Finding Your Way through the Medicaid Maze

Article excerpt

Medicaid often serves as the primary health insurer for children with disabilities. While the Medicaid program offers some important benefits, it is complex and can be difficult to understand.

These problems have to do with the way in which Medicaid was established and developed. Most industrialized nations offer universal health care, administered by the government and supported by tax dollars. Usually, these countries have clear rules regarding coverage so there is no confusion about what will be covered.

However, the American health insurance system is fragmented and confusing. There's an enormous web of individual- and group-health insurance programs, managed-care plans, health maintenance organizations (HMOs) and state and federal insurance programs.

Established in 1965, Medicaid was intended to provide insurance for families whose income was below the poverty level and for people with severe disabilities. Run primarily through state agencies, Medicaid provides a core of basic services--including doctor visits and hospital care--that's provided in all states, in accordance with federal regulations. However, optional portions of the program may be offered by different states. As a result, Medicaid rules differ substantially from state to state.

Furthermore, some states have been granted "waivers" in regard to specific federal program rules. Such waivers are issued at the request of a specific state's Medicaid program. Once a waiver has been granted to one state, other states may apply for it as well, but they are not obligated to do so.

One waiver that's been granted to several states allows Medicaid funds to be used to pay for at-home treatment for a child with a disability where hospital-based treatment is excessively expensive. This waiver was first granted in the early 1980s, and may apply in certain cases even where the family's income is above the usual Medicaid guidelines.

A more recent waiver deals with rehabilitation programs for children or adults who have experienced severe head injuries. This "head injury waiver" permits Medicaid funds to be used for community-based rehabilitation programs, in addition to the more traditional inpatient programs.

Lawmakers have changed Medicaid over the years. One such change established the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program. EPSDT provides for a periodic medical screening program for children with disabilities enrolled in Medicaid. Medical needs identified as a result of the screening program should generally be covered by Medicaid, even if they would not ordinarily be covered for adults under general Medicaid rules.

Regulations that govern EPSDT are complicated and may be subject to different interpretations, but the program remains a major key to obtaining services for children with disabilities. …