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Disability-Based Medicaid

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    Disability-Based Medicaid

    Is It Right for You?

    Everyone should be able to get health coverage. The question is, which plan is right for you and your family?

    This page looks at the different ways you might qualify for Medicaid based on your disability.

    Just because you have a disability does not mean that you qualify for one of these disability-based Medicaid programs. You may qualify for Medicaid through different rules, or you may not qualify for Medicaid at all, depending on your situation.

    Ways to Get Disability-Based Medicaid

    There are four ways to get disability-based Medicaid in Iowa that support people in different situations and have their own eligibility requirements.

    SSI-Linked Medicaid

    The most common way of getting disability-based Medicaid is getting it automatically with Supplemental Security Income (SSI) benefits. If you already get SSI benefits, you have Medicaid coverage.

    To qualify for SSI, you must:

    What is "countable income"?

    When Social Security counts your income, it’s not the same as your real, full income. Almost all of your unearned income, like Social Security Disability Insurance (SSDI), is counted, but less than half of your earned income is counted. For example, if you make $2,000 per month at a job and have no other income, that’s only $957.50 in countable monthly income. Learn more about how SSI counts your income.

    Use this tool to see your countable income:

    Your Countable Income:

    People in certain situations, including living with a dependent, might also qualify for an extra benefit called State Supplementary Assistance. Some people get State Supplementary Assistance in addition to their SSI benefit, and some people get it even if they don't qualify for SSI, because the income limits are higher. If you get State Supplementary Assistance, you also automatically get Medicaid coverage.

    Learn more about SSI and State Supplementary Assistance and see if you qualify.

    Note: If you got SSI benefits when you were a child, but then started getting Childhood Disability Benefits (CDB) when you turned 18 and stopped qualifying for SSI, you can usually keep your Medicaid coverage.

    SSI's 1619(b) Rule

    If your SSI benefits go to zero because you go back to work, an SSI rule called 1619(b) lets you keep your Medicaid coverage if you:

    • Were eligible for SSI benefits for at least one month
    • Need Medicaid coverage to keep working
    • Still meet all the other SSI requirements, such as being disabled and having resources below $2,000, and
    • Make less than $52,860 in gross income per year ($53,388 if blind).
      • If your earnings are over this limit and you have high medical expenses, you might still qualify for 1619(b). Ask your local Social Security office about the 1619(b) Individualized Earnings Threshold.

    For additional information, check out Social Security’s webpage on 1619(b), or talk to a benefits planner.

    If you don’t qualify for Medicaid through 1619(b) because your income or resources are too high, you may qualify for Medicaid for Employed People with Disabilities (MEPD). We explain MEPD later on this page.

    Medicaid Waiver Programs

    Medicaid waiver programs are for people who need higher levels of care to live in their own home or apartment in the community instead of moving into a facility. If you have a waiver, you get regular disability-based Medicaid coverage, plus extra services you need to live in the community.

    To qualify for a waiver program, you must:

    • Need a level of care normally provided by a hospital, nursing home, or other care facility.
    • Have resources that are $2,000 or less if you are single ($3,000 or less for couples).
    • Have gross income at or below $2,982 or less a month.

    Note: Waiver programs often have waiting lists, so even if you are eligible, you may not get waiver services right away. However, once you are determined eligible for a waiver, you still get regular disability-based Medicaid coverage, even if you are on the waiting list for the extra waiver services.

    Medicaid for Employed People with Disabilities (MEPD)

    Medicaid for Employed People with Disabilities (MEPD) is a program for people with disabilities who work. MEPD lets you make more money at work, save up more resources, and keep your same Medicaid coverage.

    To get Medicaid coverage through MEPD, you must:

    Depending on your income, you may have to pay a monthly premium for MEPD.

    Learn more in DB101's MEPD article.

    Other reasons you may get disability-based Medicaid

    In general, to get disability-based Medicaid, you must be eligible for SSI, SSI’s 1619(b) rule, State Supplementary Assistance, a Medicaid waiver program, or Medicaid for Employed People with Disabilities (MEPD).

    However, there are some situations where you may qualify for disability-based Medicaid but not get these other benefits:

    • You have more than $100,000 in an ABLE account.
    • You have a trust that helps you qualify for Medicaid but not for SSI.
    • You don't want to get SSI benefits.

    If you have Medicare coverage and don’t qualify for Medicaid, you may qualify for a Medicare Savings Program, which would help pay your Medicare expenses. Learn more about MSPs.

    Other ways to get Medicaid

    If you don’t qualify for any of these ways to get disability-based Medicaid, you may qualify for Medicaid through the Iowa Health and Wellness Plan (IHAWP), which has no resource limit and does not require you to have a disability.

    To qualify for the Iowa Health and Wellness Plan, your family's income must be at or below 138% of the Federal Poverty Guidelines (FPG) ($1,800 per month for an individual, $3,697 for a family of four). Children and pregnant women can have higher incomes.

    Try the tool below to see if you may qualify for Medicaid based on your family's income.

    Health Coverage Income Limits for Your Family

    Learn more in DB101's Iowa Health and Wellness Plan article.

    Medicaid, Private Coverage, and Medicare

    If you qualify for Medicaid, you should sign up for it. Here we will look at what signing up for Medicaid might mean if you also have, or want, private coverage or Medicare.

    Medicaid and Employer-Sponsored Health Coverage

    If you qualify for Medicaid, it will always be your best choice, even if your employer offers health insurance. That’s because Medicaid has no monthly premium and the copayments for services are usually much lower than copayments required by employer-sponsored plans. Also, Medicaid may cover some services that your employer-sponsored coverage does not pay for.

    If you have Medicaid and want to enroll in a health plan through an employer (either your own or a family member's), you may qualify for Iowa's Health Insurance Premium Payment (HIPP) program. If you have HIPP, Medicaid pays your plan's premium and the other costs of getting medical care, like the copayments and the deductible. (Note: For Medicaid to pay these extra costs, you must go to a Medicaid health care provider.) You are not enrolled in a Medicaid managed care plan; instead, your employer's health plan is your main health coverage.

    You must apply separately for HIPP after you are approved for Medicaid. If the state of Iowa sees that it is cost-effective to pay for your private coverage, you may qualify. Note: People who also have Medicare can't qualify for HIPP.

    Learn more about HIPP and how to apply.

    If you don't qualify for HIPP, you can have both types of coverage at the same time, but you will have to pay your employer-sponsored coverage costs yourself.

    Medicaid and Individual Plans

    If you are eligible for Medicaid, then you will not be eligible to get government help to pay for a private insurance plan. That means the private insurance plan may be expensive for you. If you qualify for Medicaid, it will always be a better option for you than paying for an individual plan.

    Medicaid and Medicare

    If you qualify for disability-based Medicaid, you may be able to get Medicaid and Medicare at the same time. Note: You usually cannot get Medicaid through the Iowa Health and Wellness Plan if you get Medicare.

    There are significant advantages to this. Most importantly, if you have both:

    • Medicaid will usually pay your Part B premium (and your Part A premium, if you have one). It may also pay your Medicare deductibles, co-insurance, and copayments.
    • You will automatically be enrolled in a Part D benchmark plan and automatically qualify for the Part D Low Income Subsidy. The Low Income Subsidy means you may not have to pay a premium for your Part D or any deductibles. All you would pay for prescription drugs are Part D’s copayments, which range from $1.60 to $12.65.
    • Medicaid covers many more services than Medicare, so by having both you’ll have better health care coverage than you would by enrolling in just one or the other.

    Contact the Iowa SHIIP and SMP if you have questions about how your Medicaid and Medicare benefits work together. To learn more, read DB101’s Medicare article.

    Who pays when you have more than one health coverage

    Depending on your situation, you might get employer-sponsored coverage, Medicaid, and Medicare all at the same time. This can sound confusing, but it can help you, because one form of coverage may pay for costs that your other coverage won't pay for.

    The rules about how your different types of coverage pay for things are very complicated, so it’s important to check with your health coverage plans when you have questions about which plan will pay for what expenses.

    Generally speaking, Medicaid will only pay for expenses that it covers and that your other coverage won't pay for.

    Note: If you use a health provider that is not covered by Medicaid, Medicaid will not pay any medical expenses. So, if your health care provider doesn’t take Medicaid and your private insurance or Medicare won’t cover everything, Medicaid won’t help pay the rest. Make sure to find providers who accept Medicaid.

    How Medicare works with other insurance shows how it works when you have Medicare and other coverage.

    Learn more

    Supplemental Security Income (SSI)

    SSI helps people with disabilities and seniors who have low income and resources.

    Medicare

    Medicare is public health coverage for people with disabilities and seniors.

    Medicaid for Employed People with Disabilities (MEPD)

    MEPD is Medicaid for people with disabilities who work.