Medicaid is a joint federal and state program that helps cover medical costs for some people with limited income and resources. The federal government has general rules that all state Medicaid programs must follow, but each state runs its program. Qualifying for Medicaid is dependent on the parent/guardian’s income. If your child receives Supplemental Security Income (SSI, also income-based) or the Waiver (eligibility is based upon the person’s support needs and is determined by your local CBDD), they will also receive Medicaid benefits. In 2019, Ohio took steps to expand Medicaid coverage to include behavioral health services for children with Autism, providing them with access to crucial therapies and treatments. Even if your child does not receive SSI, you may still qualify for one of the other Medicaid programs in Ohio.

In addition, adults with Autism may be eligible for Medicaid Buy-In. The Medicaid Buy-In program allows individuals with disabilities who are employed, earning income, and may not otherwise qualify for Medicaid due to their earnings, to “buy in” to Medicaid coverage by paying a premium. This program enables individuals with disabilities, including adults with Autism, to retain their Medicaid coverage while they are working or earning an income that would typically disqualify them from standard Medicaid coverage. The Buy-In program helps bridge the gap between employment and healthcare coverage for individuals with disabilities who might need Medicaid benefits to supplement their private insurance or cover services their private insurance might not fully address.

What are Medicaid Waivers?

In the 1950s and 1960s, if a child received an Autism diagnosis, parents were instructed to institutionalize their child. Medicaid paid money directly to the institution to tend to every child there. In the late 1960s, parents questioned and often refused this treatment, saying they wanted their children at home because it was better for the child, better for the family, better for the community, and it was cheaper. The federal government allowed states to waive the requirement that an individual live in an institution to receive access to these Medicaid funds. Waivers provide money for individuals with developmental disabilities to live in the community with services and support and to learn skills that will allow them to live more independently.

Funding for waiver programs comes from state and federal Medicaid dollars, and the local CBDDs must provide a local match to use those funds. Services across counties may differ based on the amount of county-matched dollars available. In Ohio, the Ohio Department of Developmental Disabilities and the Ohio Department of Job and Family Services govern the waivers and respective CBDDs administer the Medicaid funds to individuals with disabilities.

The distribution of waivers is determined by need, family income is not considered for waiver eligibility.

Obtaining a waiver for in-home support does not necessarily mean that there will be 24-hour supervision. (There are exceptions for emergencies, such as the illness or death of a caregiver.) There are four basic waiver programs for which an individual with Autism/disability may qualify: the Individual Options (IO) Waiver, the Self-Empowered Life (SELF) Waiver, the Level 1 Waiver, and the Participant-Directed Waiver.

Waivers are not a mandated, governmental program. Obtaining a waiver depends on the individual needing a certain level of care and/or support and available funding. Diagnosis of a disability does not automatically equal services. Recent changes to Ohio’s Waiting List for home and community-based services waivers make it easier to identify a person’s needs and coordinate services. Modifications to the Waiting List include a statewide assessment tool used to better understand a person’s need for services and any current or immediate needs they may have.

In Ohio, there are four types of waivers:

1. Level One Waiver: Provides up to $5,000 a year for a menu of items including homemaker personal care, respite services, non-medical transportation, employment supports, day programs, etc.
2. Individual Options (IO) Waiver: No cap; funding is determined and based on functional need and provides a greater level of support. Typically provided for extraordinary needs or after the child moves out of the family home.
3. SELF Waiver: Self-directed with a greater range of providers and different services including Functional Behavioral Assessment and Clinical/Therapeutic Intervention. This waiver can be a funding source for an individual who needs behavioral intervention not covered by insurance or a school program. Refer to the Medicaid Waiver website.
4. Participant-Directed Waiver: Participant-direction means the person using a waiver can make some decisions about the staff they hire or some of the services purchased with their waiver budget.

Adults choosing participant direction may direct their services, or they can choose their representative, including a friend, family member, or legal guardian.