CMS-179 (Territory) Attachment 2.6 A and Supplements 1, 2, 3, 4,

Form Approved CMS-179
OMB No. 0938-0193
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,
Subpart G

1.

Is financially eligible to receive services.

42 CFR Part 436,
Subpart F

2.

Meets the applicable non-financial eligibility conditions.
a.

For the categorically needy:
(i)

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.

(ii)

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.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 1a
Territory:

Citation(s)

Condition or Requirement

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

(v)

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).
b.

TN No:
Supersedes TN No.

For children receiving State adoption assistance who
are financially eligible under section 1902(a)(10)(A)
(ii)(VIII) of the Act, meets the non-financial eligibility
criteria of that section.

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

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 2
Territory:

Citation(s)

Condition or Requirement

1902(a)(10)(E)(i) and
1905(p) of the Act

c.

For financially eligible Qualified Medicare Beneficiaries
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)
and 1905(s) of the
Act

d.

For financially eligible Qualified Disabled and Working
Individuals covered under section 1902(a)(10)(E)(ii) of the
Act, meets the non-financial eligibility criteria of section
1905(s) of the Act.

1902(a)(10)(E)(iii) and
and 1905(p) of the Act

e.

For financially eligible Specified Low-Income Medicare
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
section 1902(a)(10)(E)(iii) of the Act, meets the
non-financial eligibility criteria of section 1905(p) of the
Act.

and 1905(p) of the Act

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 3
Territory:

Citation(s)
42 CFR 436.406

Condition or Requirement
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.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 4
Territory:

Citation(s)
42 CFR 436.403

Condition or Requirement
4.

1902(b) of the Act

Is a resident of the State, with the intent to remain permanently
or
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,
1905(a)(28) of the
Act

5.

Is not covered for Federal financial participation (FFP) for
expenditures for medical assistance services if the individual is
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.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 5
Territory:

Citation(s)
42 CFR 436.610,
1912 of the Act

Condition or Requirement
6.

If legally able, is required, as a condition of eligibility, to:
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.

b.

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

c.

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
and 436.901,
1137(a)(1) and (f)
of the Act

TN No:
Supersedes TN No.

7.

Is required, as a condition of eligibility, to furnish his/her social
security account number (or numbers, if he/she has more than
one number), with the exception of aliens seeking coverage for
the treatment of an emergency medical condition under section
1903(v)(2) of the Act or individuals who, because of wellestablished religious objections as defined in 42 CFR 435.910(h),
refuse to obtain a Social Security account number.
Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 6
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:

Citation(s)
42 CFR 436.832

Condition or Requirement
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 institutiona lized
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:

TN No:
Supersedes TN No.
Revision:

Approval Date

Effective Date
ATTACHMENT 2.6-A

Page 6a
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
o

Highest mandatory categorically needy level for an
individual, or
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
o

AFDC level; or
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: $
TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 6b
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:

Citation(s)

Condition or Requirement
4.

5.

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.)

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 $
.

TN No:
Supersedes TN No.

Approval Date

Effective Date

.

Revision:

ATTACHMENT 2.6-A
Page 7
Territory:

Citation
1902(l) of the Act

42 CFR 436
Subparts G and I

Condition or Requirement
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.

C. Financial Eligibility – Categorically and Medically Needy, Qualified
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.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 7a
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.

TN No:
Supersedes TN No.



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.
Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 7b
Territory:

Citation

TN No:
Supersedes TN No.

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.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 8
Territory:

Citation

Condition or Requirement
1.

Categorically Need Income Levels
a.

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.

b. 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)
of the Act

(iii)

Optional Qualified Medicare Beneficiaries covered
under the provisions of section 1902(a)(10)(E)(i) of the
Act.

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

(iv) Optional Specified Low-Income Medicare Beneficiaries
covered under the provisions of section
1902(a)(10)(E)(iii) of the Act.

1902(a)(10)(E)(iv)
of the Act

(v)

Optional Qualifying Individuals covered under the
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.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 9
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:

Citation(s)
1902(a)(10),
1902(a)(17), and
1902(r)(2) of the Act

Condition or Requirement
2.

Income and Resource Methodologies –
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:

NOTE:

42 CFR 436.602,
1902(a)(17)(D) of
the Act

(2)

TN No:
Supersedes TN No.

Approval Date

(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.

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

In determining relative financial responsibility of
relatives and other individuals, the Medicaid agency
considers only the income of spouses living in the
same household as available to spouses and the
income of parents as available to children living with
parents until the children become 21.

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 10
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:

Citation(s)

Condition or Requirement
b.

TN No:
Supersedes TN No.

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.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 11
Territory:
FINANCIAL ELIGIBILITY

Citation
1902(l)(3)(E) and
1902(r)(2) of the Act

Condition or Requirement
c.

Poverty-level related pregnant women and infants
(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.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 12
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,
1902(a)(17)(D) of
the Act

TN No:
Supersedes TN No.

(3)

In determining financial responsibility of relatives
and
other individuals, the Medicaid agency considers only
the income of spouses and the income of parents as
available to children until the children become 21.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 13
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:
(1)

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.

(2)

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

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 13a
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)

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

e.

In determining financial responsibility of relatives
and
other individuals, the Medicaid agency considers only
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:
(1)

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.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 13b
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
FINANCIAL ELIGIBILITY

Citation(s)

Condition or Requirement
(2)

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)

1902(a)(17)(D) of
the Act
1902(a)(10)(E)(i) and
1902(r)(2) of the Act

f.

In determining financial responsibility of relatives
and
other individuals, the Medicaid agency considers only
the income of spouses and the income of parents as
available to children until the children become 21.

For Qualified Medicare Beneficiaries covered under section
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)
of the Act

TN No:
Supersedes TN No.

g.

For Qualified Disabled and Working Individuals covered
under section 1902(a)(10)(E)(ii) of the Act, the agency uses
the methods used under the SSI program for treatment of
income.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
FINANCIAL ELIGIBILITY

Citation(s)
1902(a)(10)(E)(iii)
and 1902(r)(2) of
uses:
the Act

Condition or Requirement
h.

For Specified Low-Income Medicare Beneficiaries covered
under section 1902(a)(10)(E)(iii) of the Act, the agency

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)
and 1902(r)(2) of
the Act

i.

For Qualifying Individuals covered under section
1902(a)(10)(E)(iv) of the Act, the agency uses:
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:

TN No:
Supersedes TN No.

Approval Date

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).

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14a
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:

Citation(s)
1902(a)(10)(A)(ii)
(XIII) and 1902(r)(2)
of the Act

Condition or Requirement
k.

Working Individuals with Disabilities – BBA
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.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14b
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:

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

Condition or Requirement
l.

Working Individuals with Disabilities – Basic Coverage
Coverage Group - TWWIIA
In determining financial eligibility for working individuals
with disabilities under this provision, the following
standards and methodologies are applied:
____ The agency does not apply any income or resource
standard.
NOTE: If the above option is chosen, no further
eligibility-related options should be elected.
____ The agency applies the following income and/or
resource standard(s):

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14c
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:

Citation(s)
1902(a)(10)(A)(ii)
(XV) and 1902(r)(2)
of the Act

Condition or Requirement
Income Methodologies
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:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14d
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:

Citation(s)
1902(a)(10)(A)(ii)
(XV) and 1902(r)(2)
of the Act

Condition or Requirement
Resource Methodologies
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 employersponsored 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:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14e
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:

Citation(s)
1902(a)(10)(A)(ii)
(XV) and 1902(r)(2)
of the Act

Condition or Requirement
____ The agency does not disregard funds in retirement
accounts.
____ 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:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14f
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:

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

Condition or Requirement
m. Working Individuals with Disabilities – Employed Medically
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.
____

TN No:
Supersedes TN No.

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

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14g
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:

Citation(s)
1902(a)(10)(A)(ii)
(XVI) and 1902(r)(2)
of the Act

Condition or Requirement
Income Methodologies
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:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14h
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:

Citation(s)
1902(a)(10)(A)(ii)
(XVI) and 1902(r)(2)
of the Act

Condition or Requirement
Resource Methodologies
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:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14i
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:

Citation(s)
1902(a)(10)(A)(ii)
(XVI) and 1902(r)(2)
of the Act

Condition or Requirement
The agency does not disregard funds in retirement
accounts.
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:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14j
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:

Citation(s)
1902(a)(10)(A)(ii)
(XVI) and 1905(v)(2)
of the Act

Condition or Requirement
Definition of Employed – Employed Medically Improved
Individuals – TWWIIA
___ 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:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14k
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:

Citation(s)
1902(a)(10)(A)(ii)
(XIII) of the Act

Condition or Requirement
Payment of Premiums or Other Cost Sharing Charges
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:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14l
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:

Citation(s)
1902(a)(10)(A)(ii)
(XV) and (XVI), and
and 1916(g) of the Act

Condition or Requirement
For individuals eligible under the Basic Coverage Group
described in No. 22 on page 18e of ATTACHMENT 2.2-A,
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:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14m
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:

Citation(s)
1902(a)(10)(A)(ii)
(XV), (XVI), and
1916(g) of the Act

TN No:
Supersedes TN No.

Condition or Requirement
Premiums and Other Cost-Sharing Charges
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.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14n
Territory:

Citation
1902(a)(10)(A)(ii)
(XIX) of the Act

Condition or Requirement
n.

Family Opportunity Act (FOA)
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:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14o
Territory:

Citation
1902(a)(10)(A)(ii)
(XIX) and 1902(r)(2)
of the Act

Condition or Requirement
Income Methodologies
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:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14p
Territory:

Citation
1902(a)(10)(A)(ii)
(XIX) and 1916(i)
of the Act

Condition or Requirement
Interaction with Employer Sponsored Family Coverage
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:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14q
Territory:

Citation
1902(a)(10)(A)(ii)
(XIX) and 1916(i)
of the Act

Condition or Requirement
Payment of Premiums
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:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14r
Territory:

Citation
1902(a)(10)(A)(ii)
(XIX) and 1916(i)
of the Act

Condition or Requirement
Payment of Premiums (Continued)
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:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 15
Territory:

Citation
1917(d)(5) of the Act

Condition or Requirement
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:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 16
Territory:

Citation
1902(a)(10)(C)
of the Act

Condition or Requirement
4. Medically Needy Income Levels
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
a.

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:

TN No:
Supersedes TN No.

Approval Date

Circumstance:

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 17
Territory:

Citation
1902(a)(17)
of the Act

Condition or Requirement
b.

The agency does not deduct incurred expenses subject to
payment by a third party unless the third party is a public
program (other than Medicaid) of a State 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:
Supersedes TN No.

Approval Date

Effective Date

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:
(1) Premiums, deductibles, coinsurance and copayments.
(2) Expenses for necessary medical or remedial care
services that are recognized under State law but not
included in the State plan.
(3) 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:
Supersedes TN No.
Revision:

Approval Date

Effective Date
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)
of the Act

h.

If countable income excess the MNIL standard the
agency deducts spenddown payments made to the State
by the individual.
Individuals may elect or reject the pay in option on a:
Monthly basis; or
Quarterly basis.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 18
Territory:

Citation

Condition or Requirement
6.

1902(l)(3) of the Act

Resource Standard – Categorically Needy
a.

Except as specified in item C.6.b.-d. below, the resource
standards are the same as those in the related cash assistance
programs.

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:
Supersedes TN No.

Approval Date

Effective Date

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)
of the Act
42 CFR 436.845

7.

Resource Standard – Medically Needy
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:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 20
Territory:

Citation
1902(a)(10)(E)(i)
and 1902(r)(2) of
the Act

Condition or Requirement
8.

a.

For Qualified Medicare Beneficiaries covered under section
1902(a)(10)(E)(i) of the Act the agency uses 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.

1902(a)(10)(E)(ii)
of the Act

b.

For Qualified Disabled and Working Individuals covered
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)
and 1902(r)(2) of
the Act

c.

For Specified Low-Income Medicare Beneficiaries covered
under section 1902(a)(10)(E)(iii) of the Act the agency uses
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)
and 1902(r)(2) of
the Act

d.

For Qualifying Individuals covered under section
1902(a)(10)(E)(iv) of the Act the agency uses the following
methods for treatment of resources:
The methods of the SSI program only.
The methods 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:
Supersedes TN No.

Approval Date

Effective Date

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

1902(a)(10)(E)(i),
1902(a)(10)(E)(iii),
1902(a)(10)(E)(iv)
and 1905(p)(1)(C)
of the Act

e.

9.

For COBRA continuation beneficiaries, the agency uses the
methods of the SSI program for treatment of resources.

Resource Standard – Qualified Medicare Beneficiaries, Specified
Low-Income Medicare Beneficiaries and Qualifying Individuals
For Qualified Medicare Beneficiaries, Specified Low-Income
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)
and 1905(s) of the
Act

10. Resource Standard – Qualified Disabled and Working Individuals

1902(u) of the Act

11. For COBRA continuation beneficiaries, the resource standard is
twice the SSI resource standard for an individual.

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.

12. 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:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 22
Territory:

Citation
42 CFR 436.901

Condition or Requirement
13. Effective Date of Eligibility
a.

Groups other than Qualified Medicare Beneficiaries
(i)

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

(ii)

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:
Supersedes TN No.

Approval Date

Effective Date

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:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 24
Territory:

Citation
1902(e)(8) and
1905(a) of the Act

Condition or Requirement
b.

For Qualified Medicare Beneficiaries defined in section
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:
Supersedes TN No.

Approval Date

Effective Date

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:

Family Size
1
2
3
4
5
6
7
8
9
10
For each additional
person, add:

TN No.
Supersedes TN No.

Need Standard

Payment Standard

Maximum Payment
Amounts

$
$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$
$

$

$

$

Approval Date

Effective Date

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
poverty level:

TN No.

percent of the official Federal income

Family size

Income Level

1
2
3
4
5
6
7
8
9
10
For Each Additional
Person Add:

$
$
$
$
$
$
$
$
$
$

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
a.

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.

b.

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.
Supersedes TN No.

Approval Date

Effective Date

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

TN No.
Supersedes TN No.

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:

$
$
$
$
$
$
$
$
$
$

Approval Date

$

Effective Date

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.
Supersedes TN No.

Approval Date

Effective Date

Revision:

SUPPLEMENT 1 TO
ATTACHMENT 2.6-A
Page 6

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
INCOME LEVELS (continued)
F.

MEDICALLY NEEDY
Applicable to all groups.

(1)
Family
Size

Applicable to:

(2)
Net income level
protected for
maintenance for
months

(3)
Net income level
for persons
living in rural
areas for
months

1
2
3
4
5
6
7
8
9
10

$
$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$
$

For each additional
person, add:

$

$

Urban and Rural
Urban Only

TN No.
Supersedes TN No.

Approval Date

Effective Date

Revision:
SUPPLEMENT 2 TO
ATTACHMENT 2.6-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:
RESOURCE LEVELS
A.

CATEGORICALLY NEEDY GROUPS
1.

AFDC standards under the AFDC plan in effect on July 16, 1996:

2.

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
1
2
3
4
5
6
7
8
9
10

TN No.

Approval Date

Resource Level

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
1
2
3
4
5
6
7
8
9
10

TN No.
Supersedes TN No.

Approval Date

Resource Level

Effective Date

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
1
2
3
4
5
6
7
8
9
10

TN No.
Supersedes TN No.

Approval Date

Resource Level

Effective Date

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
1
2
3
4
5
6
7
8
9
10

TN No.
Supersedes TN No.

Approval Date

Resource Level

Effective Date

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.
Supersedes TN No.

Approval Date

Effective Date

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)
of the Act

The following criteria will be used to determine whether the agency will
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.
Supersedes TN No.

Approval Date

Effective Date

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.
Supersedes TN No.

Approval Date

Effective Date

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
1917(b)(1)(C)
of the Act

The following more liberal methodology applies to individuals who are
eligible for medical assistance under one of the following eligibility
groups:

An individual who is a beneficiary under a long-term care insurance
policy that meets the requirements of a “qualified State long-term care
insurance partnership” policy (partnership policy) as set forth below, is
given a resource disregard as described in this amendment. The amount of
the disregard is equal to the amount of the insurance benefit payments
made to or on behalf of the individual. The term “long-term care
insurance policy” includes a certificate issued under a group insurance
contract.
The State Medicaid Agency (Agency) stipulates that the following
requirements will be satisfied in order for a long-term care policy
to qualify for a disregard. Where appropriate, the Agency relies on
attestations by the State Insurance Commissioner (Commissioner)
or other State official charged with regulation and oversight of
insurance policies sold in the state, regarding information within
the expertise of the State’s Insurance Department.


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



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

TN No.
Supersedes TN No.

Approval Date

Effective Date

Revision:

SUPPLEMENT 8c TO
ATTACHMENT 2.6-A
Page 2
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:

TN No.
Supersedes TN No.



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 longterm care.



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

Approval Date

Effective Date

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.
Supersedes TN No.
Revision:

Approval Date

Effective Date

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
the Act

FOR TRANSFERS OF ASSETS FOR LESS THAN FAIR MARKET VALUE
MADE ON OR AFTER FEBRUARY 8, 2006, the agency provides for the
denial of certain Medicaid services.
1.

Institutionalized individuals are denied coverage of certain Medicaid
services upon disposing of assets for less than fair market value on or after
the look-back date.
The agency does not provide medical assistance coverage for
institutionalized individuals for the following services:
 Nursing facility services;
 Nursing facility level of care provided in a medical institution;
 Home and community-based services under a 1915(c) waiver.

2.

Non-Institutionalized Individuals
The agency withholds payment to non-institutionalized individuals for the
following services:
 Home health services (section 1905(a)(7));
 Home and community care for functionally disabled and elderly adults
(section 1905(a)(22));
 Personal care services furnished to individuals who are not inpatients
in certain medical institutions, as recognized under agency law and
specified in section 1905(a)(24).
The agency applies these provisions to the following noninstitutionalized eligibility groups. These groups can be no more
restrictive than those set forth in section 1905(a) of the Social
Security Act:

TN No.
Supersedes TN No.

Approval Date

Effective Date

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
4.

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:

5.

Penalty Period - Non-institutionalized Individuals –
The agency imposes a penalty period determined by using the same method as is
used for an institutionalized individual, including the use of the average monthly
cost of nursing facility services;
imposes a shorter penalty period than would be imposed for
institutionalized individuals, as outlined below:

6.

Penalty period for amounts of transfer less than cost of nursing facility care –
Where the amount of the transfer is less than the monthly cost of nursing facility
care, the agency imposes a penalty for less than a full month, based on the option
selected in item 4.
The State adds together all transfers for less than fair market value made
during the look-back period in more than one month and calculates a
single period of ineligibility, that begins on the earliest date that would
otherwise apply if the transfer had been made in a single lump sum.

TN No.

Approval Date

Effective Date

Supersedes TN No.

Revision:
SUPPLEMENT 9b
TO ATTACHMENT 2.6-A
Page 4
Territory:
TRANSFER OF ASSETS
7.

8.

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.

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.
Supersedes TN No.

Approval Date

Effective Date

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:

10.

(a)

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

(b)

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:
(a)

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

(b)

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

(c)

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.
Supersedes TN No.

Approval Date

Effective Date

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.
Supersedes TN No.

Approval Date

Effective Date

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:
1.

Income: The SSI breakeven point for earned income.

2.

Resources: The SSI resource standard.

TN No.

Approval Date

Effective Date

Supersedes TN No.

Revision:
SUPPLEMENT 15
TO ATTACHMENT 2.6-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
Territory:

1917(f) of
the Act

The State agency denies reimbursement for nursing facility services and other
long-term care services covered under the State plan for an individual who does
not have a spouse, child under 21 or adult disabled child residing in the
individual’s home, when the individual’s equity interest in the home exceeds the
following amount:
_____ $500,000 (increased by the annual percentage increase in the urban
component of the consumer price index beginning with 2011, rounded to
the nearest $1,000).
_____ An amount that exceeds $500,000 but does not exceed $750,000
(increased by the annual percentage increase in the urban component of
the consumer price index beginning with 2011, rounded to the nearest
$1,000).
The amount chosen by the State is _________________.
_____ This higher standard applies statewide.
_____ This higher standard does not apply statewide. It only applies in
the following areas of the State:

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

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

TN No.

Approval Date

Effective Date

Supersedes TN No.
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