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