Covered Medical Services

Handbook Content

Terms and Meanings

Some terms that we use in this chapter may not be familiar. These terms and their meanings are listed below.

  • Approved/Authorization: The decision Medicaid makes to pay for a service.
  • Limits: The most Medicaid will cover for costs or services.
  • Provider: A doctor, nurse, therapist, or another qualified health care professional.Referral: A written order from your primary care doctor for you to see a specialist or get certain medical services.
  • Services: Care, treatments, testing, checkups, equipment, supplies, and other ways your health care providers help you stay healthy.
  • Targeted Case Management: Planning of care for members with special needs or conditions to gain access to medical, social, educational, and other services.

COVERED SERVICES

ND Medicaid covers preventive, emergency, and specialty care for your mental and physical health. All covered services must be medically necessary for ND Medicaid to cover the cost of services. Medically necessary means that you truly need to have the service. Your provider can help guide you in understanding if the medical care you want would be medically necessary for you.

Your provider can help you know whether ND Medicaid covers a service. 

Generally, ND Medicaid covers medical services, that are:

  • Provided by an ND Medicaid enrolled provider
  • Medically necessary
  • A ND Medicaid covered service

Some services have:

  • Limits, and/or
  • Authorizations or referrals needed before receiving a service

If you are unsure whether a service is covered, ask your provider before you receive the service. Your provider should be able to help you.

NONCOVERED SERVICES

ND Medicaid does not cover all health care services. ND Medicaid will not cover your medical care if you are getting:

  • Services, medications, or supplies that are meant for cometic purposes or do not directly relate to your health care
  • Medications that are not FDA approved
  • Care more than 50 miles outside of North Dakota without being approved by ND Medicaid
  • Care from a provider who is not enrolled in ND Medicaid
  • Services and hospital stays that are not medically necessary
  • Not a ND Medicaid covered service

You may be responsible for your medical costs if you get medical care that is not covered by ND Medicaid.

ENROLLED PROVIDERS

Your medical costs may be covered when they are billed by providers who are enrolled in ND Medicaid. This means that the provider has a contract with the ND Medicaid program. Your medical costs may not be covered if you see a provider who is not enrolled in ND Medicaid. Sometimes you may need to see a provider who is out-of-state. These providers will need to enroll with ND Medicaid to cover your medical costs. 

You can learn more about seeing a provider outside of North Dakota in the Out of State Services chapter of this handbook.

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