Medicaid benefit limit
Benefit Limits
The Alabama Medicaid Agency establishes annual benefit
limits on certain covered services. Certain services are excluded, such as
services rendered as a result of an Early Periodic Screening, Diagnosis, and
Treatment (EPSDT) screening. The EPSDT program covers recipients under 21 years
of age. SOBRA pregnant women under 21 are not covered under EPSDT. When the
recipient has exhausted his or her benefit limit for a particular service,
providers may bill the recipient
The table below describes the benefit limitations documented
as part of eligibility verification.
Benefit Limitation
Inpatient hospital days 16 per year
Outpatient hospital days 3 per year
Physician office visits 14 per year
Eyeglass frames 1 every other year for recipients 21 years
and older
Eyeglass lenses 1 every other year for recipients 21 years
and older
Eyeglass fitting exams 1 exam every other year for
recipients 21 years and older
Eyeglass exams 1 every other year for recipients 21 years
and older
Home health visits 104 per year
Ambulatory surgery center 3 per year
Dialysis services 156 per year
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