Medicaid Benefits

Medicaid is a program provided by the government wherein states help to provide low-income families and individuals basic medical care. People eligible for Medicaid are not paid by the government; rather, the government works directly with health care providers—including doctors, hospitals, and clinics—to ensure that coverage is provided. While coverage varies state by state (and certain states require members to fund a small co-pay for medical services rendered), Medicaid defrays the cost of care to ensure that low-income individuals can remain healthy.

Individuals and families eligible for Medicaid must meet certain requirements, which vary from state to state. Factors such as age, income, family size, citizenship and disability affect the amount of coverage an individual or family may receive. Individuals and families who are admitted by income must be matched to an eligibility group to assess which needs must be met. Coverage usually begins three months retroactive to application in the program and ends when an individual’s circumstances change.

Medicaid services are offered in some form in all states, and they must be offered uniformly throughout a state. Cities cannot be covered differently than suburbs; urban areas may not offer coverage unavailable to rural ones. If a Medicaid recipient moves, however, he is not necessarily eligible for the same amount of coverage.

Benefits packages are often designed by participating states; however, states must provide a minimum amount of coverage for medically necessary basic services: hospital or nursing home care, doctor visits, lab visits, X-ray services and screening and diagnostic treatment for children, including immunizations. Beyond medically necessary services, states may or may not choose to fund prescription medications, institutionalization for the mentally challenged, dental care and vision care. Services must be adequate; that is, they must provide for the essential medical needs of enrollees.

Medicaid need not provide for all of the medical needs of all enrollees. Health care services will not be provided, for example, for low-income individuals if they do not fall into one of the predetermined eligibility groups. Optional benefits like prosthetics, physical therapy, hospice care and mental health care are determined at the state level.

States are not allowed to vary the amount of coverage based on illness or disposition. For instance, an HIV-positive individual may not be charged more for prescription drugs than an individual with the flu. Diagnosis, type of illness, and degree of illness cannot be reflected in a difference in medical coverage.