BOX 4-2
Variation in Medicaid Programs

Eligibility for Joe


Joe’s AIDS diagnosis does not guarantee that he will qualify for Medicaid or Supplemental Security Income (SSI) disability payments. First, he must obtain a Social Security Administration (SSA) determination of disability through a complex system that involves multiple organizations in determining whether a claimant is eligible for benefits. The definition applied by the SSA when making this determination is “a physical or mental impairment that keeps a person from performing any ‘substantial’ work and is expected to last 12 months or result in death” (SSA, 2004). If he is dissatisfied with the SSA’s initial decision, he can pursue a revised decision by appealing to three levels of administrative appeal that have their own procedures for evidence collection, review, and decision making. Once he has crossed this threshold, Joe is eligible for Medicaid in all five states. In Illinois, he would be allowed to earn up to 100 percent of the federal poverty level, or $738 per month in 2002. The other four states—Florida, Georgia, New York, and Texas—would require that he earn no more than the maximum disability payment, $546 per month.

Because Joe’s Medicaid eligibility is based on receipt of SSI payments, he is required to enroll in managed care in Florida and Georgia. In New York, enrollment in managed care is voluntary. In Texas, managed-care enrollment is mandatory in Harris County (Houston), but voluntary where it is available throughout the rest of the state. If Joe were to enroll in managed care in Texas, he would not face the three-prescription drug limit that fee-for-service Medicaid beneficiaries do. Managed-care plans, however, are available in only 51 of the 254 counties in Texas.


Eligibility for Nancy


If Nancy qualifies for Temporary Assistance for Needy Families (TANF), she is automatically eligible for Medicaid. The income requirements for TANF vary; in Texas she must earn no more than $188 per month, while in New York she could earn up to $577 per month and still qualify. Federal law places a five-year lifetime limit on the receipt of TANF benefits; Florida and Georgia, however, impose a four-year limit. In addition, Florida limits TANF eligibility to two years within a five-year period for most individuals. This has serious implications for Nancy’s ability to receive stable lifetime care for her HIV.

It is important to note that Nancy’s HIV diagnosis does not guarantee her access to medical care in any of the five states. If she makes too much money, for example, by working full time earning the minimum wage, she is ineligible for Medicaid coverage even in the states with the most generous eligibility requirements.



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