CMS-179 (State) Attachment 2.6 A and Supplements 1, 2, 3, 4, 5,

Form Approved CMS-179
OMB No. 0938-0193
Revision:

ATTACHMENT 2.6-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
GROUPS COVERED AND AGENCIES RESPONSIBLE
FOR ELIGIBILITY DETERMINATION

Agency

Citation(s)

Groups Covered

A. General Conditions of Eligibility
Each individual covered under the plan:
42 CFR Part 435,
Subpart G

1.

Is financially eligible (using the methods and standards described
in Parts B and C of this Attachment) to receive services.

42 CFR Part 435,
Subpart F

2.

Meets the applicable non-financial eligibility conditions.
a.

For the categorically needy:
(i)

For AFDC-related individuals (all groups except as
specified under items A.2.a.(ii) - (ix) below), meets the
non-financial criteria of the State’s AFDC plan in effect
as of July 16, 1996.

(ii) For SSI-related individuals, meets the non-financial
eligibility conditions of the SSI program or more
restrictive SSI-related categorically needy criteria.
1902(l) of the
Act

(iii) For financially eligible pregnant women, infants or
children covered under sections 1902(a)(10)(A)(i)(IV),
1902(a)(10)(A)(i)(VI), 1902(a)(10)(A)(i)(VII), or
1902(a)(10)(A)(ii)(IX) of the Act, meets the nonfinancial criteria of section 1902(1) of the Act.

1902(m) of the
Act

(iv) For financially eligible aged or disabled individuals
covered under section 1902(a)(10)(A)(ii)(X) of the Act,
meets the non-financial criteria of section 1902(m) of
the Act.

TN No:

Approval Date

Effective Date

Supersedes TN No.

Revision:

ATTACHMENT 2.6-A
Page 1a
State:

Citation(s)

Condition or Requirement

1902(a)(10)(A)(ii)(VIII)
of the Act

(v)

1902(z) of the Act

(vi) For tuberculosis-infected individuals financially
eligible under section 1902(a)(10)(A)(ii)(XII) of the
Act, meets the non-financial eligibility criteria of
section 1902(z).

1905(u)(2) of the Act

(vii) For optional targeted low-income children financially
eligible under section 1902(a)(10)(A)(ii)(XIV) of the
Act, meets the non-financial eligibility criteria of
section 1905(u)(2)(B).

1905(w) of the Act

(viii) For independent foster care adolescents financially
eligible under 1902(a)(10)(A)(ii)(XVII) of the Act,
meets the non-financial eligibility criteria of section
1905(w).

1902(aa) of the Act

(ix) For women with breast or cervical cancer financially
eligible under section 1902(a)(10)(A)(ii)(XVIII) of the
Act, meets the non-financial criteria of section
1902(aa).
b.

TN No:
Supersedes TN No.

For children receiving State adoption assistance who
are financially eligible under section 1902(a)(10)(A)
(ii)(VIII) of the Act, meets the non-financial eligibility
criteria of that section.

For the medically needy, meets the non-financial eligibility
conditions of 42 CFR Part 435 listed in A.2.a(i) or (ii)
above.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 2
State:

Citation(s)

Condition or Requirement

1902(a)(10)(E)(i) and
1905(p) of the Act

c.

For financially eligible Qualified Medicare Beneficiaries
covered under section 1902(a)(10)(E)(i) of the Act, meets
the non-financial eligibility criteria of section 1905(p) of the
Act.

1902(a)(10)(A)(E)(ii)
and 1905(s) of the
Act

d.

For financially eligible Qualified Disabled and Working
Individuals covered under section 1902(a)(10)(E)(ii) of the
Act, meets the non-financial eligibility criteria of section
1905(s) of the Act.

1902(a)(10)(E)(iii) and
and 1905(p) of the Act

e.

For financially eligible Specified Low-Income Medicare
Beneficiaries covered under section 1902(a)(10)(E)(iii) of
the Act, meets the non-financial eligibility criteria of section
1905(p) of the Act.

1902(a)(10)(E)(iv) and

f.

For financially eligible Qualifying Individuals covered
under
section 1902(a)(10)(E)(iii) of the Act, meets the
non-financial eligibility criteria of section 1905(p) of the
Act.

and 1905(p) of the Act

42 CFR 435.406

TN No:
Supersedes TN No.

3.

Is residing in the United States and-a.

Is a citizen or national of the United States;

b.

Is a qualified alien (QA) as defined in section 431 of the
Personal Responsibility and Work Opportunity
Reconciliation Act of 1996 (PRWORA) as amended, and
the QA’s eligibility is required by section 402(b) of
PRWORA as amended, and is not prohibited by section 403
of PRWORA as amended;

c.

Is a qualified alien subject to the 5-year bar described in
section 403 of PRWORA, so that eligibility is limited to
treatment of an emergency medical condition or as defined
in section 401 of PRWORA;

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 2a
State:

Citation(s)

Condition or Requirement
d.

Is a non-qualified alien, so that eligibility is limited to
treatment of an emergency medical condition or as defined
in section 401 of PRWORA; or

e.

Is a qualified alien (QA) whose eligibility is authorized
under section 402(b) of PRWORA as amended, and is not
prohibited by section 403 of PRWORA as amended.
State covers all authorized QAs.
State does not cover authorized QAs.

42 CFR 431.52
and 435.403
1902(b) of the Act

4.

Is a resident of the State with the intent to remain permanently or
for an indefinite period, regardless of whether the individual
maintains the residence permanently or at a fixed address, is
absent from the State temporarily and intends to return when the
purpose of the absence is accomplished, is placed by the State in
an out-of-state institution, or receives a title IV-E payment from
another State.
State has interstate residency agreement with the
following States:

State has open agreement(s).
Not applicable; no residency requirement.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 3
State:

Citation(s)
42 CFR 435.1008
1905(a) of the Act

Condition or Requirement
5.

42 CFR 435.1008,
1905(a) of the Act

a.

Is not an inmate of a public institution. Public institutions
do not include medical institutions, nursing facilities and
intermediate care facilities for individuals with intellectual
disabilities services, or publicly operated community
residences that serve no more than 16 residents, or certain
child care institutions.

b.

Is not a patient under age 65 in an institution for mental
diseases except as an inpatient under age 22 receiving active
treatment in an accredited psychiatric facility or program.
Not applicable with respect to individuals under age 22
in psychiatric facilities or programs. Such services are
not provided under the plan.

42 CFR 433.145,
1912 of the Act

6.

Is required, as a condition of eligibility, to assign his or her own
rights, or the rights of any other person who is eligible for
Medicaid and on whose behalf the individual has legal authority
to execute an assignment to medical support and payments for
medical care from any third party. (Medical support is defined
as support specified as being for medical care by a court or
administrative order.)
An applicant or recipient must also cooperate in establishing the
paternity of any eligible child and in obtaining medical support
and payments for himself or herself and any other person who is
eligible for Medicaid and on whose behalf the individual can
make an assignment; except that individuals described in section
1902(l)(1)(A) of the Social Security Act (pregnant women and
women in the post-partum period) are exempt from these
requirements involving paternity and obtaining support. Any
individual may be exempt from the cooperation requirements by
demonstrating good cause for refusing to cooperate.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 3a
State:

Citation(s)

Condition or Requirement
An applicant or recipient must also cooperate in identifying any
third party who may be liable to pay for care that is covered
under the State plan and providing information to assist in
pursuing these third parties. Any individual may be exempt from
the cooperation requirements by demonstrating good cause for
refusing to cooperate.
Assignment of rights is automatic because of State law.

42 CFR 435.910
1137(a)(1) and (f)
of the Act

7.

Is required, as a condition of eligibility, to furnish his/her Social
Security account number (or numbers, if he/she has more than
one number), with the exception of aliens seeking coverage for
the treatment of an emergency medical condition under section
1903(v)(2) of the Act or individuals who, because of wellestablished religious objections as defined in 42 CFR 435.910(h),
refuse to obtain a Social Security account number.

1902(c)(2) of the Act

8.

Is not required to apply for AFDC benefits under title IV-A as a
condition of applying for, or receiving, Medicaid if the individual
is a pregnant woman, infant, or child that the State elects to cover
under sections 1902(a)(10)(A)(i)(IV) and 1902(a)(10)(A)(ii)(IX)
of the Act.

1902(e)(10)(A) and
1902(e)(10)(B) of
the Act

9.

Is not required, as an individual child or pregnant woman; to
meet requirements under section 402(a)(43) of the Act to be in
certain living arrangements. (Prior to terminating AFDC
individuals who do not meet such requirements under a State's
AFDC plan, the agency determines if they are otherwise eligible
under the State's Medicaid plan.)

1906 of the Act

10. Is required to apply for enrollment in an employer-based
cost-effective group health plan, if such plan is available to the
individual. Enrollment is a condition of eligibility except for the
individual who is unable to enroll on his/her own behalf (failure
of a parent to enroll a child does not affect a child's eligibility).

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 4
State:

Citation(s)

Condition or Requirement
B. Post Eligibility Treatment of Institutionalized Individual’s Income

1924 of the Act
42 CFR 435.725
42 CFR 435.733
42 CFR 435.832

1.

The following monthly amounts for personal needs are
deducted from total monthly income in the application of an
institutionalized individual’s or couple’s income to the cost of
institutionalized care:
Personal Needs Allowance (PNA) of not less than $30 for
individuals and $60 for couples for all institutionalized persons.
a.

Aged, blind, disabled:
Individuals $
Couples
$
For the following persons with greater need:
Supplement 12 to ATTACHMENT 2.6-A describes the
greater need; describes the basis or formula for determining
the deductible amount when a specific amount is not listed
above; lists the criteria to be met; and, where appropriate,
identifies the organizational unit which determines that a
criterion is met.

b.

AFDC related:
Individuals $
Couples
$
For the following persons with greater need:
Supplement 12 to ATTACHMENT 2.6-A describes the
greater need; describes the basis or formula for determining
the deductible amount when a specific amount is not listed
above; lists the criteria to be met; and, where appropriate,
identifies the organizational unit which determines that a
criterion is met.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 4a
State:

Citation(s)

Condition or Requirement
B. Post Eligibility Treatment of Institutionalized Individual’s Income
(Continued)

1924 of the Act

2.

In addition to the amounts under item 1, the following monthly
amounts are deducted from the remaining income of an
institutionalized individual with a community spouse:
a.

The monthly income allowance for the community spouse,
calculated using the formula in section 1924(d)(2), is the
amount by which the maintenance needs standard exceeds
the community spouse’s income. The maintenance needs
standard cannot exceed the maximum prescribed in section
1924(d)(3)(C). The maintenance needs standard consists of
a poverty level component plus an excess shelter allowance.
The poverty level component is calculated using the
applicable percentage (set out in section 1924(d)(3)(B)
of the Act) of the official poverty level.
The poverty level component is calculated using a
percentage greater than the applicable percentage, equal
to
%, of the official poverty level (still subject to
maximum maintenance needs standard).
The maintenance needs standard for all community
spouses is set at the maximum permitted by section
1924(d)(3)(C). Except that, when applicable, the State
will set the community spouse’s monthly income
allowance at the amount by which exceptional
maintenance needs, established at a fair hearing, exceed
the community spouse’s income, or at the amount of
any court-ordered support.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 4b
State:

Citation(s)

Condition or Requirement
B. Post Eligibility Treatment of Institutionalized Individual’s Income
(Continued)
In determining any excess shelter allowance, utility
expenses are calculated using:
the standard utility allowance under section 5(e) of the
Food Stamp Act of 1977; or
the actual unreimbursable amount of the community
spouse’s utility expenses less any portion of such
amount included in condominium or cooperative
charges.
b. The monthly income allowance for other dependent family
members living with the community spouse is:
one-third of the amount by which the poverty level
component (calculated under section 1924(d)(3)(A)(i)
of the Act, using the applicable percentage specified in
section 1924(d)(3)(B) ) exceeds the dependent family
member’s monthly income.
a greater amounted calculated as follows:

The following definition is used in lieu of the definition
provided by the Secretary to determine the dependency of
family members under section 1924(d)(1):

TN No:
Supersedes TN No.
Revision:

Approval Date

Effective Date
ATTACHMENT 2.6-A

Page 4c
State:
Citation(s)

Condition or Requirement
B. Post Eligibility Treatment of Institutionalized Individual’s Income
(Continued)
c.

Amounts for health care expenses described below that are
incurred by and for the institutionalized individual and are
not subject to payments by a third party:
(i)

Medicaid, Medicare, and other health insurance
premiums, deductibles, or coinsurance charges,
or copayments.

(ii) Necessary medical or remedial care recognized under
State law but not covered under the State plan.
(Reasonable limits on amounts are described in
Supplement 3 to ATTACHMENT 2.6-A.)
42 CFR 435.725
42 CFR 435.733
42 CFR 435.832

3.

In addition to any amounts deductible under the items above, the
following monthly amounts are deducted from the remaining
monthly income of an institutionalized individual or an
institutionalized couple:
a.

An amount for the maintenance needs of each member of a
family living in the institutionalized individual’s home with
no community spouse living in the home. The amount must
be based on a reasonable assessment of need but must not
exceed the higher of the:



AFDC level in effect under the State’s plan as of July
16, 1996; or
Medically needy level:

(Check one)
AFDC Levels in Supplement 1 to ATTACHMENT
2.6-A
Medically needy level in Supplement 1 to
ATTACHMENT 2.6-A
Other: $
TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 4d
State:

Citation(s)

Condition or Requirement
B. Post Eligibility Treatment of Institutionalized Individual’s Income
(Continued)
b.

Amounts for health care expenses described below that have
not been deducted under 3.c. above (i.e., for an
institutionalized individual with a community spouse), are
incurred by and for the institutionalized individual or
institutionalized couple, and are not subject to the payment
by a third party:
(i)

Medicaid, Medicare, and other health insurance
premiums, deductibles, or coinsurance charges, or
copayments.

(ii) Necessary medical or remedial care recognized under
State law but not covered under the State plan.
(Reasonable limits on amount are described in
Supplement 3 to ATTACHMENT 2.6-A.)
42 CFR 435.725
42 CFR 435.733
42 CFR 435.832

4.

At the option of the State, as specified below, the following is
deducted from any remaining monthly income of an
institutionalized individual or an institutionalized couple:
A monthly amount for the maintenance of the home of the
individual or couple for not longer than 6 months if a physician
has certified that the individual, or one member of the
institutionalized couple, is likely to return to the home within that
period:
No.
Yes (the applicable amount is designated on page 4e)

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 4e
State:

Citation(s)

Condition or Requirement
Amount for maintenance of home is: $

.

Amount for maintenance of home is the actual
maintenance costs not to exceed $
.
Amount for maintenance of home is deductible when
countable income is determined under section
1924(d)(1) of the Act only if the individua l’s home and
the community spouse’s home are different.
Amount for maintenance of home is not deductible
when countable income is determined under section
1924 (d)(1) of the Act.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 5
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s)

Condition or Requirement

42 CFR 435.811,
C. FINANCIAL ELIGIBILITY
42 CFR 435.831,
42 CFR 435.840, and
Depending on whether the individual is being considered for an
42 CFR 435.845
AFDC-related or SSI-related Medicaid eligibility group, the income
and resource levels and methods for determining countable income
and resources in either the State’s AFDC plan in effect on July 16,
1996 or the SSI program apply, unless this plan provides for more
restrictive levels and methods than SSI for SSI recipients under
section 1902(f) of the Act, more liberal methods under section
1902(r)(2) of the Act, or more restrictive or liberal methods under
section 1931 of the Act, as specified below.
For individuals who are not AFDC or SSI recipients in a non-section
1902(f) State and those who are deemed to be cash assistance
recipients, the financial eligibility requirements specified in this
section C apply.

TN No:
Supersedes TN No.



Supplement 1 to ATTACHMENT 2.6-A specifies the income
eligibility standards for mandatory categorically needy, optional
categorically needy, and medically needy eligibility groups.



Supplement 2 to ATTACHMENT 2.6-A specifies the resource
eligibility standards for mandatory categorically needy, optional
categorically needy, and medically needy eligibility groups.



Supplement 3 to ATTACHMENT 2.6-A specifies the reasonable
limits on amounts of necessary medical or remedial care not
covered under Medicaid.



Supplement 4 to ATTACHMENT 2.6-A specifies the methods
for determining income eligibility, used by States that have more
restrictive methods than SSI, permitted under section 1902(f) of
the Act.
Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 6
State:

Citation

TN No:
Supersedes TN No.

Condition or Requirement


Supplement 5 to ATTACHMENT 2.6-A specifies the methods
for determining resource eligibility, used by States that have
more restrictive methods than SSI, permitted under section
1902(f) of the Act.



Supplement 5a to ATTACHMENT 2.6-A specifies the methods
for determining resource eligibility for individuals with incomes
related to the Federal poverty level, used by States that have
more restrictive methods than SSI, permitted under section
1902(f) of the Act.



Supplement 6 to Attachment 2.6-A specifies the standards for
optional State supplementary payments.



Supplement 7 to ATTACHMENT 2.6-A specifies the income
standards for 1902(f) States for categorically needy aged, blind,
or disabled individuals who are covered under requirements
more restrictive than SSI.



Supplement 8 to ATTACHMENT 2.6-A specifies the resource
standards for 1902(f) States for categorically needy aged, blind,
or disabled individuals who are covered under requirements
more restrictive than SSI.



Supplement 8a to ATTACHMENT 2.6-A specifies more liberal
methods of treating income under section 1902(r)(2) of the Act,
used by States that have less restrictive methods than the cash
assistance programs.



Supplement 8b to ATTACHMENT 2.6-A specifies more liberal
methods of treating resources under section 1902(r)(2) of the
Act, used by States that have less restrictive methods than the
cash assistance programs.



Supplement 8c to ATTACHMENT 2.6-A specifies requirements
related to the DRA long term care insurance partnership
programs.
Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 6a
State:

Citation

TN No:
Supersedes TN No.

Condition or Requirement


Supplement 9b to ATTACHMENT 2.6-A specifies the criteria
used for transfer of assets under section 1917(c) of the Act,
which affects the eligibility of institutionalized individuals on or
after February 8, 2006.



Supplement 10 to ATTACHMENT 2.6-A specifies the criteria
used to exclude the assets transferred into a Medicaid trust
because of undue hardship for categorically needy individuals, as
permitted under section 1902(d)(4) of the Act.



Supplement 11 to ATTACHMENT 2.6-A specifies cost
effectiveness methodology for COBRA continuation
beneficiaries.



Supplement 12 to ATTACHMENT 2.6-A specifies the variations
from the basic personal needs allowance under section
1902(a)(50) of the Act. It also specifies the AFDC covered
groups and the income and resource eligibility criteria for lowincome families under section 1931 of the Act.



Supplement 13 to ATTACHMENT 2.6-A specifies the treatment
of available income and resources for certain institutionalized
spouses with a community spouse under section 1924 of the Act.



Supplement 14 to ATTACHMENT 2.6 -A specifies the income
and resource requirements used by States for determining
eligibility of Tuberculosis-infected individuals whose eligibility
is determined under section 1902(z)(1) of the Act.



Supplement 15 to ATTACHMENT 2.6-A specifies
disqualification for long term care assistance for individuals with
substantial home equity.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 7
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s)
1902(r)(2) of the
Act

Condition or Requirement
1.

Methods of Determining Income
a.

AFDC-related individuals (except for individuals eligible
under section 1931 of the Act and poverty-level related
pregnant women, infants, and children).
(1) In determining countable income for AFDC-related
individuals, the following methods are used:
(a) The methods under the State's approved
AFDC plan in effect on July 16, 1996 only; or
(b) The methods under the State's approved
AFDC plan in effect on July 16, 1996 and/or
any more liberal methods described in
Supplement 8a to ATTACHMENT 2.6-A.
Note: For individuals eligible under section 1931 of the
Act, see Supplement 12 to ATTACHMENT 2.6A. For poverty-level related pregnant women,
infants, and children, see e of this section.

1902(a)(17)(D) of the Act
42 CFR 435.602

TN No:
Supersedes TN No.

(2) In determining financial responsibility of relatives and
other individuals, the Medicaid agency considers only
the income of spouses living in the same household as
available to spouses and the income of parents as
available to children living with parents until the
children become 21, with the specified exceptions for
AFDC-related and SSI-related eligibility groups.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 7a
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s)

Condition or Requirement

1902(e)(6) of the
Act

42 CFR 435.601
aged
42 CFR 435.831
1902(m)(1)(B),
1902(m)(4), and
1902(r)(2) of the Act

(3) Agency continues to treat women eligible under the
provisions of eligible under the provisions of section
1902(a)(10) of the Act as eligible, without regard to any
changes in income of the family of which she is a
member, for the 60-day period after her pregnancy ends
and any remaining days in the month in which the 60th
day falls.
b.

Aged individuals. In determining countable income for
individuals, including aged individuals with incomes up to
the Federal poverty level described in section 1902(m)(1) of
the Act, the following methods are used.
The methods of the SSI program only.
The methods of the SSI program and/or any more
liberal methods described in Supplement 8a to
ATTACHMENT 2.6-A.
For individuals other than optional state supplement
recipients, more restrictive methods than are used by
the SSI program. Any more restrictive methods are
described in Supplement 4 to ATTACHMENT 2.6-A.
NOTE: More restrictive methods cannot be applied to
aged individuals eligible under section
1902(m)(1) of the Act.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 8
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s)

Condition or Requirement
For institutional couples, the methods specified under section
1611(e)(5) of the Act.
For optional State supplement recipients under 435.232, income
methods more liberal than SSI, as specified in Supplement 8a to
ATTACHMENT 2.6-A.
For optional State supplement recipients under 435.234 in
section 1902(f) States and SSI criteria States without section
1616 or 1634 agreements—
SSI methods only.
SSI methods and/or any more liberal methods than SSI
described in Supplement 8a to ATTACHMENT 2.6-A.
Methods more restrictive than SSI. More restrictive
methods are described in Supplement 4 to ATTACHMENT
2.6-A.

1902(a)(17)(D)
of the Act
42 CFR 435.602

TN No:
Supersedes TN No.

In determining relative financial responsibility, the agency
considers only the income of spouses living in the same
household as available to spouses.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 9
State:

Citation
42 CFR 435.601,
42 CFR 435.831, and
1902(r)(2) of the Act

Condition or Requirement
c.

Blind individuals. In determining countable income for
blind individuals, the following methods are used:
The methods of the SSI program only.
SSI methods and/or any more liberal methods described
in Supplement 8a to ATTACHMENT 2.6-A.
For individuals other than optional State supplement
recipients, more restrictive methods than SSI, applied
under the provisions of section 1902(f) of the Act, as
specified in Supplement 4 to ATTACHMENT 2.6-A.
For institutional couples, the methods specified under
section 1611(e)(5) of the Act.
For optional State supplement recipients under 435.232,
income methods more liberal than SSI, as specified in
Supplement 8a to ATTACHMENT 2.6-A.
For optional State supplement recipients under 435.234
in section 1902(f) States and SSI criteria States without
section 1616 or 1634 agreements –
SSI methods only.
SSI methods and/or any more liberal methods than
SSI described in Supplement 8a to
ATTACHMENT 2.6-A
Methods more restrictive than SSI. More
restrictive methods are described in Supplement 4
to ATTACHMENT 2.6-A.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 10
State:

Citation

Condition or Requirement

42 CFR 435.602
1902(a)(17)(D)
of the Act

42 CFR 435.601,
and 435.831,
1902(m)(1)(B),
1902(m)(4), and
1902(r)(2) of the
Act

In determining relative responsibility, the agency considers
only the income of spouses living in the same household as
available to spouses and the income of parents as available
to children living with parents until the children become 21.
d.

Disabled individuals. In determining countable income of
disabled individuals, including individuals with incomes up
to the Federal poverty level described in section 1902(m)(1)
of the Act the following methods are used
The methods of the SSI program.
SSI methods and/or any more liberal methods described
in Supplement 8a to ATTACHMENT 2.6A.
For institutional couples: the methods specified under
section 1611(e)(5) of the Act.
For optional State supplement recipients under 435.232:
income methods more liberal than SSI, as specified in
Supplement 8a to ATTACHMENT 2.6-A.
For individuals other than optional State supplement
recipients (except aged and disabled individuals
described in section 1902(m)(1) of the Act); more
restrictive methods than SSI, applied under the
provisions of section 1902(f) of the Act, as specified in
Supplement 4 to ATTACHMENT 2.6 A.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 11
State:

Citation

Condition or Requirement
For optional State supplement recipients under 435.234
in section 1902(f) States and SSI criteria States without
section 1616 or 1634 agreements—
SSI methods only.
SSI methods and/or any more liberal methods than
SSI described in Supplement 8a to Attachment 2.6A.
Methods more restrictive than SSI. More
restrictive methods are described in Supplement 4
to ATTACHMENT 2.6-A.

1902(l)(3)(E) and
1902(r)(2) of the
Act

e.

Poverty level pregnant women, infants, and children. For
children. For pregnant women and infants or children
covered under the provisions of sections
1902(a)(10)(A)(i)(IV), (VI), and (VII), and
1902(a)(10)(A)(ii)(IX) of the Act-(1) The following methods are used in determining
countable income:
The methods of the State's approved AFDC plan in
effect on July 16, 1996.
The methods of the approved title IV-E plan.
The methods of the approved AFDC State plan in
effect on July 16, 1996 and/or any more liberal
methods described in Supplement 8a to
ATTACHMENT 2.6-A.
The methods of the approved title IV-E plan and/or
any more liberal methods described in Supplement
8a to ATTACHMENT 2.6-A.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 11a
State:
ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s)

Condition or Requirement

1902(a)(17)(D) of the Act
42 CFR 435.602

(2) In determining financial responsibility of relatives and
other individuals, the Medicaid agency considers only
the income of spouses living in the same household as
available to spouses and the income of parents as
available to children living with parents until the
children become 21, with the specified exceptions for
AFDC-related and SSI-related eligibility groups.

1902(e)(6) of the
Act

(3) The agency continues to treat women eligible under the
eligible under the provisions of section 1902(a)(10) of
the Act as eligible, without regard to any changes in
income of the family of which she is a member, for the
60-day period after her pregnancy ends and any
remaining days in the month in which the 60th day
falls.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 12
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s)
1902(a)(10)(E)(i),
1902(p)(1),
1902(m)(4), and
1902(r)(2) of
the Act

Condition or Requirement
f.

Qualified Medicare Beneficiaries. In determining countable
income for Qualified Medicare Beneficiaries covered under
section 1902(a)(10)(E)(i) of the Act, the following methods
are used:
The methods of the SSI program only.
SSI methods and/or any more liberal methods than SSI
described in Supplement 8a to ATTACHMENT 2.6-A.
For institutional couples, the methods specified under
section 1611(e)(5) of the Act.
If an individual receives a title II benefit, any amounts
attributable to the most recent increase in the monthly
insurance benefit as a result of a title II COLA is not
counted as income during a "transition period" beginning
with January, when the title II benefit for December is
received, and ending with the last day of the month
following the month of publication of the revised annual
Federal poverty level.
The revised poverty levels are effective no later than the
date of publication.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 12a
State:

Citation
1902(a)(10)(E)(ii)
and 1905(s) of the Act
1902(a)(10)(E)(iii)
and 1902(r)(2) of

Condition or Requirement
g.

For Qualified Disabled and Working Individuals covered
under section 1902(a)(10)(E)(ii) of the Act, the agency uses
the methods under the SSI program for treatment of income.
h.

For Specified Low-Income Medicare Beneficiaries covered
under section 1902(a)(10)(E)(iii) of the Act, the agency
uses:

the Act
The methods used under the SSI program.
The methods used under SSI program and/or more
liberal methods described in Supplement 8a to
ATTACHMENT 2.6-A. If more liberal methods are
used, the same methods are applied as in f. for QMBs.
1902(a)(10)(E)(iv)
and 1902(r)(2) of
the Act

i.

For Qualifying Individuals covered under section
1902(a)(10)(E)(iv) of the Act, the agency uses:
The methods used under the SSI program.
The methods used under SSI program and/or more
liberal methods described in Supplement 8a to
ATTACHMENT 2.6-A. If more liberal methods are
used, the same methods are applied as in f. for QMBs.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 12b
State:

Citation
1902(u) of the Act

Condition or Requirement
j.

COBRA Continuation Beneficiaries
In determining countable income for COBRA continuation
beneficiaries, the following disregards are applied:
The disregards of the SSI program;
The agency uses methodologies for treatment of income
more restrictive than the SSI program. These more
restrictive methodologies are described in Supplement 4
to ATTACHMENT 2.6-A.
NOTE:

TN No:
Supersedes TN No.

Approval Date

For COBRA continuation beneficiaries
specified at 1902(u)(4), costs incurred from
medical care or for any other type of
remedial care shall not be taken into account
in determining income, except as provided
in section 1612(b)(4)(B)(ii).

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 12c
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

Citation(s)
1902(a)(10)(A)(ii)
(XIII), 1902(f) and
1902(r)(2) of the Act

Condition or Requirement
k.

Working Individuals with Disabilities -BBA
In determining countable income and resources for working
individuals with disabilities under BBA, the following
methodologies are applied:
The methodologies of the SSI program.
The agency uses more liberal income and/or resource
methods than the SSI program. More liberal income
methodologies are described in Supplement 8a to
ATTACHMENT 2.6-A. More liberal resource
methodologies are described in Supplement 8b to
ATTACHMENT 2.6-A.
The agency uses more restrictive income and/or
resource methods than the SSI program. More
restrictive income methods are described in Supplement
4 to ATTACHMENT 2.6-A. More restrictive resource
methods are described in Supplement 5 to
ATTACHMENT 2.6-A.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 12d
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

Citation(s)
1902(a)(10)(A)(ii)
(XV) of the Act

Condition or Requirement
l.

Working Individuals with Disabilities – Basic Coverage
Coverage Group - TWWIIA
In determining financial eligibility for working individuals
with disabilities under this provision, the following
standards and methodologies are applied:
___ The agency does not apply any income or resource
standard.
NOTE: If the above option is chosen, no further
eligibility-related options should be elected.
___ The agency applies the following income and/or
resource standard(s):

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 12e
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

Citation(s)
1902(a)(10)(A)(ii)
(XV), 1902(f) and
1902(r)(2) of the Act

Condition or Requirement
Income Methodologies
In determining whether an individual meets the income
standard described above, the agency uses the following
methodologies.
The methodologies of the SSI program.
The agency uses more liberal income methods than the
SSI program. More liberal income methodologies are
described in Supplement 8a to ATTACHMENT 2.6-A.
The agency uses more restrictive income methods than
the SSI program. More restrictive income methods are
described in Supplement 4 to ATTACHMENT 2.6-A.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 12f
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

Citation(s)
1902(a)(10)(A)(ii)
(XV), 1902(f) and
1902(r)(2) of the Act

Condition or Requirement
Resource Methodologies
In determining whether the individual meets the resource
standard described above, the agency uses the following
methodologies.
Unless one of the following items is checked, the agency,
under the authority of section 1902(r)(2) of the Act,
disregards all funds held in retirement funds and accounts,
including private retirement accounts such as IRAs and
other individual accounts, and employer-sponsored
retirement plans such as 401(k) plans, Keogh plans, and
employer pension plans. Any disregard involving
retirement accounts is separately described in Supplement
8b to ATTACHMENT 2.6-A.
___ The agency disregards funds held in employersponsored retirement plans, but not private retirement
plans.
___ The agency disregards funds in retirement accounts in a
manner other than those described above. The agency’s
disregards are specified in Supplement 8b to
ATTACHMENT 2.6-A.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 12g
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

Citation(s)
1902(a)(10)(A)(ii)
(XV), 1902(f) and
1902(r)(2) of the Act

Condition or Requirement
___ The agency does not disregard funds in retirement
accounts.
The methodologies of the SSI program.
The agency uses more liberal resource methods than the
SSI program. More liberal resource methodologies are
described in Supplement 8b to ATTACHMENT 2.6-A.
The agency uses more restrictive resource methods than
the SSI program. More restrictive resource methods are
described in Supplement 5 to ATTACHMENT 2.6-A.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 12h
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

Citation(s)
1902(a)(10)(A)(ii)
(XVI) of the Act

Condition or Requirement
m. Working Individuals with Disabilities – Employed Medically
Improved Individuals - TWWIIA
In determining financial eligibility for employed medically
improved individuals under this provision, the following
standards and methodologies are applied:
The agency does not apply any income or resource
standard.
NOTE: If the above option is chosen, no further
eligibility-related options should be elected.
The agency applies the following income and/or
resource standard(s):

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 12i
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

Citation(s)
1902(a)(10)(A)(ii)
(XVI), 1902(f) and
1902(r)(2) of the Act

Condition or Requirement
Income Methodologies
In determining whether an individual meets the income
standard described above, the agency uses the following
methodologies.
The methodologies of the SSI program.
The agency uses more liberal income methods than the
SSI program. More liberal income methodologies are
described in Supplement 8a to ATTACHMENT 2.6-A.
The agency uses more restrictive income methods than
the SSI program. More restrictive income methods are
described in Supplement 4 to ATTACHMENT 2.6-A.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 12j
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

Citation(s)
1902(a)(10)(A)(ii)
(XVI), 1902(f) and
1902(r)(2) of the Act

Condition or Requirement
Resource Methodologies
In determining whether the individual meets the resource
standard described above, the agency uses the following
methodologies.
Unless one of the following items are checked, the agency,
under the authority of section 1902(r)(2) of the Act,
disregards all funds held in retirement funds and accounts,
including private retirement accounts such as IRAs and
other individual accounts, and employer-sponsored
retirement plans such as 401(k) plans, Keogh plans, and
employer pension plans. Any disregard involving
retirement accounts is separately described in Supplement
8b to ATTACHMENT 2.6-A.
__ The agency disregards funds held in employer
sponsored retirement plans, but not private retirement
plans.
The agency disregards funds in retirement accounts in a
manner other than those described above. The agency’s
disregards are specified in Supplement 8b to
ATTACHMENT 2.6-A.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 12k
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

Citation(s)
1902(a)(10)(A)(ii)
(XVI) of the Act

Condition or Requirement
The agency does not disregard funds in retirement
accounts.
The methodologies of the SSI program.
The agency uses more liberal resource methods than the
SSI program. More liberal resource methodologies are
described in Supplement 8b to ATTACHMENT 2.6-A.
The agency uses more restrictive resource methods than
the SSI program. More restrictive resource methods are
described in Supplement 5 to ATTACHMENT 2.6-A.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 12l
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

Citation(s)
1902(a)(10)(A)(ii)
(XVI) and 1905(v)(2)
of the Act

Condition or Requirement
Definition of Employed – Employed Medically Improved
Individuals – TWWIIA
The agency uses the statutory definition of “employed”,
i.e., earning at least the minimum wage, and working at
least 40 hours per month.
___ The agency uses an alternative definition of
“employed” that provides for substantial and reasonable
threshold criteria for hours of work, wages, or other
measures. The agency’s threshold criteria is described
below:

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 12m
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

Citation(s)
1902(a)(10)(A)(ii)(XIII)
of the Act

Condition or Requirement
Payment of Premiums or Other Cost Sharing Charges
For individuals eligible under the BBA eligibility group
described in No. 27 on page 23g to ATTACHMENT 2.2-A:
___ The agency requires payment of premiums or other
cost-sharing charges on a sliding scale based on
income. The premiums or other cost-sharing charges,
and how they are applied are described below:

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 12n
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

Citation(s)
1902(a)(10)(A)(ii)
(XV), (XVI), and
1916(g) of the Act

Condition or Requirement
For individuals eligible under the Basic Coverage Group
described in No. 28 on page 23g to ATTACHMENT 2.2-A,
and the Medical Improvement Group described in No. 29 on
page 23g to ATTACHMENT 2.2-A:
NOTE: Regardless of the option selected below, the agency
MUST require that individuals whose annual
adjusted gross income, as defined under IRS statute,
exceeds $75,000 pay 100 percent of premiums. The
$75,000 limit was effective October 1, 2000, and
increases by the percentage increase in the Social
Security Cost of Living increase each calendar year.
____ The agency requires individuals to pay premiums or
other cost-sharing charges on a sliding scale based
on income. For individuals with net annual income
below 450 percent of the Federal poverty level for a
family of the size involved, the amount of premiums
cannot exceed 7.5 percent of the individual’s
income.
The premiums or other cost-sharing charges, and
how they are applied are described on page 12o.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 12o
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

Citation(s)
Sections 1902(a)(10)(A)(ii)
(XV), (XVI), and 1916(g)
of the Act

TN No:
Supersedes TN No.

Condition or Requirement
Premiums and Other Cost-Sharing Charges
For the Basic Coverage Group and the Medical
Improvement Group, the agency’s premium and other
cost-sharing charges, and how they are applied, are
described below.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 12p
State:

Citation
1902(a)(10)(A)(ii)
(XIX) of the Act

Condition or Requirement
n.

Family Opportunity Act (FOA)
In determining financial eligibility for disabled children
under this provision, the following standards and
methodologies are applied:
Income Standards
___ The agency uses the family income standard of 300%
of federal poverty level;
___ The agency uses the family income standard of less
than 300% of the federal poverty level.
Specify the income standard _______
___ The agency uses a family income standard higher than
300% of the federal poverty level, (no federal financial
participation is provided for benefits to families above
300% FPL).
Specify the income standard _______
Resource Standards
Under this provision agencies may not impose resource
standards or asset tests in determining eligibility.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 12q
State:

Citation
1902(a)(10)(A)(ii)
(XIX), 1902(f) and
1902(r)(2) of the Act

Condition or Requirement
Income Methodologies
In determining whether a family meets the income standard
described above, the agency uses the following
methodologies.
___ The income methodologies of the SSI program.
___ The agency uses methodologies for treatment of income
that are more restrictive than the SSI program. These
more restrictive methodologies are described in
Supplement 4 to ATTACHMENT 2.6-A.
___ The agency uses more liberal income methodologies
than the SSI program. More liberal income
methodologies are described in Supplement 8a to
ATTACHMENT 2.6-A.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 12r
State:

Citation

Condition or Requirement

1902(cc) of the Act
and 1903(a)

Interaction with Employer Sponsored Family Coverage
For individuals eligible under the FOA eligibility group
described in No. 30 on page 23h to ATTACHMENT 2.2-A:
The agency requires parents to enroll in available group
health plans through their employers if the plan qualifies
under Section 2791(a) of the Public Health Service Act and
the employer contributes at least 50 percent of the total cost
of annual premiums for such coverage.
If such coverage is obtained, the agency (subject to the
payment of premiums described in Attachment 2.6-A, pages
12s and 12t reduces any premium imposed by the State by
an amount that reasonably reflects the premium contribution
made by the parent for private coverage on behalf of a child
with a disability; and treats such coverage as a third party
liability.
___ The agency provides for payment of all or some portion
of the annual premium for the employer-provided
private family coverage that the parent is required to
pay. Any payments made by the State are considered,
for purposes of section 1903(a), to be payments for
medical assistance.
The agency pays __________ percent of the premium.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 12s
State:

Citation
1902(a)(10)(A)(ii)
(XIX), 1916(i) and
1902(cc)(2)(A)(ii)(I)
of the Act

Condition or Requirement
Payment of Premiums
For individuals eligible under the FOA eligibility group
described in No. 30 on page 23h to ATTACHMENT 2.2-A:
___ The agency does not require the payment of premiums
for Medicaid coverage.
___ The agency requires payment of premiums on a sliding
scale based on income. The premiums, and how they
are applied are described below:
NOTE: Amounts paid for premiums for Medicaid,
required family coverage, and other costsharing may not exceed 5% of a family’s
income for families with income up to and
including 200% FPL and 7.5% of a family’s
income for families above 200% and up to
300% FPL.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 12t
State:

Citation
1902(a)(10)(A)(ii)
(XIX), 1916(i) and
1902(cc)(2)(A)(ii)(I)
of the Act

Condition or Requirement
Payment of Premiums (Continued)
NOTE: A State may not require prepayment of premiums
and may not terminate eligibility of a child for
medical assistance on the basis of failure to pay a
premium until the failure to pay continues for at
least 60 days from the date on which the premium
was past due.
NOTE: The State may waive payment of any such
premium in any case where the State determines
that requiring payment would create an undue
hardship.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 13
State:

Citation

Condition or Requirement

1917(d)(5) of the Act

2.

Medicaid Trusts
The agency does not count the funds in a trust described in
section 1917(d) in any instance where the State determines
that it would work an undue hardship. Supplement 10 to
ATTACHMENT 2.6-A specifies what constitutes an undue
hardship.

1902(a)(10)

3.

Medically Needy Income Levels (MNILS)
a.

MNILS are based on family size.

b.

The MNIL does not diminish by family size.

Supplement 1 to ATTACHMENT 2.6-A specifies the MNILs for
all covered medically needy groups. If the agency chooses more
restrictive levels under section 1902(f) of the Act, Supplement 1 to
ATTACHMENT 2.6-A so indicates.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14
State:

Citation
42 CFR.435.732 and
42 CFR 435.831

Condition or Requirement
4.

Handling of Excess Income - Spend-down for the Medically
Needy in All States and the Categorically Needy in section
1902(f) States
a.

Medically Needy
(1) The Medicaid agency considers income in excess
of the MNIL available for payment of medical or
remedial care expenses in budget periods that do
not exceed 6 months. The agency measures
available income as specified below:
The agency uses one budget period of ____
month(s) during which countable income for
the period is reduced by the amount of
incurred medical or remedial care expenses in
determining income eligibility for the period.
The agency uses more than one budget period
during which countable income for each
period is reduced by the amount of incurred
medical or remedial care expenses in
determining income eligibility for the period.
The agency uses the budget periods specified
below in the circumstances described.
Length of
Budget Period:

TN No:
Supersedes TN No.

Approval Date

Circumstance:

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14a
State:

Citation

Condition or Requirement
a.

Medically Needy (Continued)

1902(a)(17) of the Act

(2) The agency does not deduct incurred expenses
Subject to payment by a third party unless the third
party is a public program (other than Medicaid) of
a State or Territory and the program is financed by
the State or Territory.

42 CFR 435.831

(3) The agency projects or does not project
institutional expenses (other than expenses in acute
care facilities) to the end of the budget period at
the Medicaid reimbursement rate as checked
below:
the agency does not project institutional
expenses.
the agency does project institutional expenses.

42 CFR 435.831
42 CFR 435.121

(4) Subject to the carryover expenses described in
(5) below, the agency deducts incurred expenses,
based on the age of the expenses as specified
below, but only to the extent that the amount has
not been deducted previously and there is a current
liability for the amount. States must deduct current
payments on old bills not previously deducted in
any budget period.
The agency deducts the expenses regardless of
when incurred. (This is the only option
available to section 1902(f) States.)
The agency deducts expenses incurred prior to
the third month before the month of
application, but incurred no earlier
than:_________________

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14b
State:

Citation

Condition or Requirement
a.

Medically Needy (Continued)
The agency deducts expenses incurred no
earlier than the third month before the month
of application.
(5) The agency carries over unused deductible
expenses for which liability continues, to be
deducted from future excess income, to the extent
indicated below (check one):
Up to the first budget period in which there is
either no spenddown liability or no eligibility.
Beyond the first budget period in which there
is either no spenddown liability or no
eligibility, but not later than: _____________
Indefinitely.

(6) The agency deducts incurred medical or remedial care
expenses in the following order (check one):
By the type of service, in the following order:

TN No:
Supersedes TN No.

Approval Date

1.

Premiums, deductibles, coinsurance, and
copayments.

2.

Expenses for necessary medical or remedial
care services that are recognized under State
law but not included in the State plan.

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14c
State:

Citation

Condition or Requirement
a.

Medically Needy (Continued)
3.

Expenses for necessary medical or remedial
care services that are included in the State
plan, including those that exceed agency
limitations on amount, duration, or scope of
services.

In chronological order by service date.
__

In chronological order by bill submission date.

The State may set reasonable limits on the amount to be
deducted for expenses for:
1. Medicare and other health insurance premiums,
deductibles or coinsurance charges, including
enrollment fees and co-payments, or deductibles
imposed by the Medicaid program;
2. Expenses incurred by the individual; or family or
financially responsible relatives for necessary
medical and remedial services that are recognized
under State law but not included in the State plan;
3. Expenses incurred earlier than the third month
before the month of application as specified in item
4. This option is not available to section 1902(f)
States.
Reasonable limits are described below:

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 14d
State:

Citation

Condition or Requirement
a.

Medically Needy (Continued)

___ (7) If countable income excess the MNIL standard the
agency deducts spenddown payments made to the
State by the individual. Individuals may elect or
reject the pay in option on a:
monthly or
quarterly basis.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 15
State:

Citation
42 CFR 435.121
1902(f) of the Act

Condition or Requirement
b.

Categorically Needy - Section 1902(f) States
The agency applies the following policy under the
provisions of section 1902(f) of the Act. The following
amounts are deducted from income to determine the
individual’s countable income.
(1) Any SSI payments received.
(2) Any State Supplement payments received that are
within the scope of an agreement described in
section 1616 and section 1634 of the Act, or a
State supplement payment within the scope of
section 1902(a)(10)(A)(ii)(XI) of the Act.
(3) Increases in OASDI that are deducted under
435.134, 435.135, 435.137, 435.138, and section
1634(c) of the Act for individuals specified in such
sections, in the manner elected by the State under
such sections.
(4) Other deductions from income described in this
plan in Supplement 4 to ATTACHMENT 2.6A.
(5) Incurred expenses for necessary or remedial care
services as recognized under State law.

1902(a)(17) of the Act
P. L. 100-203

TN No:
Supersedes TN No.

The agency does not deduct incurred expenses
subject to payment by a third party, unless the third
party is a publicly funded program (other than
Medicaid) of a State or local government.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 15a
State:

Citation

Condition or Requirement
b.

1903(f)(2) of the
Act

Categorically Needy - Section 1902(f) States
(6) Spenddown payments made to the State by the
the individual.
Individuals may elect or reject the pay in option on
a:
Monthly; or
Quarterly Basis.
NOTE: FFP will be reduced to the extent a State is
paid a spenddown payment by the
individual.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 16
State:

Citation

Condition or Requirement
5.

Methods for Determining Resources
a.

AFDC-related individuals (except for individuals eligible
under section 1931 of the Act and poverty-level related
pregnant women, infants, and children).
(1) In determining countable resources for AFDC-related
individuals, the following methods are used:
(a) The methods under the State’s approved AFDC
plan in effect on July 16, 1996; or
(b) The method under the State's approved AFDC plan
in effect on July 16, 1996 and/or any more liberal
methods described in Supplement 8b to
ATTACHMENT 2.6-A.
Note:

42 CFR 435.602 and
1902(a)(17)(D) of the
Act

TN No:
Supersedes TN No.

For individuals eligible under section 1931 of the
Act, see Supplement 12 to ATTACHMENT 2.6-A.
For poverty-level related pregnant women, infants,
and children, see e - g of this section.

(2) In determining relative financial responsibility, the
agency considers only the resources of spouses living in
the same household as available to spouses and the
resources of parents as available to children living with
parents until the children become 21.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 17
State:

Citation
1902(a)(10)(A),
1902(a)(10)(C),
1902(f), 1902(m)(1)(B)
and 1902(r) of the Act

Condition or Requirement
b.

Aged Individuals. For aged individuals, including those
covered under section 1902(m)(1) of the Act, the agency
uses the following methods for treatment of resources:
The methods of the SSI program.
SSI methods and/or any more liberal methods described
in Supplement 8b to ATTACHMENT 2.6-A.
Methods that are more restrictive (except for individuals
described in section 1902(m)(1) of the Act) than those of
the SSI program. Supplement 5 to ATTACHMENT
2.6-A describes the more restrictive methods.

42 CFR 435.602 and
1902(a)(17)(D) of
the Act

1902(a)(10)(A),
1902(a)(10)(C),
1902(f), and
1902(r) of the Act

In determining relative financial responsibility, the agency
considers only the resources of spouses living in the same
household as available to spouses and the resources of
parents as available to children living with parents until the
children become 21.
c.

Blind individuals. For blind individuals the agency uses the
following methods for treatment of resources:
The methods of the SSI program.
SSI methods and/or any more liberal methods described
in Supplement 8b to ATTACHMENT 2.6-A.
Methods that are more restrictive than those of the SSI
program. Supplement 5 to ATTACHMENT 2.6-A
describes the more restrictive methods.

42 CFR 435.602 and
1902(a)(17)(D) of the
Act

TN No:
Supersedes TN No.

In determining relative financial responsibility, the agency
considers only the resources of spouses living in the same
household as available to spouses and the resources of
parents as available to children living with parents until the
children become 21.
Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 18
State:

Citation
1902(a)(10)(A),
1902(a)(10)(C),
1902(m)(1)(B),
1902(f) and 1902(r)(2)
of the Act

Condition or Requirement
d.

Disabled individuals, including individuals covered under
section 1902(m)(1) of the Act. The agency uses the
following methods for the treatment of resources:
The methods of the SSI program.
SSI methods and/or any more liberal methods described
in Supplement 8a to ATTACHMENT 2.6-A.
Methods that are more restrictive (except for
individuals described in section 1902(m)(1) of the Act)
than those under the SSI program. More restrictive
methods are described in Supplement 5 to
ATTACHMENT 2.6-A.

42 CFR 435.602 and
1902(a)(17)(D) of the
Act

1902(1)(3)
and 1902(r)(2)
of the Act

In determining relative financial responsibility, the agency
considers only the resources of spouses living in the same
household as available to spouses and the resources of
parents as available to children living with parents until the
children become 21.
e.

Poverty level pregnant women covered under sections
1902(a)(10)(A)(i)(IV) and 1902(a)(10)(A)(ii)(IX) of the
Act.
The agency uses the following methods in the treatment of
resources.
The methods of the SSI program only.
The methods of the SSI program and/or any more
liberal methods described in Supplement 5a to
ATTACHMENT 2.6-A or Supplement 8b to
ATTACHMENT 2.6-A.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 19
State:

Citation

Condition or Requirement
Not applicable. The agency does not consider
resources in determining eligibility.

42 CFR 435.602 and
1902(a)(17)(D) of the
Act

1902(l)(3) and
1902(r)(2) of
the Act

In determining relative financial responsibility, the agency
considers only the resources of spouses living in the same
household as available to spouses and the resources of
parents as available to children living with parents until the
children become 21.
f.

Poverty Level Infants Covered Under Section
1902(a)(10)(A)(i)(IV) of the Act.
The agency uses the following methods for the treatment of
resources:

1902(l)(3) and 1902
(r)(2) of the Act

The methods of the State's approved AFDC plan in
effect on July 16, 1996.

1902(l)(3) and 1902
(r)(2) of the Act

Methods more liberal than those in the State’s approved
AFDC plan (but not more restrictive), as described in
Supplement 8b to ATTACHMENT 2.6-A.
Not applicable. The agency does not consider
resources in determining eligibility.

42 CFR 435.602 and
1902(a)(17)(D) of the
Act

TN No:
Supersedes TN No.

In determining relative financial responsibility, the agency
considers only the resources of spouses living in the same
household as available to spouses and the resources of
parents as available to children living with parents until the
children become 21.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 19a
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s)
1902(1)(3) and
1902(r)(2) of
the Act

Condition or Requirement
g.

1.

Poverty Level Children Covered Under Section
1902(a)(10)(A)(i)(VI) of the Act.
The agency uses the following methods for the
treatment of resources:
The methods of the State's approved AFDC plan in
effect on July 16, 1996.

1902(l)(3) and
1902(r)(2)of
the Act

Methods more liberal than those in the State’s
approved AFDC plan (but not more restrictive), as
described in Supplement 8b to ATTACHMENT
2.6-A.
Not applicable. The agency does not consider
resources in determining eligibility.

42 CFR 435.602 and
1902(a)(17)(D) of
the Act

TN No:
Supersedes TN No.

In determining relative financial responsibility, the
agency considers only the resources of spouses living in
the same household as available to spouses and the
resources of parents as available to children living with
parents until the children become 21.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 19b
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s)
1902(1)(3) and
1902(r)(2) of
the Act

Condition or Requirement
.

2.

Poverty level children covered under section
1902(a)(10)(A)(i)(VII)
The agency uses the following methods for the
treatment of resources:
The methods of the State's approved AFDC plan in
effect on July 16, 1996.

1902(1)(3) and
1902(r)(2) of
the Act

Methods more liberal than those in the State’s
approved AFDC plan (but not more restrictive), as
described in Supplement 8a to ATTACHMENT
2.6-A.
Not applicable. The agency does not consider
resources in determining eligibility.

42 CFR 435.602 and
1902(a)(17)(D) of
the Act

TN No:
Supersedes TN No.

In determining relative financial responsibility, the
agency considers only the resources of spouses living in
the same household as available to spouses and the
resources of parents as available to children living with
parents until the children become 21.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 20
State:

Citation
1902(a)(10)(E)(i),
1905(p)(1)(C) and
(D) and 1902(r)(2)
of the Act

Condition or Requirement
h.

For Qualified Medicare Beneficiaries covered under section
1902(a)(10)(E)(i) of the Act the agency uses the following
methods for treatment of resources:
The methods of the SSI program only.
The methods of the SSI program and/or more liberal
methods as described in Supplement 8b to
ATTACHMENT 2.6-A.

1902(a)(10)(E)(ii) and
1905(s) of the Act

i.

For Qualified Disabled and Working Individuals covered
under section 1902(a)(10)(E)(ii) of the Act, the agency uses
SSI program methods for the treatment of resources.

1902(u) of the Act

j.

For COBRA continuation beneficiaries, the agency uses the
following methods for treatment of resources:
The methods of the SSI program only.
More restrictive methods applied under section 1902(f)
of the Act as described in Supplement 5 to Attachment
2.6-A.

1902(a)(10)(E)(iii)
of the Act

k.

Specified Low-Income Medicare Beneficiaries covered
under section 1902(a)(10)(E)(iii) of the Act
The methods of the SSI program only.
The methods used under the SSI program and/or more
liberal methods as described in Supplement 8b to
ATTACHMENT 2.6-A. If more liberal methods are
used, the same methods are applied as in h. for QMBs.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 20a
State:

Citation
1902(a)(10)(E)(iv)
of the Act

Condition or Requirement
l.

For Qualifying Individuals covered under section
1902(a)(10)(E)(iv) of the Act the agency uses the following
methods for treatment of resources:
The methods of the SSI program only.
The methods used under the SSI program and/or more
liberal methods as described in Supplement 8b to
ATTACHMENT 2.6-A. If more liberal methods are
used, the same methods are applied as in h. for QMBs.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 20b
State:

Citation

Condition or Requirement
6.

Resource Standard - Categorically Needy
a. 1902(f) States (except as specified under items 6.c. and d.
below) for aged, blind and disabled individuals:
Same as SSI resource standards.
More restrictive.
b. Non-1902(f) States (except as specified under items 6.c. and
d. below):
The resource standards are the same as those in the related
cash assistance program.
Supplement 8 to ATTACHMENT 2.6-A specifies for 1902(f)
States the categorically needy resource levels for all covered
categorically needy groups.

1902(l)(3) of
the Act

c.

For pregnant women and infants covered as optional groups
under the provisions of section 1902(a)(10)(A)(i)(IV) or
1902(a)(10(ii)(IX) of the Act, the agency applies a resource
standard.
Yes. Supplement 2 to ATTACHMENT 2.6-A specifies
the standard, which, for pregnant women, is no more
restrictive than the standard under the SSI program and
for infants, is no more restrictive than the standard
applied in the State’s approved AFDC plan in effect on
July 16, 1996.
No. The agency does not apply a resource standard to
these individuals.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 20c
State:

Citation
1902(l)(3) of
the Act

Condition or Requirement
d.

For children covered as optional groups under the provisions
of sections 1902(a)(10)(A)(i)(VI), 1902(a)(10)(A)(ii)(IX),
and 1902(l)(4) of the Act, the agency applies a resource
standard:
Yes. Supplement 2 to ATTACHMENT 2.6-A specifies
the standard, which, is no more restrictive than the
standard applied in the State’s approved AFDC plan in
effect on July 16, 1996.
No. The agency does not apply a resource standard to
these individuals.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 21
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation(s)
1902(l)(3) of
the Act

Condition or Requirement
e.

For children covered under the provisions of section
of section 1902(a)(10)(A)(i)(VII) of the Act, the agency
applies a resource standard.
Yes. Supplement 2 to ATTACHMENT 2.6-A specifies
the standard which is no more restrictive than the
standard applied in the State's approved AFDC plan in
effect on July 16, 1996.
No. The agency does not apply a resource standard to
these individuals.

1902(m)(1)(C) and
1902(m)(2)(B) of
the Act

f.

For aged and disabled individuals described in section
1902(m)(1) of the Act who are covered under section
1902(a)(10)(A)(ii)(X) of the Act, the resource standard is:
Same as SSI resource standards.
Same as the medically needy resource standards, which
are higher than the SSI resource standards (if the State
covers the medically needy).
Supplement 2 to ATTACHMENT 2.6-A specifies the
resource levels for these individuals.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 22
State:

Citation

Condition or Requirement
7.

1902(a)(10)(C)(i)
of the Act

Resource Standard - Medically Needy
a.

Resource standards are based on family size.

b.

A single standard is employed in determining resource
resource eligibility for all groups.

c.

In 1902(f) States, the resource standards are more
restrictive than in 7.b. above for-Aged
Blind
Disabled
Supplement 2 to ATTACHMENT 2.6-A specifies the
resource standards for all covered medically needy
groups. If the agency chooses more restrictive levels
under 7.c., Supplement 2 to ATTACHMENT 2.6-A so
indicates.

1902(a)(10)(E),
1905(p)(1)(D) and
1905(p)(2)(B)
of the Act

8.

Resource Standard - Qualified Medicare Beneficiaries,
Specified Low-Income Medicare Beneficiaries and
Qualifying Individuals
For Qualified Medicare Beneficiaries covered under section
1902(a)(10)(E)(i) of the Act, Specified Low-Income
Medicare Beneficiaries covered under section
1902(a)(10)(E)(iii) of the Act, and Qualifying Individuals
covered under 1902(a)(10)(E)(iv) of the Act, the resource
standard is twice the SSI standard.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 22a
State:

Citation
1902(a)(10)(E)(ii) and
1905(s) of the Act

Condition or Requirement
9.

Resource Standard - Qualified Disabled and Working
Individuals
For qualified disabled and working individuals covered
under section 1902(a)(10)(E)(ii) of the Act, the resource
standard for an individual or a couple (in the case of an
individual with a spouse) is twice the SSI resource standard.

1902(u) of the Act

10. For COBRA continuation beneficiaries, the resource
standard is:
Twice the SSI resource standard for an individual.
More restrictive standard as applied under section
1902(f) of the Act as described in Supplement 8 to
Attachment 2.6-A.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 23
State:

Citation

Condition or Requirement
11.

Excess Resources
a.

Categorically Needy, Qualified Beneficiaries, Qualified
Disabled and Working Individuals, Specified Low-Income
Medicare Beneficiaries and Qualifying Individuals
Any excess resources make the individual ineligible.

b.

Categorically Needy Only
This State has a section 1634 agreement with SSI.
Receipt of SSI is provided for individuals while
disposing of excess resources.

c.

Medically Needy
Any excess resources make the individual ineligible.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 24
State:

Citation
42 CFR 435.914

Condition or Requirement
12. Effective Date of Eligibility
a.

Groups Other Than Qualified Medicare Beneficiaries
(1) For the prospective period.
Coverage is available for the full month if the following
individuals are eligible at any time during the month.
Aged, Blind, Disabled.
AFDC-Related
Coverage is available only for the period during the
month for which the following individuals meet the
eligibility requirements
Aged, Blind, Disabled.
AFDC-Related
(2) For the retroactive period.
Coverage is available for up to three months before the
date of application if the following individuals would
have been eligible had they applied:
Aged, Blind, Disabled.
AFDC-Related
Coverage is available beginning the first day of the
third month before the date of application if the
following individuals would have been eligible at any
time during that month, had they applied.
Aged, Blind, Disabled.
AFDC-Related

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 25
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
ELIGIBILITY CONDITIONS AND REQUIREMENTS

Citation

Condition or Requirement

1920(b)(1) of the Act

(3) For a presumptive eligibility for pregnant women only.
Coverage is available for ambulatory prenatal care for
the period that begins on the day a qualified provider
determines that a woman meets any of the income
eligibility levels specified in ATTACHMENT 2.6-A of
this approved plan. If the woman files an application
for Medicaid by the last day of the month following the
month in which the qualified provider made the
determination of presumptive eligibility, the period
ends on the day that the State agency makes the
determination of eligibility based on that application. If
the woman does not file an application for Medicaid by
the last day of the month following the month in which
the qualified provider made the determination, the
period ends on that last day.

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

b.

For Qualified Medicare Beneficiaries defined in section
1905(p)(1) of the Act coverage is available beginning with
the first day of the month after the month in which the
individual is first determined to be a qualified Medicare
beneficiary under section 1905(p)(1). The eligibility
determination is valid for-12 months
6 months
months (no less than 6 months and no more than 12
months)

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 26
State:

Citation
1902(a)(18) and
1917(c) of the Act

Condition or Requirement
13. Transfer of Assets - All Eligibility Groups
The agency complies with the provisions of section 1917(c) of
the Act, with regard to the transfer of assets.
Disposal of assets at less than fair market value affects eligibility
for certain services as detailed in Supplement 9b to
ATTACHMENT 2.6-A, except in instances where the agency
determines that the transfer rules would work an undue hardship.

1902(a)(18) and
1917(d) of the Act

14. Treatment of Trusts - All Eligibility Groups
The agency complies with the provisions of section 1917(d) of
the Act, with regard to trusts.
The agency uses more restrictive methodologies under
section 1902(f) of the Act, and applies those methodologies
in dealing with trusts;
The agency meets the requirements in section 1917(d)(4)(B)
of the Act for use of Miller trusts.
The agency does not count the funds in a trust in any instance
where the agency determines that counting the funds would work
an undue hardship, as described in Supplement 10 to
ATTACHMENT 2.6-A.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:

ATTACHMENT 2.6-A
Page 26a
State:

Citation
1924 of the Act

Condition or Requirement
15. The agency complies with the provisions of section 1924 with
respect to income and resource eligibility and posteligibility
determinations for individuals who are expected to be
institutionalized for at least 30 consecutive days and who have a
spouse living in the community.
When applying the formula used to determine the amount of
resources in initial eligibility determinations, the State standard
for community spouses is:
the maximum standard permitted by law;
the minimum standard permitted by law; or
an amount between the minimum and the maximum –
$
.

TN No:
Supersedes TN No.

Approval Date

Effective Date

Revision:
SUPPLEMENT 1
TO ATTACHMENT 2.6-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
INCOME ELIGIBILITY LEVELS
A.

MANDATORY CATEGORICALLY NEEDY
1.

AFDC Standards Under the AFDC Plan in Effect on July 16, 1996:

Family Size

2.

Need Standard

Payment Standard

Maximum Payment
Amounts

Pregnant Women and Infants under Section 1902(a)(10)(i)(IV) of the Act:
Effective _______ based on the following percent of the official Federal Poverty
Level –
133 Percent; or
Percent (No less than 133 percent and no more than 185
percent)
Family Size

TN No.
Supersedes TN No.

Approval Date

Income Level

Effective Date

Revision:
SUPPLEMENT 1 TO
ATTACHMENT 2.6-A
Page 2
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
INCOME ELIGIBILITY LEVELS
(Continued)

A.

MANDATORY CATEGORICALLY NEEDY (Continued)
3.

For children under Section 1902(a)(10)(i)(VI) of the Act (children who have
attained age 1 but have not attained age 6), the income eligibility level is 133
percent of the Federal Poverty Level (as revised annually in the Federal Register)
for the family size involved.

4.

For children under Section 1902(a)(10)(i)(VII) of the Act (children who have
attained age 6 but have not attained age 19), the income eligibility level is 100
percent of the Federal Poverty Level (as revised annually in the Federal Register)
for the family size involved.

TN No.

Approval Date

Effective Date

Supersedes TN No.

Revision:
SUPPLEMENT 1 TO
ATTACHMENT 2.6-A
Page 3
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
INCOME ELIGIBILITY LEVELS
(Continued)

B.

OPTIONAL CATEGORICALLY NEEDY GROUPS WITH INCOMES RELATED TO
FEDERAL POVERTY LEVEL
1.

Pregnant Women and Infants
The levels for determining income eligibility for optional groups of pregnant
women and infants under the provisions of sections 1902(a)(10)(A)(ii)(IX) and
1902(1)(2) of the Act are as follows:
Effective
, based on
percent of the official Federal Income
Poverty Level (no less than 133 percent and no more than 185 percent, and
exceeding the income standard for mandatory categorically needy pregnant
women and infants):
Family size
1
2
3
4
5

TN No.

Income Level
$
$
$
$
$

Approval Date

Effective Date

Supersedes TN No.

Revision:

SUPPLEMENT 1 TO
ATTACHMENT 2.6-A
Page 4
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
INCOME ELIGIBILITY LEVELS
(Continued)

B.

OPTIONAL CATEGORICALLY NEEDY GROUPS WITH INCOMES RELATED TO
FEDERAL POVERTY LEVEL
2.

Children Between Ages 6 and 19
The levels for determining income eligibility for groups of children who are born
after
and who have attained six years of age but are under 19 years of
age under the provisions of section 1902(l)(2) of the Act are as follows:

Based on
poverty line.

percent (no more than 100 percent) of the official Federal income

Family size
1
2
3
4
5
6
7
8
9
10

TN No.
Supersedes TN No.

Approval Date

Income Level
$
$
$
$
$
$
$
$
$
$

Effective Date

Revision:

SUPPLEMENT 1 TO
ATTACHMENT 2.6-A
Page 5
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
INCOME ELIGIBILITY LEVELS
(Continued)

3.

Aged and Disabled Individuals Eligible Under Section 1902(m)(1)
The levels for determining income eligibility for groups of aged and disabled
individuals under the provisions of section 1902(m)(1) of the Act are as follows:
Based on

percent of the official Federal income poverty line.

Family Size
1
2
3
4
5

4.

Income Level
$
$
$
$
$

Special Income Level for Institutionalized Individuals

TN No.
Supersedes TN No.

Approval Date

Effective Date

Revision:

SUPPLEMENT 1 TO
ATTACHMENT 2.6-A
Page 5a
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
INCOME ELIGIBILITY LEVELS
(Continued)

5.

Optional Group of Children under Section 1902(l)(1)(D) of the Act.
Same as resource levels in the State’s approved AFDC plan.
Less restrictive than the AFDC levels and are as follows:

Family Size
1
2
3
4
5
6
7
8
9
10

TN No.
Supersedes TN No.

Resource Level
$
$
$
$
$
$
$
$
$
$

Approval Date

Effective Date

Revision:

SUPPLEMENT 1 TO
ATTACHMENT 2.6-A
Page 6
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
INCOME ELIGIBILITY LEVELS
Continued)

C.

QUALIFIED MEDICARE BENEFICIARIES WITH INCOMES RELATED TO
FEDERAL POVERTY LEVEL
The levels for determining income eligibility for groups of Qualified Medicare
Beneficiaries under the provision of Section 1905(p)(2)(A) and 1905(p)(4) of the Act are
as follows:
Levels:
Family Size

TN No.
Supersedes TN No.

Approval Date

Income Level

Effective Date

Revision:

SUPPLEMENT 1 TO
ATTACHMENT 2.6-A
Page 7
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
INCOME LEVELS
(continued)

F.

MEDICALLY NEEDY
Applicable to all groups.

(1)
Family
Size

Applicable to all groups except those
specified below. Excepted group
income levels are also listed on an
attached page
.

(2)
Net income level
protected for
maintenance for
months

(3)
Net income level
for persons
living in rural
areas for

1
2
3
4
5
6
7
8
9
10

$
$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$
$

For each additional
person, add:

$

$

months

Urban Only
Urban and Rural

TN No.
Supersedes TN No.

Approval Date

Effective Date

Revision:
SUPPLEMENT 2 TO
ATTACHMENT 2.6-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
RESOURCE LEVELS

A.

CATEGORICALLY NEEDY GROUPS
1.

Pregnant Women
a.

Mandatory Groups of Pregnant Women under Section
1902(a)(10)(A)(i)(IV) of the Act
Same as SSI resource levels.
No resource test.
Less restrictive than SSI resource levels and is as follows:
Family Size

Resource Level

1
2
b.

Optional Group of Pregnant Women under Section 1902(a)(10)(A)(ii)(IX)
of the Act
Same as SSI resource levels.
No resource test.
Less restrictive than SSI resource levels and is as follows:
Family Size

Resource Level

1
2
TN No.

Approval Date

Effective Date

Supersedes TN No.

Revision:

SUPPLEMENT 2 TO
ATTACHMENT 2.6-A
Page 2
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
RESOURCE LEVELS
(Continued)

2.

Infants
a.
Mandatory Group of Infants under Section 1902(a)(10)(A)(i)(IV)
of the Act
Same as resource levels in the State's approved AFDC plan.
No resource test.
Less restrictive than the AFDC levels and are as follows:
Family Size

Resource Level

1
2
3
4
5
6
7
8
9
10

TN No.
Supersedes TN No.

Approval Date

Effective Date

Revision:
SUPPLEMENT 2 TO
ATTACHMENT 2.6-A
Page 3
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
RESOURCE LEVELS
(Continued)

b.

Optional Group of Infants under Section 1902(a)(10)(A)(ii)(IX) of the Act
Same as resource levels in the State's approved AFDC plan.
No resource test.
Less restrictive than the AFDC levels and are as follows:
Family Size

Resource Level

1
2
3
4
5
6
7
8
9
10

TN No.

Approval Date

Effective Date

Supersedes TN No.

Revision:
SUPPLEMENT 2 TO
ATTACHMENT 2.6-A
Page 4
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
RESOURCE LEVELS
(Continued)

3.

Children
a.

Mandatory Group of Children under Section 1902(a)(10)(i)(VI) of the Act.
(Children who have attained age 1 but have not attained age 6.)
Same as resource levels in the State's approved AFDC plan.
No resource test.
Less restrictive than the AFDC levels and are as follows:
Family Size

Resource Level

1
2
3
4
5
6
7
8
9
10
TN No.

Approval Date

Effective Date

Supersedes TN No.

Revision:

SUPPLEMENT 2 TO
ATTACHMENT 2.6-A
Page 5
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
RESOURCE LEVELS
(Continued)

b.

Mandatory Group of Children under Section 1902(a)(10)(i)(VII) of the
Act. (Children who have attained age 6 but have not attained age 19.)
Same as resource levels in the State's approved AFDC plan.
No resource test.
Less restrictive than the AFDC levels and are as follows:
Family Size

Resource Level

1
2
3
4
5
6
7
8
9
10

TN No.
Supersedes TN No.

Approval Date

Effective Date

Revision:

SUPPLEMENT 2 TO
ATTACHMENT 2.6-A
Page 5a
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
RESOURCE LEVELS
(Continued)

b.

Optional Group of Children under Section 1902(1)(1)(D) of the Act.
Same as resource levels in the State’s approved AFDC plan.
Less restrictive than the AFDC levels and are as follows:
Family Size

Resource Level

1
2
3
4
5
6
7
8
9
10

TN No.
Supersedes TN No.

Approval Date

Effective Date

Revision:
SUPPLEMENT 2 TO
ATTACHMENT 2.6-A
Page 6

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
RESOURCE LEVELS
(Continued)

4.

Aged and Disabled Individuals Eligible Under Section 1902(m)(1)
Same as SSI resource levels.
Same as medically needy resource levels (applicable only if State has a
medically needy program)
Family Size

Resource Level

1
2
3
4
5

TN No.

Approval Date

Effective Date

Supersedes TN No.

Revision:
SUPPLEMENT 2 TO
ATTACHMENT 2.6-A
Page 7
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
RESOURCE LEVELS
(Continued)
B.

MEDICALLY NEEDY
Applicable to all groups –
Except those specified below under the provisions of section 1902(f) of the Act.
Family Size

Resource Level

1
2
3
4
5
6
7
8
9
10
Each additional person

TN No.

Approval Date

Effective Date

Supersedes TN No.

Revision:
SUPPLEMENT 3 TO
ATTACHMENT 2.6-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
REASONABLE LIMITS ON AMOUNTS FOR NECESSARY MEDICAL OR REMEDIAL
CARE NOT COVERED UNDER MEDICAID

TN No.

Approval Date

Effective Date

Supersedes TN No.
Revision:
SUPPLEMENT 4 TO
ATTACHMENT 2.6-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
METHODS FOR TREATMENT OF INCOME THAT DIFFER
FROM THOSE OF THE SSI PROGRAM
(Section 1902(f) more restrictive methods and criteria and State supplement criteria in SSI criteria
States without section 1634 agreements and in section 1902(f) States. Use to reflect more liberal
methods only if you limit to state supplement recipients. DO NOT USE this supplement to reflect
more liberal policies that you elect under the authority of section 1902(r)(2) of the Act. Use
Supplement 8a for section 1902(r)(2) methods.)

TN No.
Supersedes TN No.
Revision:

Approval Date

Effective Date

SUPPLEMENT 5 TO
ATTACHMENT 2.6-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

MORE RESTRICTIVE METHODS OF TREATING RESOURCES
THAN THOSE OF THE SSI PROGRAM
Section 1902(f) States Only

TN No.
Supersedes TN No.
Revision:

Approval Date

Effective Date

SUPPLEMENT 5a
TO ATTACHMENT 2.6-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

METHODS FOR TREATMENT OF RESOURCES
FOR INDIVIDUALS WITH INCOMES RELATED TO FEDERAL POVERTY LEVELS

(Do not complete if you are electing more liberal methods under the authority of section 1902(r)(2)
of the Act instead of the authority specific to Federal poverty levels. Use Supplement 8b for section
1902(r)(2) methods.)

TN No.
Supersedes TN No.
Revision:

Approval Date

Effective Date

SUPPLEMENT 6 TO
ATTACHMENT 2.6-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

FEDERALLY ADMINISTERED OPTIONAL STATE SUPPLEMENT:
PAYMENT GROUPS/INCOME LEVELS
Gross Income
Level

SSI
Standard

State
Benefit Supplementation

TN No.
Supersedes TN No.

Approval Date

Effective Date

Revision:
SUPPLEMENT 6 TO
ATTACHMENT 2.6-A
Page 2
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

STANDARDS FOR OPTIONAL STATE SUPPLEMENTARY PAYMENTS

Income
Level

Income
Payment Category

Reasonable
Classification

Disregards
Administered by
Employed

Federal

State

Gross

One
Person

Net

Couple

One
Person

Couple

TN No.
Supersedes TN No.
Revision:

Approval Date

Effective Date

SUPPLEMENT 7 TO
ATTACHMENT 2.6-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

INCOME LEVELS FOR 1902(f) STATES
CATEGORICALLY NEEDY WHO ARE COVERED UNDER REQUIREMENTS
MORE RESTRICTIVE THAN SSI

TN No.
Supersedes TN No.
Revision:

Approval Date

Effective Date

SUPPLEMENT 8 TO
ATTACHMENT 2.6-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

RESOURCE STANDARDS FOR 1902(f) STATES CATEGORICALLY NEEDY

TN No.
Supersedes TN No.
Revision:

Approval Date

Effective Date

SUPPLEMENT 8a
TO ATTACHMENT 2.6-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

LESS RESTRICTIVE METHODS OF TREATING INCOME
UNDER SECTION 1902(r)(2) OF THE ACT*

Section 1902(f) State

Non-Section 1902(f) State

*Less restrictive methods may not result in exceeding gross income limitations under section
1903(f).
TN No.
Supersedes TN No.
Revision:

Approval Date

Effective Date

SUPPLEMENT 8b
TO ATTACHMENT 2.6-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

LESS RESTRICTIVE METHODS OF TREATING RESOURCES
UNDER SECTION 1902(r)(2) OF THE ACT

Section 1902(f) State

Non-Section 1902(f) State

TN No.
Supersedes TN No.

Approval Date

Effective Date

Revision:
SUPPLEMENT 8c
TO ATTACHMENT 2.6-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

STATE LONG-TERM CARE INSURANCE PARTNERSHIP
1902(r)(2)
1917(b)(1)(C)

The following more liberal methodology applies to individuals who are
eligible for medical assistance under one of the following eligibility
groups:

An individual who is a beneficiary under a long-term care insurance
policy that meets the requirements of a “qualified State long-term care
insurance partnership” policy (partnership policy) as set forth below, is
given a resource disregard as described in this amendment. The amount of
the disregard is equal to the amount of the insurance benefit payments
made to or on behalf of the individual. The term “long-term care
insurance policy” includes a certificate issued under a group insurance
contract.
___

The State Medicaid Agency (Agency) stipulates that the following
requirements will be satisfied in order for a long-term care policy
to qualify for a disregard. Where appropriate, the Agency relies on
attestations by the State Insurance Commissioner (Commissioner)
or other State official charged with regulation and oversight of
insurance policies sold in the state, regarding information within
the expertise of the State’s Insurance Department.


The policy is a qualified long-term care insurance policy as
defined in section 7702B(b) of the Internal Revenue Code of
1986.



The policy meets the requirements of the long-term care
insurance model regulation and long-term care insurance
model Act promulgated by the National Association of
Insurance Commissioners (as adopted as of October 2000) as
those requirements are set forth in section 1917(b)(5)(A) of the
Social Security Act.

TN No.
Supersedes TN No.

Approval Date

Effective Date

Revision:

SUPPLEMENT 8c TO
ATTACHMENT 2.6-A
Page 2
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

TN No.
Supersedes TN No.
Revision:



The policy was issued no earlier than the effective date of this
State plan amendment.



The insured individual was a resident of a Partnership State
when coverage first became effective under the policy. If the
policy is later exchanged for a different long-term care policy,
the individual was a resident of a Partnership State when
coverage under the earliest policy became effective.



The policy meets the inflation protection requirements set forth
in section 1917(b)(1)(C)(iii)(IV) of the Social Security Act.



The Commissioner requires the issuer of the policy to make
regular reports to the Secretary that include notification
regarding when benefits provided under the policy have been
paid and the amount of such benefits paid, notification
regarding when the policy otherwise terminates, and such other
information as the Secretary determines may be appropriate to
the administration of such partnerships.



The State does not impose any requirement affecting the terms
or benefits of a partnership policy that the state does not also
impose on non-partnership policies.



The State Insurance Department assures that any individual
who sells a partnership policy receives training, and
demonstrates evidence of an understanding of such policies and
how they relate to other public and private coverage of longterm care.



The Agency provides information and technical assistance to
the Insurance Department regarding the training described
above.

Approval Date

Effective Date
SUPPLEMENT 8c TO

ATTACHMENT 2.6-A
Page 3
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

The State elects to be exempt from the standards for reciprocal recognition among
partnership States under section 6021(b) of the DRA.

TN No.
Supersedes TN No.

Approval Date

Effective Date

Revision:

SUPPLEMENT 9b TO ATTACHMENT 2.6-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
TRANSFER OF ASSETS

1917(c)

FOR TRANSFERS OF ASSETS FOR LESS THAN FAIR MARKET VALUE
MADE ON OR AFTER FEBRUARY 8, 2006, the agency provides for the denial
of certain Medicaid services.
1.

Institutionalized individuals are denied coverage of certain Medicaid
services upon disposing of assets for less than fair market value on or after
the look-back date.
The agency does not provide medical assistance coverage for
institutionalized individuals for the following services:
 Nursing facility services;
 Nursing facility level of care provided in a medical institution;
 Home and community-based services under a 1915(c) waiver.

2.

Non-Institutionalized Individuals
The agency withholds payment to non-institutionalized individuals for the
following services:
 Home health services (section 1905(a)(7));
 Home and community care for functionally disabled and elderly adults
(section 1905(a)(22));
 Personal care services furnished to individuals who are not inpatients
in certain medical institutions, as recognized under agency law and
specified in section 1905(a)(24).
The agency applies these provisions to the following noninstitutionalized eligibility groups. These groups can be no more
restrictive than those set forth in section 1905(a) of the Social
Security Act:

TN No.
Supersedes TN No.

Approval Date

Effective Date

Revision:
SUPPLEMENT 9b
TO ATTACHMENT 2.6-A
Page 2
State:
TRANSFER OF ASSETS
2.

Non-institutionalized individuals (Continued)
The following other long-term care services for which medical assistance
is otherwise under the agency plan:

3.

Penalty Date --The beginning date of each penalty period imposed for an
uncompensated transfer of assets is the later of:


the first day of the month during or after which assets have been
transferred for less than fair market value;
The State uses the first day of the month in which the assets were
transferred
The State uses the first day of the month after the month in which
the assets were transferred

OR


the date on which the individual is eligible for medical assistance under
the State Plan and is receiving institutional level of care services as
described in paragraphs 1 and 2 that, were it not for the imposition of the
penalty period, would be covered by Medicaid;
AND
which does not occur during any other period of ineligibility for services
by reason of a transfer of assets penalty.

TN No.

Approval Date

Effective Date

Supersedes TN No.

Revision:
SUPPLEMENT 9b
TO ATTACHMENT 2.6-A
Page 3
State:
TRANSFER OF ASSETS
4.

Penalty Period I - Institutionalized Individuals -In determining the penalty for an institutionalized individual, the agency uses:
the average monthly cost to a private patient of nursing facility services in
the State at the time of application;
The amount the State uses is _________.
the average monthly cost to a private patient of nursing facility services in
the community in which the individual is institutionalized at the time of
application. The amounts the State uses in communities are as follows:

5.

Penalty Period - Non-institutionalized Individuals –
The agency imposes a penalty period determined by using the same method as is
used for an institutionalized individual, including the use of the average monthly
cost of nursing facility services;
imposes a shorter penalty period than would be imposed for
institutionalized individuals, as outlined below:

6.

Penalty period for amounts of transfer less than cost of nursing facility care –
Where the amount of the transfer is less than the monthly cost of nursing facility
care, the agency imposes a penalty for less than a full month, based on the option
selected in item 4.
The State adds together all transfers for less than fair market value made
during the look-back period in more than one month and calculates a
single period of ineligibility, that begins on the earliest date that would
otherwise apply if the transfer had been made in a single lump sum.

TN No.

Approval Date

Effective Date

Supersedes TN No.

Revision:
SUPPLEMENT 9b
TO ATTACHMENT 2.6-A
Page 4
State:
TRANSFER OF ASSETS
7.

8.

Transfer Periods – transfer by a spouse that results in a penalty period for the
individual -(a)

The agency apportions any existing penalty period between the spouses
using the method outlined below, provided the spouse is eligible for
Medicaid. A penalty can be assessed against the spouse, and some portion
of the penalty against the individual remains.

(b)

If one spouse is no longer subject to a penalty, the remaining penalty
period must be served by the remaining spouse.

Treatment of a transfer of income -When income has been transferred as a lump sum, the agency will calculate the
penalty period on the lump sum value.
When a stream of income or the right to a stream of income has been transferred,
the agency will impose a penalty period for each income payment.
For transfers of individual income payments, the agency will impose
partial month penalty periods using the methodology selected in 6. above.
For transfers of the right to an income stream, the agency will base the
penalty period on the combined actuarial value of all payments
transferred.

TN No.
Supersedes TN No.

Approval Date

Effective Date

Revision:
SUPPLEMENT 9b
TO ATTACHMENT 2.6-A
Page 5
State:
TRANSFER OF ASSETS
9.

Imposition of a penalty would work an undue hardship-The agency does not impose a penalty for transferring assets for less than fair
market value in any case in which the agency determines that such imposition
would work an undue hardship. The agency will use the following criteria in
making undue hardship determinations:
Application of a transfer of assets penalty would deprive the individual:

10.

(a)

Of medical care such that the individual’s health or life would be
endangered; or

(b)

Of food, clothing, shelter, or other necessities of life.

Procedures for Undue Hardship Waivers
The agency has established a process under which hardship waivers may be
requested that provides for:
(a)

Notice to a recipient subject to a penalty that an undue hardship exception
exists;

(b)

A timely process for determining whether an undue hardship waiver will
be granted; and

(c)

A process, which is described in the notice, under which an adverse
determination can be appealed.

These procedures shall permit the facility in which the institutionalized individual
is residing to file an undue hardship waiver application on behalf of the individual
with the consent of the individual or the individual’s personal representative.

TN No.

Approval Date

Effective Date

Supersedes TN No.

Revision:
SUPPLEMENT 9b
TO ATTACHMENT 2.6-A
Page 6
State:
TRANSFER OF ASSETS
11.

Bed Hold Waivers for Hardship Applicants -The agency provides that while an application for an undue hardship waiver is
pending in the case of an individual who is a resident of a nursing facility:
Payments to the nursing facility to hold the bed for the individual will be
made for a period not to exceed
days (may not be greater than 30).

TN No.

Approval Date

Effective Date

Supersedes TN No.
Revision:
SUPPLEMENT 10
TO ATTACHMENT 2.6-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

The agency does not apply the trust provisions in any case in which the agency determines that
such application would work an undue hardship.

Under the agency’s undue hardship provisions, the agency exempts the funds in an
irrevocable burial trust.
The maximum value of the exemption for an irrevocable burial trust is $
The agency’s criteria for establishing due hardship are described below:

.

TN No.
Supersedes TN No.
Revision:

Approval Date

Effective Date

SUPPLEMENT 11
TO ATTACHMENT 2.6-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

COST EFFECTIVENESS METHODOLOGY FOR
COBRA CONTINUATION BENEFICIARIES

1902(u) of the Act

Premium payments are made by the agency only if such payments are
likely to be cost-effective. The agency specifies the guidelines used in
determining cost effectiveness by selecting one of the following methods.
The methodology as described in SMM section 3598.
Another cost-effective methodology as described below:

TN No.
Supersedes TN No.
Revision:

Approval Date

Effective Date
SUPPLEMENT 12 TO
ATTACHMENT 2.6-A
Page 1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

VARIATIONS FROM THE BASIC PERSONAL NEEDS ALLOWANCE

TN No.
Supersedes TN No.

Approval Date

Effective Date

Revision:

SUPPLEMENT 12 TO
ATTACHMENT 2.6-A
Page 2
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

ELIGIBILITY--UNDER SECTION 1931 OF THE ACT
The State covers low-income families and children under section 1931 of the Act.
The following groups were included in the AFDC State Plan effective July 16, 1996:
Pregnant women with no other eligible children.
Children age 18 who are full-time students in a secondary school or the equivalent
level of vocational or technical training.
In determining eligibility for Medicaid, the agency uses the AFDC standards and
methodologies in effect as of July 16, 1996 without modification.
In determining eligibility for Medicaid, the agency uses the AFDC standards and
methodologies in effect as of July 16, 1996 with the following modifications.
The agency applies lower income standards which are no lower than the AFDC
standards in effect on May 1, 1988, as follows:

The agency applies higher income standards than those in effect as of July 16, 1996,
increased by no more than the percentage increases in the CPI-U since July 16,
1996, as follows:

TN No.
Supersedes TN No.

Approval Date

Effective Date

Revision:

SUPPLEMENT 12 TO
ATTACHMENT 2.6-A
Page 3
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
ELIGIBILITY--UNDER SECTION 1931 OF THE ACT
(Continued)

The agency applies higher resource standards than those in effect as of July 16,
1996, increased by no more than the percentage increases in the CPI-U since July
16, 1996, as follows:

The agency uses less restrictive income and/or resource methodologies than those
in effect as of July 16, 1996, as follows:

The income and/or resource methodologies that the less restrictive methodologies
replace are as follows:

TN No.
Supersedes TN No.

Approval Date

Effective Date

Revision:

SUPPLEMENT 12 TO
ATTACHMENT 2.6-A
Page 4
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:
ELIGIBILITY--UNDER SECTION 1931 OF THE ACT
(Continued)

The agency terminates medical assistance (except for certain pregnant women and
children described in section 1902(l) of the Act) for individuals who fail to meet
Temporary Assistance for Needy Families (TANF) work requirements.
The agency defines unemployment for the section 1931 population as follows:

The agency continues to apply the following waivers of provisions of part A of Title IV
of the Act in effect as of July 16, 1996, or submitted prior to August 22, 1996 and
approved by the Secretary on or before July 1, 1997.
Waiver under sections 402(a)(41) and 407 of the Act allows the State to provide
benefits to families in which the principal earner works 100 or more hours per
month.

TN No.
Supersedes TN No.
Revision:

Approval Date

Effective Date

SUPPLEMENT 13
TO ATTACHMENT 2.6-A
Page 1
State:

Citation

Condition or Requirement

Section 1924 Provisions
A.

Income and resource eligibility policies used to determine eligibility for
institutionalized individuals who have spouses living in the community are
consistent with section 1924 of the Act.

B.

The definition of undue hardship for purposes of determining if institutionalized
spouses receive Medicaid in spite of having excess countable resources is
described below:

TN No.
Supersedes TN No.

Approval Date

Effective Date

Revision:
SUPPLEMENT 14
TO ATTACHMENT 2.6-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

INCOME AND RESOURCE REQUIREMENTS FOR
TUBERCULOSIS (TB) INFECTED INDIVIDUALS

For TB infected individuals under section 1902(z)(1) of the act, the income and resource
eligibility levels are as follows:
1.

Income: The SSI breakeven point for earned income.

2.

Resources: The SSI resource standard.

TN No.

Approval Date

Effective Date

Supersedes TN No.
Revision:
SUPPLEMENT 15
TO ATTACHMENT 2.6-A
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State:

1917(f)

The State agency denies reimbursement for nursing facility services and other
long-term care services covered under the State plan for an individual who does
not have a spouse, child under 21 or adult disabled child residing in the
individual’s home, when the individual’s equity interest in the home exceeds the
following amount:
_____ $500,000 (increased by the annual percentage increase in the urban
component of the consumer price index beginning with 2011, rounded to
the nearest $1,000).
_____ An amount that exceeds $500,000 but does not exceed $750,000
(increased by the annual percentage increase in the urban component of
the consumer price index beginning with 2011, rounded to the nearest
$1,000).
The amount chosen by the State is _________________.
_____ This higher standard applies statewide.
_____ This higher standard does not apply statewide. It only applies in
the following areas of the State:

_____ This higher standard applies to all eligibility groups.
_____ This higher standard only applies to the following eligibility
groups:

The State has a process under which this limitation will be waived in cases of
undue hardship.

TN No.
Supersedes TN No.

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