PFA Tips: Don’t Ignore Medicaid! (Part 1)
By Michael Dalto, SSI and SSDI Consultant
If you want services for your child, then don’t ignore Medicaid! Medicaid (also called “Medical Assistance”) is a comprehensive medical benefit for people who meet certain financial limits and other criteria. Medicaid covers not only basic medical needs, but also a number of services for certain people with disabilities, including attendant care, community psychiatric rehabilitation, services from the Developmental Disabilities Administration (DDA) (employment, residential and support services) and the Autism Waiver. Every form of Medicaid has a limit on income; most forms also have a limit on resources (assets). This benefit is generally funded jointly by federal and state governments.
What Can Medicaid Do for Your Child?
• Provide comprehensive medical coverage for people who have no other health insurance. Medicaid covers the same services as most other kinds of health insurance (doctors, hospitals, clinics, medical equipment and supplies, therapies, prescriptions, etc.), and some services that other insurance rarely or never covers (attendant services, community psychiatric rehabilitation, services from DDA, and the Autism Waiver, and the new Family Supports Waiver and Community Supports Waiver).
• Supplement private insurance. A person may have both private insurance and Medicaid. Medicaid supplements the private insurance. It may cover some services that private insurance doesn’t. It may also cover some services when the limits on those services for private insurance have been reached. Sometimes, Medicaid can help cover deductibles and copays, if the health care provider participates in Medicaid.
• Supplement Medicare. A person may have both Medicare and Medicaid. Medicaid eliminates almost all the costs for Medicare (premiums, deductibles, coinsurance) that the individual must otherwise pay out of pocket. NOTE: The first 5 forms of Medicaid listed below are available to people with Medicare; the 6th form is not.
• Help your child be eligible for services through a Medicaid Waiver, such as the Autism Waiver, the Community Pathways Waiver, the new Family Supports Waiver or the new Community Supports Waiver.
If you receive Medicaid in any of four ways (1 – 4 below), you meet the Medicaid eligibility requirement for any of the Medicaid Waivers. If you receive Medicaid through the Employed Individuals with Disabilities (EID) Program (5 below), you also meet the Medicaid requirement for the Community Pathways Waiver. Adult Medicaid through the Affordable Care Act (6 below) does NOT qualify you for any Medicaid Waivers. A Medicaid Waiver is a method of funding services for a limited number of people with disabilities who meet certain criteria.
The four Medicaid Waivers that are most likely relevant to your child are:
• The Autism Waiver (that serves people with autism under age 22)
• The Community Pathways Waiver (that serves adults with developmental disabilities, including autism, and is administered by the Developmental Disabilities Administration (DDA). Youths who have completed high school at age 21 or 22 receive priority for supported employment or other day services through this Waiver as part of the Governor’s Transitioning Youth Initiative)
• The new Family Supports Waiver (that will begin, in February 2018, providing individual and family supports to 400 children with developmental disabilities aged birth through 21 who are on the DDA waiting list) and
• The new Community Supports Waiver (that will start, in February 2018, to provide a wide range of services (except for residential services) to 400 adults with developmental disabilities who are on the DDA waiting list).
(NOTE: Medicaid eligibility is only ONE of the criteria that must be met to enroll in a Medicaid Waiver. You must also meet certain disability criteria, need a level of support that people receive in an institution, have a high priority for services, and be approved for a “slot” in the Waiver by the agency that administers the Waiver.)
How Can Your Child Qualify for Medicaid?
There are more than 50 ways to qualify for Medicaid in Maryland. We will focus on 6 key ways by which people with disabilities may be eligible (though there are others).
1. Supplemental Security Income (SSI) – A Marylander who receives any amount of SSI (even the minimum $1/month) is automatically eligible for Medicaid. Countable income must be under $750/month in 2018. The resource limit is $2,000.
2. Medicaid Continuation for Workers on SSI (1619(b)) – A SSI recipient whose earnings are high enough to reduce his/her SSI payment to $0 may be eligible for Medicaid through 1619(b). This rule protects Medicaid for workers whose SSI stops due to earnings, and who meet several other conditions (keeping unearned income, such as Social Security Disability and pensions, under $770 per month in 2018; keeping resources (assets) under $2,000; earning less than $40,005 per year from work in 2017 (sometimes higher); continuing to be disabled and to need Medicaid).
3. Medicaid Protection for Former SSI Recipients Who Receive Childhood Disability Benefits (CDB) (also known as Disabled Adult Child (DAC) benefits) – An adult who starts out on SSI may be switched to a Social Security Disability benefit on a parent’s earnings record when the parent retires, becomes disabled or dies. If this CDB (or DAC) benefit is high enough (generally $770 per month or higher in 2018), the person will lose eligibility for SSI. However, s/he can keep Medicaid if s/he meets all other criteria for SSI except for the income from CDB/DAC. The resource limit is $2,000.
4. Optional Medicaid – This Medicaid group is only for people who enroll in a “Medicaid Waiver” – a program that provides funding for a limited number of people with disabilities who meet certain criteria. Two Medicaid Waivers of interest to people with autism are:
• Autism Waiver (serves people under age 21 with autism)
• Community Pathways Waiver (serves adults with developmental disabilities and is administered by the Developmental Disabilities Administration (DDA))
The Optional Medicaid group has the same $2,000 resource limit as many other forms of Medicaid, but a higher income limit than most – $2,250 per month in 2018 (though the income limit for EID is higher). The higher income limit helps many people whose incomes are too high for other forms of Medicaid, such as SSI, to qualify for Medicaid and services through a Medicaid Waiver.
5. Employed Individuals with Disabilities (EID) – EID provides Medicaid to Marylanders with disabilities who meet these conditions:
• 18 – 64 years old
• Meet Social Security’s medical criteria for disability (such as people who receive Social Security Disability benefits)
• Work for pay (no minimum earnings requirement)
• Meet income and resource limits
The financial limits for EID are much higher than for other forms of Medicaid. An unmarried individual whose only income is wages can earn over $73,000 per year and still be eligible. An individual can hold resources of almost $10,000 and still qualify; many other forms of Medicaid (including the four listed above) have resource limits of only $2,000.
EID enrollees pay monthly premiums on a sliding scale from $0 – $55 per month. EID is a great way for workers with disabilities to qualify for Medicaid if they are not eligible in other ways, such as through SSI. It’s especially useful for people who get Social Security Disability benefits and who work for pay, and people with resources (assets) over $2,000.
6. Adult Medicaid through the Affordable Care Act – Unlike the five forms of Medicaid listed above, the Adult Medicaid group does not require a person to have a very significant disability (or to be disabled at all). It’s an option for adults aged 19 – 64 with household incomes below 138% of the federal poverty level for their household size ($1,387 per month for 1 person; $1,868 per month for 2 people). The household is defined similarly as for tax purposes. There is NO resource limit. Adult Medicaid is NOT available to people who are eligible for Medicare.
* This article is Part 1 of the Medicaid series. Part 2 will be released in February 2018.
© 2018 Pathfinders for Autism