# Presentation: 097229

## MEDICAID BENEFITS AND COVERAGE  An Overview

**J. P. Peters**
**Division of Medicaid & Children’s Health**
**Centers for Medicare & Medicaid Services **

## Goals

- To enable audience to distinguish  mandatory and optional services
- To acquaint audience with basic definitions and requirements of specific Medicaid services

## Basic Requirements

**Services must:**
** ****Be medical or remedial**
** ****Involve direct patient care**
**Purpose: To diagnose, treat, prevent, or limit the harmful effects of illness, injury, or other physical or mental health problems**

## What Services Are Not Covered

**Services that are not medical **
**Examples:**
**Social**
**Environmental**
**Comfort**
**Public health**

## Mandatory and Optional Services

**Only services enumerated in statute are covered**
**Mandatory services – must be covered by all States, different for categorically and medically needy**
**Optional services – States choose whether or not to cover**

## Mandatory Services for Categorically Needy

**Inpatient hospital **
**Outpatient hospital   **
**Rural health clinics (RHCs) **
**Federally qualified health centers **
**Lab and x-ray**

## Mandatory Services for Categorically Needy

**Nursing facility (ages 21 & older)**
**Family planning & supplies**
**Physicians**
**Medical & surgical furnished by dentist**
**Early & periodic screening, diagnosis and treatment (EPSDT)**

## Mandatory Services for Categorically Needy

**Home health ****  **
**Nurse/midwife**
**Pediatric & family nurse practitioner**
**     **

## Mandatory Services for Categorically Needy

**Services related to pregnancy and**
**conditions that could complicate **
**pregnancy (continued):**
**N****ecessary for the health of the pregnant woman and fetus **
**Necessary as a result of the woman having been pregnant**
**Necessary to address conditions that might complicate the pregnancy**

## Mandatory Services for Categorically Needy

**Services related to pregnancy and**
**conditions that could complicate **
**pregnancy (continued)**
**...****Include, but are not limited to: **
**Prenatal care**
**Delivery**
**Postpartum care**
**Family planning services**

## Mandatory Services for the Medically Needy

**Prenatal care and delivery services for pregnant women**
**Ambulatory services for individuals under age 18 and groups entitled to institutional services**
**Home health services for individuals entitled to skilled nursing facility services**
**Additional services if State covers services provided in institutions for mental diseases (IMDs) or intermediate care facilities for the mentally retarded (ICF/MRs) **

## Optional Services

**May be provided:**
**To categorically needy only**
**To both categorically needy and medically needy**
**Not at all**
**Descriptions on remaining slides follow**
**order in which services are listed in**
**“****Medicaid At-a-Glance 2003”**

## Optional Services

**Licensed practitioner services **
**Chiropractors (28)***
**Podiatrists (45)**
**Optometrists (50)**
**Psychologists (34)**
**Nurse anesthetists (29)**
*** ****Number of States covering service in 2003 in parentheses**** **

## Optional Services

**Private duty nursing (27)***
**Provided in the recipient’s home, a hospital, or a skilled nursing facility **
**Provided by a registered nurse or a licensed practical nurse, under the direction of the recipient’s physician**
**For recipients who require more individual and continuous care than is typically available from a visiting nurse or an institution’s nursing staff**
*** ****Number of States covering service in 2003 in parentheses**** **

## Optional Services

**Clinic services (50)***
**Preventive, diagnostic, therapeutic, rehabilitative, or palliative services **
**Furnished by a facility that is not part of a hospital but is organized and operated to provide medical care to outpatients**
*** Number of States covering service in 2003 in parentheses**** **

## Optional Services

**Home health therapies**** **
**Provided at a recipient’s place of residence**
**Based on a physician’s orders**
**Part of a written plan of care**

## Optional Services

**Home health therapies (cont.) **
**Physical therapy (49)***
**Speech and language therapy (48) **
**Occupational therapy (49) **
**Audiology services (44)**
*** Number of States covering service in 2003 in parentheses**** **

## Optional Services

**Dental services (45)***
**Physical therapy (43)**
**Occupational therapy (40)**
**Speech, hearing, and language disorders (41)**
*** Number of states covering service in 2003 in parentheses**

## Optional Services

**Prescription drugs (51)***
**Dentures (35)**
**Prosthetic devices (51)**
**Eyeglasses (45)**
**Diagnostic services (34)**
** ***** Number of States covering service in 2003 in parentheses**

## Optional Services

**Screening services (32)***
**Preventive services (37)**
**Rehabilitative services **
**Mental health rehab/stabilization (45)**
**Other/usually related to physical dib (29) **
** ***** Number of States covering service in 2003 in parentheses**

## Optional Services

**Inpatient hospital & nursing facility services in IMD – ages 65 and older (42)* **
** ***** Number of States covering service in 2003 in parentheses**

## Optional Services

**ICF/MR services (51)***
**Inpatient psychiatric (under age 21) (44)**
**Personal care services (37)**
**Targeted case management services (49)**
*** Number of States covering service in 2003 in parentheses**

## Optional Services

**Primary care case management (22)* **
**Hospice care services (45)**
**Respiratory care services (15)**
**Program of All-Inclusive Care for the Elderly (PACE) (19)**
*** ****Number of States covering service in 2003 in parentheses**