Medicaid covers doctor visits, hospital care, and prescription drugs, but the exact list depends on your state and which Medicaid program you're in
Medicaid is not one program — it is a partnership between the federal government and each state, so what your state's Medicaid pays for can differ from what another state's Medicaid pays for. Every state must cover certain services (called mandatory services), and most states cover additional services (called optional services). Your specific coverage also depends on which Medicaid category you fall into: Medicaid for low-income adults, Medicaid for children, Medicaid for pregnant people, Medicaid for seniors, or Medicaid for people with disabilities.
The fastest way to know what your state covers is to call your state Medicaid office or visit your state's Medicaid website. You can also ask your doctor's office — they deal with Medicaid claims every day and usually know what your state covers without looking it up.
Key Takeaways
- Every state must cover doctor visits, hospital stays, lab tests, X-rays, and family planning services, but coverage details vary by state.
- Prescription drugs, dental care, vision care, and mental health services are optional in some states, so you need to check your state's specific coverage.
- Long-term care in a nursing home or assisted living is covered in some states under Medicaid, but rules about how much you can own and earn are strict.
- Your state Medicaid office or your doctor's office can tell you whether a specific service or provider is covered under your plan.
Services every state's Medicaid must cover
Federal law requires every state Medicaid program to pay for inpatient hospital care (staying overnight), outpatient hospital services (emergency room and same-day procedures), physician services (doctor visits), laboratory services and X-rays, family planning services and supplies, and nursing facility care for people 21 and older. These are the baseline, and no state can remove them.
Beyond those, most states also cover home health services, transportation to medical appointments, and preventive care like screenings and vaccinations. But the details matter — one state might cover unlimited doctor visits, while another might limit you to a certain number per year. Your state's Medicaid handbook or website will spell out the limits.
Prescription drugs and pharmacy coverage
Medicaid must cover prescription drugs, but each state decides which drugs it will pay for and which ones you might have to pay for yourself or get special permission to use. This list is called a formulary. If your doctor prescribes a drug that is not on your state's formulary, you can ask your doctor to request an exception, or you can ask the state Medicaid office to review the decision.
Some states charge a small copay for prescriptions (usually $1 to $3 per prescription), and some do not charge anything. A few states limit how many prescriptions you can fill in a month. Call your state Medicaid office or check your Medicaid card to find out your state's rules.
Mental health and substance use treatment
Medicaid must cover mental health services and treatment for substance use disorder, but what that includes varies. Most states cover outpatient therapy (talking to a therapist or counselor), psychiatric visits, and medications for mental health conditions. Many states also cover inpatient psychiatric hospitalization if you need it.
Coverage for residential treatment programs (where you stay while receiving treatment) and intensive outpatient programs differs by state. Some states cover these fully, some cover them partially, and some do not cover them at all. If you need this level of care, ask your doctor or call your state Medicaid office to find out whether it is covered and whether you need prior approval from Medicaid before you start.
Dental, vision, and hearing care
Dental and vision care are optional services, meaning states can choose whether to cover them. Most states cover dental care for children, but coverage for adults is much more limited — many states cover only emergency dental care or tooth extractions. Vision care for children (eye exams and glasses) is covered in most states, but adult vision coverage is often limited to eye exams only, with glasses not covered or only partially covered.
Hearing aids and hearing tests are also optional services. Some states cover them, some do not. If you need dental work, glasses, or a hearing aid, call your state Medicaid office to ask whether it is covered. If it is not covered by Medicaid, your doctor or dentist may know about other programs that can help.
Long-term care in nursing homes and assisted living
Medicaid can pay for nursing home care if you meet your state's medical and financial requirements. Medical requirements mean a doctor must say you need that level of care. Financial requirements mean you must have limited income and assets — the limits vary by state, but generally you can own very little and earn very little to stay on Medicaid while in a nursing home.
Medicaid rules about long-term care are complex because they involve protecting your spouse's income and assets if you are married, and they involve what happens to your home. Before you enter a nursing home, talk to a social worker at the facility or call your state Medicaid office. Many states also have programs that help pay for care at home or in assisted living instead of a nursing home, and those programs have different rules.
Services Medicaid does not cover
Medicaid does not pay for cosmetic surgery, most weight-loss surgery, fertility treatments, or experimental treatments that have not been approved by the FDA. Medicaid also does not cover over-the-counter medications (like ibuprofen or cold medicine you buy without a prescription), unless your state has a specific program for certain over-the-counter drugs.
Some states do not cover certain types of therapy or rehabilitation. For example, physical therapy might be limited to a certain number of visits per year, or occupational therapy might not be covered at all. If your doctor prescribes a service and you are not sure whether Medicaid covers it, ask your doctor to check with your state Medicaid office before you receive the service. That way you will know ahead of time whether you will have to pay for it yourself.
How to find out what your state covers
Your state Medicaid office has a handbook or website that lists all covered services. You can find your state Medicaid office by searching "[your state] Medicaid" online, or you can call 1-800-MEDICARE and ask for your state Medicaid office's phone number. When you call, have your Medicaid card handy so you can give them your member ID number.
You can also ask your doctor's office or your pharmacy whether a specific service or drug is covered. They bill Medicaid regularly and often know the answer without having to call. If you are in the hospital or nursing home, the social worker or case manager there can also help you understand what is and is not covered.
Frequently Asked Questions
Does Medicaid cover my prescription if my doctor says I need it but it is not on the formulary?
You can ask your doctor to request an exception, called a prior authorization or formulary exception. Your doctor sends a letter to Medicaid explaining why you need that specific drug. Medicaid usually decides within a few days. If Medicaid says no, you can ask your doctor to appeal the decision or to prescribe a different drug that is on the formulary.
Does Medicaid cover therapy or counseling?
Yes, Medicaid covers outpatient mental health services in every state, which includes therapy and counseling. You may need a referral from your doctor, and you may have to use a provider who accepts Medicaid. Call your state Medicaid office or your doctor to find a therapist or counselor near you who takes Medicaid.
Will Medicaid pay for my glasses or hearing aid?
It depends on your state and sometimes on your age. Most states cover glasses for children but not for adults. Hearing aids are covered in some states and not in others. Call your state Medicaid office to ask whether these items are covered under your plan.
Does Medicaid cover weight-loss surgery?
Most states do not cover weight-loss surgery through Medicaid. Some states cover it only in specific situations, such as when surgery is medically necessary for a serious health condition. Ask your doctor to contact your state Medicaid office to find out whether your situation might be covered.
What if Medicaid says it will not pay for something my doctor says I need?
You have the right to appeal. Your state Medicaid office will send you a letter explaining why the service is not covered and how to appeal. You can also ask your doctor to appeal on your behalf. The appeal process usually takes a few weeks, and you can continue receiving the service while you wait for a decision in some cases.