Medicaid is health insurance, but it doesn't cover everything a doctor might recommend
Medicaid is a government health insurance program that pays for certain medical services. It covers doctor visits, hospital stays, prescription drugs, and some preventive care. But Medicaid does not cover every treatment, medication, or service a person might need. What is covered depends on which state you live in, which Medicaid program you are in, and what your doctor prescribes.
The federal government sets minimum requirements for what Medicaid must cover. States can add more services on top of those minimums. This means coverage varies significantly from state to state. A treatment covered in one state might not be covered in another.
Key Takeaways
- Medicaid covers doctor visits, hospital care, emergency services, and prescription drugs, but coverage rules differ by state.
- Some services like dental, vision, and mental health treatment are optional for states to cover, so you need to check your state's rules.
- Your doctor may prescribe something that Medicaid will not pay for, and you will need to know your options before you get the bill.
- Medicaid managed care plans (HMOs) have different coverage rules than fee-for-service Medicaid, and you should understand which one you are in.
- You can contact your state Medicaid office or your plan directly to find out whether a specific service or drug is covered before you receive it.
What Medicaid must cover in every state
Federal law requires all state Medicaid programs to cover certain core services. These include inpatient hospital care, outpatient hospital services, emergency room visits, physician services, laboratory and X-ray services, and skilled nursing facility care. Medicaid also covers family planning services, prenatal and delivery care, and pediatric services including vaccines.
Prescription drugs are a required Medicaid service, but the specific drugs covered vary. Each state maintains a formulary — a list of medications Medicaid will pay for. Your doctor's prescription might be on that list, or it might not be. If it is not, your doctor can sometimes request an exception, but that takes extra time and is not always approved.
Services that states can choose to cover or not cover
States have the option to cover many services beyond the federal minimum. Dental care is optional — some states cover it for adults, others only for children, and some do not cover it at all. Vision care and eyeglasses are also optional. Mental health and substance use treatment are required services, but the scope of coverage varies widely by state.
Physical therapy, occupational therapy, and speech therapy are optional services. Some states cover them without limits; others cover them only for children or only for a certain number of visits per year. Hearing aids and hearing tests are optional. Chiropractic care is optional in most states. If you need one of these services, you must check your state's Medicaid program to know whether it is covered.
How to learn about a specific service or drug is covered
Before you receive a service or fill a prescription, contact your Medicaid program or your managed care plan to ask whether it is covered. If you are in a Medicaid managed care plan (an HMO), call the plan's customer service number on your insurance card. If you are in fee-for-service Medicaid, contact your state Medicaid office directly.
Have your Medicaid member ID number ready when you call. Tell them the specific drug name and dose, or the specific service your doctor recommended. Ask whether it is covered, whether you need prior authorization (approval before you receive it), and what you will owe if it is covered. Some services require you to see a specific provider or get a referral first.
You can also ask your doctor's office to check coverage for you. Many offices have staff who verify coverage before scheduling procedures or sending prescriptions to the pharmacy. This is the fastest way to avoid surprises.
What happens when Medicaid does not cover something
If Medicaid will not cover a service or drug, you have several options. You can pay for it yourself if you can afford to. You can ask your doctor whether there is a similar service or drug that Medicaid does cover. You can request that your doctor submit a prior authorization request, which is a formal request for the program to make an exception.
Prior authorization requests are sometimes approved and sometimes denied. The decision usually takes a few days to a week. If it is denied, you can appeal the decision, but appeals also take time. If you need the service urgently, you may have to pay out of pocket and then try to get reimbursed later, though reimbursement is not may provide.
Differences between Medicaid managed care and fee-for-service
Most people with Medicaid are in a managed care plan, usually an HMO. In managed care, you choose or are assigned a primary care doctor who coordinates your care. You need referrals to see specialists. The HMO has its own rules about which doctors you can see and which drugs and services are covered.
Some people are in fee-for-service Medicaid, where you can see any doctor who accepts Medicaid without a referral. Fee-for-service follows your state's Medicaid rules directly. Managed care plans can have stricter coverage rules than fee-for-service, so coverage can differ depending on which type of Medicaid you are in.
State-by-state coverage differences
Because states design their own Medicaid programs within federal guidelines, coverage varies significantly. New York Medicaid covers dental care for adults; many other states do not. California covers acupuncture; most states do not. Some states cover weight loss surgery; others do not. Some states cover fertility treatment; others explicitly exclude it.
If you move to a different state, your Medicaid coverage will change. Services you had covered in your old state might not be covered in your new state. You should contact your new state's Medicaid office within 30 days of moving to understand what your new coverage includes.
Frequently Asked Questions
Will Medicaid cover a drug my doctor prescribed?
Medicaid covers prescription drugs, but each state has a list of covered medications. Your specific drug might or might not be on that list. Call your Medicaid plan or state office with the drug name and dose before you fill the prescription. Your doctor's office can also check this for you.
What if my doctor says I need something Medicaid will not cover?
Ask your doctor whether there is an alternative treatment that Medicaid does cover. You can also ask your doctor to submit a prior authorization request asking Medicaid to make an exception. If Medicaid denies the request, you can appeal or pay out of pocket if you can afford to.
Does Medicaid cover dental work?
Dental coverage is optional for states. Some states cover dental care for all Medicaid members; others cover it only for children; others do not cover it at all. Contact your state Medicaid office or your managed care plan to find out what dental services, if any, are covered where you live.
Can I see any doctor I want with Medicaid?
If you are in a Medicaid managed care plan, you must see doctors in your plan's network and usually need a referral to see a specialist. If you are in fee-for-service Medicaid, you can see any doctor who accepts Medicaid. Check your Medicaid card or call your plan to find out which type you are in.
What should I do before I get a procedure or fill a prescription?
Always contact your Medicaid plan or state office before you receive a service or fill a prescription to confirm it is covered. Ask whether you need prior authorization and what you will owe. This takes a few minutes and can save you from unexpected bills.