This part sets forth, for Guam, Puerto Rico, and the Virgin Islands—

(a) The eligibility provisions that a State plan must contain;

(b) The mandatory and optional groups of individuals to whom Medicaid is provided under a State plan;

(c) The eligibility requirements and procedures that a Medicaid agency must use in determining and redetermining eligibility, and requirements it may not use; and

(d) The availability of FFP for providing Medicaid and for administering the eligibility provisions of the plan.

[43 FR 45218, Sept. 29, 1978, as amended at 44 FR 17939, Mar. 23, 1979]

This part implements the following sections of the Act and public laws that state requirements and standards for eligibility:

402(a)(22) Eligibility of deemed beneficiaries of AFDC who receive zero payments because of recoupment of overpayments. 402(a)(37) Eligibility of individuals who lose AFDC eligibility due to increased earnings. 414(g) Eligibility of certain individuals participating in work supplementation programs. 473(b) Eligibility of children in foster care and adopted children who are deemed AFDC beneficiaries. 1902(a)(8) Opportunity to apply; assistance must be furnished promptly. 1902(a)(10) Required and optional groups. 1902(a)(12) Determination of blindness. 1902(a)(16) Out-of-State care for State residents. 1902(a)(17) Standards for determining eligibility; flexibility in the application of income eligibility standards. 1902(a)(19) Safeguards for simplicity of administration and best interests of beneficiaries. 1902(a)(34) Three-month retroactive eligibility. 1902(a) (second paragraph after (47)) Eligibility despite increased monthly insurance benefits under title II. 1902(a)(55) Mandatory use of outstation locations other than welfare offices to receive and initially process applications of certain low-income pregnant women, infants, and children under age 19. 1902(b) Prohibited conditions for eligibility:

Age requirements of more than 65 years;

State residence requirements excluding individuals who reside in the State; and

Citizenship requirement excluding United States citizens.

1902(e) Four-month continued eligibility for families ineligible because of increased hours or income from employment. 1902(e)(2) Minimum eligibility period for beneficiaries enrolled in HMO. 1902(e)(3) Optional coverage of certain disabled children at home. 1902(e)(4) Eligibility of newborn children of Medicaid-eligible women. 1902(e)(5) Eligibility of pregnant women for extended coverage for a specified period after pregnancy ends. 1903(v) Payment for emergency services under Medicaid provided to aliens. 1905(a) (i)-(viii) List of eligible individuals. 1905(a) (clause following (21)) Prohibitions against providing Medicaid to certain institutionalized individuals. 1905(a) (second sentence) Definition f essential person. 1905(d)(2) Definition of resident of an intermediate care facility for individuals with intellectual disabilities. 1905(n) Definition of qualified pregnant woman and child. 1912(a) Conditions of eligibility. 1915(c) Home or community based services. 1915(d) Home and community-based services for individuals age 65 or older. 412(e)(5) of Immigration and Nationality Act-Eligibility of certain refugees. Pub. L. 93-66, section 230 Deemed eligibility of certain essential persons. Pub. L. 93-66, section 231 Deemed eligibility of certain persons in medical institutions. Pub. L. 93-66, section 232 Deemed eligibility of certain blind and disabled medically indigent persons. Pub. L. 96-272, section 310(b)(1) Continued eligibility of certain beneficiaries of Veterans Administration pensions. Pub. L. 99-509, section 9406 Payment for emergency medical services provided to aliens. Pub. L. 99-603, section 201 Aliens granted legalized status under section 245A of the Immigration and Nationality Act (8 U.S.C. 1255a) may under certain circumstances be eligible for Medicaid. Pub. L. 99-603, section 302 Aliens granted legalized status under section 210 of the Immigration and Nationality Act may under certain circumstances be eligible for Medicaid (8 U.S.C. 1160). Pub. L. 99-603, section 303 Aliens granted legal status under section 210A of the Immigration and Nationality Act may under certain circumstances be eligible for Medicaid (8 U.S.C. 1161). [52 FR 43072, Nov. 9, 1987; 52 FR 48438, Dec. 22, 1987, as amended at 55 FR 36820, Sept. 7, 1990; 55 FR 48609, Nov. 21, 1990; 57 FR 29155, June 30, 1992; 59 FR 48811, Sept. 23, 1994]

As used in this part—

AABD means aid to the aged, blind, and disabled under title XVI of the Act;

AB means aid to the blind under title X of the Act;

AFDC means aid to families with dependent children under title IV-A of the Act;

APTD means aid to the permanently and totally disabled under title XIV of the Act;

Categorically needy refers to families and children, aged, blind or disabled individuals, and pregnant women listed under subparts B and C of this part who are eligible for Medicaid. Subpart B of this part describes the mandatory eligibility groups who, generally, are receiving or deemed to be receiving cash assistance under the Act. These mandatory groups are specified in sections 1902(a)(10)(A)(i) and 1902(e) of the Act. Subpart C of this part describes the optional eligibility groups of individuals who, generally, meet the categorical requirements that are the same as or less restrictive than those of the cash assistance programs but are not receiving cash payments. These optional groups are specified in sections 1902(a)(10)(A)(ii) and 1902(e) of the Act.

Families and children refers to eligible members of families with children who are financially eligible under AFDC or medically needy rules and who are deprived of parental support or care as defined under the AFDC program (see 45 CFR 233.90; 233.100). In addition, this group includes individuals under age 21 who are not deprived of parental support or care but who are financially eligible under AFDC or medically needy rules (see optional coverage group, § 436.222);

Medically needy means families, children, aged, blind, or disabled individuals, and pregnant women listed in subpart D of this part who are not listed in subparts B and C of this part as categorically needy but who may be eligible for Medicaid under this part because their income and resources are within limits set by the State under its Medicaid plan (including persons whose income and resources fall within these limits after their incurred expenses for medical or remedial care are deducted). (Specific financial requirements for determining eligibility of the medically needy appear in subpart I of this part.)

OAA means old age assistance under title I of the Act;

OASDI means old age, survivors, and disability insurance under Title II of the Act.

Optional targeted low-income child means a child under age 19 who meets the financial and categorical standards described below.

(1) Financial need. An optional targeted low-income child:

(i) Has a family income at or below 200 percent of the Federal poverty line for a family of the size involved;

(ii) Resides in a State with no Medicaid applicable income level (as defined in § 457.10 of this chapter); or,

(iii) Resides in a State that has a Medicaid applicable income level (as defined in § 457.10) and has family income that either:

(A) Exceeds the Medicaid applicable income level for the age of such child, but not by more than 50 percentage points (expressed as a percentage of the Federal poverty line); or

(B) Does not exceed the income level specified for such child to be eligible for medical assistance under the policies of the State plan under title XIX on June 1, 1997.

(2) No other coverage and State maintenance of effort. An optional targeted low-income child is not covered under a group health plan or health insurance coverage, or would not be eligible for Medicaid under the policies of the State plan in effect on March 31, 1997; except that, for purposes of this standard—

(i) A child shall not be considered to be covered by health insurance coverage based on coverage offered by the State under a program in operation prior to July 1, 1997 if that program received no Federal financial participation;

(ii) A child shall not be considered to be covered under a group health plan or health insurance coverage if the child did not have reasonable geographic access to care under that coverage.

(3) For purposes of this section, policies of the State plan under title XIX plan include policies under a Statewide demonstration project under section 1115(a) of the Act other than a demonstration project that covered an expanded group of eligible children but that either—

(i) Did not provide inpatient hospital coverage; or

(ii) Limited eligibility to children previously enrolled in Medicaid, imposed premiums as a condition of initial or continued enrollment, and did not impose a general time limit on eligibility.

[43 FR 45218, Sept. 29, 1978, as amended at 45 FR 24887, Apr. 11, 1980; 46 FR 47989, Sept. 30, 1981; 58 FR 4934, Jan. 19, 1993; 66 FR 2668, Jan. 11, 2001]

A State plan must—

(a) Provide that the requirements of this part are met; and

(b) Specify the groups to whom Medicaid is provided, as specified in subparts B, C, and D of this part, and the conditions of eligibility for individuals in those groups.