As a special education attorney, I ask the parents during our initial consultation whether the child has medical assistance. Oftentimes the parents respond that they have private insurance for their child. Regardless of whether the child is covered under private insurance, the child should have medical assistance. Why? Because medical assistance covers many things that are not covered by private insurance. This article provides a brief overview of why, as a parent of a special needs child, you should have medical assistance for your child and how to obtain it.
Medical assistance (hereinafter “MA”) has the broadest coverage of medical and mental health services for individuals under 18 of any insurance plan. Services provided under MA that private insurance often does not cover include behavioral health services, in-home nursing services, in-home personal care services, diapers, nutritional supplements, prescriptions and transportation to medical appointments. Behavioral health services are often referred to as “wraparound” services and included a Therapeutic Support Staff (TSS), a Mobile Therapist (MT) and a Behavior Specialist Consultant (BSC) who all work together to provide behavior support to children at home and at school. MA also covers various types of therapy such as occupational, physical, and speech and language. Often private insurance companies place a cap on these services whereas MA does not. MA can be a child’s only insurance or it can be secondary. Where it is secondary, MA will cover services not covered by insurance, including co-pays, and can cover the therapies in addition to those covered by insurance.
A common misconception about MA is that income of the parents is considered; however, income of the parents is irrelevant to eligibility. Why? Because of Category PH 95, which is considered a “loophole” and allows qualified individuals to obtain MA without consideration of the parents’ income. Generally speaking, in order to qualify under the loophole, the student must have a disability or condition that limits his or her ability to perform basic functions including physical, neurological, sensory, cognitive, and psychological functioning.
Thus, the majority of students who have an Individualized Education Plan (IEP) will be eligible for MA. In order to establish that your child meets these standards you will need to provide any medical reports, therapy reports, guidance counseling reports and Evaluation Reports (ERs) prepared by your school district, intermediate unit or early intervention program.
To apply, you can call 1-800-986-5437 and request a paper application (form PA600CH.) You must drop off the paper application at your local county assistance office along with the proper documentation requested within the application. You can also apply online or download form.
In addition to the disability documentation, you will need to provide the child’s social security card, birth certificate, proof of address and documentation of income in the child’s name (interest or dividends and earnings of a child’s income are considered.)
You may also need to obtain a Supplemental Security Income (SSI) determination. SSI provides a monthly check and MA to qualified persons who meet Social Security’s disability criteria and have low income and assets. Even if you are not seeking SSI, your local county office may advise that you need an SSI eligibility determination to obtain MA. To receive an SSI eligibility determination, you simply call 1-800-772-1213 and follow the prompts to speak to a representative to set up a phone or in-person interview. Keep in mind that parental income matters for SSI. Thus, be prepared to have documentation of income available for the interview. If you do not meet SSI requirements for income reasons, you will receive a denial letter which you then need to include with your MA application. If, however, SSI determines your child does not meet the disability standards for SSI, this will make your child ineligible for MA. Thus, you must appeal this decision and you have 65 days to do so.
Having medical coverage for your child is essential, especially when you have a child with special needs. Medical assistance provides extensive coverage that private insurance may not.
Income of the parent is not relevant to qualification for MA. Thus, parents who have a child with a disability should take the necessary steps to ensure they have MA for their child.