Overview Of Medical Assistance For Persons With Disabilities
Ages 3-21
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. 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.