Medical Assistance (MA), or Medicaid, is a federal/state
insurance program that pays for health and treatment services for children and adults with disabilities. Some
of these services include such things as health screenings, therapies, behavioral support services,
transportation, and home healthcare. Medical Assistance was authorized on July 1, 1969, under the Social
Security Act, Title XIX, Grants to States for Medical Assistance Programs. It is funded partly by the states
and partly by the federal government.
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The code of federal regulations, Title 42, The
Public Health and Welfare, is another important source of law that states the federal regulations pertaining to
medical assistance. Medical Assistance is a free program and anyone can apply for Medical Assistance, however, not
everyone with disabilities is eligible for Medical Assistance benefits. Each state establishes its own eligibility
standards, benefits package, provider requirements, payment rates, and program administration under broad federal
guidelines. This paper will provide an overview of Medical Assistance eligibility requirements, services, and the
rights of children that are Medical Assistance eligible, ages 3-21.
order to meet the federal MA qualifications, the child with disabilities must meet the U.S. citizen/alien
requirements for MA, fit into one of the categories that MA establishes, and meet income and resource requirements
(Pennsylvania Health Law Project, 2003). In order to be MA eligible in Pennsylvania, one must be a resident of the
state or a covered immigrant (Pennsylvania Health Law Project, 2003). There are several categories within MA that
cover persons with disabilities and they often have different requirements (Pennsylvania Health Law Project, 2003).
Children with disabilities that are eligible for Social Security Income (SSI) are automatically eligible for
Children with disabilities that
are categorized as severely disabled and are not on SSI are also eligible for MA, regardless of their parents’
income and assets and if their own personal income is less than the poverty level (in 2003 was $749/month). The
Department of Welfare calls this category the “loophole” category (Pennsylvania Health Law Project, 2003). In this
category, if a child’s income exceeds the poverty level, the child is still possibly eligible for CHIP (Children’s
Health Insurance Program) or may be eligible for a “Waiver” program if the child requires a higher level of care
(Pennsylvania Health Law Project, 2003). Most children in Pennsylvania with severe physical, mental, or behavioral
disabilities qualify for MA services (Education Law Center, n.d.).
Although a child with
disabilities may be receiving special education services and have a particular diagnosis, it does not mean that the
child meets the disability standards for Medical Assistance (Parents Involved Network of Pennsylvania, n.d.). The
eligibility standards for special education are different from the MA disability standards. However, a child’s
Evaluation Report (ER) can be an excellent source that documents factors that are considered in the Medical
Assistance disability standard (Parents Involved Network of Pennsylvania, n.d.).
Children with disabilities that
qualify for MA receive what is called an “ACCESS” card, which they can utilize for the purchase of a variety of
prevention and treatment services. Anything that is medically necessary must be provided and children that are
eligible are entitled to these services. Except through a “Waiver” program, MA does not cover any educational or
rehabilitation services. MA services are free and there are no co-pays or additional charges. If a family has
private medical insurance, this must be used first for the child with disabilities (Education Law Center,
Examples of behavioral health
services covered by MA include residential treatment facilities, behavioral services (wrap-around services,
therapeutic support staff), medication for behavioral problems, and partial hospitalization programs (Education Law
Center, n.d.). Examples of health services that are covered by MA include nursing care at home or at school,
therapies, communication devices, medical equipment, and personal care services for children who need assistance
with self-care skills, such as eating or dressing (Education Law Center, n.d.). MA must also provide eligible
children with any services that are necessary to meet the child’s physical or behavioral needs during the day, such
as a nurse, a specialized hearing aid, or a therapeutic support staff person. Many of these services, however, are
also considered “related services” based on IDEA regulations, and school districts are responsible for listing
these services on the child’s IEP even if the services are being covered by MA (Education Law Center,
MA recipients have certain
rights in Pennsylvania. The following list of rights is an excerpt from the Pennsylvania Law Project’s
1. The right to receive and file
an application on the same day that you ask for it.
2. The right to bring someone
with you to help you with the MA application.
3. The right to have an
application completed by a friend, relative, or official of a hospital, agency, etc. if you are ill or physically
or mentally unable to do so.
4. The right to translation
services and translated written material.
5. The right to receive coverage
beginning with the 3rd month before the application, if you qualify for retroactive MA.
6. The right to have DPW quickly
issue a MA card if you have ‘an immediate need for medical services.’
7. The right to receive
medically necessary treatment and services without discrimination based on national origin, race, color, sex, or
8. The right to free choice of
MA enrolled health care providers unless you are enrolled in the Health Choices Program.
9. The right to be treated with
dignity and respect.
10. If you are homeless, the
right to apply for MA even if you have no address.
11. The right to have the MA
programs explained to you and to receive help in determining the best possible coverage for which you
12. The right to prior notice of, and a fair hearing to
contest, any decision by the MA agency or an MA HMO to deny, terminate, or reduce benefits. (Pennsylvania Law Project, n.d.)
All decisions regarding the
rejection of MA or the reduction or termination of MA must be provided to recipients in writing and with
instructions on how to appeal. Recipients have 30 days to file appeals, but if the appeal is filed within 10 days
of the date of termination or reduction notice, MA benefits must continue until there is an outcome to the appeal
(Parents Involved Network of Pennsylvania, n.d).