Navigating the System: Medicaid, PH 95 Waiver, Act 62, and Social Security for Kids with Disabilities in Pennsylvania

by | Jun 17, 2025 | Uncategorized

Raising a child with a disability can be overwhelming—but navigating the support systems shouldn’t be. In Pennsylvania, there are multiple pathways to access care, funding, and services, but many families don’t know what they qualify for—or how to apply. This guide breaks down four major systems that can help your child: Medicaid, the PH 95 Waiver, Act 62, and the Social Security (SSI) process, specifically for children with disabilities.

🌐 1. MEDICAID IN PENNSYLVANIA: MORE THAN JUST INSURANCE

What is Medicaid?
Medicaid is a state and federally funded program that provides free or low-cost health insurance to eligible individuals—including children with disabilities. In PA, this is managed by the Department of Human Services (DHS).

What Medicaid Covers for Children:

  • Speech, occupational, physical therapy

  • Mental and behavioral health services

  • Medication and equipment

  • In-home support services

  • Transportation to medical appointments

Medicaid can also serve as secondary insurance, meaning it will cover costs your private insurance does not, including copays and deductibles.

🧾 2. PH 95 WAIVER (LOOPHOLE): MEDICAID BASED ON THE CHILD’S INCOME ONLY

What is the PH 95 Waiver?
PH 95—also called the “loophole” or Category PH 95—allows any child with a disability to qualify for Medicaid regardless of parent income. This is a game-changer for middle-income and higher-income families who would otherwise be denied Medicaid because they “make too much.”

Eligibility Requirements:

  • The child must be under 18 years old

  • Must have a disability as defined by Social Security

  • The child must require treatment or services for that disability

  • Parent income is NOT counted—only the child’s (which is usually $0)

How to Apply:

  1. Submit a COMPASS application (online at www.compass.state.pa.us)
  2. Choose “Medical Assistance for a child with a disability (PH 95)”

  1. Provide:

    • Medical documentation of the disability

    • Functional reports from doctors, therapists, or schools

3. Follow up with your local County Assistance Office

Once approved, the child receives full Medical Assistance coverage—even if the family already has private insurance.

🧠 3. ACT 62: INSURANCE COVERAGE FOR AUTISM TREATMENT

What is Act 62?
Passed in Pennsylvania in 2008, Act 62 requires private insurance companies to cover autism-related services for children and adolescents up to age 21.

Covered Services May Include:

Who Qualifies?

  • Children with a diagnosis on the autism spectrum

  • Covered under fully insured group health insurance plans in PA

  • Coverage is capped at $40,000/year (adjusted yearly for inflation), but many services are also covered through Medicaid as secondary

Important: If your insurance plan is “self-funded” (typically large employers), it may be exempt from Act 62. However, Medicaid (via PH 95) can still cover these services.

💵 4. SOCIAL SECURITY (SSI) FOR CHILDREN WITH DISABILITIES

What is SSI?
Supplemental Security Income (SSI) is a federal benefit that provides monthly payments to children with qualifying disabilities and financial need.

Who Qualifies?

  • The child must be under 18

  • Must have a medically documented disability that significantly impairs functioning

  • Family income and resources must fall below SSI limits

What Makes This Different from Medicaid?

  • SSI is a cash benefit—monthly funds to help support the child’s care

  • If approved for SSI, the child is automatically eligible for Medicaid in PA

The Application Process:

  1. Call Social Security at 1-800-772-1213 to begin the application

  2. Be prepared to provide:

    • Medical records

    • School reports (IEPs, evaluations)

    • Household income and resource information

  3. A disability determination is done by Pennsylvania’s Bureau of Disability Determination

Important Note: Many children are denied on the first attempt. Appeals are common—and sometimes necessary. Don’t give up.

⚖️ PUTTING IT ALL TOGETHER: A COMMON SCENARIO

Let’s say your child has autism and sensory issues:

  1. You apply for PH 95, and they are approved for Medicaid.

  2. Medicaid then covers therapy, evaluations, and even copays from your primary insurance.

  3. You also use Act 62 to ensure your insurance covers ABA therapy.

  4. If your family meets the income criteria, you apply for SSI to receive monthly cash assistance and automatic Medicaid.

  5. With both Act 62 + Medicaid, your child’s treatment is fully covered.

🧭 WHERE TO GET HELP

💬 Final Thoughts

These systems—Medicaid, PH 95, Act 62, and SSI—can open doors for therapies, medical care, and essential supports for children with disabilities in Pennsylvania. They can be complex and time-consuming to navigate, but they are life-changing when accessed.

As a parent or caregiver, you are not alone. Keep asking questions, keep advocating, and keep applying. Your child deserves every opportunity to grow, thrive, and succeed—and these programs are here to help make that possible.