What Does Medicaid Cover? A Guide to Understanding Your Benefits

Navigating Medicaid coverage can feel like walking through the woods without a map. You may think you’ve taken the right turn, only to find yourself lost and confused. 

Understanding the insurance program and what it covers is an important first step in taking control of your health and getting the care you need.

Read our comprehensive guide to learn more about what Medicaid covers, how these benefits may differ from state to state, and what you can do to avoid expensive medical costs.

Understanding Medicaid 

Medicaid is a federal and state program that provides healthcare coverage to lower-income families and individuals. 

Each state runs its own Medicaid program and can decide which medical services to provide to qualifying residents.

Members of Medicaid programs typically don’t have to pay monthly premiums — unless your state requires it — and services are generally free.

However, individuals may need to contribute a fixed amount for specialized services — such as prescriptions and hospital stays.

This amount will be determined by Medicaid and will be based on your individual circumstances.

Who is eligible for Medicaid?

The following groups of people are eligible for Medicaid coverage through their state’s program:

• People with disabilities

• Parents or caregivers with a low income 

• Seniors with a low income 

• Children in foster care 

• Children of low-income families 

• Pregnant women with a low income 

Can you have Medicaid and Medicare?

Medicare is a federal health insurance program that provides affordable healthcare services to senior citizens and young people with disabilities or chronic conditions.

You don’t have to fall into a specific income bracket to be eligible for Medicare, but you do need to be over the age of 65 or have been diagnosed with certain health conditions.

Some people may qualify for both Medicaid and Medicare. These individuals are called dually eligible members.

It’s not possible to purchase either or both of these insurance plans if you don’t qualify. If you’re not eligible, you would have to consider private health insurance options instead. 

The Basics of Medicaid Coverage

Although each state runs its own Medicaid program, the federal government has several rules that these programs must follow.

These rules are a federal law and include a list of mandatory services that must be covered in every state.

In addition to this mandatory list of services, states can also choose to add other Medicaid benefits for residents who are part of the program.

This means that, in some states, Medicaid members will have more services covered compared to members in other states

Medicaid programs also typically cover mental health and substance use disorder services in some states. The state program determines the type of services and coverage.

For a comprehensive list of services covered by Medicaid in your state, visit the specific program website. 

Which Services are Not Covered by Medicaid?

Medicaid programs are designed to provide essential and preventative healthcare services to members.

This means that there are a number of medical services that are considered nonessential and will not be covered by Medicaid.

Nonessential medical services usually don’t have a direct impact on a person’s immediate health.

They are also not covered to allow more Medicaid funds to be allocated to critical health services.

A list of the common nonessential medical services not covered by Medicaid includes:

• Certain cosmetic procedures: Cosmetic surgery that isn’t considered medically necessary — such as facelifts, liposuction, or similar procedures — are not covered.

• Certain dental and vision procedures: Medicaid covers basic dental and vision services for children, but the coverage for adults can vary by state. Procedures like dental implants and cosmetic eyewear are usually not covered.

• Fertility treatments: Services like in vitro fertilization (IVF), artificial insemination, and other fertility treatments are generally not covered. However, some states offer coverage for medically necessary fertility medications or procedures.

• Non emergency transportation: If you visit the doctor for regular medical appointments, Medicaid will not cover this expense.  

What happens if you need these services?

In some instances, people may require medical services that aren’t covered by health insurance.

For example, you may have been in an accident or suffered an injury to an area of your body that now requires reconstructive surgery. 

Although Medicaid won’t be able to cover this expense, you can explore other options. These may include:

• Researching state-specific programs that include these benefits and that allow out-of-state patients

• Additional supplemental insurance from a private provider, which offers extra coverage and benefits for a number of services that Medicaid doesn’t cover

• Considering visiting a community health clinic that may offer medical services at a lower cost — remember that you will have to pay for the procedure yourself 

Does Medicaid Cover Any Long-Term Care?

Medicaid long-term care is defined as assistance for people with disabilities or chronic conditions who require care similar to what they would receive in a nursing facility. 

While Medicaid does provide some coverage for long-term care, it can vary by state. If your state offers long-term care benefits, they would typically include:

• Nursing home care: Medicaid covers nursing care services that provide 24-hour care for individuals who need significant assistance with their daily activities and medical needs. 

• Home and community-based services (HCBS): Many states offer HCBS benefits that allow people to receive long-term care services from the comfort of their homes. These services may include personal care (bathing, brushing teeth, grooming, etc.), homemaker services (helping with chores and tasks to maintain the household), meal delivery, and respite care (short-term relief for primary caregivers to allow them time to rest).

• Intermediate care facilities for individuals with intellectual disabilities: Medicaid covers long-term care services for individuals with intellectual and developmental disabilities.

• Institutions for mental disease (IMD): Medicaid provides limited coverage for adults under 65 in IMDs for mental health and substance use disorder treatment (SUDT). This coverage also depends on state-specific regulations.

To qualify for Medicaid’s long-term care, you’ll need to meet a specific set of requirements related to your income and the level of support you require. 

A doctor or healthcare practitioner will typically perform a face-to-face visit to assess your condition and make a recommendation to your health insurance provider. 

What is Medicaid Managed Care?

Managed care is a useful additional Medicaid benefit that helps people enrolled in the program to use and maintain their health care coverage.

Think of managed care as having a personal guide for your health journey.

Instead of navigating the healthcare system alone, you have someone who helps you find doctors, schedule appointments, and make sure you get the care you need.

Just like a guide leads you through unfamiliar terrain, managed care organizations (MCOs) help you navigate the complexities of healthcare, ensuring you receive quality support. 

The main features of managed care include:

Where Can I Access and Learn More About Telehealth Services?

At LifeMD, a dedicated team of healthcare professionals can help you take care of your well-being. 

We offer a range of services, including consultations with licensed doctors, ordering labs, getting certain prescription drugs, and access to a leading Weight Management program.  

Make an appointment with LifeMD today to get the healthcare you need, all from the comfort of your own home.

LifeMD makes it easy to stay on top of your health because talking to a doctor, filling your prescriptions, getting your labs done—and more—are all easy and cost-effective. Come discover a healthcare solution built around you and your life.

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