From Autism Transition Handbook
Click on Applying for Social Security and Medicaid link
to return to overview/other state pages.
The following sections explain the basics of Social Security and Medicaid benefits. Parents may find assistance with securing these benefits through their local county offices, a school social worker, and/or the state's website.
Though navigating government systems to receive support to help your son or daughter may seem like a daunting task, most states have supports coordinators that can help you find and obtain the resources and support you need. It is very important to obtain original documentation that shows your son or daughter's diagnosis from a qualified professional (physician, neurologist, State Certified Psychologist, developmental pediatrician, or psychiatrist) and then register with your state's supports coordination office.
The new site, Health.gov, has prepared an excellent overview of Medicaid which can be found at http://www.healthcare.gov/using-insurance/low-cost-care/medicaid/index.html. Content from that site has been summarized in the Medicaid section below.
Applying for Social Security and Medicaid in Pennsylvania
Register with your Local MH/MR Office. Your local supports coordinator can help you identify and locate services and supports that would be helpful. Click Here for additional information on begining to apply for benefits.
Social Security Benefits
What is Supplemental Security Income?
Supplemental Security Income (SSI) is a federally funded program that provides financial assistance to individuals who have limited income and assets and qualify under other specific guidelines; it is a monthly benefit that individuals can use to pay for living expenses. SSI may be available for individuals with autism and other intellectual/developmental, or physical disabilities.
Who is Eligible for SSI?
In order to qualify for SSI, adults and children must meet a particular set of requirements. Children under the age of 18 may qualify for SSI if he/she meets Social Security’s definition of disability for a child, and if his/her income, in combination with the income of others living in the household, falls within the eligibility limits.
See Also: Children under age 18 fact sheet: www.ssa/gov/disability|childstarter kit
Young adults 18 years of age or older must adhere to the eligibility rules for adults; in particular, the income and resources of family members are no longer considered when making eligibility decisions. Even if your child was receiving SSI benefits before his or her 18th birthday, there will be a review during the one-year period that begins on their birthday and you will need to prepare a re-application to continue receiving benefits. For the adult starter kit and eligibility rules, click here For a detailed description of the requirements for determining disability for adults with autism click here.
See Also: SSI and Children turning 18
How do I apply for SSI?
There are three ways to apply for SSI: online, by phone (1-800-772-1213) or by going to a local Social Security office. You will need to bring your child's Social Security card, original birth certificate, and "medical evidence" that documents your child's diagnosis from a qualified professional. In addition, you will need to answer questions on your family's assets. If your assets exceed the maximum allowable asset level, the application will be rejected.
Even if your son or daughter does not qualify for SSI because your family income is too high, your child may still be eligible to receive Medicaid. If your assets exceed the maximum allowable asset level, the application will be rejected. If the application is rejected due to the asset test make sure to keep a copy of the rejection letter for your files. Your child may still be able to receive Medical Assistance but will need a copy of the rejection letter. As long as your son or daughter meets the SSA requirements for level of disability, they qualify for Medical Assistance.
Who Determines SSI Eligibility?
Each state has its own agency that makes the disability decision. They review the information provided to the Social Security Administration, and will ask for information from medical and school sources and other people who know about the child. There is a disability starter kit available (one for children under age 18 and another for adults) which includes a checklist and a worksheet to help gather the information you need. The contact number is 1-800-772-1213. Please note the decision can take between three and five months. Having complete information available for the interview will expedite the process. If you want to appeal your decision, read about the process in the SSA's Appeal Fact Sheet.
What are the Monthly SSI Rates for 2014?
Supplementary Security Payments vary depending upon living arrangements and income. In 2014, the maximum monthly benefit amount for an individual living alone is $721, and for an eligible couple, the monthly amount is $ 1,082. For an eligible person living in another person’s household, and receiving in-kind support of rent and food, the monthly amount is $481. This is the "Value of One-Third Reduction Rule". The rule states if you are living in somebody else’s household, and somebody in that household gives you both food and shelter (no matter its value) then the maximum amount of SSI you are eligible for goes down by 1/3.
Is There a State Supplement to SSI?
Most states offer a supplement to SSI with the exception of Arkansas, Arizona, Mississippi, North Dakota, Tennessee, and West Virginia. In a few states you may be eligible for a state payment even if you don't meet the federal standard for SSI.
What Happens if my Son or Daughter is Unable to Manage his/her Benefits?
If your son or daughter (aka, the SSI benefit recipient) is unable to manage his/her personal finances and does not have a court-appointed legal guardian, the SSI benefit recipient can request that a friend/family member or other agency/person act as his/her Representative Payee. If the SSI benefit recipient has been found to be incapacitated by a judge, the guardian of the estate/finances will be appointed Representative Payee.
A representative payee is an individual or organization appointed by SSA to receive Social Security and or SSI benefits for someone who cannot manage their monthly benefits. The main responsibilities of a payee are to use the benefits to pay for the current and foreseeable needs of the beneficiary and to properly save any benefits that are not currently needed. Additionally, a payee must keep records of expenses, and when SSA requests a report the payee must provide an accounting to SSA of how benefits were saved or spent.
As a representative payee, there are certain expenses for which you may be reimbursed. See the SSA site for more information: http://www.ssa.gov/payee/faqrep.htm. In addition to SSI, your son or daughter may be eligible for other SSA benefits, notable, SSDI (Social Security Disability Insurance). Click here Social Security benefits for a summary description of Social Security programs for which your son or daughter may be eligible.
SSA Best site will determine your child's eligibility for SSA programs. The SSA BEST customized Connection screens citizens for 17 different Social Security programs and provides them with a list of benefits they may be eligible to receive.
Going to Work: A Guide to Social Security Benefits and Employment for Young People with Disabilities 2010 edition. This very easy to understand guide from The Institute for Community Inclusion covers SSI, SSDI, the Ticket to Work Program, PASS, and while it is geared for Massachusetts residents, it is quite useful for all audiences. Similarly, the Rural Institute has a Powerpoint Presentation on SSA Work Incentives to Consider During Transition Planning.
The Red Book: Social Security's guide to programs
Information on SSI for Pennsylvania Residents
Is There a State Supplement to SSI in PA?
In the state of Pennsylvania an additional monetary benefit, known as the State Supplementary Payment, is added to the federal SSI payment. If your son or daughter lives independently, or in someone else’s household or in a Medicaid facility, he or she will receive a separate payment from Pennsylvania, in addition to the federal SSI payment. A single payment which includes both the federal SSI payment and the supplement from Pennsylvania is issued to residents of domiciliary care homes and personal care boarding homes.
For additional information see the SSI fact sheet for PA. For further information on these supplemental payments, refer to the DPW State Supplementary Bulletin. Please note that if your son or daughter's income is slightly over the eligibility requirements for SSI, he or she may still be eligible for SSP.
Who makes the eligibility determination in Pennsylvania?
The Bureau of Disability Determination processes all applications for SSI. The Social Security Administration first reviews applications for disability benefits to determine if the basic requirements of eligibility are met. Eligible applications are then forwarded to the BDD for determination of an applicant’s medical eligibility for disability benefits under the Social Security law. Medical evidence is requested and reviewed from the applicant’s doctors, hospitals and other institutions that provide medical treatment.
Is there any Additional Funding Available from the Social Security Office?
If an adult is disabled before the age of 22, he or she may be eligible for Social Security Disability Insurance (SSDI) benefits for adults disabled since childhood. Under this program, an eligible individual may receive Social Security benefits and Medicare based on his/her parents' work history. These benefits become available if the parent retires, becomes disabled and collects benefits, or is deceased. These benefits begin when the disabled child turns 18, and Medicare becomes available 24 months after this benefit begins.
For a description of other Social Security programs including Social Security Disability Income, Disabled Adult Child Program and Ticket to Work, click here.
Medicaid (Medical Assistance)
What is Medical Assistance and How is it Different from SSI?
Medicaid or Medical Assistance is a national health care program that provides medical coverage for individuals with low income and limited resources. While Supplemental Security Income (SSI) provides monthly income to help offset costs associated with a particular disability, Medicaid provides access to health care coverage that individuals and families otherwise could not access. For children with disabilities, Medicaid provides families access to speech, occupational and physical therapy and behavioral health services and has no premiums, co-pays or deductibles. Medicaid adds to any existing coverage the child has, such as private insurance. Therefore, if your child has private insurance, that must be used before you can use Medicaid benefits. For children with autism and other disabilities, there may be physical and behavioral health care needs. Behavioral health care refers to treatment that helps persons with mental health, emotional/behavioral disorders and drug/alcohol issues.
Medicaid is a state administered program so each state sets its own guidelines with regard to eligibility and services. In most states if your child qualifies for SSI, he or she automatically qualifies for Medicaid. For specific information on your state's eligibility requirements for children and adults, the Kaiser Family Foundation has an excellent resource on Medicaid and CHIP coverage. The resource, which can be accessed at http://www.kff.org/medicaid/upload/8130.pdf covers Medicaid and CHIP eligibility, enrollment and renewal polices and procedures, premium and cost sharing requirements for all fifty states. The state tables begin on page 29. Another resource from Kaiser is the Online Database of Medicaid Benefits by state. Clicking on a state shows which specific benefits are offered and the limitations or requirements for coverage. Medicaid.gov provides valuable information on Medicaid by population, topic, and state.
The Medicaid Reference Desk is a great resource that helps people with disabilities find out what Medicaid can offer them.
In most states, SSI eligibility qualifies an individual for Medicaid coverage. States where this does not apply include Connecticut, Hawaii, Illinois, Indiana, Minnesota, Missouri, New Hampshire, North Dakota, Ohio, Oklahoma, and Virginia. The eligibility criteria for these states can be found here: Medicaid for Individuals with Disabilities.
All states are required to offer these basic services through Medicaid: inpatient hospital services, outpatient hospital services, physician services, nursing facility services for persons 21 and older, home health care for persons eligible for skilled-nursing services, laboratory and x-ray services, vaccines for children, pediatric and family nurse practitioner services, early and periodic screening, diagnostic, and treatment (EPSDT) services for children under age 21, family planning services and supplies. Services such as optometrist services and eyeglasses, diagnostic services, nursing facility services for children under age 21, intermediate care facilities for people with intellectual disabilities, prosthetic devices, rehabilitation and physical therapy services, home and community-based care to persons with chronic impairments vary in whether they are offered by states, but specific benefits offered by your state can be found at Medicaid.gov.
Medicaid waivers are Home and Community-Based Services (HCBS) waivers provided by states to persons with disabilities to receive certain medical and non-medical services that help an individual at any age remain living at home or within the community instead of another residential placement. People with disabilities under the age of 21 may qualify for a waiver regardless of parental income and family resources. The local Department of Social Services district waives Medicaid requirements like parental income when determining a disabled person's eligibility.
Services provided by the Medicaid Waiver include assistive technology, environmental modifications, respite care, day and residential habilitation and prevocational services, supported employment, family education, plan of care and consolidated support services, and a live-in companion. The HCBS waiver program provides community-based long term care, services, and supports to qualified Medicaid eligible recipients.
A list of state specific waivers and research & demonstration projects can be found at Medicaid.gov as well as resources like fact sheets, proposals, and approval letters.
Pennsylvania Medicaid Program
In Pennsylvania, if you have Medical Assistance then you are also a member of a program called Health Choices. Health Choices can help you to select a physical health Medicaid managed care plan. Health Choices can be contacted at 1-800-440-3989, or contact Health Choices through the County Assistance Office.
In Pennsylvania individuals under the age of 21 are consider “children” for the purposes of Medicaid. Prior to turning 21 your child is eligible through Medicaid’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) service. Once your child turns 21 he or she is no longer eligible for Medicaid’s EPSDT but may be eligible for Medicaid, or if working Medical Assistance for Workers with Disabilities (MAWD). For detailed information on eligibility see the DPW website on Medical Assistance Eligibility Requirement. Even individuals who do not qualify for SSI may be eligible for Medical assistance under the Medical Assistance PH-95 Loophole Coverage.
How do I apply for Medicaid in Pennsylvania?
First it is important to apply for SSI. If an individual is found eligible for SSI in most states they will automatically qualify for Medicaid. Next, obtain and complete the Medical Assistance Application either online through COMPASS from your local County Assistance Office, or by downloading the application and mailing it to your local County Assistance Office. If you have questions while completing the Application call DPW at 1-800-692-7462. To avoid a caseworker rejection of your application, make sure you write on the front of your application: MA FOR DISABLED CHILD HANDBOOK SECTION 355.4.