CMS-179 2.1 - 2.7 (Territory)

Form Approved CMS-179
OMB No. 0938-0193
Revision:
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM
Territory: __________________
SECTION 2 – COVERAGE AND ELIGIBILITY
______________________________________________________________________________
Citation(s)
______________________________________________________________________________
2.1 Application, Determination of Eligibility and Furnishing Medicaid
42 CFR 436.10
and Subpart J

(a) The Medicaid agency meets all requirements of 42 CFR Part
436,
Subpart J for processing applications, determining eligibility, and
furnishing Medicaid.

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Revision:

Approval Date

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Effective Date ______

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM
Territory: __________________
SECTION 2 – COVERAGE AND ELIGIBILITY
______________________________________________________________________________
Citation(s)
______________________________________________________________________________
2.1 Application, Determination of Eligibility and Furnishing Medicaid
(Continued)
1902(a)(34) of
the Act

1902(e)(8) and
1905(a) of the Act

TN: ______

(b) (1) Except as provided in item 2.1(b)(2) below, or otherwise
specified in Attachment 2.2-A or 2.6-A, individuals are
entitled to Medicaid services under the plan during the three
months preceding the month of application, if they were, or
on application would have been, eligible. The effective date
of prospective and retroactive eligibility is specified in
ATTACHMENT 2.2-A or 2.6A.
(2) For individuals who are eligible for Medicare cost-sharing
expenses as Qualified Medicare Beneficiaries under section
1902(a)(10)(E)(i) of the Act, coverage is available for
services furnished after the end of the month in which the
individual is first determined to be a Qualified Medicare
Beneficiary. ATTACHMENT 2.6-A specifies the
requirements for determination of eligibility for this group.

Approval Date

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Effective Date ______

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Revision:
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM
Territory: __________________
SECTION 2 – COVERAGE AND ELIGIBILITY
______________________________________________________________________________
Citation(s)
______________________________________________________________________________
2.1 Application, Determination of Eligibility and Furnishing Medicaid
(Continued)
42 CFR 438.6

(c) The Medicaid agency elects to enter into a risk contract that
complies with 42 CFR 438.6 and is procured through an open,
competitive procurement process that is consistent with 45 CFR
Part 74. The risk contract is with (check all that apply):
An HMO qualified under title XIII of the Public Health
Service Act.
A MCO that meets the definition of 1903(m) of the Act and
42 CFR 438.2.
A PIHP that meets the definition of 1903(m) of the Act and
42 CFR 438.2.
A PAHP that meets the definition of 1903(m) of the Act and
42 CFR 438.2.
Not applicable.

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Approval Date

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Effective Date ______

Supersedes TN:_____
Revision:
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM
Territory: __________________
SECTION 2 – COVERAGE AND ELIGIBILITY
______________________________________________________________________________
Citation(s)
______________________________________________________________________________
2.1 Application, Determination of Eligibility and Furnishing Medicaid
(Continued)
1902(a)(55) of
the Act

(d) The Medicaid agency has procedures to take applications, assist
applicants, and perform initial processing of applications from
those poverty-related low income pregnant women, infants, and
children under age 19, described in section 1902(a)(10)(A)(i)(IV),
1902(a)(10)(A)(i)(VI), 1902(a)(10)(A)(i)(VII), and
1902(a)(10)(A)(ii)(IX) of the Act at locations other than those
used for the receipt and processing of applications for the title IVA program including Federally-qualified health centers and
disproportionate share hospitals. Such application forms do not
include the application form for cash assistance under title IV-A
except as permitted by CMS instructions.

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Approval Date

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Effective Date ______

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM
Territory: __________________
SECTION 2 – COVERAGE AND ELIGIBILITY
______________________________________________________________________________
Citation(s)
______________________________________________________________________________
2.2 Coverage and Conditions of Eligibility
42 CFR 436.10

Medicaid is available to the groups specified in ATTACHMENT 2.2A.
Mandatory categorically needy and other required special groups
only.
Mandatory categorically needy, other required special groups,
and the medically needy, but no other optional groups.
Mandatory categorically needy, other required special groups,
and specified optional groups.
Mandatory categorically needy, other required special groups,
specified optional groups, and the medically needy.
The conditions of eligibility that must be met are specified in
ATTACHMENT 2.6-A.
All applicable requirements of 42 CFR Part 436 and sections
1902(a)(10)(A)(i), 1902(a)(10)(A)(ii), 1902(a)(10)(C),
1902(a)(10)(E), 1902(a)(10)(F), 1920, 1920A and 1920B of the Act
are met.

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Revision:

Approval Date

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Effective Date ______

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM
Territory: __________________
SECTION 2 – COVERAGE AND ELIGIBILITY
______________________________________________________________________________
Citation(s)
______________________________________________________________________________
2.3 Residence
42 CFR 436.10,
436.403 and 1902(b)
of the Act, P.L. 99272 (Section 9529)
and P.L. 99-509
(Section 9405)

Medicaid is furnished to eligible individuals who are residents of the
State under 42 CFR 436.403, regardless of whether or not the
individuals maintain the residence permanently or maintain it at a
fixed address.

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Approval Date

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Effective Date ______

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

MEDICAL ASSISTANCE PROGRAM
Territory: __________________
SECTION 2 – COVERAGE AND ELIGIBILITY
______________________________________________________________________________
Citation(s)
______________________________________________________________________________
2.4 Blindness
42 CFR 436.530(b)
42 CFR 436.531

All of the requirements of 42 CFR 436.530 and 42 CFR 436.531 are
met. The definition of blindness in terms of ophthalmic measurement
used in this plan is specified in Supplement 2 to ATTACHMENT 2.2A.

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Approval Date

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Effective Date ______

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM

Territory: __________________
SECTION 2 – COVERAGE AND ELIGIBILITY
______________________________________________________________________________
Citation(s)
______________________________________________________________________________
2.5 Disability
42 CFR 436.540(b)
and 42 CFR 436.541

All of the requirements of 42 CFR 436.540 and 436.541 are met. The
definition of disability that is used in this plan is specified in
Supplement 2 to ATTACHMENT 2.2-A.

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Approval Date

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Effective Date ______

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM

Territory: __________________
SECTION 2 – COVERAGE AND ELIGIBILITY
______________________________________________________________________________
Citation(s)
______________________________________________________________________________
2.6 Financial Eligibility
42 CFR 436.10 and
Subparts G and H
1902(a)(10)(A)(i)(III),
1902(a)(10)(A)(i)(IV),
1902(a)(10)(A)(i)(V),
1902(a)(10)(A)(i)(VI),
1902(a)(10)(A)(i)(VII),
1902(a)(10)(A)(ii),
1902(a)(10)(C),
1902(a)(10)(E),
1902(a)(10)(F),
1902(r)(2), 1920,
1920A and 1920B
of the Act

(a) The financial eligibility conditions for Medicaid-only eligibility
groups and for persons deemed to be cash assistance recipients
are described in ATTACHMENT 2.6-A.

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Approval Date

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Effective Date ______

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM
Territory: __________________

SECTION 2 – COVERAGE AND ELIGIBILITY
______________________________________________________________________________
Citation(s)
______________________________________________________________________________
2.7 Medicaid Furnished Out of State
42 CFR 431.52 and
1902(b) of the Act,
P.L. 99-272 (Section
9529)

Medicaid is furnished under the conditions specified in 42 CFR
431.52 to an eligible individual who is a resident of the State while
the individual is in another State, to the same extent that Medicaid is
furnished to residents in the State.

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Approval Date

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Effective Date ______

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