Mandatory benefits include services that include inpatient and outpatient hospital services, medical services, laboratory and X-ray services, and home health care. Mandatory benefits include services that include inpatient and outpatient hospital services, medical services, laboratory and X-ray services, and home health services, and others. Optional benefits include services that include prescription drugs, case management, physical therapy and occupational therapy. Most people age 65 and older and many people under 65 with disabilities have Medicare, but Medicare doesn't cover most of the LTSS; instead, Medicaid is the primary payer of the LTSS.
LTSS encompasses a wide range of paid and unpaid medical and personal care services that help with activities of daily living (such as eating, bathing, and dressing) and instrumental activities of daily living (such as preparing meals, managing medications, and doing household chores). They are provided to people who need such services because of age, chronic illness, or disability. These services include nursing facility care, adult day care programs, home health care services, personal care services, transportation, and supported employment. They may be provided for several weeks, months or years, depending on the person's health care coverage and level of need.
For a long time, there have been difficulties in finding enough workers to provide LTSS to all those who need such services, and the COVID-19 pandemic considerably aggravated those problems. As the population ages and advances in medicine and technology allow people with severe disabilities to live longer, the number of people who need LTSS is expected to increase. Medicaid is a joint federal and state program that helps cover the medical costs of certain low-income individuals, families and children, pregnant women, the elderly, and people with disabilities. Medicaid also helps cover the medical costs of other adults. Medicaid offers benefits not normally covered by Medicare, such as personal care and nursing home care services.
The rules about who is eligible for Medicaid are different in each state. Medicaid covers a variety of inpatient and outpatient medical services. Benefits include behavioral health services, addiction treatment and recovery, dental services and prescription drugs. Consult your manual to find out what benefits you can receive.
Navigate to the different pages in this section to learn more about specific benefits. Medicaid pays Medicare premiums and often provides comprehensive coverage for services not covered by Medicare (such as most long-term services and supports) to nearly 1 in 5 Medicare beneficiaries (13 million). Medicaid accounts for one-sixth of health care spending (and half of spending on long-term services and supports) and a large part of state budgets (figure). Medicaid for Children with Special Needs (PH9) provides full and free health care (MA) coverage to children up to 18 with disabilities whose parents earn too much money to qualify for traditional Medicaid categories.
Long-term coverage of services and supports is mandatory in nursing facilities, but most HCBS coverage is optional. Medicaid accounts for one-sixth of health care spending (and half of spending on long-term services and supports) and a large part of state budgets. This change reflects the preferences of beneficiaries to receive care in non-institutional settings and the requirements for states to provide services in the least restrictive environment possible, derived from the Olmstead decision. Some states have also applied for approval to provide ongoing Medicaid coverage for children and certain adults for periods longer than one year.
The changes in Medicaid policies have implications for the approximately 80 million people who rely on the program for health coverage, for state and federal budgets and expenditures, and for healthcare providers, including nursing facilities and home and community service providers. Medicare provides health care at home and in skilled nursing facilities under specific circumstances, but the Medicare benefit is considered “post-acute care” and is generally not available to people who need ongoing services. Medicaid coverage is limited for immigrants and, with the exception of emergency services, Medicaid coverage is not available to undocumented immigrants. Unlike commercial health insurance and Medicare, Medicaid also covers non-emergency medical transportation, which helps members keep appointments, and long-term care, including nursing home care and many home and community services (HCBS).
As a result of the ACA, the average level of coverage for parents and adults without dependent children is 138 percent of the FPL, but in states that haven't adopted the expansion of the ACA, the median of parental eligibility was 38 percent of the FPL. Over time, Congress expanded the minimum federal requirements and offered new requirements and coverage options to states, especially for children, pregnant women and people with disabilities. Medicaid, also known as Medical Assistance (MA), pays for the health care services of people who qualify. Services provided in non-institutional settings are known as home and community-based services (HCBS), and these settings can include a person's home, adult day care, assisted living environments, and group homes.
