[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

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

[CITE: 42CFR435.4]



[Page 117-118]

 

                         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 

 

              Subpart A_General Provisions and Definitions

 

Sec.  435.4  Definitions and use of terms.



    As used in this part--

    AABD means aid to the aged, blind, and disabled under title XVI of 

the Act;

    AB means aid to the blind under title X of the Act;

    AFDC means aid to families with dependent children under title IV-A 

of the Act;

    APTD means aid to the permanently and totally disabled under title 

XIV of the Act;

    Categorically needy refers to families and children, aged, blind, or 

disabled individuals, and pregnant women, described under subparts B and 

C of this part who are eligible for Medicaid. Subpart B of this part 

describes the mandatory eligibility groups who, generally, are receiving 

or deemed to be receiving cash assistance under the Act. These mandatory 

groups are specified in sections 1902(a)(10)(A)(i), 1902(e), 1902(f), 

and 1928 of the Act. Subpart C of this part describes the optional 

eligibility groups of individuals who, generally, meet the categorical 

requirements or income or resource requirements that are the same as or 

less restrictive than those of the cash assistance programs and who are 

not receiving cash payments. These optional groups are specified in 

sections 1902(a)(10)(A)(ii), 1902(e), and 1902(f) of the Act.

    Families and children refers to eligible members of families with 

children who are financially eligible under AFDC or medically needy 

rules and who are deprived of parental support or care as defined under 

the AFDC program (see 45 CFR 233.90, 233.100). In addition, this group 

includes individuals under age 21 who are not deprived of parental 

support or care but are financially eligible under AFDC rules or 

medically needy rules (see optional coverage group, Sec.  435.222). It 

does not include individuals under age 21 whose eligibility for Medicaid 

is based on blindness or disability--for these individuals, SSI rules 

govern;

    Mandatory State supplement means a cash payment a State is required 

to make under section 212, Pub. L. 93-66 (July 9, 1973) to an aged, 

blind, or disabled individual. Its purpose is to provide an individual 

with the same amount of cash assistance he was receiving under OAA, AB, 

APTD, or AABD if his SSI payment is less than that amount;

    Medically needy refers to families, children, aged, blind, or 

disabled individuals, and pregnant women listed under subpart D of this 

part who are not listed in subparts B and C of this part as 

categorically needy but who may be eligible for Medicaid under this part 

because their income and resources are within limits set by the State 

under its Medicaid plan (including persons whose income and resources 

fall within these limits after their incurred expenses for medical or 

remedial care are deducted) (Specific financial requirements for 

determining eligibility of the medically needy appear in subpart I of 

this part.);

    OAA means old age assistance under title I of the Act;

    OASDI means old age, survivors, and disability insurance under title 

II of the Act;

    Optional State supplement means a cash payment made by a State, 

under section 1616 of the Act, to an aged, blind, or disabled 

individual;

    Optional targeted low-income child means a child under age 19 who 

meets the financial and categorical standards described below.

    (1) Financial need. An optional targeted low-income child:



[[Page 118]]



    (i) Has a family income at or below 200 percent of the Federal 

poverty line for a family of the size involved; and

    (ii) Resides in a State with no Medicaid applicable income level (as 

defined at Sec.  457.10 of this chapter); or

    (iii) Resides in a State that has a Medicaid applicable income level 

(as defined at Sec.  457.10 of this chapter) and has family income that 

either:

    (A) Exceeds the Medicaid applicable income level for the age of such 

child, but not by more than 50 percentage points; or

    (B) Does not exceed the income level specified for such child to be 

eligible for medical assistance under the policies of the State plan 

under title XIX on June 1, 1997.

    (2) No other coverage and State maintenance of effort. An optional 

targeted low-income child is not covered under a group health plan or 

health insurance coverage, or would not be eligible for Medicaid under 

the policies of the State plan in effect on March 31, 1997; except that, 

for purposes of this standard--

    (i) A child shall not be considered to be covered by health 

insurance coverage based on coverage offered by the State under a 

program in operation prior to July 1, 1997 if that program received no 

Federal financial participation;

    (ii) A child shall not be considered to be covered under a group 

health plan or health insurance coverage if the child did not have 

reasonable geographic access to care under that coverage.

    (3) For purposes of this section, policies of the State plan a under 

title XIX plan include policies under a Statewide demonstration project 

under section 1115(a) of the Act other than a demonstration project that 

covered an expanded group of eligible children but that either--

    (i) Did not provide inpatient hospital coverage; or

    (ii) Limited eligibility to children previously enrolled in 

Medicaid, imposed premiums as a condition of initial or continued 

enrollment, and did not impose a general time limit on eligibility.

    SSI means supplemental security income under title XVI of the Act.

    SWICA means the State Wage Information Collection Agency under 

section 1137(a) of the Act. It is the State agency administering the 

State unemployment compensation law; a separate agency administering a 

quarterly wage reporting system; or a State agency administering an 

alternative system which has been determined by the Secretary of Labor, 

in consultation with the Secretary of Agriculture and the Secretary of 

Health and Human Services, to be as effective and timely in providing 

employment related income and eligibility data.



[43 FR 45204, Sept. 29, 1978, as amended at 45 FR 24883, Apr. 11, 1980; 

46 FR 6909, Jan. 22, 1981; 46 FR 47984, Sept. 30, 1981; 51 FR 7211, Feb. 

28, 1986; 58 FR 4925, Jan. 19, 1993; 66 FR 2666, Jan. 11, 2001]