Medicaid Costs and Coverage in Ohio

“How much is Medicaid in Ohio?” is not a simple question to answer. “How much does Medicaid cost?” is a subject of understandable concern to many applicants who meet the Medicaid eligibility requirements. Answers to this question, however, vary widely and cannot easily be pinned down without knowing important information about a recipient, his or her household and the household’s medical needs. Accurate Medicaid cost estimates must take into account an applicant’s household income, what category of Medicaid coverage he or she is qualified for and what types and amounts of services he or she uses. To understand the variables and patterns involved, it helps to understand what services are covered by Medicaid, what the standard limits are for those services and which applicants are generally afforded the most access to care.

What services are covered by Medicaid in Ohio?

All types of Medicaid insurance in Ohio allow recipients access to standard primary and preventative care services. Most types of Medicaid coveragealso accommodate wide ranges of products, supports and services where the patient and his or her provider can demonstrate medical need. Access to services covered by Medicaid may vary across categories of coverage. For example, children younger than 18 years of age and pregnant women may be subject to different limitations on care and services than adults older than 64 who fall in a different Medicaid subprogram. All categories of Medicaid coverage emphasize primary and preventative care.

Routine services covered by Medicaid include pharmacy products and services. Ohio’s Department of Medicaid (ODM) provides Medicaid coverage for prescription medications and over-the-counter drugs, including birth control. Limits on how many days’ worth of doses a recipient can receive at one time apply. Different types of drugs may be subject to different limits. Medicaid insurance rules may require patients to get specific authorizations from their providers in order to receive brand name medications where equivalent generics exist. Depending on the type of Medicaid insurance and type of drug, some recipients may be required to pay a small copay for prescription medications. Learn more about covered services in our free in-depth Medicaid guide.

Kansas Medicaid services cover a broad array of addiction and substance use or abuse services. Also covered by Medicaid, where applicable, are some crisis intervention and case management options. For patients with medical need, Medicaid covers addiction medication and treatments such as buprenorphine, naltrexone and methadone. No copays are typically assessed, but all services must be provided by medical professionals authorized by the Ohio Department of Mental Health and Addiction Services. Medicaid coverage pays for ambulatory detoxification services and intensive outpatient addiction services on an as-needed basis. Medicaid insurancemay pay for personal or group counseling associated with substance use, but hard limits on access and frequency are imposed.

Dental services covered by Medicaid include routine cleanings, checkups, fillings, tooth extractions, crowns, root canals and, where medically necessary, referrals or more intensive care up to and including dental surgery. Frequency limits and copay provisions apply. Braces may be available under some types of Medicaid insurance for recipients younger than 21 years of age with prior authorization by a qualified provider. Dentures may be covered by Medicaid insurance if they are identified as medically necessary.

Primary and preventative care services covered by Medicaid for children and youth aged 21 or younger are extensive. Under its Healthchek program, Ohio Medicaid covers well-child visits at regular intervals throughout childhood, including all standard screenings and vaccinations. Treatments for any diagnoses made as the result of those screenings are, in almost all cases, automatically covered. Additionally, Healthchek Medicaid coverage pays for screenings related to vision, dental, hearing development and lead exposure. Access more information about coverage through Medicaid by downloading our comprehensive guide.

All types of Medicaid insuranceprovide access to emergency care. Ohio Medicaid insurance covers ambulance services, emergency room visits, the costs of drugs, equipment and medical services associated with emergency room evaluation, assistance and admission. All Medicaid coverage benefits related to emergency care are restricted to actual emergencies. Patients with any type of Medicaid insurance who access emergency care or emergency care facilities without a true medical emergency may be required to cover some or all of the associated costs themselves. Patients attempting to access some forms of emergency care, such as ambulance services, without a genuine emergency may be refused care and redirected to alternative, more appropriate care providers.

All types of Medicaid insurance make some provision for hospital and surgical services within a well-defined framework of limits and requirements. For example, Medicaid coverage in Ohio typically only pays for inpatient hospital services when patients obtain adequate advance authorization from their physicians. Even then, Medicaid insurance maintains firm restrictions on how much time the patient may spend in the hospital for certain types of care or particular procedures. Medical review of a patient’s status and care plan may occur if a patient exceeds established guidelines for outpatient hospital service usage. In addition to common inpatient and outpatient hospital services, specialty services may also be available. Specialty provider services are covered by Medicaid in qualifying circumstances and may include:

  • Certified Family Nurse Practitioner Services.
  • Podiatrist and Certified Pediatric Nurse Practitioner Services.
  • Chiropractic Services.
  • Physical and Occupational Therapies and Speech/Language Pathology services.
  • Optometrist and Ophthalmologist services.

To be covered by Medicaid in Ohio,equipment and supplies must be demonstrated as a medical necessity. Under Medicaid insurance, some forms of equipment will only be supplied at certain intervals. If items initially paid for by Medicaid coverage are lost or broken prior to the minimum renewal interval, recipients will be responsible for the full cost of replacement.

Medicaid insurance in Ohio offers family planning and birth control services and medications to all Medicaid recipients. Medicaid coverage comprehensively covers costs related to pregnancy. For women already enrolled in Medicaid, preconception care services may begin prior to pregnancy. During pregnancy,services covered by Medicaid encompass prenatal care (including assessments of prenatal risk), ultrasounds, counseling services, pregnancy-related education and coordination of care services. Where appropriate, high risk monitoring and transportation support to and from appointments are also covered. Medicaid insurance pays for Nurse Midwife and delivery services.

What does Medicaid not cover in Ohio?

Medicaid insurance coverage in Ohio does not pay for any procedures or services which are not considered preventative care, essential primary care or genuine emergency care unless they have been otherwise established to be medically necessary. Medicaid insurance does not cover products, supplies or services that exceed established usage limits for a recipient’s condition or category of coverage. Medicaid coverage does not include procedures or services that are deemed solely cosmetic in nature and which are unrelated to a health condition. As noted above, many services covered by Medicaid will only be paid for if recipients receive advance authorization from an approved provider.

How much does Medicaid cost in Ohio?

Medicaid cost estimatesin Ohio are influenced by many factors and can vary significantly from one enrollee to another. What type of Medicaid insurance a recipient has plays a role in the types and frequencies of services he or she can expect Medicaid to pay for and whether or not copays will be required for those services. How much Medicaid costs is also influenced by household income. Households with higher incomes are more likely to be required to pay copayments for services. Recipients in some categories of Medicaid insurance coverage are subject to regular premiums or to spend-down requirements that must be met before their benefits become available. Before completing the Medicaid application process, it is important to understand these requirements.

When estimating the costs of Medicaid, the most important factor is recipient compliance with program rules. Medicaid insurance does not cover products and services delivered by or received from unauthorized providers. Some services and procedures are only covered by Medicaid if proper authorizations are obtained from qualified providers in advance. Recipient compliance with these rules will directly impact the total costs of care they can expect under Medicaid.