Having health care benefits or insurance for children with disabilities or special health care needs helps you pay for essential medical care. Technically, Medicaid is not considered an insurance plan, but many people refer to it that way. It is a program that helps people get many different types of medical and health-related services, depending on their needs and what they are approved for.
For many families, Medicaid programs (described below) offer much-needed free or low-cost health care. Most Medicaid programs have household income requirements. However, there are certain Medicaid programs, known as waivers, which only look at your child’s income. Waiver programs let people with disabilities or special health care needs get Medicaid services and supports right in the community.
Many children with families who earn too much to get regular Medicaid can still get these important services through one of the waiver programs. To find out more, see our page on Waivers.
How Does Medicaid Work for Children with Disabilities
Medicaid is a government program that provides medical services for people who meet certain income or disability requirements. It covers medically necessary services such as: doctor's visits (including preventive care), dental care, therapies (such as physical, occupational, or speech therapy), mental health and substance use disorder, medical equipment and supplies, some prescriptions, transportation to doctor's visits or to pick up medicine, and more. There are a number of programs that fall under the Medicaid umbrella. These include:
- Traditional Medicaid: allows your child to see any doctor who accepts Medicaid. Medicaid pays these doctors directly for their services. Most children with disabilities cannot get traditional Medicaid because they are required to enroll in a managed care program.
- Medicaid Managed Care Programs: allows your child to see doctors and health care professionals within a network. These networks are run by managed care organizations (companies that contract with doctors and other health care professionals into provider networks) that have contracts with the state of Texas. Nearly all Texans on Medicaid are in a managed care program.
- STAR: serves pregnant women, newborns, as well as low-income families and children. It covers basic medical services. STAR does not serve children who receive Supplemental Security Income (SSI) or who get waiver services.
- STAR Health: a program for children in custody of the Texas Department of Family and Protective Services (DFPS), or certain young adults who were in foster care as children, including those children who get Medicaid waiver services. It covers basic medical services and long-term services and supports (LTSS). STAR Health also provides service coordination and service management.
- STAR Kids: a program for children age 20 and younger who receive SSI or who get Medicaid waiver services. It covers basic medical services and long-term services and supports (LTSS). STAR Kids also provides service coordination, service planning, and transition planning.
- STAR+PLUS: serves Texans over the age of 21 with disabilities or special health care needs. It covers basic medical services and long-term services and supports (LTSS). Most children with disabilities who receive Medicaid transition to STAR+PLUS when they turn 21.
- Medicaid Buy-In and Medicaid Buy-In for Children: allow people who have certain disabilities or special health care needs and do not meet Medicaid income requirements to purchase Medicaid coverage. Rates are set on a sliding scale based on either the person’s income or the family income. See our page on Medicaid Buy-In Programs to learn more.
- Medicaid Waiver Programs: Medicaid-funded programs that help people with disabilities or special health care needs get services and supports that allow them to live and thrive in community settings. These programs consider only your child’s income, even if your child is age 17 or younger. Many children who are not approved for other Medicaid programs are able to get waivers. See our Waivers page to learn more.
Who Can Get Medicaid?
To get Medicaid in Texas, a person must:
- Be a U.S. citizen or have an acceptable immigration status.
- Live in Texas.
- Meet certain income rules.
Visit the website for Children’s Medicaid and Children’s Health Insurance Program (CHIP) or YourTexasBenefits.com to learn more.
In some cases, Medicaid might not consider all of your family’s income. They might allow you to subtract certain expenses. Examples include certain expenses that can be claimed on your federal income tax return.
If your child is approved for Supplemental Security Income (SSI) benefits to help with living expenses, they can also be approved for Medicaid.
What Does Medicaid Offer Children with Disabilities or Special Health Care Needs?
Medicaid Buy-In for Children, Medicaid Buy-In for working adults with disabilities, STAR Health, STAR+PLUS, and the STAR Kids program (beginning November 1, 2016) are all designed to make sure children and adults with disabilities or special health care needs have health care coverage. Medicaid health coverage includes acute care services (like doctor's visits, hospitals, physical, occupational, and speech therapy), behavioral health services, pharmacy services, and some long-term services and supports (like attendant care and nursing).
As we mentioned above, there are specific Medicaid programs, also known as waivers to help children with disabilities or special health care needs live and thrive in the community. These programs have long interest lists (wait lists) that might take many years. So, even if you don’t think that your child would need the waiver services now, it’s a good idea to sign up as early as possible.
How Does Medicaid Work?
Once you have applied for Medicaid for your child and received their benefits cards, you will need to:
- Pick a managed care plan. You will receive a letter in the mail that will give you the options available in your area.
- Pick a main doctor that is in network with the managed care plan you pick. You can find a doctor in the following ways:
- Pick your child’s dental plan and main dentist at CHIP’s Find a Dental Plan page.
- Find a pharmacy that will take Medicaid benefits.
Your child’s main doctor will then refer you to (help you find) specialists and therapists who also take Medicaid and can help your child. All Medicaid programs encourage families to use the medical home model of care.
How Do I Apply for Medicaid for My Child?
In Texas, Medicaid programs are managed by the Health and Human Services Commission (HHSC). You can apply for any program for your child by visiting your local HHSC office. You can find that office by calling 2-1-1 or visiting 2-1-1 Texas online. You can also get free help applying for Medicaid services for your child from a community partner organization. When you apply for Medicaid, you may need to show or send:
- Proof of money you and each family member who lives with you earns from a job or other sources. Pay stubs or earning statements are most common, but there are other documents that can be used too.
- Social Security numbers or immigration document numbers.
- Details about current health insurance or any job-related health insurance that might be available to you.
If you and your child don’t want to go apply in person, there are other choices:
- Apply for Medicaid online on the Your Texas Benefits website. You will have a chance to show proof of income, Social Security numbers, and insurance after you apply.
- Apply by phone by calling 2-1-1. They will start the application over the phone and mail it to you to sign.
- Print a Medicaid application and fill it out.
Once you have filled out the application and gathered your other proof, you can:
- Take it to an HHSC benefits office. Call 2-1-1 to find an office near you.
- Fax it to 1-877-447-2839. If your form is 2-sided, don’t forget to fax both sides separately.
- Mail it to the state office at:
- Health and Human Services Commission
P.O. Box 149024
Austin, TX 78714-9968
You should expect to hear back in about 45 days, on average.
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