Facts
on Medicaid for Children
prepared by
Advocates for Children's Services
CONTENTS:
What is
Medicaid for children?
Who qualifies for services under the Medicaid Act?
If a child
qualifies for Medicaid, to what services is he entitled?
What
can be done if a child qualifies for but is denied services,
or
services are inappropriately reduced or terminated?
Stages to appeal a
Medicaid decision
What is
Medicaid for children?
Medicaid is the primary source of health care for
children from low income families and children in foster care. The
Medicaid program for children is known as the Early, Periodic,
Screening, Diagnosis, and Treatment program (EPSDT). North Carolina
calls its Medicaid program for children Health Check. Medicaid is
financed jointly by the federal government and the states. Federal
guidelines require that Medicaid for children covers a broad range
of medical and mental health services for children under age 21.
Though Medicaid was enacted by Congress more than 35 years ago, it
still receives insufficient funding and is far from providing
comprehensive services to all qualified individuals.
Who
qualifies for services under the Medicaid Act?
Eligibility is determined one of two ways. Children
are either eligible because of their family’s income (income
guidelines vary by the age of the child and the number of people
living in the household), or due to medical necessity (a child with
high medical expenses but whose family does not meet the income
eligibility.)
To apply for Medicaid, contact your local Department of Social
Services, the local Health Department, or call the Office of Citizen
Services CARE-LINE Information and Referral Service toll-free at
1-800-662-7030 (Voice and Spanish).
If a
child qualifies for Medicaid, to what services is he entitled?
As a preventative measure, he is entitled to regular
well-child checkups and shots, covering the following areas:
medical, hearing, dental, and vision. Mental health services are
also covered. Additionally, he is entitled to care when referred by
a health, developmental, or educational professional, when a
kindergarten or sports physical is required, or when he has an
illness that requires close monitoring.
The child and/or his caregiver is entitled to be informed of his
rights to these services and to transportation, meals, and lodging
related to obtaining these services, as necessary.
What can be done if a child qualifies for but is denied
services, or services are inappropriately reduced or terminated?
The day a child is enrolled in Medicaid, he and/or
his caregiver should be informed of the process to use to appeal a
treatment or service decision made by Medicaid. In addition, the
child and/or his caregiver must be told of proposed changes to
service (a cutback or termination of services) in advance of the
change taking place, so there is time to express disagreement.
Stages to appeal a Medicaid decision:
Following are the different stages to appealing a
Medicaid decision. Only move on to the next level if the previous
level has failed to produce action. Be sure to document well all of
your efforts.
- 1. Express your concerns to the service
provider.*
- 2. Write a letter to the Children’s Services
Supervisor demanding
the medically necessary services
- 3. Call
Advocates for Children's Services to discuss the situation.
- 4. File a Contested Case Petition.
*
(If the issue is urgent, go straight to
step 3.)
Prepared by
Advocates for Children's Services
201 West Main Street, Suite 400, Durham, NC 27702
919-226-0051
E-mail:
ACSinfo@legalaidnc.org ยท Website:
www.legalaidnc.org
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purposes only and do not constitute legal advice. Please contact your
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Legal Aid of North Carolina is a statewide, nonprofit law firm that
provides free legal services in civil matters to low-income people in
order to ensure equal access to justice and to remove legal barriers
to economic opportunity.