A joint federal and state program, Medicaid provides health insurance to low-income individuals and families. States can design their Medicaid programs, offering mandatory and optional benefits. This article explains the difference and provides details on each category.

Mandatory Benefits:
These are core services that all states must offer to Medicaid beneficiaries under federal law. The Social Security Act (SSA) and specific regulations (CFR) define the requirements for each benefit. Here’s a breakdown of the mandatory benefits:

  • Hospital Services: Inpatient and outpatient care at hospitals (1905(a)(1) & (2), 42 CFR 440.10 & 440.20).
  • Clinics: Services provided by Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) (1905(a)(2), 42 CFR 440.20).
  • Diagnostics: Lab tests, X-rays, and other diagnostic services (1905(a)(3), 42 CFR 440.30 & 441.17).
  • Nursing Care: Skilled nursing facility services for short-term or long-term needs (1905(a)(4)(A), 42 CFR 440.40 & 440.155).
  • Preventive Care: Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services for children under 21 (1905(a)(4)(B), 42 CFR 440.40 & 441 Subpart B).
  • Family Planning: Services to help with birth control and family planning (1905(a)(4)(C), 42 CFR 441.20).
  • Physician Services: Visits with doctors and other healthcare providers (1905(a)(5), 42 CFR 440.50).
  • Home Health Care: Skilled nursing and other healthcare services provided in the home (1905(a)(7), 42 CFR 440.70 & 441.15).
  • Midwife & Nurse Practitioners: Services by certified nurse midwives and pediatric/family nurse practitioners (1905(a)(17) & (21), 42 CFR 440.165 & 441.21 & 440.166(b) & 441.22).
  • Birth Centers: Deliveries at freestanding birth centers meeting state licensing or recognition standards (1905(a)(28)).
  • Medication-Assisted Treatment (MAT): Treatment for opioid use disorder using medications and counseling (1905(a)(29)).
  • Clinical Trials: Costs associated with participating in approved clinical trials (1905(a)(30)).

Optional Benefits:
These are additional services that states can offer to Medicaid beneficiaries at their discretion. Here are some of the most common optional benefits:

  • Other Practitioner Services: Services provided by dentists, physical therapists, occupational therapists, and speech-language pathologists (1905(a)(6), (10), & (11), 42 CFR 440.60, 440.100 & 440.110).
  • Prescription Drugs: Coverage for prescription medications (1905(a)(12), 42 CFR 440.120(a) & 441.25).
  • Dental Services: Routine and major dental care (1905(a)(10), 42 CFR 440.100).
  • Vision Care: Eyeglasses and other vision services (1905(a)(12), 42 CFR 440.120(d)).
  • Home and Community-Based Services (HCBS): Services that allow individuals with disabilities to live in the community rather than institutions (1915(c), (i), (j), & (k), 42 CFR 440.182 & 441.450-484 & 441.500-590).
  • Case Management: Services that help coordinate care for individuals with complex medical needs (1905(a)(19), 42 CFR 440.169 & 441.18).
  • Hospice Care: Care for terminally ill individuals (19 )

Remember: Knowing your benefits and choosing the right program empowers you to manage your healthcare effectively. Utilize the resources provided to make informed decisions for your well-being.

Resources for Choosing the Right Plan: