Medical Insurance for People with Special Needs

Today’s blog post continues the series about Special Needs Law.  The blog post on February 19, 2015 gave an overview of the legal issues facing people with special needs.  The blog post on February 5, 2015 discussed the new ABLE accounts.  The blog post on February 26, 2015 discussed sources of income for people with special needs.

Today’s post discusses Medical Insurance for People with Special Needs.

The medical insurance coverage to people with special needs is linked to their source(s) of income.

SUPPLEMENTAL SECURITY INCOME (the Social Security disability system for people who do not have enough of a work history to qualify for Social Security Disability Income.)

Medicaid Medical Coverage – People who receive Supplemental Security Income automatically qualify for Medicaid medical coverage.  Medicaid medical coverage insures doctor visits, hospital stays, prescriptions, and other “traditionally insured” health costs.  For people who are “high functioning” despite their special need, this Medicaid medical coverage may be the only Medicaid coverage necessary.

Medicaid Long Term Care Coverage – SSI recipients who need help with Activities of Daily Living (bathing, toileting, grooming, dressing, walking, eating, and getting in our out of bed or a chair) may need Medicaid coverage for long term care (from an arm of Medicaid called the Aged, Blind and Disabled.)  Because SSI recipients can have no more than $2,000 in assets, they usually qualify for Medicaid long term care coverage automatically.  (Some states, including Ohio, where I practice, have a Medicaid asset limit below $2,000, so, as a practical matter, SSI recipients in these states may have an asset limit lower than the federal rules say.)  Long term care coverage insurance for nursing home costs, assisted living costs, or the cost of in-home help with Activities of Daily Living in addition to the coverage for traditional medical costs such as doctor visits and hospital stays.  For people whose special needs create a need for help with Activities of Daily Living, this Medicaid coverage of long term care may be the most important government benefit they receive.

SOCIAL SECURITY DISABILITY INCOME (the Social Security income program for disable people who have qualifying work history.)

Medicare – People who receive Social Security Disability Income can get Medicare coverage two years (the rules use the language “24 months” probably because SSDI comes as a monthly payment) after the disability income starts.  The Medicare available to people with special needs who receive disability income is the same as Medicare for seniors.  It covers 80% of costs, and the insured person can pay the 20% themselves or can buy additional insurance (an Advantage Plan or a Medicare Supplement) to cover it.

Affordable Care Act – Until Medicare starts (and the 24 month count doesn’t start unless the disabled person is receiving Social Security Disability Income,)  the Affordable Care Act is the source of health insurance for people with special needs (just like it is for everyone else.)

Medicaid for Long Term Care – Medicare and the Affordable Care Act provide insurance coverage for “traditional” medical costs such as doctor visits, prescriptions, hospital stays, etc.  They do NOT provide coverage for long term care costs such as nursing homes, assisted living, or in-home help with Activities of Daily Living (bathing, toileting, dressing, grooming, eating, walking, or getting in and out of bed or a chair.)  Further, a person receiving SSDI does NOT automatically qualify for Medicaid for long term care.  SSDI recipients who need Medicaid coverage for long term care must qualify for that coverage under Medicaid’s separate rules in their state.


Someone with special needs who does not, for whatever reason, qualify for Supplemental Security Income or for Social Security Disability Income must rely on the Affordable Care Act for health insurance and on the Medicaid Aged, Blind and Disabled program for long term care.

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