Alabama Medicaid Covered Services: Benefits, Copays, and Limits

Alabama Medicaid covered services include primary and specialist doctor visits, hospital care, prescription drugs, lab and imaging, behavioral health treatment, limited dental and vision benefits, nursing home and home-based long-term care, home health, durable medical equipment, and non-emergency medical transportation. Adults face specific caps on office visits, prescriptions, and other benefits; children under 21 receive far broader coverage through the EPSDT program, which overrides most adult limits when a service is medically necessary.

Doctor Visits and Preventive Care

Routine physician visits are covered in offices, clinics, hospital outpatient departments, and emergency rooms. Adults are limited to 14 physician office visits per calendar year. That count includes prenatal and postnatal visits, family planning, specialist referrals, consultations, and psychotherapy. The Alabama Medicaid Agency can approve additional visits when they are medically necessary.¹

Preventive care covers health screenings, immunizations, and wellness check-ups. Medicaid also pays for laboratory testing, X-rays, and other ancillary services when a qualified provider orders them. Durable medical equipment such as wheelchairs and home medical supplies requires prior authorization, and the dispensing provider must submit medical justification to the Medicaid fiscal agent within seven state working days of dispensing the equipment.

The Alabama Coordinated Health Network divides the state into seven regions and connects recipients with primary care providers, specialists, and community resources. The ACHN coordinates your care but does not directly deliver services.²

Hospital Care

Both inpatient and outpatient hospital care are covered when medically necessary. Inpatient benefits include overnight stays, surgical procedures, room and board, and skilled nursing during the stay. Physician services delivered while you are an inpatient are covered for up to 16 dates of service per physician, per calendar year. That cap is separate from the 14-visit outpatient limit. Each specialty within a physician group counts as a single provider for the cap, and both limits can be exceeded on medical necessity grounds.¹

Outpatient hospital coverage includes emergency room visits, observation stays, and same-day surgery. Many non-emergency hospital services and complex procedures require prior authorization before they are provided. Acentra Health processes those requests for the Alabama Medicaid Agency, and providers submit them online.³

Prescription Drug Benefits

Alabama Medicaid manages pharmacy costs through a Preferred Drug List. Drugs on the PDL, which covers most generics, do not require pre-approval. Non-preferred and brand-name drugs generally need prior authorization from the prescribing provider.

Adults can fill up to five prescriptions per month, and no more than four of those may be brand-name drugs. Three categories get higher allowances: antipsychotics, antiretrovirals, and anti-epileptic medications, each allowed up to 10 prescriptions per month. Prescriptions filled through the three-month maintenance supply program do not count toward the monthly limit at all.⁴ Children under 21 are exempt from the monthly cap under EPSDT.

If You Have Both Medicare and Medicaid

When you are dual-eligible, Medicare becomes the primary payer for most services, including prescription drugs. You are automatically enrolled in a Medicare Part D drug plan, which takes over responsibility for your medications, and you automatically receive Extra Help to lower your Part D premiums, deductibles, and copays. If Medicare does not cover a particular prescription, Medicaid may still cover it.⁵

Behavioral Health

Outpatient therapy, counseling, and treatment for both mental health conditions and substance use disorders are covered. Federal parity law requires Medicaid behavioral health coverage to be no more restrictive than coverage for physical conditions, so copays, visit limits, prior authorization, and medical necessity standards must be comparable across the two.⁶

Inpatient psychiatric care is covered for recipients under 21 and for adults 65 and older. In the older-adult group, inpatient psychiatric services must be delivered in a free-standing psychiatric hospital under the direction of a geriatric psychiatrist, and stays are unlimited as long as they remain medically necessary.⁷ More intensive behavioral health services, including partial hospitalization, residential treatment, and inpatient stays, require precertification before services begin.

Dental and Vision Coverage

Dental

Children under 21 get comprehensive dental coverage through EPSDT, including preventive cleanings, restorative work, and treatment for anything found during a dental screening. Routine adult dental care is generally not a covered benefit. The exception is pregnant recipients age 21 and older, who receive dental coverage during pregnancy and through the end of the month falling 60 days after delivery.⁸ Federal law now allows states to extend full postpartum Medicaid coverage to 12 months, but Alabama’s dental benefit for pregnant adults still ends at the 60-day postpartum mark.⁹

Vision

Adults age 21 and older are eligible for one complete eye exam and one pair of eyeglasses every two calendar years. Children under 21 receive up to two complete eye exams per calendar year, or more often if medically necessary, and up to two pairs of glasses per year when an exam supports it.¹⁰ Additional pairs within the same year require prior authorization.¹¹

Long-Term Care and Home-Based Services

Nursing Facility Care

Nursing home coverage includes room, board, skilled nursing, and personal care assistance for recipients who meet a nursing facility level of care. Residents must contribute most of their income toward the cost of care, keeping only a personal needs allowance set at the federal minimum of $30 per month for items the facility does not provide.¹²

If your spouse enters a nursing home, federal spousal impoverishment protections apply. For 2026, the community spouse can keep up to $162,660 in countable assets. The at-home spouse is also entitled to a monthly maintenance needs allowance of up to $4,066.50 drawn from the institutionalized spouse’s income.

Home and Community-Based Waivers

Alabama runs seven waiver programs that let people who would otherwise need nursing home care receive services at home or in the community. All seven use the same income threshold of $2,982 per month for 2026.¹³ The waivers are:

Elderly and Disabled (E&D) Waiver, for older adults and people with physical disabilities.
Intellectual Disabilities (ID) Waiver, for individuals with intellectual disabilities.
State of Alabama Independent Living (SAIL) Waiver, focused on independent living supports.
Living at Home (LAH) Waiver, for people who can remain at home with assistance.
Technology Assisted (TA) Waiver for Adults, for adults who depend on medical technology.
Community Waiver Program (CWP), a community-based alternative to institutional care.
Alabama Community Transition (ACT) Waiver, to help people move out of institutional settings.

All waiver participants must meet financial, medical, and program-specific requirements and must be willing to receive services in their home or community. Wait lists are common, so applying early matters.¹⁴

Home Health

Separate from the waiver programs, Alabama Medicaid covers home health services including skilled nursing care and therapy delivered in your home. These services are available to recipients with an illness or disability who need medical care but do not require institutionalization.

Non-Emergency Medical Transportation

Medicaid pays for rides to and from medical appointments through the Non-Emergency Transportation program. Covered trips include visits to doctors, dentists, hospitals, pharmacies, and any other provider of covered services. Transportation can be in your personal vehicle, a friend or family member’s car, a city bus, or a community van, but Medicaid requires you to use the least costly option available.

To arrange a ride, call 1-800-362-1504 and press option 4. Requests should be made before your appointment when possible; urgent or emergency care trips can be reported within 24 hours afterward. Get the seven-digit request number before hanging up, because that is your receipt. If the trip is approved, Medicaid loads payment onto an EBT Transportation card, which works like a debit card to pay for the ride.¹⁵

Copayments

Alabama Medicaid charges small copayments for most services, including physician office visits, inpatient and outpatient hospital care, durable medical equipment, medical supplies, and prescriptions. The following groups are exempt:

Recipients under age 18
Pregnant recipients, for pregnancy-related services
Family planning services
Emergency services
Nursing home residents
Native Americans

A provider cannot refuse to see you because you cannot pay the copayment. You still receive the service.¹⁶

Broader Coverage for Children Under 21

The Early and Periodic Screening, Diagnostic, and Treatment program is the most comprehensive piece of Alabama Medicaid. EPSDT requires the state to cover any Medicaid-eligible service that is medically necessary to treat a condition found during a screening, even if that service would normally exceed adult benefit limits.¹⁷ In practice, children are not subject to the 14-visit cap, the 5-drug prescription limit, or many of the other restrictions that apply to adults.

EPSDT screenings, called Well Child Checkups in Alabama, include physical exams, developmental assessments, dental checkups, hearing and vision tests, immunizations, and lab work. When a screening finds a problem, the program covers the full course of treatment. A child who needs intensive therapy, specialized equipment, or a service not listed in Alabama’s standard benefit package can still receive it if a provider determines it is medically necessary.

Estate Recovery After Death

Long-term care coverage carries a consequence many families do not learn about until it is too late. After a Medicaid recipient dies, the Alabama Medicaid Agency is required by law to seek repayment from the recipient’s estate for certain services. Recovery applies in two situations: for permanently institutionalized recipients of any age who were required to contribute their income toward care, and for any recipient who was 55 or older when they received Medicaid-covered services.

The state will not pursue recovery while a surviving spouse is alive, or if the recipient is survived by a child under 21 or a blind or permanently disabled child of any age. The agency must also grant hardship waivers when recovery would cause undue hardship, defined in Alabama as situations where the estate is a family farm or business that produces limited income and is the sole income-producing asset of the heirs.¹²

Recipients who hold long-term care insurance policies that let them qualify for Medicaid by disregarding certain assets may receive partial protection from estate recovery for the amount that was disregarded. Understanding these rules before applying for long-term care Medicaid can save a family significant money later.¹⁸

1
Alabama Administrative Code. Alabama Administrative Code 560-X-6-.14 – Limitations on Services
2
Alabama Medicaid. Alabama Coordinated Health Network
3
Acentra Health. Alabama Medicaid Prior Authorization Website
4
Alabama Medicaid. Frequently Asked Questions – Pharmacy Limits
5
Medicare.gov. Medicaid
6
Medicaid.gov. Parity
7
Alabama Administrative Code. Alabama Administrative Code Chapter 560-X-5 – Psychiatric Facilities for Individuals 65 or Over
8
Alabama Medicaid. Maternity Dental Benefit Coverage
9
Alabama Administrative Code. Alabama Administrative Code 560-X-15-.03 – Limitations
10
Alabama Administrative Code. Alabama Administrative Code Chapter 560-X-17 – Eye Care Services
11
Alabama Medicaid. Eye Care Services
12
Alabama Administrative Code. Alabama Administrative Code 560-X-33-.05 – Estate Recovery
13
Alabama Medicaid. Medicaid Income Limits for 2026
14
Alabama Medicaid. Home and Community-Based Waiver Services
15
Alabama Medicaid. Frequently Asked Questions About NET
16
Alabama Administrative Code. Alabama Administrative Code 560-X-1-.25 – Copayment (Cost-Sharing)
17
Medicaid.gov. Early and Periodic Screening, Diagnostic, and Treatment
18
Medicaid.gov. Estate Recovery