Optional Medicaid Coverage Offered By States

Each state has the ability to offer additional Medicaid coverage, known as Medicaid waivers, to several different groups of people. Optional Medicaid eligibility groups typically include children and parents that are above the mandatory limits of Medicaid coverage, people with certain disabilities and the elderly.

Over half of the elderly qualify through optional Medicaid eligibility categories and overall, about a third of Medicaid recipients qualify through the optional groups. Most people that qualify for the optional groups are typically poor, have long-term health care needs, and require extensive medical care.

Surprisingly, more that two-thirds of all Medicaid spending is for optional services. This is because most of the optional spending is on those groups of people that are most vulnerable and need the most services, such as the elderly that need long-term care in a nursing facility.

The most common optional Medicaid coverage groups include:

* The Medically Needy (MN) group includes people that do not meet the financial standards to qualify them for program benefits through a mandatory coverage group. They may qualify by incurring medical bills that reduce their excess income and financial resources to qualifying levels.

* The Poverty Level (PL) group are also called the Aged and Disabled group, includes individuals over the age of 65 or with a disability who have low income but do not qualify under a mandatory Medicaid coverage category.

* The Medicaid buy-in group includes disabled adults participating through authority in the 1977 Balanced Budget Act or the Tickets to Work and Work Incentives Improvement Act (TWWIIA).

* The Special Income Group are individuals that receive care in an institutional setting like a nursing facility or Intermediate Care Facility for the Mentally Retarded or Developmentally Disabled, or in a home and community based services waiver program and who are not otherwise eligible for Medicaid.

* People that requre hospice care, have low income but do not qualify under another Medicaid coverage category.

* The Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 group includes children that need institutional care who many be served in their homes for lower cost and whose family income is not included.

* Pregnant women with income above the threshold for mandatory Medicaid coverage but below a federal higher income level.

* Women participating in a Breast and Cervical Cancer Treatment Program.

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