9.03 Categorical and financial criteria

Coverage groups and income standards. An individual must meet the criteria for at least one of the following coverage groups: Deemed newborn 45 45 42 CFR § 435.117. Eligibility Standards Part 2 – Page 21 (Sec.9.00, Sub.9.03) Basis. This sub clause implements §§ 1902(e)(4) and 2112(e) of the Act. Eligibility (i) Medicaid coverage will be provided to a child from birth until the child's first birthday without application if, on the date of the child's birth, the child's mother was eligible for and received covered services under Medicaid or CHIP (including during a retroactive period of eligibility under § 70.01(b)) regardless of whether payment for services for the mother is limited to services necessary to treat an emergency medical condition, as defined in § 17.02(d); 46 (ii) The child is deemed to have applied and been determined eligible for Medicaid effective as of the date of birth, and remains eligible regardless of changes in circumstances (except if the child dies or ceases to be a resident of the state or the child's representative requests a voluntary termination of the child's eligibility) until the child's first birthday. (iii) A child qualifies for this group regardless of whether they continue to live with their mother. (iv) This provision applies in instances where the labor and delivery services were furnished prior to the date of application and covered by Medicaid based on retroactive eligibility. (v) Exception: A child born to a woman who has not met her spenddown on the day of delivery is ineligible for coverage under this group. (vi) There are no Medicaid income or resource standards that apply. Medicaid identification number (i) The Medicaid identification number of the child’s mother serves as the child's identification number, and all claims for covered services provided to the child may be submitted and paid under such number, unless and until AHS issues the child a separate identification number in accordance with (3)(ii) of this paragraph. (ii) AHS will issue a separate Medicaid identification number for the child prior to the effective date of any termination of the mother's eligibility or prior to the date of the child's first birthday, whichever is sooner, unless the child is determined to be ineligible (such as, because the child is not a state resident), except that AHS will issue a separate Medicaid identification number for the child promptly after it is notified of a child under 1 year of age residing in the state and born to a mother whose coverage is limited to services necessary for the treatment of an emergency medical condition, consistent with § 17.02(c). Children with adoption assistance, foster care, or guardianship care under title IV-E 47 46 Refugee Medical Assistance (Refugee Assistance Rule 5100) is not Medicaid and does not satisfy this requirement. 47 42 CFR § 435.145. Eligibility Standards Part 2 – Page 22 (Sec.9.00, Sub.9.03) Basis. This sub clause implements §§ 1902(a)(10)(A)(i)(I) and 473(b)(3) of the Act. Eligibility. Medicaid coverage will be provided to an individual under age 21, living in Vermont for whom: (i) An adoption assistance agreement is in effect with a state or tribe under Title IV-E of the Act, regardless of whether adoption assistance is being provided or an interlocutory or other judicial decree of adoption has been issued; or (ii) Foster care or kinship guardianship assistance maintenance payments are being made by a state or tribe under Title IV-E of the Act. Income standard. There is no Medicaid income standard that applies. Committed children in the custody of the state who are not IV-E eligible must pass the applicable eligibility tests before their eligibility for Medicaid can be established. Special needs adoption 48 Basis. This sub clause implements § 1902(a)(10)(A)(ii)(VIII) of the Act. Eligibility. Medicaid coverage will be provided to an individual under age 21: (i) For whom an adoption assistance agreement (other than an agreement under Title IV-E of the Act) between a state and the adoptive parent or parents is in effect; (ii) Whom the state agency which entered into the adoption agreement determined could not be placed for adoption without Medicaid coverage because the child has special needs for medical or rehabilitative care; and (iii) Who, prior to the adoption agreement being entered into, was eligible for Medicaid. Income standard. There is no Medicaid income standard that applies. Former foster child 49 Basis. This sub clause implements § 1902(a)(10)(A)(i)(IX) of the Act. Eligibility. Medicaid coverage will be provided to an individual who: (i) Is under age 26; and (ii) If the individual attained 18 years of age prior to January 1, 2023: Is not eligible and enrolled for mandatory coverage under §§ 7.03(a)(1), (2), (3), (6), (7); 8.05(a), 48 42 CFR § 435.227. 49 42 CFR § 435.150; Social Security Act § 1902(a)(10)(A)(i)(IX). Eligibility Standards Part 2 – Page 23 (Sec.9.00, Sub.9.03) (b), (c), (f), (h), (i), (j); or 9.03(c); and Was in foster care under the responsibility of Vermont and enrolled in Medicaid under the state's Medicaid State plan or 1115 demonstration upon attaining age 18; or (iii) If the individual attained 18 years of age on or after January 1, 2023: Is not enrolled for mandatory coverage under §§ 7.03(a)(1), (2), (3), (6), (7); 8.05(a), (b), (c), (f), (h), (i), (j); or 9.03(c); and Was in foster care under the responsibility of any state and enrolled in Medicaid under a state’s Medicaid State plan or 1115 demonstration upon attaining age 18 or such higher age as the state may have elected. Income standard. There is no Medicaid income standard that applies. Individual with breast or cervical cancer 50 Basis. This sub clause implements §§ 1902(a)(10)(A)(ii)(XVIII) and 1902(aa) of the Act. Eligibility (i) Medicaid coverage will be provided to an individual who: Is under age 65; Is not eligible and enrolled for mandatory coverage under the state's Medicaid State plan; Has been determined to need treatment for breast or cervical cancer through a screening under the Centers for Disease Control and Prevention (CDC) breast and cervical cancer early detection program (BCCEDP); 51 and Does not otherwise have creditable coverage, as defined in § 2704(c) of the PHS Act, for treatment of their breast or cervical cancer. Creditable coverage is not considered to be available just because the individual may: (I) Receive medical services provided by the Indian Health Service, a tribal organization, or an Urban Indian organization; or (II) Obtain health insurance coverage only after a waiting period of uninsurance. (ii) An individual whose eligibility is based on this group is entitled to full Medicaid coverage; coverage is not limited to coverage for treatment of breast and cervical cancer. 50 42 CFR § 435.213; CMS SHO Letter (January 4, 2001). 51 A woman is considered to have been screened and eligible for this group if she has received a screening mammogram, clinical breast exam, or Pap test; or diagnostic services following an abnormal clinical breast exam, mammogram, or Pap test; and a diagnosis of breast or cervical cancer or of a pre-cancerous condition of the breast or cervix as the result of the screening or diagnostic service. Eligibility Standards Part 2 – Page 24 (Sec.9.00, Sub.9.03) (iii) Medicaid eligibility for an individual in this group begins following the screening and diagnosis and continues as long as a treating health professional verifies the individual is in need of cancer treatment services. (iv) There is no waiting period of prior uninsurance before an individual who has been screened can become eligible for Medicaid under this group. Treatment need. An individual is considered to need treatment for breast or cervical cancer if, in the opinion of the individual's treating health professional (i.e., the individual who conducts the screen or any other health professional with whom the individual consults), the screen (and diagnostic evaluation following the clinical screening) determines that: (i) Definitive treatment for breast or cervical cancer is needed, including a precancerous condition or early stage cancer, and which may include diagnostic services as necessary to determine the extent and proper course of treatment; and (ii) More than routine diagnostic services or monitoring services for a precancerous breast or cervical condition are needed. Income standard. In order to qualify for screening under (f)(2)(i)(C) above, an individual must be determined by BCCEDP to have limited income. In addition to meeting the criteria described in this sub clause, the individual must meet all other Medicaid nonfinancial criteria. Family planning services 52 Basis. This sub clause implements §§ 1902(a)(10)(A)(ii)(XXI) and 1902(ii) and clause (XVI) in the matter following 1902(a)(10)(G) of the Act. Eligibility. Medicaid coverage of the services described in (g)(4) of this sub clause will be provided to an individual (male and female) who meets all of the following requirements: (i) Is not pregnant; and (ii) Meets the income eligibility requirements under (g)(3) of this sub clause. Income standard. The individual has MAGI-based household income (as defined in § 28.03) that is at or below the income standard for a pregnant woman as described in § 7.03(a)(2). The individual's household income is determined in accordance with § 28.03(j). Covered services. An individual eligible under this sub clause is covered for family planning and family planning-related benefits. HIV/AIDS. See, HIV/AIDS Rule 5800 et seq. 52 42 CFR § 435.214. Eligibility Standards Part 2 – Page 25 (Sec.10.00, Sub.10.01) Refugee Medical Assistance. See, Refugee Medical Assistance Rule 5100 et seq. Pharmacy benefits (01/15/2017, GCR 16-095)