Revision: ATTACHMENT 2.2‑A
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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
GROUPS COVERED AND AGENCIES RESPONSIBLE
FOR ELIGIBILITY DETERMINATION
Agency* Citation(s) Groups Covered
The following groups are covered under this plan.
A. Mandatory Coverage ‑ Categorically Needy
42 CFR 436.110 1. All Recipients of OAA, AB, APTD and AABD
1902(a)(10)(A)(i)(I)
and 1931 of the Act This includes all individuals who are essential persons under the State plan and who could be recipients if the State plan were as broad as permitted for Federal financial participation. Also included are low-income families and children under section 1931 of the Act who, except as provided in Supplement 12 to ATTACHMENT 2.6-A, meet the:
financial eligibility requirements under the State’s Aid to Families with Dependent Children (AFDC) plan in effect as of July 16, 1996; and
eligibility requirements under section 406(a) through (c) of title IV of the Social Security Act, in effect as of July 16, 1996.
The income standards for OAA, AB, APTD, AABD and AFDC payments are listed in Supplement 1 to ATTACHMENT 2.6‑A.
The resource eligibility standards are listed in Supplement 2 to ATTACHMENT 2.6-A.
The definitions of blindness in terms of ophthalmic measurement and of permanent and total disability used in this plan are specified in Supplement 2 to ATTACHMENT 2.2-A.
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Territory:
Agency* Citation(s) Groups Covered
A. Mandatory Coverage ‑ Categorically Needy (Continued)
42 CFR 436.111 2. a. Individuals who would be eligible for OAA, AB, APTD, or AABD except for an eligibility requirement used in those programs that is specifically prohibited under title XIX of the Act.
1902(a)(17)(D) b. Individuals who are ineligible for assistance under the
of the Act the State’s title IV-A plan solely because of eligibility requirements that are specifically prohibited under Medicaid. Included are:
Families denied assistance under title IV-A solely because of income and resources deemed to be available from:
Stepparents who are not legally liable for support of stepchildren under a State law of general applicability;
Grandparents;
Legal guardians; Individual alien sponsors who are not organizations; and
Siblings.
(2) Other:
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Territory:
Agency* Citation(s) Groups Covered
A. Mandatory Coverage – Categorically Needy (Continued)
42 CFR 436.112 3. Individuals who would be eligible for OAA, AB, APTD, or AABD, or AFDC, except for the increase in OASDI benefits under Pub. L. 92‑336 (July 1, 1972), who were entitled to OASDI in August 1972, and who were receiving cash assistance in August 1972.
Includes persons who would have been eligible for cash assistance but had not applied in August 1972 (this group was included in this State's August 1972 plan).
Includes persons who would have been eligible for cash assistance in August 1972 if not in a medical institution or intermediate care facility (this group was included in this State's August 1972 plan).
Not applicable with respect to intermediate care facilities; the State did or does not cover this service.
42 CFR 436.114(e), 4. Title IV-E Subsidized Adoption or Foster Care Children.
42 CFR 436.118 and
1902(a)(10)(A)(i)(I) Individuals who meet the requirements of section 473(b) of the
of the Act Act for whom an adoption assistance agreement is in effect or foster care maintenance payments are made under title IV-E of the Act.
42 CFR 436.114(f) 5. Extended Medicaid Due to Support Collections
to (h), 408(a)(11)(B),
1931(c)(1), and Families who have received Medicaid under section 1931 of the
1902(a)(10)(A)(i)(I) Act for 3 of the preceding 6 months and lose eligibility as a result
of the Act of collection or increased collection of child or spousal support under part D of title IV of the Act continue to be eligible for the immediately succeeding 4 months.
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Territory:
Citation(s) Groups Covered
A. Mandatory Coverage - Categorically Needy (Continued)
42 CFR 436.116 6. Transitional Medical Assistance
408(a)(11)(A), 1925,
1902(a)(10)(A)(i)(I), Families who have received Medicaid under section 1931 of the
1902(a)(52), and Act for 3 of the preceding 6 months and lose eligibility as a result
1931 of the Act of increased working hours or earned income of the caretaker relative or loss of a time-limited earned income disregard remain eligible for the immediately succeeding 6-month period and, if they meet certain requirements, may remain eligible for the following 6-month period.
1902(a)(10)(A)(i)(IV), 7. Poverty-level related women during pregnancy (and during the
1902(l)(1)(A), 60-day postpartum period beginning on the last day of the
1902(l)(1)(B) and pregnancy) and infants younger than 1 year old.
1902(l)(4)(B) of
the Act The income standard for this group is specified in Supplement 1 to ATTACHMENT 2.6-A.
1902(a)(10)(A)(i)(VI), 8. Poverty-level related children:
1902(l)(1)(C) and
1902(l)(4)(B) of the a. Who have attained 1 year of age, but have not attained 6
Act years of age.
1902(a)(10)(A)(i)(VII), b. Who have attained 6 years of age, but have not attained 19
1902(l)(1)(D) and years of age.
1902(l)(4)(B) of the
Act The income standards for these groups are specified in Supplement 1 to ATTACHMENT 2.6-A.
The resource standards are specified in Supplement 2 to ATTACHMENT 2.6-A.
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Territory:
Citation(s) Groups Covered
A. Mandatory Coverage - Categorically Needy (Continued)
1902(a)(10)(A)(i)(III) 9. Qualified pregnant women and children.
and 1905(n) of the Act
42 CFR 436.120 The following individuals who meet the income and resource requirements of the State’s July 16, 1996 approved AFDC plan:
A pregnant woman whose pregnancy has been medically verified; and
b. A child who is younger than 19 years old.
1902(e)(5) of the Act 10. Extended Eligibility for Pregnant Women.
42 CFR 436.122
A woman who, while pregnant, is eligible for, applied for, and received Medicaid under the approved State plan on the day her pregnancy ends. The woman continues to be eligible, as though she were pregnant, for all pregnancy-related and postpartum medical assistance under the plan for a 60-day period (beginning on the last day of her pregnancy) and for any remaining days in the month in which the 60th day falls.
1902(e)(6) of the Act 11. Continuous Eligibility for Pregnant Women.
42 CFR 436.122
A pregnant woman who would otherwise lose eligibility because of a change in family income is deemed to continue to be eligible for all pregnancy-related and postpartum medical assistance under the plan through the last day of the month in which the 60-day postpartum period ends (which begins on the last day of her pregnancy).
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Territory:
Citation(s) Groups Covered
A. Mandatory Coverage - Categorically Needy (Continued)
1902(e)(4) of the Act 12. Deemed Newborns.
42 CFR 436.124
A child born to a woman who was eligible for an receiving Medicaid (including coverage of an alien for labor and delivery as emergency medical services) for the date of the child’s birth including retroactively. The child is deemed eligible for one year from birth as long as the mother remains eligible or would remain eligible if still pregnant and the child remains in the same household as the mother.
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Territory:
Agency* Citation(s) Groups Covered
Optional Groups Other Than the Medically Needy
42 CFR 436.210 1. Individuals described below who are not described in section
1902(a)(10)(A)(ii)(I) 1902(a)(10)(A)(i) of the Act and who meet the income and
and 1905(a) of the resource requirements of OAA, AB, APTD, or AABD, or the
Act State’s July 16, 1996 AFDC plan, but who do not receive cash assistance.
The State covers all individuals as described above.
The State covers only the following group or groups of individuals:
1902(a)(10)(A)(ii) Aged
and 1905(a) of Blind
the Act Disabled
Parents and Other Caretaker Relatives
Pregnant Women
NOTE: For children under age 21, see B.9.
42 CFR 436.211 2. Individuals described below who are not described in section
1902(a)(10)(A)(ii)(IV) 1902(a)(10)(A)(i) of the Act and who would be eligible for OAA,
and 1905(a) of the Act AB, APTD, or AABD, or who would meet the income and resource requirements of the State’s July 16, 1996 AFDC plan, if they were not in a medical institution.
The State covers all individuals as described above.
The State covers only the following group or groups of individuals:
*Agency that determined eligibility for coverage
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Territory:
Agency* Citation(s) Groups Covered
B. Optional Coverage Groups Other than Medically Needy (Continued)
1902(a)(10)(A)(ii) 3. Individuals who would be eligible for OAA, AB, APTD, AABD,
(III) and 1905(a) or AFDC if coverage under the State’s plan for these programs
of the Act were as broad as permitted under the Act.
42 CFR 436.212
Individuals meeting a broader definition of permanent and total disability.
Individuals meeting a broader definition of blindness.
The following individuals who would be eligible for AFDC if coverage under the State’s AFDC plan in effect as of July 16, 1996 were as broad as allowed under title IV-A of the Act:
Individuals under the age of –
21
20
19
18
Parents and Other Caretaker Relatives
Pregnant Women
Others, as specified below:
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Territory:
Agency* Citation(s) Groups Covered
B. Optional Groups Other Than the Medically Needy (Continued)
42 CFR 436.212 &
1902(e)(2) of the 4. The State deems as eligible those individuals who became
Act, P.L. 99‑272 otherwise ineligible for Medicaid while enrolled in an HMO
(section 9517) P.L. qualified under Title XIII of the Public Health Service Act or
101‑508 (section while enrolled in an entity described in section (iii), (E) or (G) or
4732) and 1903(m) 1903(m)(6) of the Act, or a Competitive Medical Plan (CHP)
(2)(B) of the Act with a Medicare contract under section 1876 of the Act, but who have been enrolled in the HMO or entity for leas than the minimum enrollment period listed below. The HMO or entity must have a risk contract as specified in 42 CFR 434.20(a). Coverage under this section is limited to HMO services and family planning services described in section 1905(a)(4)(C).
The State elects not to guarantee eligibility.
The State elects to guarantee eligibility. The minimum enrollment period is months (not to exceed six).
The State measures the minimum enrollment period from:
The date beginning the period of enrollment in the HMO or other entity, without any intervening disenrollment, regardless of Medicaid eligibility.
The date beginning the period of enrollment in the HMO as a Medicaid patient (including periods when payment is made under this section), without any intervening disenrollment.
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Territory:
Agency* Citation(s) Groups Covered
B. Optional Groups Other Than the Medically Needy (Continued)
The date beginning the last period of enrollment in the HMO as a Medicaid patient (not including periods when payment is made under this section), without any intervening disenrollment of periods of enrollment as a privately paying patient. (A new minimum enrollment period begins each time the individual becomes Medicaid eligible other than under this section.)
1932(a)(4) of the The Medicaid Agency may elect to restrict the disenrollment of
Act Medicaid enrollees of MCOs, PIHIPs, PAHPs, and PCCMs in accordance with the regulations at 42 CFR 438.56.
This requirement applies unless a recipient can demonstrate good cause for disenrolling or if he/she moves out of the entity’s service area or becomes ineligible.
Disenrollment rights are restricted for a period of months (not to exceed 12 months).
During the first three months of each enrollment period the recipient may disenroll without cause. The State will provide notification, at least once per year, to recipients enrolled with such organization of their right to and restrictions of terminating such enrollment.
No restrictions upon disenrollment rights.
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Territory:
Agency* Citation(s) Groups Covered
Optional Groups Other Than the Medically Needy (Continued)
1903(m)(2)(H), In the case of individuals who have become ineligible for Medicaid
1902(a)(52) of for the brief period described in section 1903(m)(2)(H) and who
the Act were enrolled with an entity having a contract under section
P.L. 101‑508 1903(m) when they became ineligible, the Medicaid agency may
(section 4732) elect to reenroll those individuals in the same entity if that entity
42 CFR 438.56(g) still has a contract.
The agency elects to reenroll the above individuals who are ineligible in a month but in the succeeding two months become eligible, into the same entity in which they were enrolled at the time eligibility was lost.
The agency elects not to reenroll above individuals into the same entity in which they were previously enrolled.
*Agency that determined eligibility for coverage
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Territory:
Agency* Citation(s) Groups Covered
B. Optional Groups Other Than the Medically Needy (Continued)
42 CFR 436.217 5. A group or groups of individuals who would be eligible for Medicaid under the plan if they were in a NF or an ICF/MR, who but for the provision of home and community‑based services under a waiver granted under 42 CFR Part 441, Subpart G would require institutionalization, and who will receive home and community‑based services under the waiver. The group or groups covered are listed in the waiver request. This option is effective on the effective date of the State’s section 1915(c) waiver under which this group(s) is covered. In the event an existing 1915(c) waiver is amended to cover this group(s), this option is effective on the effective date of the amendment.
6. The State covers the 42 CFR 436.217 group in item 4 above and covers individuals under a PACE program under section 1934 of the Act using institutional rules in a manner similar to the use of such rules under the 42 CFR 436.217 group.
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Territory:
Agency* Citation(s) Groups Covered
B. Optional Groups Other Than the Medically Needy (Continued)
1902(a)(10)(A)(ii) 7. Individuals who are in institutions for at least 30 consecutive
(V) of the Act days and who are eligible under a special income level. Eligibility begins on the first day of the 30-day period. These individuals meet the income standards specified in Supplement 1 to ATTACHMENT 2.6-A.
The State covers all individuals as described above.
The State covers only the following group or groups of individuals:
Aged
Blind
Disabled
Individuals under the age of –
21
20
19
18
Parents and Other Caretaker Relatives
Pregnant Women
42 CFR 436.220 8. All individuals who are not described in section 1902(a)(10)(A)(i)
1902(a)(10)(A)(ii)(II) of the Act and would meet the income and resource requirements
and 1905(a) of the of the State’s July 16, 1996 AFDC plan if their work-related
Act child care costs were paid their earnings rather than by a State agency as a service expenditure. The State’s AFDC plan deducts work-related child care costs from income to determine the amount of AFDC.
The State covers all individuals as described above.
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Territory:
Agency* Citation(s) Groups Covered
B. Optional Groups Other Than the Medically Needy
(Continued)
1902(a)(10)(A)(ii) The State covers only the following groups or groups of
and 1905(a) of individuals:
The Act
Individuals under the age of—
21
20
19
18
Parents and Other Caretaker Relatives
Pregnant women
42 CFR 436.210 9. a. All individuals who are not described in section 1902(a)(10)
42 CFR 436.222 (A)(i) of the Act, and who meet the income and resource
1902(a)(10)(A)(ii)(I) requirements of the July 16, 1996 AFDC plan, the title IV-E
and 1905(a)(i) of the State plan, the SSI program, or an optional State Supplement;
Act and are under the age indicated below:
21
20
19
18
b. Reasonable classifications of individuals described in (a) above as follows:
(1) Individuals for whom public agencies are assuming full or partial financial responsibility and who are:
(a) In foster homes (and are under the age of ).
(b) In private institutions (and are under the age of ).
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Territory:
Agency* Citation(s) Groups Covered
B. Optional Groups Other Than the Medically Needy
(Continued)
(c) In addition to the group under b.(l)(a) and (b), individuals placed in foster homes or private institutions by private, nonprofit agencies (and are under the age of ).
(2) Individuals in adoptions subsidized in full or part by a public agency (who are under the age of ).
(3) Individuals in nursing facilities (NFs) (who are under the age of ). NF services are provided under this plan.
(4) In addition to the group under (b)(3), individuals in ICF/MRs (who are under the age of ).
(5) Individuals receiving active treatment as inpatients in psychiatric facilities or programs (who are under the age of ). Inpatient psychiatric services for individuals under age 21 are provided under this plan.
(6) Other defined groups (and ages), as specified in Supplement 1 to ATTACHMENT 2.2-A.
l902(a)(10)(A)(ii) 10. A child for whom there is in effect a State adoption assistance
(VIII) of the Act agreement (other than under title IV‑E of the Act), who, as
42 CFR 436.224 determined by the State adoption agency, cannot be placed for adoption without medical assistance because the child has special needs for medical or rehabilitative care, and who before execution of the agreement –
Was eligible for Medicaid under the State's approved Medicaid plan; or
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Territory:
Agency* Citation(s) Groups Covered
Optional Groups Other Than the Medically Needy (Continued)
Would have been eligible for Medicaid if the standards and methodologies of the title IV‑E foster care program were applied rather than the AFDC standards and methodologies.
The State covers these individuals under the age of –
21
20
19
18
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Territory:
Agency* Citation(s) Groups Covered
B. Optional Groups Other Than the Medically Needy (Continued)
42 CFR 436.230 11. Essential spouse of a recipient of:
OAA
AB
APTD
AABD
Spouse is living with and determined essential to the well being of the recipient of OAA, AB, APTD, or AABD, and his (her) needs are taken into consideration in determining the amount of financial assistance.
1902(a)(10)(A)(i) 12. Optional poverty-level related pregnant women and infants,
(IV), 1902(a)(10) younger than 1 year old.
(A)(ii)(IX) and
1902(l)(4)(B) of The following individuals who are not eligible under 1902(a)(10)
the Act (A)(i) of the Act and whose income does not exceed the income level specified in Supplement 1 to ATTACHMENT 2.6-A for a family of the same size, including the woman and unborn child or infant, and who meet the resource standards specified in Supplement 2 to ATTACHMENT 2.6-A.
Women during pregnancy (and during the 60-day postpartum period beginning on the last day of the pregnancy; and
Infants under 1 year of age.
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Territory:
Agency* Citation(s) Groups Covered
B. Optional Groups Other Than the Medically Needy
(Continued)
Optional poverty-level related children:
1902(a)(10)(A)(i)(VI), a. Who have attained 1 year of age but have not attained 6 years
1902(l)(1)(c), and of age.
(4)(B) of the Act
1902(a)(10)(A)(i)(VII), b. Who have attained 6 years of age but have not attained 19
1902(l)(1)(d), and years of age.
(4)(B) of the Act
Supplement 1 to ATTACHMENT 2.6-A specifies the income levels and Supplement 2 to ATTACHMENT 2.6-A specifies the resource levels for these groups.
1902(a)(10)(A)(ii) 14. Individuals –
(X) and 1902(m)(1)
and 1902(m)(2) a. Who are 65 years old or older or are disabled as determined
of the Act under section 1614 of the Act;
b. Whose income does not exceed the income level (established at an amount up to 100 percent of the Federal income poverty level) specified in Supplement 1 to ATTACHMENT 2.6-A for a family of the same size; and
c. Whose resources do not exceed the maximum allowed under SSI or under the State’s medically needy program.
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Territory:
Agency* Citation(s) Groups Covered
B. Optional Groups Other Than the Medically Needy (Continued)
1902(a)(47) and 15. Presumptive Eligibility for Pregnant Women.
1920 of the Act
Pregnant women who are determined by a “qualified provider” (as defined in section 1920(b)(2) of the Act) based on preliminary information, to meet the highest applicable income criteria specified in this plan under ATTACHMENT 2.6-A and are therefore determined to be presumptively eligible for ambulatory prenatal care during a presumptive eligibility period in accordance with section 1920 of the Act.
The presumptive period begins on the day that the determination is made. If an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility was made, the presumptive period ends on the day that the Medicaid agency makes a determination of eligibility based on that application. If an application is not filed by the last day of the month following the month the determination of presumptive eligibility was made, the presumptive period ends on that last day.
Presumptive eligibility for pregnant women is limited to no more than one period per pregnancy.
The Medicaid agency requires that a written application be completed and signed by the woman.
Yes
No
1902(a)(10)(A)(ii) 16. Individuals who would be eligible for Medicaid under the plan if
(VII) of the Act they were in a medical institution, who are terminally ill, and who receive hospice care in accordance with a voluntary election described in section 1905(o) of the Act.
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Territory:
Citation(s) Groups Covered
Optional Groups Other Than the Medically Needy (Continued)
The State covers all individuals as described above.
The State covers only the following group or groups of individuals:
Aged
Blind
Disabled
Individuals under the age of—
21
20
19
18
Parents and Other Caretaker Relatives
Pregnant Women
1902(a)(10)(F) and 17. Individuals entitled to elect COBRA continuation coverage and
and 1902(u)(1) coverage and whose income as determined under section 1612 of
of the Act the Act for purposes of the SSI program, is no more than 100
42 CFR 436.229 percent of the Federal poverty level, whose resources are no more than twice the SSI resource limit for an individual, and for whom the State determines that the cost of COBRA premiums is likely to be less than the Medicaid expenditures for an equivalent set of services. See Supplement 11 to ATTACHMENT 2.6-A.
1902(a)(10)(A)(ii) 18. Optional Targeted Low Income Children younger than age 19
(XIV) and 1905(u) who:
(2)(B) of the Act
42 CFR 436.229 a. are not eligible for Medicaid under any other mandatory or optional eligibility group or eligible as medically needy (without spenddown liability);
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Territory:
Citation Groups Covered
Optional Coverage Other Than the Medically Needy (Continued)
b. would not have been eligible for Medicaid under the policies in the State’s Medicaid plan as in effect on March 31, 1997 (but taking into account the expansion of age eligibility provided for in 1902(l)(1)(D));
c. are not covered under a group health plan or other group health insurance (as such terms are defined in section 2791 of the Public Health Service Act) other than under a health insurance program in operation before July 1, 1997 offered by a State or territory which receives no Federal funds for the program; and
d. have family income at or below:
200 percent of the Federal Poverty Level (FPL) for the size family size involved, as revised annually in the Federal Register; or
percentage of the Federal Poverty Level, which is in excess of the "Medicaid applicable income level" (as defined in section 2110(b)(4) of the Act) but by no more than 50 percentage points.
The State covers:
All children described above who are under age (18, 19) with family income at or below percent of the Federal poverty level.
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Territory:
Citation Groups Covered
B. Optional Groups Other Than the Medically Needy (Continued)
The following reasonable classifications of children described above who are under age (18, 19) with family income at or below the percent of the Federal poverty level specified for the classification:
(ADD NARRATIVE DESCRIPTION(S) OF THE REASONABLE CLASSIFICATION(S) AND THE PERCENT OF THE FEDERAL POVERTY LEVEL USED TO ESTABLISH ELIGIBILITY FOR EACH CLASSIFICATION.)
1902(e)(12) of the 19. Continuous Eligibility for Children.
Act
A child under age (not to exceed age 19) who has been determined eligible under section 1902(a)(10)(A) of the Act is deemed to be eligible for a total of months (not to exceed 12 months) regardless of changes in circumstances other moving out of the State or than attainment of the maximum age stated above, until the earlier of:
The end of the period (not to exceed 12 months) of continuous eligibility; or
The time that the individual exceeds that age.
1902(a)(47) and 20. Presumptive Eligibility for Children
1920A of the Act
42 CFR 436.1100 Children under age (no more than 19) who are determined by
through 436.1102 a "qualified entity" (as defined in 1920A(b)(3)(A) of the Act) based on preliminary information, to meet the highest applicable income criteria specified in this plan under ATTACHMENT 2.6-A and are therefore determined to be presumptively eligible during a presumptive eligibility period in accordance with 1902A of the Act.
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Territory:
Citation Groups Covered
B. Optional Groups Other Than the Medically Needy (Continued)
The presumptive period begins on the day that the determination is made. If an application for Medicaid is filed on the child's behalf by the last day of the month following the month in which the determination of presumptive eligibility was made, the presumptive period ends on the day that the Medicaid agency makes a determination of eligibility based on that application. If an application is not filed on the child's behalf by the last day of the month following the month the determination of presumptive eligibility was made, the presumptive period ends on that last day.
The following types of “qualified entities” are used to determine presumptive eligibility.
The State requires that a written application be completed and signed by the child’s parent or other representative:
Yes
No
1902(a)(10)(A)(ii) 21. Individuals not described in 1902(a)(10)(A)(i) of the Act who are
(XII) and 1902(z) infected with tuberculosis whose income and resources do not
of the Act exceed the maximum amounts described in Supplement 14 to ATTACHMENT 2.6-A.
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Territory:
Citation Groups Covered
B. Optional Groups Other Than the Medically Needy (Continued)
1902(a)(10)(A)(ii) 22. BBA Work Incentives Eligibility Group
(XIII) of the Act
Individuals with a disability whose net family income is below 250 percent of the Federal poverty level for a family of the size involved and who, except for earned income, meet all criteria for receiving benefits under the SSI program. See page 14a of ATTACHMENT 2.6‑A.
1902(a)(10)(A)(ii) 23. TWWIIA Basic Coverage Group
(XV) of the Act
Individuals with a disability at least 16 but less than 65 years of age whose income and resources do not exceed a standard established by the State. See page 14b of ATTACHMENT 2.6‑A.
1902(a)(10)(A)(ii) 24. TWWIIA Medical Improvement Group
(XVI) of the Act
Employed individuals at least 16 but less than 65 years of age with a medically improved disability whose income and resources do not exceed a standard established by the State. See page 14f of ATTACHMENT 2.6A.
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Territory:
Citation Groups Covered
B. Optional Groups Other Than the Medically Needy (Continued)
1902(a)(10)(A)(ii) 25. Family Opportunity Act
(XIX) of the Act
Children who have not attained 19 years of age, who would be considered disabled under section 1614(a)(3)(C) of the Act, and whose family income meets the standard described on Page 14h of ATTACHMENT 2.6-A.
Beginning with the effective date of its plan amendment, the State covers all children eligible under this group, as described below; or
In the case of the second, third, and fourth quarters of fiscal year 2007, the State covers children who were born on or after January 1, 2001, or who were born on or after the following earlier date ______________.
In the case of each quarter of fiscal year 2008, the State covers children who were born on or after October 1, 1995, or who were born on or after the following earlier date ___________.
In the case of each quarter of fiscal year 2009 and each quarter of any fiscal year thereafter, the State covers children who were born after October 1, 1989.
TN No: Approval Date Effective Date
Supersedes TN No.
Revision: ATTACHMENT 2.2‑A
Page 18g
Territory:
Citation Groups Covered
Optional Groups Other Than the Medically Needy (Continued)
1902(a)(10)(A) 26. Certain Women with Breast or Cervical Cancer
(ii)(XVIII) and
1902(aa) of the Act The State covers medical assistance for women who:
a. Have been screened for breast or cervical cancer under the Centers for Disease Control and Prevention, Breast and Cervical Cancer Early Detection Program established under title XV of the Public Health Service Act in accordance with the requirements of section 1504 of that Act;
b. Need treatment for breast or cervical cancer, including a pre-cancerous condition of the breast or cervix;
c. Are not otherwise covered under creditable coverage, as defined in section 2701(c) of the Public Health Service Act, but applied without regard to paragraph (1)(F) of such section;
d. Are not eligible for Medicaid under any mandatory categorically needy eligibility group described in 1902(a)(10)(A)(i) of the Act; and
e. Have not attained age 65.
TN No: Approval Date Effective Date
Supersedes TN No.
Revision: ATTACHMENT 2.2‑A
Page 18h
Territory:
Citation Groups Covered
C. Optional Groups Other Than the Medically Needy (Continued)
1920B and 1902(aa) ___ 27. Presumptive Eligibility for Certain Women with Breast or
of the Act Cervical Cancer
The State covers medical assistance during a presumptive eligibility period for women who are determined by a “qualified entity” (as defined in section 1920B(b)(2) of the Act) based on preliminary information, to be woman described in 1902(aa) the Act related to certain breast and cervical cancer patients.
The State limits the classes of entities that may become qualified entities as follow:
The presumptive period begins on the date that a qualified entity determines the woman to be eligible. The period ends on the date that the Medicaid agency makes a determination with respect to the woman’s eligibility for Medicaid. However, if the woman does not apply for Medicaid (or a Medicaid application was not made on her behalf) by the last day of the month following the month in which the determination of presumptive eligibility was made, the presumptive period ends on that last day.
TN No: Approval Date Effective Date
Supersedes TN No.
Revision: ATTACHMENT 2.2‑A
Page 19
Territory:
Agency* Citation(s) Groups Covered
C. Optional Coverage of the Medically Needy
42 CFR 436.301 This plan includes the medically needy.
1902(a)(10)(C) of
the Act No.
Yes. This plan covers:
1902(a)(10)(C)(ii)(II) 1. Pregnant women during the course of their pregnancy who, except
of the Act and 42 for income and/or resources, would be eligible as categorically
CFR 436.301(b)(1)(i) needy under 1902(a)(10)(A) of the Act.
1902(e)(5) of the Act 2. Women who, while pregnant, are eligible for, applied for, and
42 CFR 436.301(b) received Medicaid as medically needy under the approved State
(1)(iv) plan on the date the pregnancy ends. These women continue to be eligible, as though they were pregnant, for all pregnancy‑related and postpartum medical assistance, under the plan for a 60‑day period (beginning with the date the pregnancy ends), and any remaining days in the month in which the 60th day falls.
1902(a)(10)(C)(ii)(I) 3. Individuals under age 18 who, but for income and/or resources,
of the Act and 42 would be eligible as mandatory categorically needy under section 1902(a)(10)(A)(i) of the Act.
TN No: Approval Date Effective Date
Supersedes TN No.
Revision: ATTACHMENT 2.2‑A
Page 20
Territory:
Agency* Citation(s) Groups Covered
C. Optional Coverage of the Medically Needy (Continued)
1902(e)(4) of the 4. A child born to a woman who is eligible for and receiving
Act and 42 CFR Medicaid as medically needy for the date of the child’s birth,
436.301(b)(1)(iii) including retroactively. The child is deemed to have applied and been found eligible for Medicaid for the date of birth and remains eligible for one year from birth as long as the mother remains eligible, or would remain eligible if still pregnant, and the child remains in the same household as the mother.
42 CFR 436.308 5. Medically Needy Children
1902(a)(10)(C)(i)
of the Act a. Individuals who are financially eligible as medically needy, are not eligible in accordance with section 1902(a)(10)(A) of the Act, are not described in section C.3. above and who are under the age of—
21
20
19
18 or under age 19 who are full‑time students in a secondary school or in the equivalent level of vocational or technical training
b. Reasonable classifications of financially eligible individuals under the age of 21, 20, 19, or 18 as specified below:
(1) Individuals for whom public agencies are assuming full or partial responsibility and who are:
(a) In foster homes (and are under the age of _____).
TN No: Approval Date Effective Date
Supersedes TN No.
Revision: ATTACHMENT 2.2‑A
Page 21
Territory:
Agency* Citation(s) Groups Covered
C. Optional Coverage for the Medically Needy (Continued)
(b) In private institutions (and are under the age of _____).
(c) In addition to the group under b.(l)(a) and (b), individuals placed in foster homes or private institutions by private, nonprofit agencies (and are under the age of ).
(2) Individuals in adoptions subsidized in full or part by a public agency (who are under the age of ).
(3) Individuals in nursing facilities (NFs) (who are under the age of ). NF services are provided under this plan.
(4) In addition to the group under (b)(3), individuals in ICF/MRs (who are under the age of ).
(5) Individuals receiving active treatment as inpatients in psychiatric facilities or programs (who are under the age of ). Inpatient‑psychiatric services for individuals under age 21 are provided under this plan.
(6) Other defined groups (and ages), as specified in Supplement 1 to ATTACHMENT 2.2‑A.
TN No: Approval Date Effective Date
Supersedes TN No.
Revision: ATTACHMENT 2.2‑A
Page 22
Territory:
Agency* Citation(s) Groups Covered
C. Optional Coverage for the Medically Needy (Continued)
42 CFR 436.310 6. Parents and Other Caretaker Relatives
42 CFR 436.320 7. Aged Individuals
42 CFR 436.321 8. Blind Individuals
42 CFR 436.322 9. Disabled Individuals
TN No: Approval Date Effective Date
Supersedes TN No.
Revision: ATTACHMENT 2.2‑A
Page 23
Territory:
Agency* Citation(s) Groups Covered
D. Optional Coverage – Qualified Medicare Beneficiaries
1902(a)(10)(E)(i) 1. Qualified Medicare Beneficiaries –
and 1905(p)(4)
of the Act a. Who are entitled to hospital insurance benefits under Medicare Part A, (but not pursuant to an enrollment under section 1818A of the Act);
b. Whose income does not exceed the percent of the Federal poverty level specified in Supplement 1 to ATTACHMENT 2.6-A; and
c. Whose resources do not exceed twice the maximum standard under SSI.
1905(p)(3) of the Act (Medical assistance for this group is limited to Medicare cost-sharing as defined in section 1905(p)(3) of the Act).
1902(a)(10)(E)(ii) 2. Qualified Disabled and Working Individuals –
and 1905(s) of
the Act a. Who are entitled to hospital insurance benefits under Medicare Part A under section 1818A of the Act;
b. Whose income does not exceed 200 percent of the Federal poverty level; and
c. Whose resources do not exceed twice the maximum standard under SSI.
d. Who are not otherwise eligible for medical assistance under title XIX of the Act.
1905(p)(3)(A)(i) (Medical assistance for this group is limited to cost-sharing as
of the Act defined in section 1905(p)(3)(A)(i) of the Act.)
TN No: Approval Date Effective Date
Supersedes TN No.
Revision: ATTACHMENT 2.2‑A
Page 24
Territory:
Agency* Citation(s) Groups Covered
D. Optional Coverage – Qualified Medicare Beneficiaries
1902(a)(10)(E)(iii) 3. Specified Low-Income Medicare Beneficiaries –
and 1905(p)(4)
of the Act a. Who are entitled to hospital insurance benefits under Medicare Part A (but not pursuant to an enrollment under section 1818A of the Act);
Whose income is greater than 100 percent but less than 120 percent of the Federal poverty level; and
Whose resources do not exceed twice the maximum standard under SSI.
Medical assistance for this group is limited to Medicare Part B premiums under section 1839 of the Act.)
1902(a)(10)(E)(iv) 4. Qualifying Individuals –
and 1905(p)(4)
of the Act a. Who are entitled to hospital insurance benefits under Medicare Part A (but not pursuant to an enrollment under section 1818A of the Act);
b. Whose income is greater than 120 percent but less than 135 percent of the Federal poverty level;
Whose resources do not exceed twice the maximum standard under SSI;
Who are not otherwise eligible for medical assistance under title XIX of the Act.
(Medical assistance for this group is limited to Medicare Part B premiums under section 1839 of the Act)
TN No: Approval Date Effective Date
Supersedes TN No.
Revision: SUPPLEMENT 1 TO
ATTACHMENT 2.2-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
REASONABLE CLASSIFICATIONS OF INDIVIDUALS UNDER
THE AGE OF 21, 20, 19, OR 18
TN No: Approval Date Effective Date
Supersedes TN No.
Revision: SUPPLEMENT 2 TO
ATTACHMENT 2.2-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
A. DEFINITION OF BLINDNESS IN TERMS OF OPHTHALMIC MEASUREMENT
TN No: Approval Date Effective Date
Supersedes TN No.
Revision: SUPPLEMENT 2 TO
ATTACHMENT 2.2-A
Page 2
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
B. DEFINITION OF PERMANENT AND TOTAL DISABILITY
TN No: Approval Date Effective Date
Supersedes TN No.
Revision: SUPPLEMENT 3 TO
ATTACHMENT 2.2-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
METHOD FOR DETERMINING COST EFFECTIVENESS
OF CARING FOR CERTAIN DISABLED CHILDREN AT HOME
TN No: Approval Date Effective Date
Supersedes TN No.
| File Type | application/msword |
| File Title | Revision: |
| Author | CMS |
| Last Modified By | CMS |
| File Modified | 2008-05-28 |
| File Created | 2008-04-25 |