CMS-179 Attachment 2.2 A and Supplements 1 - 3

Form Approved CMS-179
OMB No. 0938-0193
Revision:

ATTACHMENT 2.2-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
GROUPS COVERED AND AGENCIES RESPONSIBLE
FOR ELIGIBILITY DETERMINATION

Agency*

Citation(s)

Groups Covered

The following groups are covered under this plan.
A. Mandatory Coverage - Categorically Needy
42 CFR 436.110
1902(a)(10)(A)(i)(I)
and 1931 of the Act

1.

All Recipients of OAA, AB, APTD and AABD
This includes all individuals who are essential persons under the
State plan and who could be recipients if the State plan were as
broad as permitted for Federal financial participation. Also
included are low-income families and children under section
1931 of the Act who, except as provided in Supplement 12 to
ATTACHMENT 2.6-A, meet the:
a.

financial eligibility requirements under the State’s Aid to
Families with Dependent Children (AFDC) plan in effect as
of July 16, 1996; and

b.

eligibility requirements under section 406(a) through (c) of
title IV of the Social Security Act, in effect as of July 16,
1996.

The income standards for OAA, AB, APTD, AABD and AFDC
payments are listed in Supplement 1 to ATTACHMENT 2.6-A.
The resource eligibility standards are listed in Supplement 2 to
ATTACHMENT 2.6-A.
The definitions of blindness in terms of ophthalmic measurement
and of permanent and total disability used in this plan are
specified in Supplement 2 to ATTACHMENT 2.2-A.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 2
Territory:

Agency*

Citation(s)

Groups Covered

A. Mandatory Coverage - Categorically Needy (Continued)
42 CFR 436.111

1902(a)(17)(D)
of the Act

2. a.

b.

Individuals who would be eligible for OAA, AB, APTD, or
AABD except for an eligibility requirement used in those
programs that is specifically prohibited under title XIX of
the Act.
Individuals who are ineligible for assistance under the
the State’s title IV-A plan solely because of eligibility
requirements that are specifically prohibited under Medicaid.
Included are:
(1) Families denied assistance under title IV-A solely
because of income and resources deemed to be
available from:





Stepparents who are not legally liable for support
of stepchildren under a State law of general
applicability;
Grandparents;
Legal guardians; Individual alien sponsors who are
not organizations; and
Siblings.

(2) Other:

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 3
Territory:

Agency*

Citation(s)

A.
42 CFR 436.112

Groups Covered
Mandatory Coverage – Categorically Needy (Continued)
3. Individuals who would be eligible for OAA, AB, APTD, or
AABD, or AFDC, except for the increase in OASDI benefits
under Pub. L. 92-336 (July 1, 1972), who were entitled to
OASDI in August 1972, and who were receiving cash assistance
in August 1972.
Includes persons who would have been eligible for cash
assistance but had not applied in August 1972 (this group
was included in this State's August 1972 plan).
Includes persons who would have been eligible for cash
assistance in August 1972 if not in a medical institution or
intermediate care facility (this group was included in this
State's August 1972 plan).
Not applicable with respect to intermediate care facilities;
the State did or does not cover this service.

42 CFR 436.114(e),
42 CFR 436.118 and
1902(a)(10)(A)(i)(I)
of the Act

4.

42 CFR 436.114(f)
to (h), 408(a)(11)(B),
1931(c)(1), and
1902(a)(10)(A)(i)(I)
of the Act

5.

TN No:
Supersedes TN No.

Title IV-E Subsidized Adoption or Foster Care Children.
Individuals who meet the requirements of section 473(b) of the
Act for whom an adoption assistance agreement is in effect or
foster care maintenance payments are made under title IV-E of
the Act.
Extended Medicaid Due to Support Collections
Families who have received Medicaid under section 1931 of the
Act for 3 of the preceding 6 months and lose eligibility as a result
of collection or increased collection of child or spousal support
under part D of title IV of the Act continue to be eligible for the
immediately succeeding 4 months.
Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 4
Territory:

Citation(s)

Groups Covered

A. Mandatory Coverage - Categorically Needy (Continued)
42 CFR 436.116
408(a)(11)(A), 1925,
1902(a)(10)(A)(i)(I),
1902(a)(52), and
1931 of the Act

6.

Families who have received Medicaid under section 1931 of the
Act for 3 of the preceding 6 months and lose eligibility as a result
of increased working hours or earned income of the caretaker
relative or loss of a time-limited earned income disregard remain
eligible for the immediately succeeding 6-month period and, if
they meet certain requirements, may remain eligible for the
following 6-month period.

1902(a)(10)(A)(i)(IV),
1902(l)(1)(A),
1902(l)(1)(B) and
1902(l)(4)(B) of
the Act

7.

1902(a)(10)(A)(i)(VI),
1902(l)(1)(C) and
1902(l)(4)(B) of the
Act

8.

1902(a)(10)(A)(i)(VII),
1902(l)(1)(D) and
1902(l)(4)(B) of the
Act

Transitional Medical Assistance

Poverty-level related women during pregnancy (and during the
60-day postpartum period beginning on the last day of the
pregnancy) and infants younger than 1 year old.
The income standard for this group is specified in Supplement 1
to ATTACHMENT 2.6-A.
Poverty-level related children:
a.

Who have attained 1 year of age, but have not attained 6
years of age.

b.

Who have attained 6 years of age, but have not attained 19
years of age.

The income standards for these groups are specified in
Supplement 1 to ATTACHMENT 2.6-A.
The resource standards are specified in Supplement 2 to
ATTACHMENT 2.6-A.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 5
Territory:

Citation(s)

Groups Covered

A. Mandatory Coverage - Categorically Needy (Continued)
1902(a)(10)(A)(i)(III)
and 1905(n) of the Act
42 CFR 436.120

9.

Qualified pregnant women and children.
The following individuals who meet the income and resource
requirements of the State’s July 16, 1996 approved AFDC plan:
a. A pregnant woman whose pregnancy has been medically
verified; and
b.

1902(e)(5) of the Act
42 CFR 436.122

A child who is younger than 19 years old.

10. Extended Eligibility for Pregnant Women.
A woman who, while pregnant, is eligible for, applied for, and
received Medicaid under the approved State plan on the day her
pregnancy ends. The woman continues to be eligible, as though
she were pregnant, for all pregnancy-related and postpartum
medical assistance under the plan for a 60-day period (beginning
on the last day of her pregnancy) and for any remaining days in
the month in which the 60th day falls.

1902(e)(6) of the Act
42 CFR 436.122

11.

Continuous Eligibility for Pregnant Women.
A pregnant woman who would otherwise lose eligibility because
of a change in family income is deemed to continue to be eligible
for all pregnancy-related and postpartum medical assistance
under the plan through the last day of the month in which the 60day postpartum period ends (which begins on the last day of her
pregnancy).

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 6
Territory:

Citation(s)

Groups Covered

A. Mandatory Coverage - Categorically Needy (Continued)
1902(e)(4) of the Act
42 CFR 436.124

12. Deemed Newborns.
A child born to a woman who was eligible for an receiving
Medicaid (including coverage of an alien for labor and delivery
as emergency medical services) for the date of the child’s birth
including retroactively. The child is deemed eligible for one year
from birth as long as the mother remains eligible or would
remain eligible if still pregnant and the child remains in the same
household as the mother.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 7
Territory:

Agency*

Citation(s)

Groups Covered

B. Optional Groups Other Than the Medically Needy
42 CFR 436.210
1902(a)(10)(A)(ii)(I)
and 1905(a) of the
Act

1.

Individuals described below who are not described in section
1902(a)(10)(A)(i) of the Act and who meet the income and
resource requirements of OAA, AB, APTD, or AABD, or the
State’s July 16, 1996 AFDC plan, but who do not receive cash
assistance.
The State covers all individuals as described above.
The State covers only the following group or groups of
individuals:

1902(a)(10)(A)(ii)
and 1905(a) of
the Act

Aged
Blind
Disabled
Parents and Other Caretaker Relatives
Pregnant Women
NOTE: For children under age 21, see B.9.

42 CFR 436.211
1902(a)(10)(A)(ii)(IV)
and 1905(a) of the Act

2.

Individuals described below who are not described in section
1902(a)(10)(A)(i) of the Act and who would be eligible for
OAA,
AB, APTD, or AABD, or who would meet the income and
resource requirements of the State’s July 16, 1996 AFDC plan, if
they were not in a medical institution.
The State covers all individuals as described above.
The State covers only the following group or groups of
individuals:

*Agency that determined eligibility for coverage
TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 8
Territory:

Agency*

Citation(s)

Groups Covered

B. Optional Coverage Groups Other than Medically Needy (Continued)
1902(a)(10)(A)(ii)
(III) and 1905(a)
of the Act
42 CFR 436.212

3.

Individuals who would be eligible for OAA, AB, APTD, AABD,
or AFDC if coverage under the State’s plan for these programs
were as broad as permitted under the Act.
Individuals meeting a broader definition of permanent and
total disability.
Individuals meeting a broader definition of blindness.
The following individuals who would be eligible for AFDC
if coverage under the State’s AFDC plan in effect as of July
16, 1996 were as broad as allowed under title IV-A of the
Act:
Individuals under the age of –
21
20
19
18
Parents and Other Caretaker Relatives
Pregnant Women
Others, as specified below:

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 9
Territory:

Agency*

Citation(s)

Groups Covered

B. Optional Groups Other Than the Medically Needy (Continued)
42 CFR 436.212 &
1902(e)(2) of the
Act, P.L. 99-272
(section 9517) P.L.
101-508 (section
4732) and 1903(m)
(2)(B) of the Act

4.

The State deems as eligible those individuals who became
otherwise ineligible for Medicaid while enrolled in an HMO
qualified under Title XIII of the Public Health Service Act or
while enrolled in an entity described in section (iii), (E) or (G) or
1903(m)(6) of the Act, or a Competitive Medical Plan (CHP)
with a Medicare contract under section 1876 of the Act, but who
have been enrolled in the HMO or entity for leas than the
minimum enrollment period listed below. The HMO or entity
must have a risk contract as specified in 42 CFR 434.20(a).
Coverage under this section is limited to HMO services and
family planning services described in section 1905(a)(4)(C).
The State elects not to guarantee eligibility.
The State elects to guarantee eligibility. The minimum
enrollment period is
months (not to exceed six).
The State measures the minimum enrollment period from:
The date beginning the period of enrollment in the
HMO or other entity, without any intervening
disenrollment, regardless of Medicaid eligibility.
The date beginning the period of enrollment in the
HMO as a Medicaid patient (including periods when
payment is made under this section), without any
intervening disenrollment.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 10
Territory:

Agency*

Citation(s)

Groups Covered

B. Optional Groups Other Than the Medically Needy (Continued)
The date beginning the last period of enrollment in the
HMO as a Medicaid patient (not including periods
when payment is made under this section), without any
intervening disenrollment of periods of enrollment as a
privately paying patient. (A new minimum enrollment
period begins each time the individual becomes
Medicaid eligible other than under this section.)
1932(a)(4) of the
Act

The Medicaid Agency may elect to restrict the disenrollment of
Medicaid enrollees of MCOs, PIHIPs, PAHPs, and PCCMs in
accordance with the regulations at 42 CFR 438.56.
This requirement applies unless a recipient can demonstrate good
cause for disenrolling or if he/she moves out of the entity’s service
area or becomes ineligible.
Disenrollment rights are restricted for a period of
(not to exceed 12 months).

months

During the first three months of each enrollment period the
recipient may disenroll without cause. The State will provide
notification, at least once per year, to recipients enrolled with
such organization of their right to and restrictions of terminating
such enrollment.
No restrictions upon disenrollment rights.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 10a
Territory:

Agency*

Citation(s)

Groups Covered

B. Optional Groups Other Than the Medically Needy (Continued)
1903(m)(2)(H),
1902(a)(52) of
the Act
P.L. 101-508
(section 4732)
42 CFR 438.56(g)

In the case of individuals who have become ineligible for Medicaid
for the brief period described in section 1903(m)(2)(H) and who
were enrolled with an entity having a contract under section
1903(m) when they became ineligible, the Medicaid agency may
elect to reenroll those individuals in the same entity if that entity
still has a contract.
The agency elects to reenroll the above individuals who are
ineligible in a month but in the succeeding two months
become eligible, into the same entity in which they were
enrolled at the time eligibility was lost.
The agency elects not to reenroll above individuals into the
same entity in which they were previously enrolled.

*Agency that determined eligibility for coverage
TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 11
Territory:

Agency*

Citation(s)

Groups Covered

B. Optional Groups Other Than the Medically Needy (Continued)
42 CFR 436.217

TN No:
Supersedes TN No.

5.

A group or groups of individuals who would be eligible for
Medicaid under the plan if they were in a NF or an ICF/MR, who
but for the provision of home and community-based services
under a waiver granted under 42 CFR Part 441, Subpart G would
require institutionalization, and who will receive home and
community-based services under the waiver. The group or
groups covered are listed in the waiver request. This option is
effective on the effective date of the State’s section 1915(c)
waiver under which this group(s) is covered. In the event an
existing 1915(c) waiver is amended to cover this group(s), this
option is effective on the effective date of the amendment.

6.

The State covers the 42 CFR 436.217 group in item 4 above and
covers individuals under a PACE program under section 1934 of
the Act using institutional rules in a manner similar to the use of
such rules under the 42 CFR 436.217 group.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 12
Territory:

Agency*

Citation(s)

B.
1902(a)(10)(A)(ii)
(V) of the Act

Groups Covered

Optional Groups Other Than the Medically Needy (Continued)
7.

Individuals who are in institutions for at least 30 consecutive
days and who are eligible under a special income level.
Eligibility begins on the first day of the 30-day period. These
individuals meet the income standards specified in Supplement 1
to ATTACHMENT 2.6-A.
The State covers all individuals as described above.
The State covers only the following group or groups of
individuals:
Aged
Blind
Disabled
Individuals under the age of –
21
20
19
18
Parents and Other Caretaker Relatives
Pregnant Women

42 CFR 436.220
1902(a)(10)(A)(ii)(II)
and 1905(a) of the
Act

8.

All individuals who are not described in section 1902(a)(10)(A)(i)
of the Act and would meet the income and resource requirements
of the State’s July 16, 1996 AFDC plan if their work-related
child care costs were paid their earnings rather than by a State
agency as a service expenditure. The State’s AFDC plan deducts
work-related child care costs from income to determine the
amount of AFDC.
The State covers all individuals as described above.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 13
Territory:

Agency*

Citation(s)

Groups Covered

B. Optional Groups Other Than the Medically Needy
(Continued)
1902(a)(10)(A)(ii)
and 1905(a) of
The Act

The State covers only the following groups or groups of
individuals:
Individuals under the age of—
21
20
19
18
Parents and Other Caretaker Relatives
Pregnant women

42 CFR 436.210
42 CFR 436.222
1902(a)(10)(A)(ii)(I)
and 1905(a)(i) of the
Act

9.

a.

All individuals who are not described in section 1902(a)(10)
(A)(i) of the Act, and who meet the income and resource
requirements of the July 16, 1996 AFDC plan, the title IV-E
State plan, the SSI program, or an optional State Supplement;
and are under the age indicated below:
21
20
19
18

b.

Reasonable classifications of individuals described in (a)
above as follows:
(1) Individuals for whom public agencies are assuming full
or partial financial responsibility and who are:
(a) In foster homes (and are under the age of

).

(b) In private institutions (and are under the age of

TN No:
Supersedes TN No.

Approval Date

Effective Date

).

Revision:

ATTACHMENT 2.2-A
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Territory:

Agency*

Citation(s)

Groups Covered

B. Optional Groups Other Than the Medically Needy
(Continued)
(c) In addition to the group under b.(l)(a) and (b),
individuals placed in foster homes or private
institutions by private, nonprofit agencies (and are
under the age of
).
(2) Individuals in adoptions subsidized in full or part by a
public agency (who are under the age of ).
(3) Individuals in nursing facilities (NFs) (who are under the
age of
). NF services are provided under this plan.
(4) In addition to the group under (b)(3), individuals in
ICF/MRs (who are under the age of ).
(5) Individuals receiving active treatment as inpatients in
psychiatric facilities or programs (who are under the age
of
). Inpatient psychiatric services for individuals
under age 21 are provided under this plan.
(6) Other defined groups (and ages), as specified in
Supplement 1 to ATTACHMENT 2.2-A.
l902(a)(10)(A)(ii)
(VIII) of the Act
42 CFR 436.224

10. A child for whom there is in effect a State adoption assistance
agreement (other than under title IV-E of the Act), who, as
determined by the State adoption agency, cannot be placed for
adoption without medical assistance because the child has special
needs for medical or rehabilitative care, and who before execution
of the agreement –
(a) Was eligible for Medicaid under the State's approved
Medicaid plan; or

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 15
Territory:

Agency*

Citation(s)

Groups Covered

B. Optional Groups Other Than the Medically Needy (Continued)
(b) Would have been eligible for Medicaid if the standards and
methodologies of the title IV-E foster care program were
applied rather than the AFDC standards and methodologies.
The State covers these individuals under the age of –
21
20
19
18

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 16
Territory:

Agency*

Citation(s)

Groups Covered

B. Optional Groups Other Than the Medically Needy (Continued)
42 CFR 436.230

11. Essential spouse of a recipient of:
OAA
AB
APTD
AABD
Spouse is living with and determined essential to the well being of
the recipient of OAA, AB, APTD, or AABD, and his (her) needs
are taken into consideration in determining the amount of financial
assistance.

1902(a)(10)(A)(i)
(IV), 1902(a)(10)
(A)(ii)(IX) and
1902(l)(4)(B) of
the Act

TN No:
Supersedes TN No.

12. Optional poverty-level related pregnant women and infants,
younger than 1 year old.
The following individuals who are not eligible under 1902(a)(10)
(A)(i) of the Act and whose income does not exceed the income
level specified in Supplement 1 to ATTACHMENT 2.6-A for a
family of the same size, including the woman and unborn child or
infant, and who meet the resource standards specified in
Supplement 2 to ATTACHMENT 2.6-A.
a.

Women during pregnancy (and during the 60-day postpartum
period beginning on the last day of the pregnancy; and

b.

Infants under 1 year of age.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
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Territory:

Agency*

Citation(s)

Groups Covered

B. Optional Groups Other Than the Medically Needy
(Continued)
13. Optional poverty-level related children:
1902(a)(10)(A)(i)(VI),
1902(l)(1)(c), and
(4)(B) of the Act

a.

Who have attained 1 year of age but have not attained 6 years
of age.

1902(a)(10)(A)(i)(VII),
1902(l)(1)(d), and
(4)(B) of the Act

b.

Who have attained 6 years of age but have not attained 19
years of age.

Supplement 1 to ATTACHMENT 2.6-A specifies the income
levels and Supplement 2 to ATTACHMENT 2.6-A specifies the
resource levels for these groups.
1902(a)(10)(A)(ii)
(X) and 1902(m)(1)
and 1902(m)(2)
of the Act

TN No:
Supersedes TN No.

14. Individuals –
a.

Who are 65 years old or older or are disabled as determined
under section 1614 of the Act;

b.

Whose income does not exceed the income level (established
at an amount up to 100 percent of the Federal income poverty
level) specified in Supplement 1 to ATTACHMENT 2.6-A
for a family of the same size; and

c.

Whose resources do not exceed the maximum allowed under
SSI or under the State’s medically needy program.

Approval Date

Effective Date

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ATTACHMENT 2.2-A
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Territory:

Agency*

Citation(s)

Groups Covered

B. Optional Groups Other Than the Medically Needy (Continued)
1902(a)(47) and
1920 of the Act

15. Presumptive Eligibility for Pregnant Women.
Pregnant women who are determined by a “qualified provider” (as
defined in section 1920(b)(2) of the Act) based on preliminary
information, to meet the highest applicable income criteria
specified in this plan under ATTACHMENT 2.6-A and are
therefore determined to be presumptively eligible for ambulatory
prenatal care during a presumptive eligibility period in accordance
with section 1920 of the Act.
The presumptive period begins on the day that the determination is
made. If an application for Medicaid is filed by the last day of the
month following the month in which the determination of
presumptive eligibility was made, the presumptive period ends on
the day that the Medicaid agency makes a determination of
eligibility based on that application. If an application is not filed
by the last day of the month following the month the
determination of presumptive eligibility was made, the
presumptive period ends on that last day.
Presumptive eligibility for pregnant women is limited to no more
than one period per pregnancy.
The Medicaid agency requires that a written application be
completed and signed by the woman.
Yes
No

1902(a)(10)(A)(ii)
(VII) of the Act

TN No:
Supersedes TN No.

16. Individuals who would be eligible for Medicaid under the plan if
they were in a medical institution, who are terminally ill, and who
receive hospice care in accordance with a voluntary election
described in section 1905(o) of the Act.
Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 18a
Territory:

Citation(s)

Groups Covered

B. Optional Groups Other Than the Medically Needy (Continued)
The State covers all individuals as described above.
The State covers only the following group or groups of
individuals:
Aged
Blind
Disabled
Individuals under the age of—
21
20
19
18
Parents and Other Caretaker Relatives
Pregnant Women
1902(a)(10)(F) and
and 1902(u)(1)
of the Act
42 CFR 436.229

17. Individuals entitled to elect COBRA continuation coverage and
coverage and whose income as determined under section 1612 of
the Act for purposes of the SSI program, is no more than 100
percent of the Federal poverty level, whose resources are no more
than twice the SSI resource limit for an individual, and for whom
the State determines that the cost of COBRA premiums is likely to
be less than the Medicaid expenditures for an equivalent set of
services. See Supplement 11 to ATTACHMENT 2.6-A.

1902(a)(10)(A)(ii)
(XIV) and 1905(u)
(2)(B) of the Act
42 CFR 436.229

18. Optional Targeted Low Income Children younger than age 19
who:

TN No:
Supersedes TN No.

a.

are not eligible for Medicaid under any other mandatory or
optional eligibility group or eligible as medically needy
(without spenddown liability);

Approval Date

Effective Date

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ATTACHMENT 2.2-A
Page 18b
Territory:

Citation

Groups Covered

B. Optional Coverage Other Than the Medically Needy (Continued)
b.

c.

d.

would not have been eligible for Medicaid under the policies
in the State’s Medicaid plan as in effect on March 31, 1997
(but taking into account the expansion of age eligibility
provided for in 1902(l)(1)(D));
are not covered under a group health plan or other group
health insurance (as such terms are defined in section 2791 of
the Public Health Service Act) other than under a health
insurance program in operation before July 1, 1997 offered by
a State or territory which receives no Federal funds for the
program; and
have family income at or below:
200 percent of the Federal Poverty Level (FPL) for the
size family size involved, as revised annually in the
Federal Register; or
percentage of the Federal Poverty Level, which is
in excess of the "Medicaid applicable income level" (as
defined in section 2110(b)(4) of the Act) but by no more
than 50 percentage points.

The State covers:
All children described above who are under age
(18, 19)
with family income at or below
percent of the Federal
poverty level.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 18c
Territory:

Citation

Groups Covered

B. Optional Groups Other Than the Medically Needy (Continued)
The following reasonable classifications of children described
above who are under age
(18, 19) with family income at
or below the percent of the Federal poverty level specified for
the classification:
(ADD NARRATIVE DESCRIPTION(S) OF THE
REASONABLE CLASSIFICATION(S) AND THE PERCENT
OF THE FEDERAL POVERTY LEVEL USED TO ESTABLISH
ELIGIBILITY FOR EACH CLASSIFICATION.)
1902(e)(12) of the
Act

19. Continuous Eligibility for Children.
A child under age
(not to exceed age 19) who has been
determined eligible under section 1902(a)(10)(A) of the Act is
deemed to be eligible for a total of
months (not to exceed 12
months) regardless of changes in circumstances other moving out
of the State or than attainment of the maximum age stated above,
until the earlier of:
The end of the period (not to exceed 12 months) of
continuous eligibility; or
The time that the individual exceeds that age.

1902(a)(47) and
1920A of the Act
42 CFR 436.1100
through 436.1102

TN No:
Supersedes TN No.

20. Presumptive Eligibility for Children
Children under age
(no more than 19) who are determined by
a "qualified entity" (as defined in 1920A(b)(3)(A) of the Act)
based on preliminary information, to meet the highest applicable
income criteria specified in this plan under ATTACHMENT 2.6-A
and are therefore determined to be presumptively eligible during a
presumptive eligibility period in accordance with 1902A of the
Act.
Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 18d
Territory:

Citation

Groups Covered

B. Optional Groups Other Than the Medically Needy (Continued)
The presumptive period begins on the day that the determination is
made. If an application for Medicaid is filed on the child's behalf
by the last day of the month following the month in which the
determination of presumptive eligibility was made, the
presumptive period ends on the day that the Medicaid agency
makes a determination of eligibility based on that application. If
an application is not filed on the child's behalf by the last day of
the month following the month the determination of presumptive
eligibility was made, the presumptive period ends on that last day.
The following types of “qualified entities” are used to determine
presumptive eligibility.
The State requires that a written application be completed and
signed by the child’s parent or other representative:
Yes
No
1902(a)(10)(A)(ii)
(XII) and 1902(z)
of the Act

TN No:
Supersedes TN No.

21. Individuals not described in 1902(a)(10)(A)(i) of the Act who are
infected with tuberculosis whose income and resources do not
exceed the maximum amounts described in Supplement 14 to
ATTACHMENT 2.6-A.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 18e
Territory:

Citation

Groups Covered

B. Optional Groups Other Than the Medically Needy (Continued)
1902(a)(10)(A)(ii)
(XIII) of the Act

22. BBA Work Incentives Eligibility Group
Individuals with a disability whose net family income is below
250 percent of the Federal poverty level for a family of the size
involved and who, except for earned income, meet all criteria for
receiving benefits under the SSI program. See page 14a of
ATTACHMENT 2.6-A.

1902(a)(10)(A)(ii)
(XV) of the Act

23. TWWIIA Basic Coverage Group
Individuals with a disability at least 16 but less than 65 years of
age whose income and resources do not exceed a standard
established by the State. See page 14b of ATTACHMENT 2.6-A.

1902(a)(10)(A)(ii)
(XVI) of the Act

24. TWWIIA Medical Improvement Group
Employed individuals at least 16 but less than 65 years of age with
a medically improved disability whose income and resources do
not exceed a standard established by the State. See page 14f of
ATTACHMENT 2.6A.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 18f
Territory:

Citation

Groups Covered

B. Optional Groups Other Than the Medically Needy (Continued)
1902(a)(10)(A)(ii)
(XIX) of the Act

25. Family Opportunity Act
Children who have not attained 19 years of age, who would be
considered disabled under section 1614(a)(3)(C) of the Act, and
whose family income meets the standard described on Page 14h of
ATTACHMENT 2.6-A.
Beginning with the effective date of its plan amendment, the
State covers all children eligible under this group, as
described below; or
In the case of the second, third, and fourth quarters of fiscal
year 2007, the State covers children who were born on or
after January 1, 2001, or who were born on or after the
following earlier date ______________.
In the case of each quarter of fiscal year 2008, the State
covers children who were born on or after October 1, 1995, or
who were born on or after the following earlier date
___________.
In the case of each quarter of fiscal year 2009 and each
quarter of any fiscal year thereafter, the State covers children
who were born after October 1, 1989.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 18g
Territory:

Citation

Groups Covered

B. Optional Groups Other Than the Medically Needy (Continued)
1902(a)(10)(A)
(ii)(XVIII) and
1902(aa) of the Act

TN No:
Supersedes TN No.

26. Certain Women with Breast or Cervical Cancer
The State covers medical assistance for women who:
a.

Have been screened for breast or cervical cancer under the
Centers for Disease Control and Prevention, Breast and
Cervical Cancer Early Detection Program established under
title XV of the Public Health Service Act in accordance with
the requirements of section 1504 of that Act;

b.

Need treatment for breast or cervical cancer, including a precancerous condition of the breast or cervix;

c.

Are not otherwise covered under creditable coverage, as
defined in section 2701(c) of the Public Health Service Act,
but applied without regard to paragraph (1)(F) of such
section;

d.

Are not eligible for Medicaid under any mandatory
categorically needy eligibility group described in
1902(a)(10)(A)(i) of the Act; and

e.

Have not attained age 65.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 18h
Territory:

Citation

Groups Covered

C. Optional Groups Other Than the Medically Needy (Continued)
1920B and 1902(aa) ___ 27. Presumptive Eligibility for Certain Women with Breast or
of the Act
Cervical Cancer
The State covers medical assistance during a presumptive
eligibility period for women who are determined by a “qualified
entity” (as defined in section 1920B(b)(2) of the Act) based on
preliminary information, to be woman described in 1902(aa) the
Act related to certain breast and cervical cancer patients.
The State limits the classes of entities that may become qualified
entities as follow:
The presumptive period begins on the date that a qualified entity
determines the woman to be eligible. The period ends on the date
that the Medicaid agency makes a determination with respect to
the woman’s eligibility for Medicaid. However, if the woman
does not apply for Medicaid (or a Medicaid application was not
made on her behalf) by the last day of the month following the
month in which the determination of presumptive eligibility was
made, the presumptive period ends on that last day.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 19
Territory:

Agency*

Citation(s)

Groups Covered

C. Optional Coverage of the Medically Needy
42 CFR 436.301
1902(a)(10)(C) of
the Act

This plan includes the medically needy.

1902(a)(10)(C)(ii)(II)
of the Act and 42
CFR 436.301(b)(1)(i)

1.

Pregnant women during the course of their pregnancy who, except
for income and/or resources, would be eligible as categorically
needy under 1902(a)(10)(A) of the Act.

1902(e)(5) of the Act
42 CFR 436.301(b)
(1)(iv)

2.

Women who, while pregnant, are eligible for, applied for, and
received Medicaid as medically needy under the approved State
plan on the date the pregnancy ends. These women continue to be
eligible, as though they were pregnant, for all pregnancy-related
and postpartum medical assistance, under the plan for a 60-day
period (beginning with the date the pregnancy ends), and any
remaining days in the month in which the 60th day falls.

1902(a)(10)(C)(ii)(I)
of the Act and 42

3.

Individuals under age 18 who, but for income and/or resources,
would be eligible as mandatory categorically needy under section
1902(a)(10)(A)(i) of the Act.

TN No:
Supersedes TN No.

No.
Yes. This plan covers:

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 20
Territory:

Agency*

Citation(s)

Groups Covered

C. Optional Coverage of the Medically Needy (Continued)
1902(e)(4) of the
Act and 42 CFR
436.301(b)(1)(iii)

4.

A child born to a woman who is eligible for and receiving
Medicaid as medically needy for the date of the child’s birth,
including retroactively. The child is deemed to have applied and
been found eligible for Medicaid for the date of birth and remains
eligible for one year from birth as long as the mother remains
eligible, or would remain eligible if still pregnant, and the child
remains in the same household as the mother.

42 CFR 436.308
1902(a)(10)(C)(i)
of the Act

5.

Medically Needy Children
a.

Individuals who are financially eligible as medically needy,
are not eligible in accordance with section 1902(a)(10)(A) of
the Act, are not described in section C.3. above and who are
under the age of—
21
20
19
18 or under age 19 who are full-time students in a
secondary school or in the equivalent level of vocational
or technical training

b.

Reasonable classifications of financially eligible individuals
under the age of 21, 20, 19, or 18 as specified below:
(1) Individuals for whom public agencies are assuming
full or partial responsibility and who are:
(a) In foster homes (and are under the age of
_____).

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 21
Territory:

Agency*

Citation(s)

Groups Covered

C. Optional Coverage for the Medically Needy (Continued)
(b) In private institutions (and are under the
age of _____).
(c) In addition to the group under b.(l)(a) and
(b), individuals placed in foster homes or
private institutions by private, nonprofit
agencies (and are under the age of
).

TN No:
Supersedes TN No.

Approval Date

(2)

Individuals in adoptions subsidized in full or
part by a public agency (who are under the
age of
).

(3)

Individuals in nursing facilities (NFs) (who
are under the age of
). NF services are
provided under this plan.

(4)

In addition to the group under (b)(3),
individuals in ICF/MRs (who are under the
age of
).

(5)

Individuals receiving active treatment as
inpatients in psychiatric facilities or programs
(who are under the age of
).
Inpatient-psychiatric services for individuals
under age 21 are provided under this plan.

(6)

Other defined groups (and ages), as specified
in Supplement 1 to ATTACHMENT 2.2-A.

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 22
Territory:

Agency*

Citation(s)

Groups Covered

C. Optional Coverage for the Medically Needy (Continued)
42 CFR 436.310

6.

Parents and Other Caretaker Relatives

42 CFR 436.320

7.

Aged Individuals

42 CFR 436.321

8.

Blind Individuals

42 CFR 436.322

9.

Disabled Individuals

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 23
Territory:

Agency*

Citation(s)

Groups Covered

D. Optional Coverage – Qualified Medicare Beneficiaries
1902(a)(10)(E)(i)
and 1905(p)(4)
of the Act

1.

1905(p)(3) of the Act

1902(a)(10)(E)(ii)
and 1905(s) of
the Act

1905(p)(3)(A)(i)
of the Act

TN No:
Supersedes TN No.

Qualified Medicare Beneficiaries –
a.

Who are entitled to hospital insurance benefits under
Medicare Part A, (but not pursuant to an enrollment under
section 1818A of the Act);

b.

Whose income does not exceed the percent of the Federal
poverty level specified in Supplement 1 to ATTACHMENT
2.6-A; and

c.

Whose resources do not exceed twice the maximum standard
under SSI.

(Medical assistance for this group is limited to Medicare costsharing as defined in section 1905(p)(3) of the Act).
2.

Qualified Disabled and Working Individuals –
a.

Who are entitled to hospital insurance benefits under
Medicare Part A under section 1818A of the Act;

b.

Whose income does not exceed 200 percent of the Federal
poverty level; and

c.

Whose resources do not exceed twice the maximum standard
under SSI.

d.

Who are not otherwise eligible for medical assistance under
title XIX of the Act.

(Medical assistance for this group is limited to cost-sharing as
defined in section 1905(p)(3)(A)(i) of the Act.)

Approval Date

Effective Date

Revision:

ATTACHMENT 2.2-A
Page 24
Territory:

Agency*

Citation(s)

Groups Covered

D. Optional Coverage – Qualified Medicare Beneficiaries
1902(a)(10)(E)(iii)
and 1905(p)(4)
of the Act

3.

Specified Low-Income Medicare Beneficiaries –
a.

Who are entitled to hospital insurance benefits under
Medicare Part A (but not pursuant to an enrollment under
section 1818A of the Act);

b.

Whose income is greater than 100 percent but less than 120
percent of the Federal poverty level; and

c.

Whose resources do not exceed twice the maximum standard
under SSI.

Medical assistance for this group is limited to Medicare Part B
premiums under section 1839 of the Act.)
1902(a)(10)(E)(iv)
and 1905(p)(4)
of the Act

4.

Qualifying Individuals –
a.

Who are entitled to hospital insurance benefits under
Medicare Part A (but not pursuant to an enrollment under
section 1818A of the Act);

b.

Whose income is greater than 120 percent but less than 135
percent of the Federal poverty level;

c.

Whose resources do not exceed twice the maximum standard
under SSI;

d.

Who are not otherwise eligible for medical assistance under
title XIX of the Act.

(Medical assistance for this group is limited to Medicare Part B
premiums under section 1839 of the Act)
TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

SUPPLEMENT 1 TO
ATTACHMENT 2.2-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
REASONABLE CLASSIFICATIONS OF INDIVIDUALS UNDER
THE AGE OF 21, 20, 19, OR 18

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

SUPPLEMENT 2 TO
ATTACHMENT 2.2-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:

A.

DEFINITION OF BLINDNESS IN TERMS OF OPHTHALMIC MEASUREMENT

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

SUPPLEMENT 2 TO
ATTACHMENT 2.2-A
Page 2
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:

B.

DEFINITION OF PERMANENT AND TOTAL DISABILITY

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

SUPPLEMENT 3 TO
ATTACHMENT 2.2-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
METHOD FOR DETERMINING COST EFFECTIVENESS
OF CARING FOR CERTAIN DISABLED CHILDREN AT HOME

TN No:
Supersedes TN No.

Approval Date

Effective Date

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