What does Medicaid cover?

Last verified: June 2026

Medicaid coverage depends on a two-layer system: federal law sets the floor, and each state decides how much higher to go. What does Medicaid cover in your state? At minimum, it covers the same core services that federal law requires every state to provide — but most states layer on dozens of additional benefits. As of 2025, Medicaid covers roughly 83 million people, or about 1 in 5 Americans, per KFF.

The practical answer varies considerably by state, age, and eligibility category. A child enrolled through CHIP-Medicaid in Ohio gets different benefits than a senior in a nursing facility in Mississippi. That variation is intentional — the program was designed to let states tailor coverage to their populations and budgets, within federal rules.

This page explains the federal mandatory benefit categories, the optional benefits states commonly add, the unique protections for children under 21, and what Medicaid largely does not cover.

Mandatory benefits every state must cover

Federal law (Social Security Act Title XIX) requires all state Medicaid programs to cover a defined set of services. States have some flexibility in how they deliver these services, but they cannot drop them from the program without losing federal matching funds.

Per CMS, mandatory Medicaid benefits include:

• Inpatient hospital services
• Outpatient hospital services
• Physician services
• Laboratory and X-ray services
• Home health services (for enrollees who qualify for nursing facility care)
• Nursing facility services for adults
• Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) for enrollees under age 21
• Family planning services and supplies
• Non-emergency medical transportation to covered services
• Nurse-midwife services
• Medication Assisted Treatment (MAT) for opioid use disorder
• Tobacco cessation counseling for pregnant women

The scope of these mandatory benefits is broad, but "covered" does not always mean "unlimited." States set the type, amount, duration, and scope of each service within federal guidelines. A state can, for example, limit inpatient hospital days to a set number per year, as long as that limit is medically sufficient for most enrollees and does not discriminate based on diagnosis.

Tobacco cessation counseling for pregnant women became mandatory under the Affordable Care Act — it was previously optional. That change took effect starting with fiscal year 2011 state plans, per CMS guidance.

Optional benefits states may choose to add

No state stops at the mandatory floor. Every state elects at least some optional benefits, and the most widely elected ones have become de facto universal. Prescription drugs are the clearest example — all states cover them even though federal law does not require it.

Common optional benefits that most states cover:

• Prescription drugs
• Dental services for adults
• Vision care and eyeglasses
• Physical therapy
• Occupational therapy
• Speech, hearing, and language services
• Dentures and prosthetics
• Hospice care
• Personal care services (help with activities of daily living)
• Home and community-based services (HCBS) for long-term care
• Case management
• Private duty nursing
• Inpatient psychiatric services for individuals under age 21

The variation in optional benefits is where states differ most sharply. Per KFF research (2025), per full-benefit enrollee spending ranged from $3,713 per year in Alabama to $10,229 per year in the District of Columbia. That gap reflects not just cost differences but genuine differences in which services states elect to cover.

Adult dental coverage is one of the most uneven optional benefits. Some states cover only emergency extractions. Others cover preventive cleanings, fillings, dentures, and periodontal care. A few cover orthodontia in limited circumstances. There is no federal mandate for adult dental coverage at all — it is entirely discretionary.

Home and community-based services (HCBS) waivers deserve special mention. Under Section 1915(c) of the Social Security Act, states can apply for federal waivers to offer personal care, supported employment, adult day services, and similar supports outside of nursing facilities. As of 2025, all states operate at least one HCBS waiver, though most have waiting lists. Getting on a waiver can take months to years in high-demand states.

EPSDT: the most comprehensive benefit in Medicaid

EPSDT — Early and Periodic Screening, Diagnostic, and Treatment — applies to all Medicaid enrollees under age 21. It is not just a benefit; it is a legal guarantee. Authorized under SSA 1905(a)(4)(B) and 1905(r), EPSDT requires states to cover any service that is medically necessary for a child, even if that service is not otherwise in the state's Medicaid plan for adults.

This is a critical distinction. An adult in the same state might have no dental coverage and no behavioral health benefit. The child gets both — mandated by federal law regardless of what the state elected for its adult population.

EPSDT covers:

• Comprehensive physical examinations on a schedule set by the American Academy of Pediatrics
• Immunizations per the Advisory Committee on Immunization Practices (ACIP) schedule
• Vision screening and corrective lenses
• Hearing screening and hearing aids when needed
• Dental care including preventive services, restorations, and orthodontia when medically necessary
• Mental health and behavioral health services
• Developmental screenings and early intervention referrals
• Lead screening and follow-up treatment
• Any other service deemed medically necessary for the child

The "any medically necessary service" clause is the heart of EPSDT. Parents and advocates have successfully used it to obtain coverage for speech therapy, applied behavior analysis (ABA) for autism, private duty nursing, and durable medical equipment that states would otherwise deny for adults.

Medicaid covers nearly half of all children with special health care needs in the United States, per KFF (2025). For many of these children, EPSDT is the only mechanism that makes comprehensive care financially possible.

How managed care affects what you can access

Most Medicaid enrollees do not receive care directly through the state. In a managed care arrangement, your MCO determines which providers are in-network, which prior authorization rules apply, and how quickly referrals are processed. Two enrollees in the same state can have meaningfully different experiences depending on which MCO they're assigned to — the underlying benefit package is set by the state, but MCOs vary in network breadth and administrative processes.

Fee-for-service (FFS) Medicaid still exists in some states and for certain populations, particularly long-term care enrollees and people who are dually eligible for Medicare and Medicaid. Under FFS, the state pays providers directly rather than through an MCO. Access can actually be better under FFS in rural areas where MCO networks are thin — or worse, depending on provider Medicaid acceptance rates in your region.

If your state uses managed care and you are denied a service you believe is covered, you have the right to appeal. State Medicaid agencies maintain independent appeals processes, and managed care denials are subject to external independent review in most states.

What Medicaid does not typically cover

There are real gaps. Knowing them matters as much as knowing what is covered.

Long-term custodial care for working-age adults. This is the biggest misconception. Medicaid covers nursing facility services — but for most working-age adults under 65, the pathway to those benefits requires spending down nearly all assets first (in states without HCBS waiver alternatives). The program was primarily designed to cover acute and preventive medical care. Long-term care benefits for non-elderly, non-disabled adults without waiver coverage are narrow in most states.

Medicaid does pay for 61% of all long-term care spending in the U.S., per KFF — but that spending is concentrated among elderly and disabled enrollees who qualify under specific categories, not the general adult population.

Other common exclusions:

• Cosmetic procedures not medically necessary
• Most over-the-counter drugs (though some states cover select OTC items)
• Services from out-of-network providers in managed care plans, except in emergencies
• Care received outside the United States
• Most non-emergency dental care for adults in states that do not elect the dental benefit
• Experimental treatments not yet approved by CMS or the state

A common misconception: many people assume Medicaid works like Medicare, covering a fixed national benefit package everywhere. It does not. A service covered in California may not be covered in Texas. That is not a glitch — it reflects how the program was designed.

Medicaid also does not cover Medicare cost-sharing for most dual-eligible beneficiaries on a dollar-for-dollar basis. For the roughly 13 million people enrolled in both programs, Medicaid helps with Medicare premiums and some cost-sharing, but the specific wrap-around coverage varies by the dual-eligibility category and the state.

ACA expansion and the Alternative Benefit Plan

Adults who gained Medicaid eligibility through the Affordable Care Act expansion — generally adults with incomes up to 138% of the Federal Poverty Level in expansion states — receive coverage through an Alternative Benefit Plan (ABP). ABPs are mandatory for this population under federal law and must include the ten essential health benefits required of ACA marketplace plans.

That includes mental health and substance use disorder services on par with medical and surgical benefits, maternity care, and preventive care. In many states, the ABP is identical to the state's standard Medicaid benefit package. In others, the ABP was designed specifically to meet the ACA essential health benefit requirements and may differ slightly from traditional Medicaid coverage.

If you enrolled through the ACA expansion, your state's Medicaid agency can confirm which benefit plan you're in. The distinction matters most for behavioral health coverage, where the mental health parity rules for ABPs are clearer than the rules that apply to traditional Medicaid populations.

How to find what your state covers

Federal law requires states to publish their Medicaid State Plan — a formal document describing every benefit the state has elected, the service limits, and the reimbursement methods. These documents are public and available through Medicaid.gov, though they are dense reading.

More practical approaches for most enrollees:

• Call your state Medicaid agency directly — most have member services lines
• If enrolled in a managed care plan, call your MCO's member services number
• Review your MCO's Evidence of Coverage document, which lists covered services
• Use the Medicaid.gov benefit comparison tools to see state-by-state benefit elections
• Consult a patient advocate or social worker if navigating complex coverage questions

For children, always ask about EPSDT specifically. Frontline staff at MCOs sometimes incorrectly deny services based on adult coverage rules that do not apply under EPSDT. If a service is medically necessary and your child is under 21, the state is required to cover it regardless of what the general adult plan says. Escalate denials to the state Medicaid agency if necessary.

Coverage also changes. States amend their Medicaid plans, add and remove optional benefits, and adjust service limits. If you had a service covered last year and it was denied this year, a change in your state's plan or MCO contract may explain it — not necessarily a change in your eligibility.

Medicaid vs. Medicare: a quick distinction

Medicaid and Medicare are both federal health programs, and the difference between Medicare and Medicaid trips up a lot of people. Medicare is a federal insurance program for people 65 and older and certain individuals with disabilities — eligibility is based on age or disability status and work history, not income. Medicaid is an income-based assistance program jointly funded by the federal government and states.

Medicare does not cover most long-term care. Medicaid does — for those who qualify financially. That is the reason Medicaid covers 5 in 8 nursing home residents in the United States, per KFF (2025), despite Medicare being the primary coverage for most seniors. Seniors often transition to Medicaid for nursing home costs after depleting their savings under Medicare's 100-day post-hospital benefit limit.

For a full comparison of the programs, see our Medicaid vs. Medicare guide.