Information Avenue Archives

Medicaid
For children in middle to upper income families

Contrary to popular belief, Medicaid is not just for children who are in a low income family. With the help of the Home and Community Based Services (HCBS) waiver program, children who are at risk of being institutionalized can qualify for Medicaid services. The purpose of the program is to develop and implement creative alternatives to placing a child in an institutional setting. Therefore, under the waiver program, a disabled child who would be eligible for Medicaid only if he or she was in an institution, can qualify to receive services, regardless of the parents’ income. The idea behind these waivers is that many children can be cared for at home at a cost that is less than if the child were placed in an institution.

Services offered under the HCBS waivers include home health aid services, personal care services, respite care, behavior intervention training, transportation, communication services and other services approved by HCFA, the organization who is financially responsible for the Medicaid program. In addition, once the child has been determined to be at risk of being institutionalized, the child will qualify for full medical benefits as well. Federal regulations permit HCBS waiver programs to serve the "physically disabled, the developmentally disabled, or the mentally retarded or mentally ill."

Each state has different eligibility requirements and different programs, however, the following criteria is mandatory:

• The child must be under 18 years of age and have been diagnosed with a chronic disability.

• The parents’ income must be too high to qualify for SSI for the child.

• The level of care required by the child must be equivalent to that provided in a hospital, skilled nursing facility, or intermediate care facility for those with mental retardation/developmental disabilities.

• The child’s home provides a safe and appropriate environment for care.

• The total annual cost to Medicaid must not exceed the amount Medicaid would pay if the child were institutionalized.

• The child must not have income or assets of more than the current standards for a child living in an institution.

In an effort to determine whether a child is at risk of becoming institutionalized, the state may consider the following factors:

• The child may have significant care needs in terms of self-help or activities of daily living (i.e., bathing, eating, dressing, and grooming).

• The child may have severe aggressive behavior problems resulting in frequent tantrums or injurious actions directed toward himself or others.

• The child may have intense medical needs and require skilled nursing care.

States have the flexibility to design each waiver program and select the best mix of services they wish to provide their population. The first in-home community based waiver was developed in 1981 and there are now over 200 HCBS waiver programs in effect, serving more than 250,000 individuals, as a cost effective and human alternative to an institutional setting.

If a child has been deemed eligible to receive Medicaid based on a waiver program, he or she is entitled to receive the following services:

• Physician services
• Prescribed drugs and supplies
• Inpatient hospital services
• Nursing facility care services
• Emergency ambulance services
• Dental services
• Community care services (as described earlier as part of the HCBS waiver)
• Non-emergency transportation
• Outpatient surgical services
• Medical equipment and supplies
• Exams, immunizations, and treatment for children
• Family planning services
• Home health services
• Hospice care services

An important thing to keep in mind, however, is that Medicaid will cover physician services providing the physician accepts Medicaid payments (not all health providers will take patients with Medicaid). And, if your child is currently insured through an insurance company/HMO, the private insurance company will be listed as your child’s primary insurance and Medicaid will be listed as a secondary insurance (whatever your primary insurance does not cover, Medicaid will pay the difference).

If you are interested in learning more about Medicaid waivers, please contact the agency in your state that handles Medicaid applications. For a complete listing of agencies, please visit the following web site: http://www.hcfa.gov/medicaid/scon1.htm#F.

References:

• http://www.hcfa.gov/medicaid/ltc8.htm
• http://www.familyvoices.org/KATIEBEC.html
• http://www.ssa.gov/OP_Home/ssact/title19/1915.htm#c8

 

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