[Code of Federal Regulations]

[Title 42, Volume 3]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR435.121]



[Page 116-118]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 435_ELIGIBILITY IN THE STATES, DISTRICT OF COLUMBIA, THE NORTHERN 

MARIANA ISLANDS, AND AMERICAN SAMOA--Table of Contents

 

         Subpart B_Mandatory Coverage of the Categorically Needy

 

Sec. 435.121  Individuals in States using more restrictive requirements 

for Medicaid than the SSI requirements.



    (a) Basic eligibility group requirements. (1) If the agency does not 

provide Medicaid under Sec. 435.120 to aged, blind, and disabled 

individuals who are SSI recipients, the agency must provide Medicaid to 

aged, blind, and disabled individuals who meet eligibility requirements 

that are specified in this section.

    (2) Except to the extent provided in paragraph (a)(3) of this 

section, the agency may elect to apply more restrictive eligibility 

requirements to the aged, blind, and disabled that are more restrictive 

than those of the SSI program. The more restrictive requirements may be 

no more restrictive than those requirements contained in the State's 

Medicaid plan in effect on January 1, 1972. If any of the State's 1972 

Medicaid plan requirements were more liberal than of the SSI program, 

the State must use the SSI requirement instead of the more liberal 

requirements, except to the extent the State elects to use more liberal 

criteria under Sec. 435.601.

    (3) The agency must not apply a more restrictive requirement under 

the provisions of paragraph (a)(2) of this section if:

    (i) The requirement conflicts with the requirements of section 1924 

of the Act, which governs the eligibility and post-eligibility treatment 

of income and resources of institutionalized individuals with community 

spouses;

    (ii) The requirement conflicts with a more liberal requirement which 

the agency has elected to use under Sec. 435.601; or

    (iii) The more restrictive requirement conflicts with a more liberal 

requirement the State has elected to use under Sec. 435.234(c) in 

determining eligibility for State supplementary payments.

    (b) Mandatory coverage. If the agency chooses to apply more 

restrictive requirements than SSI to aged, blind, or disabled 

individuals, it must provide Medicaid to:

    (1) Individuals who meet the requirements of section 1619(b)(3) of 

the Act even though they may not continue to meet the requirements of 

this section; and

    (2) Qualified Medicare beneficiaries described in section 1905(p) of 

the Act and qualified working disabled individuals described in section 

1905(s) of the Act without consideration of the more restrictive 

eligibility requirements specified in this section.

    (3) Individuals who:

    (i) Qualify for benefits under section 1619(a) or are in eligibility 

status under section 1619(b)(1) of the Act as determined by SSA; and

    (ii) Were eligible for Medicaid under the more restrictive criteria 

in the State's approved Medicaid plan in the reference month--the month 

immediately preceding the first month in which they became eligible 

under section 1619(a) or (b)(1) of the Act. ``Were eligible for 

Medicaid'' means that individuals were issued Medicaid cards by the 

State for the reference month. Under this provision, the reference month 

for determining Medicaid eligibility for all individuals under section 

1619 of the Act is the month immediately preceding the first month of 

the most recent period of eligibility under section 1619 of the Act.



[[Page 117]]



    (c) Group composition. The agency may apply more restrictive 

requirements only to the aged, to the blind, to the disabled, or to any 

combination of these groups. For example, the agency may apply more 

restrictive requirements to the aged and disabled under this provision 

and provide Medicaid to all blind individuals who are SSI recipients.

    (d) Nonfinancial conditions. The agency may apply more restrictive 

requirements that are nonfinancial conditions of eligibility. For 

example, the agency may use a more restrictive definition of disability 

or may limit eligibility of the disabled to individuals age 18 and 

older, or both. If the agency limits eligibility of disabled individuals 

to individuals age 18 or older, it must provide Medicaid to individuals 

under age 18 who receive SSI benefits and who would be eligible to 

receive AFDC under the State's approved plan if they did not receive 

SSI. If the agency imposed an age limit for disabled individuals under 

its 1972 approved State plan but does not use that limit, it must apply 

the same nonfinancial requirement to individuals under age 18 that it 

applies to disabled individuals age 18 and older.

    (e) Financial conditions. (1) The agency may apply more restrictive 

requirements that are financial conditions of eligibility.

    (2) Any income eligibility standards that the agency applies must:

    (i) Equal the income standard (or Federal Benefit Rate (FBR)) that 

would be used under SSI based on an individual's living arrangement; or

    (ii) Be a more restrictive standard which is no more restrictive 

than that under the approved State's January 1, 1972 Medicaid plan.

    (3) If the categorically needy income standard established under 

paragraph (e)(2) of this section is less than the optional categorically 

needy standard established under Sec. 435.230, the agency must provide 

Medicaid to all aged, blind, and disabled individuals who have income 

equal to or below the higher standard.

    (4) In a State that does not have a medically needy program that 

covers aged, blind, and disabled individuals, the agency must allow 

individuals to deduct from income incurred medical and remedial expenses 

(that is, spend down) to become eligible under this section. However, 

individuals with income above the categorically needy standards may only 

spend down to the standard selected by the State under paragraph (e)(2) 

of this section which applies to the individual's living arrangement.

    (5) In a State that elects to provide medically needy coverage to 

aged, blind, and disabled individuals, the agency must allow individuals 

to deduct from income incurred medical and remedial care expenses (spend 

down) to become categorically needy when they are SSI recipients 

(including individuals deemed to be SSI recipients under Sec. Sec. 

435.135, 435.137, and 435.138), eligible spouses of SSI recipients, 

State supplement recipients, and individuals who are eligible for a 

supplement but who do not receive supplementary payments. Such persons 

may only spend down to the standard selected by the State under 

paragraph (e)(2) of this section. Individuals who are not SSI 

recipients, eligible spouses of SSI recipients, State supplement 

recipients, or individuals who are eligible for a supplement must spend 

down to the State's medically needy income standards for aged, blind, 

and disabled individuals in order to become Medicaid eligible.

    (f) Deductions from income. (1) In addition to any income disregards 

specified in the approved State plan in accordance with Sec. 

435.601(b), the agency must deduct from income:

    (i) SSI payments;

    (ii) State supplementary payments that meet the conditions specified 

in Sec. Sec. 435.232 and 435.234; and

    (iii) Expenses incurred by the individual or financially responsible 

relatives for necessary medical and remedial services that are 

recognized under State law and are not subject to payment by a third 

party, unless the third party is a public program of a State or 

political subdivision of a State. These expenses include Medicare and 

other health insurance premiums, deductions and coinsurance charges, and 

copayments or deductibles imposed under Sec. 447.51 or Sec. 447.53 of 

this chapter. The agency may set reasonable limits on



[[Page 118]]



the amounts of incurred medical expenses that are deducted.

    (2) For purposes of counting income with respect to individuals who 

are receiving benefits under section 1619(a) f the Act or are in section 

1619(b)(1) of the Act status but who do not meet the requirements of 

paragraph (b)(3)(ii) of this section, the agency may disregard some or 

all of the amount of the individual's income that is in excess of the 

SSI Federal benefit rate under section 1611(b) of the Act.



[58 FR 4926, Jan. 19, 1993]