Medicaid Services for Children

Types of services covered

Medicaid will pay for all:

• well care appointments
• sick care
• immunizations
• lab testing
• oral health care

Under the Early & Periodic Screening, Diagnostic & Treatment Program (EPSDT), children are encouraged to see their doctor for early and regular care.

Medicaid asks that children are brought in to see a dentist at the time of their first tooth, or by the age of 1, and twice a year thereafter. Medicaid also pays for limited orthodontia (braces for the teeth). In order for orthodontia to be covered, your child’s disability must actually affect their eating or their breathing. Medicaid extends coverage only for medically necessary treatment, and therefore will not cover cosmetic procedures.

Medicaid also covers transportation to Medicaid-paid services and visits. This benefit must be requested. Please visit the Health Care Policy and Financing website for more information.

Medicaid also pays for Home Health. Home Health covers personal care, certified nursing assistant services, and nursing services. To determine if your child qualifies or any of these home health services, please call a Home Health agency in your area for a home assessment.

Medicaid also covers durable medical equipment, which includes:

• wheelchairs,
• leg braces, and
• standers  

These items must be medically necessary and within the normal course and duration of treatment for the child’s illness or disability.

Medicaid also pays for eyeglasses and annual eye exams.  Please be aware, however, that Medicaid will only pay for basic lenses and frames. Other options, such as bendable frames and scratch coating are not covered. Medicaid will pay for extra pairs of glasses if they are medically necessary.

Medicaid also covers prescriptions. If you would like to see the list of medications, please see the Health Care Policy and Financing website for a complete list.

Medicaid covers most prescriptions, but usually these are generic drug options. You are required to use a generic option before a name-brand can be provided. Your doctor can help you in assessing whether your child needs a name-brand or a generic medication.

Medicaid pays for hospitalizations, as long as they are medically necessary.

Billing and restrictions

For children and youth, under the age of 19, there are no co-pays and no deductibles for any of the services we have discussed. As of a person’s 19th birthday, they will be required to pay a small copay for doctor visits, prescriptions, and hospitalizations.

Children 20 and under are not subject to balance billing. You may erroneously receive a bill in the mail from a medical provider, seeking reimbursement for medical expenses not paid for by Medicaid. Please note that you are not responsible for paying such bills. If you receive such a bill, please seek assistance from Healthy Communities or your Accountable Care representative to have these costs erased.

Medicaid is intended only for in-state services. Out-of-state services are provided only for medically necessary services that are not available in Colorado.

Finding a doctor

To find a doctor who accepts Medicaid, please visit the Health Care Policy and Financing website or by calling the Healthy Communities office in your county. Please be aware, however, that a provider may refuse to accept Medicaid, or any patient at any time.

Some services under Medicaid require Utilization Management, this is also known as a Prior Authorization. Your doctor will be required  to submit a Prior Authorization request, and a letter of medical necessity, for any such services. Please see the fee schedule at the Health Care Policy and Financing website to see which services require a prior authorization.

As you can see, Medicaid covers a wide variety of medical services for children with disabilities or who are from low-income families.  However, coverage varies widely based on such factors as the child’s age, medical needs, and medical necessity.  If you have any questions, please visit the Health Care Policy and Financing website, or call your local health communities office or your Accountable Care case manager.