Form CMS-10283 Section 1925 Transitional Medical Assistance Pre-print

Revision:

SUPPLEMENT 12 TO
ATTACHMENT 2.6-A
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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
ELIGIBILITY UNDER SECTION 1925 OF THE ACT
TRANSITIONAL MEDICAL ASSISTANCE

The State covers low-income families and children for Transitional Medical Assistance (TMA)
under section 1925 of the Social Security Act (the Act). This coverage is provided for families
who no longer qualify under section 1931 of the Act due to increased earned income, or working
hours, from the caretaker relative’s employment, or due to the loss of a time-limited earned
income disregard. (42 CFR 435.112, 1902(a)(52), 1902(e)(1), and 1925 of the Act)
The amount, duration, and scope of services for this coverage are specified in Section 3.1.G of
this State plan.
For Medicaid eligibility to be extended through TMA, families must have been Medicaid eligible
under section 1931 (months of retroactive eligibility may be used to meet this requirement):
____

During at least 3 of the 6 months immediately preceding the month in which the family
became ineligible under section 1931.

____

For fewer than 3 of the 6 previous months immediately preceding the month in which the
family became ineligible under section 1931. Specify:

The State extends Medicaid eligibility under TMA for an initial period of:
____ 6 months. For TMA eligibility to continue into a second 6-month extension period, the
family must meet the reporting, technical, and income eligibility requirements specified
at section 1925(b) of the Act.
____

12 months. Section 1925(b) does not apply for a second 6-month extension period.

The State collects and reports participation information to the Department of Health and Human
Services as required by section 1925(g) of the Act, in accordance with the format, timing, and
frequency specified by the Secretary and makes such information publicly available.
TN No.
Supersedes TN No. ____

Approval Date

Effective Date ____

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this
information collection is estimated to average one hour per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.