Medicaid Coverage for Joint Pain Treatments

What Is Medicaid?

Medicaid is a health insurance program for people with low income. Unlike Medicare, which is a federal program with the same rules everywhere, Medicaid is run by each state. This means the rules and coverage can be very different depending on where you live.

Medicaid covers millions of Americans, including many older adults with joint pain. If you qualify, Medicaid can help pay for doctor visits, physical therapy, and some injection treatments.

Understanding State Variations

The biggest thing to know about Medicaid is that every state is different. The federal government sets minimum standards, but states can choose to cover more services or set their own rules.

What Every State Must Cover

Federal law requires all state Medicaid programs to cover certain services:

• Doctor visits
• Hospital care
• Lab tests and X-rays
• Nursing facility services
• Home health services

What States Can Choose to Cover

Many joint pain treatments are optional under federal rules. This means your state decides whether to cover them:

• Hyaluronic acid injections
• Physical therapy beyond minimum requirements
• Prescription pain medications
• Durable medical equipment like braces

How to Find Your State’s Coverage

1. Call your state Medicaid office - The phone number is on your Medicaid card
2. Visit your state Medicaid website - Search for your state name plus “Medicaid coverage”
3. Ask your doctor’s billing office - They often know what Medicaid covers
4. Contact a Medicaid managed care plan - If you are enrolled in one, call member services

Dual Eligible: Medicare and Medicaid Together

Some people qualify for both Medicare and Medicaid. This is called being “dual eligible.” If you have both programs, you may have extra benefits and lower costs.

How Dual Coverage Works

When you have both Medicare and Medicaid:

1. Medicare pays first for covered services
2. Medicaid pays second for costs Medicare does not cover
3. Your costs are minimal - often zero for covered services

For example, Medicare Part B covers hyaluronic acid injections for knee arthritis. If you have both Medicare and Medicaid, Medicare pays 80% and Medicaid typically pays the remaining 20%. You pay nothing.

To learn more about Medicare coverage, see our Medicare Part B coverage guide.

What Treatments Are Typically Covered

Here is what most state Medicaid programs cover for joint pain. Remember to verify coverage with your specific state.

Physical Therapy Under Medicaid

All states cover some physical therapy, but the rules differ:

• Visit limits - Some states cap visits per year (often 20-30)
• Prior authorization - Many states require approval before starting PT
• Provider requirements - Must use a Medicaid-enrolled therapist

If you reach your state’s visit limit, ask your doctor about getting an exception for medical necessity.

Prior Authorization in Medicaid

Many Medicaid programs require prior authorization (PA) before approving certain treatments. This means your doctor must get approval before providing the treatment.

What Requires Prior Authorization

Common treatments needing PA in many states:

• Hyaluronic acid injections
• Extended physical therapy
• MRI scans
• Brand-name medications
• Durable medical equipment

The PA Process

1. Your doctor submits a request to Medicaid or your managed care plan
2. The program reviews medical records and necessity
3. Decision is made - usually within 14 days (faster for urgent needs)
4. You receive notification of approval or denial

Finding Medicaid-Enrolled Providers

You must see providers who are enrolled in Medicaid. Not all doctors accept Medicaid patients, so finding the right provider is important.

How to Find a Provider

Questions to Ask Providers

Before scheduling, ask:

1. “Do you accept [your state] Medicaid?”
2. “Are you enrolled as a Medicaid provider?”
3. “Do you accept my specific managed care plan?”
4. “Is prior authorization needed for this treatment?”

If You Cannot Find a Provider

If you have trouble finding a Medicaid provider for joint care:

• Contact your managed care plan about network adequacy
• Ask your state Medicaid office for help
• Check community health centers, which must accept Medicaid
• Look into university or teaching hospitals

Appeals and Fair Hearings

If Medicaid denies a treatment or service, you have the right to appeal. This is called a “fair hearing.”

Your Rights

How to File an Appeal

1. Request a fair hearing in writing within the deadline (usually 60-90 days)
2. State the reason you disagree with the decision
3. Include supporting documents - doctor letters, medical records
4. Request continuation of benefits if appealing a reduction in services
5. Attend the hearing by phone or in person

Tips for a Successful Appeal

• Meet all deadlines - Missing the deadline means losing your appeal rights
• Get a letter from your doctor explaining medical necessity
• Gather documentation of past treatments and their results
• Request an expedited review if delay would harm your health
• Consider getting help from a legal aid organization

Resources for Help

You do not have to navigate Medicaid alone. Free assistance is available.

Where to Get Help

For Dual Eligible Individuals

If you have both Medicare and Medicaid:

• SHIP (State Health Insurance Assistance Program) - Free Medicare counseling at shiphelp.org
• 1-800-MEDICARE (1-800-633-4227) - Help with Medicare questions
• Medicare-Medicaid Coordination Office - For issues involving both programs

Key Takeaways

Related Resources

• Medicare Part B Coverage Guide - For dual eligible beneficiaries
• Hyaluronic Acid Injections: Complete Guide
• Understanding Prior Authorization
• Out-of-Pocket Costs Explained