What benefits are available?
Benefits include but are not limited to:
- Emergency and Physician Services
- Mental Health Treatment
- Prescriptions
- Medical Supplies and Equipment
- Rehabilitation Services
Who is eligible?
To be eligible for PH95, the child must be:
- Under age 18 and a Pennsylvania resident;
- Lawfully present and provide or apply for a Social Security Number; and
- Disabled according to Social Security Administration (SSA) standards. Disabilities include physical, developmental, mental health, or intellectual.
Financial Eligibility Factors:
- The child’s countable income must be at or below 100% of the current year’s Federal Poverty Income Guidelines (FPIG).
- Uses SSA rules for determining countable income. Less than half of the child’s earned income is countable.
- Court-ordered child support and any RSDI income the child receives is excluded.
- Parental income must be verified but will be excluded in this category.
- The child must not qualify for any other Medicaid category. It is the category of last resort.
More Information
Learn more about the Children with Special Needs (PH95) Medicaid Category.
PH95 Frequently Asked Questions
Documentation that details the child’s medical condition must be provided in order for Medicaid to be authorized presumptively. Presumptive eligibility allows the child to begin receiving Medicaid until their medical condition is certified as meeting SSA’s disability criteria. Acceptable disability verification to presumptively authorize PH 95 includes but it not limited to:
- An Individualized Evaluation Plan (IEP)
- An Early Intervention Evaluation or Mental Health facility discharge report
The child’s medical condition must be verified as meeting SSA’s disability criteria by the Department of Human Services’ Medical Review Team. The CAO will send you a letter requesting additional medical documentation. Documentation that is submitted to the CAO must be current, comprehensive, and verify all the child’s signs, symptoms, findings, duration, and functional impact as it relates to their disability. If you do not have the medical documentation, take the letter to your child’s provider(s) who is treating the condition(s).
Documentation is due within 30 days of the mail date of the letter, but if you need additional time, contact your CAO as soon as possible. As long as you are cooperating with the request for the documentation, your child’s MA can remain open.
The disability certification stands until the child turns age 18 or you report the medical condition has changed or is no longer disabling. The child’s Medicaid benefits are required to be renewed at least every 12 months. The parents and the child must report and verify all income again to ensure the child is in the correct category.