Technical Assistance Partnership for Child and Family Mental Health

MARCH2003

Question: Who can be enrolled in the Medicaid Program? Specifically, what groups of children, adolescents, and families are Medicaid eligible?

Answer: States have some discretion in determining which groups their Medicaid programs will cover and the financial criteria for Medicaid eligibility. To be eligible for Federal funds, States are required to provide Medicaid coverage for most individuals who receive Federally assisted income maintenance payments, as well as for related groups not receiving cash payments. Some examples of the mandatory Medicaid eligibility groups follow:

Low income families with children who are eligible for Temporary Assistance to Needy Families (TANF)
Supplemental Security Income (SSI) recipients including children and adolescents
Infants born to Medicaid-eligible pregnant women (Medicaid eligibility must continue throughout the first year of life as long as the infant remains in the mother's household and she remains eligible, or would be eligible if she were still pregnant)
Children under age 6 and pregnant women whose family income is at or below 133% of the Federal poverty level. (The minimum mandatory income level for pregnant women and infants in certain States may be higher than 133% if the State had established a higher percentage for covering those groups as of certain dates.)
Until age 19, all children born after September 30, 1983 (or such earlier date as the State may choose) in families with incomes at or below the Federal poverty level (This phases in coverage, so that by the year 2002, all poor children under age 19 will be covered.)

Once eligibility is established, pregnant women through the end of the calendar month in which the 60th day after the end of the pregnancy falls, regardless of any change in family income. (States are not required to have a resource test for these poverty-level related groups. However, any resource test imposed can be no more restrictive than that of the TANF program for infants and children and the SSI program for pregnant women.)
Recipients of adoption assistance and foster care under Title IV-E of the Social Security Act

States also have the option to provide Medicaid coverage for other "categorically needy" groups. These optional groups share characteristics of the mandatory groups, but the eligibility criteria are somewhat more liberally defined. Examples of the optional groups that States may cover as categorically needy (and for which they will receive Federal matching funds) under the Medicaid program follow:

Infants up to age 1 and pregnant women not covered under the mandatory rules whose family income is below 185% of the Federal poverty level, the percentage to be set by each State
Optional targeted low-income children
Children under age 21 who meet income and resources requirements for TANF, but who otherwise are not eligible for TANF (e.g., children who are living in a two-parent household in a state that does not cover two parent households)
Persons who would be eligible if institutionalized but are receiving care under home- and community-based services waivers (This is sometimes known as the Katie Beckett waiver, which will be defined in next month's FAQ.)

Medically Needy Eligibility Groups

The option to have a "medically needy" program allows States to extend Medicaid eligibility to additional qualified persons who may have too much income to qualify under the mandatory or optional categorically needy groups. This option allows them to "spend down" to Medicaid eligibility by incurring medical and remedial care expenses to offset their excess income, thereby reducing it to a level below the maximum allowed by that State's Medicaid plan. States may also allow families to establish eligibility as medically needy by paying monthly premiums to the State in an amount equal to the difference between family income (reduced by unpaid expenses, if any, incurred for medical care in previous months) and the income eligibility standard. Eligibility for the medically needy program does not have to be as extensive as the categorically needy program. However, States that elect to include the medically needy under their plans are required to include certain children under age 18 and pregnant women who, except for income and resources, would be eligible as categorically needy.

Amplification on Medicaid Eligibility

Coverage may start retroactive to any or all of the 3 months prior to application if the individual would have been eligible during the retroactive period. Coverage generally stops at the end of the month in which a person's circumstances change. Most States have additional ""State-only" programs to provide medical assistance for specified poor persons who do not qualify for the Medicaid program. No Federal funds are provided for State-only programs. Medicaid does not provide medical assistance for all poor persons. Even under the broadest provisions of the Federal statute (except for emergency services for certain persons), the Medicaid program does not provide health care services, even for very poor persons, unless they are in one of the groups designated above. Low income is only one test for Medicaid eligibility; assets and resources are also tested against established thresholds. As noted earlier, categorically needy persons who are eligible for Medicaid may or may not also receive cash assistance from the TANF program or from the SSI program. Medically needy persons who would be categorically eligible except for income or assets may become eligible for Medicaid solely because of excessive medical expenses.

States may use more liberal income and resources methodologies to determine Medicaid eligibility for certain TANF-related and aged, blind, and disabled individuals under sections 1902(r)(2) and 1931 of the Social Security Act.

Home About Us About Systems of Care Contact Us Events & Presentations Newsletter Consultant Pool Special Topics Column Grantee Locator Webinars Resource Specialties Child Welfare Education Family Involvement Juvenile Justice Mental Health Primary Care Substance Abuse Sustainability Youth Involvement Regional Technical Assistance Region I Region II Region III Region IV Region V Region VI Communities of Practice Cultural and Linguistic Competence Early Childhood Transition-Aged Youth	Primary Care and Systems of Care Frequently Asked Questions
	MARCH2003 Question: Who can be enrolled in the Medicaid Program? Specifically, what groups of children, adolescents, and families are Medicaid eligible? Answer: States have some discretion in determining which groups their Medicaid programs will cover and the financial criteria for Medicaid eligibility. To be eligible for Federal funds, States are required to provide Medicaid coverage for most individuals who receive Federally assisted income maintenance payments, as well as for related groups not receiving cash payments. Some examples of the mandatory Medicaid eligibility groups follow: Low income families with children who are eligible for Temporary Assistance to Needy Families (TANF) Supplemental Security Income (SSI) recipients including children and adolescents Infants born to Medicaid-eligible pregnant women (Medicaid eligibility must continue throughout the first year of life as long as the infant remains in the mother's household and she remains eligible, or would be eligible if she were still pregnant) Children under age 6 and pregnant women whose family income is at or below 133% of the Federal poverty level. (The minimum mandatory income level for pregnant women and infants in certain States may be higher than 133% if the State had established a higher percentage for covering those groups as of certain dates.) Until age 19, all children born after September 30, 1983 (or such earlier date as the State may choose) in families with incomes at or below the Federal poverty level (This phases in coverage, so that by the year 2002, all poor children under age 19 will be covered.) Once eligibility is established, pregnant women through the end of the calendar month in which the 60th day after the end of the pregnancy falls, regardless of any change in family income. (States are not required to have a resource test for these poverty-level related groups. However, any resource test imposed can be no more restrictive than that of the TANF program for infants and children and the SSI program for pregnant women.) Recipients of adoption assistance and foster care under Title IV-E of the Social Security Act States also have the option to provide Medicaid coverage for other "categorically needy" groups. These optional groups share characteristics of the mandatory groups, but the eligibility criteria are somewhat more liberally defined. Examples of the optional groups that States may cover as categorically needy (and for which they will receive Federal matching funds) under the Medicaid program follow: Infants up to age 1 and pregnant women not covered under the mandatory rules whose family income is below 185% of the Federal poverty level, the percentage to be set by each State Optional targeted low-income children Children under age 21 who meet income and resources requirements for TANF, but who otherwise are not eligible for TANF (e.g., children who are living in a two-parent household in a state that does not cover two parent households) Persons who would be eligible if institutionalized but are receiving care under home- and community-based services waivers (This is sometimes known as the Katie Beckett waiver, which will be defined in next month's FAQ.) Medically Needy Eligibility Groups The option to have a "medically needy" program allows States to extend Medicaid eligibility to additional qualified persons who may have too much income to qualify under the mandatory or optional categorically needy groups. This option allows them to "spend down" to Medicaid eligibility by incurring medical and remedial care expenses to offset their excess income, thereby reducing it to a level below the maximum allowed by that State's Medicaid plan. States may also allow families to establish eligibility as medically needy by paying monthly premiums to the State in an amount equal to the difference between family income (reduced by unpaid expenses, if any, incurred for medical care in previous months) and the income eligibility standard. Eligibility for the medically needy program does not have to be as extensive as the categorically needy program. However, States that elect to include the medically needy under their plans are required to include certain children under age 18 and pregnant women who, except for income and resources, would be eligible as categorically needy. Amplification on Medicaid Eligibility Coverage may start retroactive to any or all of the 3 months prior to application if the individual would have been eligible during the retroactive period. Coverage generally stops at the end of the month in which a person's circumstances change. Most States have additional ""State-only" programs to provide medical assistance for specified poor persons who do not qualify for the Medicaid program. No Federal funds are provided for State-only programs. Medicaid does not provide medical assistance for all poor persons. Even under the broadest provisions of the Federal statute (except for emergency services for certain persons), the Medicaid program does not provide health care services, even for very poor persons, unless they are in one of the groups designated above. Low income is only one test for Medicaid eligibility; assets and resources are also tested against established thresholds. As noted earlier, categorically needy persons who are eligible for Medicaid may or may not also receive cash assistance from the TANF program or from the SSI program. Medically needy persons who would be categorically eligible except for income or assets may become eligible for Medicaid solely because of excessive medical expenses. States may use more liberal income and resources methodologies to determine Medicaid eligibility for certain TANF-related and aged, blind, and disabled individuals under sections 1902(r)(2) and 1931 of the Social Security Act.

Primary Care and Systems of Care Frequently Asked Questions

Primary Care and Systems of Care
Frequently Asked Questions