Every state's Medicaid program must cover a federal list of mandatory benefits, including hospital care, physician services, home health and transportation to medical care. Prescription drugs, adult dental, eyeglasses, personal care and hospice are optional benefits that each state decides whether to add through its state plan. What you or a parent actually gets also depends on age, on the managed-care plan or waiver that delivers the care, and, for expansion adults, on an Alternative Benefit Plan.

In This Guide

What Medicaid Covers in Every State: The Mandatory Benefits

The Centers for Medicare & Medicaid Services (CMS) publishes the federal benefit list on Medicaid.gov, and states that "States are required to provide all mandatory benefits under federal law." These are the 18 mandatory benefits on that list, in CMS's wording, with what each one means in practice.

Mandatory benefit What it means for you
Inpatient hospital services Hospital care when you are admitted as an inpatient
Outpatient hospital services Hospital services when you are not admitted
Physician services Services furnished by a physician, including medical and surgical care for eye disease
Rural health clinic services Required consistent with state law permitting such services
Federally qualified health center services Care at a Federally Qualified Health Center
Laboratory and X-ray services Lab tests and X-rays
Nursing facility services Covered for people 21 and older
Home health services Part-time or intermittent nursing, home health aide services, and medical supplies and equipment, ordered as part of a written plan of care
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services Screening, diagnosis and treatment for enrollees under 21
Family planning services Family planning services and supplies, with no cost sharing allowed
Tobacco cessation counseling for pregnant women Counseling to help a pregnant enrollee quit tobacco
Nurse midwife services Care from a nurse midwife
Certified pediatric and family nurse practitioner services Care from a certified pediatric or family nurse practitioner
Freestanding birth center services Covered when the center is licensed or otherwise recognized by the state
Transportation to medical care The state must ensure necessary transportation to and from providers
Medication Assisted Treatment (MAT) Approved drugs to treat opioid use disorder, including methadone, plus counseling and behavioral therapy
Routine patient costs in qualifying clinical trials Routine items and services for enrollees in a qualifying clinical trial
Concurrent care for children receiving hospice Care for a child receiving hospice, provided concurrently with hospice

The home health benefit can't be limited to people who are homebound, and a state can't make it contingent on needing nursing or therapy services.

How the statute's list compares

The Social Security Act carries its own required list. Section 1902(a)(10)(A) requires a state plan to make available "at least the care and services listed in paragraphs (1) through (5), (13)(B), (17), (21), (28), (29), and (30)" of section 1905(a) for the individuals that subparagraph describes, and section 1902(a)(10)(C) sets separate rules for other groups.

The statute's list and the Medicaid.gov list differ in two places. Paragraph (13)(B), approved adult vaccines recommended by the Advisory Committee on Immunization Practices and their administration, is in the statutory list but not named on Medicaid.gov's list. Home health services are on Medicaid.gov's list but not among the (10)(A) paragraphs; section 1902(a)(10)(D) separately provides home health for anyone entitled to nursing facility services under the state plan.

MAT is still mandatory, with no end date

Medication Assisted Treatment entered the federal benefit list through section 1006(b) of the SUPPORT for Patients and Communities Act of 2018. As enacted, the MAT benefit ran only from October 1, 2020 through September 30, 2025. The Consolidated Appropriations Act, 2024 (P.L. 118-42) removed that end date, so the MAT benefit did not lapse in 2025. A state is excepted only if it certifies, at least every 5 years, that a shortage of qualified MAT providers or facilities makes statewide coverage not feasible.

Mandatory doesn't mean identical for every enrollee

The federal minimum in 42 CFR 440.210 is written for the categorically needy. Certain noncitizens receive only the limited services specified in 42 CFR 440.255. The minimum for the medically needy (people who qualify through spend-down) is narrower under 42 CFR 440.220, so the medical services a medically needy enrollee gets depend on what the state plan provides for that group.

Optional Medicaid Benefits Your State Chooses

CMS states that "States may provide optional benefits if they choose to add them through the state plan process," and 42 CFR 440.225 says services not required under 42 CFR 440.210 and 440.220 "may be furnished under the State plan at the State's option." The federal optional list includes these benefits most relevant to adults and older adults.

Optional benefit Where to learn more
Prescription drugs Georgia Medicaid prescription coverage, one state's example
Dental services Medicaid dental coverage by state
Dentures Medicaid dental coverage by state
Eyeglasses Georgia Medicaid vision coverage, one state's example
Speech, hearing and language disorder services, including adult hearing aids Georgia Medicaid hearing aid coverage, one state's example
Physical therapy and occupational therapy Your state's covered-services list
Prosthetics Your state's covered-services list
Hospice Your state's covered-services list
Private duty nursing Your state's covered-services list
Personal care Medicaid HCBS waivers by state
Case management Your state's covered-services list
Other licensed practitioner services Your state's covered-services list

A few of these carry detail worth knowing before you ask your state:

  • Dental: CMS states that "There are no minimum requirements for adult dental coverage." Dentures are a separate optional benefit, so a state can cover one without the other.
  • Eye care: treatment of eye disease is covered as a mandatory physician or hospital service for the categorically needy even in a state that limits or omits the optional eyeglasses benefit.
  • Prescription drugs: for an adult on the traditional benefit list, drug coverage turns on the state's plan, while an expansion adult's benchmark coverage must include prescription drugs, one of the Essential Health Benefits.
  • Personal care: state-plan personal care must be provided by someone who is not a legally responsible relative. As a state-plan service it must follow the statewideness and comparability rules, and the federal authority to cap enrollment that 1915(c) waivers carry does not reach it.
  • Case management: a state may target case management to specific groups or areas of the state rather than offering it statewide.
  • Private duty nursing: this means nursing for people who need more individual and continuous care than a visiting nurse or the facility's nursing staff routinely provides. For whether Medicaid can cover round-the-clock help at home, see whether Medicaid pays for 24-hour home care.

What Does Medicaid Cover for Long-Term Care?

Nursing facility services (for ages 21 and over) and home health services are mandatory, and home and community-based services (HCBS) are optional. The Medicaid and CHIP Payment and Access Commission (MACPAC) puts it this way: "The only two mandatory LTSS benefits provided to these beneficiaries are nursing facility and home health services. All other LTSS benefits are optional."

How a state offers an optional long-term care service changes who can get it. MACPAC explains that once a state puts an optional service in its state plan, it must be provided to all individuals eligible under the pathways that grant the traditional benefit package, while waivers "permit states to provide optional benefits only to specific groups and to cap enrollment." Under a Medicaid 1915(c) waiver, each enrollee must be evaluated as needing the institutional level of care the waiver replaces, and the state may cap the number of people served. That cap is why a state can offer home care through a waiver and still have a waiting list.

For state-by-state detail, see Medicaid nursing home coverage by state, Medicaid HCBS waivers by state and the PACE program, explained in our PACE guide.

Why Your Medicaid Coverage May Differ

Two people on Medicaid in different states, or in different plans, can have different benefits. Four layers explain most of the difference.

Your state's choices

Optional benefits are where states diverge, and the published state rules show it. In Tennessee, TennCare's benefit package for adults 21 and older without Medicare and outside long-term care covers pharmacy, dental, hospice, physical, occupational and speech therapy, and private duty nursing. TennCare limits several of these adult benefits: adult vision is limited to medical evaluation and management of eye conditions plus the first pair of cataract glasses or contact lenses after cataract surgery, and private duty nursing is limited to supporting a ventilator or other life-sustaining medical technology.

In Florida, the Agency for Health Care Administration runs Statewide Medicaid Managed Care, and state law requires its medical plans to cover at minimum 29 service categories, including prescription drugs, home health agency services and transportation to covered services. Florida law also lets plans "customize benefit packages for nonpregnant adults, vary cost-sharing provisions, and provide coverage for additional services."

Your managed-care plan

If a managed care organization (MCO) delivers your benefits, your coverage runs through that plan. Federal regulation defines an MCO as an entity with a comprehensive risk contract with the state, and the state pays it a capitation payment for each enrollee "regardless of whether the particular beneficiary receives services during the period covered by the payment." TennCare, for example, delivers its covered services through the member's MCO.

An Alternative Benefit Plan, if you're an expansion adult

Under section 1937 of the Social Security Act, a state may cover the Affordable Care Act adult expansion group through an Alternative Benefit Plan (ABP) instead of the traditional benefit package, and CMS states the ABP "is mandatory for the Medicaid expansion population.", Any ABP must provide at least the Essential Health Benefits described in the Affordable Care Act. The Affordable Care Act's Essential Health Benefits are ten categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

A state may not require certain people to enroll in an ABP, including people entitled to any part of Medicare, people eligible because they are blind or disabled, terminally ill people receiving hospice, and the medically frail. Expansion adults who meet one of those exemptions must be given the option of an ABP that includes all benefits available under the approved state plan.

Limits and prior authorization

Covered does not mean unlimited. Under 42 CFR 440.230, a state may place appropriate limits on a service based on medical necessity or utilization control, but each service must be sufficient in amount, duration and scope to reasonably achieve its purpose, and a required service can't be arbitrarily denied or reduced solely because of a person's diagnosis, type of illness or condition.

In fee-for-service Medicaid, starting January 1, 2026, a state must decide a standard prior authorization request for items and services other than drugs within 7 calendar days (extendable by up to 14 days in some cases) and an expedited request within 72 hours, unless state law sets a shorter timeframe. The decision comes with notice and fair hearing rights.

Under 21: EPSDT Covers More

The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit is Medicaid's child health benefit for enrollees under 21. Section 1905(r)(5) of the Social Security Act includes "such other necessary health care, diagnostic services, treatment, and other measures described in subsection (a) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan."

In practice, a service your state treats as optional for adults can still be required for a child who needs it. EPSDT vision services must at a minimum include eyeglasses, and EPSDT hearing services must at a minimum include hearing aids., For under-21 enrollees, EPSDT can also expand home health and private duty nursing beyond the limits applied to adults. Georgia's version is described in our guide to Georgia Medicaid for children and EPSDT.

What Medicaid Doesn't Cover, or Limits

These are the gaps to check for, each tied to the rule behind it.

  • Optional benefits your state didn't elect. A state may cover eyeglasses for adults but is never required to, and each state decides whether to cover adult hearing aids, cap them or exclude them.,
  • Care in an institution for mental diseases. Federal law excludes Medicaid payment for care or services for "any individual who has not attained 65 years of age and who is a patient in an institution for mental diseases," meaning a hospital, nursing facility or other institution of more than 16 beds primarily engaged in treating mental diseases. The exclusion has exceptions, including inpatient psychiatric hospital services for people under 21, and inpatient hospital and nursing facility services for people 65 or older.
  • Long-term care outside your benefit package. In Tennessee, nursing facility care and home and community-based services are not covered under the adult benefit package described above (Benefit Package B), so personal care, adult day services and home modifications require CHOICES or ECF CHOICES enrollment.
  • Services denied for medical necessity or prior authorization. A state may apply medical-necessity and utilization limits, and in fee-for-service Medicaid a prior authorization decision comes with notice and fair hearing rights. If that happens, see Medicaid appeals and fair hearings.

Rides to Medical Appointments

CMS states that "states must ensure both emergency and non-emergency medical transportation where necessary for the beneficiary to receive covered services." A state may also set up a brokerage program covering wheelchair vans, taxis, stretcher cars, bus passes and tickets for people with no other means of transportation. Our guide to Medicaid non-emergency medical transportation covers the ride benefit in detail. For other ride options, see our guide to senior transportation.

What You May Pay

A state may charge cost sharing (copays and similar charges) for most covered services, but federal rules cap it by family income. Under 42 CFR 447.52, for services other than drugs and non-emergency use of the emergency department, the cap is a small fixed dollar amount when family income is at or below 100% of the federal poverty level (FPL), 10% of what the state Medicaid agency pays for the service at 101% to 150% of FPL, and 20% of what the agency pays above 150% of FPL. The fixed dollar caps rise each year with the medical care component of the Consumer Price Index. Drugs and non-emergency emergency department visits have their own caps under 42 CFR 447.53 and 447.54.

Three more rules decide what you actually owe:

  • Some people and services are exempt. People and services in the exempt groups listed in 42 CFR 447.56(a) owe nothing under the 42 CFR 447.52 caps, though a state may still charge even an exempt person for non-preferred drugs and for non-emergency use of the emergency department. Check that list before assuming you owe anything.
  • A family-level ceiling applies. Where family income is above 100% but not above 150% of FPL, total cost sharing the state imposes under section 1916A of the Social Security Act for everyone in the family can't exceed 5% of family income; above 150% of FPL, the same 5% ceiling covers premiums and cost sharing together.
  • Low income protects access. For an enrollee with family income at or below 100% of FPL, the state plan must specify that no provider may deny services because the person can't pay the cost sharing. Family planning services and supplies carry no cost sharing at all.

If You Have Medicare and Medicaid

If you have both programs and you're entitled to any part of Medicare, a state can't require you to enroll in an Alternative Benefit Plan. How the two programs share costs is covered in our guides to dual eligibility, Medicare vs. Medicaid and what Medicare doesn't cover.

How to Find Out What Your Plan Covers

Your state's covered-services list and your plan's member handbook are the documents that answer the question for you. Brevy's state guides walk through the benefit list in five states:

For any other state, start with Medicaid guides by state. If a service is denied, the appeals and fair hearings guide explains the next step.

Frequently Asked Questions

Does Medicaid cover surgery?

Surgical care falls under Medicaid's mandatory medical categories rather than the optional list. CMS lists inpatient hospital services, outpatient hospital services and physician services as mandatory, and federal law treats medical and surgical care for eye disease, for example, as physician or hospital services. Physician services also include medical and surgical services furnished by a dentist, to the extent state law allows, that would be physician services if a physician furnished them. A state may still require medical necessity and prior authorization before a procedure.

What does full Medicaid cover compared with limited Medicaid?

If you qualify through spend-down as medically needy, the federal floor is much shorter. Under 42 CFR 440.220, the federal minimum for medically needy coverage includes prenatal care and delivery services, ambulatory services as the state plan defines them for children under 18 and for groups entitled to institutional services, home health services for anyone entitled to skilled nursing facility services, and extended postpartum pregnancy-related services. Beyond that, a medically needy enrollee gets what the state plan provides for that group, so ask your state for the medically needy benefit list rather than assuming the full mandatory list applies.

What does Medicaid cover for seniors?

For an older adult, the benefits that matter most are usually long-term care. Nursing facility care for people 21 and older and home health are guaranteed in every state's plan for the categorically needy. Help at home or in the community, such as personal care attendants and adult day care, exists only where your state has elected it, and a state that offers it through a waiver may limit it to specific groups and cap enrollment, which is how waiting lists form. If you're entitled to any part of Medicare, your state can't require you to enroll in an Alternative Benefit Plan.

Does Medicaid pay for assisted living?

Medicaid can pay for some of the care in assisted living, but not the rent or meals. Federal law lets a home and community-based services waiver pay for services "other than room and board," so a waiver may cover the personal care and supportive services an assisted living resident receives while the resident remains responsible for the housing and meal costs. For ways to cover the rest, see how to pay for assisted living.

Learn More

MedicaidDoes Medicaid Cover Dental for Adults? Coverage by StateDoes Medicaid cover dental for adults? It depends on your state. See what every state and DC covers in 2026, from yearly caps and their periods to dentures. MedicaidMedicaid Guides by StateMedicaid works differently in every state, from who qualifies to what's covered and how to apply. See what varies and jump to your state's full guide. MedicaidMedicaid Nursing Home Coverage by StateMedicaid pays for nursing-home care in every state, but the income cap, level-of-care test, and rules vary. The federal floor, what changes, and your state. MedicaidMedicaid HCBS Waivers by StateMedicaid HCBS waivers pay for care at home instead of a nursing facility. How 1915(c) waivers work, who qualifies, why waitlists happen, and your state's guide. MedicaidMedicaid Appeals and Fair HearingsDenied Medicaid? You can appeal, and one deadline decides whether your benefits keep flowing during the appeal. Know your fair-hearing rights and act fast. MedicareMedicare vs. MedicaidMedicare vs. Medicaid: Medicare is federal insurance for people 65+; Medicaid is state-run help for limited incomes. See costs, nursing homes and having both.

Find personalized help checking what your state's Medicaid and your plan cover at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.

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