Medicaid Costs and Coverage in Massachusetts

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Medicaid coverage in Massachusetts was created in order for low-income individuals and families to have comprehensive healthcare that they can afford. Most potential petitioners have questions surrounding the program, like, “How much is Medicaid?”, “What are the out-of-pocket expenses?” and, “What services are covered by Medicaid?” Medicaid cost estimates are difficult to outline, since there are several contributing factors, including the age of the applicant, the medical procedures needed and the income level of the applicant. Copayments, deductibles and premiums are all considered out-of-pocket expenses for Medicaid coverage, and by understanding the services covered by Medicaid and what does Medicaid not cover for an applicant can determine if expenses will be included. It is worth noting that Medicaid coverage is intended to be extremely low-cost, since it is a program funded on a federal and state level. Coverage for Medicaid in Massachusetts will include the federally mandated benefits that are required by law, but also include the optional benefits that Massachusetts elects to cover. To find out more information regarding the types of Medicaid insurance options available, as well as the Medicaid services covered for approved applicants, continue reviewing the information below.

What services are covered by Medicaid in Massachusetts?

Learning what services are covered by Medicaid is an important part of understanding basic Medicaid coverage in Massachusetts. With different types of Medicaid insurance options available to approved applicants, services and treatments that are covered can change. There are also other factors that can contribute to the different types of services Medicaid will cover. For instance, Medicaid is geared toward providing healthcare to petitioners 21 years of age and under, so there may be services covered by Medicaid for children that are not necessarily covered for adults. Important Medicaid services covered in the state of Massachusetts include, but are not limited to:

  • Doctor’s office visits.
  • Hospital stays.
  • Rehabilitation services.
  • Therapeutic services.
  • Behavioral health services.
  • Substance abuse disorder services.
  • Prescription drugs.
  • Emergency transportation services.

To review a full list of Medicaid-covered services, download our free guide.

It is worth noting that Medicaid coverage in Massachusetts is intended for procedures, services and treatments that are deemed medically necessary, rather than optional or elected. If a doctor finds a service to be medically necessary for the patient, but it is not covered by Medicaid, he or she can seek prior authorization or prior approval.

What services are not covered by Medicaid in Massachusetts?

Understanding Medicaid services not covered in Massachusetts is just as important as determining the services Medicaid will cover. Unexpected financial burdens can be quite costly for approved applicants, especially when they expect Medicaid coverage to be there. With the variety of Medicaid insurance options available, along with the variables that can contribute to coverage changes, it is worth preparing ahead of time. Since Medicaid coverage is intended for medically necessary procedures, ruling out what Medicaid will not cover can be done by determining if a procedure or service is elected or optional, or if the doctor or physician is even a Medicaid provider in the first place. Other services that Medicaid does not cover in Massachusetts can include, but are not limited to:

  • Experimental services and treatments.
  • Cosmetic surgeries and services.
  • Health services provided by relatives or friends.
  • Medical equipment not prescribed.
  • Orthodontic services.

An important piece of information to understand involving Medicaid coverage is that there can always be exceptions to the rule or the fine print involved. Coverage for Medicaid services can fluctuate, depending on different factors. So, while Medicaid might not choose to cover a specific service as a whole, the program may provide different elements of the service or components of it, instead. In addition, it is important to note that children who are covered through CHIP instead of Medicaid will incur different costs and coverage.

If you have determined that the medical services you seek will be covered, learn how to apply for Medicaid.

How much does Medicaid cost in Massachusetts?

Most new applicants wonder, “How much does Medicaid cost, and will there be any out-of-pocket expenses for my family?” In truth, it is hard to provide exact Medicaid cost estimates, since there are many different moving parts to the program. However, copayments, deductibles and premiums should be expected for specific services and treatments. For instance, prescription drugs may have different fees associated, depending on whether or not the drug is generic or brand name. There also may be copayments for Medicaid coverages that extend beyond what is generally covered already or the timeframe in which something is covered. Copayments, while considered out-of-pocket expenses, still remain incredibly low, usually only a few dollars, at most.

There are exemptions to Medicaid coverage copayments that should be taken into account, too. If a service is covered by Medicaid, then copayments are not necessary for petitioners 21 years of age and younger, pregnant women, eligible seniors and American Indians or Native Alaskans. These groups of eligible applicants are exempt from having to pay out-of-pocket copayment fees. There are additional Medicaid coverage exemptions to take into account in Massachusetts which can directly affect out-of-pocket fees for many approved petitioners.

It is also important to consider that while out-of-pocket expenses for Medicaid coverage in Massachusetts can vary, there are cases in which Medicaid will reimburse specific medical bills that have occurred prior to Medicaid approval. For instance, if Medicaid denies an applicant incorrectly, but later overturns the denial, and instead, approves the applicant, any services that should have been covered by Medicaid in the interim can be reimbursed. In this case, the healthcare provider pays the applicant, and will bill Medicaid for the services rendered, instead.

Download our guide to review more information about the costs and coverage associate with Medicaid.