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Medicaid - Scope of Services

Title XIX of the Social Security Act (the Medicaid program) allows considerable flexibility within the States' Medicaid plans. However, some Federal requirements are mandatory if Federal matching funds are to be received. A State's Medicaid program must offer medical assistance for certain basic services to most categorically needy populations. These services generally include:

   inpatient hospital services;

   outpatient hospital services;

   prenatal care;

   vaccines for children;

   physician services;

   nursing facility services for persons aged 21 or older;

   family planning services and supplies;

   rural health clinic services;

   home health care for persons eligible for skilled-nursing services;

   laboratory and x-ray services;

   pediatric and family nurse practitioner services;

   nurse-midwife services;

   Federally-qualified health-center (FQHC) services, and ambulatory services of an FQHC that would be available in other settings; and

   early and periodic screening, diagnostic, and treatment (EPSDT) services for children under age 21.

States also may receive Federal matching funds for providing certain optional services. The most common of the 34 currently-approved optional Medicaid services include:

   diagnostic services;

   clinic services;

   intermediate care facilities for the mentally retarded (ICFs/MR);

   prescribed drugs and prosthetic devices;

   optometrist services and eyeglasses;

   nursing facility services for children under age 21;

   transportation services;

   rehabilitation and physical therapy services; and

   home and community-based care to certain persons with chronic impairments.


The Balanced Budget Act included another provision for eligible persons as a State option known as PACE (Programs of All-inclusive Care for the Elderly). PACE provides an alternative to institutional care for persons aged 55 and over who require a nursing facility level of care. The PACE team offers and manages all health, medical and social services, and mobilizes other services as needed to provide preventative, rehabilitative, curative and supportive services. This care is provided in day health centers, homes, hospitals and nursing homes -- while helping the person maintain independence, dignity and quality of life. PACE functions within the Medicare program as well as under Medicaid. Regardless of source of payment, PACE providers receive payment only through the PACE agreement, and must make available all items and services covered under both Titles XVIII and XIX without amount, duration or scope limitations, and without application of any deductibles, co-payments or other cost sharing. The individuals enrolled in PACE receive benefits solely through the PACE program.

See these topics for additional information:

   Medicaid - Overview

   Medicaid - Eligibility

   Medicaid - Amount and Duration of Services

   Medicaid - Payment for Services

   Medicaid - Data Summary and Trends

   Relationship of Medicaid and Medicare


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