Medicaid covers about 15 million people with disabilities — over one-third of the nation’s disabled population — and is the primary source of health insurance for disabled individuals in the United States. Beyond medical care, Medicaid funds critical services for people with disabilities, including long-term services and supports (LTSS), assistive technology, school-based therapies, supported employment, mental health services, and non-emergency medical transportation. These services have expanded over decades, improving access to health care, independent living, employment, and overall quality of life.

Despite these supports, many disabled people face persistent barriers that lead to disparities that undermine their health and well-being. People with disabilities experience worse health outcomes, higher rates of chronic conditions, and higher risk of mortality compared to non-disabled people. Medicaid members with disabilities, in particular, often face significant barriers when accessing health care — from limited physical accessibility of facilities to communication challenges for people with hearing or visual impairments, intellectual/developmental disabilities (I/DD), mental health, and/or cognitive disabilities. Disparities are even more pronounced for women and communities of color. For example, American Indian, Alaskan Native, and Black individuals have higher disability rates, but lower enrollment in Medicaid home- and community-based services (HCBS). Among Medicaid beneficiaries with I/DD, people of color are up to 12 percent less likely to enroll in 1915(c) waiver programs compared to their white peers.

To identify opportunities for states to improve health and reduce disparities among Medicaid members with disabilities, the Center for Health Care Strategies (CHCS) convened a group of disabled leaders and allies from policy, philanthropy, research, advocacy, and other sectors. Through this convening, CHCS sought to better understand efforts underway across the country to improve care for people with disabilities served by Medicaid and distill promising practices. This blog post highlights three opportunities for state action, drawn from insights shared during the convening.

Medicaid Opportunities to Improve Health Care Access, Quality, and Outcomes for People with Disabilities

Through the convening, participants identified three key areas where states can take action to improve health care access, quality, and outcomes and reduce disparities among Medicaid members with disabilities. These include: (1) reducing administrative burdens for disabled people in accessing services; (2) supporting disability competent care; and (3) implementing alternatives to cutting optional Medicaid-funded disability services.

1. Reduce administrative burdens for disabled people in accessing Medicaid with presumptive eligibility.

In all but eight states, Medicaid eligibility for people with disabilities is directly linked to eligibility for Supplemental Security Income (SSI). To qualify for SSI and Medicaid, applicants must meet the Social Security Administration’s (SSA) definition of disability: a permanent physical or mental condition that prevents the individual from working. Moreover, many members must re-prove their disability annually, even for permanent disabilities. This can cause administrative burdens for both state staff and enrollees. In some states, the average disability application takes more than two years to get approved, which may include rounds of denials and appeals. These delays, combined with lengthy eligibility assessments, can prevent timely access to critical Medicaid services.

To help alleviate these barriers, nine states have implemented presumptive eligibility policies that allow people with pending SSA disability determinations or Medicaid applications to access Medicaid-covered services. For example, Washington State uses a Section 1115 waiver to expedite access to specific Medicaid-funded HCBS services and medical coverage. The state also uses a disability self-attestation form that allows someone exiting an acute care hospital to begin receiving HCBS upon discharge while SSA disability determination is pending. The potential impact of the retroactive coverage provision under the 2025 budget reconciliation act (H.R. 1; now P.L. 119-21) on this strategy is unknown at this time.

Not all people with disabilities qualify for Medicaid through disability eligibility pathways. For those who qualify under Medicaid expansion, new federal requirements under P.L. 119-21 further complicate access. The act mandates that Medicaid expansion beneficiaries participate in qualifying activities, such as working or volunteering, at least 80 hours per month. While some expansion members are exempt from this requirement, a majority of adults age 50-64 enrolled in Medicaid expansion under the Affordable Care Act have at least one physical health disability and many are too disabled to meet work requirements, yet not disabled enough to qualify for an exemption. The vast majority of expansion adults ages 50-64 report having a health condition that prevents them from working, and a large number of older adults do not meet the SSI definition of “disability.” This could potentially cause them to become subject to work requirements and ultimately lose coverage. Due to this, one strategy to consider is to ensure that the medically frail exemption appropriately covers people with disabilities. This will help ensure coverage is provided to this population to support their needs and offer flexibility in work requirements.

2. Support disability competent care among providers with training, payment reform, and data collection initiatives.

People with disabilities often face challenges with the quality of health care they receive. Individuals who are dually eligible for both Medicare and Medicaid and have a disability, for example, receive worse clinical care than dually eligible individuals who are not disabled. In a survey of U.S. physicians, only 56 percent strongly agreed that they welcome disabled people into their practices, and only 40 percent felt confident in their ability to provide the same quality of care for people with disabilities as they do for non-disabled individuals. Combined with a lack of training in disability-competent care (DCC) and a limited understanding of the unique needs of disabled people in health care settings, provider biases can result in serious consequences — including misdiagnosis, failure to recommend preventive care or provide referrals, suggestions of less effective treatment, and even avoidance of treating disabled people. This results in a negative care experience for people with disabilities, and can also contribute to poorer health outcomes and, in some cases, premature death. While training is important, it is insufficient on its own.

To improve the quality of care for Medicaid members with disabilities, states can support disability-competent care for providers. Approaches might include:

• Investing in and requiring that Medicaid providers participate in DCC training. For example, in response to concerns from Medicaid members with disabilities, Colorado established a DCC program for primary care and behavioral health care settings. The program uses a tool to assess providers’ ability to support physical, programmatic, and communication access to care.
• Using payment levers to address systemic barriers to quality care. State Medicaid agencies can implement payment approaches to strengthen DCC, such as enhanced per-member-per-month payments for demonstrating DCC capabilities, incentive payments for DCC, and grants to cover DCC upfront costs. Medicaid agencies could also consider site neutral payments to ensure that care delivered in more accessible hospital settings is reimbursed equitably, without creating cost disparities that affect how services are funded.
• Standardizing disability demographic data collection and DCC quality measures. Disability data collection is inconsistent across states due to a lack of clear guidance and limitations in current disability measures. To address this, the National Committee for Quality Assurance (NCQA) is enhancing its Healthcare Effectiveness Data and Information Set (HEDIS) to include disability-specific measures, promoting more consistent data collection. Standardizing these efforts can help Medicaid agencies better identify members with disabilities and assess the accessibility and quality of their care.

3. Implement alternatives to cutting optional Medicaid disability services through mechanisms such as ILOS and disability service administrative integration.

The majority of Medicaid services for people with disabilities, such as HCBS, are optional for states. With federal Medicaid spending estimated to decrease by approximately $911 billion over the next decade, states may need to reduce these optional services and rely instead on mandatory Medicaid services, which often require institutional residency to receive care. During Medicaid budget pressures between 2010 and 2012, for example, every state and the District of Columbia cut spending to at least one optional HCBS program, either by reducing inflation-adjusted, per-beneficiary spending or limiting enrollment. To prevent similar cuts, states can consider alternative approaches to administering and providing optional Medicaid services for people with disabilities. Alternatives might include:

• Expanding the use of managed care in lieu of services (ILOS) to deliver more cost-effective services. ILOS are a permanent option for states under federal Medicaid managed care regulations, allowing managed care organizations (MCOs) to provide medically appropriate, cost-effective substitutes for Medicaid benefits. It can also be used as a mechanism for funding HCBS, helping to prevent institutional care. While ILOS presents a valuable alternative for MCOs, it remains an optional choice for MCOs to adopt. In 2022, California became the first state to use ILOS authority — rather than a section 1115 waiver, which requires a lengthier approval process with CMS — to cover a robust set of Medicaid services, including disability-related services, such as personal care and environmental accessibility modifications. Thirty-four other states have also authorized ILOS, with 13 using it for health-related social need services that sometimes mirror disability services. For these states, ILOS offers a path to cost savings by focusing on preventive and cost-effective service alternatives. Preliminary analysis in California shows that nine out of 12 ILOS services demonstrate cost-effectiveness.
• Cost savings through administrative integration of state-level disability services. Public services for people with disabilities are organized through various governmental administrative structures, which are often siloed by disability type and may result in financial inefficiencies. In many states, the administration of Medicaid HCBS waivers is divided across multiple agencies. In some cases, entire departments are designated to serve individuals with specific disabilities (e.g., I/DD, mental health disabilities, physical disabilities, and aging populations, among others). With P.L. 119-21 introducing significant cuts in federal Medicaid funding, states will need to optimize limited resources. One way to achieve more administrative efficiencies is to create a more integrated state-level disability service system. For example, in 2024, Tennessee merged its Department of Intellectual and Developmental Disabilities with its Commission on Aging and Disability to create a new Department of Disability and Aging. Similarly, Delaware’s Division of Services for Aging and Adults with Physical Disabilities integrates planning and service delivery for older adults, people with physical disabilities, and their caregivers.

Looking Ahead

Improving care and addressing health disparities for people with disabilities requires states to identify and implement policies and practices that better meet the needs of disabled people. The opportunities highlighted in this blog post — reducing administrative burdens for disabled people in accessing Medicaid with presumptive eligibility, supporting DCC among providers through training, payment reform, and data collection initiatives, and avoiding cuts to HCBS through ILOS and administrative integration — offer practical strategies for Medicaid agencies to more effectively support people with disabilities. By leveraging these opportunities, states can strengthen access to care, improve quality, and promote more equitable outcomes for the millions of people in the U.S. with disabilities who have Medicaid.