Medical & Social Security

Part 1: The Pennsylvania "PH95" Loophole

The most important thing for every Pittsburgh autism parent to know is that your income does not disqualify your child from Medical Assistance (Medicaid). Under a specific category called PH95, Pennsylvania provides full Medicaid coverage to children with a disability (including Autism Spectrum Disorder) regardless of how much money the parents make.

Why is PH95 a Game-Changer?

• Secondary Insurance: It acts as a secondary payer, covering the high co-pays and deductibles from your primary employer-based insurance.
• Wraparound Services: It is the "key" that unlocks Intensive Behavioral Health Services (IBHS), commonly known as "Wraparound" or ABA therapy.
• Essential Supplies: It covers the cost of prescriptions, specialized medical equipment, and even diapers/incontinence supplies for children age 3 and older.
• In-Home Support: It funds Personal Care Assistants (PCAs) if your child requires one-on-one help at home or in the community.

The COMPASS Application Strategy

You apply for PH95 through the PA COMPASS website. Follow these specific "insider" tips to ensure your application isn't filtered out by mistake:

1. The "Disabled Child" Note: When applying online or via paper, write “CHILD WITH DISABILITY CATEGORY PH-95” in large letters in the comments or notes section.
2. The Income Question: You must report your household income, but don't panic. The system is legally required to bypass those limits once the disability is verified.
3. The Screening Process: The County Assistance Office (CAO) may require you to apply for SSI first. Keep the "Denial Letter" you receive from Social Security; this is a required piece of evidence for the PH95 category.

Part 2: Supplemental Security Income (SSI)

While Medical Assistance (PH95) ignores your income, SSI does not. SSI is a federal program that provides a monthly cash payment to help with the costs of raising a child with a disability.

The Two Hurdles of SSI:

To qualify, your family must pass two separate evaluations:

1. The Financial Hurdle (Deeming): Social Security looks at the parents' income and assets (bank accounts, second cars, etc.). If you make "too much," you will be denied financially before they even look at your child's medical records.
2. The Medical Hurdle: Your child must meet the "Childhood Listing of Impairments." For autism, this means proving "marked and severe functional limitations" in areas like communication, social interaction, and self-regulation.

Part 3: Your Mandatory Document Checklist

Never start these applications without your "Life Binder" ready. Missing one document can delay your benefits by months.

The "Big Five" Medical Documents:

• Evaluation Report (ER): The formal document from the psychologist that diagnosed your child. It should ideally be less than one year old.
• Individualized Education Plan (IEP): Your child's school records, which prove they need extra support in a classroom setting.
• Form PA 1663: The "Medical Assessment" form. Your child’s pediatrician must sign this to certify the disability for the state.
• Therapy Progress Notes: Recent reports from speech, occupational, or physical therapists.
• Prescription Records: A list of all medications your child currently takes.

The "Big Five" Financial Documents:

• Pay Stubs: The last 30 days of income for every working adult in the house.
• Bank Statements: Full statements for the last three months for all checking and savings accounts.
• Proof of Residency: A utility bill or lease showing your Pittsburgh address.
• Identification: Original Birth Certificates and Social Security Cards for everyone in the household.
• Asset Records: Documentation of life insurance policies, stocks, or additional property.

Part 4: Pro-Tips for Success

• Keep a Paper Trail: Every time you speak to the County Assistance Office or Social Security, write down the date, the name of the worker, and what was said.
• The 10-Day Rule: If the state sends you a "Request for Information," you usually have only 10 days to respond. If you can't get the document in time, call them immediately to ask for an extension.
• Appeal Everything: Initial denials are extremely common. You have the right to an appeal (Fair Hearing). Many families who are initially rejected are approved once they present their case to a judge.