Medical Assistance PA
When I moved from Canada to the Philadelphia area, I was a bit confused as to what services I could receive for my children. There were very little resources out there provided to my family regarding my children’s disabilities and the support that was offered was scarce. No one told me about the PA Medicaid loophole, getting a PA Access Card or anything.
Honestly, I started to regret the move back to the States. Why did it have to be so difficult to access this information? What is the big “secret” behind getting MA? Is there a stigma attached with it that people do not want to associate themselves with for some reason?
I still really don’t know the answer to those questions. What I do know, is that it is absolutely NECESSARY for you to apply for Medical Assistance if you have a child with a disability.
For the purposes of this post, I want to clarify a few things.
- The information here may not apply to your state. Please contact your state’s Disability Protection and Advocacy Agency for specifics on where to go.
- This information applies to Pennsylvania’s disabled children, but Medicaid varies from state to state.
- Being on Medicaid and having an IEP/504 are exclusive of each other. One does not guarantee the other.
- In PA, a disabled child on Medicaid has nothing to do with Social Security income. Not even a part of this conversation. Again, contact the P&A agency in your state if you need help with that.
- In PA, you do not have to provide your Medicaid number during an IEP meeting (in order to receive IEP services). However, it gives schools just another option for funding (so I always sign mine). However, in some states (again, not in PA), what the school collects in Medicaid funding may affect the amount of outside services they can receive.
Why Disabled Children should be on Medical Assistance
With Medicaid, you then open the doors to many opportunities for your child and your family. Opportunities that may not necessarily have available to you prior to the assistance. Many think that their coverage or spouse’s coverage from work is sufficient. Wraparound Behavioral Health Services (in PA) is one of them.
And, it might be. But here’s some food for thought: A good friend of mine has decent coverage from her spouse. However, her spouse’s union went on strike for 2-3 months. And during a strike, you don’t get health insurance.
Thankfully she has medical assistance for her disabled child, but what if she hadn’t? This is a process. It doesn’t happen overnight. But as the old saying goes, “Better to have it and not need it, than need it and not have it.” It can be a life ring.
My own son developed his seizure condition literally overnight. One day he wasn’t having seizures, the next day he was. And one of his medications costs $85 a month, one is $300 a month.
Medicaid in PA works that my son gets everything from his primary insurance (my husband’s employer) first, then everything that is not covered gets picked up by Medical Assistance. If he did not have Medicaid, that $385 co-pay would be our responsibility.
When your child is an adult and needs OVR….you don’t get OVR services unless the child is has a PA Access Card.
PA Medicaid Loophole
If you have a child under the age of 18, he/she is considered “disabled” under SSA standards if he/she has a medically determinable physical or mental impairment, which; results in marked and severe functional limitations; and has lasted or can be expected to last for  a continuous period of not less than 12 months.
The PA Medicaid Loophole: What’s different in PA is that the parents’ household income is not a factor for consideration. I have more on that below.
Applying for Medicaid in PA
There  are 2 ways to apply:
1. The easiest way is to apply online via COMPASS
There is also another site that explains the process in great detail that I love called MA for the Disabled Child In PA so please review it prior to applying.
2. You may also contact the Dept. of Public Welfare in your County.
- Bring your child’s SS Card
- Medical Evaluation (must have five axis diagnosis)
- Make a copy of SS card
- Medical Evaluation (for the County Assistance to keep)
It may take 2-3 weeks to receive your ACCESS card. You will first receive an ELIGIBLE NOTICE paper then you will receive your ACCESS card.
PH 95 Loophole
We were on a roll where we were declined every year. Then, I started only using paper applications and across the top, in Sharpie, I’d write: “K is a PH 95 kid.”
I have since gone back to online renewals, and there are sections for comments. I put “K is a PH 95 kid.” This way, our application does not get held up by them trying to verify income.
**Please note** I have known MANY families who were denied the first time and appealed and received it. It seems this is becoming more commonplace. Do not get discouraged, just reapply.
Who Qualifies for Medicaid in PA
The following are some of the great benefits for having medical assistance but are not limited to these services since it varies with each individual child:
- Covers complete medical care for the disabled child (for example, will cover co-pays from your primary insurance if your child has that)
- Specialists
- orthotics
- Therapies-OT, PT, SLP
- hippotherapy
- covers respite care for the family where approved
- animal-assisted therapy
- out-patient, in-home, clinical, and in-patient
- Dental-especially if your child needs cleanings more than 2x a year
- Covers all medications for disabled child
- psychiatric care (if necessary)
- Covers evaluations-including independent evaluations at approved specialist locations (this is huge if you are battling your district over independent evals!)
- *Covers wrap-around services or Behavioral Health Rehabilitation Services-program that provides services to children in their own home and community with a strong emphasis on natural supports. This can also include services for siblings if the non-disabled sibling has “issues” due to having a disabled brother or sister.
- diapers/pull-ups after age 3
- an Art Reach card for discounted arts and museums services
*****NOTE: As stated before, this is not limited to this list. This is just an example and can vary from case-to-case. It is also coverage UPON APPROVAL OF FACILITY/SPECIALIST.
I hope you found this helpful. I encourage you and your family to apply if you have not done so already since it will open-the-door to many more resources for your child and your family. It can be a bit cumbersome at first with the paperwork, but it is worth it to get the services you may need.
It really can be the life ring that you need.
Keep being amazing,
Michele
Blog owner’s note: This post was originally published in 2011, but was recently updated and reposted.
PH-95-Loophole