What Does Medicaid NOT Cover?

Having health insurance is not always as easy as creating an account on the Marketplace website, applying for health insurance coverage, and getting approval for you and your family. Oftentimes, the cost of health insurance can be unaffordable. Even with subsidies, you find that monthly premiums are out of reach and health coverage unattainable. This is where Medicaid can help you and your family secure healthcare and not place you in a financial bind like traditional insurance.

What is Medicaid?

Medicaid is a state-sponsored health insurance program designed to provide health insurance for those unable to afford traditional Marketplace health insurance. It also assists individuals who do not have an option for health insurance through an employer because they do not offer it, or it is unaffordable.

Medicaid is available to low-income families, pregnant women, the elderly, and those with disabilities. In most states, one can qualify for Medicaid through their financial status alone—this would be up to 137% of the federal poverty level. Unfortunately, Texas has not expanded. Their current level stands at 14% of the federal poverty level. You must also meet other stipulations like household size, age, or be disabled.

What Benefits Are Covered by Medicaid in Texas?

The federal government has set Medicaid mandatory benefits, but each state is allowed to establish its own schedule of benefits as long as they do not fall below the minimum standard.

 Mandatory benefits that states are required to provide by federal law include:

  • Inpatient/Outpatient Services
  • Physician Services
  • Laboratory and X-ray Services
  • Home Health Services
  • Family Planning Services
  • Freestanding Birth Center Services
  • Certified Pediatric and Family Nurse Practitioner Services
  • EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services

These are optional services that states can include but are not required to by federal law:

  • Prescription Drug
  • Chiropractic Services
  • Physical/Occupational Therapy
  • Dental/Vision Services
  • Speech/Hearing/Language Services
  • Inpatient Physician Services
  • Private Duty Nursing
  • Hospice
  • Intermediate Care Facility Services
  • State Planned Home Services

This is not a complete list; other benefits exist. Refer to the website for an exhaustive list.

One issue you may experience is a provider not accepting Medicaid. While rare, it does happen. While you will not cruise up to a hospital in critical need of medical care and be turned away, there can be some minor instances where a doctor or facility will require you to receive medical care at another location.

What Does Medicaid Insurance NOT Cover?

Now that we’ve been introduced to what Medicaid covers, let’s give some examples of what Medicaid in Texas does not cover.

Location: One issue you may run into with Medicaid coverage is if the provider you visit accepts the Medicaid you are covered under. For instance, you travel to see a family member away from home and become sick or injure yourself. If you try to see a doctor and use your Medicaid insurance, chances are you will not have coverage. On the other hand, if the situation you experience is life-threatening, you would most likely be able to use your insurance.

Necessity: Medicaid will also not cover procedures they deem unnecessary. While this is true of most insurance companies nowadays, it is especially true of Medicaid insurance. You will notice this is standard with most optional benefits. For instance, routine dental care can be covered in some instances, while having your teeth whitened is considered cosmetic, thus not necessary, and would not be a covered benefit.

Over the Counter: Much like regular health insurance, Medicaid won’t cover over-the-counter drugs or supplies. If a physician does not prescribe it, you will be required to purchase the medication or medical device out of your own pocket. This includes vitamins and other personal health aids.

Personal Choice: This can be items that go above and beyond what is necessary—things like private duty nurses or home care. If the doctor states proper care can be given in a facility, a patient can’t request special treatment and expect it to be approved.

As we alluded to earlier, this can be facility based. Unfortunately, some doctors and medical facilities look at the bottom line and recognize that they do not get paid as much from Medicaid as they do from traditional health insurance companies, so they do not accept those who are covered by Medicaid insurance. Again, if you are in an emergency situation, hospitals cannot turn a screaming ambulance away, but for a stubbed toe, chances are you will be asked to find a facility that accepts Texas Medicaid.

The Medicaid Coverage Gap

There comes a time when an individual or family may not be eligible for either Medicaid or the Affordable Care Act subsidies. This is called the Coverage Gap. This is unique to Texas and a handful of states. It is due to the state’s non-approval of the expansion of Medicaid. As mentioned, most state’s coverage is 137% of the federal poverty level, while Texas rests at 14 percent. So, at the moment, if you are living above that 14%, you can no longer be covered by Medicaid. For Texas as a whole, 1.7 million are left out of receiving coverage for Medicaid due to the coverage gap.

Medicaid Continuous Coverage Ending

Another consideration with the status reevaluation of Medicaid recipients is that Continuous Coverage will be coming to an end. Since March 2020, Medicaid has been following COVID guidelines of continuous coverage, and individuals and families have been allowed to keep their healthcare coverage. As of April 1, 2023, this policy will be ending. This could automatically disenroll many currently receiving benefits who qualified for a listed reason and would no longer qualify. For instance, if they began receiving coverage under Medicaid as a pregnant mother but since have given birth, they may now no longer qualify for Medicaid. Measures have been taken to ensure that Medicaid recipients continue receiving benefits.

NOTE: The Affordable Care Act will be holding a Special Enrollment Period for those losing their health care coverage in this manner. It will begin 60 days before the loss of coverage and extend to 60 days after the end of coverage. You will need to submit your application quickly if you do not want a gap in coverage.


Insurance laws are ever-changing. It can sometimes be confusing to know what a policy covers, who it covers, and where you can use it. It is good to know you have experts in your corner, like those at Cover Mile, to guide you when you have questions about your insurance policy and to assist you in securing a new policy, so you and your family have the coverage you deserve. Contact us today.