This page outlines mandatory and optional Medicaid state plan benefits and the relevant section of the Social Security Act and applicable coverage regulation(s) under which each benefit is authorized. States are required to provide all mandatory benefits under federal law. States may provide optional benefits if they choose to add them through the state plan process.
Mandatory Benefits
- Transportation to medical care (1902(a)(4), 42 CFR 431.53 and 42 CFR 440.170)
- Inpatient hospital services (1905(a)(1), 42 CFR 440.10)
- Outpatient hospital services (1905(a)(2)(A), CFR 440.20(a))
- Rural health clinic services (1905(a)(2)(B), 42 CFR 440.20(b))
- Federally qualified health center services (1905(a)(2)(C))
- Laboratory and X-ray services (1905(a)(3), 42 CFR 440.30, and 42 CFR 441.17)
- Nursing facility services (1905(a)(4)(A), 42 CFR 440.40 and 42 CFR 440.155)
- Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services (1905(a)(4)(B), 1905(r), 42 CFR 440.40, 42 CFR 441 Subpart B)
- Family planning services (1905(a)(4)(C), 42 CFR 441.20)
- Tobacco cessation counseling for pregnant women (1905(a)(4)(D))
- Physician services (1905(a)(5), 42 CFR 440.50)
- Home health services (1905(a)(7), 42 CFR 440.70 and 42 CFR 441.15)
- Nurse Midwife services (1905(a)(17), 42 CFR 440.165 and 42 CFR 441.21)
- Certified pediatric and family nurse practitioner services (1905(a)(21), 42 CFR 440.166(b) and 42 CFR 441.22)
- Freestanding birth center services when licensed or otherwise recognized by the state (1905(a)(28))
- Medication Assisted Treatment (MAT) (1905(a)(29))
- Routine patient costs of items and services for beneficiaries enrolled in qualifying clinical trials (1905(a)(30))
Optional Benefits
- Other licensed practitioner services (1905(a)(6), 42 CFR 440.60)
- Private duty nursing services (1905(a)(8), 42 CFR 440.80)
- Clinic services (1905(a)(9), 42 CFR 440.90)
- Dental services (1905(a)(10), 42 CFR 440.100)
- Physical therapy (1905(a)(11), 42 CFR 440.110(a))
- Occupational therapy (1905(a)(11), 42 CFR 440.110(b))
- Speech, hearing and language disorder services (1905(a)(11), 42 CFR 440.110(c))
- Prescription drugs (1905(a)(12), 42 CFR 440.120(a) and 42 CFR 441.25)
- Dentures (1905(a)(12), 42 CFR 440.120(b))
- Prosthetics (1905(a)(12), 42 CFR 440.120(c))
- Eyeglasses (1905(a)(12), 42 CFR 440.120(d))
- Other diagnostic, screening, preventive, and rehabilitative services (1905(a)(13), 42 CFR 440.130)
- Services for individuals age 65 or older in an Institution for Mental Disease (IMD) (1905(a)(14), 42 CFR 440.140)
- Services in an intermediate care facility for Individuals with intellectual disability (1905(a)(15), 42 CFR 440.150)
- Inpatient psychiatric services for individuals under age 21 (1905(a)(16), 42 CFR 440.160 and 441 Subpart D)
- Hospice (1905(a)(18))
- Case management (1905(a)(19), 42 CFR 440.169 and 42 CFR 441.18)
- TB-related services (1905(a)(19))
- Respiratory care for ventilator-dependent individuals (1905(a)(20), 42 CFR 440.185)
- Personal care (1905(a)(24), 42 CFR 440.167)
- Primary care case management (1905(a)(25), 42 CFR 440.168)
- Primary and secondary medical strategies, treatment, and services for individuals with sickle cell disease (1905(a)(27))
- State plan home and community based services (1915(i), 42 CFR 440.182)
- Self-directed personal assistance services (1915(j), 42 CFR 441.450-441.484)
- Community First Choice Option (CFC) (1915(k), 42 CFR 441.500-590)
- Alternative Benefit Plan (ABP) (1937,* 42 CFR 440.300)
- Health homes for enrollees with chronic conditions (1945)
- Other services approved by the Secretary**
*The ABP is mandatory for the Medicaid expansion population.
**This includes services furnished in a religious nonmedical health care institution, emergency hospital services by a non-Medicare certified hospital, and critical access hospital (CAH).