five%20Medicare%20beneficiaries%20%2812.5%20million%29.
[10]: https://www.kff.org/medicaid/issue-brief/medicaid-a-primer-key-information-on-the-nations-health-coverage-program-for-low-income-people/#:~:text=A%20large%20body%20of%20research,care%20among%20Medicaid%20enrollees%20%28Figure%207%29.
[11]: https://www.cbpp.org/research/policy-basics-introduction-to-medicaid
