Medicaid Map

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.

In 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 MA.

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, n.d).

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, n.d.).

MA recipients have certain rights in Pennsylvania. The following list of rights is an excerpt from the Pennsylvania Law Project’s website:

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 disability.

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 qualify.

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).

Medical Assistance provides valuable health and treatment services to children with disabilities in order to help them to make meaningful progress and to achieve greater independence. As educators, it is important that we provide families with resources about Medical Assistance so that they can pursue the potential benefits and services that the program provides.