What Is Medicaid, and How Can FEDlogic Help?

Medicaid is a vital public health insurance program that provides coverage for low-income individuals, including children, some adults, pregnant women, and people with disabilities. Created in 1965 alongside Medicare, Medicaid aims to ensure access to healthcare services and improve health outcomes for vulnerable populations. Today, Medicaid insures over 72 million Americans, making it the nation’s largest health insurer. It covers a wide range of services, including preventive care, hospital stays, prescription drugs, and nearly half of all U.S. births.

While Medicaid is jointly funded by the federal and state governments, each state operates its own program under federal guidelines. Federal contributions to Medicaid funding range from 50% to 77%, depending on the state.

Medicaid Expansion and Its Impact
The Affordable Care Act (ACA) expanded Medicaid eligibility starting in 2014, allowing more low-income adults to qualify for coverage. This expansion, adopted by 40 states and the District of Columbia, increased federal funding to cover 90% of costs for new enrollees, with states covering the remaining 10%. Medicaid expansion has significantly improved healthcare access, reducing uninsured rates and narrowing racial and income-based disparities. Expansion has also led to better health outcomes, including earlier cancer diagnoses, improved maternal and infant health, and increased access to mental health services.

In addition to health benefits, Medicaid expansion has reduced financial burdens for low-income families by decreasing medical debt and unpaid bills. For states, expansion has boosted economic activity, strengthened community health centers, and reduced uncompensated care costs.

The Challenges and How FEDlogic Can Help
Despite its benefits, navigating Medicaid’s complex rules and eligibility requirements can be overwhelming. FEDlogic specializes in guiding our clients’ employees and their household members through this process. Whether they’re exploring Medicaid eligibility, managing Medicaid expansion benefits, or addressing changes in state policies, FEDlogic offers personalized support to help understand your options and maintain coverage.

With decades of experience, FEDlogic is committed to helping individuals and families secure the healthcare they need. By simplifying Medicaid’s complexities, we empower your employees and their household members to focus on what matters most—your health and well-being.

FEDlogic’s Monthly Webinar Series

Join us on the last Wednesday of each month at 1:00pm Central for our monthly webinar series. Our webinars are designed to provide your employees with valuable insights and knowledge on various topics related to Federal and state benefits.

In February, we will take a deep dive into retirement and maximizing benefits. As always, this webinar will include an overview of Federal benefits and how FEDlogic can help.

We explore a different topic nearly every month. Don't miss this opportunity to learn about the FEDlogic experience with your employees and teammates. For those unable to attend the live sessions, the webinars are recorded and available to access through the employee resources page on our website.

Register now and secure your spot for our upcoming webinars in 2025 by clicking on the image below!

How PH95 Medical Assistance Can Support Employees and Their Families in Pennsylvania

At FEDlogic, we understand how important it is for employees to access the healthcare resources they need. One often-overlooked benefit for residents of Pennsylvania is the PH95 Medical Assistance program, which can provide extensive coverage for children under 18 with disabilities or serious health conditions. If your employees have children who may qualify, this benefit could significantly ease the financial burden of necessary medical and behavioral services.

What is PH95 Medical Assistance?

PH95 Medical Assistance is a special category under Medicaid that offers comprehensive health coverage for children, particularly those with physical or behavioral disabilities. This program includes services that may not be covered by employer-based insurance, such as in-home nursing, behavioral health rehabilitation services, and physical, speech, or occupational therapy—often without the restrictions of annual or lifetime caps. It also covers essential services like prescription medications, diapers, and transportation to medical appointments.

Who Qualifies for PH95?

Contrary to common misconceptions, not all children with disabilities automatically qualify for Medical Assistance. To be eligible under PH95, a child must meet specific disability standards, which include certain conditions outlined by the Social Security Administration. Importantly, parental income and assets do not factor into eligibility, allowing children with severe disabilities to access necessary services without financial penalties based on household earnings.

To be eligible, the child must:

• Be under 18.

• Be a resident of the state of Pennsylvania.

• Meet the Social Security disability criteria.

• Have income below the program's limits. While income is considered for some aspects, significant deductions can help children with disabilities remain eligible even if their family’s income exceeds the typical thresholds.

How FEDlogic Can Help

Navigating the application process for PH95 Medical Assistance can be complex. As your resource for federal and state benefits navigation and guidance, FEDlogic can help guide employees through the process to ensure they access all resources available to them. Our team can provide clarity on eligibility requirements, documentation needed, and assistance with the application process.

The PH95 Medical Assistance program is a vital resource for residents of the state of Pennsylvania that can greatly benefit employees with children who have special healthcare needs. By leveraging FEDlogic’s expertise, your team can ensure that eligible employees are able to navigate the application process smoothly and access the critical healthcare services their families need. Please reach out to us for more information on how we can assist your employees in accessing this valuable program.

Understanding TEFRA and Medicaid Options for Children with Disabilities

The Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 (PL No. 97-248, Section 134) allows states to provide Medicaid coverage for children with severe disabilities who need institutional-level care, without considering family income. This provision enables children under 19 who require care typically offered in hospitals, skilled nursing facilities, or intermediate care facilities for individuals with intellectual disabilities (ICF/IID) to receive Medicaid benefits based on their own income rather than their family’s.

The TEFRA/Katie Beckett State Plan Option allows families to access Medicaid for children who need institutional-level care but can be safely cared for at home. The program is designed to be cost-neutral to the state, meaning the cost of care at home must be comparable to the cost of institutional care. Currently, 19 states and the District of Columbia have adopted this option, though the number of children served varies by state due to differing eligibility criteria and available services. Those states include:

• Alaska

• Delaware

• District of Columba

• Georgia

• Idaho

• Lousiana

• Maine

• Massachusettes

• Michigan

• Minnesota

• Mississippi

• Nebraska

• Nevada

• Oklahoma

• Rhode Island

• South Carolina

• South Dakota

• Vermont

• West Virginia

• Wisconsin

For example, in Minnesota, the TEFRA program allows children needing institutional care to qualify with a household income up to 100% of the Federal Poverty Level (FPL) or with an income spend-down. Families may also need to pay a monthly parental fee based on income and family size, but parental income is not a factor in eligibility.

TEFRA Look-Alike Programs

Some states have created programs similar to TEFRA but through different legal frameworks. These "look-alike" programs expand Medicaid eligibility for children with disabilities.

• Arkansas offers a Home Care for Children program, a look-alike program that uses a sliding-scale fee based on income. Title V/CSHCN staff help families understand the fee structure and determine if the program is more cost-effective than their current medical expenses.

• New Hampshire operates a Home Care for Children with Severe Disabilities program that disregards parental income for children needing institutional-level care, including those with serious emotional disturbances, developmental disabilities, or physical disabilities. This program is broader than many TEFRA programs, extending to a wider range of disabilities.

Other Medicaid Pathways for Children with Disabilities

In addition to TEFRA and look-alike programs, some states offer alternate Medicaid pathways. For example, Pennsylvania’s PH-95 program, addressed fully in a previous article in this newsletter, provides Medicaid for children with disabilities who meet the Supplemental Security Income (SSI) disability criteria but exceed SSI’s household income and asset limits. Like TEFRA, PH-95 disregards family income, but eligibility requires a child to be denied SSI first. PH-95 offers comprehensive coverage, which can supplement existing insurance if needed.

How FEDlogic Experts Can Help

Understanding Medicaid options for children with disabilities can be complex, and navigating the application process can be challenging. FEDlogic experts are here to assist families interested in exploring TEFRA, look-alike programs, and other Medicaid pathways. Our team can guide you through the eligibility criteria, help determine the best program for your child’s needs, and answer any questions about the application process.

Contact us today to learn more about how these programs can support your employee’s families and help ensure their children receive the care they need while still keeping an eye on healthcare spending.

FEDlogic’s HR Refresher Series

Client Spotlight: Team Fishel

FEDlogic is proud to recognize Team Fishel as one of our client partners.

Team Fishel is headquartered in Columbus, Ohio, but their reach extends across the nation, serving their electric, natural gas, and telecommunication customers with engineering, construction, and maintenance solutions. A family-owned business spanning eight decades, they pride themselves in teamwork and employ more than 2,500 Teammates. Team Fishel's commitment to safety, quality, and customer satisfaction makes them a beacon of excellence in providing infrastructure solutions.

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_{DISCLAIMER: The information, education, and advice provided by FEDlogic, LLC (“FEDlogic”) shall be intended for educational purposes only. Each individual’s circumstances are inherently different from those of another, and therefore, the advice given to an individual may result in unintended consequences to another. The information provided by FEDlogic shall not constitute legal, financial, or accounting advice and further shall not be interpreted as advice from the Federal government. While FEDlogic makes every effort to ensure that the information provided by its consultants is up-to-date, useful, and accurate, FEDlogic makes no guarantees and may not be held liable nor responsible for any inaccuracy or detrimental consequence resulting from the information provided. Notwithstanding the foregoing, any errors or omissions discovered by FEDlogic, its agents, or its customers will be addressed and resolved as soon as possible.}