Medicaid covers a wide range of health care services, from doctor visits and hospital stays to prescription drugs, mental health treatment, long-term nursing home care, and comprehensive children’s health services. For many enrollees, it does this with little to no out-of-pocket cost. The total premiums and cost sharing for a Medicaid household cannot exceed 5% of the family’s income, and many services have no copay at all.
Core Medical Services
Every state Medicaid program must cover a baseline set of services required by federal law. These include inpatient hospital stays, outpatient doctor visits, lab tests, X-rays, and preventive screenings. Prescription drugs are covered in all states, as are prosthetics, eyeglasses, and dentures. If you need physical therapy, occupational therapy, or speech therapy, those are covered too.
Beyond the basics, states can add optional benefits on top of the federal minimum. This is why Medicaid coverage can look different depending on where you live. One state might offer extensive adult dental care while another covers only emergency dental work. The same goes for services like chiropractic care, podiatry, and private duty nursing. If you’re unsure what your state covers, your state Medicaid agency’s website will list the full benefit package.
Children’s Coverage Through EPSDT
Medicaid’s benefit for children under 21, called Early and Periodic Screening, Diagnostic, and Treatment (EPSDT), is one of the most comprehensive health insurance benefits available in the U.S. It goes well beyond what most private insurance plans offer for kids. States are required to provide any medically necessary service to treat or correct a health condition discovered during a screening, even if that service isn’t normally part of the state’s Medicaid plan for adults.
EPSDT includes full physical exams, developmental screenings, immunizations, lead blood tests at 12 and 24 months, and routine vision and hearing checks. Dental care starts as early as needed and covers pain relief, infection treatment, tooth restoration, and medically necessary orthodontics. When a screening turns up a problem, the state must cover the diagnostic workup and whatever treatment follows. For families with children who have complex medical or developmental needs, this benefit can be life-changing.
Mental Health and Substance Use Treatment
Medicaid is the single largest payer for behavioral health services in the country. Coverage includes outpatient therapy, inpatient psychiatric care for individuals under 21, and community-based mental health services through certified behavioral health clinics. For substance use disorders, all state Medicaid programs are now required to cover medication-assisted treatment, which combines counseling with medications that reduce cravings and withdrawal symptoms for opioid addiction.
Many states have expanded these benefits further through waivers that allow coverage of residential treatment programs, services for youth with substance use disorders, and specialized care for pregnant and postpartum women dealing with addiction. Medicaid also covers treatment related to neonatal abstinence syndrome, helping both mothers and newborns affected by opioid exposure.
Long-Term Care and Nursing Homes
Medicaid is the primary way most Americans pay for long-term nursing home care. Medicare covers only short-term skilled nursing after a hospital stay, typically up to 100 days. Medicaid, by contrast, pays for ongoing custodial care in a nursing facility for people who qualify financially and medically. It also covers home and community-based services that help people stay in their own homes rather than moving into a facility, including personal care assistance and case management.
Eligibility for long-term care benefits uses different financial rules than standard Medicaid. There is a five-year “look-back period” on asset transfers. If you gave away money or property for less than its fair value during the five years before applying, you can be denied long-term care coverage for a penalty period. Trusts funded with your own assets can also count against you. These rules exist to prevent people from sheltering wealth to qualify for benefits.
For married couples, federal spousal impoverishment protections keep the spouse who doesn’t need nursing home care from losing everything. The healthy spouse is allowed to retain a portion of the couple’s income and assets so they can continue living independently. One important detail many people don’t realize: states are required to recover Medicaid costs from a deceased enrollee’s estate for nursing facility services, home and community-based services, and related hospital and drug costs.
Pregnancy and Postpartum Care
Medicaid covers prenatal visits, labor and delivery, and postpartum care. It pays for nearly half of all births in the United States. Pregnancy-related services are exempt from any copayments or cost sharing, meaning you pay nothing out of pocket for covered maternity care.
Traditionally, Medicaid coverage ended 60 days after delivery, which left many new mothers without insurance during a critical recovery period. As of April 2023, 31 states and the District of Columbia have extended postpartum coverage to a full 12 months. This extension covers ongoing checkups, mental health treatment for postpartum depression, and management of conditions like gestational diabetes or high blood pressure that can persist after pregnancy.
Coverage for Seniors With Medicare
About 12 million Americans are “dually eligible,” meaning they qualify for both Medicare and Medicaid. For these individuals, Medicaid acts as a secondary layer of insurance that fills the gaps Medicare leaves behind. Medicare doesn’t cover long-term custodial care, has limited dental and vision benefits, and charges premiums, deductibles, and copays that can add up quickly on a fixed income.
Medicaid can pay Medicare premiums, deductibles, and cost sharing for dual-eligible individuals. It also picks up services Medicare doesn’t cover at all, like long-term nursing home stays, personal care assistance, and transportation to medical appointments. The federal Medicare-Medicaid Coordination Office works to align benefits between the two programs so that dually eligible individuals don’t fall through administrative cracks.
How It Helps With Early Diagnosis
One of Medicaid’s most significant but less visible benefits is giving people access to care they’ve been putting off. A study of enrollees in Michigan’s Medicaid expansion found that 42% of those with a chronic health condition had at least one condition newly diagnosed after gaining coverage. About a third of enrollees with hypertension, diabetes, heart disease, or mood disorders were learning about these conditions for the first time. Chronic lung disease had the highest rate of new detection, with 36% of those who had the condition being diagnosed only after enrollment.
These aren’t minor findings. Undiagnosed diabetes, untreated high blood pressure, and unmanaged heart disease all lead to emergencies, hospitalizations, and premature death. Catching them early, when they can be controlled with medication and lifestyle changes, is exactly the kind of care that keeps people out of the emergency room.
What You’ll Pay Out of Pocket
Medicaid’s cost sharing is dramatically lower than private insurance. Federal rules cap what states can charge, and the limits are tied to income:
- Outpatient visits: Up to $4 for those at or below 100% of the federal poverty level ($15,060 per year for an individual in 2024)
- Inpatient hospital stays: Up to $75 for those at or below 100% FPL
- Prescription drugs: Up to $4 for preferred medications, up to $8 for non-preferred, at or below 100% FPL
- Emergency room visits: Up to $8 for non-emergency use of the ER at or below 100% FPL
Several categories of services are completely exempt from cost sharing regardless of income: emergency care, family planning, preventive services for children, and pregnancy-related care. And the hard ceiling applies across the board. No Medicaid household can be asked to spend more than 5% of their income on premiums and cost sharing combined. For a single person earning $15,060 a year, that’s a maximum of about $63 per month for all health care costs.
Who Qualifies
Eligibility depends on your income, household size, and the state you live in. In states that expanded Medicaid under the Affordable Care Act, most adults with household income up to 138% of the federal poverty level qualify. For a single person in 2024, that’s about $20,783 per year. For a family of three, it’s roughly $35,632.
Children generally qualify at higher income thresholds than adults, often up to 200% of the poverty level or more depending on the state. Pregnant women, people with disabilities, and adults over 65 have separate eligibility pathways with their own rules. In states that haven’t expanded Medicaid, childless adults often don’t qualify regardless of how low their income is, though children, pregnant women, and people with disabilities in those states still have access.
For most applicants, eligibility is based purely on income with no asset test. The exception is older adults and people with disabilities, whose eligibility is determined using methods similar to Social Security’s disability program, which can include limits on savings and other resources.