- What is Medicaid and how does it work?
- Is Medicaid free?
- What services are available?
- What is the difference between a state plan and a waiver?
- Who is eligible for Medicaid?
- Will I qualify for Medicaid if I receive SSI?
- What happens if I get SSDI, or qualify for both Medicare and Medicaid?
- Will I lose Medicaid if I get a job or have a reduced SSI payment?
- What if I am denied Medicaid?
- Medicaid Advocacy
Medicaid is a program run by the federal and state governments together. This is why it looks a little bit different in each state. The federal government pays at least half of the cost of Medicaid in each state, but it might pay much more and the amount it pays might change over time. This is because the payment is based on the average income of a person in each state. In general, wealthier states have to pay more for their Medicaid programs and poorer states get more money from the federal government. States and the federal government both have the freedom to change the rules of Medicaid, although doing so is not always easy.
No. Different states, and different plans within each state, will have different payment rules. Sometimes you will be asked to pay a monthly fee, or premium, or sometimes you will pay a fee each time you use a service. Medicaid is designed to make services affordable for the people who need them, but it is not free.
Because Medicaid rules are different in each state and territory, the services covered under the plans are also different. This means that people with disabilities will have different resources available depending on where they live, and also what type of disability they have. In addition to helping pay for regular medical care, medication, and hospital stays, Medicaid also provides services to help people with disabilities live and work in their communities instead of in institutions. The federal government says that there are some services that all states must provide, while others are optional.
Each state has its own programs, but all of these must meet the minimum federal standards for covering certain services. These plans also include whatever optional coverage the state chooses. These state plans must be basically the same everywhere inside the state, so that people have equal access to these services statewide.
States can also use ‘waivers’ to provide services to people with other needs, such as people with disabilities. In many cases, waivers also cover all of the services given under the basic state plan, plus the extra services. For example, most state plans cover regular visits to the doctor. A Medicaid waiver for people with I/DD might cover these visits but also provide an in-home nurse or personal attendant.
There are currently 125 waivers to support people with I/DD living in their communities, and others for people with physical disabilities and people who are older (usually 65 or above). Every state has at least one waiver, but the U.S. territories do not.
These waiver programs may not have enough money to offer all of the services needed to all of the people who need them. They usually have only a certain number of ‘slots.’ States do not have to provide services covered by waivers to everyone who meets the requirements, and so there are often waiting lists for these programs.
Medicaid was designed to support people with limited income, and so people who cannot afford to purchase health insurance and do not have jobs that provide it for them are usually eligible. There are many things that can qualify someone for Medicaid, including special health needs, low income, age, or a combination of these. Although people with disabilities are not always eligible, they usually fit into at least one of the most common optional coverage groups. This can happen if they have moderate income but very high medical expenses, if they are receiving institutional care, or if they need hospice care. It is illegal for a state to limit or deny mandatory services because of a medical diagnosis, type of illness, or condition.
Most people who receive Supplemental Security Income (SSI) are automatically eligible for Medicaid, but not always. In a few states it is harder to get Medicaid coverage than SSI, and people have to apply separately to see if they are eligible for SSI and Medicaid.
Medicare and Medicaid both provide health care services, but the rules are different. Medicare does not have waivers for people with disabilities. People who receive Social Security Disability Income (SSDI) are eligible for Medicare, as are people with disabilities who are older than 65. A person who is eligible for both programs is ‘dual eligible’, and can enjoy any benefits provided by Medicare and still look to Medicaid if they need more help.
Sometimes people who work are asked to pay for Medicaid if they want to keep their coverage. This is called a ‘buy-In,’ and it allows people with disabilities to keep their Medicaid benefits even if their income increases, their SSI payment is reduced, or they do not receive SSI. Other waivers have rules that allow people with disabilities who work or have higher incomes to get coverage anyway, because they understand that people with disabilities tend to have more medical expenses.
If you are told that you do not qualify for Medicaid or for a particular service that you need and you feel this decision is wrong, you can appeal it. This process is different in different places, so you should find out what it is in your state. If you appeal is not successful, you can ask for a Medicaid Fair Hearing. At this point it is a good idea to get help from an advocate who is an expert on Medicaid laws and is familiar with how these hearings work. At the hearing, a judge will decide what you are entitled to under Medicaid rules. If the rules say you are just not covered for what you need, a hearing will not help you. In this case, all you can do is work to get the rules changed.
Medicaid rules are complicated and they are always changing. Waivers, which are often the most important source of services for people with disabilities, are always being reviewed and rewritten. This can be a good opportunity to speak out about what services you need.
Medicaid was designed to provide basic health insurance, before most lawmakers had people with disabilities in mind. Of course everyone needs basic health care, but people with disabilities often still have to explain why they need services to support community-based living (instead of institutional care) and why these should be paid for by taxpayers.
The waivers that provide these services are the result of hard work by people with disabilities speaking out about what they need. Lawmakers are always worried about spending too much money, but they are also worried about people not having services they want. Disability advocates need to be clear that Medicaid coverage of community-based services is a basic right.