What Medicaid Usually Covers: From Doctor Visits to Hospital Care and Prescriptions

Medicaid can be a lifeline if you’re struggling to afford health care. But it’s not always clear what Medicaid actually covers or how coverage can vary by state.

This guide walks through the types of services Medicaid often pays for, especially doctor visits, hospital care, and prescriptions, and how to find out exactly what your own plan covers. It also explains who typically qualifies, how coverage decisions are made, and what to do if something is denied.

HowToGetAssistance.org is not a government agency, not an insurance company, and not an application site. This article is for information only, to help you understand the usual process and then contact official Medicaid offices for your specific situation.

Medicaid in Plain English

Medicaid is a public health insurance program that helps people with limited income and resources pay for medical care. It is funded by both the federal government and the states, but each state runs its own Medicaid program.

Because of this:

• Basic categories of coverage are similar across the country, but
• Exact covered services, rules, and limits can differ by state.

To get details that apply to you, you’ll need to check with:

• Your state Medicaid agency
• Your plan’s member handbook (if you are in a managed care plan)
• The official Medicaid customer service line in your state

Who Typically Qualifies for Medicaid Coverage

Eligibility rules vary by state, but people who often qualify include:

• Adults with low income (especially in states that expanded Medicaid)
• Children in low-income households
• Pregnant people
• Older adults with limited income and assets
• People with disabilities
• Certain foster youth or people in specific care programs

States usually look at:

• Household income
• Family size
• Citizenship or immigration status requirements
• State residency
• Sometimes assets/resources, especially for long-term care programs

To see if you qualify, you generally must apply through your state’s official benefits portal, local office, or Medicaid hotline.

What Medicaid Typically Covers: Big Picture

Medicaid coverage is built around two types of benefits:

• Mandatory services: States are required to cover these (with some differences in how they’re delivered).
• Optional services: States can choose whether to cover these, and many do.

Below is a general overview. For exact coverage, limits, and copays, check with your state Medicaid agency or your plan’s handbook.

Doctor Visits Under Medicaid

Primary Care and Routine Visits

Medicaid usually covers doctor visits for:

• Checkups and routine care
• Sick visits when you’re ill or injured
• Chronic condition management (like diabetes or high blood pressure)
• Referrals to specialists when needed

Key points:

• You might be asked to choose a primary care provider (PCP) if you’re in a managed care plan.
• Some visits may require prior authorization (approval in advance), especially for certain procedures or specialist services.
• For many low-income groups, copays are small or sometimes $0, depending on the state and type of visit.

Specialist Visits

Medicaid generally covers specialist care when medically necessary, such as:

• Cardiologists
• Endocrinologists
• Orthopedists
• Mental health specialists
• Other medical specialists

However:

• Referrals from your primary doctor are often required.
• In-network providers (doctors who take your specific Medicaid plan) typically cost less or have no additional cost to you.
• Out-of-network specialist visits may not be covered or may require special approval.

Hospital Care Under Medicaid

Medicaid typically covers a broad range of inpatient and outpatient hospital services when they are medically necessary.

Inpatient Hospital Stays

This usually includes:

• Room and board in the hospital
• Surgery and procedures
• Nursing care
• Medications given in the hospital
• Required tests and imaging (like X-rays, MRIs, CT scans)
• Emergency room visits that lead to hospital admission

Things to know:

• Some states require prior authorization for non-emergency admissions.
• Emergency care is generally covered when it meets emergency criteria, but states may review if something truly counted as an emergency.
• There may be limits on the number of days covered per year, depending on the state.

Outpatient Hospital Services

Medicaid often covers hospital-based outpatient services, such as:

• Same-day surgeries
• Lab tests and imaging
• Some specialty treatments
• Certain therapies done at hospital clinics

Depending on your state:

• You may have a small copay for outpatient visits.
• Some high-cost procedures may need prior authorization.

Prescription Drug Coverage Under Medicaid

While prescription drugs are technically an “optional” service under federal rules, all states currently provide some level of prescription drug coverage through Medicaid.

Typical Prescription Coverage

Medicaid prescription coverage often includes:

• Generic medications
• Many brand-name drugs (with limits or prior authorizations)
• Long-term medications for chronic conditions
• Some specialty medications, which often require more paperwork or approvals

States and plans usually have a preferred drug list (PDL) or formulary:

• This is a list of medications the plan covers.
• Drugs not on the list may require special approval before they’re covered.
• Substitutions may be suggested (for example, generic instead of brand-name).

Copays and Limits for Prescriptions

Depending on your state and eligibility group:

• You may pay a small copay per prescription, often lower for generics.
• There may be monthly limits on the number of prescriptions, especially for certain groups.
• Some medications may require:
  • Prior authorization
  • Step therapy (trying lower-cost drugs before higher-cost ones)
  • Quantity limits

Your pharmacist or doctor can often help you understand what is covered under your specific Medicaid plan.

Other Services Medicaid Often Covers

While this guide focuses on doctor visits, hospital care, and prescriptions, many Medicaid programs also cover:

• Laboratory tests and X-rays
• Emergency services
• Maternity and newborn care
• Behavioral health and substance use treatment
• Nursing home care and some home- and community-based services
• Preventive services like vaccines and screening tests
• Pediatric services, including dental and vision in many states

Coverage details vary widely by state, so it’s important to confirm with your state Medicaid agency or plan.

At-a-Glance: Common Medicaid-Covered Services

*“Usually covered” means these services are commonly part of Medicaid benefits but details, limits, and rules vary by state and plan.

How to Confirm What YOUR Medicaid Plan Covers

Because Medicaid is state-run, the most reliable details come directly from your official state sources. To check coverage:

1. Find your state Medicaid program name.
   Look for “Medicaid” plus your state’s name through an official government site, or contact your state health or human services department.

2. Review your member ID card or enrollment packet.
   It usually lists:

   • Your plan name (for example, a managed care organization)
   • Member services phone number
   • Website for coverage details

3. Call your plan’s member services or the state Medicaid hotline.
   You can ask:

   • “Is [service] covered under my plan?”
   • “Are there limits or prior authorization needed for [service]?”
   • “Which providers are in-network near me?”

4. Ask your doctor’s office to check.
   Many clinics verify Medicaid coverage and authorization requirements before scheduling procedures.

What Documents to Gather for Applying to Medicaid

To find out whether Medicaid will cover your visits, hospital care, and prescriptions, you often must be enrolled first. Application steps differ by state, but common documents include:

• Identity: Driver’s license, state ID, or other photo ID
• Social Security number (for each person applying, when available)
• Proof of income: Pay stubs, employer letter, unemployment statements
• Proof of residency: Utility bill, lease, or official mail with your address
• Immigration or citizenship documents, if applicable
• Health insurance information if you have any other coverage

You’ll typically apply through:

• Your state’s official online benefits portal
• A local Medicaid office or county human services department
• A state or county phone line where you can request an application or get help

HowToGetAssistance.org cannot accept applications and cannot check your eligibility or status. Those steps must be done through official state channels.

What Happens After You Apply

Once you submit an application through the official state system:

1. Review and verification
   The state checks your income, residency, and other eligibility factors. They may request additional documents.

2. Approval or denial notice
   You’ll receive a written notice by mail (and sometimes online) that:

   • Approves or denies coverage
   • Lists your coverage start date
   • Explains your plan type and possibly your assigned PCP

3. Enrollment in a managed care plan (in many states)
   You may be asked to choose a health plan or be assigned one. The plan will send:

   • A member ID card
   • A benefits handbook summarizing what is covered

4. Using your coverage
   Present your Medicaid or plan ID card when you:

   • Visit a doctor or hospital
   • Fill a prescription at the pharmacy

Common Reasons Services Get Delayed or Denied

Even if you have Medicaid, certain services may be delayed, limited, or denied. Some common reasons include:

• Not medically necessary under program rules
  If the service doesn’t meet your state’s definition of “medically necessary,” it might not be covered.

• Lack of prior authorization
  Some hospital stays, procedures, and brand-name prescriptions require advance approval. If this wasn’t done, the claim may be denied.

• Out-of-network provider
  If your plan works with a network of providers, going outside that network may lead to higher costs or no coverage, unless it’s an emergency or pre-approved.

• Exceeded benefit limits
  Some services (like certain therapies or number of hospital days) have annual or lifetime limits set by the state or plan.

• Eligibility issues
  Coverage may be paused or ended if:

  • You didn’t complete a renewal on time
  • Your income or household changed and no update was reported

If something is denied, your notice is required to explain why and outline your rights to appeal.

How Appeals and Reviews Usually Work

If Medicaid or your plan denies a service or payment you believe should be covered:

1. Read the denial notice carefully.
   It should state:

   • The reason for the denial
   • The deadline to appeal (very important)
   • How to file an appeal or fair hearing request

2. Gather supporting information.
   This may include:

   • A letter from your doctor explaining why you need the service
   • Medical records or test results
   • Any related documents from your plan

3. File an appeal through the official process.
   This might be:

   • An internal appeal with your Medicaid plan
   • A state fair hearing with a hearing officer or administrative law judge
   • Sometimes both, in a certain order

4. Keep copies and proof of submission.
   Keep:

   • Copies of all letters
   • Fax confirmations or certified mail receipts
   • Notes of who you spoke with and when

Appeal rules, deadlines, and forms vary by state and plan, so follow the instructions in your official denial notice closely.

If You Don’t Qualify for Medicaid or Lose Coverage

If you’re not eligible for Medicaid or your coverage ends, some other options may help you access doctor visits, hospital care, and medications:

• Children’s health programs (CHIP)
  In many states, children in families that earn too much for Medicaid may qualify for a separate children’s coverage program.

• Health insurance marketplace plans
  Depending on your income and household size, you may qualify for subsidized private plans through your state or federal health insurance marketplace.

• Community health centers and free/low-cost clinics
  Many provide:

  • Low-cost primary care
  • Some specialty services
  • Help accessing affordable prescriptions

• Prescription assistance programs
  Some pharmacies, manufacturers, and nonprofits offer discounts or assistance programs for certain medications.

• Hospital financial assistance programs
  Many hospitals have charity care or sliding-scale programs for people without coverage or with very low income.

To find local help, you can contact:

• 2-1-1 (in many areas) to connect with local health and social services
• Your county health department
• Community health centers or nonprofit clinics in your area

How to Make Sure You’re Using an Official Medicaid Channel

Because Medicaid is an important benefit, there are unfortunately scams and unofficial sites that may try to collect your personal information or charge you fees.

To protect yourself:

• Look for .gov websites
  Official state Medicaid sites often end in “.gov” or are clearly linked from your state government website.

• Be cautious of fees
  Applying for Medicaid through official channels is typically free. Be wary of anyone who:

  • Guarantees approval for a fee
  • Asks you to pay to submit your application

• Use official phone numbers and offices
  Get contact numbers from:

  • Your state government website
  • Printed materials from your county or state office
  • Information given by recognized public agencies

• Protect your personal information
  Only share details like your Social Security number or immigration documents with:

  • Official state agencies
  • Authorized Medicaid plans
  • Trusted assister organizations clearly recognized by the state

HowToGetAssistance.org does not request or process applications, Social Security numbers, or medical information.

Understanding what Medicaid covers—especially for doctor visits, hospital care, and prescriptions—can help you plan your health care and ask the right questions. The exact details depend on your state’s Medicaid program and your specific plan, so your next step is to contact your state Medicaid agency or your plan’s member services line for personalized coverage information.