Medicaid offers healthcare coverage 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.
ALERT: Medicaid members have been involved in two data breaches in 2023.
Medicaid offers different programs to provide you healthcare coverage if you’re an adult over 19, living in Idaho and meet income requirements.
- With an income under 138 percent of the federal poverty level (FPL)
- Are pregnant with an income under 138 percent of FPL
- Are a women diagnosed with breast or cervical cancer through Women's Health Check.
- Are 65 or older and meet income requirements
- Are blind or disabled (using Social Security criteria)
- Medicare Savings Program
- Basic Plan – If you don’t typically have special health needs, but need basic health, prevention, and wellness benefits, this plan is for you. The basic plan includes annual physicals, immunizations, most prescriptions doctor and hospital visits, and more.
- Enhanced Plan – If you have a disability or special health need, this plan has all the benefits of the basic plan, plus additional specialized benefits. Most of the time, you will need a referral from a doctor to become eligible for this plan.
- Medicare Medicaid Coordinated Plan – If you are enrolled in both Medicare and Medicaid (also known as dual eligibles), you will be on this plan. It has all the benefits of the enhanced plan, plus allows you to enroll in a managed care plan to help coordinate their Medicare and Medicaid benefits. One advantage to managed care is access to a care coordinator who will help you with complex medical conditions to achieve better health.
Visit the Health Plans library to view more details about available health plans and find cost-sharing information.
Medicaid will pay for 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
The Weight Management benefit is designed to help eligible members, and their families improve their lifestyle through:
- Physical fitness
- Balanced diet
- Personal health education
If you qualify, you 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 your responsibility.
Weight management qualification guidance
- You must have full basic or enhanced Medicaid coverage to qualify.
- You must also meet the following criteria by age:
- Be an adult over 21 and have a body mass index of 30 or higher or 18.5 or lower according to the Centers for Disease Control and Prevention adult body mass index calculator.
- Be a child 5-21 and have a body mass index that falls in either the overweight or the underweight category according to the Centers for Disease Control and Prevention child and teen body mass index calculator.
- If you are on the Home Care for Certain Disabled Children Program (Katie Beckett) and Medicare-Medicaid Coordinated Plan you aren’t eligible for these benefits.
Steps to sign up for the PHA program
- If you’re interested in the program, visit your primary care provider (PCP).
- Your PCP will initiate the process by printing and filling out their portion of the Preventive Health Assistance Agreement Form.
- You then will need to fill out your section of the form.
- Take the form to the weight management provider you’ve chosen ad get 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.
Idaho Medicaid contracts with Medical Transportation Management, Inc. (MTM.) to manage a statewide network of transportation providers for Idaho's NEMT services for Medicaid eligible members who have no other means of transportation. The Idaho NEMT program covers transportation in-state and out-of-state, to and from healthcare services covered under the Medicaid program.
Idaho rules for the non-emergency medical transportation program can be found at IDAPA 16.03.09.870 through 873.
If you have a medical appointment but you don’t have a car, can’t operate a car, or don’t have a friend or family member who can take you, 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 two business days before your appointment.
You may reach MTM to request transportation by calling 877-503-1261, by visiting MTM's Medicaid Transportation website, or by using MTM's Transport Service Management Portal. Trips can be scheduled 24 hours a day, 7 days a week.
If you or someone you’re helping has questions about MTM, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 888-561-8747.
Appeals or Grievances: If you or someone you’re helping has questions about the grievance or appeal process, please call: 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 or someone you are helping has questions about MTM, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1-888-561-8747.
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.
Appeals and Fair Hearings
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 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 member as repayment for any medical care services that were provided to the member and paid for by Medicaid, while the member was over 55, 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 member 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.
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 21, or is blind or permanently disabled (based on Social Security criteria), regardless of where he or she lives.
Idaho Medicaid Estate Recovery will exempt all property, whether held in trust or not, if the property is owned by an American Indian or Alaskan Native and located within the boundaries of a tribal reservation.
As individual circumstances vary, and for more information, call the Estate Recovery Office at 866-849-3843 or email FinancialRecovery@dhw.idaho.gov.
Estate Recovery Brochures
Other services from Medicaid partners
Other healthcare assistance services
