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How the PH-95 Loophole Can Help Cover Children With Disabilities


For individuals and families alike, obtaining health insurance can be complicated. There are plenty of things to consider, but most of the angst centers on cost. While all of us are looking for high-quality and complete health care coverage, we want to do so at a price point that we can afford.

The good news, however, is that some coverage options are completely free. While the coverage requirements may be strict, these options offer high-quality care at an extremely attractive price point.

In this post, we want to discuss one of those options for children with disabilities. It is called PH-95. Whether you have a newborn with birth defects or have a child with some sort of disabilities, PH-95 can be a great way to get them covered—all for free.

Eligibility Under PH-95


PH-95 is also known as Medicaid for a child with a disability. It offers completely free medical coverage so long as several requirements are met.

First, there is an age requirement. PH-95 defines a child as someone who is 18 years old or younger. This is a basic, straightforward requirement that your child will need to meet before proceeding.

Next, your child must have a disability. The word disability is vague, but you can find the definition in the Social Security disability guidelines. Specifically, the standards that you will want to review are called the “Childhood Listings of Impairments.” Clicking here to view these standards, you can see that they can include things like impairments related to low birth weight, skin disorders, neurological disorders, and more. You will definitely want to review these standards to ensure that your child is eligible.

From there, let’s talk about income and resources. The PH-95 program does not consider assets from the parent or child, but it does consider income that is legally considered to be the child’s. Specifically, the child with disabilities can only get medical coverage under PH-95 if he or she has countable income of no more than $1,041 per month. This number is from 2019, however, and the number increases every year. Things like interest, dividends, and income from the child’s job are counted, while things like court-ordered child support are not. You can see a full list of what is and is not included by clicking here. There are also deductions that reduce the countable income and make your child eligible for PH-95.

Ultimately, parental income is not included in this analysis, but the PH-95 program still requires parents (or caregivers) to submit proof of their income.

Applying For PH-95 Coverage

If you believe that your child is eligible for PH-95 coverage, there are several steps to apply for coverage.

First, you will need to obtain your child’s birth certificate. If you do not have one on file, you will need to reach out to your local or state government and obtain a copy. If you live in Pennsylvania, for instance, you can get your child’s birth certificate by calling the Department of Health Division of Vital Records.

Next, you will need your child’s Social Security guard. If your child doesn't have one or you have misplaced your child’s Social Security guard, you can contact your local Social Security office.

Third, you must assemble documentation on your child’s disability. Because those who make disability determinations won’t independently evaluate your child, you'll need to make sure this documentation is thorough and complete. When doing this, you don’t necessarily have to determine if your child’s disability meets a particular disability standard. Rather, include things like the severity, duration, and frequency of your child’s limitation. Getting documentation from doctors, teachers, and therapists can also be helpful.

Fourth, you’ll need to submit your application. You can do this in several ways, including online, by phone, by certified mail, or in-person.

Finally, you’ll need to get a Supplemental Security Income (“SSI”) eligibility determination. Even if your family isn’t seeking SSI, your local Social Security office may require you to go through this process.

Getting High-Quality Coverage for Free

In the end, PH-95 coverage can be an excellent option for your family. Whether you have one or several children with disabilities, we encourage you to seriously consider this option. It can go a long way in easing your financial stress while helping your children get covered.

© 2020 PA Health Advocates, LLC

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