What Medicaid Covers: A Guide for Dual Eligibles and Younger Beneficiaries
Medicaid is a vital safety net program that helps millions of Americans access health care, especially those with limited income or resources. While many associate Medicaid with lower-income families or children, it also plays a critical role in helping people on Medicare; often referred to as dual eligibles, afford the care they need. This post will answer the question; what does Medicaid cover.
Whether you’re on Medicare and Medicaid or qualify for Medicaid under age 65, it’s important to understand what the program covers and how it can help you.
Who Qualifies for Medicaid
Medicaid eligibility is based on income and household size, but each state runs its own Medicaid program within federal guidelines. In general, you may qualify if you:
- Have a low income and limited assets
- Are pregnant
- Are a child or teenager
- Are disabled or blind
- Are 65 or older
- Receive Supplemental Security Income (SSI)
- Receive Medicare and meet your state’s Medicaid income limits (dual eligible)
Many adults under 65 who qualify for Medicaid do so through the Medicaid expansion under the Affordable Care Act.
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What Medicaid Covers
Medicaid coverage varies by state, but all states must cover a core set of benefits, including:
For Everyone (All Beneficiaries)
- Doctor visits
- Hospital services – in-patient and out-patient
- Emergency care
- Lab and X-ray services
- Nursing facility services
- Preventive care and screenings
- Prescription drugs (in most states – not all)
- Family planning services
- Mental health and substance use disorder services
Click here for a full list of mandatory benefits that Medicaid must cover
Additional Coverage for Medicare Beneficiaries
If you qualify for both Medicare and Medicaid, Medicaid helps cover costs Medicare doesn’t. Depending on your income level and the Medicaid program you qualify for, it may pay for:
- Medicare Part A and B premiums
- Medicare deductibles, coinsurance, and copays
- Long-term care services, such as nursing home care
- In-home support services
- Non-emergency transportation to medical appointments
- Dental, vision, and hearing benefits (varies by state)
This extra help is incredibly valuable, especially for seniors or those with disabilities who may struggle to afford out-of-pocket Medicare costs.
Medicaid and Long-Term Care
One of Medicaid’s most significant benefits is long-term care coverage. Medicare only covers short-term skilled nursing or rehab, but Medicaid may pay for:
- Extended nursing home care
- Assisted living in some states
- Personal care services at home
Many people spend down their assets to qualify for Medicaid when they need these services, as they can be extremely expensive without coverage.
Learn about alternatives to long term care insurance
Medicaid for Younger Adults and Children
For individuals under age 65 who don’t yet qualify for Medicare, Medicaid may provide:
- Comprehensive pediatric care through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit
- Maternity and postpartum care
- Birth control and reproductive health services
- Support for individuals with disabilities, including waivers for home- and community-based care
How to Apply
Individuals can apply for Medicaid at any time of year through their state’s Medicaid office or through Healthcare.gov in participating states. Those on Medicare with a limited income may also qualify for a Medicare Savings Program (MSP); a Medicaid-administered program that helps pay Medicare costs.
Medicare beneficiaries who don’t qualify for full Medicaid may qualify for partial assistance through MSP; Medicare Savings Programs. These programs offer different levels of help such as: QMB, SLMB, or QI. These programs can make a major difference in managing healthcare expenses.
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Need help applying or understanding what you qualify for? Your local Medicaid office, a Medicare agent, or a SHIP (State Health Insurance Assistance Program) counselor can provide free, unbiased guidance.