MEDICAID

 

Medicaid was established in 1965 by Title XIX of the Social Security Act to provide medical assistance for selected groups of low-income individuals and families.

Medicaid does not pay money to you; instead, it sends payments directly to your health care providers.

Each state has flexibility in structuring their Medicaid programs. Within broad national guidelines established by Federal statutes, regulations, and policies, each state:

    1. Establishes its own eligibility standards
    2. Determines the type, amount, duration, and scope of services
    3. Sets the rate of payment for services
    4. Administers its own program

Medicaid policies for eligibility, services, and payment are complex and vary considerably, even among states of similar size or geographic proximity. For military families this means reapplication for both SSI and Medicaid when PCSing interstate and familiarizing oneself with a new system once more. Gaining as much knowledge as possible about the system in the new state prior to transition will enable families to more effectively access Medicaid as a resource. Terminology, resources and eligibility may vary enormously from state to state.

The eligibility for children falls into three broad categories:

    1. Mandatory eligibility through Supplemental Security Income (SSI) eligibility
    2. Eligibility through the state exercising its option to cover a specific group of children
    3. Eligibility as “medically needy” individuals

 

WHY MEDICAID?

Military families may question the need to apply for Medicaid for their child. After all, they already have medical benefits available to them through TriCare. Services and resources provided by Medicaid will vary according to the specific individual involved and their own medical needs as required. However, Medicaid can provide assistance with the following:

    • Subsidizing insurance co-pays for therapies and treatment
    • Provision of medically necessary equipment/supplies
    • In home personal care services as determined appropriate
    • Provision of diapers and related supplies for children over 3 with medical need

Please note that the above are examples of medically related expenses that Medicaid can assist with and that this list is by no means exhaustive. Provision will vary according to individual medical needs and accurate referral and prescription from a doctor.

 

 Eligibility categories:

 1. MANDATORY ELIGIBILITY THROUGH SSI ELIGIBILITY

In thirty-eight states and in the District of Columbia, children with disabilities who qualify for SSI also qualify for Medicaid. The other twelve states apply different standards with regards to disability, income and resources. However, most children who receive SSI also become eligible for Medicaid.

 

STATES WHERE CHILDREN ARE AUTOMATICALLY ELIGIBLE WITH SSI ELIGIBILITY:

 

Alabama Idaho* Montana South Dakota
Alaska* Iowa Nebraska* Tennessee
Arizona Kansas Nevada* Texas
Arkansas Kentucky New Jersey Utah*
California Louisiana New Mexico Vermont
Colorado Maine New York Washington
Delaware Maryland Oregon West Virginia
District of Columbia Massachusetts Pennsylvania Wisconsin
Florida Michigan Rhode Island Wyoming
Georgia Mississippi South Carolina

 

* A SEPARATE APPLICATION IS REQUIRED FOR MEDICAID

209(B) STATES: (states that use more than the SSI eligibility for Medicaid eligibility, also known as Medically Needy states.)  See section 3 below for further definition of this category.

 

Connecticut Indiana New Hampshire Ohio
Hawaii Minnesota North Carolina Oklahoma
Illinois†† Missouri††† North Dakota Virginia

 

Three of the 209(B) States exclude some or all SSI children from Medicaid. Children in these states may receive Medicaid through another category but not as SSI eligible children. These are as follows:

 

Connecticut excludes children with disabilities

††Illinois excludes children who are blind and children with disabilities

†††Missouri excludes children who are blind

Please remember that there are other ways that mandatory coverage is provided, other than through SSI eligibility. These include families receiving benefits under the ADFC Program (Aid to Families with Dependent Children) and children in poverty.

 

2. ELIGIBILITY THROUGH THE STATE EXERCISING ITS OPTION TO COVER A SPECIFIC GROUP OF CHILDREN

States have the option to cover other low-income groups as they deem appropriate.   Individuals who may be covered in these optional groups are entitled to the same services as individuals in the mandatory coverage groups. In order to find out what types of optional coverage is available in your state contact your local DSHS office.

There is one category of optional coverage under Medicaid, which is especially important to be aware of in regards to Non-Institutionalized Children with Disabilities.

There is a variety of terminology used regarding this option, but it is most commonly referred to as the “Katie Beckett” provision or waiver. Under this provision of law, states can extend Medicaid coverage to certain children with disabilities who live at home.

These children must:

(a)    Meet the SSI definition of disability;

(b)    Require the level of care available in a nursing home or hospital but which can also be appropriately provided outside a facility.

The waiver was so named for Katie Beckett, a child who required the use of a ventilator and was thus unable to live at home because her family income would have made her ineligible for SSI and therefore Medicaid.  Without the ability to access these resources the family could not afford to sustain the level of medical care required for Katie to live at home.

This situation arose due to the fact that children living in medical institutions for more than 30 days are considered to be “permanently” residing outside the home and therefore only the child’s income and resources are used for SSI eligibility.  When children live at home or return to live at home, their parent’s income is “deemed” available to them and therefore they can quickly be found ineligible for SSI and subsequently Medicaid.  This type of provision supports the family’s privilege and choice to care for family members with disabilities at home with the necessary support.  It is a more beneficial and cost-effective choice for states in that it prevents unnecessary expenditure on full time, permanent care for people who have the potential to live within and contribute to their community in so many ways.

Please remember that the Katie Beckett waiver/provisions for non-institutionalized children with disabilities are just one form of optional coverage.  Each state has established criteria for individuals to be served in optional coverage groups and there are frequently a variety of ways that a child may become eligible within the same system.

 

3. ELIGIBILITY AS “MEDICALLY NEEDY” INDIVIDUALS

States can also elect to cover individuals who are defined as medically needy. These are children who do not meet SSI eligibility criteria but who meet SSI disability criteria and have high medical bills. After deducting medical expenses, their income must fall below the state’s medically needy “protected income” level.

If a state chooses to provide medically needy coverage, it must cover all children under 18 and pregnant women who would qualify under one of the mandatory eligibility groups (SSI or AFDC) if their income or resources were lower.  Thirty-five states and the District of Columbia have a medically needy program.

EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT PROGRAM (EPSDT)

All Medicaid eligible children from birth to 21 are entitled to services under EPSDT.  This program makes health care accessible to families by identifying mental or physical health concerns through periodic screening and then providing diagnostic services and health care to treat conditions diagnosed by the screen.  Any health or educational professional may refer a Medicaid-eligible child to the EPSDT Program. Services can include but are not limited to the following: developmental assessments, lab tests, immunizations, hearing and vision exams and treatment and dental care.

 

MEDICAID PROGRAMS & ELIGIBILITY IN THE STATES

STATE

USES SSI CRITERIA

209(B) OPTION **

KATIE BECKETT

MEDICALLY NEEDY

ALABAMA

YES

ALASKA

YES

ARIZONA

YES

ARKANSAS

YES

YES

YES

CALIFORNIA

YES

YES

COLORADO

YES

CONNECTICUT

YES

YES

YES

DELEWARE

YES

DISTRICT OF COLUMBIA

YES

YES

YES

FLORIDA

YES

YES

GEORGIA

YES

YES

YES

HAWAII

YES

YES

YES

IDAHO

YES

YES

ILLINOIS

YES

YES

INDIANA

YES

IOWA

YES

YES

KANSAS

YES

YES

KENTUCKY

YES

YES

LOUISIANA

YES

YES

MAINE

YES

YES

YES

MARYLAND

YES

YES

MASSACHUSETTS

YES

YES

YES

MICHIGAN

YES

YES

MINNESOTA

YES

YES

MISSISSIPPI

YES

MISSOURI

YES

MONTANA

YES

YES

YES

NEBRASKA

YES

YES

YES

NEVADA

YES

YES

NEW HAMPSHIRE

YES

YES

YES

NEW JERSEY

YES

YES

NEW MEXICO

YES

NEW YORK

YES

YES

NORTH CAROLINA

YES

YES

YES

NORTH DAKOTA

YES

YES

OHIO

YES

OKLAHOMA

YES

YES

OREGON

YES

YES

PENNSLYVANIA

YES

YES

YES

RHODE  ISLAND

YES

YES

YES

SOUTH CAROLINA

YES

SOUTH DAKOTA

YES

YES

TENNESSEE

YES

YES

TEXAS

YES

YES*

UTAH

YES

YES

YES

VERMONT

YES

YES

YES

VIRGINIA

YES

YES

WASHINGTON

YES

YES

YES

WEST VIRGINIA

YES

YES

YES

WISCONSIN

YES

YES

YES

WYOMING

YES

*The medically needy program in Texas covers only the “mandatory” medically needy groups.  It does not cover the aged, blind and disabled.

**209 (b) states use a more restrictive criteria to determine eligibility than are used by the SSI program.

Think of SSI eligibility as your “doorway” to Medicaid eligibility and that some states use a more strict set of requirements. Military families, who find themselves ineligible for Medicaid because of their SSI ineligibility, should know that establishing the disability eligibility will enable their child to receive the Medicaid benefit when their child turns 18 or if their economic situation changes.

To find the phone number of the Medicaid office nearest you call 1-800-633-4227 and follow the prompts through “Other Options”.

Each state is required to identify the federal programs they implement as well as any state specific Medicaid waivers.  The U.S. Department of Health and Human Services CMS Centers for Medicare and Medicaid Services web site is a great place to gain this information.  The site is www.cms.hhs.gov and covers basic to in-depth information.

 Remember, the Medicaid program varies from state to state.  Always verify your state’s requirements for eligibility, waiver programs, application and covered services.  Doing research is your best offense!

 

 

“Working Together with Military Families of Individuals with DisAbilities!”

[wpdm_file id=35]