Over 10 million people qualify for Medicaid based on a disability. Although many are dually eligible for Medicare and Medicaid, most (6.2 million) do not have Medicare coverage. People under age 65 who qualify for Medicaid on the basis of a disability include adults and children with disabilities that they have had since birth and others who have disabling conditions acquired through illness, injury, or trauma. Medicaid beneficiaries enrolled through disability pathways include those with physical conditions (such as quadriplegia, traumatic brain injuries); intellectual or developmental disabilities (for example, cerebral palsy, autism, Down syndrome); and serious behavioral disorders or mental illness (such as schizophrenia or bipolar disorder).
Over one-third of Medicaid beneficiaries who qualify on the basis of a disability do so through receipt of Supplemental Security Income (SSI), the federal cash assistance program for the elderly and people with disabilities who have low levels of income and assets.
SSI disability pathway
SSI is a federal program providing cash assistance to low-income persons with disabilities (under age 65) and seniors (age 65 and older). In most states, SSI beneficiaries are a mandatory population for state Medicaid programs and are automatically eligible for Medicaid.
Nearly all Medicaid disability pathways use the same definition of disability that SSI uses. This is also the definition used for adults in the Social Security Disability Insurance (SSDI) program, through which qualifying individuals may obtain Medicare after a 24-month waiting period.
This definition was designed to grant eligibility for federal income support when an individual’s ability to work is significantly impaired, rather than when broad criteria concerning functional or health status are met. As a result, many individuals who have multiple chronic conditions may not be eligible for Medicaid on the basis of a disability. In addition, some enrollees could meet the criteria to be considered disabled but because they already have obtained Medicaid through a non-disability pathway (e.g., as a low-income child or parent) they have not sought a disability determination.
Other eligibility pathways
Medicaid programs may also offer eligibility to people with disabilities through other optional pathways. Generally, individuals still must meet the SSI definition of disability, but their countable income or assets may be above SSI levels. These include:
- Poverty level. States have the option to cover people with disabilities with income or assets above the level permitted for SSI eligibility.
- Medically needy.Under this option, people with disabilities who have higher incomes can spend down to a state-specified medically needy income level by incurring medical expenses.
- Special income level.Under this option, states can cover institutionalized individuals with incomes up to 300 percent of the SSI benefit rate (approximately $2,199 per month for an individual, or 222 percent of the federal poverty level); states may also extend this eligibility to individuals who receive home and community- based waiver services as an alternative to institutionalization.
- Working people with disabilities.States must cover certain qualified, severely impaired individuals whose earnings would otherwise disqualify them from Medicaid; states can allow certain other working people with disabilities to buy into Medicaid.
- Home and community-based services (HCBS).States may extend eligibility to individuals who receive certain HCBS and require an institutional level of care or meet other needs-based criteria that assess functional status.
TABLE 1. Eligibility Pathways for People with Disabilities
|Eligibility group||Federal statutory and regulatory requirements||State plan options|
|Disabled individuals (under age 65)||Disabled individuals receiving SSI
Disabled adult children
Optional poverty and low-income-related pathways
Individuals with disabilities receiving services in the community
|Medically needy||Medically needy option2
Notes: FPL is federal poverty level. Aid to Families with Dependent Children (AFDC) is the cash assistance program that was replaced by Temporary Assistance to Needy Families (TANF) in 1996. SSI is Supplemental Security Income.
1 Rather than conferring automatic Medicaid eligibility on all SSI recipients, states (referred to as 209b states) can use more restrictive criteria to determine Medicaid eligibility.
2 States can choose to cover medically needy individuals that would be categorically eligible, except for their incomes. Specifically, states can cover individuals with incomes above categorically needy income levels up to 133 percent of the state’s 1996 AFDC level. This includes individuals age 65 and older, individuals with disabilities, as well as parents, pregnant women, and children. If states choose to cover individuals under the medically needy pathway, then states are required to cover children under 18 and pregnant women during the course of their pregnancy.
Source: MACPAC, 2017, Federal Requirements and State Options: Eligibility.
Medicaid and Persons with Disabilities, Chapter 1 of MACPAC’s March 2012 Report to the Congress on Medicaid and CHIP
Access to Care for Persons with Disabilities, Chapter 3 of MACPAC’s June 2013 Report to the Congress on Medicaid and CHIP
Data Book: Beneficiaries Dually Eligible for Medicare and Medicaid, a joint project of MACPAC and the Medicare Payment Advisory Commission (MedPAC)