Medicaid Coverage and Benefits

The federal government requires that states provide certain mandatory medical benefits to people who are eligible for Medicaid. States can choose to provide additional, optional benefits.

  • Hospital visits and stay
  • Doctors’ office visits
  • Prenatal care and delivery
  • Nursing home services
  • Home health services
  • Early childhood screening which includes, vision and hearing testing, as well as a comprehensive physical exam, developmental history, appropriate immunizations, laboratory tests, dental care, and health education.
  • Emergency medical transportation

Children's Health Insurance Program (CHIP)

What is CHIP?

CHIP, which stands for Children’s Health Insurance Program, provides low-cost insurance for children whose families do not meet the income eligibility requirements for Medicaid. CHIP may also provide coverage for pregnant women in some states, but does not cover adults caring for children that qualify for CHIP. CHIP is jointly funded by the state and federal government.

CHIP is required to provide some services, but states may decide to cover more services. For example, all well-child doctor and dental visits are free of charge. There may be copayments for other services and some states charge a monthly premium that will never exceed 5% of the family’s total monthly income. Eligibility requirements vary by state.

All CHIP plans cover:

  • Routine check-ups
  • Immunizations
  • Doctor visits
  • Prescriptions
  • Dental and eye care
  • Inpatient and outpatient hospital care
  • Laboratory and x-ray services
  • Emergency services

Early, Periodic, Screening, Diagnosis and Treatment (EPSDT)

What is EPSDT?

Early, Periodic, Screening, Diagnosis and Treatment is a benefit provided by Medicaid to all individuals enrolled in Medicaid under the age of 21. These services are comprehensive and intended to find and prevent health issues.

Services covered include:

  • Screening services
  • Health and developmental history
  • Physical exam
  • Immunizations
  • Laboratory tests
  • Health education
  • Dental
  • Hearing
  • Diagnostic services, if identified by a screening examination
  • Treatment for any identified physical and mental illnesses or conditions

Activities of Daily Living (ADLs) and Instrumental Activies of Daily Living (IADLs)

ADLs and IADLs are terms used for the different levels of support an individual needs to remain in their home and active in the community.

ADLs

People who need help with Activities of Daily Living (ADL) are individuals who need long-term services and supports to help them maintain a healthy life.

ADLs Include:

  • Personal hygiene
  • Using the bathroom
  • Dressing
  • Feeding themselves
  • Walking or moving from one place to another

IADLs

People who need help with Instrumental Activities of Daily Living (IADL) are individuals who need long-term supports to help them remain independent and in their home or community setting. They may also be referred to as the ABD population – Aged, People who are Blind, or People with Disabilities.

IADLs Include:

  • Grocery shopping
  • Medication reminders
  • Housekeeping
  • Transportation

Long-Term Services and Supports (LTSS)

LTSS, which stands for Long-term Services and Supports, are the services and support to help people living with a disability or chronic illness with their daily living needs so they are able to remain active in the community. Medicaid covers these services based on the needs of each person. Services can be delivered through home- and community-based services, a nursing home or other similar settings.

An assessment is required by each state to determine which Activities of Daily Living (ADLs) individuals need assistance with. This assessment may be done by a state worker or by a qualified individual that is contracted by the state. Once the assessment is completed, an appropriate setting for care is determined by the assessment and then chosen by the individual and any health care decision makers in their life.

A separate assessment may also be done to determine a person’s ability to complete Instrumental Activities of Daily Living (IADLs). After this assessment is completed, an individual would then select and hire a personal care attendant or company to help them complete these tasks in a home- or community- based setting.

Home- and Community-Based Services (HCBS)

What is HCBS?

Home- and Community-Based Services (HCBS) are services provided to Medicaid beneficiaries in their own homes or communities. These programs serve a variety of targeted population groups, including people with intellectual or developmental disabilities, physical disabilities and/or mental illness. They are designed to help people live on their own rather than in a costly facility.

HCBS services include:

  • Personal care like showering
  • Transportation services
  • Skilled nursing care
  • Occupational, speech and physical therapy
  • Dietary management
  • Home-delivered meals
  • Home chores

 

Who delivers HCBS?

Some Home- and Community-Based Services (HCBS) services like skilled nursing care and occupational, physical or speech therapy are delivered by qualified and, in some cases, licensed professionals.

Other services that are offered to keep people in their homes or communities are delivered by family members or other people who already provide support to an individual. These may include completing chores around the house and making meals. If an individual does not have family that is able to provide these services, a paid caregiver can also help an individual with these tasks.

Waivers

What are Waivers?

States may waive certain rules of Medicaid to cover specific populations with specific services. These are called Medicaid Waivers.

Examples of Medicaid Waiver coverage:

  • Intellectual and Developmental Disabilities
  • Mental Health
  • Traumatic Brain Injuries
  • Substance Use Disorders
Video: Medicaid Spotlight: Waivers
Medicaid Spotlight: Waivers

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