Legally Disabled Definition for Medicaid

For eligibility purposes for Aged, Blind and Disabled (ABD) Medicaid, Medicaid nearly always uses the same definition of “legally disabled” as does the Supplemental Security Income (SSI) program. SSI, which is administered by the Social Security Administration (SSA), provides monthly cash assistance to those who are blind, disabled, or 65 years of age and above, who have low income and assets.

SSI defines “disability” for persons 18 years of age and older as the inability to undertake “substantial gainful activity” (essentially work) due to a significant physical or mental condition that will likely result in death or has continued or is expected to continue on a persistent basis for at least 12 months. (Note that the substantial gainful activity criteria does not apply to persons who are blind). Examples of conditions for which one might be determined to be “legally disabled” are Parkinson’s disease, cancer, coronary heart disease, schizophrenia, and cerebral palsy.

In the majority of the states, a disabled individual approved for SSI benefits is automatically eligible for ABD Medicaid. This is because many states use the same criteria, including the definition of disability, as the SSI program. However, states are permitted to use more restrictive requirements than SSI. For instance, a lower income limit, a lower asset limit, and / or a more restrictive definition of disability or blindness. Eight states, called 209(b) states, have elected to use at least one eligibility criteria more restrictive criteria than SSI. These states are Connecticut, Hawaii, Illinois, Minnesota, Missouri, New Hampshire, North Dakota, and Virginia. (CT, MO, and NH do not include in their disability definition persons under 18 years old who are not blind. Instead, these individuals can be Medicaid-eligible through the Temporary Assistance for Needy Families program.)

It is always best to contact one’s state Medicaid agency to inquire about the “legally disabled” definition in the state in which one resides. Medicaid is complicated, and unfortunately, the rules tend to change.

Though the topic of this discussion is being “legally disabled” for Medicaid eligibility purposes, it is important to mention that for Aged, Blind and Disabled Medicaid, a person who is 65 years of age or older does not have to be disabled in ordered to be eligible. Furthermore, in order to qualify for long-term care Medicaid, such as nursing home care or home and community based services (HCBS) via a Medicaid Waiver, seniors do not have to be disabled. Rather, they must demonstrate a functional need for benefits; they must require a “Nursing Home Level of Care”. While a functional needs assessment is done to determine one’s level of care need, the need for assistance with Activities of Daily Living (ADLs), such as bathing, grooming, mobility, and toiletry, is often used as an indicator to determine if the need requirement is met. In addition to functional need, there are other Medicaid eligibility criteria that must be met. See state-by-state criteria.