Benefits

States must provide children with a comprehensive benefit package, although for other populations they have substantial flexibility to design their benefit packages subject to certain minimum requirements. For adults, states must provide “mandatory services,” which include hospital care and physician services.

States also have the option to cover additional services, such as prescription drugs. In all cases the scope of the services covered must be sufficient to generally meet the needs of enrollees.

Medicaid guarantees comprehensive services for children through Early and Periodic Screening, Diagnosis, and Treatment (EPSDT). EPSDT is intended to assure a uniform federal benefit package for children, covering screening and early intervention services to promote children’s healthy development, as well as vision, dental, and hearing services, and the diagnostic and treatment services that a child may need.

The scope of benefits and the standards for accessing benefits often exceeds those that exist in the private insurance market. Nonetheless, most children in Medicaid do not require extensive services; children are by far the least expensive group covered by the program, costing, on average, $1,543 per child, compared to $2,215 per adult, $10,159 per disabled enrollee, and $11,705 per elderly enrollee. In addition, although children and their parents make up the majority of the Medicaid population, they account for less than 40 percent of federal Medicaid spending (Congressional Budget Office, March 2009).