subchapter 23D MEDICAID ELIGIBILITY GROUPS AND CLASSIFICATION

 

SECTION .0100 COVERAGE GROUPS

 

10A NCAC 23d .0101 MANDATORY GROUPS

The following groups required by 42 U.S.C. 1396a (a)(10) or 1396u-1 shall be eligible for Medicaid:

(1) Individuals who meet the requirements under 42 U.S.C. 1396u-1.

(2) Individuals receiving four months continued Medicaid when eligibility under 42 U.S.C. 1396u-1 is lost due to collection or increased collection of child support.

(3) Individuals receiving transitional Medicaid as described in 42 U.S.C. 1396s when eligibility under 42 U.S.C. 1396u-1 is lost due to increased earnings.

(4) Individuals for whom an adoption assistance agreement is in effect or foster care maintenance payments are being made under Title IV E of the Social Security Act as described at 42 U.S.C. 673 (b).

(5) Qualified pregnant women as defined at 42 U.S.C. 1396d(n)(1).

(6) Qualified children as defined at 42 U.S.C. 1396d(n)(2).

(7) Pregnant women, during a 60 day period following termination of the pregnancy, for pregnancy related and post partum services if they applied for Medicaid prior to termination of the pregnancy and were eligible on the date pregnancy is terminated.

(8) Children, born to a woman who was eligible for and receiving Medicaid on the date of the child's birth, for up to one year from the date of birth; as described at 42 U.S.C. 1396a(e)(4).

(9) Individuals receiving SSI under Title XVI of the Social Security Act.

(10) Individuals who meet the requirements under 42 U.S.C. 1382h(a) or (b)(1).

(11) Blind or disabled individuals who were eligible in December 1973 as blind or disabled and who for each consecutive month since December 1973 continue to meet December 1973 eligibility criteria.

(12) Individuals who were eligible in December 1973 as aged, or blind, or disabled with an essential spouse and who, for each consecutive month since December 1973, continue to live with the essential spouse and meet December 1973 eligibility criteria.

(13) Individuals who in December 1973 were eligible as the essential spouse of an aged, or blind, or disabled individual and who for each consecutive month since December 1973, have continued to live with that individual who has met December 1973 eligibility criteria.

(14) Qualified Medicare Beneficiaries described at 42 U.S.C. 1396d(p).

(15) Pregnant women whose countable income does not exceed the percent of the income official poverty line, established at 42 U.S.C. 1396a(1)(2), for pregnancy related services including labor and delivery.

(16) Children born after September 30, 1983 and who are under age 19 who are described at 42 U.S.C. 1396a(1).

(17) Qualified Disabled and Working Individuals described at 42 U.S.C. 1396d(s).

(18) Individuals as described at 42 U.S.C. 1396a(a)(10)(E)(iii).

(19) Individuals who would continue to be eligible for SSI except for specific Title II benefits or cost-of-living adjustments as described at 42 U.S.C. 1383c.

 

History Note: Authority G.S. 108A-54; 42 U.S.C. 1396a(a)(10); 42 U.S.C. 1396a(e)(4); 42 U.S.C. 1396a(f); 42 C.F.R. 435.110; 42 C.F.R. 435.112; 42 C.F.R. 435.113; 42 C.F.R. 435.114; 42 C.F.R. 435.115; 42 C.F.R. 435.116; 42 C.F.R. 435.117; 42 C.F.R. 435.118; 42 C.F.R. 435.121; 42 C.F.R. 435.131; 42 C.F.R. 435.132; 42 C.F.R. 435.133;

Eff. September 1, 1984;

Amended Eff. January 1, 1995; March 1, 1993; January 4, 1993; April 1, 1992;

Temporary Amendment September 13, 1999;

Temporary Amendment Expired June 27, 2000;

Temporary Amendment September 12, 2000;

Amended Eff. August 1, 2002;

Transferred from 10A NCAC 21B .0101 Eff. May 1, 2012.

10A ncac 23D .0102 OPTIONAL GROUPS

The following optional groups of individuals described by 42 U.S.C. 1396a(a)(10)(A)(ii) and 42 U.S.C. 1396a(a)(10)(C) shall be eligible for Medicaid:

(1) Children:

(a) Children under age one whose family income is more than the amount established under Item (16), Rule .0101 of this Section and not more than a percent of the federal poverty level established by the General Assembly;

(b) Children under age 21 who meet the eligibility requirements of this Subchapter;

(c) Qualified children under age 19 as described in Item (6), Rule .0101 of this Section, who were born on or before September 30, 1983, and whose income is not more than 100% of the federal poverty level;

(d) Adopted children under age 18 with special needs, as described at 42 U.S.C. 1396a(a)(10)(A)(ii)(VIII).

(2) Individuals receiving optional state supplemental payment.

(3) Caretaker relatives of eligible dependent children.

(4) Pregnant women:

(a) Whose countable income is more than the amount established under Item (15), Rule .0101 of this Section and not more than a percent of the federal poverty level established by the General Assembly, or

(b) Who, if their countable income exceeds the percent of the federal poverty level, established in Sub-item (4)(a) of this Rule, meet the eligibility criteria for medically needy set forth in this Subchapter.

(5) Aged, blind and disabled individuals whose income is at or below 100% of the Federal Poverty Level, adjusted each April 1, and who meet the resource requirements of SSI, but who do not receive cash assistance.

(6) Women, as described at 42 U.S.C. 1396a(a)(10)(A)(ii)(XVIII) who:

(a) have been screened for breast or cervical cancer under the Centers for Disease Control and Prevention breast and cervical cancer early detection program established under Title XV of the Public Health Service Act in accordance with the requirements of section 1504 of that Act and need treatment for breast or cervical cancer, including a precancerous condition of the breast or cervix;

(b) are not otherwise covered under creditable coverage, as defined in section 2701(c) of the Public Health Service Act;

(c) are not otherwise eligible for Medicaid; and

(d) have not attained age 65.

 

History Note: Authority G.S. 108A-54; 42 C.F.R. 435.210; 42 C.F.R. 435.222; 42 C.F.R. 435.230; 42 C.F.R. 435.301; 42 C.F.R. 435.308; 42 C.F.R. 435.322; 42 C.F.R. 435.330; 42 U.S.C. 1396(a)(10)(A)(ii); 42 U.S.C. 1396a(a)(10)(C); S.L. 1983, c. 1034, s. 62.2; S.L. 1987, c. 738, s. 69 and 70; S.L. 1989, c. 752, s. 133;

Eff. September 1, 1984;

Amended Eff. February 1, 1992; July 1, 1991; August 1, 1990;

Temporary Amendment Eff. September 12, 1994, for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Temporary Amendment Eff. October 1, 1994, for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Amended Eff. January 1, 1995;

Temporary Amendment Eff. February 23, 1999;

Amended Eff. August 1, 2000;

Temporary Amendment Eff. January 1, 2002;

Amended Eff. April 1, 2003;

Transferred from 10A NCAC 21B .0102 Eff. May 1, 2012.

 

section .0200 - classification

 

10A NCAC 23d .0201 CLASSIFICATION

(a) The following individuals shall be classified as categorically needy:

(1) Individuals described in Item (1) of Rule .0101 of this Subchapter;

(2) Deemed recipients of SSI described in Item (19) of Rule .0101 of this Subchapter; and individuals who are eligible for public assistance cash payments but who choose not to apply for cash payments;

(3) Individuals described in Items (2), (3), and (4) of Rule .0101 of this Subchapter;

(4) Pregnant women described in:

(A) Item (5) or (15) of Rule .0101 of this Subchapter; or

(B) Sub-item (1)(d) of Rule .0102 of this Subchapter;

(5) Individuals under 21 described in:

(A) Item (6) or (16) of Rule .0101 of this Subchapter; or

(B) Sub-item (1)(a) of Rule .0102 of this Subchapter; or

(C) Sub-item (1)(d) of Rule .0102 of this Subchapter who meet the eligibility requirements for categorically needy in this Subchapter;

(6) Qualified Medicare Beneficiaries described in Item (14) of Rule .0101 of this Subchapter;

(7) Individuals described in Item (11), (12), or (13) of Rule .0101 of this Subchapter who were receiving cash assistance payments in December 1973;

(8) Individuals described in Item (7) of Rule .0101 of this Subchapter who were classified categorically needy when pregnancy terminated;

(9) Individuals described in Item (8) of Rule .0101 of this Subchapter whose mother is classified as categorically needy;

(10) Individuals described in Sub-item (1)(c) of Rule .0102 of this Subchapter; or

(11) Individuals described in Sub-item (1)(d) of Rule .0102 of this Subchapter.

(b) The following individuals who are not eligible as categorically needy and meet the requirements for medically needy set forth in this Subchapter shall be classified medically needy:

(1) Pregnant women described in:

(A) Item (7) of Rule .0101 of this Subchapter who were classified medically needy when their pregnancy terminated; or

(B) Sub-item (4)(b) of Rule .0102 of this Subchapter;

(2) Individuals under age 21;

(3) Caretaker relatives of eligible dependent children; or

(4) Aged, blind or disabled individuals not eligible for a public assistance cash payment.

 

History Note: Filed as a Temporary Amendment Eff. October 1, 1994, for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Filed as a Temporary Amendment Eff. September 12, 1994, for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Authority G.S. 108A-54; 42 C.F.R. 435.2; 42 C.F.R. 435.4;

Eff. September 1, 1984;

Amended Eff. January 1, 1995; August 1, 1990;

Temporary Amendment Eff. September 13, 1999;

Temporary Amendment Expired June 27, 2000;

Temporary Amendment Eff. September 12, 2000;

Amended Eff. August 1, 2002;

Transferred from 10A NCAC 21B .0408 Eff. May 1, 2012.