How States can Implement the Standardized Modified Adjusted Gross Income (MAGI) Conversion Methodology from State Medicaid and CHIP Data. Attachment 1, Eligibility Groups in 2014

02/11/2013

Medicaid MAGI-based Eligibility
Group Social Security Act Citation Regulation 42 CFR
* Represents existing groups that will be consolidated in 2014

Mandatory

Parents/caretaker relatives

· Low-income families

1902(a)(10)(A)(i)(I) and 1931

435.110

Consolidated group for pregnant women

· Low-income families*

· Qualified Pregnant women*

· Poverty-level related pregnant women (mandatory) *

· Pregnant women financially eligible for AFDC *

· Pregnant women who would be eligible for AFDC if not institutionalized*

· Poverty-level related pregnant women (optional) *

1902(a)(10)(A)(i)(I) and 1931

1902(a)(10)(A)(i)(III)

1902(a)(10)(A)(i)(IV)

1902(a)(10)(A)(ii)(I)

1902(a)(10)(A)(ii)(IV)

1902(a)(10)(A)(ii)(IX)

435.116

Consolidated group for children <19

· Low-income families*

· Qualified children <19*

· Poverty-level related infants (mandatory)*

· Poverty-level related children 1— 5*

· Poverty-level children 6 — 18*

· Children who would be eligible for AFDC if not institutionalized*

· Poverty-level related infants (optional)*

1902(a)(10)(A)(i)(I) and 1931

1902(a)(10)(A)(i)(III)

1902(a)(10)(A)(i)(IV)

1902(a)(10)(A)(i)(VI)

1902(a)(10)(A)(i)(VII)

1902(a)(10)(A)(ii)(IV)

1902(a)(10)(A)(ii)(IX)

435.118

Adult group (non-pregnant individuals aged 19—64 not eligible for Medicare with income no more than 133% FPL )

1902(a)(10)(A)(i)(VIII)

435.119

Optional:

Parents and other caretaker relatives financially eligible for AFDC

1902(a)(10)(A)(ii)(I)

Guidance forthcoming

Reasonable classifications of children under age 21 financially eligible for AFDC or who would be financially eligible if not institutionalized

1902(a)(10)(A)(ii)(I) and (IV)

435.222

Individuals under age 21 who are under State adoption assistance agreements

1902(a)(10)(A)(ii)(VIII)

435.227

Optional targeted low-income children under age 19

1902(a)(10)(A)(ii)(XIV)

435.229

Optional group for individuals needing treatment for tuberculosis

1902(a)(10)(A)(ii)(XII)

 

Optional Chafee independent foster care adolescents under age 21

1902(a)(10)(A)(ii)(XVII)

Guidance forthcoming

Individuals under age 65 with income more than 133% FPL and at or below standard established by State

1902(a)(10)(A)(ii)(XX)

435.218

Family Planning Option

1902(a)(10)(A)(ii)(XXI)

Guidance forthcoming

MAGI-Excepted Eligibility
Group Social Security Act Citation Regulation 42 CFR
* Represents existing groups that will be consolidated in 2014

Mandatory

Children receiving foster care, adoption assistance, or kinship guardianship assistance under title IV-E
Note: automatically eligible without an income test performed by Medicaid

1902(a)(10)(A)(i)(I)

435.115(e) and 435.145

Former foster care children up to age 26 Note: eligible without an income test

1902(a)(10)(A)(i)(IX)

Guidance forthcoming

Medicare Savings Program

Qualified Medicare Beneficiary (QMB)

1902(a)(10)(E)(i) and 1905(p)

 

Specified Low Income Medicare Beneficiary (SLMB)

1902(a)(10)(E)(iii) and 1905(p)(3)(A)(ii)

 

Qualifying Individuals (QI)

1902(a)(10)(E)(iv) and 1905(p)(3)(A)(ii)

 

Qualified Disabled and Working Individuals (QDWI)

1902(a)(10)(E)(ii), 1905(p)(3)(A)(i), and 1905(s)

 

Aged, blind or disabled individuals · SSI recipients in 1634 and SSI Criteria States

· Individuals meeting more restrictive criteria than SSI in 209(b) States

1902(a)(10)(A)(i)(II)

1902(f)

435.120

435.121

Working disabled individuals

1902(a)(10)(A)(i)(II), 1619(a),

1619(b), and 1905(q)

 

Disabled widows and widowers ineligible for SSI due to increase in OASDI (DWB)

1634(b)

435.137

Disabled adult children (DAC)

1634(c)

 

Early widows/widowers

1634(d)

435.138

Individuals ineligible for SSI/SSP because of requirements prohibited by Medicaid

 

435.122

Individuals receiving mandatory state supplements

 

435.130

Individuals who would be eligible for SSI/SSP but for OASDI COLA increases since April 1977

Section 503 of P.L. 94-566

435.135

Individuals who would be eligible for SSI/SSP but for OASDI COLAs in 1972 (closed to new enrollment)

Public Law 92-36

435.134

Institutionalized individuals continuously eligible since 1973 (closed to new enrollment)

 

435.132

Blind or disabled individuals eligible in 1973 (closed to new enrollment)

 

435.133

Individuals eligible as essential spouses in 1973 (closed to new enrollment)

 

435.131

Optional

Women needing treatment for breast or cervical cancer Note: eligible based on screening by CDC program without an income test performed by Medicaid

1902(a)(10)(A)(ii)(XVIII)

Guidance forthcoming

Aged, blind, or disabled individuals financially eligible for SSI cash assistance

1902(a)(10)(A)(ii)(I)

435.210 or 435.230

Aged, blind, or disabled individuals who would be financially eligible for SSI cash assistance if they were not institutionalized

1902(a)(10)(A)(ii)(IV)

435.211

Individuals in institutions who are eligible under a special income level

1902(a)(10)(A)(ii)(V)

435.236

Individuals eligible for home and community-based waiver services under institutional rules

1902(a)(10)(A)(ii)(VI)

435.217

Individuals receiving hospice care

1902(a)(10)(A)(ii)(VII) and 1905(o)

 

Poverty level (100% FPL) aged or disabled individuals

1902(a)(10)(A)(ii)(X) and 1902(m)(1)

 

Aged, blind, or disabled individuals receiving only optional State supplements

1902(a)(10)(A)(ii)(IV) and (XI)

435.232 or

435.234

Work Incentives Eligibility Group (BBA) with income less than 250% FPL

1902(a)(10)(A)(ii)(XIII)

 

Ticket to Work Basic Group (TWWIIA) of working disabled individuals

1902(a)(10)(A)(ii)(XV)

 

Ticket to Work Medical Improvements Group (TWWIIA MI) of working disabled individuals

1902(a)(10)(A)(ii)(XVI)

 

Family Opportunity Act for Children with Disabilities (FOA)

1902(a)(10)(A)(ii)(XIX)

 

Individuals eligible for home and community based state plan services (150% FPL)

1902(a)(10)(A)(ii)(XXII) and 1915(i)

435.219

Individuals eligible for home and community based state plan services (special income level)

1902(a)(10)(A)(ii)(XXII) and 1915(i)

435.219

Qualified disabled children under age 19 who would be eligible for Medicaid if they were in a medical institution (TEFRA children)

1902(e)(3)

435.225

Individuals participating in a PACE program under institutional rules

1934

 

Medically Needy

Pregnant women

1902(a)(10)(C)

435.301

Children under age 18

1902(a)(10)(C)

435.301

Individuals under age 21 (or under age 20 or 19) or reasonable classifications of such individuals.

1902(a)(10)(C)

435.308

Parents and other caretaker relatives

1902(a)(10)(C)

435.310

Aged

1902(a)(10)(C)

435.320, 435.330

Blind

1902(a)(10)(C)

435.322, 435.330, 435.340

Disabled

1902(a)(10)(C)

435.324, 435.330, 435.340

Special Status
Group Social Security Act Citation Regulation 42 CFR
* Represents existing groups that will be consolidated in 2014

Mandatory

Deemed newborns

1902(e)(4)

435.117

Transitional Medical Assistance

408(a)(11)(A), 1902(a)(52), 1902(e)(1)(B), 1925, and 1931(c)(2)

Additional guidance forthcoming

Medicaid extension due to spousal support collections

408(a)(11)(B) and 1931(c)(1)

§435.115(f) — (h)

Existing Medicaid Regulatory Groups Which Will Not Exist in 2014

The following groups that currently exist in regulation are obsolete and will be deleted through future rulemaking:

Mandatory

· Individuals receiving AFDC - 435.110

· Individuals ineligible for AFDC for reasons that don’t apply for Medicaid - 435.113

· Individuals who would be eligible for AFDC but for increase in OASDI in 1972 - 435.114

· Individuals deemed to be receiving AFDC - 435.115(a) — (d)

· Qualified Family Members - 1902(a)(10)(A)(i)(V) — 435.119

Optional

· Individuals who would be eligible for AFDC but for child care expenses - 1902(a)(10)(A)(ii)(II) — 435.220

· Individuals who would be eligible for AFDC if the IV-A plan were as broad as allowed - 1902(a)(10)(A)(ii)(III) — 435.223

 

CHIP Eligibility Groups in 2014

Group

Social Security Act Citation

Regulation

42 CFR

Targeted low-income children

2102(b)(1)(B)(v)

457.310

Deemed newborns

2112 (e)

 

Children ineligible for Medicaid due to loss of income disregards

2101 (f)

457.340(d)

Coverage from conception to birth

2102(b)(1)(B)(v)

457.310

Children with access to public employee coverage

2110(b)(2)(B) and (b)(6)

 

Children eligible for dental only supplemental coverage

2110(b)(2)

 

Targeted low-income pregnant women

2112

 

Pregnant women with access to public employee coverage

2110(b)(2)(B) and (b)(6)

 

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