Amount and duration of Medicaid services

Within broad Federal guidelines, States determine the amount and duration of services offered under their Medicaid programs. They may limit, for example, the number of days of hospital care or the number of physician visits covered. However, States are prohibited from limiting the duration of coverage for medically necessary inpatient hospital services provided to Medicaid-eligible children under age six who are in “disproportionate share hospitals” (defined below) and to infants in all hospitals.

With certain exceptions, a State’s Medicaid Plan must allow recipients to have freedom of choice among participating providers of health care. States may provide and pay for Medicaid services through various pre-payment arrangements, such as health maintenance organizations (HMOs).

In general, States are required to provide comparable amounts, duration and scope of services to all categorically-needy eligiblepersons. But there are two important exceptions:

  1. Health care services identified under the EPSDT program as being “medically necessary” for eligible children must be provided by Medicaid, 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 those specific service); and
  2. States may request “waivers” for home and community-based services (HCBS) under which they offer an alternative health care package for persons who might otherwise be institutionalized under Medicaid (i.e., only those persons so designated might receive HCBS). States are not limited in the scope of services they can provide under such waivers as long as they are cost effective (except that, other than as a part of respite care, they may not provide room and board for such recipients).
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