Exhibit F and G

Revision: ATTACHMENT 2.6‑A

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

GROUPS COVERED AND AGENCIES RESPONSIBLE

FOR ELIGIBILITY DETERMINATION

Agency Citation(s) Groups Covered

A. General Conditions of Eligibility

Each individual covered under the plan:

42 CFR Part 435, 1. Is financially eligible (using the methods and standards described

Subpart G in Parts B and C of this Attachment) to receive services.

42 CFR Part 435, 2. Meets the applicable non-financial eligibility conditions.

Subpart F

a. For the categorically needy:

1. For AFDC‑related individuals (all groups except as specified under items A.2.a.(ii) - (ix) below), meets the non‑financial criteria of the State’s AFDC plan in effect as of July 16, 1996.

2. For SSI‑related individuals, meets the non‑financial eligibility conditions of the SSI program or more restrictive SSI‑related categorically needy criteria.

1902(l) of the (iii) For financially eligible pregnant women, infants or

Act children covered under sections 1902(a)(10)(A)(i)(IV), 1902(a)(10)(A)(i)(VI), 1902(a)(10)(A)(i)(VII), or 1902(a)(10)(A)(ii)(IX) of the Act, meets the non‑

financial criteria of section 1902(1) of the Act.

1902(m) of the (iv) For financially eligible aged or disabled individuals

Act covered under section 1902(a)(10)(A)(ii)(X) of the Act, meets the non‑financial criteria of section 1902(m) of the Act.

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State:

Citation(s) Condition or Requirement

1902(a)(10)(A)(ii)(VIII) (v) For children receiving State adoption assistance who

of the Act are financially eligible under section 1902(a)(10)(A) (ii)(VIII) of the Act, meets the non-financial eligibility criteria of that section.

1902(z) of the Act (vi) For tuberculosis-infected individuals financially eligible under section 1902(a)(10)(A)(ii)(XII) of the Act, meets the non-financial eligibility criteria of section 1902(z).

1905(u)(2) of the Act (vii) For optional targeted low-income children financially eligible under section 1902(a)(10)(A)(ii)(XIV) of the Act, meets the non-financial eligibility criteria of section 1905(u)(2)(B).

1905(w) of the Act (viii) For independent foster care adolescents financially eligible under 1902(a)(10)(A)(ii)(XVII) of the Act, meets the non-financial eligibility criteria of section 1905(w).

1902(aa) of the Act (ix) For women with breast or cervical cancer financially eligible under section 1902(a)(10)(A)(ii)(XVIII) of the Act, meets the non-financial criteria of section 1902(aa).

2. For the medically needy, meets the non‑financial eligibility conditions of 42 CFR Part 435 listed in A.2.a(i) or (ii) above.

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State:

Citation(s) Condition or Requirement

1902(a)(10)(E)(i) and c. For financially eligible Qualified Medicare Beneficiaries

1905(p) of the Act covered under section 1902(a)(10)(E)(i) of the Act, meets the non‑financial eligibility criteria of section 1905(p) of the Act.

1902(a)(10)(A)(E)(ii) d. For financially eligible Qualified Disabled and Working

and 1905(s) of the Individuals covered under section 1902(a)(10)(E)(ii) of the

Act Act, meets the non‑financial eligibility criteria of section 1905(s) of the Act.

1902(a)(10)(E)(iii) and e. For financially eligible Specified Low-Income Medicare

and 1905(p) of the Act Beneficiaries covered under section 1902(a)(10)(E)(iii) of the Act, meets the non‑financial eligibility criteria of section 1905(p) of the Act.

1902(a)(10)(E)(iv) and f. For financially eligible Qualifying Individuals covered under

and 1905(p) of the Act section 1902(a)(10)(E)(iii) of the Act, meets the non‑financial eligibility criteria of section 1905(p) of the Act.

42 CFR 435.406 3. Is residing in the United States and‑‑

a. Is a citizen or national of the United States;

b. Is a qualified alien (QA) as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) as amended, and the QA’s eligibility is required by section 402(b) of PRWORA as amended, and is not prohibited by section 403 of PRWORA as amended;

c. Is a qualified alien subject to the 5-year bar described in section 403 of PRWORA, so that eligibility is limited to treatment of an emergency medical condition or as defined in section 401 of PRWORA;

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State:

Citation(s) Condition or Requirement

d. Is a non-qualified alien, so that eligibility is limited to treatment of an emergency medical condition or as defined in section 401 of PRWORA; or

e. Is a qualified alien (QA) whose eligibility is authorized under section 402(b) of PRWORA as amended, and is not prohibited by section 403 of PRWORA as amended.

State covers all authorized QAs.

State does not cover authorized QAs.

42 CFR 431.52 4. Is a resident of the State with the intent to remain permanently or

and 435.403 for an indefinite period, regardless of whether the individual

1902(b) of the Act maintains the residence permanently or at a fixed address, is absent from the State temporarily and intends to return when the purpose of the absence is accomplished, is placed by the State in an out-of-state institution, or receives a title IV-E payment from another State.

State has interstate residency agreement with the following States:

State has open agreement(s).

Not applicable; no residency requirement.

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State:

Citation(s) Condition or Requirement

42 CFR 435.1008 5. a. Is not an inmate of a public institution. Public institutions

1905(a) of the Act do not include medical institutions, nursing facilities and intermediate care facilities for the mentally retarded, or publicly operated community residences that serve no more than 16 residents, or certain child care institutions.

42 CFR 435.1008, b. Is not a patient under age 65 in an institution for mental

1905(a) of the Act diseases except as an inpatient under age 22 receiving active treatment in an accredited psychiatric facility or program.

Not applicable with respect to individuals under age 22 in psychiatric facilities or programs. Such services are not provided under the plan.

42 CFR 433.145, 6. Is required, as a condition of eligibility, to assign his or her own

1912 of the Act rights, or the rights of any other person who is eligible for Medicaid and on whose behalf the individual has legal authority to execute an assignment to medical support and payments for medical care from any third party. (Medical support is defined as support specified as being for medical care by a court or administrative order.)

An applicant or recipient must also cooperate in establishing the paternity of any eligible child and in obtaining medical support and payments for himself or herself and any other person who is eligible for Medicaid and on whose behalf the individual can make an assignment; except that individuals described in section 1902(l)(1)(A) of the Social Security Act (pregnant women and women in the post‑partum period) are exempt from these requirements involving paternity and obtaining support. Any individual may be exempt from the cooperation requirements by demonstrating good cause for refusing to cooperate.

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State:

Citation(s) Condition or Requirement

An applicant or recipient must also cooperate in identifying any third party who may be liable to pay for care that is covered under the State plan and providing information to assist in pursuing these third parties. Any individual may be exempt from the cooperation requirements by demonstrating good cause for refusing to cooperate.

Assignment of rights is automatic because of State law.

42 CFR 435.910 7. Is required, as a condition of eligibility, to furnish his/her Social 1137(a)(1) and (f) Security account number (or numbers, if he/she has more than

of the Act one number), with the exception of aliens seeking coverage for the treatment of an emergency medical condition under section 1903(v)(2) of the Act or individuals who, because of well-established religious objections as defined in 42 CFR 435.910(h), refuse to obtain a Social Security account number.

1902(c)(2) of the Act 8. Is not required to apply for AFDC benefits under title IV‑A as a condition of applying for, or receiving, Medicaid if the individual is a pregnant woman, infant, or child that the State elects to cover under sections 1902(a)(10)(A)(i)(IV) and 1902(a)(10)(A)(ii)(IX) of the Act.

1902(e)(10)(A) and 9. Is not required, as an individual child or pregnant woman; to

1902(e)(10)(B) of meet requirements under section 402(a)(43) of the Act to be in

the Act certain living arrangements. (Prior to terminating AFDC individuals who do not meet such requirements under a State's AFDC plan, the agency determines if they are otherwise eligible under the State's Medicaid plan.)

1906 of the Act 10. Is required to apply for enrollment in an employer-based cost‑effective group health plan, if such plan is available to the individual. Enrollment is a condition of eligibility except for the individual who is unable to enroll on his/her own behalf (failure of a parent to enroll a child does not affect a child's eligibility).

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State:

Citation(s) Condition or Requirement

B. Post Eligibility Treatment of Institutionalized Individual’s Income

1924 of the Act 1. The following monthly amounts for personal needs are

42 CFR 435.725 deducted from total monthly income in the application of an

42 CFR 435.733 institutionalized individual’s or couple’s income to the cost of

42 CFR 435.832 institutionalized care:

Personal Needs Allowance (PNA) of not less than $30 for individuals and $60 for couples for all institutionalized persons.

1. Aged, blind, disabled:

Individuals $

Couples $

For the following persons with greater need:

Supplement 12 to ATTACHMENT 2.6-A describes the greater need; describes the basis or formula for determining the deductible amount when a specific amount is not listed above; lists the criteria to be met; and, where appropriate, identifies the organizational unit which determines that a criterion is met.

2. AFDC related:

Individuals $

Couples $

For the following persons with greater need:

Supplement 12 to ATTACHMENT 2.6-A describes the greater need; describes the basis or formula for determining the deductible amount when a specific amount is not listed above; lists the criteria to be met; and, where appropriate, identifies the organizational unit which determines that a criterion is met.

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State:

Citation(s) Condition or Requirement

B. Post Eligibility Treatment of Institutionalized Individual’s Income

(Continued)

1924 of the Act 2. In addition to the amounts under item 1, the following monthly amounts are deducted from the remaining income of an institutionalized individual with a community spouse:

a. The monthly income allowance for the community spouse, calculated using the formula in section 1924(d)(2), is the amount by which the maintenance needs standard exceeds the community spouse’s income. The maintenance needs standard cannot exceed the maximum prescribed in section 1924(d)(3)(C). The maintenance needs standard consists of a poverty level component plus an excess shelter allowance.

The poverty level component is calculated using the applicable percentage (set out in section 1924(d)(3)(B) of the Act) of the official poverty level.

The poverty level component is calculated using a percentage greater than the applicable percentage, equal to %, of the official poverty level (still subject to maximum maintenance needs standard).

The maintenance needs standard for all community spouses is set at the maximum permitted by section 1924(d)(3)(C). Except that, when applicable, the State will set the community spouse’s monthly income allowance at the amount by which exceptional maintenance needs, established at a fair hearing, exceed the community spouse’s income, or at the amount of any court-ordered support.

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State:

Citation(s) Condition or Requirement

2. Post Eligibility Treatment of Institutionalized Individual’s Income

(Continued)

In determining any excess shelter allowance, utility expenses are calculated using:

the standard utility allowance under section 5(e) of the Food Stamp Act of 1977; or

the actual unreimbursable amount of the community spouse’s utility expenses less any portion of such amount included in condominium or cooperative charges.

2. The monthly income allowance for other dependent family members living with the community spouse is:

one-third of the amount by which the poverty level component (calculated under section 1924(d)(3)(A)(i) of the Act, using the applicable percentage specified in section 1924(d)(3)(B) ) exceeds the dependent family member’s monthly income.

a greater amounted calculated as follows:

The following definition is used in lieu of the definition provided by the Secretary to determine the dependency of family members under section 1924(d)(1):

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State:

Citation(s) Condition or Requirement

B. Post Eligibility Treatment of Institutionalized Individual’s Income (Continued)

c. Amounts for health care expenses described below that are incurred by and for the institutionalized individual and are not subject to payments by a third party:

1. Medicaid, Medicare, and other health insurance premiums, deductibles, or coinsurance charges, or copayments.

2. Necessary medical or remedial care recognized under State law but not covered under the State plan. (Reasonable limits on amounts are described in Supplement 3 to ATTACHMENT 2.6-A.)

42 CFR 435.725 3. In addition to any amounts deductible under the items above, the

42 CFR 435.733 following monthly amounts are deducted from the remaining

42 CFR 435.832 monthly income of an institutionalized individual or an institutionalized couple:

a. An amount for the maintenance needs of each member of a family living in the institutionalized individual’s home with no community spouse living in the home. The amount must be based on a reasonable assessment of need but must not exceed the higher of the:

• AFDC level in effect under the State’s plan as of July 16, 1996; or

• Medically needy level:

(Check one)

AFDC Levels in Supplement 1 to ATTACHMENT

2.6-A

Medically needy level in Supplement 1 to ATTACHMENT 2.6-A

Other: $

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State:

Citation(s) Condition or Requirement

B. Post Eligibility Treatment of Institutionalized Individual’s Income (Continued)

b. Amounts for health care expenses described below that have not been deducted under 3.c. above (i.e., for an institutionalized individual with a community spouse), are incurred by and for the institutionalized individual or institutionalized couple, and are not subject to the payment by a third party:

1. Medicaid, Medicare, and other health insurance premiums, deductibles, or coinsurance charges, or copayments.

2. Necessary medical or remedial care recognized under State law but not covered under the State plan. (Reasonable limits on amount are described in Supplement 3 to ATTACHMENT 2.6-A.)

42 CFR 435.725 4. At the option of the State, as specified below, the following is

42 CFR 435.733 deducted from any remaining monthly income of an

42 CFR 435.832 institutionalized individual or an institutionalized couple:

A monthly amount for the maintenance of the home of the individual or couple for not longer than 6 months if a physician has certified that the individual, or one member of the institutionalized couple, is likely to return to the home within that period:

No.

Yes (the applicable amount is designated on page 4e)

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State:

Citation(s) Condition or Requirement

Amount for maintenance of home is: $ .

Amount for maintenance of home is the actual maintenance costs not to exceed $ .

Amount for maintenance of home is deductible when countable income is determined under section 1924(d)(1) of the Act only if the individual’s home and the community spouse’s home are different.

Amount for maintenance of home is not deductible when countable income is determined under section 1924 (d)(1) of the Act.

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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s) Condition or Requirement

42 CFR 435.811, C. FINANCIAL ELIGIBILITY

42 CFR 435.831,

42 CFR 435.840, and Depending on whether the individual is being considered for an

42 CFR 435.845 AFDC-related or SSI-related Medicaid eligibility group, the income and resource levels and methods for determining countable income and resources in either the State’s AFDC plan in effect on July 16, 1996 or the SSI program apply, unless this plan provides for more restrictive levels and methods than SSI for SSI recipients under section 1902(f) of the Act, more liberal methods under section 1902(r)(2) of the Act, or more restrictive or liberal methods under section 1931 of the Act, as specified below.

For individuals who are not AFDC or SSI recipients in a non‑section 1902(f) State and those who are deemed to be cash assistance recipients, the financial eligibility requirements specified in this section C apply.

• Supplement 1 to ATTACHMENT 2.6‑A specifies the income eligibility standards for mandatory categorically needy, optional categorically needy, and medically needy eligibility groups.

• Supplement 2 to ATTACHMENT 2.6‑A specifies the resource eligibility standards for mandatory categorically needy, optional categorically needy, and medically needy eligibility groups.

• Supplement 3 to ATTACHMENT 2.6-A specifies the reasonable limits on amounts of necessary medical or remedial care not covered under Medicaid.

• Supplement 4 to ATTACHMENT 2.6-A specifies the methods for determining income eligibility, used by States that have more restrictive methods than SSI, permitted under section 1902(f) of the Act.

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• Supplement 5 to ATTACHMENT 2.6-A specifies the methods for determining resource eligibility, used by States that have more restrictive methods than SSI, permitted under section 1902(f) of the Act.

• Supplement 5a to ATTACHMENT 2.6-A specifies the methods for determining resource eligibility for individuals with incomes related to the Federal poverty level, used by States that have more restrictive methods than SSI, permitted under section 1902(f) of the Act.

• Supplement 6 to Attachment 2.6-A specifies the standards for optional State supplementary payments.

• Supplement 7 to ATTACHMENT 2.6‑A specifies the income standards for 1902(f) States for categorically needy aged, blind, or disabled individuals who are covered under requirements more restrictive than SSI.

• Supplement 8 to ATTACHMENT 2.6‑A specifies the resource standards for 1902(f) States for categorically needy aged, blind, or disabled individuals who are covered under requirements more restrictive than SSI.

• Supplement 8a to ATTACHMENT 2.6‑A specifies more liberal methods of treating income under section 1902(r)(2) of the Act, used by States that have less restrictive methods than the cash assistance programs.

• Supplement 8b to ATTACHMENT 2.6‑A specifies more liberal methods of treating resources under section 1902(r)(2) of the Act, used by States that have less restrictive methods than the cash assistance programs.

• Supplement 8c to ATTACHMENT 2.6-A specifies requirements related to the DRA long term care insurance partnership programs.

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State:

Citation Condition or Requirement

• Supplement 9b to ATTACHMENT 2.6-A specifies the criteria used for transfer of assets under section 1917(c) of the Act, which affects the eligibility of institutionalized individuals on or after February 8, 2006.

• Supplement 10 to ATTACHMENT 2.6-A specifies the criteria used to exclude the assets transferred into a Medicaid trust because of undue hardship for categorically needy individuals, as permitted under section 1902(d)(4) of the Act.

• Supplement 11 to ATTACHMENT 2.6-A specifies cost effectiveness methodology for COBRA continuation beneficiaries.

• Supplement 12 to ATTACHMENT 2.6-A specifies the variations from the basic personal needs allowance under section 1902(a)(50) of the Act. It also specifies the AFDC covered groups and the income and resource eligibility criteria for low-income families under section 1931 of the Act.

• Supplement 13 to ATTACHMENT 2.6-A specifies the treatment of available income and resources for certain institutionalized spouses with a community spouse under section 1924 of the Act.

• Supplement 14 to ATTACHMENT 2.6 ‑A specifies the income and resource requirements used by States for determining eligibility of Tuberculosis‑infected individuals whose eligibility is determined under section 1902(z)(1) of the Act.

• Supplement 15 to ATTACHMENT 2.6-A specifies disqualification for long term care assistance for individuals with substantial home equity.

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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s) Condition or Requirement

1902(r)(2) of the 1. Methods of Determining Income

Act

a. AFDC‑related individuals (except for individuals eligible under section 1931 of the Act and poverty-level related pregnant women, infants, and children).

(1) In determining countable income for AFDC‑related individuals, the following methods are used:

(a) The methods under the State's approved AFDC plan in effect on July 16, 1996 only; or

(b) The methods under the State's approved AFDC plan in effect on July 16, 1996 and/or any more liberal methods described in Supplement 8a to ATTACHMENT 2.6-A.

Note: For individuals eligible under section 1931 of the Act, see Supplement 12 to ATTACHMENT 2.6-A. For poverty-level related pregnant women, infants, and children, see e of this section.

1902(a)(17)(D) of the Act (2) In determining financial responsibility of relatives and

42 CFR 435.602 other individuals, the Medicaid agency considers only the income of spouses living in the same household as available to spouses and the income of parents as available to children living with parents until the children become 21, with the specified exceptions for AFDC-related and SSI-related eligibility groups.

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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s) Condition or Requirement

1902(e)(6) of the (3) Agency continues to treat women eligible under the

Act provisions of eligible under the provisions of section 1902(a)(10) of the Act as eligible, without regard to any changes in income of the family of which she is a member, for the 60‑day period after her pregnancy ends and any remaining days in the month in which the 60th day falls.

42 CFR 435.601 b. Aged individuals. In determining countable income for aged

42 CFR 435.831 individuals, including aged individuals with incomes up to

1902(m)(1)(B), the Federal poverty level described in section 1902(m)(1) of

1902(m)(4), and the Act, the following methods are used.

1902(r)(2) of the Act

The methods of the SSI program only.

The methods of the SSI program and/or any more liberal methods described in Supplement 8a to ATTACHMENT 2.6‑A.

For individuals other than optional state supplement recipients, more restrictive methods than are used by the SSI program. Any more restrictive methods are described in Supplement 4 to ATTACHMENT 2.6‑A.

NOTE: More restrictive methods cannot be applied to aged individuals eligible under section 1902(m)(1) of the Act.

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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s) Condition or Requirement

For institutional couples, the methods specified under section 1611(e)(5) of the Act.

For optional State supplement recipients under 435.232, income methods more liberal than SSI, as specified in Supplement 8a to ATTACHMENT 2.6‑A.

For optional State supplement recipients under 435.234 in section 1902(f) States and SSI criteria States without section 1616 or 1634 agreements—

SSI methods only.

SSI methods and/or any more liberal methods than SSI described in Supplement 8a to ATTACHMENT 2.6-A.

Methods more restrictive than SSI. More restrictive methods are described in Supplement 4 to ATTACHMENT 2.6-A.

1902(a)(17)(D) In determining relative financial responsibility, the agency

of the Act considers only the income of spouses living in the same

42 CFR 435.602 household as available to spouses.

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State:

Citation Condition or Requirement

42 CFR 435.601, c. Blind individuals. In determining countable income for

42 CFR 435.831, and blind individuals, the following methods are used:

1902(r)(2) of the Act

The methods of the SSI program only.

SSI methods and/or any more liberal methods described in Supplement 8a to ATTACHMENT 2.6‑A.

For individuals other than optional State supplement recipients, more restrictive methods than SSI, applied under the provisions of section 1902(f) of the Act, as specified in Supplement 4 to ATTACHMENT 2.6‑A.

For institutional couples, the methods specified under section 1611(e)(5) of the Act.

For optional State supplement recipients under 435.232, income methods more liberal than SSI, as specified in Supplement 8a to ATTACHMENT 2.6‑A.

For optional State supplement recipients under 435.234 in section 1902(f) States and SSI criteria States without section 1616 or 1634 agreements –

SSI methods only.

SSI methods and/or any more liberal methods than SSI described in Supplement 8a to ATTACHMENT 2.6-A

Methods more restrictive than SSI. More restrictive methods are described in Supplement 4 to ATTACHMENT 2.6-A.

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State:

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42 CFR 435.602 In determining relative responsibility, the agency considers

1902(a)(17)(D) only the income of spouses living in the same household as

of the Act available to spouses and the income of parents as available to children living with parents until the children become 21.

42 CFR 435.601, d. Disabled individuals. In determining countable income of

and 435.831, disabled individuals, including individuals with incomes up

1902(m)(1)(B), to the Federal poverty level described in section 1902(m)(1)

1902(m)(4), and of the Act the following methods are used

1902(r)(2) of the

Act The methods of the SSI program.

SSI methods and/or any more liberal methods described in Supplement 8a to ATTACHMENT 2.6A.

For institutional couples: the methods specified under section 1611(e)(5) of the Act.

For optional State supplement recipients under 435.232: income methods more liberal than SSI, as specified in Supplement 8a to ATTACHMENT 2.6‑A.

For individuals other than optional State supplement recipients (except aged and disabled individuals described in section 1902(m)(1) of the Act); more restrictive methods than SSI, applied under the provisions of section 1902(f) of the Act, as specified in Supplement 4 to ATTACHMENT 2.6 A.

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State:

Citation Condition or Requirement

For optional State supplement recipients under 435.234 in section 1902(f) States and SSI criteria States without section 1616 or 1634 agreements—

SSI methods only.

SSI methods and/or any more liberal methods than SSI described in Supplement 8a to Attachment 2.6-A.

Methods more restrictive than SSI. More restrictive methods are described in Supplement 4 to ATTACHMENT 2.6‑A.

1902(l)(3)(E) and e. Poverty level pregnant women, infants, and children. For

1902(r)(2) of the children. For pregnant women and infants or children

Act covered under the provisions of sections 1902(a)(10)(A)(i)(IV), (VI), and (VII), and 1902(a)(10)(A)(ii)(IX) of the Act‑‑

1. The following methods are used in determining countable income:

The methods of the State's approved AFDC plan in effect on July 16, 1996.

The methods of the approved title IV-E plan.

The methods of the approved AFDC State plan in effect on July 16, 1996 and/or any more liberal methods described in Supplement 8a to ATTACHMENT 2.6-A.

The methods of the approved title IV‑E plan and/or any more liberal methods described in Supplement 8a to ATTACHMENT 2.6-A.

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State:

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s) Condition or Requirement

1902(a)(17)(D) of the Act (2) In determining financial responsibility of relatives and

42 CFR 435.602 other individuals, the Medicaid agency considers only the income of spouses living in the same household as available to spouses and the income of parents as available to children living with parents until the children become 21, with the specified exceptions for AFDC-related and SSI-related eligibility groups.

1902(e)(6) of the (3) The agency continues to treat women eligible under the

Act eligible under the provisions of section 1902(a)(10) of the Act as eligible, without regard to any changes in income of the family of which she is a member, for the 60‑day period after her pregnancy ends and any remaining days in the month in which the 60th day falls.

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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s) Condition or Requirement

1902(a)(10)(E)(i), f. Qualified Medicare Beneficiaries. In determining countable

1902(p)(1), income for Qualified Medicare Beneficiaries covered under

1902(m)(4), and section 1902(a)(10)(E)(i) of the Act, the following methods

1902(r)(2) of are used:

the Act

The methods of the SSI program only.

SSI methods and/or any more liberal methods than SSI described in Supplement 8a to ATTACHMENT 2.6‑A.

For institutional couples, the methods specified under section 1611(e)(5) of the Act.

If an individual receives a title II benefit, any amounts attributable to the most recent increase in the monthly insurance benefit as a result of a title II COLA is not counted as income during a "transition period" beginning with January, when the title II benefit for December is received, and ending with the last day of the month following the month of publication of the revised annual Federal poverty level.

The revised poverty levels are effective no later than the date of publication.

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State:

Citation Condition or Requirement

1902(a)(10)(E)(ii) g. For Qualified Disabled and Working Individuals covered

and 1905(s) of the Act under section 1902(a)(10)(E)(ii) of the Act, the agency uses the methods under the SSI program for treatment of income.

1902(a)(10)(E)(iii) h. For Specified Low-Income Medicare Beneficiaries covered

and 1902(r)(2) of under section 1902(a)(10)(E)(iii) of the Act, the agency uses:

the Act

The methods used under the SSI program.

The methods used under SSI program and/or more liberal methods described in Supplement 8a to ATTACHMENT 2.6-A. If more liberal methods are used, the same methods are applied as in f. for QMBs.

1902(a)(10)(E)(iv) i. For Qualifying Individuals covered under section

and 1902(r)(2) of 1902(a)(10)(E)(iv) of the Act, the agency uses:

the Act

The methods used under the SSI program.

The methods used under SSI program and/or more liberal methods described in Supplement 8a to ATTACHMENT 2.6-A. If more liberal methods are used, the same methods are applied as in f. for QMBs.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 12b

State:

Citation Condition or Requirement

1902(u) of the Act j. COBRA Continuation Beneficiaries

In determining countable income for COBRA continuation beneficiaries, the following disregards are applied:

The disregards of the SSI program;

The agency uses methodologies for treatment of income more restrictive than the SSI program. These more restrictive methodologies are described in Supplement 4 to ATTACHMENT 2.6‑A.

NOTE: For COBRA continuation beneficiaries specified at 1902(u)(4), costs incurred from medical care or for any other type of remedial care shall not be taken into account in determining income, except as provided in section 1612(b)(4)(B)(ii).

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 12c

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

Citation(s) Condition or Requirement

1902(a)(10)(A)(ii) k. Working Individuals with Disabilities ‑BBA

(XIII), 1902(f) and

1902(r)(2) of the Act In determining countable income and resources for working individuals with disabilities under BBA, the following methodologies are applied:

The methodologies of the SSI program.

The agency uses more liberal income and/or resource methods than the SSI program. More liberal income methodologies are described in Supplement 8a to ATTACHMENT 2.6-A. More liberal resource methodologies are described in Supplement 8b to ATTACHMENT 2.6-A.

The agency uses more restrictive income and/or resource methods than the SSI program. More restrictive income methods are described in Supplement 4 to ATTACHMENT 2.6-A. More restrictive resource methods are described in Supplement 5 to ATTACHMENT 2.6-A.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 12d

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

Citation(s) Condition or Requirement

1902(a)(10)(A)(ii) l. Working Individuals with Disabilities – Basic Coverage

(XV) of the Act Coverage Group - TWWIIA

In determining financial eligibility for working individuals with disabilities under this provision, the following standards and methodologies are applied:

___ The agency does not apply any income or resource standard.

NOTE: If the above option is chosen, no further eligibility-related options should be elected.

___ The agency applies the following income and/or resource standard(s):

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 12e

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

Citation(s) Condition or Requirement

1902(a)(10)(A)(ii) Income Methodologies

(XV), 1902(f) and

1902(r)(2) of the Act In determining whether an individual meets the income standard described above, the agency uses the following methodologies.

The methodologies of the SSI program.

The agency uses more liberal income methods than the SSI program. More liberal income methodologies are described in Supplement 8a to ATTACHMENT 2.6-A.

The agency uses more restrictive income methods than the SSI program. More restrictive income methods are described in Supplement 4 to ATTACHMENT 2.6-A.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 12f

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

Citation(s) Condition or Requirement

1902(a)(10)(A)(ii) Resource Methodologies

(XV), 1902(f) and

1902(r)(2) of the Act In determining whether the individual meets the resource standard described above, the agency uses the following methodologies.

Unless one of the following items is checked, the agency, under the authority of section 1902(r)(2) of the Act, disregards all funds held in retirement funds and accounts, including private retirement accounts such as IRAs and other individual accounts, and employer-sponsored retirement plans such as 401(k) plans, Keogh plans, and employer pension plans. Any disregard involving retirement accounts is separately described in Supplement 8b to ATTACHMENT 2.6-A.

___ The agency disregards funds held in employer-sponsored retirement plans, but not private retirement plans.

___ The agency disregards funds in retirement accounts in a manner other than those described above. The agency’s disregards are specified in Supplement 8b to ATTACHMENT 2.6-A.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 12g

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

Citation(s) Condition or Requirement

1902(a)(10)(A)(ii) ___ The agency does not disregard funds in retirement

(XV), 1902(f) and accounts.

1902(r)(2) of the Act

The methodologies of the SSI program.

The agency uses more liberal resource methods than the SSI program. More liberal resource methodologies are described in Supplement 8b to ATTACHMENT 2.6-A.

The agency uses more restrictive resource methods than the SSI program. More restrictive resource methods are described in Supplement 5 to ATTACHMENT 2.6-A.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 12h

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

Citation(s) Condition or Requirement

1902(a)(10)(A)(ii) m. Working Individuals with Disabilities – Employed Medically

(XVI) of the Act Improved Individuals - TWWIIA

In determining financial eligibility for employed medically improved individuals under this provision, the following standards and methodologies are applied:

The agency does not apply any income or resource standard.

NOTE: If the above option is chosen, no further eligibility-related options should be elected.

The agency applies the following income and/or resource standard(s):

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 12i

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

Citation(s) Condition or Requirement

1902(a)(10)(A)(ii) Income Methodologies

(XVI), 1902(f) and

1902(r)(2) of the Act In determining whether an individual meets the income standard described above, the agency uses the following methodologies.

The methodologies of the SSI program.

The agency uses more liberal income methods than the SSI program. More liberal income methodologies are described in Supplement 8a to ATTACHMENT 2.6-A.

The agency uses more restrictive income methods than the SSI program. More restrictive income methods are described in Supplement 4 to ATTACHMENT 2.6-A.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 12j

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

Citation(s) Condition or Requirement

1902(a)(10)(A)(ii) Resource Methodologies

(XVI), 1902(f) and

1902(r)(2) of the Act In determining whether the individual meets the resource standard described above, the agency uses the following methodologies.

Unless one of the following items are checked, the agency, under the authority of section 1902(r)(2) of the Act, disregards all funds held in retirement funds and accounts, including private retirement accounts such as IRAs and other individual accounts, and employer-sponsored retirement plans such as 401(k) plans, Keogh plans, and employer pension plans. Any disregard involving retirement accounts is separately described in Supplement 8b to ATTACHMENT 2.6-A.

__ The agency disregards funds held in employer sponsored retirement plans, but not private retirement plans.

The agency disregards funds in retirement accounts in a manner other than those described above. The agency’s disregards are specified in Supplement 8b to ATTACHMENT 2.6-A.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 12k

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

Citation(s) Condition or Requirement

1902(a)(10)(A)(ii) The agency does not disregard funds in retirement

(XVI) of the Act accounts.

The methodologies of the SSI program.

The agency uses more liberal resource methods than the SSI program. More liberal resource methodologies are described in Supplement 8b to ATTACHMENT 2.6-A.

The agency uses more restrictive resource methods than the SSI program. More restrictive resource methods are described in Supplement 5 to ATTACHMENT 2.6-A.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 12l

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

Citation(s) Condition or Requirement

1902(a)(10)(A)(ii) Definition of Employed – Employed Medically Improved

(XVI) and 1905(v)(2) Individuals – TWWIIA

of the Act

The agency uses the statutory definition of “employed”, i.e., earning at least the minimum wage, and working at least 40 hours per month.

___ The agency uses an alternative definition of “employed” that provides for substantial and reasonable threshold criteria for hours of work, wages, or other measures. The agency’s threshold criteria is described below:

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 12m

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

Citation(s) Condition or Requirement

1902(a)(10)(A)(ii)(XIII) Payment of Premiums or Other Cost Sharing Charges

of the Act

For individuals eligible under the BBA eligibility group described in No. 27 on page 23g to ATTACHMENT 2.2‑A:

___ The agency requires payment of premiums or other cost‑sharing charges on a sliding scale based on income. The premiums or other cost-sharing charges, and how they are applied are described below:

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 12n

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

Citation(s) Condition or Requirement

1902(a)(10)(A)(ii) For individuals eligible under the Basic Coverage Group

(XV), (XVI), and described in No. 28 on page 23g to ATTACHMENT 2.2-A,

1916(g) of the Act and the Medical Improvement Group described in No. 29 on page 23g to ATTACHMENT 2.2-A:

NOTE: Regardless of the option selected below, the agency MUST require that individuals whose annual adjusted gross income, as defined under IRS statute, exceeds $75,000 pay 100 percent of premiums. The $75,000 limit was effective October 1, 2000, and increases by the percentage increase in the Social Security Cost of Living increase each calendar year.

____ The agency requires individuals to pay premiums or other cost‑sharing charges on a sliding scale based on income. For individuals with net annual income below 450 percent of the Federal poverty level for a family of the size involved, the amount of premiums cannot exceed 7.5 percent of the individual’s income.

The premiums or other cost-sharing charges, and how they are applied are described on page 12o.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 12o

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

Citation(s) Condition or Requirement

Sections 1902(a)(10)(A)(ii) Premiums and Other Cost‑Sharing Charges

(XV), (XVI), and 1916(g)

of the Act For the Basic Coverage Group and the Medical Improvement Group, the agency’s premium and other cost‑sharing charges, and how they are applied, are described below.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 12p

State:

Citation Condition or Requirement

1902(a)(10)(A)(ii) n. Family Opportunity Act (FOA)

(XIX) of the Act

In determining financial eligibility for disabled children under this provision, the following standards and methodologies are applied:

Income Standards

___ The agency uses the family income standard of 300% of federal poverty level;

___ The agency uses the family income standard of less than 300% of the federal poverty level.

Specify the income standard _______

___ The agency uses a family income standard higher than 300% of the federal poverty level, (no federal financial participation is provided for benefits to families above 300% FPL).

Specify the income standard _______

Resource Standards

Under this provision agencies may not impose resource standards or asset tests in determining eligibility.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 12q

State:

Citation Condition or Requirement

1902(a)(10)(A)(ii) Income Methodologies

(XIX), 1902(f) and

1902(r)(2) of the Act In determining whether a family meets the income standard described above, the agency uses the following methodologies.

___ The income methodologies of the SSI program.

___ The agency uses methodologies for treatment of income that are more restrictive than the SSI program. These more restrictive methodologies are described in Supplement 4 to ATTACHMENT 2.6-A.

___ The agency uses more liberal income methodologies than the SSI program. More liberal income methodologies are described in Supplement 8a to ATTACHMENT 2.6-A.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 12r

State:

Citation Condition or Requirement

1902(cc) of the Act Interaction with Employer Sponsored Family Coverage

and 1903(a)

For individuals eligible under the FOA eligibility group described in No. 30 on page 23h to ATTACHMENT 2.2‑A:

The agency requires parents to enroll in available group health plans through their employers if the plan qualifies under Section 2791(a) of the Public Health Service Act and the employer contributes at least 50 percent of the total cost of annual premiums for such coverage.

If such coverage is obtained, the agency (subject to the payment of premiums described in Attachment 2.6-A, pages 12s and 12t reduces any premium imposed by the State by an amount that reasonably reflects the premium contribution made by the parent for private coverage on behalf of a child with a disability; and treats such coverage as a third party liability.

___ The agency provides for payment of all or some portion of the annual premium for the employer-provided private family coverage that the parent is required to pay. Any payments made by the State are considered, for purposes of section 1903(a), to be payments for medical assistance.

The agency pays __________ percent of the premium.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 12s

State:

Citation Condition or Requirement

1902(a)(10)(A)(ii) Payment of Premiums

(XIX), 1916(i) and

1902(cc)(2)(A)(ii)(I) For individuals eligible under the FOA eligibility group

of the Act described in No. 30 on page 23h to ATTACHMENT 2.2‑A:

___ The agency does not require the payment of premiums for Medicaid coverage.

___ The agency requires payment of premiums on a sliding scale based on income. The premiums, and how they are applied are described below:

NOTE: Amounts paid for premiums for Medicaid, required family coverage, and other cost- sharing may not exceed 5% of a family’s income for families with income up to and including 200% FPL and 7.5% of a family’s income for families above 200% and up to 300% FPL.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 12t

State:

Citation Condition or Requirement

1902(a)(10)(A)(ii) Payment of Premiums (Continued)

(XIX), 1916(i) and

1902(cc)(2)(A)(ii)(I) NOTE: A State may not require prepayment of premiums

of the Act and may not terminate eligibility of a child for medical assistance on the basis of failure to pay a premium until the failure to pay continues for at least 60 days from the date on which the premium was past due.

NOTE: The State may waive payment of any such premium in any case where the State determines that requiring payment would create an undue hardship.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 13

State:

Citation Condition or Requirement

1917(d)(5) of the Act 2. Medicaid Trusts

The agency does not count the funds in a trust described in section 1917(d) in any instance where the State determines that it would work an undue hardship. Supplement 10 to ATTACHMENT 2.6‑A specifies what constitutes an undue hardship.

1902(a)(10) 3. Medically Needy Income Levels (MNILS)

1. MNILS are based on family size.

2. The MNIL does not diminish by family size.

Supplement 1 to ATTACHMENT 2.6-A specifies the MNILs for all covered medically needy groups. If the agency chooses more restrictive levels under section 1902(f) of the Act, Supplement 1 to ATTACHMENT 2.6-A so indicates.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 14

State:

Citation Condition or Requirement

42 CFR.435.732 and 4. Handling of Excess Income ‑ Spend‑down for the Medically

42 CFR 435.831 Needy in All States and the Categorically Needy in section 1902(f) States

1. Medically Needy

1. The Medicaid agency considers income in excess of the MNIL available for payment of medical or remedial care expenses in budget periods that do not exceed 6 months. The agency measures available income as specified below:

The agency uses one budget period of ____ month(s) during which countable income for the period is reduced by the amount of incurred medical or remedial care expenses in determining income eligibility for the period.

The agency uses more than one budget period during which countable income for each period is reduced by the amount of incurred medical or remedial care expenses in determining income eligibility for the period. The agency uses the budget periods specified below in the circumstances described.

Length of

Budget Period: Circumstance:

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 14a

State:

Citation Condition or Requirement

a. Medically Needy (Continued)

1902(a)(17) of the Act (2) The agency does not deduct incurred expenses Subject to payment by a third party unless the third party is a public program (other than Medicaid) of a State or Territory and the program is financed by the State or Territory.

42 CFR 435.831 (3) The agency projects or does not project institutional expenses (other than expenses in acute care facilities) to the end of the budget period at the Medicaid reimbursement rate as checked below:

the agency does not project institutional expenses.

the agency does project institutional expenses.

42 CFR 435.831 (4) Subject to the carryover expenses described in

42 CFR 435.121 (5) below, the agency deducts incurred expenses, based on the age of the expenses as specified below, but only to the extent that the amount has not been deducted previously and there is a current liability for the amount. States must deduct current payments on old bills not previously deducted in any budget period.

The agency deducts the expenses regardless of when incurred. (This is the only option available to section 1902(f) States.)

The agency deducts expenses incurred prior to the third month before the month of application, but incurred no earlier than:_________________

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 14b

State:

Citation Condition or Requirement

1. Medically Needy (Continued)

The agency deducts expenses incurred no earlier than the third month before the month of application.

(5) The agency carries over unused deductible expenses for which liability continues, to be deducted from future excess income, to the extent indicated below (check one):

Up to the first budget period in which there is either no spenddown liability or no eligibility.

Beyond the first budget period in which there is either no spenddown liability or no eligibility, but not later than: _____________

Indefinitely.

6. The agency deducts incurred medical or remedial care expenses in the following order (check one):

By the type of service, in the following order:

1. Premiums, deductibles, coinsurance, and copayments.

2. Expenses for necessary medical or remedial care services that are recognized under State law but not included in the State plan.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 14c

State:

Citation Condition or Requirement

1. Medically Needy (Continued)

3. Expenses for necessary medical or remedial care services that are included in the State plan, including those that exceed agency limitations on amount, duration, or scope of services.

In chronological order by service date.

__ In chronological order by bill submission date.

The State may set reasonable limits on the amount to be deducted for expenses for:

1. Medicare and other health insurance premiums, deductibles or coinsurance charges, including enrollment fees and co-payments, or deductibles imposed by the Medicaid program;

2. Expenses incurred by the individual; or family or financially responsible relatives for necessary medical and remedial services that are recognized under State law but not included in the State plan;

3. Expenses incurred earlier than the third month before the month of application as specified in item 4. This option is not available to section 1902(f) States.

Reasonable limits are described below:

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 14d

State:

Citation Condition or Requirement

1. Medically Needy (Continued)

___ (7) If countable income excess the MNIL standard the agency deducts spenddown payments made to the State by the individual. Individuals may elect or reject the pay in option on a:

monthly or

quarterly basis.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 15

State:

Citation Condition or Requirement

42 CFR 435.121 b. Categorically Needy - Section 1902(f) States

1902(f) of the Act

The agency applies the following policy under the provisions of section 1902(f) of the Act. The following amounts are deducted from income to determine the individual’s countable income.

1. Any SSI payments received.

2. Any State Supplement payments received that are within the scope of an agreement described in section 1616 and section 1634 of the Act, or a State supplement payment within the scope of section 1902(a)(10)(A)(ii)(XI) of the Act.

3. Increases in OASDI that are deducted under 435.134, 435.135, 435.137, 435.138, and section 1634(c) of the Act for individuals specified in such sections, in the manner elected by the State under such sections.

4. Other deductions from income described in this plan in Supplement 4 to ATTACHMENT 2.6A.

5. Incurred expenses for necessary or remedial care services as recognized under State law.

1902(a)(17) of the Act The agency does not deduct incurred expenses

P. L. 100-203 subject to payment by a third party, unless the third party is a publicly funded program (other than Medicaid) of a State or local government.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 15a

State:

Citation Condition or Requirement

2. Categorically Needy - Section 1902(f) States

1903(f)(2) of the (6) Spenddown payments made to the State by the

Act the individual.

Individuals may elect or reject the pay in option on a:

Monthly; or

Quarterly Basis.

NOTE: FFP will be reduced to the extent a State is paid a spenddown payment by the individual.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 16

State:

Citation Condition or Requirement

5. Methods for Determining Resources

a. AFDC‑related individuals (except for individuals eligible under section 1931 of the Act and poverty-level related pregnant women, infants, and children).

(1) In determining countable resources for AFDC‑related individuals, the following methods are used:

(a) The methods under the State’s approved AFDC plan in effect on July 16, 1996; or

2. The method under the State's approved AFDC plan in effect on July 16, 1996 and/or any more liberal methods described in Supplement 8b to ATTACHMENT 2.6‑A.

Note: For individuals eligible under section 1931 of the Act, see Supplement 12 to ATTACHMENT 2.6-A. For poverty-level related pregnant women, infants, and children, see e - g of this section.

42 CFR 435.602 and (2) In determining relative financial responsibility, the

1902(a)(17)(D) of the agency considers only the resources of spouses living in

Act the same household as available to spouses and the resources of parents as available to children living with parents until the children become 21.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 17

State:

Citation Condition or Requirement

1902(a)(10)(A), b. Aged Individuals. For aged individuals, including those

1902(a)(10)(C), covered under section 1902(m)(1) of the Act, the agency

1902(f), 1902(m)(1)(B) uses the following methods for treatment of resources:

and 1902(r) of the Act

The methods of the SSI program.

SSI methods and/or any more liberal methods described in Supplement 8b to ATTACHMENT 2.6‑A.

Methods that are more restrictive (except for individuals described in section 1902(m)(1) of the Act) than those of the SSI program. Supplement 5 to ATTACHMENT 2.6‑A describes the more restrictive methods.

42 CFR 435.602 and In determining relative financial responsibility, the agency

1902(a)(17)(D) of considers only the resources of spouses living in the same

the Act household as available to spouses and the resources of parents as available to children living with parents until the children become 21.

1902(a)(10)(A), c. Blind individuals. For blind individuals the agency uses the

1902(a)(10)(C), following methods for treatment of resources:

1902(f), and

1902(r) of the Act The methods of the SSI program.

SSI methods and/or any more liberal methods described in Supplement 8b to ATTACHMENT 2.6‑A.

Methods that are more restrictive than those of the SSI program. Supplement 5 to ATTACHMENT 2.6‑A describes the more restrictive methods.

42 CFR 435.602 and In determining relative financial responsibility, the agency

1902(a)(17)(D) of the considers only the resources of spouses living in the same

Act household as available to spouses and the resources of parents as available to children living with parents until the children become 21.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 18

State:

Citation Condition or Requirement

1902(a)(10)(A), d. Disabled individuals, including individuals covered under

1902(a)(10)(C), section 1902(m)(1) of the Act. The agency uses the

1902(m)(1)(B), following methods for the treatment of resources:

1902(f) and 1902(r)(2)

of the Act The methods of the SSI program.

SSI methods and/or any more liberal methods described in Supplement 8a to ATTACHMENT 2.6‑A.

Methods that are more restrictive (except for individuals described in section 1902(m)(1) of the Act) than those under the SSI program. More restrictive methods are described in Supplement 5 to ATTACHMENT 2.6‑A.

42 CFR 435.602 and In determining relative financial responsibility, the agency

1902(a)(17)(D) of the considers only the resources of spouses living in the same

Act household as available to spouses and the resources of parents as available to children living with parents until the children become 21.

1902(1)(3) e. Poverty level pregnant women covered under sections

and 1902(r)(2) 1902(a)(10)(A)(i)(IV) and 1902(a)(10)(A)(ii)(IX) of the

of the Act Act.

The agency uses the following methods in the treatment of resources.

The methods of the SSI program only.

The methods of the SSI program and/or any more liberal methods described in Supplement 5a to ATTACHMENT 2.6-A or Supplement 8b to ATTACHMENT 2.6‑A.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 19

State:

Citation Condition or Requirement

Not applicable. The agency does not consider resources in determining eligibility.

42 CFR 435.602 and In determining relative financial responsibility, the agency

1902(a)(17)(D) of the considers only the resources of spouses living in the same

Act household as available to spouses and the resources of parents as available to children living with parents until the children become 21.

1902(l)(3) and f. Poverty Level Infants Covered Under Section

1902(r)(2) of 1902(a)(10)(A)(i)(IV) of the Act.

the Act

The agency uses the following methods for the treatment of resources:

1902(l)(3) and 1902 The methods of the State's approved AFDC plan in

(r)(2) of the Act effect on July 16, 1996.

1902(l)(3) and 1902 Methods more liberal than those in the State’s approved

(r)(2) of the Act AFDC plan (but not more restrictive), as described in Supplement 8b to ATTACHMENT 2.6‑A.

Not applicable. The agency does not consider resources in determining eligibility.

42 CFR 435.602 and In determining relative financial responsibility, the agency

1902(a)(17)(D) of the considers only the resources of spouses living in the same

Act household as available to spouses and the resources of parents as available to children living with parents until the children become 21.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 19a

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s) Condition or Requirement

1902(1)(3) and g. 1. Poverty Level Children Covered Under Section

1902(r)(2) of 1902(a)(10)(A)(i)(VI) of the Act.

the Act

The agency uses the following methods for the treatment of resources:

The methods of the State's approved AFDC plan in effect on July 16, 1996.

1902(l)(3) and Methods more liberal than those in the State’s

1902(r)(2)of approved AFDC plan (but not more restrictive), as

the Act described in Supplement 8b to ATTACHMENT 2.6‑A.

Not applicable. The agency does not consider resources in determining eligibility.

42 CFR 435.602 and In determining relative financial responsibility, the 1902(a)(17)(D) of agency considers only the resources of spouses living in

the Act the same household as available to spouses and the resources of parents as available to children living with parents until the children become 21.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 19b

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s) Condition or Requirement

1902(1)(3) and . 2. Poverty level children covered under section

1902(r)(2) of 1902(a)(10)(A)(i)(VII)

the Act

The agency uses the following methods for the treatment of resources:

The methods of the State's approved AFDC plan in effect on July 16, 1996.

1902(1)(3) and Methods more liberal than those in the State’s

1902(r)(2) of approved AFDC plan (but not more restrictive), as

the Act described in Supplement 8a to ATTACHMENT 2.6‑A.

Not applicable. The agency does not consider resources in determining eligibility.

42 CFR 435.602 and In determining relative financial responsibility, the 1902(a)(17)(D) of agency considers only the resources of spouses living in

the Act the same household as available to spouses and the resources of parents as available to children living with parents until the children become 21.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 20

State:

Citation Condition or Requirement

1902(a)(10)(E)(i), h. For Qualified Medicare Beneficiaries covered under section

1905(p)(1)(C) and 1902(a)(10)(E)(i) of the Act the agency uses the following

(D) and 1902(r)(2) methods for treatment of resources:

of the Act

The methods of the SSI program only.

The methods of the SSI program and/or more liberal methods as described in Supplement 8b to ATTACHMENT 2.6‑A.

1902(a)(10)(E)(ii) and i. For Qualified Disabled and Working Individuals covered

1905(s) of the Act under section 1902(a)(10)(E)(ii) of the Act, the agency uses SSI program methods for the treatment of resources.

1902(u) of the Act j. For COBRA continuation beneficiaries, the agency uses the following methods for treatment of resources:

The methods of the SSI program only.

More restrictive methods applied under section 1902(f) of the Act as described in Supplement 5 to Attachment 2.6‑A.

1902(a)(10)(E)(iii) k. Specified Low‑Income Medicare Beneficiaries covered

of the Act under section 1902(a)(10)(E)(iii) of the Act

The methods of the SSI program only.

The methods used under the SSI program and/or more liberal methods as described in Supplement 8b to ATTACHMENT 2.6‑A. If more liberal methods are used, the same methods are applied as in h. for QMBs.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 20a

State:

Citation Condition or Requirement

1902(a)(10)(E)(iv) l. For Qualifying Individuals covered under section

of the Act 1902(a)(10)(E)(iv) of the Act the agency uses the following methods for treatment of resources:

The methods of the SSI program only.

The methods used under the SSI program and/or more liberal methods as described in Supplement 8b to ATTACHMENT 2.6‑A. If more liberal methods are used, the same methods are applied as in h. for QMBs.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 20b

State:

Citation Condition or Requirement

6. Resource Standard ‑ Categorically Needy

1. 1902(f) States (except as specified under items 6.c. and d. below) for aged, blind and disabled individuals:

Same as SSI resource standards.

More restrictive.

2. Non-1902(f) States (except as specified under items 6.c. and d. below):

The resource standards are the same as those in the related cash assistance program.

Supplement 8 to ATTACHMENT 2.6-A specifies for 1902(f) States the categorically needy resource levels for all covered categorically needy groups.

1902(l)(3) of c. For pregnant women and infants covered as optional groups

the Act under the provisions of section 1902(a)(10)(A)(i)(IV) or 1902(a)(10(ii)(IX) of the Act, the agency applies a resource standard.

Yes. Supplement 2 to ATTACHMENT 2.6-A specifies the standard, which, for pregnant women, is no more restrictive than the standard under the SSI program and for infants, is no more restrictive than the standard applied in the State’s approved AFDC plan in effect on July 16, 1996.

No. The agency does not apply a resource standard to these individuals.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 20c

State:

Citation Condition or Requirement

1902(l)(3) of d. For children covered as optional groups under the provisions

the Act of sections 1902(a)(10)(A)(i)(VI), 1902(a)(10)(A)(ii)(IX), and 1902(l)(4) of the Act, the agency applies a resource standard:

Yes. Supplement 2 to ATTACHMENT 2.6-A specifies the standard, which, is no more restrictive than the standard applied in the State’s approved AFDC plan in effect on July 16, 1996.

No. The agency does not apply a resource standard to these individuals.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 21

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s) Condition or Requirement

1902(l)(3) of e. For children covered under the provisions of section

the Act of section 1902(a)(10)(A)(i)(VII) of the Act, the agency applies a resource standard.

Yes. Supplement 2 to ATTACHMENT 2.6‑A specifies the standard which is no more restrictive than the standard applied in the State's approved AFDC plan in effect on July 16, 1996.

No. The agency does not apply a resource standard to these individuals.

1902(m)(1)(C) and f. For aged and disabled individuals described in section

1902(m)(2)(B) of 1902(m)(1) of the Act who are covered under section

the Act 1902(a)(10)(A)(ii)(X) of the Act, the resource standard is:

Same as SSI resource standards.

Same as the medically needy resource standards, which are higher than the SSI resource standards (if the State covers the medically needy).

Supplement 2 to ATTACHMENT 2.6‑A specifies the resource levels for these individuals.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 22

State:

Citation Condition or Requirement

7. Resource Standard ‑ Medically Needy

a. Resource standards are based on family size.

1902(a)(10)(C)(i) b. A single standard is employed in determining resource

of the Act resource eligibility for all groups.

c. In 1902(f) States, the resource standards are more restrictive than in 7.b. above for‑‑

Aged

Blind

Disabled

Supplement 2 to ATTACHMENT 2.6‑A specifies the resource standards for all covered medically needy groups. If the agency chooses more restrictive levels under 7.c., Supplement 2 to ATTACHMENT 2.6-A so indicates.

1902(a)(10)(E), 8. Resource Standard ‑ Qualified Medicare Beneficiaries,

1905(p)(1)(D) and Specified Low‑Income Medicare Beneficiaries and

1905(p)(2)(B) Qualifying Individuals

of the Act

For Qualified Medicare Beneficiaries covered under section 1902(a)(10)(E)(i) of the Act, Specified Low‑Income Medicare Beneficiaries covered under section 1902(a)(10)(E)(iii) of the Act, and Qualifying Individuals covered under 1902(a)(10)(E)(iv) of the Act, the resource standard is twice the SSI standard.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 22a

State:

Citation Condition or Requirement

1902(a)(10)(E)(ii) and 9. Resource Standard ‑ Qualified Disabled and Working

1905(s) of the Act Individuals

For qualified disabled and working individuals covered under section 1902(a)(10)(E)(ii) of the Act, the resource standard for an individual or a couple (in the case of an individual with a spouse) is twice the SSI resource standard.

1902(u) of the Act 10. For COBRA continuation beneficiaries, the resource standard is:

Twice the SSI resource standard for an individual.

More restrictive standard as applied under section 1902(f) of the Act as described in Supplement 8 to Attachment 2.6‑A.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 23

State:

Citation Condition or Requirement

11. Excess Resources

a. Categorically Needy, Qualified Beneficiaries, Qualified Disabled and Working Individuals, Specified Low‑Income Medicare Beneficiaries and Qualifying Individuals

Any excess resources make the individual ineligible.

b. Categorically Needy Only

This State has a section 1634 agreement with SSI. Receipt of SSI is provided for individuals while disposing of excess resources.

c. Medically Needy

Any excess resources make the individual ineligible.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 24

State:

Citation Condition or Requirement

42 CFR 435.914 12. Effective Date of Eligibility

a. Groups Other Than Qualified Medicare Beneficiaries

(1) For the prospective period.

Coverage is available for the full month if the following individuals are eligible at any time during the month.

Aged, Blind, Disabled.

AFDC-Related

Coverage is available only for the period during the month for which the following individuals meet the eligibility requirements

Aged, Blind, Disabled.

AFDC-Related

(2) For the retroactive period.

Coverage is available for up to three months before the date of application if the following individuals would have been eligible had they applied:

Aged, Blind, Disabled.

AFDC-Related

Coverage is available beginning the first day of the third month before the date of application if the following individuals would have been eligible at any time during that month, had they applied.

Aged, Blind, Disabled.

AFDC-Related

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 25

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation Condition or Requirement

1920(b)(1) of the Act (3) For a presumptive eligibility for pregnant women only.

Coverage is available for ambulatory prenatal care for the period that begins on the day a qualified provider determines that a woman meets any of the income eligibility levels specified in ATTACHMENT 2.6‑A of this approved plan. If the woman files an application for Medicaid by the last day of the month following the month in which the qualified provider made the determination of presumptive eligibility, the period ends on the day that the State agency makes the determination of eligibility based on that application. If the woman does not file an application for Medicaid by the last day of the month following the month in which the qualified provider made the determination, the period ends on that last day.

1902(e)(8) and b. For Qualified Medicare Beneficiaries defined in section

1905(a) of the Act 1905(p)(1) of the Act coverage is available beginning with the first day of the month after the month in which the individual is first determined to be a qualified Medicare beneficiary under section 1905(p)(1). The eligibility determination is valid for‑‑

12 months

6 months

months (no less than 6 months and no more than 12 months)

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 26

State:

Citation Condition or Requirement

1902(a)(18) and 13. Transfer of Assets ‑ All Eligibility Groups

1917(c) of the Act

The agency complies with the provisions of section 1917(c) of the Act, with regard to the transfer of assets.

Disposal of assets at less than fair market value affects eligibility for certain services as detailed in Supplement 9b to ATTACHMENT 2.6‑A, except in instances where the agency determines that the transfer rules would work an undue hardship.

1902(a)(18) and 14. Treatment of Trusts ‑ All Eligibility Groups

1917(d) of the Act

The agency complies with the provisions of section 1917(d) of the Act, with regard to trusts.

The agency uses more restrictive methodologies under section 1902(f) of the Act, and applies those methodologies in dealing with trusts;

The agency meets the requirements in section 1917(d)(4)(B) of the Act for use of Miller trusts.

The agency does not count the funds in a trust in any instance where the agency determines that counting the funds would work an undue hardship, as described in Supplement 10 to ATTACHMENT 2.6‑A.

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: ATTACHMENT 2.6‑A

Page 26a

State:

Citation Condition or Requirement

1924 of the Act 15. The agency complies with the provisions of section 1924 with respect to income and resource eligibility and posteligibility determinations for individuals who are expected to be institutionalized for at least 30 consecutive days and who have a spouse living in the community.

When applying the formula used to determine the amount of resources in initial eligibility determinations, the State standard for community spouses is:

the maximum standard permitted by law;

the minimum standard permitted by law; or

an amount between the minimum and the maximum –

$ .

TN No: Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 1

TO ATTACHMENT 2.6‑A

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

INCOME ELIGIBILITY LEVELS

1. MANDATORY CATEGORICALLY NEEDY

1. AFDC Standards Under the AFDC Plan in Effect on July 16, 1996:

Maximum Payment

Family Size Need Standard Payment Standard Amounts

2. Pregnant Women and Infants under Section 1902(a)(10)(i)(IV) of the Act:

Effective _______ based on the following percent of the official Federal Poverty Level –

133 Percent; or

Percent (No less than 133 percent and no more than 185 percent)

Family Size Income Level

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 1 TO ATTACHMENT 2.6‑A

Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

INCOME ELIGIBILITY LEVELS

(Continued)

1. MANDATORY CATEGORICALLY NEEDY (Continued)

2. For children under Section 1902(a)(10)(i)(VI) of the Act (children who have attained age 1 but have not attained age 6), the income eligibility level is 133 percent of the Federal Poverty Level (as revised annually in the Federal Register) for the family size involved.

2. For children under Section 1902(a)(10)(i)(VII) of the Act (children who have attained age 6 but have not attained age 19), the income eligibility level is 100 percent of the Federal Poverty Level (as revised annually in the Federal Register) for the family size involved.

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 1 TO ATTACHMENT 2.6‑A

Page 3

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

INCOME ELIGIBILITY LEVELS

(Continued)

B. OPTIONAL CATEGORICALLY NEEDY GROUPS WITH INCOMES RELATED TO FEDERAL POVERTY LEVEL

1. Pregnant Women and Infants

The levels for determining income eligibility for optional groups of pregnant women and infants under the provisions of sections 1902(a)(10)(A)(ii)(IX) and 1902(1)(2) of the Act are as follows:

Effective , based on percent of the official Federal Income Poverty Level (no less than 133 percent and no more than 185 percent, and exceeding the income standard for mandatory categorically needy pregnant women and infants):

Family size Income Level

1 $

2 $

3 $

4 $

5 $

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 1 TO ATTACHMENT 2.6‑A

Page 4

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

INCOME ELIGIBILITY LEVELS

(Continued)

B. OPTIONAL CATEGORICALLY NEEDY GROUPS WITH INCOMES RELATED TO FEDERAL POVERTY LEVEL

2. Children Between Ages 6 and 19

The levels for determining income eligibility for groups of children who are born after and who have attained six years of age but are under 19 years of age under the provisions of section 1902(l)(2) of the Act are as follows:

Based on percent (no more than 100 percent) of the official Federal income poverty line.

Family size Income Level

1 $

2 $

3 $

4 $

5 $

6 $

7 $

8 $

9 $

10 $

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 1 TO ATTACHMENT 2.6‑A

Page 5

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

INCOME ELIGIBILITY LEVELS

(Continued)

3. Aged and Disabled Individuals Eligible Under Section 1902(m)(1)

The levels for determining income eligibility for groups of aged and disabled individuals under the provisions of section 1902(m)(1) of the Act are as follows:

Based on percent of the official Federal income poverty line.

Family Size Income Level

1 $

2 $

3 $

4 $

5 $

4. Special Income Level for Institutionalized Individuals

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 1 TO ATTACHMENT 2.6‑A

Page 5a

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

INCOME ELIGIBILITY LEVELS

(Continued)

2. Optional Group of Children under Section 1902(l)(1)(D) of the Act.

Same as resource levels in the State’s approved AFDC plan.

Less restrictive than the AFDC levels and are as follows:

Family Size Resource Level

1 $

2 $

3 $

4 $

5 $

6 $

7 $

8 $

9 $

10 $

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 1 TO ATTACHMENT 2.6‑A

Page 6

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

INCOME ELIGIBILITY LEVELS

Continued)

C. QUALIFIED MEDICARE BENEFICIARIES WITH INCOMES RELATED TO FEDERAL POVERTY LEVEL

The levels for determining income eligibility for groups of Qualified Medicare Beneficiaries under the provision of Section 1905(p)(2)(A) and 1905(p)(4) of the Act are as follows:

Levels:

Family Size Income Level

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 1 TO ATTACHMENT 2.6‑A

Page 7

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

INCOME LEVELS

(continued)

6. MEDICALLY NEEDY

Applicable to all groups. Applicable to all groups except those specified below. Excepted group income levels are also listed on an attached page .

(1) (2) (3)

Family Net income level Net income level

Size protected for for persons

maintenance for living in rural

months areas for

months Urban Only

Urban and Rural

1 $ $

2 $ $

3 $ $

4 $ $

5 $ $

6 $ $

7 $ $

8 $ $

9 $ $

10 $ $

For each additional

person, add: $ $

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 2 TO ATTACHMENT 2.6‑A

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

RESOURCE LEVELS

1. CATEGORICALLY NEEDY GROUPS

1. Pregnant Women

1. Mandatory Groups of Pregnant Women under Section 1902(a)(10)(A)(i)(IV) of the Act

Same as SSI resource levels.

No resource test.

Less restrictive than SSI resource levels and is as follows:

Family Size Resource Level

1

2

2. Optional Group of Pregnant Women under Section 1902(a)(10)(A)(ii)(IX) of the Act

Same as SSI resource levels.

No resource test.

Less restrictive than SSI resource levels and is as follows:

Family Size Resource Level

1

2

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 2 TO

ATTACHMENT 2.6‑A

Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

RESOURCE LEVELS

(Continued)

2. Infants

a. Mandatory Group of Infants under Section 1902(a)(10)(A)(i)(IV) of the Act

Same as resource levels in the State's approved AFDC plan.

No resource test.

Less restrictive than the AFDC levels and are as follows:

Family Size Resource Level

1

2

3

4

5

6

7

8

9

10

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 2 TO ATTACHMENT 2.6‑A

Page 3

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

RESOURCE LEVELS

(Continued)

b. Optional Group of Infants under Section 1902(a)(10)(A)(ii)(IX) of the Act

Same as resource levels in the State's approved AFDC plan.

No resource test.

Less restrictive than the AFDC levels and are as follows:

Family Size Resource Level

1

2

3

4

5

6

7

8

9

10

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 2 TO ATTACHMENT 2.6‑A

Page 4

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

RESOURCE LEVELS

(Continued)

3. Children

a. Mandatory Group of Children under Section 1902(a)(10)(i)(VI) of the Act. (Children who have attained age 1 but have not attained age 6.)

Same as resource levels in the State's approved AFDC plan.

No resource test.

Less restrictive than the AFDC levels and are as follows:

Family Size Resource Level

1

2

3

4

5

6

7

8

9

10

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 2 TO

ATTACHMENT 2.6‑A

Page 5

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

RESOURCE LEVELS

(Continued)

b. Mandatory Group of Children under Section 1902(a)(10)(i)(VII) of the Act. (Children who have attained age 6 but have not attained age 19.)

Same as resource levels in the State's approved AFDC plan.

No resource test.

Less restrictive than the AFDC levels and are as follows:

Family Size Resource Level

1

2

3

4

5

6

7

8

9

10

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 2 TO

ATTACHMENT 2.6‑A

Page 5a

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

RESOURCE LEVELS

(Continued)

b. Optional Group of Children under Section 1902(1)(1)(D) of the Act.

Same as resource levels in the State’s approved AFDC plan.

Less restrictive than the AFDC levels and are as follows:

Family Size Resource Level

1

2

3

4

5

6

7

8

9

10

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 2 TO ATTACHMENT 2.6‑A

Page 6

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

RESOURCE LEVELS

(Continued)

4. Aged and Disabled Individuals Eligible Under Section 1902(m)(1)

Same as SSI resource levels.

Same as medically needy resource levels (applicable only if State has a medically needy program)

Family Size Resource Level

1

2

3

4

5

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 2 TO ATTACHMENT 2.6‑A

Page 7

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

RESOURCE LEVELS

(Continued)

B. MEDICALLY NEEDY

Applicable to all groups –

Except those specified below under the provisions of section 1902(f) of the Act.

Family Size Resource Level

1

2

3

4

5

6

7

8

9

10

Each additional person

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 3 TO ATTACHMENT 2.6‑A

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

REASONABLE LIMITS ON AMOUNTS FOR NECESSARY MEDICAL OR REMEDIAL CARE NOT COVERED UNDER MEDICAID

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 4 TO ATTACHMENT 2.6‑A

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

METHODS FOR TREATMENT OF INCOME THAT DIFFER

FROM THOSE OF THE SSI PROGRAM

(Section 1902(f) more restrictive methods and criteria and State supplement criteria in SSI criteria States without section 1634 agreements and in section 1902(f) States. Use to reflect more liberal methods only if you limit to state supplement recipients. DO NOT USE this supplement to reflect more liberal policies that you elect under the authority of section 1902(r)(2) of the Act. Use Supplement 8a for section 1902(r)(2) methods.)

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 5 TO ATTACHMENT 2.6‑A

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

MORE RESTRICTIVE METHODS OF TREATING RESOURCES

THAN THOSE OF THE SSI PROGRAM

Section 1902(f) States Only

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 5a TO ATTACHMENT 2.6‑A

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

METHODS FOR TREATMENT OF RESOURCES

FOR INDIVIDUALS WITH INCOMES RELATED TO FEDERAL POVERTY LEVELS

(Do not complete if you are electing more liberal methods under the authority of section 1902(r)(2) of the Act instead of the authority specific to Federal poverty levels. Use Supplement 8b for section 1902(r)(2) methods.)

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 6 TO ATTACHMENT 2.6‑A

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

FEDERALLY ADMINISTERED OPTIONAL STATE SUPPLEMENT:

PAYMENT GROUPS/INCOME LEVELS

Gross Income SSI State

Level Standard Benefit Supplementation

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 6 TO ATTACHMENT 2.6‑A

Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

STANDARDS FOR OPTIONAL STATE SUPPLEMENTARY PAYMENTS

Income

Income Level Disregards

Payment Category Administered by Gross Net Employed

Reasonable One One

Classification Federal State Person Couple Person Couple

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 7 TO ATTACHMENT 2.6‑A

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

INCOME LEVELS FOR 1902(f) STATES

CATEGORICALLY NEEDY WHO ARE COVERED UNDER REQUIREMENTS

MORE RESTRICTIVE THAN SSI

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 8 TO ATTACHMENT 2.6‑A

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

RESOURCE STANDARDS FOR 1902(f) STATES -

CATEGORICALLY NEEDY

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 8a TO ATTACHMENT 2.6‑A

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

LESS RESTRICTIVE METHODS OF TREATING INCOME

UNDER SECTION 1902(r)(2) OF THE ACT*

Section 1902(f) State Non-Section 1902(f) State

*Less restrictive methods may not result in exceeding gross income limitations under section 1903(f).

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 8b TO ATTACHMENT 2.6‑A

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

LESS RESTRICTIVE METHODS OF TREATING RESOURCES

UNDER SECTION 1902(r)(2) OF THE ACT

Section 1902(f) State Non-Section 1902(f) State

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 8c TO ATTACHMENT 2.6‑A

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

STATE LONG-TERM CARE INSURANCE PARTNERSHIP

1902(r)(2) The following more liberal methodology applies to individuals who are

1917(b)(1)(C) eligible for medical assistance under one of the following eligibility groups:

An individual who is a beneficiary under a long-term care insurance policy that meets the requirements of a “qualified State long-term care insurance partnership” policy (partnership policy) as set forth below, is given a resource disregard as described in this amendment. The amount of the disregard is equal to the amount of the insurance benefit payments made to or on behalf of the individual. The term “long-term care insurance policy” includes a certificate issued under a group insurance contract.

___ The State Medicaid Agency (Agency) stipulates that the following requirements will be satisfied in order for a long-term care policy to qualify for a disregard. Where appropriate, the Agency relies on attestations by the State Insurance Commissioner (Commissioner) or other State official charged with regulation and oversight of insurance policies sold in the state, regarding information within the expertise of the State’s Insurance Department.

• The policy is a qualified long-term care insurance policy as defined in section 7702B(b) of the Internal Revenue Code of 1986.

• The policy meets the requirements of the long-term care insurance model regulation and long-term care insurance model Act promulgated by the National Association of Insurance Commissioners (as adopted as of October 2000) as those requirements are set forth in section 1917(b)(5)(A) of the Social Security Act.

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 8c TO

ATTACHMENT 2.6‑A

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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

• The policy was issued no earlier than the effective date of this State plan amendment.

• The insured individual was a resident of a Partnership State when coverage first became effective under the policy. If the policy is later exchanged for a different long-term care policy, the individual was a resident of a Partnership State when coverage under the earliest policy became effective.

• The policy meets the inflation protection requirements set forth in section 1917(b)(1)(C)(iii)(IV) of the Social Security Act.

• The Commissioner requires the issuer of the policy to make regular reports to the Secretary that include notification regarding when benefits provided under the policy have been paid and the amount of such benefits paid, notification regarding when the policy otherwise terminates, and such other information as the Secretary determines may be appropriate to the administration of such partnerships.

• The State does not impose any requirement affecting the terms or benefits of a partnership policy that the state does not also impose on non-partnership policies.

• The State Insurance Department assures that any individual who sells a partnership policy receives training, and demonstrates evidence of an understanding of such policies and how they relate to other public and private coverage of long-term care.

• The Agency provides information and technical assistance to the Insurance Department regarding the training described above.

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 8c TO

ATTACHMENT 2.6‑A

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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

The State elects to be exempt from the standards for reciprocal recognition among partnership States under section 6021(b) of the DRA.

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 9b TO ATTACHMENT 2.6‑A

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

TRANSFER OF ASSETS

1917(c) FOR TRANSFERS OF ASSETS FOR LESS THAN FAIR MARKET VALUE MADE ON OR AFTER FEBRUARY 8, 2006, the agency provides for the denial of certain Medicaid services.

1. Institutionalized individuals are denied coverage of certain Medicaid services upon disposing of assets for less than fair market value on or after the look‑back date.

The agency does not provide medical assistance coverage for institutionalized individuals for the following services:

• Nursing facility services;

• Nursing facility level of care provided in a medical institution;

• Home and community-based services under a 1915(c) waiver.

2. Non‑Institutionalized Individuals

The agency withholds payment to non‑institutionalized individuals for the following services:

• Home health services (section 1905(a)(7));

• Home and community care for functionally disabled and elderly adults (section 1905(a)(22));

• Personal care services furnished to individuals who are not inpatients in certain medical institutions, as recognized under agency law and specified in section 1905(a)(24).

The agency applies these provisions to the following non­institutionalized eligibility groups. These groups can be no more restrictive than those set forth in section 1905(a) of the Social Security Act:

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 9b TO ATTACHMENT 2.6‑A

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State:

TRANSFER OF ASSETS

2. Non‑institutionalized individuals (Continued)

The following other long‑term care services for which medical assistance is otherwise under the agency plan:

3. Penalty Date ‑‑The beginning date of each penalty period imposed for an uncompensated transfer of assets is the later of:

• the first day of the month during or after which assets have been transferred for less than fair market value;

The State uses the first day of the month in which the assets were transferred

The State uses the first day of the month after the month in which the assets were transferred

OR

• the date on which the individual is eligible for medical assistance under the State Plan and is receiving institutional level of care services as described in paragraphs 1 and 2 that, were it not for the imposition of the penalty period, would be covered by Medicaid;

AND

which does not occur during any other period of ineligibility for services by reason of a transfer of assets penalty.

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 9b TO ATTACHMENT 2.6‑A

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State:

TRANSFER OF ASSETS

4. Penalty Period I - Institutionalized Individuals ‑‑

In determining the penalty for an institutionalized individual, the agency uses:

the average monthly cost to a private patient of nursing facility services in the State at the time of application;

The amount the State uses is _________.

the average monthly cost to a private patient of nursing facility services in the community in which the individual is institutionalized at the time of application. The amounts the State uses in communities are as follows:

4. Penalty Period ‑ Non‑institutionalized Individuals –

The agency imposes a penalty period determined by using the same method as is used for an institutionalized individual, including the use of the average monthly cost of nursing facility services;

imposes a shorter penalty period than would be imposed for institutionalized individuals, as outlined below:

6. Penalty period for amounts of transfer less than cost of nursing facility care –

Where the amount of the transfer is less than the monthly cost of nursing facility care, the agency imposes a penalty for less than a full month, based on the option selected in item 4.

The State adds together all transfers for less than fair market value made during the look-back period in more than one month and calculates a single period of ineligibility, that begins on the earliest date that would otherwise apply if the transfer had been made in a single lump sum.

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 9b TO ATTACHMENT 2.6‑A

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State:

TRANSFER OF ASSETS

7. Transfer Periods – transfer by a spouse that results in a penalty period for the individual --

(a) The agency apportions any existing penalty period between the spouses using the method outlined below, provided the spouse is eligible for Medicaid. A penalty can be assessed against the spouse, and some portion of the penalty against the individual remains.

(b) If one spouse is no longer subject to a penalty, the remaining penalty period must be served by the remaining spouse.

8. Treatment of a transfer of income ‑‑

When income has been transferred as a lump sum, the agency will calculate the penalty period on the lump sum value.

When a stream of income or the right to a stream of income has been transferred, the agency will impose a penalty period for each income payment.

For transfers of individual income payments, the agency will impose partial month penalty periods using the methodology selected in 6. above.

For transfers of the right to an income stream, the agency will base the penalty period on the combined actuarial value of all payments transferred.

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 9b TO ATTACHMENT 2.6‑A

Page 5

State:

TRANSFER OF ASSETS

9. Imposition of a penalty would work an undue hardship--

The agency does not impose a penalty for transferring assets for less than fair market value in any case in which the agency determines that such imposition would work an undue hardship. The agency will use the following criteria in making undue hardship determinations:

Application of a transfer of assets penalty would deprive the individual:

1. Of medical care such that the individual’s health or life would be endangered; or

2. Of food, clothing, shelter, or other necessities of life.

10. Procedures for Undue Hardship Waivers

The agency has established a process under which hardship waivers may be requested that provides for:

1. Notice to a recipient subject to a penalty that an undue hardship exception exists;

2. A timely process for determining whether an undue hardship waiver will be granted; and

3. A process, which is described in the notice, under which an adverse determination can be appealed.

These procedures shall permit the facility in which the institutionalized individual is residing to file an undue hardship waiver application on behalf of the individual with the consent of the individual or the individual’s personal representative.

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 9b TO ATTACHMENT 2.6‑A

Page 6

State:

TRANSFER OF ASSETS

11. Bed Hold Waivers for Hardship Applicants --

The agency provides that while an application for an undue hardship waiver is pending in the case of an individual who is a resident of a nursing facility:

Payments to the nursing facility to hold the bed for the individual will be made for a period not to exceed days (may not be greater than 30).

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 10 TO ATTACHMENT 2.6‑A

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

The agency does not apply the trust provisions in any case in which the agency determines that such application would work an undue hardship.

Under the agency’s undue hardship provisions, the agency exempts the funds in an irrevocable burial trust.

The maximum value of the exemption for an irrevocable burial trust is $ .

The agency’s criteria for establishing due hardship are described below:

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 11 TO ATTACHMENT 2.6‑A

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

COST EFFECTIVENESS METHODOLOGY FOR

COBRA CONTINUATION BENEFICIARIES

1902(u) of the Act Premium payments are made by the agency only if such payments are likely to be cost-effective. The agency specifies the guidelines used in determining cost effectiveness by selecting one of the following methods.

The methodology as described in SMM section 3598.

Another cost-effective methodology as described below:

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 12 TO

ATTACHMENT 2.6‑A

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

VARIATIONS FROM THE BASIC PERSONAL NEEDS ALLOWANCE

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 12 TO

ATTACHMENT 2.6‑A

Page 2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ELIGIBILITY‑‑UNDER SECTION 1931 OF THE ACT

The State covers low‑income families and children under section 1931 of the Act.

The following groups were included in the AFDC State Plan effective July 16, 1996:

Pregnant women with no other eligible children.

Children age 18 who are full‑time students in a secondary school or the equivalent level of vocational or technical training.

In determining eligibility for Medicaid, the agency uses the AFDC standards and methodologies in effect as of July 16, 1996 without modification.

In determining eligibility for Medicaid, the agency uses the AFDC standards and methodologies in effect as of July 16, 1996 with the following modifications.

The agency applies lower income standards which are no lower than the AFDC standards in effect on May 1, 1988, as follows:

The agency applies higher income standards than those in effect as of July 16, 1996, increased by no more than the percentage increases in the CPI‑U since July 16, 1996, as follows:

TN No. Approval Date Effective Date

Supersedes TN No.

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 1931 OF THE ACT

(Continued)

The agency applies higher resource standards than those in effect as of July 16, 1996, increased by no more than the percentage increases in the CPI‑U since July 16, 1996, as follows:

The agency uses less restrictive income and/or resource methodologies than those in effect as of July 16, 1996, as follows:

The income and/or resource methodologies that the less restrictive methodologies replace are as follows:

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 12 TO

ATTACHMENT 2.6‑A

Page 4

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

ELIGIBILITY‑‑UNDER SECTION 1931 OF THE ACT

(Continued)

The agency terminates medical assistance (except for certain pregnant women and children described in section 1902(l) of the Act) for individuals who fail to meet Temporary Assistance for Needy Families (TANF) work requirements.

The agency defines unemployment for the section 1931 population as follows:

The agency continues to apply the following waivers of provisions of part A of Title IV of the Act in effect as of July 16, 1996, or submitted prior to August 22, 1996 and approved by the Secretary on or before July 1, 1997.

Waiver under sections 402(a)(41) and 407 of the Act allows the State to provide benefits to families in which the principal earner works 100 or more hours per month.

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 13 TO ATTACHMENT 2.6‑A

Page 1

State:

Citation Condition or Requirement

Section 1924 Provisions

A. Income and resource eligibility policies used to determine eligibility for institutionalized individuals who have spouses living in the community are consistent with section 1924 of the Act.

B. The definition of undue hardship for purposes of determining if institutionalized spouses receive Medicaid in spite of having excess countable resources is described below:

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 14 TO ATTACHMENT 2.6‑A

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

INCOME AND RESOURCE REQUIREMENTS FOR

TUBERCULOSIS (TB) INFECTED INDIVIDUALS

For TB infected individuals under section 1902(z)(1) of the act, the income and resource eligibility levels are as follows:

1. Income: The SSI breakeven point for earned income.

2. Resources: The SSI resource standard.

TN No. Approval Date Effective Date

Supersedes TN No.

Revision: SUPPLEMENT 15 TO ATTACHMENT 2.6‑A

Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State:

1917(f) The State agency denies reimbursement for nursing facility services and other long-term care services covered under the State plan for an individual who does not have a spouse, child under 21 or adult disabled child residing in the individual’s home, when the individual’s equity interest in the home exceeds the following amount:

_____ $500,000 (increased by the annual percentage increase in the urban component of the consumer price index beginning with 2011, rounded to the nearest $1,000).

_____ An amount that exceeds $500,000 but does not exceed $750,000 (increased by the annual percentage increase in the urban component of the consumer price index beginning with 2011, rounded to the nearest $1,000).

The amount chosen by the State is _________________.

_____ This higher standard applies statewide.

_____ This higher standard does not apply statewide. It only applies in the following areas of the State:

_____ This higher standard applies to all eligibility groups.

_____ This higher standard only applies to the following eligibility groups:

The State has a process under which this limitation will be waived in cases of undue hardship.

TN No. Approval Date Effective Date

Supersedes TN No.