The Children with Special Needs Category provides full Medical Assistance (MA) benefits to children up to age 18 who meet disability requirements and do not receive Supplemental Security Income (SSI) benefits under Title XVI of the Social Security Act.
The Children with Special Needs category (PH 95) is authorized only after eligibility for all other MA categories has been explored.
NOTE: If the family wants the child authorized in MAWD (and the child meets MAWD criteria) instead of PH95, the CAO must explain to the family the requirement to pay a monthly premium.
NOTE: The CAO should not review the child for spend-down if eligible for PH95.
The County Assistance Office (CAO) will determine eligibility for Children with Special Needs based on the requirements in this Chapter and the following chapters:
General Information - Chapter 303
Application - Chapter 304
Students - Chapter 314
Identity – Chapter 320
Citizen/Alien – Chapter 322
Residence – Chapter 323
Income – Chapter 350
Self-Employment – Chapter 352
Reporting Changes – Chapter 370
Renewal – Chapter 376
Notices – Chapter 377
Verification – Chapter 378
Disability Advocacy Program – Supplemental Handbook Chapter 820
Appeal and Fair Hearing – Supplemental Handbook Chapter 870
Overpayment Recovery – Supplemental Handbook Chapter 910
Reimbursement – Supplemental Handbook Chapter 915 Reimbursement
Enumeration- Supplemental Handbook Chapter 950
The Children with Special Needs category provides the following benefits:
Children's HealthCare Benefits Package (Chapter 338, Appendix A, Health Care Benefits Packages.)
Retroactive Coverage – Children with Special Needs benefits may only be authorized for the retroactive period when medical documentation [either by the Social Security Administration (SSA) or the Medical Review Team (MRT) determination] confirms the disability existed in the retroactive period.
A child should be authorized presumptively when:
The CAO receives documentation of a disability from a physician or psychologist. The documentation must detail the child’s medical condition.
The child with special needs has not been determined disabled by SSA or MRT. A Disability Advocacy Program (DAP) referral should be completed for the MRT review.
Acceptable disability verification for presumptive eligibility includes, but is not limited to:
An Individualized Education Plan (IEP).
An Individualized Family Service Plan (IFSP).
An Early Intervention evaluation.
A Mental Health facility discharge report.
A completed Physician Certification for Child with Special Needs Form (PA 1960) which is to include:
NOTE: Like with other medical assessment forms, the PA 1960 form needs to be completed and signed by a licensed psychologist, physician, or medical professional.
Another completed Medical Assessment Form, which indicates the child may meet disability criteria. Other assessment forms include, but are not limited to:
There is no presumptive eligibility for retroactive MA for the Children with Special Needs category.
The CAO will verify the following:
Income: Parents (natural and adoptive) and child must report and verify all earned and unearned income.
Birth date.
Disability or a pending application for a disability determination by SSA or by DHS’s MRT.
Explain the use of the Authorization for Information (PA 4) when collateral contacts are necessary. Complete the form only if the collateral contact requires written consent from the individual for the verification to be released. (Section 378.4, Collateral Contacts)
Updated March 24, 2025, Replacing July 26, 2018