[Note: Medicaid provides health care for about half of persons with AIDS in the U.S. Benefits expert Thomas P. McCormack explains entry criteria for this program.]

How many times have we read that you have to be disabled to be eligible for Medicaid (Medi-Cal in California), that if you are "only" HIV-positive you cannot qualify--and that changing the rules to cover persons who are not yet disabled would by itself fix the problem? In fact the truth is more complicated.

In all states, Medicaid now covers poor persons who are: over age 65; under age 18; pregnant; blind; members of families with children (including--in almost all states--the father if he is at home); and those found disabled by SSA (the U.S. Social Security Administration). So, in reality, Medicaid covers six different kinds of poor persons--and the disabled are only one of those six.

It is true that many persons do qualify for Medicaid in the "disabled" category--but many others get it through the other five category routes. SSA generally accepts an AIDS diagnosis as disabling if it actually prevents substantial work, but it also accepts persons who are 'only' HIV-positive as disabled, if their medical conditions prevent work.

Most of the first AIDS patients were childless, sighted gay men in the prime of life, whose route to Medicaid--indeed, whose only possible route to Medicaid--was as disabled. And so the myth grew that only AIDS patients found disabled by SSA could get Medicaid.

Medicaid has been available all along--and has been awarded to thousands of other poor persons who are "only" HIV- positive--because they were under 18; over 65; blind; pregnant; or members of families raising minor children.

And in addition, almost all of the larger, wealthier states use their own money--without federal help--to give similar medical assistance to poor persons who don't fit in any of the six federal Medicaid categories. Most notably, this does include not-yet-disabled, childless adults in the prime of life.)

In fact, since AIDS emerged in the early 1980s, federal Medicaid has been broadened to cover childless, not-yet- disabled adults in several ways: (1) States can pay COBRA premiums (to keep health insurance from one's former job in force for 18 or even 29 months after leaving work) with federal Medicaid money, for anyone with countable income under the national poverty level ($707 monthly for the unemployed, $1,458 for those working), even those who are not disabled or members of the other five Medicaid categories.

Related Articles from the GayToday Archive: GayToday's Continuing Series: HIV/AIDS Rights Bill Needed to Contain Costs Income-Protection Insurance Plan Will Include HIV/AIDS AIDS Funding & Congress Related Sites: AIDS Treatment News GayToday does not endorse related sites.

(2) States can get waivers under federal law to cover needy, "pre-disabled" persons who are not in any Medicaid category through their Medicaid programs--but only if they can show that federal costs will not be increased. (While this "budget neutrality" rule is tough to meet, Oregon and Tennessee have already done it and expanded their Medicaid programs, and Maine, Massachusetts and other states are now trying to do so also.)

(3) States can already offer Medicaid with federal support, at small premiums, to working persons with medically disabling conditions (whom SSA cannot consider "disabled" because they are actually working) with incomes up to about $43,000 a year. Alaska, Iowa, Massachusetts, Minnesota, Oregon, Vermont, and Wisconsin have already done this--and as this article went to press, a bill was on Governor Gray Davis' desk for California to do so too.

(4) One little-noticed result of the 1996 welfare reform law was that states gained the right to define what constitutes a family for Medicaid coverage purposes. Under the old AFDC welfare system, families with fathers at home could only be eligible if he had been laid off after long employment, or if he met state "incapacity" rules (temporary disability less strict than SSA's). Now, under the reformed TANF welfare system, almost all states have dropped these limits and cover all poor families with children--no matter what the father's status.

(5) Under the state Child Health Insurance Program (CHIP) created by the 1997 Balanced Budget Act, children under age 19 with family incomes under 200% of poverty [currently meaning incomes under $22,400 per year for a family of two, $27,700 for three, $33,400 for four, or $39,000 for five] are eligible for Medicaid or similar CHIP health insurance even if they are not disabled. The law even gives states the right, in some case, to give this coverage to the children's parents--whether or not they are disabled. Vice President Gore has called for making the parental coverage standard in this program, and for increasing the income level as well.

But there will be even more about to be offered to states under the bipartisan Work Incentives Improvement Act (S. 331/H.R. 1180)--not currently law, but expected to clear Congress in the fall of 1999:

(6) On a demonstration project basis, many states that take the option to cover the working disabled can then also give Medicaid, under the same income rules, to "pre-disabled" persons who are at risk of becoming fully disabled without early Medicaid treatment. These states would get extra federal money for doing so, too.

(7) And states which cover the working disabled can also include those working persons who have recovered from their disabilities but still have a potentially serious condition like HIV. Here, too, extra federal money can help states do this.

States need to take the working disabled coverage option--and then go on to take the sub-options of covering those at risk of becoming disabled and those who have recovered but still have serious underlying conditions. Both the "pre-disabled" and the "ex-disabled" could then get Medicaid with incomes up to about $43,000 yearly.

Without this, "waiving" the disability rule alone won't do much good. The fact is that non-disabled persons are likely to be employed, even if at menial jobs. Someone earning as little as the minimum wage gets an income of about $950 monthly. That is far, far above the Medicaid level for a non- disabled person, which averages about $350 in even the most generous states (through the "General Assistance" programs which many but not all states have). And it's even above the levels for those who are disabled--$500 in most states, $676 in the most generous state (California).

So waiving the disability rule won't do much alone. It will take careful, thoughtful advocacy at the state level to enact the Medicaid coverage choices which states already have--and the new ones they will shortly get.

[Thomas McCormack, email tomxix@ix.netcom.com, wrote the AIDS Benefits Handbook (Yale University Press) and handled Medicaid eligibility policy at the federal Department of Health and Human Services. He has done benefits advocacy for several AIDS and disability groups and now serves as policy consultant for the Title II Community AIDS National Network. These opinions are his own, and not those of any organization.]