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Medicaid - Amount and Duration of Services

Within broad Federal guidelines and certain limitations, States determine the amount and duration of services offered under their Medicaid programs. States may limit, for example, the number of days of hospital care or the number of physician visits covered. Two restrictions apply: (1) limits must result in a sufficient level of services to reasonably achieve the purpose of the benefits; and (2) limits on benefits may not discriminate among beneficiaries based on medical diagnosis or condition.

In general, States are required to provide Medicaid coverage for comparable amounts, duration and scope of services to all categorically-needy and categorically-related eligible persons. There are two important exceptions: 1) Medically necessary health care services identified under the EPSDT program for eligible children which are within the scope of mandatory or optional services under Federal law, must be covered even if those services are not included as part of the covered services in that State's Plan (i.e., only these specific children might receive that specific service); and 2) States may request "waivers" to pay for otherwise-uncovered home and community-based services (HCBS) for Medicaid-eligible persons who might otherwise be institutionalized (i.e., only persons so designated might receive HCBS). States have few limitations on the services that may be covered under such waivers as long as the services are cost effective (except that, other than as a part of respite care, they may not provide room and board for such recipients). With certain exceptions, a State's Medicaid Plan must allow recipients to have some informed choices among participating providers of health care, and to receive quality care that is appropriate and timely.

See these topics for additional information:

·   Medicaid - Overview

·   Medicaid - Eligibility

·   Medicaid - Scope of Services

·   Medicaid - Payment for Services

·   Medicaid - Data Summary and Trends

·   Relationship of Medicaid and Medicare

Source

http://www.cms.hhs.gov/MedicareProgramRatesStats/02_SummaryMedicareMedicaid.asp

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