Revision: ATTACHMENT 2.6‑A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
ELIGIBILITY CONDITIONS AND REQUIREMENTS
Citation(s) Condition or Requirement
A. Each individual covered under the plan meets the following conditions:
42 CFR Part 436, 1. Is financially eligible to receive services.
Subpart G
42 CFR Part 436, 2. Meets the applicable non-financial eligibility conditions.
Subpart F
a. For the categorically needy:
For AFDC-related individuals (all groups except as specified under items A.2.a.(ii) – (ix) below), meets the non‑financial eligibility conditions of the State’s AFDC plan in effect as of July 16, 1996.
For aged, blind and disabled groups (all groups except as specified under items A.2.a(ii) – (ix) below), meets the non-financial eligibility conditions of the related cash assistance program.
1902(l) of the Act (iii) For financially eligible pregnant women, infants, or children with incomes up to a percentage of the Federal poverty level covered as optional groups 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 Act (iv) For financially eligible aged or disabled individuals 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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Territory:
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).
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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Territory:
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.
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Territory:
Citation(s) Condition or Requirement
42 CFR 436.406 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;
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.
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Territory:
Citation(s) Condition or Requirement
42 CFR 436.403 4. Is a resident of the State, with the intent to remain permanently or
1902(b) of the Act for an indefinite period, regardless of whether the individual 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; State has no interstate residency agreements.
42 CFR 436.1004, 5. Is not covered for Federal financial participation (FFP) for
1905(a)(28) of the expenditures for medical assistance services if the individual is
Act residing, as defined in 42 CFR 435.1010, as an:
a. Inmate of a public institution; or
b. Inpatient in an institution for mental diseases and is under age 65, unless the individual is under age 22 and receiving inpatient psychiatric services under 42 CFR 440.160.
Not applicable with respect to inpatient psychiatric services for individuals under age 22 because such services are not provided under the plan.
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Territory:
Citation(s) Condition or Requirement
42 CFR 436.610, 6. If legally able, is required, as a condition of eligibility, to:
1912 of the Act
a. Assign to the Medicaid agency his or her own 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.
Cooperate with the Medicaid agency in establishing the paternity of any eligible child born out of wedlock and in obtaining medical support and payments for medical care for the individual or any other person who is eligible for Medicaid and on whose behalf the individual can make an assignment, except that the individuals are exempt from these requirements if they are poverty-level related pregnant women or women in the post-partum period eligible under 1902(l)(1)(A) of the Act or are individuals who establish good cause, as determined by the Medicaid agency, for not cooperating; and
Cooperate in identifying and providing information to assist the Medicaid agency in pursing any third party which may be liable to pay for care and services available under the Medicaid plan unless the individual establishes good cause, as determined by the Medicaid agency, for not cooperating.
Assignment of rights to benefits is automatic because of State law.
42 CFR 435.910 7. Is required, as a condition of eligibility, to furnish his/her social
and 436.901, security account number (or numbers, if he/she has more than
1137(a)(1) and (f) one number), with the exception of aliens seeking coverage for
of the Act 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.
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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
Citation(s) Condition or Requirement
42 CFR 436.832 B. Post-Eligibility Treatment of Institutionalized Individuals
The following monthly amounts for personal needs are deducted from total monthly income in the application of an institutionalized individual’s or couple’s income to the cost of institutionalized care:
1. Personal Needs Allowance (PNA) of Not Less Than $30 For Individuals and $60 For Couples For All Institutionalized Persons.
a. Aged, blind, disabled:
Individuals $
Couples $
For the following persons with greater need:
Supplement 7 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.
b. AFDC related:
Children $
Adults $
For the following persons with greater need:
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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
Citation(s) Condition or Requirement
Supplement 7 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. For the maintenance needs of the spouse at home with no other family members. The amount is based on a reasonable assessment of need but does not exceed the higher of the:
o Highest mandatory categorically needy level for an individual, or
o Medically needy level for an individual.
as selected below: (Check one)
Mandatory categorically needy level in Supplement 1 to ATTACHMENT 2.6-A
Medically needy level in Supplement 1 to ATTACHMENT 2.6-A
Other: $
3. For the maintenance needs of each family member at home whether or not a spouse is also in the home. The amount must be based on a reasonable assessment of need but must not exceed the higher of the:
o AFDC level; or
o Medically needy level:
as selected below: (Check one)
AFDC levels in Supplement 1 to ATTACHMENT 2.6-A
Medically needy levels in Supplement 1 to ATTACHMENT 2.6-A
Other: $
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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
Citation(s) Condition or Requirement
Amounts for health care expenses described below that are incurred by and for the institutionalized individual or the institutionalized couple and are not subject to the payment by a third party:
a. Medicaid, Medicare, and other health insurance premiums, deductibles, or coinsurance charges, and copayments.
b. 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.)
5. A monthly amount for the maintenance of the home of the an institutionalized individual or institutionalized 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 home within that period:
No.
Yes.
Amount for the maintenance of home is: $ .
Amount for maintenance of home is the actual maintenance costs not to exceed $ .
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Territory:
Citation Condition or Requirement
1902(l) of the Act 6. Benefits paid under AB, APTD, or AABD to blind or disabled individuals during the initial 2 months in which the individuals receive care in a hospital, SNF, or ICF if the individuals are allowed to retain the benefits under agreement with the facility; or during a temporary stay in a hospital, SNF, or ICF, if it is determined that the individuals’ stay is not likely to exceed 3 months and they must continue to maintain a home to which they may return upon leaving the institution.
42 CFR 436 C. Financial Eligibility – Categorically and Medically Needy, Qualified
Subparts G and I Medicare Beneficiaries, Qualified Disabled and Working Individuals, Qualifying Individuals, and Specified Low-Income Medicare Beneficiaries
For an individual being considered for an AFDC-related Medicaid eligibility group, the income and resource levels and methods for determining countable income and resources in the State’s AFDC plan in effect on July 16, 1996 or more liberal methods under section 1902(r)(2) of the Act, or more restrictive or liberal methods under section 1931 of the Act, apply as specified below.
For individuals not in AFDC-related groups, the income and resource levels and methods of the appropriate cash assistance programs or more liberal methods under section 1902(r)(2) of the Act, apply as specified below.
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Territory:
Citation Condition or Requirement
For individuals who are deemed to be cash assistance recipients under section 1931 of the Act, the financial eligibility requirements specified in this section C, ATTACHMENT 2.2-A and the Supplements to ATTACHMENT 2.6-A 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 criteria used by the State to not count the funds in a trust as specified in ATTACHMENT 2.6-A, page 15, item 3 because it would work an undue hardship.
Supplement 7 to ATTACHMENT 2.6‑A specifies the variations from the basic personal needs allowance under section 1902(a)(50) of the Act.
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.
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Territory:
Citation Condition or Requirement
Supplement 8c to ATTACHMENT 2.6-A specifies requirements related to the DRA long term care insurance partnership programs.
Supplement 9b to ATTACHMENT 2.6-A specifies the criteria used for transfers of assets under section 1917(c) of the Act, which affects the eligibility of institutionalized individuals on or after February 8, 2006.
Supplement 11 to ATTACHMENT 2.6-A specifies cost effectiveness methodology for COBRA continuation beneficiaries.
Supplement 12 to ATTACHMENT 2.6-A specifies the AFDC covered groups and the income and resource eligibility criteria for low-income families under section 1931 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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Territory:
Citation Condition or Requirement
Categorically Need Income Levels
For categorically needy groups other than those specified in items C.1.b and c. below, the financial eligibility income levels for the related cash assistance programs are applied. Supplement 1 to ATTACHMENT 2.6-A specifies the payment standard under the State’s AFDC plan in effect on July 16, 1996.
Supplement 1 to ATTACHMENT 2.6-A specifies the income eligibility levels for the following groups of individuals with income standards related to the Federal income poverty level:
1902(l) of the Act (i) Optional categorically needy groups of pregnant women, infants or children covered under the provisions of sections 1902(a)(10)(A)(i)(IV), 1902(a)(10)(A)(i)(VI), 1902(a)(10)(A)(i)(VII), 1902(a)(10)(A)(ii)(IX), and 1902(l)(4)(A) of the Act.
1902(m) of the Act (ii) Optional categorically needy aged and disabled individuals covered under the provisions of section 1902(m)(1) of the Act.
1902(a)(10)(E)(i) (iii) Optional Qualified Medicare Beneficiaries covered
of the Act under the provisions of section 1902(a)(10)(E)(i) of the Act.
1902(a)(10)(E)(iii) (iv) Optional Specified Low-Income Medicare Beneficiaries
of the Act covered under the provisions of section 1902(a)(10)(E)(iii) of the Act.
1902(a)(10)(E)(iv) (v) Optional Qualifying Individuals covered under the
of the Act provisions of section 1902(a)(10)(E)(iv) of the Act.
1902(a)(10)(E)(ii) c. For optional groups of Qualified Disabled and Working Disabled Individuals, the financial eligibility income levels specified in section 1905(s) of the Act are applied.
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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
Citation(s) Condition or Requirement
1902(a)(10), 2. Income and Resource Methodologies –
1902(a)(17), and
1902(r)(2) of the 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 and 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 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 c.-e. of this section.
42 CFR 436.602, (2) In determining relative financial responsibility of
1902(a)(17)(D) of relatives and other individuals, the Medicaid agency
the Act 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.
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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
Citation(s) Condition or Requirement
b. Aged, Blind and Disabled Individuals. For aged, blind, and disabled individuals, including aged and disabled individuals covered under section 1902(m)(1) of the Act, the agency uses the following methods for determining countable income and resources.
(1) The methods of the appropriate cash assistance program only; or
(2) The methods of the appropriate cash assistance program and/or more liberal methods described in Supplements 8a and 8b to ATTACHMENT 2.6‑A.
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Territory:
FINANCIAL ELIGIBILITY
Citation Condition or Requirement
1902(l)(3)(E) and c. Poverty-level related pregnant women and infants
1902(r)(2) of the Act
(1) For pregnant women and infants covered under sections 1902(a)(10)(A)(i)(IV), 1902(a)(10)(ii)(IX), or 1902(l)(4) of the Act, the agency uses the following methods in determining countable income:
The methods of the State’s approved AFDC plan in effect on July 16, 1996;
The methods of the State’s approved title IV-E plan;
The methods of the State’s AFDC State plan in effect on July 16, 1996 and/or any more liberal methods described in Supplement 8a to ATTACHMENT 2.6-A; or
The methods of the State’s approved title IV‑E plan and/or any more liberal methods described in Supplement 8a to ATTACHMENT 2.6-A.
The methods used under sections 1612 and 1613 of the Act;
The methods used under sections 1612 and 1613 of the Act and/or any more liberal methods described in Supplement 3 to ATTACHMENT 2.6-A; or
Not applicable. The agency does not consider resources in determining eligibility.
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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
FINANCIAL ELIGIBILITY
Citation(s) Condition or Requirement
(2) For infants covered under sections 1902(a)(10)(A)(i)(IV), 1902(a)(10)(A)(i)(IX) or 1902(l)(4) of the Act, the agency uses the following methods in the treatment of resources:
The methods of the State’s approved AFDC plan in effect on July 16, 1996 only.
The methods of 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; or
Not applicable. The agency does not consider resources in determining eligibility.
42 CFR 436.602, (3) In determining financial responsibility of relatives and
1902(a)(17)(D) of other individuals, the Medicaid agency considers only
the Act the income of spouses and the income of parents as available to children until the children become 21.
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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
FINANCIAL ELIGIBILITY
Citation(s) Condition or Requirement
d. For poverty-level related children aged 1 up to age 6 who are described in sections 1902(a)(10)(A)(i)(VI), 1902(l)(1)(C) and 1902(l)(4)(B) of the Act:
The agency uses the following methods for determining countable income:
The methods of the State’s approved AFDC plan in effect on July 16, 1996 only;
The methods of 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;
The methods of the State’s approved title IV-E plan only; or
The methods of the State’s approved title IV-E plan and/or any more liberal methods described in Supplement 8a to ATTACHMENT 2.6-A.
The agency uses the following methods in the treatment of resources:
The methods of the State’s approved AFDC plan in effect on July 16, 1996 only;
The methods of 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; or
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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
FINANCIAL ELIGIBILITY
Citation(s) Condition or Requirement
Not applicable. The agency does not consider resources in determining eligibility.
42 CFR 436.602, (3) In determining financial responsibility of relatives and
1902(a)(17)(D) of other individuals, the Medicaid agency considers only
the Act the income of spouses and the income of parents as available to children until the children become 21.
For poverty-level related children aged 6 up to age 19 who are described in sections 1902(a)(10)(A)(i)(VII), 1902(l)(1)(D) and 1902(l)(4)(B) of the Act:
The agency used the following methods for determining countable income:
The methods of the State’s approved AFDC plan in effect on July 16, 1996 only;
The methods of 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;
The methods of the State’s approved title IV-E plan only; or
The methods of the State’s 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 PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
FINANCIAL ELIGIBILITY
Citation(s) Condition or Requirement
The agency uses the following methods in the treatment of resources:
The methods of the State’s approved AFDC plan in effect on July 16, 1996 only;
The methods of 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; or
Not applicable. The agency does not consider resources in determining eligibility.
42 CFR 436.602, (3) In determining financial responsibility of relatives and
1902(a)(17)(D) of other individuals, the Medicaid agency considers only
the Act the income of spouses and the income of parents as available to children until the children become 21.
1902(a)(10)(E)(i) and f. For Qualified Medicare Beneficiaries covered under section
1902(r)(2) of the Act 1902(a)(10)(E)(i) of the Act, the agency uses the following methods for treatment of income --
The methods used under the SSI program.
The methods used under the SSI program and/or more liberal methods described in Supplement 8a to ATTACHMENT 2.6-A.
1902(a)(10)(E)(ii) g. For Qualified Disabled and Working Individuals covered
of the Act under section 1902(a)(10)(E)(ii) of the Act, the agency uses the methods used under the SSI program for treatment of income.
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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
FINANCIAL ELIGIBILITY
Citation(s) Condition or Requirement
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 g. 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 g. for QMBs.
1902(u) of the Act j. COBRA Continuation Beneficiaries - In determining countable income for COBRA continuation beneficiaries, the agency applies the disregards of the SSI program;
NOTE: For COBRA continuation beneficiaries specified at section 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).
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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
Citation(s) Condition or Requirement
1902(a)(10)(A)(ii) k. Working Individuals with Disabilities – BBA
(XIII) 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 methodologies than the SSI program. More liberal 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.
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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
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):
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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
Citation(s) Condition or Requirement
1902(a)(10)(A)(ii) Income Methodologies
(XV) 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 income methodologies of the SSI program.
____ 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.
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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
Citation(s) Condition or Requirement
1902(a)(10)(A)(ii) Resource Methodologies
(XV) 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.
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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
Citation(s) Condition or Requirement
1902(a)(10)(A)(ii) ____ The agency does not disregard funds in retirement
(XV) and 1902(r)(2) accounts.
of the Act
____ The agency uses resource methodologies in addition to any indicated above that are more liberal than those used by the SSI program. More liberal resource methodologies are described in Supplement 8b to ATTACHMENT 2.6-A.
____ The agency uses the resource methodologies of the SSI Program.
TN No: Approval Date Effective Date
Supersedes TN No.
Revision: ATTACHMENT 2.6‑A
Page 14f
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
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 14g
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
Citation(s) Condition or Requirement
1902(a)(10)(A)(ii) Income Methodologies
(XVI) 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 income methodologies of the SSI program.
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 14h
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
Citation(s) Condition or Requirement
1902(a)(10)(A)(ii) Resource Methodologies
(XVI) 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 14i
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
Citation(s) Condition or Requirement
1902(a)(10)(A)(ii) The agency does not disregard funds in retirement
(XVI) and 1902(r)(2) accounts.
of the Act
The agency uses resource methodologies in addition to any indicated above that are more liberal than those used by the SSI program. More liberal resource methodologies are described in Supplement 8b to ATTACHMENT 2.6-A.
The agency uses the resource methodologies of the SSI Program.
TN No: Approval Date Effective Date
Supersedes TN No.
Revision: ATTACHMENT 2.6‑A
Page 14j
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
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 14k
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
Citation(s) Condition or Requirement
1902(a)(10)(A)(ii) Payment of Premiums or Other Cost Sharing Charges
(XIII) of the Act
For individuals eligible under the BBA eligibility group described in No. 21 on page 18e of 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 14l
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
Citation(s) Condition or Requirement
1902(a)(10)(A)(ii) For individuals eligible under the Basic Coverage Group
(XV) and (XVI), and described in No. 22 on page 18e of ATTACHMENT 2.2-A, and 1916(g) of the Act the Medical Improvement Group described in No. 23 on
page 18e of 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 14m.
TN No: Approval Date Effective Date
Supersedes TN No.
Revision: ATTACHMENT 2.6‑A
Page 14m
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
Citation(s) Condition or Requirement
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 14n
Territory:
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 14o
Territory:
Citation Condition or Requirement
1902(a)(10)(A)(ii) Income Methodologies
(XIX) 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 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 14p
Territory:
Citation Condition or Requirement
1902(a)(10)(A)(ii) Interaction with Employer Sponsored Family Coverage
(XIX) and 1916(i)
of the Act For individuals eligible under the FOA eligibility group described in No. 24 on page 18f of 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 14q and 14r) 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 14q
Territory:
Citation Condition or Requirement
1902(a)(10)(A)(ii) Payment of Premiums
(XIX) and 1916(i)
of the Act For individuals eligible under the FOA eligibility group described in No. 24 on page 18f of 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 14r
Territory:
Citation Condition or Requirement
1902(a)(10)(A)(ii) Payment of Premiums (Continued)
(XIX) and 1916(i)
of the Act NOTE: A State may not require prepayment of premiums 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 15
Territory:
Citation Condition or Requirement
1917(d)(5) of the Act 3. Medicaid Trusts
The agency does not count the funds in a trust as described above in any instance where the State determines that it would work an undue hardship. Supplement 4 to ATTACHMENT 2.6‑A specifies what constitutes an undue hardship.
TN No: Approval Date Effective Date
Supersedes TN No.
Revision: ATTACHMENT 2.6‑A
Page 16
Territory:
Citation Condition or Requirement
1902(a)(10)(C) 4. Medically Needy Income Levels
of the Act
a. Medically needy income levels (MNILs) are based on family size.
b. The MNIL does not diminish by family size.
Supplement 1 to ATTACHMENT 2.6-A specifies the MNILs for all covered medically needy groups.
42 CFR 436.831 5. Handling of Excess Income – Spend-down for Medically Needy
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 six months. The agency measures available income as specified below:
The agency uses one budget period of ___ months(s) during which countable income for the period is reduced by the amount of incurred medical and 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 and 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 17
Territory:
Citation Condition or Requirement
1902(a)(17) b. The agency does not deduct incurred expenses subject to
of the Act payment by a third party unless the third party is a public program (other than Medicaid) of a State and the program is financed by the State.
c. 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 436.831 d. Subject to the carryover expenses described in (e) below, the agency deducts incurred expenses, based on the age of the expenses as checked below, but only to the extent that the amount has not been previously deducted 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.
The agency deducts expenses incurred prior to the third month before the month of application, but incurred no earlier than: .
The agency deducts expenses incurred no earlier than the third month before the month of application.
TN No: Approval Date Effective Date
Supersedes TN No.
Revision: ATTACHMENT 2.6‑A
Page 17a
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
Citation(s) Condition or Requirement
e. 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 or no eligibility, but not later than
.
Indefinitely.
f. The agency deducts incurred medical or remedial care expenses in the following order (check one):
By the type of service, in the following order:
Premiums, deductibles, coinsurance and co-payments.
Expenses for necessary medical or remedial care services that are recognized under State law but not included in the State plan.
Expenses for necessary medical or remedial care services that is included in the State plan, including those that exceed agency limitation on amount, duration and scope of services.
In chronological order by service date.
In chronological order by bill submission date.
TN No: Approval Date Effective Date
Supersedes TN No.
Revision: ATTACHMENT 2.6‑A
Page 17b
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
Citation(s) Condition or Requirement
g. 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 d.
Reasonable limits are described below:
1903(f)(2) h. If countable income excess the MNIL standard the
of the Act agency deducts spenddown payments made to the State by the individual.
Individuals may elect or reject the pay in option on a:
Monthly basis; or
Quarterly basis.
TN No: Approval Date Effective Date
Supersedes TN No.
Revision: ATTACHMENT 2.6‑A
Page 18
Territory:
Citation Condition or Requirement
Resource Standard – Categorically Needy
Except as specified in item C.6.b.-d. below, the resource standards are the same as those in the related cash assistance programs.
1902(l)(3) of the Act b. For pregnant women and infants covered as optional groups under the provisions of section 1902(a)(10)(A)(i)(IV) or 1902(a)(10)(A)(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 sections 1612 and 1613 of the Act 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 19
Territory:
Citation Condition or Requirement
1902(l)(3) of the Act c. For children aged 1 up to age 6 who are covered as optional groups under the provisions 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, for 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(l)(3) of the Act d. For children aged 6 up to age 19 who are covered as optional groups under the provisions of sections 1902(a)(10)(A)(i)(VII), 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, for 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(a)(10)(C) 7. Resource Standard – Medically Needy
of the Act
42 CFR 436.845 For individuals covered as medically needy, the agency applies a resource standard.
Yes. Supplement 2 to ATTACHMENT 2.6-A specifies the standard, which, for 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 20
Territory:
Citation Condition or Requirement
1902(a)(10)(E)(i) 8. a. For Qualified Medicare Beneficiaries covered under section
and 1902(r)(2) of 1902(a)(10)(E)(i) of the Act the agency uses the following
the Act methods for treatment of resources:
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) b. For Qualified Disabled and Working Individuals covered
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(a)(10)(E)(iii) c. 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 following methods for treatment of resources:
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. If more liberal methods are used, the same methods are applied as in a. for QMBs.
1902(a)(10)(E)(iv) d. For Qualifying Individuals covered under section
and 1902(r)(2) of 1902(a)(10)(E)(iv) of the Act the agency uses the following
the Act methods for treatment of resources:
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. If more liberal methods are used, the same methods are applied as in a. for QMBs.
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
Territory:
Citation(s) Condition or Requirement
1902(u) of the Act e. For COBRA continuation beneficiaries, the agency uses the methods of the SSI program for treatment of resources.
1902(a)(10)(E)(i), 9. Resource Standard – Qualified Medicare Beneficiaries, Specified
1902(a)(10)(E)(iii), Low-Income Medicare Beneficiaries and Qualifying Individuals
1902(a)(10)(E)(iv)
and 1905(p)(1)(C) For Qualified Medicare Beneficiaries, Specified Low-Income
of the Act Medicare Beneficiaries and Qualifying Individuals covered under sections 1902(a)(10)(E)(i), 1902(a)(10)(E)(iii) and 1902(a)(10)(E)(iv) of the Act, the resource standard is twice the SSI resource standard.
1902(a)(10)(E)(ii) 10. Resource Standard – Qualified Disabled and Working Individuals
and 1905(s) of the
Act For Qualified Disabled and Working Individuals covered under section 1902(a)(10)(E)(ii) of the Act, the resource standard is twice the SSI resource standard.
1902(u) of the Act 11. For COBRA continuation beneficiaries, the resource standard is twice the SSI resource standard for an individual.
Excess Resources – Categorically Needy and Medically Needy, Qualified Medicare Beneficiaries, Qualified Disabled and Working Individuals, Specified Low-Income Medicare Beneficiaries, and Qualifying Individuals
Any excess resources make the individual ineligible.
TN No: Approval Date Effective Date
Supersedes TN No.
Revision: ATTACHMENT 2.6‑A
Page 22
Territory:
Citation Condition or Requirement
42 CFR 436.901 13. Effective Date of Eligibility
Groups other than Qualified Medicare Beneficiaries
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 or Disabled
AFDC-Related
Coverage is available only for the period during the month for which the following individuals meet the eligibility requirements:
Aged, Blind or Disabled
AFDC-Related
For the retroactive period –
Coverage is available only for the period during the month for which the following individuals meet the eligibility requirements:
Aged, Blind or Disabled
AFDC-Related
TN No: Approval Date Effective Date
Supersedes TN No.
Revision: ATTACHMENT 2.6‑A
Page 23
Territory:
Citation Condition or Requirement
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 or 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 had they applied:
Aged, Blind or Disabled
AFDC-Related
TN No: Approval Date Effective Date
Supersedes TN No.
Revision: ATTACHMENT 2.6‑A
Page 24
Territory:
Citation Condition or Requirement
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: SUPPLEMENT 1
TO ATTACHMENT 2.6‑A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
INCOME ELIGIBILITY LEVELS
A. CATEGORICALLY NEEDY
AFDC Standards Under the AFDC Plan in Effect on July 16, 1996:
Maximum Payment
Family Size Need Standard Payment Standard Amounts
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 1 TO ATTACHMENT 2.6‑A
Page 2
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
INCOME ELIGIBILITY LEVELS (Continued)
B. OPTIONAL CATEGORICALLY NEEDY GROUPS WITH INCOME 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 section 1902(a)(10)(A)(i)(IV), 1902(a)(10)(A)(ii)(IX) and 1902(l)(2) of the Act are as follows:
Effective ______________, based on percent of the official Federal income poverty level:
Family size Income Level
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 1 TO ATTACHMENT 2.6‑A
Page 3
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
INCOME ELIGIBILITY LEVELS (Continued)
B. OPTIONAL CATEGORICALLY NEEDY GROUPS WITH INCOMES RELATED TO FEDERAL POVERTY LEVEL
2. Children
Children Aged 1 Up to Age 6
For children under section 1902(a)(10)(A)(i)(VI) of the Act, the income eligibility level is percent of the Federal poverty level (as revised annually in the Federal Register) for the family size involved.
Children Aged 6 Up to Age 19
For children under section 1902(a)(10)(A)(i)(VII) of the Act, the income eligibility level is 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 4
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
INCOME ELIGIBILITY LEVELS (Continued)
3. Aged and Disabled Individuals under Section 1902(m) of the Act
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 $
6 $
7 $
8 $
9 $
10 $
For Each Additional
Person, Add: $
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
Territory:
INCOME ELIGIBILITY LEVELS (continued)
C. OPTIONAL GROUP OF QUALIFIED MEDICARE BENEFICIARIES
The levels for determining income eligibility for Qualified Medicare Beneficiaries under the provision of Section 1905(p)(2)(A) and 1905(p)(4) of the Act are based on 100 percent of the official Federal Poverty level.
D. OPTIONAL GROUP OF SPECIFIED LOW-INCOME MEDICARE BENEFICIARIES
The levels for determining income eligibility for Specified Low-Income Medicare Beneficiaries under the provision of Section 1905(p)(2)(A) and 1905(p)(4) of the Act are based on___________ percent of the official Federal Poverty level.
E. OPTIONAL GROUP OF QUALIFYING INDIVIDUALS
The levels for determining income eligibility for Qualifying Individuals under the provision of Section 1905(p)(2)(A) and 1905(p)(4) of the Act are greater than 120 percent but less than 135 percent of the official Federal Poverty level.
F. OPTIONAL GROUP OF QUALIFIED WORKING DISABLED INDIVIDUALS
The levels for determining income eligibility for Qualified Disabled Working Individuals under the provision of Sections 1905(s) and 1905(p)(4) of the Act are based on 200 percent of the Federal Poverty Level.
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
Territory:
INCOME LEVELS (continued)
MEDICALLY NEEDY
Applicable to all groups. Applicable to:
(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 and Rural
Urban Only
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
Territory:
RESOURCE LEVELS
CATEGORICALLY NEEDY GROUPS
AFDC standards under the AFDC plan in effect on July 16, 1996:
Pregnant Women
Optional Group of Pregnant Women under section 1902(a)(10)(A)(i)(IV) or 1902(a)(10)(A)(ii)(IX) of the Act
Same as the resource levels under section 1612 and 1613 of the Act.
No resource test.
Less restrictive levels than those under section 1612 and 1613 of the Act 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 2
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
RESOURCE LEVELS (cont’d)
3. Infants
a. Optional Group of Infants under section 1902(a)(10)(A)(i)(IV) or (1902)(a)(10)(A)(ii)(IX) of the Act
Same as resource levels in the State's approved AFDC plan in effect as of July 16, 1996.
Less restrictive than the AFDC levels in effect as of July 16, 1996, 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
Territory:
RESOURCE LEVELS (cont’d)
4. Children
a. Optional Group of Children Aged 1 up to Age 6 under section 1902(a)(10)(A)(i)(VI) of the Act
Same as resource levels in the State's approved AFDC plan in effect as of July 16, 1996.
Less restrictive than the AFDC levels in effect as of July 16, 1996, 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
Territory:
RESOURCE LEVELS (cont’d)
4. Children
b. Optional Group of Children Aged 6 up to Age 19 under section 1902(a)(10)(A)(i)(VII) of the Act
Same as resource levels in the State's approved AFDC plan in effect as of July 16, 1996.
Less restrictive than the AFDC levels in effect as of July 16, 1996, 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
Territory:
RESOURCE LEVELS (cont’d)
5. Aged and Disabled Individuals Eligible Under Section 1902(m) of the Act
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
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
Territory:
RESOURCE LEVELS (Continued)
B. MEDICALLY NEEDY
Applicable to all groups ‑
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
Territory:
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
Territory:
CONSIDERATION OF MEDICAID QUALIFYING TRUSTS – UNDUE HARDSHIP
1917(d)(5) The following criteria will be used to determine whether the agency will
of the Act not count the funds in a trust as specified in ATTACHMENT 2.6-A, page 15, item 3, because it would work an undue hardship.
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 7 TO
ATTACHMENT 2.6‑A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
VARIATIONS FROM THE BASIC PERSONAL NEEDS ALLOWANCE
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
Territory:
LESS RESTRICTIVE METHODS OF TREATING INCOME
UNDER SECTION 1902(r)(2) OF THE ACT
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
Territory:
LESS RESTRICTIVE METHODS OF TREATING RESOURCES
UNDER SECTION 1902(r)(2) OF THE ACT
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
Territory:
STATE LONG-TERM CARE INSURANCE PARTNERSHIP
1902(r)(2) and The following more liberal methodology applies to individuals who are
1917(b)(1)(C) eligible for medical assistance under one of the following eligibility
of the Act 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
Page 2
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
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
Page 3
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
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
Territory:
TRANSFER OF ASSETS
1917(c) of FOR TRANSFERS OF ASSETS FOR LESS THAN FAIR MARKET VALUE
the Act 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
Page 2
Territory:
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
Page 3
Territory:
TRANSFER OF ASSETS
Penalty Period - 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 used by the agency 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 amount used by the agency for communities are as follows:
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:
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
Page 4
Territory:
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
Territory:
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:
Of medical care such that the individual’s health or life would be endangered; or
Of food, clothing, shelter, or other necessities of life.
Procedures for Undue Hardship Waivers
The agency has established a process under which hardship waivers may be requested that provides for:
Notice to a recipient subject to a penalty that an undue hardship exception exists;
A timely process for determining whether an undue hardship waiver will be granted; and
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
Territory:
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 11 TO ATTACHMENT 2.6‑A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
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
Territory:
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 follow:
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 follow:
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 follow:
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
Territory:
ELIGIBILITY‑‑UNDER SECTION 1931 OF THE ACT
(Continued)
The agency uses less restrictive income and/or resource methodologies than those in effect as of July 16, 1996, as follow:
The income and/or resource methodologies that the less restrictive methodologies replace are as follows:
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 the Temporary Assistance for Needy Families (TANF) work requirements.
The agency defines unemployment for the section 1931 population as follows:
TN No. Approval Date Effective Date
Supersedes TN No.
Revision: SUPPLEMENT 12 TO ATTACHMENT 2.6‑A
Page 3
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
ELIGIBILITY‑‑UNDER SECTION 1931 OF THE ACT
(Continued)
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 section 402(a)(41) and 402(a)(38) 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 14 TO ATTACHMENT 2.6‑A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
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:
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
Territory:
1917(f) of The State agency denies reimbursement for nursing facility services and other
the Act 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.
| File Type | application/msword |
| File Title | Revision: |
| Author | CMS |
| Last Modified By | Annette Pearson |
| File Modified | 2015-04-09 |
| File Created | 2015-04-09 |