In this article
- Medicaid coverage at a glance
- What is Medicaid required to cover in every state?
- Medicaid benefits that are optional for each state
- Is Medicaid coverage different for Medicaid expansion populations?
- How does Medicaid coverage compare to Marketplace and employer-sponsored health plans?
- Frequently asked questions about Medicaid’s coverage
Medicaid provides comprehensive health coverage to low-income individuals and families in every U.S. state and territory. But what Medicaid will cover depends on the state where you live and certain other factors, including your age. (Some services are covered only for enrollees under age 21.)1
Here’s an overview of how Medicaid coverage varies:
Medicaid coverage at a glance
More than 71 million low-income people in the United States had Medicaid coverage at the start of 2025.2 Particularly for children, who account for more than a third of all Medicaid enrollees,3 Medicaid is among the most comprehensive coverage available.4
Learn about state Medicaid guidelines regarding eligibility and enrollment for children.
One 2021 study found that out-of-pocket costs for Medicaid enrollees are substantially lower than out-of-pocket costs for people with private health coverage.5 Many Medicaid services do not have cost-sharing (meaning enrollees do not have to pay for the services through co-pays, deductibles, or coinsurance),6 and total out-of-pocket expenses under Medicaid are capped at no more than 5% of a household’s income.7
What is Medicaid required to cover in every state?
Medicaid is run by each state, and jointly funded by the state and federal government. The federal government sets minimum coverage requirements, including a wide range of medical care and equipment that Medicaid must cover.
These include healthcare expenses such as inpatient and outpatient hospital care, physician services, home healthcare, dental care for children, and family planning services.8
Medicaid benefits that are optional for each state
In addition, there’s a wide range of optional benefits that states can choose – but are not required – to provide, including prescription drugs, dental care for adults, physical and occupational therapy, and hospice care.8
Some optional benefits, such as prescription drugs,9 are covered by every state’s Medicaid program even though this is not required by the federal Medicaid law. Coverage of other benefits, including adult dental care – varies by state.
Is Medicaid coverage different for Medicaid expansion populations?
Medicaid coverage rules differ depending on whether we’re talking about the Medicaid expansion population (covered under the Affordable Care Act’s expansion of Medicaid) or the rest of a state’s Medicaid population.1011 As of 2025, 40 states and the District of Columbia have implemented ACA’s Medicaid expansion.
For the expansion population in these states, state Medicaid programs are required to cover the ACA’s essential health benefits (EHBs), as defined by the state’s EHB benchmark plan.10 But for the rest of a state’s Medicaid population, the traditional Medicaid rules regarding mandatory and optional benefits are applicable.8
So for example, while prescription drug coverage is an EHB under the ACA12 (and thus must be covered for the Medicaid expansion population), it’s an optional benefit for the traditional Medicaid population813 But as noted above, all states choose to provide prescription drug coverage under their Medicaid programs for both the expansion and traditional Medicaid populations.9
The important point for consumers to understand is that Medicaid coverage differs from one state to another since states make their own decisions regarding the long list of optional benefits.8 Consumers shouldn’t assume that Medicaid benefits will be the same in every state, and should always reach out to the state Medicaid office or their Medicaid managed care plan if they have questions about what’s covered in their state.
Learn whether you can use your state’s Medicaid coverage in another state.
How does Medicaid coverage compare to Marketplace and employer-sponsored health plans?
In general, Medicaid provides comprehensive coverage – including the same sort of services typically covered by Marketplace plans and employer-sponsored plans – but with very low out-of-pocket costs. Medicaid also covers some services that generally aren’t covered by private health insurance, such as custodial long-term care and transportation to medical appointments.14
Here’s an overview of how Medicaid compares with private health insurance:
Compare costs: Medicaid, Marketplace plans, employer-sponsored insurance |
|||
|---|---|---|---|
| Medicaid | ACA Marketplace plans | Employer-sponsored insurance | |
| Premiums | Free or low-cost15 | Average full-price premium in 2025 is $619/month, but the average premium after subsidies are applied is $113/month. 16 | In 2024, the average single employee’s total premium was $746/month, while the average total family premium was $2,131/month. But employers pay the bulk of this, leaving employees to pay average premiums of $114/month and $525/month, respectively.17 |
| Out-of-pocket costs | Free or low-cost, depending on the service. Total out-of-pocket costs are capped at no more than 5% of household income.7 | Varies depending on metal level and whether the plan includes cost-sharing reductions.
Under federal rules, the maximum out-of-pocket limit cannot exceed $9,200 for a single person in 2025.18 |
Out-of-pocket maximums vary considerably, ranging from under $2,000 to over $6,000 per enrollee.17 Under federal rules, the limit cannot exceed $9,200 for a single person in 2025.18 |
Compare eligibility: Medicaid, Marketplace plans, employer-sponsored insurance |
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|---|---|---|---|
| Medicaid | ACA Marketplace plans | Employer-sponsored insurance | |
| Eligibility | Based on income, with limits that vary by state and depending on whether the person is a child, pregnant woman, parent, low-income adult, disabled, or elderly.19 Both income and asset limits apply if the person is disabled or at least 65 years old.20 | Enrollment is open to people who are lawfully present in the U.S., not enrolled in Medicare, and not incarcerated.21
Access to subsidies depends on income and whether the person has access to other coverage that’s considered affordable and comprehensive.22 |
Plans are offered by employers, so only eligible employees (and their family members) can enroll. Coverage is often only offered to employees who work at least 30 hours per week.23 |
Compare coverage: Medicaid, Marketplace plans, employer-sponsored insurance |
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|---|---|---|---|
| Medicaid | ACA Marketplace plans | Employer-sponsored insurance | |
| Coverage scope | Federal rules require mandatory benefits to be covered in every state, and allow states discretion on coverage of numerous optional benefits.8 Medicaid is comprehensive, and includes coverage for some services that typically are not covered by private health insurance.24 | Essential health benefits must be covered, with specific benefits that vary by state.25 | In the small group market, essential health benefits must be covered, with specific benefits that vary by state.25
Across large group and self-insured plans, coverage varies but is typically quite comprehensive, as larger employers tend to offer more robust benefits.17 |
| Dental/vision coverage | Required to be covered for children. Coverage for adults varies by state.2627 | Covered as an essential health benefit for children25 (dental can be integrated with the plan or provided via a separate stand-alone plan).
Rarely included in adult coverage, but can be purchased via separate stand-alone coverage.28 |
Generally not included in employer-sponsored medical plans, but typically offered as a separate plan that’s part of the employer’s overall benefit package. |
| Custodial long-term care coverage | Covered in every state. Medicaid is the primary payer for 63% of nursing home residents in the U.S.29
Nearly all states’ Medicaid programs also offer home and community-based long-term care services that allow people to receive custodial long-term care outside of a nursing home.30 |
Typically not covered31 | Typically not covered31 |
| Access to providers | Access to care is generally comparable to the access people have with private insurance, but access is more limited for certain types of providers, such as psychiatrists and dentists.32
One study found that physicians are less likely to accept Medicaid than private health insurance.33 |
Provider network scope varies by plan.
Most plans are EPOs or HMOs, which do not cover out-of-network care unless it’s an emergency. |
Provider network scope varies by plan.
PPOs, which include out-of-network coverage, are the most common type of employer-sponsored coverage.34 |
Frequently asked questions about Medicaid coverage
Can I use my Medicaid coverage in another state?
No, you generally cannot use your Medicaid outside of your home state, except for emergencies. And you cannot be covered by multiple states’ Medicaid programs at once.
Because each state has its own Medicaid eligibility requirements, your Medicaid enrollment will not transfer to another state. If you’re moving out of state, you will need to apply for Medicaid in your new state and be approved by that state’s Medicaid program.
Read more about what happens with your Medicaid coverage in another state.
Does Medicaid cover dental treatment?
In most states, Medicaid covers at least some dental services for enrollees who are 21 and older35 – and all states are required to cover dental benefits for children enrolled in Medicaid.36
Read more about Medicaid’s coverage of dental care.
Are undocumented immigrants covered by Medicaid?
Whether individuals who are not lawfully present in the U.S. are eligible for Medicaid coverage depends on their income, where they live, their age, and whether or not they’re pregnant. But these persons cannot be covered by federally funded Medicaid, so states that choose to provide Medicaid benefits to undocumented immigrants must do so using only state funds.37
Learn which states provide Medicaid coverage to undocumented immigrants.
Who’s covered by CHIP (the Children’s Health Insurance Program)?
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written hundreds of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.
Footnotes
- “Early and Periodic Screening, Diagnostic, and Treatment” Medicaid.gov. Accessed June 16, 2025 ⤶
- “January 2025 Medicaid & CHIP Enrollment Data Highlights” Medicaid.gov. Accessed June 16, 2025 ⤶ ⤶
- “Fact Sheet: Medicaid” American Hospital Association. Feb. 2025 ⤶
- “Biden-Harris Administration Releases Historic Guidance on Health Coverage Requirements for Children and Youth Enrolled in Medicaid and the Children’s Health Insurance Program” Centers for Medicare & Medicaid Services. Sep. 26, 2024 ⤶
- “Comparison of Utilization, Costs, and Quality of Medicaid vs Subsidized Private Health Insurance for Low-Income Adults” JAMA Network. Jan. 5, 2021 ⤶
- “Out-of-Pocket Cost Exemptions” Medicaid.gov. Accessed May 15, 2025 ⤶
- “Tracking the Medicaid Provisions in the 2025 Reconciliation Bill” KFF.org. May 14, 2025 ⤶ ⤶
- “Mandatory & Optional Medicaid Benefits” Medicaid.gov. Accessed May 15, 2025 ⤶ ⤶ ⤶ ⤶ ⤶ ⤶
- “Prescription Drugs” Medicaid.gov. Accessed May 15, 2025 ⤶ ⤶
- “Medicaid Alternative Benefit Plan Coverage: Frequently Asked Questions” Congressional Research Service. Nov. 26, 2018 ⤶ ⤶
- ”Alternative Benefit Plan Coverage” Medicaid.gov. Accessed June 19, 2025 ⤶
- “Essential Health Benefits: HHS Informational Bulletin” Centers for Medicare & Medicaid Services. Accessed May 16, 2025 ⤶
- States must use what’s called an Alternative Benefits Plan (APB) to cover the Medicaid expansion population, and APBs must include coverage for the ACA’s essential health benefits. States also have the option to cover additional Medicaid populations under an ABP. If they do, those ABPs must include coverage for the essential health benefits, rather than following the traditional mandatory and optional benefits guidelines. ⤶
- “10 Things to Know About Medicaid” (Number 4). KFF.org. Feb. 18, 2025 ⤶
- “Medicaid & CHIP coverage” Medicaid.gov. Accessed May 16, 2025 ⤶
- “2025 Marketplace Open Enrollment Period Public Use Files” (Columns AA and AB) CMS.gov, May 12, 2025 ⤶
- “Employer Health Benefits, 2024 Annual Survey” KFF. Oct. 9, 2024. ⤶ ⤶ ⤶
- “Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2025 Benefit Year” Centers for Medicare & Medicaid Services. November 15, 2023. ⤶ ⤶
- “Medicaid, Children's Health Insurance Program, & Basic Health Program Eligibility Levels” Centers for Medicare & Medicaid Services. December 2023. ⤶
- “Medicaid Eligibility and Enrollment Policies for Seniors and People with Disabilities (Non-MAGI) During the Unwinding” KFF.org. June 20, 2024 ⤶
- “Are you eligible to use the Marketplace?” HealthCare.gov. Accessed May 16, 2025 ⤶
- “The Premium Tax Credit – The basics” Internal Revenue Service. Accessed May 16, 2025 ⤶
- “Identifying full-time employees” Internal Revenue Service. Accessed May 16, 2025 ⤶
- “10 Things to Know About Medicaid” (Number 4). KFF.org. Feb. 18, 2025 ⤶
- “Information on Essential Health Benefits (EHB) Benchmark Plans” Centers for Medicare & Medicaid Services. Accessed May 16, 2025 ⤶ ⤶ ⤶
- “Dental Care” Medicaid.gov. Accessed May 16, 2025 ⤶
- “Medicaid vision coverage for adults varies widely by state” National Institutes of Health. Aug. 6, 2024 ⤶
- “Dental and Vision Coverage in the Health Insurance Marketplace” Anthem. Accessed May 16, 2025 ⤶
- “A Look at Nursing Facility Characteristics Between 2015 and 2024” KFF.org. Dec. 6, 2024 ⤶
- “Home & Community-Based Services 1915(c)” Medicaid.gov. Accessed May 16, 2025 ⤶
- “When Should You Start Investing in Long-Term Care Insurance?” National Council on Aging. Aug. 8, 2024 ⤶ ⤶
- “10 Things to Know About Medicaid” (Number 8). KFF.org. Feb. 18, 2025 ⤶
- “Findings from the National Electronic Health Records Survey” MACPAC. June 2021 ⤶
- “What Types of Employer-Sponsored Health Insurance Plans Do Workers Have?” KFF.org. May 28, 2024 ⤶
- “Medicaid Adult Dental Benefits Are on the Move in 2024” CareQuest. July 16, 2024 ⤶
- “Early and Periodic Screening, Diagnostic, and Treatment” Medicaid.gov. Accessed June 19, 2025 ⤶
- “5 Key Facts About Immigrants and Medicaid” KFF.org. Feb. 19, 2025 ⤶
- “Medicaid, Children’s Health Insurance Program, & Basic Health Program Eligibility Levels” Medicaid.gov. Accessed June 16, 2025 ⤶
