About Medicaid for Adults

Medicaid offers healthcare coverage for adults that address a variety of health needs, including coverage for low-income adults, pregnant women, the elderly, and people with disabilities who meet certain income criteria. 

Medicaid programs

Medicaid offers different programs to provide healthcare coverage for adults in Idaho:

  • Adults with income under 138 percent of the federal poverty level (FPL)
  • Pregnant women with income under 138 percent of FPL
  • Women diagnosed with breast or cervical cancer with income under 200 percent of FPL (see Women's Health Check for more options)
  • People aged 65 or older who meet income requirements 
  • People who are blind or disabled (using Social Security criteria)
  • Medicare Savings Program

If you or someone in your family needs healthcare, you should apply for Medicaid even if you are not sure you qualify. Some income and resources are not counted when determining your eligibility. For example, owning your home might not prevent you from getting Medicaid.

Elderly couple looking at booklet taking notes
Idaho Medicaid Health Plan Booklet 2020
This booklet has information about each of Medicaid’s healthcare benefit plans. It explains healthcare services, behavioral health (mental health and substance use disorder) services, prescription drug coverage, long-term services and supports, and much more.
Medicaid plans available
  • Basic Plan – This plan provides health, prevention, and wellness benefits for adults who do not have special health needs. This plan includes annual physicals, immunizations, most prescriptions, doctor and hospital visits, and more.
  • Enhanced Plan –This plan is for individuals with disabilities or special health needs. This plan has all the benefits of the Basic Plan, plus additional benefits. Most of the time, individuals will need to be referred by a doctor to become eligible for the enhanced plan.
  • Medicare-Medicaid Coordinated Plan – Designed for people who are eligible and enrolled in both Medicare and Medicaid, (also known as dual eligibles). This plan has all the benefits of the Enhanced Plan, plus allows people to enroll in a managed care plan to help coordinate Medicare and Medicaid benefits. There are many advantages to enrolling in managed care, one of the most valuable is access to a care coordinator who helps people with complex medical conditions to achieve better health.

To view more details about available health plans and find cost-sharing information please see below:

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What's covered

Medicaid will pay for a number of services, such as:

  • Annual physicals
  • Counseling and mental health services
  • Dental (dental services)
  • Doctor visits
  • Durable Medical Equipment
  • Emergency Medical Transportation
  • Home health care (doctor prescribed)
  • Hospice care
  • Immunizations
  • Inpatient and outpatient hospital care
  • Lab tests
  • Medical equipment and supplies
  • Medical transportation services
  • Nurse midwife
  • Pregnancy and family planning services
  • Prescriptions
  • Primary Care Case Management
  • Prosthetics/orthotics
  • Substance abuse treatment
  • Smoking Cessation
  • Vision (vision services)
  • Weight loss
  • X-rays 
Preventative Health Assistance (PHA) Benefit

The Weight Management benefit (WM) is designed to help eligible participants and their families improve their lifestyle through:

  • Physical fitness
  • Balanced diet
  • Personal health education 

Qualifying participants can earn up to $200 each year to help pay for services offered by PHA providers such as participation in the National Diabetes Prevention Program, fees for a weight management program, a gym membership, healthy lifestyle classes, or nutrition classes or services. Any additional fees are the participant’s responsibility.

WM Qualification Guidance: 

  • Participants must have full Basic or Enhanced Medicaid coverage to qualify.
  • Participants must also meet the following criteria by age:
    • Adults (21 or older): a body mass index (BMI) of 30 or higher or 18.5 or lower according to the CDC Adult BMI Calculator.
    • Children (5 to 21 years old): a body mass index (BMI) that falls in either the overweight or the underweight category according to the CDC Child and Teen BMI Calculator.
  • Participants on the Home Care for Certain Disabled Children Program (Katie Beckett) and Medicare-Medicaid Coordinated Plan participants are not eligible for these benefits.

Steps to sign up for the PHA program

  1. Participants interested in the program should visit their primary care provider (PCP).
  2. The PCP will initiate the process by printing and filling out their portion of the PHA Agreement Form.
  3. The participant is then responsible for filling out their section of the form.
  4. The participant takes the form to the WM provider they’ve chosen to receive services from for their signature. After all sections are complete, the form must be submitted to the PHA program for approval. The benefit will start on the date of approval. 
Non-Emergency Medical Transportation Services (NEMT)

Idaho Medicaid contracts with MTM (Medical Transportation Management, Inc) to manage a statewide network of transportation providers for Idaho's NEMT services for Medicaid-eligible participants who have no other means of transportation. The Idaho NEMT program covers transportation in-state and out-of-state and to and from healthcare services when those services are covered under the Medicaid program.

If you have a medical appointment, but you do not have a car, cannot operate a car, or do not have a friend or family member who can take you to your apppointment, you can request transportation through MTM. 

  • If you have a vehicle to transport yourself or family members to their appointments, please contact MTM and ask about their mileage reimbursement program.
  • MTM will review your request and decide if Medicaid will pay for your transportation. MTM will review your request based on the least expensive transportation available and the closest available Medicaid provider for the service.
  • If you have been referred for medical care outside your community, MTM may ask for a referral from your doctor before they will schedule your transportation.
  • You need to call at least 48 hours before your appointment.

You may reach MTM to request transportation by calling 1-877-503-1261, by visiting MTM's Medicaid Transportation website, or by using MTM's Transport Service Management Portal. Routine trips can be scheduled Monday through Friday from 8 a.m. to 6 p.m.

Appeals or Grievances: If you or someone you are helping has questions about the grievance or appeal process, please call: 1-866-436-0457 or complete the MTM “contact us” on-line form. Information and personal contact information will be securely transmitted directly to MTM and will be kept confidential to the extent required by HIPAA.

If you have questions or feedback for the Medicaid NEMT Team responsible for overseeing the contract with MTM, you may complete our online feedback form, email the team at MedicaidTransport@dhw.idaho.gov, or call 1-800-296-0509.

Electronic Visit Verification (EVV)

If you receive Personal Care Services or Home Health Services, you may be impacted by EVV. It is a new system your caregiver or home health attendant may use to document the services you receive. To see more about EVV please visit the EVV webpage.

Estate recovery process

Medicaid estate recovery is the process through which each state recovers the costs of medical services it has paid from the estate of the person who received those services. The Medicaid estate recovery program impacts two groups of people receiving Medicaid benefits:

  • Anyone over the age of 55 who has received Medicaid assistance, and
  • Anyone who is permanently institutionalized and has received Medicaid assistance, regardless of age.

The estate recovery program may collect money from the estate of a deceased Medicaid recipient as repayment for any medical care services that were provided to the recipient and paid for by Medicaid, while the recipient was over 55 years of age, or permanently institutionalized, regardless of age.

Medical care includes a wide range of services, including nursing home and community based in-home care services. It also includes any hospital and prescription drug services the participant received while in a nursing home, or while receiving in-home care. Medical care also includes capitation payments to Medicaid-contracted health insurance companies or medical providers administering a defined package of benefits. The federal government directs states to pursue Medicaid estate recovery for these services.

Federal law recognizes that the needs of certain relatives can take precedence over the state’s interest in recovering assets from the deceased. For this reason, states are not allowed to pursue Medicaid estate recovery under the following circumstances:

  • During the lifetime of the surviving spouse, regardless of where he or she lives.
  • From a surviving child who is under age 21 years or is blind or permanently disabled (based on Social Security criteria), regardless of where he or she lives.

As individual circumstances vary, and for more information, please call the Estate Recovery Office at 1-866-849-3843.

Other services from Medicaid partners

External resources
Services provided by Optum Idaho. If you have questions regarding these services, please contact us: 1-855-233-6262.
External resources
Provided by MCNA Dental through the Idaho Smiles program. If you have questions regarding these services, please contact us: 1 -855-202-0973
external resources
Find non-emergency medical transportation for Medicaid participants.

Other healthcare assistance services

Father playing with son outside
Medicaid programs designed for children are available. Learn more to see if your child(ren) may be eligible for CHIP or Children's Medicaid.
Doctor consulting with patients
Households over the income for Medicaid programs may be eligible for the Advance Payment of Tax Credit, a private insurance tax credit that can help you pay for your healthcare coverage insurance costs.

Rules

External Resources
View the Idaho rules regarding the administration of Medicaid in Idaho.
External Resources
Learn more about Social Security benefits, such as Medicare and retirement benefits, by visiting the Social Security Administration website.