Who Is Covered By Medicaid

What Are Some Of The Services Covered By Medicaid

What are some of the services covered by Medicaid?

• Dental services and related treatment
• Dialysis services
• Home and Community Based Services

Anyone who meets the Medicaid eligibility requirements can receive Medicaid. A Medicaid recipient can be any age, race or sex.

Select here to see who is eligible for Medicaid.

What are some of the services not covered under Medicaid?

• Cosmetic surgery that is not medically necessary
• Experimental or investigational services, surgeries, treatments, and medications
• Infertility treatment

What Does Medicaid Cover

Medicaid is a social insurance program administered by state and federal governments designed to cover the basic healthcare needs of lower income families in America. This means that Medicaid helps people with low incomes cover their health care costs. But what does Medicaid cover for you? And are you eligible for Medicaid in your state?

To qualify for Medicaid coverage, a person must make less than 133 percent of the federal poverty line, which is about $16,000 for an individual or about $32,000 for a family of four.

In recent years, Medicaid enrollment has surged across the U.S. and now, along with the companion Childrens Health Insurance Program program, cover more than 74 million people.

Children’s Oral Health Initiative

The Centers for Medicare & Medicaid Services is committed to improving access to dental and oral health services for children enrolled in Medicaid and CHIP. We have been making considerable progress in our efforts to ensure that low-income children have access to oral health care. From 2007 to 2011, almost half of all states achieved at least a ten percentage point increase in the proportion of children enrolled in Medicaid and CHIP that received a preventive dental service during the reporting year. Yet, tooth decay remains one of the most common chronic childhood diseases.

To support continued progress, in 2010 CMS launched the Children’s Oral Health Initiative and set goals for improvement by FFY 2015. To achieve those goals, we have adopted a national oral health strategy through which we are working diligently with states and federal partners, as well as the dental provider community, children’s advocates and other stakeholders to improve children’s access to dental care.

To support state Medicaid and CHIP programs in achieving their improvement goals, we developed Keep Kids Smiling: Promoting Oral Health Through the Medicaid Benefit for Children and Adolescents . It provides an overview of the children’s dental benefit in Medicaid, support for evidence-based policies at the state level, and details of successful strategies with state examples.

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Appeals And Fair Hearings

Medicaid estate recovery is the process through which each state recovers the costs of medical services it has paid from the estate of the person who received those services. The Medicaid estate recovery program impacts two groups of people receiving Medicaid benefits:

• Anyone over the age of 55 who has received Medicaid assistance, and
• Anyone who is permanently institutionalized and has received Medicaid assistance, regardless of age.

The estate recovery program may collect money from the estate of a deceased Medicaid recipient as repayment for any medical care services that were provided to the recipient and paid for by Medicaid, while the recipient was over 55 years of age, or permanently institutionalized, regardless of age.

Medical care includes a wide range of services, including nursing home and community based in-home care services. It also includes any hospital and prescription drug services the participant received while in a nursing home, or while receiving in-home care. Medical care also includes capitation payments to Medicaid-contracted health insurance companies or medical providers administering a defined package of benefits. The federal government directs states to pursue Medicaid estate recovery for these services.

• During the lifetime of the surviving spouse, regardless of where he or she lives.
• From a surviving child who is under age 21 years or is blind or permanently disabled , regardless of where he or she lives.

What Do I Need To Do To Get Travel Reimbursement To And From My Medical Appointment

The Medicaid Non-Emergency Medical Travel Form must be completed and signed by the recipient, parent or guardian. The Medical Provider section of the form must be completed and signed by the receptionist, nurse or medical provider.

NEMT Payment Authorization Form must also be completed to have your payments either direct deposited into your checking or savings account or onto an electronic debit card.

The form, along with any necessary documentation, may be turned in at your local Department of Social Services office, mailed directly to: Department of Social Services, Office of Finance/EBT, 700 Governors Drive, Pierre, SD, 57501, emailed to , or faxed to 605.773.8461.

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Who Is Covered By Medicaid

While Medicare benefits are the same throughout the country, Medicaid, which covers mainly low-income adults, children, pregnant women, and some parents, varies from state to state. In states that have chosen to expand Medicaid under the Affordable Care Act , people can qualify for Medicaid if their income level is below 133% of the federal poverty level. Therefore, in states that have expanded Medicaid, more people are covered and insured. In states without expansion, many people neither qualify for Medicaid nor are able to afford a subsidized private health plan through the Health Insurance Marketplace.

To find out if you qualify for Medicaid in your state, clickhere.

How Did The Affordable Care Act Change Medicaid

Medicaid plays an even more important role in insuring low-income Americans due to the Affordable Care Act. As noted, the ACA provides coverage for poor and low-income adults by expanding eligibility for Medicaid to 138 percent of the poverty line. As of April 2020, 35 states plus the District of Columbia have implemented the Medicaid expansion to serve poor and low-income adults. By 2029, 14 million more low-income adults will have enrolled in Medicaid and gained access to affordable comprehensive health coverage due to the ACA, CBO estimates.

The expansion is a very good financial deal for states. After picking up all expansion costs for the first three years, the federal government now pays 90 percent of expansion costs on a permanent basis. And by greatly reducing the number of uninsured, the expansion will save states and localities substantial sums on uncompensated care for the uninsured. Some expansion states have also experienced savings in mental health programs, criminal justice systems, and other budget areas.

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After Congress Fails To Add Dental Coverage Medicare Weighs Limited Benefit Expansion

By Susan JaffeOctober 17, 2022

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Individuals Age 21 And Older

States may elect to provide dental services to their adult Medicaid-eligible population or, elect not to provide dental services at all, as part of its Medicaid program. While most states provide at least emergency dental services for adults, less than half of the states provide comprehensive dental care. There are no minimum requirements for adult dental coverage.

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What Is A Dual Special Needs Plan

A Dual Special Needs Plan is a type of health insurance plan for people who have both Medicaid and Medicare. These people are dual-eligible because theyre eligible to receive Medicaid benefits as well as Medicare benefits.

Dual Special Needs Plans provide extra help to those who need it. That may be because of income, disabilities, age and/or health conditions. A Dual Special Needs Plan works together with your Medicaid health plan. Youll keep all your Medicaid benefits. Most dual health plans also give you more benefits and features than you get with Original Medicare. All with as low as a $0 plan premium. Learn more about dual health insurance plan benefits.

See UnitedHealthcare plans in your area

Dual-eligible or Medicaid plan benefits can change depending on where you live. Search using your ZIP code to find the best plan to meet your health care needs.

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This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook. Limitations, copays and restrictions may apply. For more information, call UnitedHealthcare Connected® Member Services or read the UnitedHealthcare Connected® Member Handbook. Benefits, List of Covered Drugs, pharmacy and provider networks and/or copayments may change from time to time throughout the year and on January 1 of each year.

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What Are The Disadvantages Of Medicaid

The list of services not covered by Medicaid is not the only downside to the program. Some other disadvantages of Medicaid include:

• Eligibility differs by state, so you may not qualify where you live but otherwise would if you lived in a different state.
• Benefits can change year to year based on budget cuts and other legislation.
• Options for providers may be limited and quality of care can be sometimes diminished.

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Does My States Medicaid Program Cover Cgm

It depends. In states that have expanded Medicaid, more people with diabetes are able to access Medicaid coverage benefits, which may include CGM access depending on the state. But even if CGM is covered under your states policy, each state has its own criteria for which individuals qualify to receive it. For example, some states only cover CGM for type 1 diabetes, and other states have differing policies for short-term and long-term CGM use. To find out more about your specific states policy, see the map below:

This map is the general landscape of Medicaid coverage for CGM. The 6 states shown in red offer no published coverage policy of CGM for Medicaid recipients, while the other states offer some degree of coverage, as shown in the legend.

15 states Medicaid programs provide CGM for people with type 1 diabetes only: California , Louisiana, Maryland, Michigan, Mississippi, Missouri, Nevada, New York, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Wisconsin, and Wyoming.

27 states Medicaid programs provide CGM for people with both type 1 and type 2 diabetes: Alaska, Arkansas , Colorado, Connecticut, Delaware, Idaho, Illinois, Iowa, Indiana, Kentucky, Maine, Massachusetts, Minnesota, Montana, New Hampshire, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, Texas, Utah, Vermont, Virginia, Washington, and West Virginia.

2 states Medicaid programs provide CGM for children only: Alabama and Georgia.

Can I Get Reimbursed To Travel To Medical Appointments Out

Medicaid covered services received more than 50 miles outside of the state of South Dakota, except Bismarck, ND, will require prior authorization. This applies to all Medicaid recipients, including those not in the PCP or HHP program.

If your doctor recommends you see a doctor out-of-state, please ask your doctor if prior authorization is needed before you make the appointment. If approval is not given, you will be responsible for the medical bill and travel costs.

Prior authorization must be approved before travel expenses can be approved or paid.

NOTE: If you are in the PCP or HHP program and traveling to Bismarck, ND, a referral from your PCP or HHP is still required. If you are not in the PCP or HHP program, travel will only be reimbursed if Bismarck, ND, is the closest provider capable of providing the services.

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What Is A Health Home

South Dakotas health home program offers enhanced health care services to Medicaid recipients with chronic conditions like asthma, COPD, diabetes, heart disease, hypertension, obesity, substance use disorder, mental health conditions, pre-diabetes, tobacco use, cancer, hypercholesterolemia, depression, and musculoskeletal and neck/back disorders.

The full definition of core services can be found by clicking here.

Health Homes are encouraged to utilize health information technology to more efficiently and effectively coordinate the care of Health Home patients.

Through the provision of the six core services, the Health Home initiative aims to reduce inpatient hospitalization and emergency room visits, increase the integration between physical and behavioral health services and enhance transitional care between institutions and the community.

Dental Benefits For Children In Medicaid

Medicaid covers dental services for all child enrollees as part of a comprehensive set of benefits, referred to as the Early and Periodic Screening, Diagnostic and Treatment benefit. Though oral screening may be part of a physical exam, it does not substitute for a dental examination performed by a dentist. A referral to a dentist is required for every child in accordance with the periodicity schedule set by a state.

Dental services for children must minimally include:

• Relief of pain and infections
• Restoration of teeth
• Maintenance of dental health

The EPSDT benefit requires that all services must be provided if determined medically necessary. States determine medical necessity. If a condition requiring treatment is discovered during a screening, the state must provide the necessary services to treat that condition, whether or not such services are included in a state’s Medicaid plan.

Each state is required to develop a dental periodicity schedule in consultation with recognized dental organizations involved in child health care. Dental services may not be limited to emergency services for children entitled to EPSDT.

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Medicaid Spending Is Concentrated On The Elderly And People With Disabilities

Seniors and people with disabilities make up 1 in 4 beneficiaries but account for almost two-thirds of Medicaid spending, reflecting high per enrollee costs for both acute and long-term care . Medicaid is the primary payer for institutional and community-based long-term services and support as there is limited coverage under Medicare and few affordable options in the private insurance market. Over half of Medicaid spending is attributable to the highest-cost five percent of enrollees. However, on a per-enrollee basis, Medicaid is low-cost compared to private insurance, largely due to lower Medicaid payment rates for providers. Analysis shows that if adult Medicaid enrollees had job-based coverage instead, their average health care costs would be more than 25% higher. Medicaid spending per enrollee has also been growing more slowly than private insurance premiums and other health spending benchmarks.

Figure 9: Medicaid per enrollee spending is significantly greater for the elderly and individuals with disabilities compared to children and adults.

How Long Does My Enrollment Last

Enrolled providers who have not had paid claims within a 24 month period may be terminated for inactivity. Providers are required to maintain their record as changes occur and also complete revalidation in accordance to federal requirements upon South Dakota Medicaid notice. The revalidation process is anticipated to occur every 3-5 years.

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Who Is Eligible For Health Homes

South Dakota has two types of Health Homes — those led by Primary Care Providers and those led by a Community Mental Health Centers — to serve Medicaid recipients with complex health care needs resulting in high costs to Medicaid. Individuals who are eligible for these two health homes include: