LegiStorm

Summary:

Medicaid is a joint federal-state program that finances the delivery of primary and acute medical services, as well as long-term services and supports (LTSS), to a diverse low-income population. In general, individuals qualify for Medicaid coverage by meeting the requirements of a specific eligibility pathway. An eligibility pathway is the federal statutory reference that extends Medicaid coverage to certain groups of individuals. Each eligibility pathway specifies the group of individuals covered by the pathway (i.e., the categorical criteria). It also specifies the financial requirements applicable to the group (i.e., the financial criteria), including income and, sometimes, resources (i.e., assets). In addition, an eligibility pathway often dictates the services that individuals are entitled to under Medicaid. Some eligibility groups are mandatory, meaning all states with a Medicaid program must cover them; other eligibility groups are optional. Older adults and individuals with disabilities are more likely to require LTSS due to chronic disabling conditions or other functional or cognitive impairments (e.g., extended nursing facility care, personal care, and other home and community-based services). Federal policymakers have an interest in understanding Medicaid eligibility pathways for these populations, as Medicaid plays a key role in providing LTSS coverage. Generally, LTSS is not covered by Medicare or major health insurance plans in the private market. In fact, Medicaid is the largest single payer of LTSS in the United States, accounting for 42% of all LTSS expenditures in 2016 (or $154 billion). Individuals eligible for or enrolled in Medicaid who are in need of Medicaid-covered LTSS must demonstrate the need for long-term care by meeting state-based level-of-care criteria. They may also be subject to a separate set of Medicaid financial eligibility rules. This report focuses on the ways in which adults aged 65 and older and individuals with disabilities qualify for Medicaid based on their age or disability status; that is, the eligibility pathways where the categorical criteria are being aged, blind, or disabled (referred to as "ABD" or "ABD eligibility"). Individuals who qualify for Medicaid on the basis of being blind or disabled include adults under the age of 65 as well as children. Generally, ABD populations qualify for Medicaid through an eligibility pathway under one of two broad coverage groups described in this report: Supplemental Security Income (SSI)-Related Pathways and Other ABD Pathways. SSI-Related Pathways SSI is a federal program that provides cash assistance to aged, blind, or disabled individuals who have limited income and resources. SSI rules form the foundation of Medicaid eligibility criteria for ABD populations. Thus, the relationship between SSI and Medicaid is important to understanding Medicaid eligibility for ABD populations, as states are generally required to provide Medicaid coverage for SSI recipients. The SSI-Related Pathways consist of Medicaid eligibility groups that generally meet the categorical and financial criteria of the SSI program, including SSI Recipients, Special Groups of Former SSI Recipients, and Other SSI-Related Groups. Other ABD Pathways States may extend Medicaid coverage to older adults and individuals with disabilities who have higher levels of income or resources than SSI program rules permit. These optional pathways allow states to offer Medicaid eligibility to individuals receiving LTSS either in an institution or home and community-based setting; working individuals who may need LTSS to support employment; and individuals with high medical expenses who "spend down" or deplete their income and resources. These optional eligibility pathways, referred to as Other ABD Pathways, include the following: Poverty-Related, Special Income Level, Special Home and Community-Based Services (HCBS) Waiver Group, HCBS State Plan, Katie Beckett, Buy-In, and Medically Needy. Topics Covered in This Report This report begins with an overview of Medicaid eligibility, followed by a summary of ABD eligibility pathways (i.e., SSI-Related Pathways and Other ABD Pathways). Next, it provides information about the categorical and financial eligibility criteria for each Medicaid ABD eligibility pathway. The Appendix provides tables that include statutory references and certain financial eligibility criteria for each Medicaid ABD eligibility pathway.