Download the PDF version of this page: Frequently Asked Questions about Medicaid: Natural Support

Some people who receive Medicaid services are told that they cannot receive additional services because their needs can be met by “natural support.” This FAQ explains what “natural support” is, and how you can appeal a denial of services based on “natural support.” There are numerous agencies that administer Ohio Medicaid programs, including the Ohio Office of Medical Assistance, the Ohio Department of Job and Family Services, the Ohio Department of Developmental Disabilities, Care Star, Area Agencies on Aging, and county boards of developmental disabilities. This FAQ refers to all of these agencies as “the Medicaid agency.”


What is natural support?

Basically, natural support is help and care that someone receives from their friends, family, or community. It’s unpaid, voluntary services provided to an individual receiving Medicaid services.  Federal law requires the Medicaid agency to consider “the extent of, and need for, any family or other supports” for an individual receiving Medicaid services.  42 U.S.C. § 1396n(i)(1)(G)(ii)(I)(bb).

The Ohio Department of Developmental Disabilities defines natural support as “the personal associations and relationships typically developed in the community that enhance the quality of life for individuals. Natural supports may include family members, friends, neighbors, and others in the community or organizations that serve the general public who provide voluntary support to help an individual achieve agreed upon outcomes through the ISP development process.” Ohio Administrative Code § 5123:2-9-06(B)(14). Other Medicaid programs do not have a definition of natural support, but they look to the same groups of people—family, friends, neighbors, and community groups—to provide voluntary services.

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Who is required to provide natural support?

Natural support is “voluntary,” which means that no one should be forced to provide natural support.  Individuals who receive services also have a choice about whether they want to receive natural support from a particular person.  However, the Medicaid agency often assumes that family members who live with an individual or other people who have previously provided unpaid services will provide natural support.

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When will an agency look into natural support?

Any time you request services—especially home and community-based services like home health aides or transportation—the Medicaid agency will consider whether natural support is an option. For example, the Ohio Developmental Disabilities Profile (ODDP), which is used to determine an individual’s funding range for the IO Waiver, includes several questions about natural support. 

Some people who receive waiver services have been told that they must use natural support because waivers do not provide 24-hour care. This is an incorrect statement.  No waiver is prohibited from providing 24-hour care if it is medically necessary for the individual and the services can be provided within the funding range for that program.

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Can my family members be required to provide unpaid natural support if they have been my paid providers in the past?

It is common for the Medicaid agency to propose that a family member provide unpaid natural support instead of being a paid provider. The Medicaid agency often assumes that a family member could continue to provide the same services through unpaid natural support. However, many family members would have to find other paid employment if they were no longer a paid provider.  If the Medicaid agency makes this incorrect assumption, you should discuss this with your case manager.

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What if I disagree with a determination that someone should provide natural support?

If your services are reduced or denied based on natural support, you have the right to appeal by requesting a hearing. At your hearing, you can present evidence about why the person cannot provide the required amount of natural support.  Consider the following issues:

  • Is the person unavailable at the times that you need assistance?  For example, if you need assistance at a time that the person is at work.
  • Does the person have the physical ability to provide the services?  For example, if you need to be lifted out of bed and the person is unable to lift you.
  • Does the person have the mental ability to provide the services?  For example, if there are complicated procedures that the person cannot understand to perform safely with training.
  • Does the person have the necessary equipment?  For example, if you need to be transported, but the person does not have a reliable vehicle.
  • Is the person being expected to provide too much natural support?  For example, if the person is unable to meet their own personal needs (work/school, sleep) or the needs of other people who depend on them (children, other family members) because of the amount of natural support.

You should also gather documents that show why your needs can’t be met with natural support, such as a doctor’s letter that explains why the person is physically unable to provide the services, or a work schedule that shows when the person is unavailable.

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