When your child has been diagnosed, you must apply for Medical Assistance to help cover the cost of therapy for your child. This can be very confusing for a parent. Here is a step-by-step process that should help make things just a little easier for you.
HELP! My child was just diagnosed with Autism! What do I do FIRST?
Get your paperwork in order
You will need a copy of the diagnosis that was given to you in the report from the doctor that did the evaluation on your child.
Here is a list of paperwork you will need to provide with the application. Make copies of:
- the diagnosis from the doctor that did the evaluation
- your child’s social security card
- your child’s birth certificate
- your child’s medical insurance ( if they have insurance at this time)
- your car insurance card
- your recent pay stubs for 1 month
- rejection letter OR approval letter from Social Security
Get an SSI Eligibility Determination
Call Social Security at 1-800-772-1213. Let them know that your child has been diagnosed with Autism and you need to apply for Social Security. Your income WILL apply until your child reaches the age of 18 years old. They can set you up with an appointment via phone or in person. Sometimes this can take a few weeks to set up. Another option, and often a faster one, is to go into your local Social Security office. Find your local office here.
You will need to provide the Social Security office with the following items to apply:
- Your child’s Social Security card
- Birth Certificate
- Copy of the diagnosis of Autism
- Pay stubs, stocks, bonds or any other types of income
- You will need to have photo ID with you
After your get your letter of rejection (it’s okay if you do!) OR approval you will then:
Apply for Medical Assistance
If you are applying by mail, it is a good idea to make a copy of ALL documents that you are sending to them.
Write a cover letter and attach it to the application. This is an example of the cover letter and what to say:
To whom it may concern:
My son John Doe has been diagnosed with an Autism Spectrum Disorder. I am applying for a child with a disability, PH 95 Loophole Handbook Section 355.4. I have enclosed all documents and this application. Please contact me at ( give your phone number and email address) if you have any questions.
This takes about 30 days to process the application and you should hear back from them. You will be asked to pick a Medical Assistance HMO, for example Gateway or UPMC-4U, from Health Choices.
Read the Pennsylvania Health Law Project’s guide to obtaining Medical Assistance for more information.
Frequently Asked Questions
Do I have to apply for Medical Assistance for my child if we don’t want to services?
No, you do not, however, if you want services in the future you will have to apply.
If my income does not count for Medical Assistance then why do I need to provide my income? What if I DON’T provide them with this information?
This is the rules that they have put in place and they are asking for the documents. Your application will be rejected until you provide this information.
How long does it take to process the Medical Assistance application?
About 30 days, sometimes longer if they are backed up. If you don’t hear anything in 45 days please contact your local office to find out what is going on.
What does a Medical Assistance card pay for?
- Behavioral health services such as wraparound services
- Occupational therapy
- Speech therapy
- Physical therapy
- Doctor visits and co-pays
- Emergency room visits
- Prescriptions for medications
- Eye glasses
- Dental exams
- Diapers or pull-ups for children over the age of 3
- Durable medical equipment, such as strollers
Please note: ALWAYS check with your provider to make sure that they accept Medical Assistance.
What if my child’s doctor does NOT take Medical Assistance, but takes our primary health insurance? Can we still use our doctor?
YES! You will just have to cover the cost of the copay if you have one with your primary insurance.
How often do we have to reapply for Medical Assistance?
Once a year you will get a letter asking you to reapply for Medical Assistance. They will ask you to provide any updated information, such as income. You MUST fill this out and get it back to them within the dates that they have requested or your child will lose their Medical Assistance benefits.
We hope this has helped you in filling out your child’s Medical Assistance application.