TN 4 (07-95)
SI 01715.005 Medicaid Groups
A. Policy — Mandatory Groups of Aged, Blind and Disabled
Certain groups are mandated eligibility for Medicaid; i.e., States must provide Medicaid to eligible members of these groups.
1. Mandatory Categorically Needy
Most States define the aged, blind and disabled in this group as SSI beneficiaries, but the States are not required to follow the SSI criteria to determine Medicaid eligibility; they may choose to use at least one criterion (e.g., a definition of disability) which is more restrictive than the SSI program. States which use more restrictive criteria are called 209(b) States. These States are listed in SI 01715.010A.1.
2. Cash Assistance Related Groups
These are specified coverage groups. For example, States must provide Medicaid to pregnant women, mothers, and their children up to age 6 with income up to 133 percent of the Federal poverty level and families with older children born after September 30, 1983 who are not yet age 19 with income up to the Federal poverty level.
3. Considered Cash Assistance Recipients
These coverage groups include section 1619(b) participants and some individuals who would continue to be eligible for SSI but for specific title II benefits or cost-of-living adjustments (COLA’s). Section SI 01715.015B provides more detailed information about these groups.
4. “Grand-fathered” Individuals
Individuals converted from the predecessor Aid to the Aged, Aid to the Blind, Aid to the Permanently and Totally Disabled, and Aid to the Aged, Blind and Disabled programs to SSI who still receive mandatory State supplementary payments under the rules of a predecessor program also must continue to receive Medicaid coverage.
5. Qualified Medicare Beneficiaries
Qualified Medicare Beneficiaries (QMB’s) are individuals who are entitled to Medicare Part A (either with or without payment of premiums) with income usually counted according to the SSI rules at or below the Federal poverty guidelines with resources not exceeding twice the SSI standard. States determine QMB eligibility, and Medicaid pays all Medicare-related expenses for QMB’s (premiums, deductibles and coinsurance). Many SSI beneficiaries meet the QMB eligibility factors.
6. Specified Low - Income Medicare Beneficiaries
Beginning in 1993, State Medicaid agencies will pay the Medicare Part B premiums for SLMB’s who meet the QMB eligibility standards except for income, and their income does not exceed 110 percent of the Federal poverty guidelines (120 percent for 1995 and after).
The Medicaid statute requires the States to pay Medicare Part B premiums for specified low-income Medicare beneficiaries (SLMB’s).
7. Qualified Disabled and Working Individuals
Congress established a Medicare provision for the working disabled who lose Medicare entitlement because their work exceeds the substantial gainful activity levels after the extended period of eligibility (DI 13010.210). These individuals are permitted to purchase premium Medicare Hospital Insurance (HI, also known as Part A) and Supplemental Medical Insurance (also known as Part B) so long as they remain disabled.
QDWI’s are working disabled individuals who also have limited income and resources. These individuals receive Medicaid assistance towards the cost of Medicare Hospital Insurance and are not otherwise eligible for Medicaid.
The QDWI resources standard is twice the SSI standard; family income may not exceed 200 percent of the Federal poverty guidelines. Resources and income are usually counted according to the SSI rules. Very few, if any, SSI beneficiaries will be QDWI’s.
B. Policy — Optional Categorically Needy
The optional categorically needy groups a State elects to cover are specified in the State’s approved Medicaid plan from a list specified in section 1902 of the Act. States elect to treat the optional categorically needy as if they were cash assistance beneficiaries.
NOTE: Unlike medically needy, discussed in C.1. below, optional categorically needy eligibility does not include a spenddown feature. Spenddown is discussed in SI 01715.010A.1.
Most optional groups consist of individuals who would be eligible as mandatory categorically needy except for income.
Most EØ1’s are individuals who would be eligible for SSI except for medical institutionalization (i.e., whose countable income is below the Federal benefit rate (FBR) but above the payment cap). Most EØ 1"s on the supplemental security record (SSR) fit into this group. Note that because these individuals do not receive cash assistance, Medicaid State agencies determine their Medicaid eligibility.
Special Income Limit for the Institutionalized
States can elect special income limits for residents of medical institutions who would be eligible for SSI but for income and can use a State-selected limit which is higher than that of the FBR but does not exceed three times the SSI FBR.
State Supplementary Payments (SSP) - only
These individuals are eligible for only optional SSP because countable income exceeds the FBR.
Poverty Level Income
States may elect to provide categorical Medicaid eligibility for individuals who are aged, blind or disabled who would be eligible for SSI but for income, and their income does not exceed a limit up to the Federal poverty guidelines.
C. Policy — Other Coverage Groups
1. Medically Needy
States may elect to provide Medicaid to individuals who are categorically related (e.g., who are aged, blind or disabled) but who have too much income or resources to be categorically eligible. Resource standards for the medically needy are at the option of the State, but the income standard is limited to no more than 133 1/3 percent of the State’s AFDC payment for a household of comparable size. Spenddown, the deduction of incurred medical expenses from income over a budgeting period (discussed in SI 01715.010A.1.), is used to reduce countable income to the medically needy income limits.
Some States have medically needy programs only for AFDC - related individuals. Others have medically needy programs for their AFDC - related and SSI-related groups. Thirty four States, the District of Columbia and the NMI have medically needy programs for their aged, blind and disabled. See the chart in SI 01715.020 for a list of States that have medically needy programs for the aged, blind, and disabled individuals.
2. Some Other Groups
States may choose to provide Medicaid coverage to specific groups of individuals. Some groups need only be specified in the State’s Medicaid Plan (e.g., children kept at home instead of being medically institutionalized). In other cases, the State may request a waiver of the regular rules from CMS, which if approved, provides specified services to members of the waiver group. Examples of both of these groups can be found in the deeming instructions on children affected by State Home Care Plans, located in SI 01310.201 through SI 01310.209.
Another example of a waiver group is severely disabled children in Indiana. Indiana uses more restrictive eligibility requirements than those of the SSI program and only provides Medicaid to nonblind children who meet the State’s AFDC - related standards. Indiana has a waiver for its “Crippled Children” program. Having a waiver for this group permits the State to provide specified, limited, services to individuals who might ordinarily not be eligible for any Medicaid coverage.
Waivers vary from State-to-State and over time within a State. Familiarity with whether a State has medically needy coverage and what, if any, options a State has elected under Medicaid promotes better referrals. FO’s follow RO and local guidelines for these referrals.
EØ1’s, SI 02005.020F, SI 02301.215
Extended Period of Eligibility, DI 13010.210
Medicaid Spenddown, SI 01715.010A.1.
Premium HI for the Working Disabled, HI 00801.170B
Qualified Disabled and Working Individuals, QDWI’s, HI 00801.170E.1.
Qualified Medicare Beneficiaries, QMB’s, HI 00801.139
Section 1619 and Medicaid, SI 02302.010A through SI 02302.010C
State Home Care Plans, Waiver of Parental Deeming Rules, SI 01310.201 through SI 01310.209