GENERAL INFORMATION – ABOUT MEDICAID BENEFITS           

These tables reflect services, limitations and reimbursement methodologies in effect at five specific points in time - January 1, 2003, October 1, 2004, October 1, 2006, October 1, 2008 and October 1, 2010. For each point in time, there are tables for all fifty states, the District of Columbia and the five U.S. territories: American Samoa, Guam, the Northern Mariana Islands, Puerto Rico and the Virgin Islands (henceforth collectively called "states" for simplicity). The source documents were Medicaid State Plans and State Plan amendments submitted to and approved by the Department of Health and Human Services' Centers for Medicare & Medicaid Services (CMS). Additional information was obtained from state web sites.

From this information, state-specific summaries were prepared by Esther Reagan at Health Management Associates and sent to Medicaid officials in the respective jurisdictions for validation. Notes on the structure as well as definitions used throughout the database are included below; please contact Jhamirah Howard or Laura Snyder at the Kaiser Commission on Medicaid and the Uninsured with any questions.

1. Every state Medicaid program covers certain population groups that are defined in federal law as mandatory; often these groups are collectively called the Categorically Needy (CN) although technically coverage of some CN populations is optional. States may also cover additional groups at their option; these groups are often collectively called the Medically Needy (MN) although a subset also bears the name and, as previously indicated some CN populations are optional. For simplicity, if a state only covers the mandatory population groups, the acronym CN appears. If the state has chosen to cover any of the optional population groups, the acronym MN also appears, however the specific groups covered are not identified. States with waivers may have their Medicaid populations identified differently on the tables. See the state-specific footnotes for additional information.
   • The mandatory coverage groups are primarily:
     • Low-income families with children receiving cash assistance through the Temporary Assistance for Needy Families (TANF) program (and for a short period thereafter) or with income and assets meeting requirements of the Aid to Families with Dependent Children (AFDC) program that were in effect in July 1996 before passage of the TANF block grant welfare reform law;
     • Persons receiving Supplemental Security Income (SSI) benefits (although a few states have more restrictive requirements);
     • Pregnant women and children with family income below specified levels;
     • Children receiving foster care and adoption assistance under Title IV-E of the Social Security Act;
     • "Dual eligible" Medicare beneficiaries (also called Qualified Medicare Beneficiaries, or QMBs); and
     • Special protected groups including certain working disabled beneficiaries and former recipients of SSI benefits.
   • The most common optional coverage groups include:
     • The Medically Needy group - individuals who do not meet the financial standards to qualify them for program benefits through a mandatory coverage group but may qualify by "spending down" - incurring medical bills that reduce their excess income and/or resources to qualifying levels;
     • The Poverty Level group - also called the Aged and Disabled group - individuals over age 65 or with a disability who have low income but do not qualify under a mandatory coverage category;
     • The Medicaid "buy-in" group, i.e., disabled adults participating through authority in the Balanced Budget Act of 1997 or the Ticket to Work and Work Incentives Improvement Act (TWWIIA);
     • The Special Income group - individuals receiving care in an institutional setting such as a nursing facility or Intermediate Care Facility for the Mentally Retarded/Developmentally Disabled (ICF/MR) or alternatively in a home and community-based services waiver program and who are not otherwise Medicaid eligible;
     • Individuals who require hospice care, have low income but do not qualify under another Medicaid coverage category;
     • The TEFRA (Tax Equity and Fiscal Responsibility Act of 1982) group - children needing institutional care who may be served in their homes for lower cost and whose family income is not counted;
     • Pregnant women with income above the threshold for mandatory coverage but below a federally-specified higher income level; and
     • Breast and Cervical Cancer Treatment Program participants.
2. Federal law also specifies services that must be covered by Medicaid programs. Other services may be offered, at a state's option, if approved by CMS. Mandatory coverages include:
   • Inpatient hospital services, excluding services for mental disease;
   • Outpatient hospital services;
   • Federally qualified health center services;
   • Rural health clinic services (if permitted under state law);
   • Laboratory and x-ray services rendered outside a hospital or clinic;
   • Nursing facility services for beneficiaries age 21 and older;
   • Physician services;
   • Certified pediatric and family nurse practitioner services (when licensed to practice under state law);
   • Nurse mid-wife services;
   • Medical and surgical services of a dentist;
   • Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services for children;
   • Family planning services and supplies;
   • Home health services for beneficiaries who are entitled to nursing facility services under the state's Medicaid plan, including intermittent or part-time nursing services, home health aide services and medical supplies and appliances for use in the home;
   • Pregnancy-related services and services for other conditions that might complicate pregnancy, as well as postpartum care for 60 days;
   • Tobacco Cessation Services for Pregnant Women (beginning October 1, 2010); and
   • Freestanding Birthing Center Services (when licensed or otherwise recognized by a State).
   See the service-specific footnotes for additional information.
3. The information in these tables does not reflect policies relative to separate State Children's Health Insurance Programs (SCHIP or CHIP).
4. With the exceptions noted in the tables, the information represents a state's policies applicable to adult Medicaid beneficiaries receiving care on a "fee for service" basis. It was not feasible to include the nuances associated with coverages and limitations for care provided by the many contracted managed care organizations operating within the states because, in some cases, they are allowed to use different coverage and reimbursement policies. To the extent possible, distinctions affecting coverages, limitations and copayment requirements have been made in the tables for states with research and demonstration waivers. See the state-specific footnotes for additional information.
5. If a "No" appears in the "Is the Benefit Covered?" column on a table, the service is not covered for adults in the particular state as of the specific point in time or the state does not allow direct reimbursement to the provider type although the service may be covered when billed by another provider, e.g., therapy services provided in an institutional setting. The "Copayment Requirement" field on a table is blank unless the state requires a copayment for that service. The state-specific footnotes may provide additional information regarding copayment requirements. Other fields may be blank unless the state has identified a specific and noteworthy characteristic beyond those in the state or service-specific footnotes.
6. Although a particular service may not be identified on a table as covered, the state is obligated by federal law to provide it for a child if it has been determined medically necessary through an Early and Periodic Screening, Diagnosis and Treatment (EPSDT) screening (e.g., a well-child exam) and the state agrees with that determination.
7. Likewise, although a particular service may not be identified on a table as covered, the state is also obligated to pay Medicare coinsurance and/or deductible amounts up to specified limits for Qualified Medicare Beneficiaries (QMBs) receiving a service covered by Medicare, even if the Medicaid program does not otherwise cover it or the individual is not otherwise eligible for Medicaid benefits.
8. Absent Waiver or State Plan approval from CMS, federal regulations preclude states from charging copayments for services rendered to Medicaid-eligible children up to age 18 (although most states with copayment policies extend the exemption up to age 21). Copayments cannot be charged for emergency services, pregnancy or family planning services or for services rendered to beneficiaries residing in institutions, e.g., nursing facilities. As a result of language in the ARRA of 2009, American Indians are exempted from any state Medicaid copayment requirement for services furnished by the Indian Health Service, an Indian Tribe, Tribal Organization or Urban Indian Organization or through referral from one of these entities to a contracted health services provider. There are premium exemptions as well.
9. "Year" may refer to calendar year, state fiscal year, contract year or any other 12-month period.
10. States establish prior approval requirements for many individual procedures, items or circumstances to assure medical necessity and appropriate utilization of funds. Identification of every prior approval requirement on these tables was not feasible so only selected requirements appear. The service-specific footnotes reference other common prior approval requirements. An exception to any coverage limitation cited would require prior approval by the state Medicaid agency.
11. A summary of acronyms used in the tables appears below. Many of the terms are explained in service-specific footnotes.
    • ADL: Activities of Daily Living - a term used to describe an individual's need for Personal Care services
    • APC: Ambulatory Payment Classifications - a methodology used by the Medicare program and a number of state Medicaid programs to group outpatient hospital services that are similar clinically and in terms of the resources they require such that an all-inclusive payment may be made
    • APG: Ambulatory Patient Group - a methodology similar to APCs used to group and reimburse outpatient hospital services
    • ASA: American Society of Anesthesiologists - an organization setting base rates for anesthesia services that some states use
    • ASC: Ambulatory Surgery Center
    • BBA: Balanced Budget Act of 1997 - a federal law providing states an option to cover working disabled persons
    • AWP: Average Wholesale Price - a term used in prescription drug pricing
    • CHIP: State Children's Health Insurance Program - created in 1997 through addition of Title XXI to the Social Security Act - until 2009 the acronym was SCHIP
    • CHIPRA: Children's Health Insurance Program Reauthorization Act - the 2009 law that reauthorized CHIP and includedother provisions affecting Medicaid
    • CMS: Centers for Medicare & Medicaid Services within the U.S. Department of Health and Human Services
    • CN: Categorically Needy
    • CRNA: Certified Registered Nurse Anesthetist
    • CT: CT Scan - Computerized Axial Tomography
    • DAW: Dispense As Written - a term related to the dispensing of prescription drugs
    • DME: Durable Medical Equipment
    • DRG: Diagnosis Related Groups: a per-discharge reimbursement methodology that bases payment on the patient's age, primary diagnosis and procedures rendered during an inpatient hospital stay
    • EPSDT: Early and Periodic Screening, Diagnosis and Treatment
    • ER: Emergency Room, or Emergency Department of a hospital
    • FQHC: Federally Qualified Health Center
    • FUL: Federal Upper Limit - a term used in prescription drug pricing
    • HIFA: Health Insurance Flexibility and Accountability - a type of Section 1115 Waiver
    • ICF/MR: Intermediate Care Facility for the Mentally Retarded/Developmentally Disabled
    • ICU: Intensive Care Unit
    • IMD: Institution for Mental Diseases - a hospital or nursing facility for inpatient treatment of persons with mental illness
    • LOC: Level of Care
    • LOS: Length of Stay
    • LTACH: Long-Term Acute Care Hospital
    • LTC: Long-Term Care
    • MAC: Maximum Allowable Cost - a term used in prescription drug pricing alternatively with SMAC
    • MN: Medically Needy
    • MSW: Medical Social Worker
    • OT: Occupational Therapy
    • OTC: Over the Counter, as in drugs available without a prescription
    • PDL: Preferred Drug List
    • PIHP: Prepaid Inpatient Health Plan - an entity that provides specialty services, often related to mental health and substance abuse that are generally reimbursed on a capitation basis
    • PRTF: Private Residential Treatment Facility
    • PT: Physical Therapy
    • RBRVS: Resource Based Relative Value Scale - often used in setting reimbursement rates for physician services
    • RHC: Rural Health Clinic
    • RN: Registered Nurse
    • RX: Prescription
    • SBIRT: Screening, Brief Intervention and Referral for Treatment - a term used relative to substance abuse services
    • SMAC: State Maximum Allowable Cost - a term used in prescription drug pricing alternatively with MAC
    • SP: Speech Pathology - sometimes called Speech Therapy
    • TWWIIA: Ticket to Work and Work Incentives Improvement Act - a federal law providing states an option to cover working disabled persons
    • WAC: Wholesale Acquisition Cost - a term used in prescription drug pricing

• The mandatory coverage groups are primarily:
  
  • Low-income families with children receiving cash assistance through the Temporary Assistance for Needy Families (TANF) program (and for a short period thereafter) or with income and assets meeting requirements of the Aid to Families with Dependent Children (AFDC) program that were in effect in July 1996 before passage of the TANF block grant welfare reform law;
  • Persons receiving Supplemental Security Income (SSI) benefits (although a few states have more restrictive requirements);
  • Pregnant women and children with family income below specified levels;
  • Children receiving foster care and adoption assistance under Title IV-E of the Social Security Act;
  • “Dual eligible” Medicare beneficiaries (also called Qualified Medicare Beneficiaries, or QMBs); and
  • Special protected groups including certain working disabled beneficiaries and former recipients of SSI benefits.
    
    
• The most common optional coverage groups include:
• The Medically Needy group – individuals who do not meet the financial standards to qualify them for program benefits through a mandatory coverage group but may qualify by “spending down” – incurring medical bills that reduce their excess income and/or resources to qualifying levels;
• The Poverty Level group – also called the Aged and Disabled group – individuals over age 65 or with a disability who have low income but do not qualify under a mandatory coverage category;
• The Medicaid “buy-in” group, i.e., disabled adults participating through authority in the Balanced Budget Act of 1997 or the Ticket to Work and Work Incentives Improvement Act (TWWIIA);
• The Special Income group – individuals receiving care in an institutional setting such as a nursing facility or Intermediate Care Facility for the Mentally Retarded/Developmentally Disabled (ICF/MR) or alternatively in a home and community based services waiver program and who are not otherwise Medicaid eligible;
• Individuals who require hospice care, have low income but do not qualify under another Medicaid coverage category;
• The TEFRA (Tax Equity and Fiscal Responsibility Act of 1982) group – children needing institutional care who may be served in their homes for lower cost and whose family income is not counted;
• Pregnant women with income above the threshold for mandatory coverage but below a federally-specified higher income level; and
• Breast and Cervical Cancer Treatment Program participants.

4. Federal law also specifies services that must be covered by Medicaid programs. Other services may be offered, at a state’s option, if approved by CMS. Mandatory coverages include:

• Inpatient hospital services, excluding services for mental disease;
• Outpatient hospital services;
• Federally qualified health center services;
• Rural health clinic services (if permitted under state law);
• Laboratory and x-ray services rendered outside a hospital or clinic;
• Nursing facility services for beneficiaries age 21 and older;
• Physician services;
• Certified pediatric and family nurse practitioner services (when licensed to practice under state law);
• Nurse mid-wife services;
• Medical and surgical services of a dentist;
• Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services for children;
• Family planning services and supplies;
• Home health services for beneficiaries who are entitled to nursing facility services under the state’s Medicaid plan, including intermittent or part-time nursing services, home health aide services and medical supplies and appliances for use in the home; and
• Pregnancy-related services and services for other conditions that might complicate pregnancy, as well as postpartum care for 60 days.

5. The information in these tables does not reflect policies relative to separate State Children’s Health Insurance Programs (SCHIP or CHIP).
   
   
6. With a few exceptions noted in the tables, the information represents a state’s policies applicable to adult Medicaid beneficiaries receiving care on a “fee for service” basis. It was not feasible to include the nuances associated with coverages and limitations for care provided by the many contracted managed care organizations operating within the states because, in some cases, they are allowed to use different coverage and reimbursement policies. To the extent possible, distinctions affecting coverages, limitations and copayment requirements have been made in the tables for those states with research and demonstration waivers. See the state-specific footnotes for additional information.
   
   
7. If a “No” appears in the “Is the Benefit Covered?” column on a table, the service is not covered for adults in the particular state as of the specific point in time or the state does not allow direct reimbursement to the provider type although the service may be covered when billed by another provider, e.g., therapy services provided in an institutional setting. The “Copayment Requirement” field on a table is blank unless the state requires a copayment for that service. The state-specific footnotes may provide additional information regarding copayment requirements. Other fields may be blank unless the state has identified a specific and noteworthy characteristic beyond those in the state or service-specific footnotes.
   
   
8. Although a particular service may not be identified on a table as covered, the state is obligated by federal law to provide it for a child if it has been determined medically necessary through an Early and Periodic Screening, Diagnosis and Treatment (EPSDT) screening and the state agrees with that determination.
   
   
9. Likewise, although a particular service may not be identified on a table as covered, the state is also obligated to pay Medicare coinsurance and/or deductible amounts up to specified limits for Qualified Medicare Beneficiaries (QMBs) receiving a service covered by Medicare, even if the Medicaid program does not otherwise cover it or the individual is not otherwise eligible for Medicaid benefits.
   
   
10. Absent waiver approval from CMS, federal regulations preclude states from charging copayments for services rendered to Medicaid-eligible children up to age 18 (although most states with copayment policies extend the exemption up to age 21). Copayments cannot be charged for emergency services, pregnancy or family planning services, or for services rendered to beneficiaries residing in institutions, e.g., nursing facilities.
    
    
11. A reference in a table to “year” may mean calendar year, state fiscal year, contract year or any other 12-month period.
    
    
12. States establish prior approval requirements for many individual procedures, items or circumstances to assure medical necessity and appropriate utilization of funds. Identification of every prior approval requirement on these tables was not feasible so only selected requirements appear. The service-specific footnotes reference other common prior approval requirements. An exception to any coverage limitation cited would require prior approval by the state Medicaid agency.
    
    
13. A summary of acronyms used in the tables appears below. Many of the terms are explained in service-specific footnotes.

State Footnotes