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Medicaid for Family Members with Special Needs


Medicaid is an entitlement program that pays for medical assistance for certain individuals and families with low incomes and resources. Additionally, Medicaid provides health coverage to individuals with disabilities, including those who are working or who want to work.

What is Medicaid?

Medicaid is a federal program administered by the states that covers basic health and long-term care services for eligible children, adults, pregnant women, individuals with disabilities, and the elderly in families with low income and limited resources. Medicaid may provide eligible military families with benefits over and above those offered by TRICARE, although it will be necessary for them to reapply upon each move to another state.

Who is eligible for Medicaid?

Medicaid is jointly funded by federal and state governments, but states generally have broad discretion in determining which groups their Medicaid programs will cover and the financial criteria for Medicaid eligibility. There are no age restrictions for Medicaid coverage and the income restrictions vary from state to state:

  • Pregnant women and infants below 133 percent of the Federal Poverty Level (FPL). Medicaid covers pregnant women and infants in families at or below 133 percent of the FPL. In 2011 for a family of three, that means an income below $24,644.90 per year. Federal Poverty Charts are available at the Medicaid website.
  • Pregnant women and infants above 133 percent of the FPL. Medicaid may cover groups, such as pregnant women and infants, with incomes above 133 percent and up to 185 percent of the FPL. Medicaid calls this group "categorically needy."
  • Children, elderly, or persons with disabilities above 185 percent of the FPL. Medicaid may cover groups such as children, the elderly, or persons with disabilities who have too much income to meet financial eligibility (above 185 percent of the FPL), but who incur large medical or long-term care expenses and can qualify for Medicaid by "spending down," i.e., reducing their income through medical expenses. Medicaid calls this group "medically needy." States that cover the medically needy do not have to offer the same benefit package to them as they offer to the categorically needy.
  • Disabled children receiving Supplemental Security Income (SSI). In many states, disabled children receiving cash assistance under the SSI program are automatically qualified for Medicaid coverage. Some states use more restrictive eligibility criteria than those used by the SSI program, and therefore, receipt of SSI does not guarantee eligibility for Medicaid.
  • Waivers. States can apply to the Centers for Medicare & Medicaid Services for waivers to provide Medicaid to populations beyond what traditionally can be covered under the state plan. These may include coverage for persons in institutional settings or targeted services to particular groups, such as technology-dependent children, individuals with traumatic brain injuries, or persons with mental or developmental disabilities. More information about waivers is available on the Medicaid website.

What benefits does Medicaid provide for individuals with disabilities?

Individuals with disabilities who are eligible for Medicaid are entitled to all services that are deemed medically necessary. States establish and administer their own Medicaid programs and determine the type, amount, duration, and scope of services within broad federal guidelines. States are required to cover certain mandatory benefits, and can choose to provide other optional benefits through the Medicaid program.

  • Mandatory benefits. Mandatory benefits include, but are not limited to:
  • Hospital, home health, clinic, and laboratory services. These include inpatient and outpatient hospital services, home health services, physician services, certified pediatric and family nurse practitioner services, rural health clinic services, federally qualified health center services, and laboratory and X-ray services.
  • Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services. The EPSDT benefit provides comprehensive and preventive health care services for children under age twenty-one who are enrolled in Medicaid. EPSDT is key to ensuring that children and adolescents receive appropriate preventive, dental, mental health, developmental, and specialty services.
  • Nursing facility services. Nursing facility Services are provided by Medicaid certified nursing homes, which primarily provide three types of services: skilled nursing or medical care and related services; rehabilitation needed due to injury, disability, or illness; and long-term care.
  • Transportation. Transportation to medical care is also a mandatory benefit.
  • Optional benefits. Optional benefits vary by state and may include coverage for prescription drugs; physical therapy; occupational therapy; speech, hearing and language disorder services; respiratory care services; other diagnostic, screening, preventive and rehabilitative services; and services in an intermediate care facility for the mentally disabled.

Where and how do I apply for Medicaid?

Supplemental Security Income (SSI) recipients should apply at the local Social Security office. To find the nearest office, enter your ZIP code using the Social Security Office Locator. Many states have now made it possible to apply in other locations, such as hospitals, public health clinics, or, in some cases, by mail.

When applying for Medicaid, you may need to bring proof of income (e.g., check stubs); proof of assets (e.g., bank statement, value of car, etc.); Social Security card; two forms of identification (ID) (e.g., military ID, other photo ID such as a driver's license, social security card, birth certificate, etc.); and/or proof of residence (e.g., utility bill, telephone bill, or a rent receipt). Contact the Social Security office to determine the exact documents that will be required upon application.

Where can I find more information?

More information on the general Medicaid program is available on the Medicaid website. The website also provides links to Medicaid information by state, to include contact information for the state office.

You can also find more information through our elearning module on this topic.


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