Alabama Medicaid

Medicaid Benefits

Below are some questions people often ask about Medicaid benefits. Click on the questions to see the answers. Help may, also, be available by calling 1-800-362-1504.

How can I find out what Alabama Medicaid covers and does not cover?

Links for Covered Services Handbook, Covered Services Handout and Non-Covered Services are located on this Alabama Medicaid website page: http://medicaid.alabama.gov/content/4.0_Programs/4.1_Covered_Services.aspx.

Does Alabama Medicaid have co-payments and deductibles?

Medicaid recipients may be asked to pay a small part of the cost (co-payment) of some medical services they receive. Medicaid pays the rest. Providers cannot charge any additional amount other than the co-payment for Medicaid-covered services. Co-payments range from $1.30 to $3.90 for each visit, and between 65 cents and $3.90 for prescription drugs and medical supplies and appliances. When a Medicaid recipient is admitted to the hospital, the co-payment is $50. Some services do not require a co-payment, including birth control services, case management, chemotherapy, emergencies, home health care services, mental health and substance abuse treatment services, outpatient physical therapy, radiation treatment, and kidney dialysis, among others. Co-payments are not required if the recipient is in a nursing home, under age 18, pregnant or a Native American Indian with an active user letter from the Indian Health Services (IHS).

Can I get a list of providers/doctors who take Alabama Medicaid?

Alabama Medicaid does not maintain a list of Medicaid providers who are not in the Patient 1st program. That is because doctors who have signed up with Alabama Medicaid decide when,and if, they will see a Medicaid patient on a case-by-case basis. So, it is up to the patient to find out ahead of time if the doctor will accept their Medicaid coverage. The exception to this is the Patient 1st program. Anyone in this program has a “personal doctor” (primary medical provider) who has agreed to see them for all of their medical care, or to refer them to other doctors or clinics if care is needed that they cannot provide.

Can I see a doctor who is located outside of Alabama?

Some providers who practice within 30 miles of the Alabama border may enroll to provide care to Medicaid recipients. Services may be provided out of state in the case of an emergency and when it would be hazardous to have the patient travel back to Alabama for treatment. Any out-of-state provider must agree to enroll with Alabama Medicaid, accept Medicaid payment and agree to file a claim for services.

I am pregnant. Can I go to any obstetrician (OB) doctor?

No. In order for Medicaid to pay for your care, you must go through the maternity program for your county unless you live in one of these counties: Autauga, Bullock, Butler, Crenshaw, Elmore, Lowndes, Montgomery, and Pike. If you live in one of those counties you may go to any OB doctor who will accept your Medicaid. A maternity care program directory and list of providers can be found on the following Alabama Medicaid website link: http://medicaid.alabama.gov/content/5.0_Managed_Care/5.2_Other_MC_Programs/5.2.2_Maternity.aspx. It is important call as soon as possible to start your maternity care.

Does Alabama Medicaid cover emergency room visits?

Alabama Medicaid does pay for emergency room visits when a person has a serious health problem that he or she reasonably believes could cause serious damage to their health or body if they do not get medical care right away. For ER visits that are not urgent, Medicaid pays for three non-emergency outpatient hospital visits per calendar year. Examples of non-emergencies include upset stomach, sore throat, mild cough, rash, and low-grade fever. There are no limits on outpatient hospital visits for lab work or x-rays.

Will Alabama Medicaid cover charges for an out-of-town emergency room visit?

Alabama Medicaid will cover out-of-state services in case of an emergency and when it would be hazardous to have the patient travel back to Alabama for treatment. However, any out-of-state provider must agree to enroll with Alabama Medicaid, accept Medicaid payment and agree to file a claim for services.

My child is sick and we are in another Alabama city. Can I take him to any doctor?

If you are on the Patient 1st program, you will still need a referral from your Patient 1st doctor in order for Medicaid to pay for the visit. The doctor must also be enrolled with Alabama Medicaid and agree to file a claim to Medicaid. If you are not part of the Patient 1st program you may see an any enrolled doctor who agrees to accept your Medicaid.

Where can I find a list of dentists for children?

A dentist for a child may be found at the following Alabama Medicaid website link: http://medicaid.alabama.gov/content/4.0_Programs/4.2_Medical_Services/4.2.2_Dental/4.2.2.1_Find_Dentist.aspx.

Does Alabama Medicaid cover braces?

Alabama Medicaid does not cover orthodontics (braces) except under certain conditions. Services must be received through Children’s Rehabilitation Services (CRS) or another qualified clinic enrolled as a contract vendor with Alabama Medicaid. More information can be found on the following Alabama Medicaid website link:http://medicaid.alabama.gov/content/4.0_Programs/4.2_Medical_Services/4.2.2_Dental.aspx.

What happens if you use up all of your visits and you still need to go to the doctor ?

Office visits are limited to 14 visits per calendar year. Recipients are encouraged to plan their visits carefully. The only exception would be an EPSDT-screened child under the age of 21 who qualifies for extra Medicaid benefits. If additional care is needed, Federally Qualified Health Centers (FQHCs) and other public clinics may be able to help. More information can be found at the following Alabama Medicaid website link: http://medicaid.alabama.gov/content/4.0_Programs/4.4_Medical_Facilities/4.4.3_FQHCs.aspx.

Does a lab visit for a test or office visit for shots count as a visit if you do not see the doctor?

That is possible. You should check with your provider to find out.

How many outpatient hospital visits does Alabama Medicaid cover?

Alabama Medicaid pays for emergency and non-emergency outpatient hospital visits when medically necessary. There are no limits on outpatient hospital visits for lab work, x-ray services, radiation treatment, or chemotherapy. Alabama Medicaid, also, pays for three outpatient surgical procedures per calendar year if the surgeries are done in a place called an Ambulatory Surgical Center.

Does Alabama Medicaid cover Well Child/Early, Periodic, Screening, Diagnosis and Treatment (EPSDT) checkups?

Yes. Alabama Medicaid does cover these checkups for children which includes a complete exam to see if a child is growing properly and to check for eye and ear problems, sugar diabetes, low blood or sickle cell disease, stomach problems, and to see if additional tests or shots are needed. More information is available at the following Alabama Medicaid website link: http://medicaid.alabama.gov/content/4.0_Programs/4.2_Medical_Services/4.2.3_EPSDT.aspx.

Does Alabama Medicaid cover eye exams and glasses?

Yes. Alabama Medicaid pays for eye exams and eyeglasses once every three calendar years for adults (21 and older) and once every calendar year for children under age 21. Contact lenses may be provided only under certain conditions and when approved ahead of time.

Does Alabama Medicaid cover visits to a psychiatrist?

Yes. As long as the psychiatrist is a Medicaid provider, the visit will be covered. A primary medical provider referral is not necessary.

Does Alabama Medicaid pay for chiropractors?

Yes. However, chiropractors are covered only for certain Medicare patients (QMB-Qualified Medicare Beneficiary)or children referred as a result of an EPSDT screening.

Does Alabama Medicaid cover lap band surgery?

Yes. However, Alabama Medicaid covers this type of "bariatric" surgery for Medicaid-eligible recipients between 18 and 64 years of age who meet certain medical criteria. There are very specific prior authorization requirements needed ahead of time. Surgery for recipients who are under 18 years old, and who have one or more immediate life-threatening co-morbidities, will be considered for authorization on a case-by-case basis. Please, discuss the possibility of lap band surgery and the steps needed with your doctor. This type of surgery for cosmetic purposes-only is not covered.

Does Alabama Medicaid cover breast lifts, tummy tucks or liposuction?

Alabama Medicaid does not pay for cosmetic surgery or procedures. However, there may be coverage for eligible recipients if a procedure is found to be medically-necessary. These cases would require approval ahead of time (prior authorization).

Can a doctor bill an Alabama Medicaid patient for a no show fee?

Doctors enrolled with Alabama Medicaid agree to accept Medicaid's payment, plus, any copayment, as payment in full. So, the doctor or clinic may not charge or bill the recipient for cancelled or missed appointments.

Can my doctor charge me for filling out forms so my child can go to school or play sports?

A recipient may be billed for services that are non-covered and for which Medicaid will not make any payment. Services that are more than the set limitation (for example, physician visits, hospital visits, or eyeglasses limit) are considered non-covered services. Alabama Medicaid does not reimburse providers for completing forms for school, family medical leave or other purposes not requested at the time of service. Providers may bill the recipient for this service under certain conditions. Providers are requested to discuss with, and tell recipients before providing services about their responsibilities for payment of services not covered by the Alabama Medicaid program.

Frequently Asked Questions