Here’s what we’ll cover:
- What is Medicaid?
- What is the Children’s Health Insurance Program (CHIP)?
- What services are covered by Medicaid for children with disabilities?
- How can children with disabilities qualify for Medicaid?
- How do I apply for Medicaid?
- What do I need to know about Medicaid once I have it?
What is Medicaid?
Medicaid is a public health insurance plan that is supported by the federal and state government. It’s for people who have low income or disabilities.
All states have their own versions of Medicaid. For example, it’s called MassHealth in Massachusetts, and Healthy Louisiana in Louisiana. Your state will have its own criteria for qualifying, and its own set of Medicaid plan choices.
Your child would have to qualify based on your household income, but the guidelines are different if they have a disability. (A person with a disability may have a higher family income limit.)
It can be very useful to have Medicaid for a child with disabilities because it offers a wide range of disability benefits. It’s worth seeing if your child can qualify for Medicaid, even if your family’s income is too high. And even if you have private insurance, you may also be able to get Medicaid as a secondary insurance for a child with a disability. (This means Medicaid may pay for services that your private insurance doesn’t cover, and it can usually pay for co-pays and other out-of-pocket expenses.)
Each state runs its own Medicaid program, so learn about how Medicaid works in your state.
What is the Children’s Health Insurance Program (CHIP)?
CHIP is the public Childrens’ Health Insurance Program that works with Medicaid in each state. It covers health services for children who qualify. Sometimes it’s a separate program and sometimes it’s part of the Medicaid plan. In some states, CHIP also covers pregnant women.
CHIP has higher income limits than Medicaid, so you may be able to get it for your child, even if your income is too high to get Medicaid.
Usually you would apply for both Medicaid and CHIP at the same time, but your state’s application system will walk you through that.
What services are covered by Medicaid for children with disabilities?
Medicaid covers things that most health plans offer, like doctor’s visits, hospital stays, and emergency care.
But it also offers special services for children and adults with disabilities. Ask what benefits your plan offers that relate to your child’s needs.
Medicaid covers services like:
- Early and Periodic Screening, Diagnostic, and Treatment (EPSDT services): Medicaid programs in all states are required to cover these services for all children under age 21. They include diagnostic tests for autism or other developmental disabilities, and help ensure that children are screened and treated for potential health and developmental conditions. This includes addressing developmental delay, hearing, vision, mental health, oral health, autism, and more
- Personal Care Attendants (PCAs) or Direct Service Workers to help care for your child at home. This is for people who cannot take care of their own daily needs, like eating, bathing, dressing, and moving around their house. Based on your child’s needs, you could get a certain number of hours per week to hire a PCA to help with these tasks
- Therapies like speech, OT, and PT
- Special equipment or devices that help with medical, communication, or mobility needs
- Diapers or pull-ups for children over 3 or 4 if their disability makes them incontinent (not having the control to use the toilet)
Medicaid also has benefits that help pay for transportation to your medical appointments!
The federal government requires state Medicaid programs to cover certain services, and states can opt to cover extra services as well.
- Here’s a quick list of Medicaid benefits that all states must provide, (and some optional ones)
- Check the actual eligibility requirements from your state
Other services from your state, with or without Medicaid
Each state has an agency–or office–that offers services for children and adults with disabilities. You may be able to get services from this office, whether or not you have Medicaid. (There may be more services available if you have Medicaid, so be sure to ask!)
In Louisiana, Medicaid plans are run by Healthy Louisiana.
All Healthy Louisiana plans include at least these services:
- Behavioral health services
- Chronic illness management
- Dental services
- Durable medical equipment, prosthetics, orthotics, and certain supplies
- Early and periodic screening, diagnostic, and treatment (EPSDT)/well-child visits
- Emergency and non-emergency medical transportation
- Emergency medical services
- Family planning services
- Inpatient/outpatient hospital services
- Laboratory tests and x-rays
- Pregnancy and newborn care
- Prescription medicines/pharmacy
- Rural health clinic services
- Unlimited Primary Care Physician (PCP) visits
- Vision services
- Women’s health services
In-home help from a Personal Care Attendant (PCA) or Direct Service Worker (DSW):
You may be able to get these services if you’re not getting them from another program.
- For children from 0-20: EPSDT Personal Care Services
- For a family member older than 22: Long-Term Personal Care Services (LTPCS)
Other services from Louisiana, with or without Medicaid
You can find other services for children with disabilities through the Office for Citizens with Developmental Disabilities (OCDD). To learn more, read this article about OCDD services, or call your local Human Services District (HSD) office.
Massachusetts’ Medicaid is called MassHealth
What services does MassHealth cover?
It depends on the type of MassHealth coverage you have. To learn about covered services for different coverage levels, see the MassHealth Member Booklet, or call MassHealth at (800) 841-2900 (TDD/TTY 711).
Along with other benefits, there are special services and programs that some children may qualify for:
A Personal Care Attendant (PCA) can come to your home and help care for your child. A PCA Management Agency will work with your family to find out how many hours a week are needed to help your child. You will hire a PCA of your choice to help you at home, and bill MassHealth to pay them.
Mental health and behavioral health programs:
- Covered Services for Mental Health and Substance Use Disorder
- Children’s Behavioral Health Initiative (CBHI)
Other services from Massachusetts, with or without Medicaid:
The Department of Developmental Services (DDS) offers other services to children with disabilities. Contact them to see what your child qualifies for.
How can children with disabilities qualify for Medicaid?
To qualify for Medicaid, it depends on the family’s income and the child’s disability.
- For children, the family’s income will usually have to be below a limit, and their disability must fit Medicaid’s definition
- The income limit may be higher for those with a disability
- In some cases a child with a disability could qualify for Medicaid even if the family’s income is above the limit—but the family would have to pay premiums
But each state has its own criteria. Learn about Medicaid in your state.
Look up your state’s income limits for Medicaid programs. The limits will depend on these two factors:
- MAGI: Modified Adjusted Gross Income: your household income with some adjustments
- FPL: Federal Poverty Level: a standard income level that is used to decide who should get benefits
Example FPL and Medicaid eligibility:
- The FPL (Federal Poverty Level) for a family of 4 is $30,000 per year. If your family makes this amount, that’s 100% of the FPL
- If your household makes $60,000, that’s 200% of the FPL. This would qualify your family for Medicaid in some states
- This chart tells you what percentage of the FPL is the limit to qualify for Medicaid for children of different ages, pregnant women, and other adults
You should qualify if your household income is less than the income limit. But if your child has a disability, the limit may be higher. Even if your income is higher, it’s worth learning more!
If your child gets SSI benefits, they will automatically qualify for Medicaid! (Read more about SSI: Supplemental Security Income.) If your child has been approved for SSI, the Social Security Administration will share the information with Medicaid, and you will hear from Medicaid by mail.
In Louisiana, Medicaid plans are run by Healthy Louisiana.
- Healthy Louisiana used to be called Bayou Health
- LaCHIP, a Medicaid program for children, is part of this
There are different kinds of programs. To see if your child qualifies, look at this chart with income limits for the different Medicaid programs.
In Massachusetts, Medicaid is called MassHealth.
There are different coverage levels. See the MassHealth Member Handbook to learn who can qualify for each of them.
How do I apply for Medicaid?
To apply for Medicaid for your child with a disability, you can go through your state’s Medicaid office or your state’s Healthcare Insurance Marketplace. The Marketplace is also where you would enroll in other health insurance plans. Those have specific enrollment periods during the year, but for Medicaid you can apply any time.
You’ll have to set up an account, and then you can log in anytime to see how the application is going. They will tell you if you qualify, and what forms to fill out. You can apply online, by mail, by phone, or in person.
There are usually 2 parts to applying for Medicaid:
- Apply for Medicaid: This is to see if you qualify. You fill out a Disability Report and the general application
- Enroll in a health plan: Choose and enroll in a Medicaid plan from your state’s choices
Choose from different Medicaid plans
Most states offer some choices of Medicaid health plans, or different levels of coverage based on your situation or disability. In some cases, you will have to compare the benefits and costs and choose one that fits your needs. All plans in all states must include the required Medicaid benefits, but they may have different optional benefits.
Sometimes the plan choices are only for kids with certain diagnoses, like autism, significant medical needs, or behavioral health conditions (which includes mental health and substance use disorders). In these cases, Medicaid may assign a plan based on what your child qualifies for. When you start the application process, your Medicaid office will describe the options and usually have a place online where you can compare plans side-by-side.
Tips for applying for Medicaid
- Gather the documents with the information you need:
- Your child’s diagnosis, medicines, medical specialists, and other supports they get from state disability programs
- Your financial records, including your latest tax return
- Proof of U.S. citizenship and residence in your state
- Take a deep breath and be ready to stick with it. It can be a long, detailed process
- If you need help, call the Medicaid office or find a local agent or “assister” Assisters are trained to help people apply for Medicaid and other Marketplace health plans
- You can also call the national Medicaid hotline toll free at (888) 342-6207. They answer calls Monday through Friday from 7am to 5pm (For TTY, call (800) 220-5404)
How to apply for Healthy Louisiana
You can apply online, by phone, by mail, or in person. Applying online is usually faster.
Go to the Healthy Louisiana webpage and follow the instructions. You’ll have to create an account to do the application online, but it is free.
This can be complicated! If you have questions about enrolling in a health plan, call (855) 229-6848.
Choose a health plan
If you qualify for Healthy Louisiana (Medicaid), you can enroll in one of these 6 health plans. They are also called MCO’s, or Managed Care Organizations.
- AmeriHealth Caritas
- Healthy Blue
- Humana (new choice since 2022!)
- Louisiana Healthcare Connections
They all include the same Basic Plan Benefits that are required by all Medicaid programs. But each MCO, or health plan, offers some extra benefits as well.
Healthy Louisiana may have to choose an initial plan for you, but you have 90 days to change to a different plan if you want. After that, you will be able to change only during the open enrollment periods each year.
Dental Plans include DentaQuest and MCNA Dental. Learn about getting dental care for people with disabilities in Louisiana.
You will get 2 health insurance cards:
- 1 for Healthy Louisiana: This shows that you are a Medicaid member
- 1 for your Health Plan: This is what you show at your doctor appointments
Learn more from the Louisiana Dept. of Health:
How to get help applying for health insurance in Louisiana:
- If you have questions about enrolling in a Healthy Louisiana health plan, call: (855) 229-6848
- Contact your local Medicaid application center and ask for help
- Call your local Medicaid office and ask for help
- Use this online form to send them a question about any Medicaid program. They should reply to your email address
- Call your local office of Navigators for a Healthy Louisiana. They are there to help people apply for insurance and know how to use it. They can help with Medicaid or other insurance plans. They do not work for the state or for any one insurance plan
- Phone: (800) 435-2432
- Email: email@example.com
English not your preferred language?
- If you want to get help in your own language, you can do that!
- Call this number: (888) 342-6207
- Tell them what language you need. They will get you help for free
To apply for MassHealth:
Go to the Application page on the MassHealth website. It will tell you how to apply in any of these ways:
- This is the fastest way to apply
- Create an account and fill out the application in the MA Medicaid system, OR at MAhealthconnector.org
- Download the MassHealth application
- Fill it out and mail or fax it to the address or number on the application
- Call MassHealth at (800) 841-2900 (TTY: (800) 497-4648)
- This is an automated phone system. Listen carefully and be patient!
- Make an appointment with one of the MassHealth Enrollment Centers or call an Enrollment Assister who can help you
- Find out before you go what information and documents you will need to bring
Tips on filling out the form:
- Fill it out completely
- Fill out the Supplements if they apply to you. If your child is over 18 and you don’t have guardianship, fill out the Authorized Representative Form at the end of the application. This will give you permission to manage your child’s insurance
- If you fill out any extra pages or forms, attach them to the application when you send it in
Different coverage types
MassHealth has 6 different coverage types. These are not health plans, but levels of coverage. When you apply, they will give you the level with the best coverage that you qualify for.
- MassHealth Standard: The highest level of coverage for those who qualify
- MassHealth CommonHealth: For adults and children with disabilities who don’t qualify for Masshealth Standard, but need similar services
- Masshealth CarePlus: Covers a range of benefits for those who don’t qualify for Masshealth Standard
- MassHealth Family Assistance: Covers a smaller range of services for those who don’t qualify for MassHealth Standard
- Premium Assistance: Pays for the premiums if you have another health insurance plan
- Masshealth Limited: Emergency services for those whose immigration status doesn’t qualify them for another plan
Different health plans
Once you have applied, qualified, and been assigned a level of coverage, you will choose and enroll in a health plan in your area.
If you need more help with this process, call any of these other helpful resources:
- Health Care For All’s free Helpline: Call (800) 272-4232
- The Family-to-Family Health Information Center: You can get free, confidential help navigating the MassHealth system. Staff can help you through the process of applying, and help you understand the coverage options. This service is offered by Mass Family Voices, a project of the Federation for Children with Special Needs
- The UMass Disability Evaluation Services (DES) Help Line: Call (888) 497-9890
- The Autism Insurance Resource Center (If your child has an autism diagnosis):
- Call: (774) 455-4056 or (800) 642-0249
- Email: firstname.lastname@example.org
What do I need to know about using Medicaid once I have it?
How can I find out what services my Medicaid plan covers?
Your plan may have benefits that you’re not aware of. Find out! Here are 3 ways to learn about your benefits:
- Call the number on the back of your Medicaid Plan card
- Look in the Member Handbook (You should have gotten one when you finished applying)
- Call your Medicaid office or find a local agent or “assister”
If you talk to someone about benefits, explain your child’s disability and specific needs. (Be honest and don’t candy-coat it.) Ask what benefits may be useful.
Do I need to get services approved? What is Prior Authorization? [h3]
Most Medicaid benefits are covered without having to do anything, but some of them need to be approved in advance. This is called Prior Authorization. This is only for certain kinds of benefits, services, or medicines.
If you’re not sure if a benefit needs prior authorization, call the number on the back of your Medicaid card. They will tell you if it’s required, and what you need to do.
Do I need to renew Medicaid every year? [h3]
Yes. Every year you will have to show Medicaid that you still qualify. This may be called a re-determination or eligibility review. If your income or disability have not changed, you should still qualify.
Medicaid stopped requiring these reviews during the pandemic, but they are starting them again in 2023.
If you have been a Medicaid member for close to a year, or more, you may want to check.
Here’s what to do:
- Log in to your online state Medicaid portal. It should tell you when you have to renew
- Make sure your Medicaid plan has your correct contact information. If you move or change your phone number, call or go online to correct anything
- Keep an eye out for letters from your state Medicaid office. Be careful not to throw anything away, and make sure to respond to any mailings that need your attention
Now you know why it’s important to consider Medicaid for children with disabilities. Medicaid has excellent benefits on its own, and you can also combine it with another health insurance. Signing up for health insurance can be complicated, but there are people who can help you through it. See if you qualify for Medicaid so you can find the best services to help your child live their best life!