Medicaid Costs and Coverage in Ohio
“How much is Medicaid in Ohio?” is a common question asked by low-income patients in need of health care coverage. Medicaid coverage funding comes from both the federal government and the individual states, and is administered by states in compliance with federal guidelines. As a result of this operating arrangement, there can be very real differences in Medicaid cost estimates and what services are covered by Medicaid. The ACA Medicaid Expansion, which was optional and not adopted by all states, further broadened these variations in coverage and expenses. Learn more about the types of Medicaid insurance policies and the cost of Medicaid coverage in Ohio by reviewing the sections below.
Types of Medicaid Insurance in Ohio
“What services are covered by Medicaid?” and, “how much does Medicaid cost?” are not questions to which there are universal, straightforward answers. The costs associated with Medicaid coverage differ according to enrollee age, disability status, income level and other factors. Despite these variations, Medicaid recipients can generally expect access to the same core Essential Health Benefits (EHB). When it comes to what services are covered by OH Medicaid, all types of Medicaid insurance include: ambulatory patient services, emergency services, hospitalization when necessary, pregnancy care and services, mental health and addiction services, prescription drug coverage and more. Download our free guide to review more of the services covered by Medicaid.
Medicaid coverage provides all-inclusive care for eligible children younger than the age of 19, with particular emphasis on primary and preventive care in keeping with its Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) methodology. Every state is required by federal law to develop and adopt an approved schedule of care delineating which services are covered by Medicaid, in which all recipients younger than the age of 19 are automatically enrolled. This schedule includes routine, age-appropriate screenings and immunizations. Medicaid coverage is also strongly responsive to the concerns of the parents/guardians, teachers and care providers of enrolled children; requests for additional preventative care assessments, screenings and referrals are typically approved.
Other types of Medicaid insurance, such as the Healthy Start/Children’s Health Insurance Program (CHIP) provide enrollees access to equivalent Medicaid coverage. CHIP is a bridge program that extends Medicaid enrollment to low-income or at-risk children and pregnant women who would not otherwise meet the eligibility requirements. CHIP covers nearly all costs associated with pregnancy, prenatal care and birth for income-qualified pregnant women of any age.
What services are covered by Medicaid for adults, outside of bridge programs like CHIP, are generally slightly different than those available to children. The Medicaid Expansion, which Ohio adopted, adjusted the eligibility criteria for Medicaid services, and significantly increased the number of adults between the ages of 19 and 64 newly eligible for coverage. Adults enrolled in Medicaid are entitled to annual well-patient visits with their primary care physicians and regular appointments with qualified, participating professionals offering vision and hearing care services.
Examples of vision include standard eye exams, age-appropriate screenings and prescription glasses, if needed. Medicaid coverage restricts the types of glasses that can be reimbursed under the program, and typically requires advance authorization by a qualified provider for contact lenses and other alternative vision supports. Other products and services, such as eye surgery or prosthetic eyes, may become eligible for coverage by OH Medicaid if they are deemed medically necessary.
Similarly, adults’ access to dental services covered by Medicaid is largely governed by factors such as recipient age, the nature and urgency of requested services and the availability of qualified providers. Federal law only requires that Medicaid extend dental services to children and young adults age 21 or younger. Ohio typically offers regular dental checkups and teeth cleanings to enrolled adults. Upon a finding of medical necessity, Ohio Medicaid coverage will also cover the costs of root canals, fillings or crowns, tooth extraction and/or dental surgery.
Supplemental services are covered by Medicaid if they reduce barriers to care for enrollees. Examples include transportation assistance and trained staff to assist recipients in completing required program applications or forms.
What does Medicaid not cover in Ohio?
Exactly what services are covered by Medicaid in Ohio differs from patient to patient, depending on age, health, income and other qualifying factors. Generally, however, Medicaid does not cover elective, cosmetic and otherwise optional or unnecessary products or services. Routine care, such as well-patient visits, may also be limited to a certain number of encounters per a given span of time. Medicaid coverage in Ohio is not available, for example, for more than one dental cleaning or pair of glasses per year unless they are justified by medical necessity. Specialty products or services may not be covered by OH Medicaid without prior authorization. Medicaid coverage does not extend to non-emergency products or services delivered by providers who are not enrolled in types of Medicaid plans.
How much does Medicaid cost in Ohio?
Individual Medicaid cost estimates are almost entirely dependent on an enrollee’s specific circumstances and eligibility factors. However, it is a foundational tenet of Medicaid coverage that enrollees do not pay copays on qualified preventative care services.
Out-of-pocket Medicaid price estimates associated with non-preventative care vary based on the product/service in question, enrollee income and whether or not the enrollee is part of an exempt population. Exempt populations include enrollees residing in assisted living or nursing facilities and recipients with certain developmental disabilities.
Under Ohio Medicaid coverage, copays may be required from non-exempt populations for non-preventative care, such as supplemental dental and vision services or prescription medications. In most cases, the costs of Medicaid copays are extremely low – often only a few dollars. Copays and other out-of-pocket Ohio Medicaid expenses are usually capped at a specific percentage of annual income. Learn more about the costs and coverage associated with Medicaid by downloading our comprehensive guide.