7.03 Categorical and financial criteria

Coverage groups and income standards. The individual must meet the criteria for at least one of the following coverage groups: Parent and other caretaker relative. 4 A parent or caretaker relative of a dependent child (as defined in § 3.00) and their spouse, if living within the same household as the parent or caretaker relative, with a MAGI-based household income, as defined in § 28.03, that is at or below a specified dollar amount that is set based on the parent or caretaker relative’s family size and whether they live in or outside of Chittenden County. A chart of these dollar amounts is made publicly available via website. Pregnant woman 5 (i) A woman during pregnancy and the post partum period, as defined in the definition of pregnant woman in § 3.00, with a MAGI-based household income, as defined in § 28.03, that is at or below 208 percent of the FPL for the applicable family size. (ii) Retroactive eligibility: A woman may be retroactively granted Medicaid eligibility under this coverage group if she was pregnant during the retroactive period defined in § 70.01(b) and met all eligibility criteria. If she applies for Medicaid after her pregnancy ends, but was pregnant on or after April 1, 2023, and met all eligibility criteria at § 70.01(b), she may also be granted eligibility through the end of the month in which the post partum period ends. 1 42 CFR § 435.406. 2 42 CFR § 435.403. 3 42 CFR § 435.610. 4 42 CFR § 435.110. 5 42 CFR § 435.116. Eligibility Standards Part 2 – Page 3 (Sec.7.00, Sub.7.03) (iii) Continuous eligibility: An eligible pregnant woman who would lose eligibility because of a change in circumstances, including a change in household income, household composition or categorical eligibility, is deemed to continue to be eligible throughout the pregnancy and the post partum period without regard to a change in circumstances unless: The woman requests voluntary termination; The woman ceases to be a resident of Vermont; The woman dies; or AHS determines that eligibility was determined incorrectly at the most recent determination or redetermination of eligibility because of agency error or fraud, abuse, or perjury attributed to the woman. 6 This provision applies to a medically-needy pregnant woman as follows: If the woman meets her spenddown while pregnant, her eligibility continues during the remainder of her pregnancy and post partum period. The woman does not have to meet a spenddown again until the end of her post partum period. Child 7 (i) An individual, who is under the age of 19 8, with a MAGI-based household income, as defined in § 28.03, that is at or below 312 percent of the FPL for the applicable family size. (ii) Continuous eligibility for children effective January 1, 2024 9: This provision implements section 1902(e)(12) of the Social Security Act. The length of the continuous eligibility period is 12 months. The continuous eligibility period begins on the effective date of the individual’s initial eligibility or most recent renewal or most recent redetermination if the redetermination results in the reestablishment of the annual renewal date pursuant to § 73.03. An individual’s eligibility may not be terminated during a continuous eligibility period, regardless of any changes in circumstances, unless: (I) The individual attains the age of 19; 6 CMS SHO Letter No. 21-007 (December 7, 2021). 7 42 CFR § 435.118. 8 Medicaid will be provided to a child eligible and enrolled under this sub clause for the full calendar month within which their 19th birthday occurs. 9 42 CFR § 435.926. Eligibility Standards Part 2 – Page 4 (Sec.7.00, Sub.7.03) (II) The individual ceases to be a resident of Vermont; (III) The individual or the individual’s representative requests a voluntary termination of eligibility; (IV) AHS determines that eligibility was erroneously granted at the most recent determination, redetermination or renewal of eligibility because of agency error or fraud, abuse or perjury attributed to the individual or the individual’s representative; or (V) The individual dies. This provision also applies to children who are under the age of 19 and eligible for Medicaid under MABD categorically-needy coverage groups. 10 This provision does not apply to medically-needy children, children in a period of presumptive eligibility who have not yet received an eligibility determination on a regular Medicaid application, or children eligible for Medicaid on the basis of Transitional Medical Assistance. (iii) Continuous eligibility for a hospitalized child 11: This provision implements section 1902(e)(7) of the Act. Medicaid will be provided to an individual eligible and enrolled under this sub clause until the end of an inpatient stay for which inpatient services are furnished, if the individual: (I) Was receiving inpatient services covered by Medicaid on the date the individual is no longer eligible under this sub clause, based on the individual's age; and (II) Would remain eligible but for attaining such age. [Reserved] Adult 12 (i) Effective January 1, 2014, an individual who: Is age 19 or older and under age 65; Is not pregnant; Is not entitled to or enrolled in Medicare under parts A or B of Title XVIII of the Act; 13 10 See, § 8.03(d)(2). 11 42 CFR § 435.172. 12 42 CFR § 435.119. 13 Note: The definition of adult in Medicaid (42 CFR § 435.119) and the Exchange (45 CFR § 155.305) rules varies with respect to whether the individual can be entitled to Medicare Part B, but not yet enrolled. AHS has adopted the Medicaid Eligibility Standards Part 2 – Page 5 (Sec.7.00, Sub.7.03) Is not otherwise eligible for and enrolled in a mandatory coverage group; and Has household income that is at or below 133 percent of the FPL for the applicable family size. (ii) Coverage for children under 21: 14 Medicaid cannot be provided under this sub clause to a parent or other caretaker relative living with a child who is under the age of 21 unless such child is receiving benefits under Medicaid or Dr. Dynasaur, or otherwise is enrolled in MEC. Families with Medicaid eligibility extended because of increased earnings; Transitional Medical Assistance under § 1925 of the Social Security Act 15 (i) In general. Families who become ineligible for Medicaid because a parent or caretaker relative has new or increased earnings may be eligible for Transitional Medical Assistance (TMA) for up to 12 months, beginning with the month immediately following the month in which they become ineligible. TMA will be provided to a parent or other caretaker relative who was eligible and enrolled for Medicaid under § 7.03(a)(1), and any dependent child of such parent or other caretaker relative who was eligible and enrolled under § 7.03(a)(3), in at least 1 out of the 6 months immediately preceding the month that eligibility for the parent or other caretaker relative under § 7.03(a)(1) was lost due to increased earnings. If a dependent child of the parent or caretaker relative remains eligible for Medicaid under § 7.03(a)(3), the child will continue to receive Medicaid coverage under that category. (ii) Initial 12-month extension. For a parent or caretaker relative to remain eligible for the initial 12- month extension, they must continue to have a dependent child, as defined in § 3.00, living with them. Parents, caretaker relatives, and children eligible for TMA must continue to reside in Vermont. Families with Medicaid eligibility extended because of increased collection of spousal support 16 (i) Eligibility. Extended Medicaid coverage will be provided to a parent or other caretaker relative who was eligible and enrolled for Medicaid under § 7.03(a)(1), and any dependent child of such parent or other caretaker relative who was eligible and enrolled under § 7.03(a)(3), in at least 3 out of the 6 months immediately preceding the month that eligibility for the parent or other caretaker relative under § 7.03(a)(1) was lost due to increased collection of spousal support under Title IV-D of the Act. (ii) The extended Medicaid coverage is for 4 months following the month in which the individual version. 14 42 CFR § 435.119(c). 15 §§ 408(a)(11)(A), 1902(e)(1), 1925, and 1931(c)(2) of the Social Security Act. 16 42 CFR § 435.115; §§ 408(a)(11)(B) and 1931(c)(1) of the Social Security Act. Eligibility Standards Part 2 – Page 6 (Sec.8.00, Sub.8.01) becomes ineligible for Medicaid due to increased collection of spousal support by the parent or other caretaker relative. Medically Needy (i) In general. An individual under age 21, a pregnant woman, or a parent or other caretaker relative, as described above, may qualify for MCA as medically needy even if their income exceeds coverage group limits. (ii) Income eligibility. 17 For purposes of determining medically-needy eligibility under this sub clause, AHS applies the MAGI-based methodologies defined in § 28.03 subject to the requirements of § 28.04. (iii) Eligibility based on countable income. If countable income determined under paragraph (a)(8)(ii) of this sub clause is equal to or less than the PIL for the individual’s family size, the individual is eligible for Medicaid. (iv) Spenddown rules. The provisions under § 30.00 specify how an individual may use non-covered medical expenses to “spend down” their income to the applicable limits. Coverage of long-term care services and supports. 18 For an individual eligible for MCA who seeks Medicaid coverage of long-term care services and supports under MCA, AHS will apply the following rules in determining the individual’s eligibility for such coverage: (i) Substantial home-equity under § 29.09(d)(6); and (ii) Income and resource transfers under § 25.00. No resource tests. There are no resource tests for the coverage groups described under (a) of this subsection. Medicaid for the aged, blind, and disabled (MABD) (01/01/2026, GCR 25-051)