Medicaid: A Complex and Legislative Mosaic

By Branche, Benjamin T. | The Exceptional Parent, March 2011 | Go to article overview
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Medicaid: A Complex and Legislative Mosaic


Branche, Benjamin T., The Exceptional Parent


Why should parents of children or loved ones with disabilities understand the vast differences in state Medicaid Laws? What impact do the state differences have on families who are subject to temporary assignments to different states, such as military families, governmental workers and migrant workers? Everyone who has ever been a parent of, cared for, or worked with a child or loved one with a disability has most likely heard of Medicaid. Medicaid is a state and federally-funded health care insurance program available to low-income individuals and families and those demonstrating the requisite need. The program was established on July 30, 1965 pursuant to Title XIX of the Social Security Act ("SSA").

Although the Medicaid provisions under the SSA are already complex, the program is made more complicated because each state is responsible for separately administering the program with oversight from the Center for Medicare and Medicaid Services (CMS). There are requirements imposed by the Federal government and additional requirements for service, delivery, funding, eligibility and quality standards established by CMS. Based on the statute and regulations, most states fall into one of the following categories:

SSI States: States covering anyone who qualifies for the Supplemental Security Income (SSI) program (aged, blind and disabled). Although SSI is not required for Medicaid, it automatically is granted in these states if SSI benefits are received.

Section 209(b) States: States under this scheme may adopt requirements that are more restrictive than the Federal SSI rules. Currently, the 209(b) states are CT, HI, IL, IN, MN, NH, ND, OH, OK, VA.

Optional Coverage for Categorically Needy Persons: Some states cover "categorically needy persons" whereby benefits are provided to those who would qualify for SSI, but are not receiving it. States with this program that also adopt the "medically needy standard" are considered "Income Cap states." They are AL, AK, CO, DE, ID, MS, NE, NM, SC, SD and WY.

Medically Needy States: Under this optional program Medicaid benefits are provided if a person would categorically qualify for Medicaid, but exceeds the income level. These states include CA, CT, GA, HA, IL, KY, ME, MD, MA, NH, NJ, NY, NC, ND, PA, RI, SC, TN, VT, VA, WA, WV, WI and the District of Columbia.

Some states publicly administer Medicaid, while others subcontract the services to private companies. Medicaid has 25 different eligibility categories, which fall into 5 main coverage groups: children, adults with dependent children, pregnant women with children, individuals over age 65, and individuals with disabilities. The number of Medicaid categories and stringent requirements cause significant confusion when people seek to be qualified, and this is exacerbated by the fact that each state has its own name for Medicaid, its own procedures, and a variety of requirements.

There are a number of requirements that each state must adhere to because Medicaid is partially funded by the Federal government. Once such requirement is that a state may not have a residency term requirement, meaning it must automatically be available to residents as soon as they move into the state. Further, states must provide certain services.

Services Under Medicaid

Required services under the Medicaid program include:

* Physician's services

* Nurse midwife services

* Pediatric and family nurse practitioner services

* Federally qualified health center (FQHC)

* Laboratories and X-ray services

* Rural health clinic services

* Prenatal care

* Family planning services

* Skilled nursing facility services for persons over age 21

* Home health care services for persons over 21 who are eligible for skilled nursing services

* Early and periodic screening, diagnosis, and treatment for persons under age 21 (EPSDT)

* Vaccines for children

There also are a number of programs the states may optionally choose to administer, the most common of which are:

* Optometrists Services and Eyeglasses

* Private Duty Nursing

* Clinic Services

* Dental Services

* Physical/Occupational Therapy

* Prescribed Drugs

* Prosthetic Devices

* Diagnostic Services

* Intermediate Care Facility Services

* Nursing Facility Services for Persons Under Age 21

* Emergency Hospital Services

* Case Management Services

* Home and Community-Based Services for Individuals with Disabilities and Chronic Medical Conditions

Waiver Programs

Under Section 1915(c) of the SSA, Medicaid law authorizes the Secretary of the U.

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