- Categorically Eligible
- Categorically Needy
- Dual Eligible
- HCBS waiver
- Intermediate Care
- Medically Fragile
- Medically Needy
- Nursing Care
- Special Needs
This means that you belong to a group, such as children or people with disabilities, that must be covered by Medicaid according to the law. However, you might have too much money or assets to get Medicaid even if you belong to this group. This means that you are eligible because you belong to the group, but you do not necessarily need Medicaid. States can choose to expand these groups to help more people get services. This is usually done through waivers.
This refers to people who belong to any of the groups that Medicaid has to cover by law. This includes people with low incomes, elderly people, children, and people with disabilities. The difference between categorically eligible and categorically needy is that categorically needy people DO need Medicaid services, and they automatically qualify for them. These rules apply to Medicaid in every state. State plans must cover people who are categorically needy if they want to receive money from the federal government.
People who are dual eligible can get both Medicaid and Medicare. Some plans have rules about people who are dual eligible, so the services you can get may be different than regular Medicaid services. Usually, what happens is that Medicaid will step in to help cover any services you need that are not already covered by Medicare. Many plans have very specific rules about people who are dual eligible and what they can and cannot get, so make sure you ask specific questions about this.
These are Home- and Community-Based Services waivers. These are programs to help states pay for care for people with disabilities in their homes and communities rather than in institutions or state hospitals. Using a waiver, states can change the rules of basic Medicaid to help pay for services not covered by other state programs. Waivers are usually directed at groups of people who might need extra services, like people with disabilities or older adults.
This is a lower level of care than nursing care. It is provided in an intermediate care facility (sometimes called an ICF/MR) unless services can be provided at home. “Intermediate” means in-between, so intermediate care is between primary care (which is basic doctor and dentist visits) and nursing care, which is more like hospital care.
This means that you are in stable condition but depend on regular treatments, medicines, or equipment to live. It also usually means that you need help with daily activities. This is a long-term condition that results from some kinds of illness or from some disabilities. States sometimes have waivers designed to provide care for children or adults considered medically fragile.
Medically needy means that you might have too much money to qualify for Medicaid, but you also have health expenses that are higher than average. States might let you get Medicaid because the cost of your care lowers your income to levels that would otherwise make you eligible. Sometimes this is linked to “spend-down” rules that tell how much your care has to cost you, compared to how much money you make, before you can get Medicaid.
This is the level of care above intermediate care. It is usually given in a nursing home unless it can be done at your home. Nursing care requires support from nurses or other trained staff, help with medicine, regular supervision, and help moving around and doing daily activities.
Many programs now put people with disabilities in charge of their own care. Sometimes this means working with family and state agencies to make a care plan or person-centered plan. Sometimes it can mean hiring, paying, and managing your own personal care attendant and having Medicaid pay you back the money. Self-direction is a good option for many people because it lets you have more control over what services you get and where you get them.
Special needs is a term used in some Medicaid programs to include people who need more than basic health services. Sometimes this means almost anything, but sometimes it is very specific. If you think you are eligible for a program that is for people with special needs, ask your state agency what this means where you live.