8.05 The categorically-needy coverage groups

Eligibility Standards Part 2 – Page 9 (Sec.8.00, Sub.8.05) An individual applying for MABD must meet the criteria of one or more of the following categories. Individual enrolled in SSI/AABD 20 An individual who is granted SSI/AABD by the SSA is automatically eligible for MABD. In addition to SSI/AABD enrollees, this group includes an individual who is: (i) Receiving SSI pending a final determination of blindness or disability; or (ii) Receiving SSI under an agreement with the SSA to dispose of resources that exceed the SSI dollar limits on resources (recoupment). Medicaid eligibility for an individual in this group is automatic; there are no Medicaid income or resource standards that apply. Individual who is SSI-eligible An individual who would be eligible for SSI/AABD except that they: (i) Have not applied for SSI/AABD 21; or (ii) Do not meet SSI/AABD requirements not applicable to Medicaid (e.g., participation in vocational rehabilitation or a substance abuse treatment program) 22. An individual in this group must: (i) Have MABD income for the individual’s financial responsibility group (as defined in § 29.03) that is at or below the SSI/AABD payment level for the individual’s Medicaid group (as defined in § 29.04); (ii) Have MABD resources for the individual’s financial responsibility group that is at or below the SSI/AABD maximum for the individual’s Medicaid group; and (iii) Meet the MABD nonfinancial criteria. Individual eligible for SSI but for earnings 23 (Section 1619(b) of the Social Security Act) An individual whom the SSA determines eligible under the Act (§1619(b)) because they meet all SSI/AABD eligibility requirements except for the amount of their earnings and who: 20 42 CFR § 435.120. 21 42 CFR § 435.210. 22 42 CFR § 435.122. 23 42 CFR § 435.120(c). Eligibility Standards Part 2 – Page 10 (Sec.8.00, Sub.8.05) (i) Does not have sufficient earnings to provide the reasonable equivalent of publicly-funded attendant care services that would be available if they did not have such earnings; and (ii) Is seriously inhibited by the lack of Medicaid coverage in their ability to continue to work or obtain employment. Medicaid eligibility for an individual in this group is automatic; there are no Medicaid income or resource standards that apply. Individual with disabilities who is working (Medicaid for working people with disabilities (MWPD)) An individual with disabilities who is working and, except for the amount of their income and resources, is otherwise eligible for MABD, and who: (i) Has MABD income for the individual’s financial responsibility group (as defined in § 29.03), that is: Below 250% of the FPL for the individual’s Medicaid group (as defined in § 29.04); and After disregarding the working disabled person’s earnings, Social Security Disability Insurance benefits (SSDI) including, if applicable, Social Security retirement benefits automatically converted from SSDI 24, and any veterans’ disability benefits, and, if married, all income of the working disabled person’s spouse 25, has MABD income that is: (I) Less than the applicable PIL if they are in a Medicaid group of one; or (II) Less than the applicable SSI/AABD payment level if they are in a Medicaid group of two. (ii) Has resources at the time of enrollment in the group that do not exceed $10,000.00 26 for a single individual and $15,000.00 27 for a couple (see § 29.08(i)(8) for resource exclusion after enrollment). The individual’s earnings must be documented by evidence of: (i) Federal Insurance Contributions Act tax payments; (ii) Self-employment Contributions Act tax payments or reported self-employment income from the individual’s most recent Federal Income Tax Return and relevant schedules. For an individual who has been self-employed for less than a year, AHS may accept as documentation of the individual’s self-employment business records showing income and expenses for the relevant period; or 24 33 VSA § 1902(b). 25 33 VSA § 1902(b). 26 33 VSA § 1902(b). 27 33 VSA § 1902(b). Eligibility Standards Part 2 – Page 11 (Sec.8.00, Sub.8.05) (iii) A written business plan approved and supported by a third-party investor or funding source. Earnings, SSDI, and veterans’ disability benefits of the working disabled person and, if married, the income of their spouse are not disregarded for an individual with spend-down requirements who does not meet all of the above requirements and seeks coverage under the medically-needy coverage group (see § 8.06). Child under 18 who lost SSI because of August 1996 change in definition of disability. An individual under the age of 18 who lost their SSI or SSI/AABD eligibility because of the more restrictive definition of disability enacted in August 1996 but who continues to meet all other MABD criteria until their 18th birthday. 28 The definition of disability for this group is the definition of childhood disability in effect prior to the 1996 revised definition. Certain spouses and surviving spouses. An individual with a disability if they meet all of the following conditions: The individual is: (i) A surviving spouse; or (ii) A spouse who has obtained a legal dissolution and: Was the spouse of the insured for at least 10 years; and Remains single. The individual meets one of the following groups of criteria under the Act: 29 (i) The individual: Applied for SSI-related Medicaid no later than July 1, 1988; Was receiving SSI/AABD in December 1983; Lost SSI/AABD in January 1984 due to a statutory elimination of an additional benefit reduction factor for surviving spouses before attainment of age 60; Has been continuously entitled to surviving spouse insurance based on disability since January 1984; and Would continue to be eligible for SSI/AABD if they had not received the increase in social security disability or retirement benefits. (ii) The individual: 28 Personal Responsibility and Work Opportunity Reconciliation Act of 1996 § 211(a); Balanced Budget Act of 1997 § 4913. 29 Social Security Act §§ 1634(b)(1) and 1634(d); 42 USC §§ 1383c(b)(1) and 1383c(d). Eligibility Standards Part 2 – Page 12 (Sec.8.00, Sub.8.05) Lost SSI/AABD benefits due to a mandatory application for and receipt of social security disability, retirement or survivor benefits; Is not yet eligible for Medicare Part A; Is at least age 50 30, but has not yet attained age 65; and Would continue to be eligible for SSI/AABD if they were not receiving social security disability or retirement benefits. An individual in this group must: (i) After deducting the increase in social security disability or retirement benefits, have MABD income for the individual’s financial responsibility group (as defined in § 29.03) that is at or below the SSI/AABD payment level for the individual’s Medicaid group (as defined in § 29.04); (ii) Have MABD resources for the individual’s financial responsibility group that is at or below the SSI/AABD maximum for the individual’s Medicaid group; and (iii) Meet the MABD nonfinancial criteria. Disabled adult child (DAC) 31 An individual with a disability under the Act (§1634(c)) who: (i) Is at least 18 years of age; (ii) Has blindness or a disability that began before age 22; (iii) Is entitled to social security benefits on their parents’ record due to retirement, death, or disability benefits and lost SSI/AABD due to receipt of this benefit or an increase in this benefit; and (iv) Would remain eligible for SSI/AABD in the absence of the social security retirement, death, or disability benefit or increases in that benefit. An individual in this group must: (i) After deducting the social security benefits on their parents’ record, have MABD income for the individual’s financial responsibility group (as defined in § 29.03) that is at or below the SSI/AABD payment level for the individual’s Medicaid group (as defined in § 29.04); (ii) Have MABD resources for the individual’s financial responsibility group that is at or below the SSI/AABD maximum for the individual’s Medicaid group; and 30 Note: 42 CFR § 435.138 says at least age 60. However, it has been determined that the reference to age 50 is correct. See, SSA’s Program Operations Manual System (POMS) SI 01715.015(B)(5)(c). 31 Social Security Act § 1634(c). Eligibility Standards Part 2 – Page 13 (Sec.8.00, Sub.8.05) (iii) Meet the MABD nonfinancial criteria. Individual eligible under the Pickle Amendment 32 An individual determined eligible under the Pickle Amendment to Title XIX of the Act (§1939(a)(5)(E)) who: (i) Is receiving social security retirement or disability benefits (OASDI); (ii) Was eligible for and received SSI or SSI/AABD for at least one month after April 1977; and (iii) Lost SSI/AABD benefits but would be eligible for them if all increases in the social security benefits due to annual cost-of-living adjustments (COLAs) were deducted from their income. An individual in this group must: (i) After deducting the increase in social security benefits due to annual COLAs, have MABD income for the individual’s financial responsibility group (as defined in § 29.03) that is at or below the SSI/AABD payment level for the individual’s Medicaid group (as defined in § 29.04); (ii) Have MABD resources for the individual’s financial responsibility group that is at or below the SSI/AABD maximum for the individual’s Medicaid group; and (iii) Meet the MABD nonfinancial criteria. Individual eligible for Medicaid in December 1973. 33 An individual who was eligible for Medicaid in December 1973 and meets at least one of the following criteria: An institutionalized individual who was eligible for Medicaid in December 1973, or any part of that month, as an inpatient of a medical institution or intermediate care facility that was participating in the Medicaid program and who, for each consecutive month after December 1973: (i) Continues to meet the Medicaid eligibility requirements in effect in December 1973 for institutionalized individuals; (ii) Continues to reside in the institution; and (iii) Continues to be classified as needing institutionalized care. A blind or disabled individual who does not meet current criteria for blindness or disability, but: (i) Was eligible for Medicaid in December 1973 as a blind or disabled individual, whether or not they were receiving cash assistance in December 1973; 32 Section 503 of P.L. 94-566; 42 CFR § 435.135(a)(3). 33 42 CFR §§ 435.131, 435.132 and 435.133. Eligibility Standards Part 2 – Page 14 (Sec.8.00, Sub.8.05) (ii) For each consecutive month after December 1973 continues to meet the criteria for blindness or disability and the other conditions of eligibility in effect in December 1973; (iii) Has MABD income for the individual’s financial responsibility group (as defined in § 29.03) that is at or below the SSI/AABD payment level for the individual’s Medicaid group (as defined in § 29.04); (iv) Has MABD resources for the individual’s financial responsibility group that are at or below the SSI/AABD maximum for the individual’s Medicaid group; and (v) Meets the MABD nonfinancial criteria. An individual who was eligible for Medicaid in December 1973 as an essential spouse of an aged, blind, or disabled individual who was receiving cash assistance, if the following conditions are met: 34 (i) The aged, blind, or disabled individual continues to meet the December 1973 Medicaid eligibility requirements; and (ii) The essential spouse continues to meet the conditions that were in effect in December, 1973 for having their needs included in computing the payment to the aged, blind, or disabled individual. Individual eligible for AABD in August 1972 35 An individual who meets the following conditions: (i) In August 1972 the individual was entitled to social security retirement or disability and eligible for AABD, or would have been eligible if they had applied, or were not in a medical institution or intermediate care facility; and (ii) Would currently be eligible for SSI or SSI/AABD except that the 20 percent cost-of-living increase in social security benefits effective September 1972 raised their income over the AABD limit. An individual in this group must: (i) After deducting the increase in social security benefits due to COLA increase effective September 1972, have MABD income for the individual’s financial responsibility group (as defined in § 29.03) that is at or below the SSI/AABD payment level for the individual’s Medicaid group (as defined in § 29.04); (ii) Have MABD resources for the individual’s financial responsibility group that is at or below the SSI/AABD maximum for the individual’s Medicaid group; and 34 An “essential spouse” is defined as one who is living with the individual, whose needs were included in determining the amount of SSI or SSI/AABD payment to an aged, blind, or disabled individual living with the essential spouse, and who is determined essential to the individual’s well-being. 35 42 CFR § 435.134. Eligibility Standards Part 2 – Page 15 (Sec.8.00, Sub.8.05) (iii) Meet the MABD nonfinancial criteria. Individual eligible for MABD-based Medicaid coverage of long-term care services and supports [Reserved] Individual who would be eligible for cash assistance if they were not in a medical institution 36 (i) Basis. This section implements section 1902(a)(10)(A)(ii)(IV) of the Act. (ii) Eligibility. An aged, blind, or disabled individual who is in a medical institution and who: Is ineligible for SSI/AABD because of lower income standards used under the program to determine eligibility for institutionalized individuals; but Would be eligible for SSI/AABD if they were not institutionalized. Individual living in a medical institution eligible under a special income level. 37 An aged, blind or disabled individual who is living in a medical institution and who: (i) Has lived in an institution for at least 30 consecutive days; (ii) Has MABD income for the individual’s financial responsibility group (as defined in § 29.03) that does not exceed 300 percent of the maximum SSI federal payment to an individual living independently in the community (institutional income standard (IIS)); 38 (iii) Has MABD resources for the individual’s financial responsibility group that is at or below the SSI/AABD maximum for the individual’s Medicaid group (as defined in § 29.04), except that if an individual’s resources are in excess of the SSI/AABD maximum and the individual has a spouse, a resource evaluation process of assessment and allocation must be performed at the beginning of the individual’s first continuous period of long-term care, as set forth in § 29.10(e); and (iv) Meets the MABD non-financial criteria. Individual in special income group who qualifies for home and community-based services. An individual who qualifies for home and community-based services and who: (i) Would be eligible for MABD under paragraph (k)(3) of this subsection if they were living in a medical institution; (ii) Has MABD income for the individual’s financial responsibility group that is above the PIL and at or 36 42 CFR § 435.211. 37 42 CFR § 435.236. 38 For the purpose of determining income eligibility, an individual applying for Medicaid coverage of long-term care services and supports under MABD is a Medicaid group of one, even if they have a spouse (see § 29.04(d)). Eligibility Standards Part 2 – Page 16 (Sec.8.00, Sub.8.05) below the IIS; and (iii) Can receive appropriate long-term medical care in the community as determined by AHS. Individual under special income level who is receiving hospice services. An individual who: (i) Would be eligible for MABD under paragraph (k)(3) of this subsection if they were living in a medical institution; (ii) Can receive appropriate medical care in the community, the cost of which is no greater than the estimated cost of medical care in an appropriate institution; and (iii) Receives hospice care as described in § 30.01(d) and defined in § 1905(o) of the Social Security Act. Disabled child in home care (DCHC, Katie Beckett). 39 A disabled individual who: (i) Requires the level of care provided in a medical institution; For purposes of § 8.05(k)(6): (I) A “medical institution” means a hospital, skilled nursing facility, or intermediate care facility; and (II) “Requires the level of care provided in a medical institution” means the individual is living at home but requires the level of care provided in a medical institution. AHS determines whether the individual requires the level of care provided in a medical institution. AHS may designate a standardized assessment tool which AHS will use whenever it determines whether an individual requires an institutional level of care. Level of care eligibility for DCHC may be reviewed by AHS annually, unless it is determined that the frequency of reviews should be altered due to the unique circumstances of the individual, or when there is a change in health or functional status of the individual. (ii) Except for income or resources, would be eligible for MABD if they were living in a medical institution; (iii) Can receive the appropriate institutional level of care outside of a medical institution and the estimated Medicaid cost of such care is no greater than the estimated Medicaid cost of appropriate institutional care; (iv) Is age 18 or younger; (v) Has MABD income (described at § 29.11), excluding their parents’ income, no greater than the Institutional Income Standard (IIS); and (vi) Has MABD resources (described at § 29.07), excluding their parents’ resources, no greater than 39 Social Security Act § 1902(e)(3); 42 CFR § 435.225. Eligibility Standards Part 2 – Page 17 (Sec.8.00, Sub.8.06) the resource limit for a Medicaid group of one. Individual eligible for MWPD. An individual who qualifies for home and community-based services and meets the eligibility requirements for MWPD as set forth in § 8.05(d). Individual under the PIL who qualifies for home and community-based services. An individual who qualifies for home and community-based services and who: (i) Would be eligible for MABD under paragraph (k)(3) of this subsection if they were living in a medical institution; (ii) Has MABD income for the individual’s financial responsibility group that is at or below the PIL; and (iii) Can receive appropriate long-term medical care in the community as determined by AHS.