us/regulation/42/435/116/d/4

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us/regulation/42/435/116/d/4 — Axiom

(a)Basis. This section implements sections…#

(a) Basis. This section implements sections 1902(a)(10)(A)(i)(III) and (IV); 1902(a)(10)(A)(ii)(I), (IV), and (IX); and 1931(b) and (d) of the Act.

(b)Scope. The agency must provide Medicaid to pregnant…∀ 1#

(b) Scope. The agency must provide Medicaid to pregnant women whose household income is at or below the income standard established by the agency in its State plan, in accordance with paragraph (c) of this section.

(c)Income standard. The agency must establish in its State…∀ 3#

(1) The minimum income standard is the higher of:

(i)133 percent FPL for the applicable family size; or#

(i) 133 percent FPL for the applicable family size; or

(ii)Such higher income standard up to 185 percent FPL, if…#

(ii) Such higher income standard up to 185 percent FPL, if any, as the State had established as of December 19, 1989 for determining eligibility for pregnant women, or, as of July 1, 1989, had authorizing legislation to do so.

(2) The maximum income standard is the higher of—

(i) The highest effective income level in effect under the Medicaid State plan for coverage under the sections specified at paragraph (a) of this section, or waiver of the State plan covering pregnant women, as of March 23, 2010 or December 31, 2013, if higher, converted to a MAGI-equivalent standard in accordance with guidance issued by the Secretary under section 1902(e)(14)(A) and (E) of the Act; or

(ii) 185 percent FPL.

(d) Covered services. (1) Pregnant women are covered under this section for the full Medicaid coverage described in paragraph (d)(2) of this section, except that the agency may provide only pregnancy-related services described in paragraph (d)(3) of this section for pregnant women whose income exceeds the applicable income limit established by the agency in its State plan, in accordance with paragraph (d)(4) of this section.

(2) Full Medicaid coverage consists of all services which the State is required to cover under § 440.210(a)(1) of this subchapter and all services which it has opted to cover under § 440.225 and § 440.250(p) of this subchapter.

(3) Pregnancy-related services consists of services covered under the State plan consistent with § 440.210(a)(2) and § 440.250(p) of this subchapter.

(4) Applicable income limit for full Medicaid coverage of pregnant women. For purposes of paragraph (d)(1) of this section—

(i) The minimum applicable income limit is the State's AFDC income standard in effect as of May 1, 1988 for the applicable family size converted to a MAGI-equivalent standard in accordance with guidance issued by the Secretary under section 1902(e)(14)(A) and (E) of the Act.

(ii) The maximum applicable income limit is the highest effective income level for coverage under section 1902(a)(10)(A)(i)(III) of the Act or under section 1931(b) and (d) of the Act in effect under the Medicaid State plan or waiver of the State plan as of March 23, 2010 or December 31, 2013, if higher, converted to a MAGI-equivalent standard.

in view

Whole section

Encodings · 7

minimum_income_standard_floor_fpl_ratio42 CFR § 435.116 (c) · parameter

42 CFR 435.116(c)(1)(i)

name: minimum_income_standard_floor_fpl_ratio
kind: parameter
dtype: Rate
source: 42 CFR 435.116(c)(1)(i)
metadata:
  proof:
    atoms:
      - path: versions[0].formula
        kind: amount
        source:
          corpus_citation_path: us/regulation/42/435/116
          excerpt: 133 percent FPL for the applicable family size
versions:
  - effective_from: '2014-01-01'
    formula: '1.33'

minimum_income_standard_ceiling_fpl_ratio42 CFR § 435.116 (c) · parameter

42 CFR 435.116(c)(1)(ii)

name: minimum_income_standard_ceiling_fpl_ratio
kind: parameter
dtype: Rate
source: 42 CFR 435.116(c)(1)(ii)
metadata:
  proof:
    atoms:
      - path: versions[0].formula
        kind: amount
        source:
          corpus_citation_path: us/regulation/42/435/116
          excerpt: Such higher income standard up to 185 percent FPL
versions:
  - effective_from: '2014-01-01'
    formula: '1.85'

maximum_income_standard_floor_fpl_ratio42 CFR § 435.116 (c) · parameter

42 CFR 435.116(c)(2)(ii)

name: maximum_income_standard_floor_fpl_ratio
kind: parameter
dtype: Rate
source: 42 CFR 435.116(c)(2)(ii)
metadata:
  proof:
    atoms:
      - path: versions[0].formula
        kind: amount
        source:
          corpus_citation_path: us/regulation/42/435/116
          excerpt: 185 percent FPL
versions:
  - effective_from: '2014-01-01'
    formula: '1.85'

pregnant_woman_eligible42 CFR § 435.116 (b) · derived

42 CFR 435.116(b)

name: pregnant_woman_eligible
kind: derived
entity: Person
dtype: Judgment
period: Month
source: 42 CFR 435.116(b)
metadata:
  proof:
    atoms:
      - path: versions[0].formula
        kind: condition
        source:
          corpus_citation_path: us/regulation/42/435/116
          excerpt: >-
            The agency must provide Medicaid to pregnant women whose household
            income is at or below the income standard
versions:
  - effective_from: '2014-01-01'
    formula: >-
      person_is_pregnant

      and (household_income_as_fraction_of_fpl <=
      state_plan_pregnant_women_income_standard_fpl_ratio)

pregnant_woman_income_within_full_medicaid_applicable_income_limit42 CFR § 435.116 (d) · derived

42 CFR 435.116(d)(1)

name: pregnant_woman_income_within_full_medicaid_applicable_income_limit
kind: derived
entity: Person
dtype: Judgment
period: Month
source: 42 CFR 435.116(d)(1)
metadata:
  proof:
    atoms:
      - path: versions[0].formula
        kind: condition
        source:
          corpus_citation_path: us/regulation/42/435/116
          excerpt: >-
            the agency may provide only pregnancy-related services ... for
            pregnant women whose income exceeds the applicable income limit
versions:
  - effective_from: '2014-01-01'
    formula: >-
      household_income_as_fraction_of_fpl <=
      state_plan_full_medicaid_applicable_income_limit_fpl_ratio

pregnant_woman_full_medicaid_coverage42 CFR § 435.116 (d) · derived

42 CFR 435.116(d)(1)-(2)

name: pregnant_woman_full_medicaid_coverage
kind: derived
entity: Person
dtype: Judgment
period: Month
source: 42 CFR 435.116(d)(1)-(2)
metadata:
  proof:
    atoms:
      - path: versions[0].formula
        kind: condition
        source:
          corpus_citation_path: us/regulation/42/435/116
          excerpt: >-
            Pregnant women are covered under this section for the full Medicaid
            coverage
versions:
  - effective_from: '2014-01-01'
    formula: |-
      pregnant_woman_eligible
      and pregnant_woman_income_within_full_medicaid_applicable_income_limit

pregnant_woman_pregnancy_related_services_only42 CFR § 435.116 (d) · derived

42 CFR 435.116(d)(1), (d)(3)

name: pregnant_woman_pregnancy_related_services_only
kind: derived
entity: Person
dtype: Judgment
period: Month
source: 42 CFR 435.116(d)(1), (d)(3)
metadata:
  proof:
    atoms:
      - path: versions[0].formula
        kind: condition
        source:
          corpus_citation_path: us/regulation/42/435/116
          excerpt: >-
            the agency may provide only pregnancy-related services ... for
            pregnant women whose income exceeds the applicable income limit
            established by the agency in its State plan
versions:
  - effective_from: '2014-01-01'
    formula: |-
      pregnant_woman_eligible
      and not pregnant_woman_income_within_full_medicaid_applicable_income_limit

▸rulespec code

Shown source

regulations/42-cfr/435/116.yaml

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Rules

minimum_income_standard_floor_fpl_ratio

Parameter(c) in text ↖

source: 42 CFR 435.116(c)(1)(i)

- name: minimum_income_standard_floor_fpl_ratio
  kind: parameter
  dtype: Rate
  source: 42 CFR 435.116(c)(1)(i)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: amount
          source:
            corpus_citation_path: us/regulation/42/435/116
            excerpt: 133 percent FPL for the applicable family size
  versions:
    - effective_from: '2014-01-01'
      formula: '1.33'

minimum_income_standard_ceiling_fpl_ratio

Parameter(c) in text ↖

source: 42 CFR 435.116(c)(1)(ii)

- name: minimum_income_standard_ceiling_fpl_ratio
  kind: parameter
  dtype: Rate
  source: 42 CFR 435.116(c)(1)(ii)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: amount
          source:
            corpus_citation_path: us/regulation/42/435/116
            excerpt: Such higher income standard up to 185 percent FPL
  versions:
    - effective_from: '2014-01-01'
      formula: '1.85'

maximum_income_standard_floor_fpl_ratio

Parameter(c) in text ↖

source: 42 CFR 435.116(c)(2)(ii)

- name: maximum_income_standard_floor_fpl_ratio
  kind: parameter
  dtype: Rate
  source: 42 CFR 435.116(c)(2)(ii)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: amount
          source:
            corpus_citation_path: us/regulation/42/435/116
            excerpt: 185 percent FPL
  versions:
    - effective_from: '2014-01-01'
      formula: '1.85'

pregnant_woman_eligible

Derived(b) in text ↖

source: 42 CFR 435.116(b)

- name: pregnant_woman_eligible
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 CFR 435.116(b)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: condition
          source:
            corpus_citation_path: us/regulation/42/435/116
            excerpt: >-
              The agency must provide Medicaid to pregnant women whose household income is at or
              below the income standard
  versions:
    - effective_from: '2014-01-01'
      formula: >-
        person_is_pregnant

        and (household_income_as_fraction_of_fpl <=
        state_plan_pregnant_women_income_standard_fpl_ratio)

pregnant_woman_income_within_full_medicaid_applicable_income_limit

Derived(d) in text ↖

source: 42 CFR 435.116(d)(1)

- name: pregnant_woman_income_within_full_medicaid_applicable_income_limit
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 CFR 435.116(d)(1)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: condition
          source:
            corpus_citation_path: us/regulation/42/435/116
            excerpt: >-
              the agency may provide only pregnancy-related services ... for pregnant women whose
              income exceeds the applicable income limit
  versions:
    - effective_from: '2014-01-01'
      formula: >-
        household_income_as_fraction_of_fpl <=
        state_plan_full_medicaid_applicable_income_limit_fpl_ratio

pregnant_woman_full_medicaid_coverage

Derived(d) in text ↖

source: 42 CFR 435.116(d)(1)-(2)

- name: pregnant_woman_full_medicaid_coverage
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 CFR 435.116(d)(1)-(2)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: condition
          source:
            corpus_citation_path: us/regulation/42/435/116
            excerpt: Pregnant women are covered under this section for the full Medicaid coverage
  versions:
    - effective_from: '2014-01-01'
      formula: |-
        pregnant_woman_eligible
        and pregnant_woman_income_within_full_medicaid_applicable_income_limit

pregnant_woman_pregnancy_related_services_only

Derived(d) in text ↖

source: 42 CFR 435.116(d)(1), (d)(3)

- name: pregnant_woman_pregnancy_related_services_only
  kind: derived
  entity: Person
  dtype: Judgment
  period: Month
  source: 42 CFR 435.116(d)(1), (d)(3)
  metadata:
    proof:
      atoms:
        - path: versions[0].formula
          kind: condition
          source:
            corpus_citation_path: us/regulation/42/435/116
            excerpt: >-
              the agency may provide only pregnancy-related services ... for pregnant women whose
              income exceeds the applicable income limit established by the agency in its State plan
  versions:
    - effective_from: '2014-01-01'
      formula: |-
        pregnant_woman_eligible
        and not pregnant_woman_income_within_full_medicaid_applicable_income_limit

▸citations (5)

References

This rule cites 5 other rules.

42 CFR § 440.210 (a)(1)inferredUS Federal › Regulations › Title 42 › § 440 › (210)(a)(1)
42 CFR § 440.225inferredUS Federal › Regulations › Title 42 › § 440 › (225)
42 CFR § 440.250 (p)inferredUS Federal › Regulations › Title 42 › § 440 › (250)(p)
42 CFR § 440.210 (a)(2)inferredUS Federal › Regulations › Title 42 › § 440 › (210)(a)(2)
42 CFR § 440.250 (p)inferredUS Federal › Regulations › Title 42 › § 440 › (250)(p)