Introduction

Medicaid

When your son or daughter becomes eligible for Supplemental Security Income (SSI) they will receive Medicaid medical insurance benefits.  Medicaid is a federal medical insurance program that is administered by the state.  It is designed to assist people with disabilities and low income with little or no resources.  The federal government funds a portion of Medicaid and the rest is paid by each state so every state sets its own rules as to who is eligible for this health insurance and what services will be covered.  In January, 2014, the Centers for Medicare & Medicaid Services (CMS) released a report entitled, Autism Spectrum Disorders (ASD) State of the States of Services and Supports for People with ASD, which provides a nationwide summary of state services for people with Autism Spectrum Disorder (ASD) and policies related to people with ASD.  The report provides information on existing programs and policies in all 50 states and the District of Columbia.  Parents need to search out Medicaid providers and Medicaid will pay for doctor's visits, hospitalization, outpatient hospital care, laboratory tests, x-rays and prescription medications within certain limits.  You will need to pick a primary care doctor after the initial approval.  However, it is also possible to choose your private health insurance company as your primary insurance coverage and Medicaid as a secondary insurance.  Please note that some states will cover ABA (Applied Behavioral Analysis) services.   For further information on Medicaid and Autism Services see the guidelines provided by the Social Security Administration.

Medicare

If your son or daughter is eligible for Social Security Disability Insurance (SSDI) they will receive, after a two year waiting period, Medicare medical insurance benefits.  Medicare is a federal health insurance program for individuals over 65 years of age and for persons with a disability.  During the two year waiting period for Medicare your son or daughter will receive a modified Medicaid insurance coverage; the coverage is available only after $1,000 has been spent within a 30 day period every month for two years.  In most cases this coverage would only be beneficial if hospitalization occurs.  Medicare always needs to be the primary insurance for the disabled person; however, many individuals also have a secondary insurance for further coverage.  Medicare Part A is hospital insurance and Medicare Part B pays for doctor's services, outpatient hospital care, laboratory tests and x-rays.  Medicare Part D has numerous pharmacies at varying prices and drug plans which cover prescription drugs.  Every year at the beginning of October until December 31, parents can compare pricing of the various pharmacies and their drug coverage plans to see what plans cover the prescription drugs needed at the best price.  Medicare provides agents available to discuss drug plans.  In addition, every month a fee (currently $104) will be removed from the monthly SSDI check deposited in your son or daughter's account to pay Medicare plus the monthly fee from the designated pharmacy drug plan.  In addition, there is a $147 yearly deductible which has to be covered at the beginning of every new calendar year.  For further information see Autism Spectrum Disorders (ASD): State of the States of Services and Supports for People with ASD.

Medwaiver

The government has provided another service called the Medicaid Waivers for Individuals with Autism.  Medicaid waivers are specials services that provide Home and Community-Based Services (HCBS) currently to 49 States and the District of Columbia.  These services can be provided at any age regardless of parental income and resources.  In other words, Medicaid requirements regarding parental income are "waived".  Medicaid Waiver Services include: adaptive technology, environmental modifications, respite care, day and residential habitation and prevocational services, supported employment, family education, plan of care of support services, and live-in companion.  These services provide each family with a caseworker to help implement the program and work closely with the family.  Many parents will utilize respite care by finding a caretaker for their child which will give them some hours away so that families can enjoy a periodic "break".  Unfortunately, many states have severe financial deficits and, therefore, the waiting period for receiving Medwaiver services is long.  In some cases there may even be a "freeze" on the waiver.  For further information see Waivers.