42 C.F.R. Subpart B—Mandatory Coverage of the Categorically Needy
Title 42 - Public Health
This subpart prescribes requirements for coverage of categorically needy individuals. (a) A Medicaid agency must provide Medicaid to individuals receiving cash assistance under OAA, AFDC, AB, APTD, or AABD. (b) For purposes of this section, an individual is receiving cash assistance if his needs are considered in determining the amount of the payment. This includes an individual whose presence in the home is considered essential to the well-being of a recipient under the State's plan for OAA, AFDC, AB, APTD, or AABD if that plan were as broad as allowed under the Act for FFP. (a) The agency must provide Medicaid to individuals who would be eligible for OAA, AB, APTD, or AABD except for an eligibility requirement used in those programs that is specifically prohibited under title XIX of the Act. (b) The agency also must provide Medicaid to: (1) Individuals denied AFDC solely because of policies requiring the deeming of income and resources of the following individuals who are not included as financially responsible relatives under section 1902(a)(17)(D) of the Act: (i) Stepparents who are not legally liable for support of stepchildren under a State law of general applicability; (ii) Grandparents (iii) Legal guardians; (iv) Aliens sponsors who are not organizations; and (v) Siblings. (2) [Reserved] [58 FR 4934, Jan. 19, 1993, as amended at 59 FR 43053, Aug. 22, 1994] The agency must provide Medicaid to individuals who meet the following conditions: (a) In August 1972, the individual was entitled to OASDI and— (1) He was receiving cash assistance; or (2) He would have been eligible for cash assistance if he had applied, and the Medicaid plan covered this optional group; or (3) He would have been eligible for cash assistance if he were not in a medical institution or intermediate care facility, and the Medicaid plan covered this optional group. (b) The individual would currently be eligible for cash assistance except that the increase in OASDI under Pub. L. 92–336 raised his income over the limit allowed under the cash assistance program. This includes an individual who— (1) Meets all current requirements for cash assistance except for the requirement to file an application; or (2) Would meet all current requirements for cash assistance if he were not in a medical institution or intermediate care facility, and the Medicaid plan covers this optional group. (a) The Medicaid agency must provide Medicaid to individuals deemed to be receiving AFDC, as specified in this section. (b) The State must deem individuals to be receiving AFDC who are denied a cash payment from the title IV-A State agency solely because the amount of the AFDC payment would be less than $10. (c) The State may deem participants in a work supplementation program to be receiving AFDC under section 414(g) of the Act. This section permits States, for purposes of title XIX, to deem an individual and any child or relative of the individual (or other individual living in the same household) to be receiving AFDC, if the individual— (1) Participates in a State-operated work supplementation program under section 414 of the Act; and (2) Would be eligible for an AFDC cash payment if the individual were not participating in the work supplementation program. (d) The State must deem to be receiving AFDC those individuals who are denied AFDC payments from the title IV-A State agency solely because that agency is recovering an overpayment. (e) The State must deem to be receiving AFDC individuals described in section 473(a)(1) of the Act— (1) For whom an adoption assistance agreement is in effect under title IV-E of the Act, whether or not adoption assistance is being provided or an interlocutory or other judicial decree of adoption has been issued; or (2) For whom foster care maintenance payments are made under title IV-E of the Act. (f) The State must deem an individual to be receiving AFDC if a new collection or increased collection of child or spousal support under title IV-D of the Social Security Act results in the termination of AFDC eligibility in accordance with section 406(h) of the Social Security Act. States must continue to provide Medicaid for four consecutive calendar months, beginning with the first month of AFDC ineligibility, to each dependent child and each relative with whom such a child is living (including the eligible spouse of such relative as described in section 406(b) of the Social Security Act) who: (1) Becomes ineligible for AFDC on or after August 16, 1984; and (2) Has received AFDC for at least three of the six months immediately preceding the month in which the individual becomes ineligible for AFDC; and (3) Becomes ineligible for AFDC wholly or partly as a result of the initiation of or an increase in the amount of a child or spousal support collection under title IV-D. (g)(1) Except as provided in paragraph (g)(2) of this section, individuals who are eligible for extended Medicaid lose this coverage if they move to another State during the 4-month period. However, if they move back to and reestablish residence in the State in which they have extended coverage, they are eligible for any of the months remaining in the 4-month period in which they are residents of the State. (2) If a State has chosen in its State plan to provide Medicaid to non-residents, the State may continue to provide the 4-month extended benefits to individuals who have moved to another State. (h) For purposes of paragraph (f) of this section: (1) The new collection or increased collection of child or spousal support results in the termination of AFDC eligibility when it actively causes or contributes to the termination. This occurs when: (i) The change in support collection in and of itself is sufficient to cause ineligibility. This rule applies even if the support collection must be added to other, stable income. It also applies even if other independent factors, alone or in combination with each other, might simultaneously cause ineligibility; or (ii) The change in support contributes to ineligibility but does not by itself cause ineligibility. Ineligibility must result when the change in support is combined with other changes in income or changes in other circumstances and the other changes in income or circumstances cannot alone or in combination result in termination without the change in support. (2) In cases of increases in the amounts of both the support collections and earned income, eligibility under this section does not preclude eligibility under 45 CFR 233.20(a)(14) or section 1925 of the Social Security Act (which was added by section 303(a) of the Family Support Act of 1988 (42 U.S.C. 1396r–6)). Extended periods resulting from both an increase in the amount of the support collection and from an increase in earned income must run concurrently. [46 FR 47989, Sept. 30, 1981, as amended at 52 FR 43072, Nov. 9, 1987; 52 FR 48438, Dec. 22, 1987; 55 FR 48610, Nov. 21, 1990; 59 FR 59377, Nov. 17, 1994] (a) If a family loses AFDC solely because of increased income from employment or increased hours of employment, the agency must continue to provide Medicaid for 4 months to all members of the family if— (1) The family received AFDC in any 3 or more months during the 6-month period immediately before the month in which it became ineligible for AFDC; and (2) At least one member of the family is employed throughout the 4-month period, although this need not be the same member for the whole period. (b) The 4 calendar month period begins on the date AFDC is terminated. If AFDC benefits are terminated retroactively, the 4 calendar month period also begins retroactively with the first month in which AFDC was erroneously paid. [43 FR 45218, Sept. 29, 1978, as amended at 45 FR 24887, Apr. 11, 1980] The agency must provide Medicaid to children for whom adoption assistance or foster care maintenance payments are made under title IV-E of the Act. [47 FR 28656, July 1, 1982] (a) The Medicaid agency must provide Medicaid to a pregnant woman whose pregnancy has been medically verified and who— (1) Would be eligible for an AFDC cash payment (or would be eligible for an AFDC cash payment if coverage under the State's AFDC plan included the AFDC-unemployed parents program) if her child had been born and was living with her in the month of payment; (2) Is a member of a family that would be eligible for an AFDC cash payment if the State's AFDC plan included an AFDC-unemployed parents program; or (3) Meets the income and resource requirements of the State's approved AFDC plan. In determining whether the woman meets the AFDC income and resource requirements, the unborn child or children are considered members of the household, and the woman's family is treated as though deprivation exists. (b) The provisions of paragraphs (a) (1) and (2) of this section are effective October 1, 1984. The provisions of paragraph (a)(3) of this section are effective July 1, 1986. (c) The agency must provide Medicaid to children who meet all of the following criteria: (1) They are born after September 30, 1983; (2) Effective October 1, 1988, they are under age 6 (or if designated by the State, any age that exceeds age 6 but does not exceed age 8), and effective October 1, 1989 they are under age 7 (or if designated by the State, any age that exceeds age 7 but does not exceed age 8); and (3) They meet the income and resource requirements of the State's approved AFDC plan. [52 FR 43072, Nov. 9, 1987, as amended at 55 FR 48610, Nov. 21, 1990; 58 FR 48614, Sept. 17, 1993] (a) Definition. A qualified family member is any member of a family, including pregnant women and children eligible for Medicaid under §436.120 of this subpart, who would be receiving AFDC cash benefits on the basis of the unemployment of the principal wage earner under section 407 of the Act had the State not chosen to place time limits on those benefits as permitted under section 407(b)(2)(B)(i) of the Act. (b) State plan requirement. The State plan must provide that the State makes Medicaid available to any individual who meets the definition of “qualified family member” as specified in paragraph (a) of this section. (c) Applicability. The provisions in this section are applicable from October 1, 1992, through September 30, 1998. [58 FR 48614, Sept. 17, 1993] (a) The Medicaid agency must provide categorically needy Medicaid eligibility for an extended period following termination of pregnancy to women who, while pregnant, applied for, were eligible for, and received Medicaid services on the day that their pregnancy ends. This period extends from the last day of pregnancy through the end of the month in which a 60-day period, beginning on the last day of the pregnancy, ends. Eligibility must be provided, regardless of changes in the woman's financial circumstances that may occur within this extended period. These pregnant women are eligible for the extended period for all services under the plan that are pregnancy-related (as defined in §440.210(c)(1) of this subchapter). (b) The provisions of paragraph (a) of this section apply to Medicaid furnished on or after April 7, 1986. [55 FR 48610, Nov. 21, 1990] (a) The Medicaid agency must provide categorically needy Medicaid eligibility to a child born to a woman who is eligible for and receiving Medicaid on the date of the child's birth. The child is deemed to have applied and been found eligible for Medicaid on the date of birth and remains eligible as categorically needy for one year so long as the woman remains eligible and the child is a member of the woman's household. If the mother's basis of eligibility changes to medically needy, the child is eligible as medically needy under §436.301(b)(1)(iii). (b) The requirements under paragraph (a) of this section apply to children born on or after October 1, 1984. [52 FR 43073, Nov. 9, 1987; 52 FR 48438, Dec. 22, 1987] The agency must provide the services necessary for the treatment of an emergency medical condition as defined in §440.255(c) of this chapter to those aliens described in §436.406(c) of this subpart. [55 FR 36820, Sept. 7, 1990]
Title 42: Public Health
PART 436—ELIGIBILITY IN GUAM, PUERTO RICO, AND THE VIRGIN ISLANDS
Subpart B—Mandatory Coverage of the Categorically Needy
§ 436.100 Scope.
§ 436.110 Individuals receiving cash assistance.
§ 436.111 Individuals who are not eligible for cash assistance because of a requirement not applicable under Medicaid.
§ 436.112 Individuals who would be eligible for cash assistance except for increased OASDI under Pub. L. 92–336 (July 1, 1972).
§ 436.114 Individuals deemed to be receiving AFDC.
§ 436.116 Families terminated from AFDC because of increased earnings or hours of employment.
§ 436.118 Children for whom adoption assistance or foster care maintenance payments are made.
§ 436.120 Qualified pregnant women and children who are not qualified family members.
§ 436.121 Qualified family members.
§ 436.122 Pregnant women eligible for extended coverage.
§ 436.124 Newborn children.
§ 436.128 Coverage for certain qualified aliens.
