Mandatory and Optional Benefits Under Medicaid

It can be difficult to navigate the complex world of health insurance, particularly if you are trying to understand the Medicaid coverage maze. Because there are so many Mandatory and Optional Benefits Under Medicaid, it can be difficult to tell exactly what is included.


This blog post will detail the Mandatory and Optional Benefits Under Medicaid to help readers better comprehend its advantages.

Mandatory and Optional Benefits Under Medicaid

A Brief Introduction

Medicaid is a joint federal-state initiative that attempts to increase access to healthcare for individuals and families with limited financial means. Although states may choose to extend their Medicaid programs beyond what is required by federal law, there are significant variations in coverage across the country.

What Does Medicaid Cover?

Medicaid coverage is extensive and can help pay many of the costs connected with long-term care. Doctor visits, nursing facility stays, emergency services, outpatient services, medical equipment, and hospice care are all covered by Medicaid. As can be seen, Medicaid can be of tremendous assistance to those in need of long-term care, such as those suffering from Alzheimer’s disease or the elderly with severe mobility challenges.

What Does Medicaid Not Cover?

Although Medicaid appears to cover almost everything, it may not always give complete coverage. Medicaid, for example, does not fund private nursing or services performed by a household member. Bandages, adult diapers, and other disposables are also not covered. Cosmetic surgery and chiropractic care are also not covered; nevertheless, these two services are often not required when caring for seniors.


Mandatory and Optional Benefits Under Medicaid

Mandatory Benefits

All Medicaid programs must offer certain services, which are known as mandatory benefits. They must be given to all eligible people under state Medicaid programs and are non-negotiable. The following are the principal groups of required benefits:

  • Inpatient hospital services
  • Outpatient hospital services
  • EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services
  • Nursing Facility Services
  • Home health services
  • Physician services
  • Rural health clinic services
  • Federally qualified health center services
  • Laboratory and X-ray services
  • Family planning services
  • Nurse Midwife services
  • Certified Pediatric and Family Nurse Practitioner services
  • Freestanding Birth Center services (when licensed or otherwise recognized by the state)
  • Transportation to medical care
  • Tobacco cessation counseling for pregnant women

Optional Benefits:

Benefits that are optional are just that—optional. States are always free to decide whether or not to provide these services, and coverage varies greatly from one state to the next. The following list of frequently covered extra benefits:

  • Occupational therapy
  • Speech, hearing, and language disorder services
  • Respiratory care services
  • TB-Related Services
  • Inpatient psychiatric services for those under the age of 21
  • Other services approved by the Secretary*
  • Other diagnostics, screening, preventive, and rehabilitative services
  • Podiatry services
  • Optometry services
  • Dental Services
  • Dentures
  • Prosthetics
  • Eyeglasses
  • Chiropractic services
  • Other practitioner services
  • Prescription Drugs
  • Clinic services
  • Physical therapy
  • Private duty nursing services
  • Hospice
  • Case management
  • Services for persons Aged 65 or Older in an Institution for Mental Disease (IMD)
  • Services in an intermediate care facility for those with Intellectual Disability
  • Personal Care
  • State Plan Home and Community Based Services- 1915(i)
  • Self Directed Personal Assistance Services- 1915(j)
  • Community First Choice Option- 1915(k)

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Advantages of Medicaid

  • Medicaid provides some financial security because many medical care expenses are covered by this program. This means that folks on a lesser income who need to travel to the hospital for critical surgery will be less financially burdened as a result.
  • Medicaid recipients are eligible to care through privately managed care programs. These plans are primarily responsible for providing access to Medicaid-covered services.
  • Medicaid is a government program that assists the elderly as well as those with disabilities. Seniors and disabled people, in particular, have been proven to account for around two-thirds of medical aid spending in the United States.
  • Those on Medicaid will see that their patient copays are often smaller and more inexpensive. Typically, they might be as cheap as $2, and there are some operations that don’t even require a copay.

Disadvantages of Medicaid

  • Some Medicaid recipients, particularly older people in nursing homes, have become targets of prejudice. These people are more prone to this form of treatment than others, and they may also be transferred to different facilities.
  • With Medicaid, some operations may be rejected even after services have been delivered to an individual. This is because some services are considered experimental or unneeded and hence are not reimbursed by Medicaid.
  • While Medicaid, as previously stated, is intended to help low-income individuals, not all low-income folks will be eligible for this service. Each state has its own set of unique standards for Medicaid eligibility.
  • If someone on Medicaid has an emergency, they may receive lesser quality treatment merely because they are on Medicaid. The affected individual may be unable to receive part of the necessary treatment if they are on Medicaid.

These are some of the most common benefits and drawbacks of participating in a program like Medicaid. The most important thing to remember is that having Medicaid is not a terrible thing, and it should not make you feel like you don’t deserve the same level of medical care as everyone else. Despite the fact that this type of service does not cover every single treatment, it does cover a lot of the essentials and may even end up covering an important emergency procedure that you may want as well.

Who does Medicaid serve?

Medicaid programs target specific populations, such as:

  • Pregnant women with low income
  • Children of low-income families
  • Children in foster care
  • People with disabilities
  • Seniors with low income
  • Parents or caregivers with low income

States may also choose to extend eligibility to other categories, such as low-income individuals who do not have children.



Understanding the structure of Mandatory and Optional Benefits Under Medicaid can make navigating the Medicaid system much simpler, despite the fact that it can initially seem intimidating. You can choose the finest healthcare solutions for you and your family by being knowledgeable about your coverage options. Always seek advice from a reputable healthcare physician or the Medicaid office in your state when in doubt. Take control of your Medicaid coverage by arming yourself with knowledge because your health is too essential to leave to chance.



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