§ 248.10 Coverage and conditions of eli

gibility for medical assistance.

(a) Definitions. When used in this part:

(1) The term "categorically needy" refers to an individual who is receiving financial assistance under the State's approved plan under title I, IV-A, X, XIV, or XVI of the Social Security Act, or is in need under the State's standards for financial eligibility in such plan. (See § 233.20 of this chapter.)

(2) The term "medically needy" refers to an individual whose income and resources equal or exceed the State's standards under the appropriate financial assistance plan but are insufficient to meet his costs for medical insurance premiums and for necessary medical and remedial care and services recognized under State law but not encompassed in the State plan for medical assistance, plus his costs for medical and remedial care and services included in the State plan.

(b) State plan requirements. A State plan under title XIX of the Social Security Act must:

(1) Provide that medical assistance will be available to the following groups of "categorically needy" persons:

(i) All individuals receiving aid or assistance under the State's approved plans under titles I, IV-A, X, XIV, and XVI of the Act; this includes all individuals who (a) are essential persons under the State plan and (b) could be recipients, if the State plan were as broad as permitted for Federal financial participation;

(ii) All individuals under 21 who are, or would be, except for age of school attendance requirements, dependent children under the State's approved AFDC plan;

(iii) All persons who would be eligible for aid or assistance under one of the other approved State plans except for any eligibility condition or other requirement in such plan that is specifically prohibited in a program of medical assistance under title XIX of the Act.

(2) Specify any other groups of "categorically needy" individuals (not covered by subparagraph (1) of this paragraph), that will be included in the program. These may include:

(i) Persons who meet all the conditions of eligibility, including financial eligibility, of one of the State's other ap

proved plans, but have not applied for such assistance.

(li) Persons in a medical facilityskilled nursing home, hospital, institution for tuberculosis, or mental diseasewho, if they left such facility, would be eligible for financial assistance under another of the State's approved plans. This includes persons in medical facilities who have enough income to meet their personal needs while in the institution, but not enough to meet their needs outside the facility according to the appropriate State plan.

(iii) Persons who would be eligible for financial assistance under another State public assistance plan, except that the State plan imposes eligibility conditions more stringent than, or in addition to, those required under the Social Security Act. For example, persons who are needy and 18 years of age or older and permanently and totally disabled under the Federal definition of permanent and total disability, but who are excluded from APTD under the State's more restricted definition of disability; or persons who would be eligible for AFDC if the State's program covered families with children deprived of parental support or care to the full extent permitted under title IV-A of the Act, including AFDC for families with unemployed fathers.

(iv) All individuals under 21 who qualify on the basis of financial eligibility, but do not qualify as dependent children under a State's AFDC plan; or groups of such individuals if based on reasonable classifications. Children in foster homes or private institutions for whom public agencies are assuming financial responsibility, in whole or in part, constitute a reasonable classification. The additional inclusion of children placed in foster homes or private institutions by private, nonprofit agencies would also be considered reasonable.

(v) Caretaker relatives enumerated in section 406 (a) (1) of the Act who have in their care one or more children under 21 who, except for age or school attendance requirements, would be dependent children under the State's AFDC plan.

(vi) Individuals who would be eligible for financial assistance if their work related child care costs were paid out of earnings rather than as a service expenditure by the agency, provided the State plan for financial assistance otherwise recognizes child care costs in determining the amount of the payment.

(3) Specify, if the plan includes the medically needy, that it covers all medically needy groups that correspond to the covered categorically needy groups. Exception: coverage of "essential" spouses of recipients of OAA, AB, APTD, or AABD does not require coverage of essential spouses of nonmoney payment recipients, either categorically needy or medically needy.

(4) Specify all conditions of eligibility that must be met by members of all optional groups included in the plan.

(5) If the plan includes groups of individuals for whose medical care and services Federal financial participation is not available, specify such groups, and provide that the State agency will establish methods for identifying the expenditures for medical care and services in which Federal financial participation may not be claimed.

(c) Conditions for plan approval. (1) All groups the State elects to include in the program are based on reasonable classifications, that is, they do not result in arbitrary or inequitable treatment of individuals or groups, or result in exclusion of groups or persons on the basis of any classification that is arbitrary or unreasonable, or is otherwise inconsistent with the broad objectives of title XIX of the Act.

(2) There is clarity as to what groups are included, and which are within the scope, and which are outside the scope, of Federal financial participation in the cost of medical assistance provided.

(3) Except for need, the conditions of eligibility that are imposed on elective groups (including any groups for whose medical care and services Federal financial participation is not available) are not more stringent or more numerous than those imposed on individuals receiving aid or assistance under any of the approved State plans.

(4) No age, residence, citizenship, or other requirement is imposed that is prohibited by title XIX of the Act.

(5) No person unrelated to the applicant or recipient is held financially responsible for him; nor is any condition of eligibility imposed that holds a relative responsible who is not the spouse of the individual who needs medical care or services, or the parent of such individual, who is under 21, or is blind, or is permanently and totally disabled.

(d) Federal financial participation(1) Administrative costs. Federal finan

cial participation is available in the administrative costs of providing medical care and services to all persons covered under the plan, including those in the cost of whose medical care and services the Federal Government does not share, provided all other provisions of the approved State plan are applicable to them.

(2) Medical assistance. Federal financial participation is available, pursuant to part 250 of this chapter, in payments for medical care and services provided under the State plan to any financially eligible individual who is:

(i) Under the age of 21; or

(ii) A parent or other caretaker relative specified in section 406 (a) (1) of the Act (see § 233.90 (c) (1) (v) (a) of this chapter with whom a child under the age of 21 is living, if such relative is eligible or would, except that the child is not regularly attending school or a course of vocational training, and except for need, be eligible to receive payments within the scope of Federal financial participation under title IV-A of the Act; only one such parent or other caretaker relative, plus the spouse of such parent (who meets the conditions specified in section 406(b) (1) of the Act (see § 237.50 (b) (3) (4) of this chapter)), are within the scope of Federal financial participation under title IV-A of the Act; or

(iii) 65 years of age or older; or
(iv) Blind; or

(v) 18 years of age or older and permanently and totally disabled; or

(vi) The spouse of a recipient of OAA, AB, APTD, or AABD who is considered "an essential person" (see § 248.11 of this part);

but excluding any such care or services provided to any individual who is an inmate of a public institution (except as a patient in a medical institution), or who is under age 65 and a patient in an institution for tuberculosis or mental diseases. See § 248.60.

(3) Federal financial participation is available in medical assistance provided to individuals who were eligible therefor in the month in which the medical care or services were provided.

(4) Federal financial participation is available in medical assistance for individuals, in accordance with the State plan, during a temporary period while the effects of certain eligibility conditions such as blindness, disability, continued

absence or incapacity of a parent, or unemployment of a father, are being

overcome.

[36 F.R. 3870, Feb. 27, 1971]

§ 248.11 Title XIX; optional inclusion of certain "essential persons" under plan approved under title I, X, XIV, or XVI; Federal financial participation.

Effective with respect to payments made on or after January 2, 1968, under a State plan approved under title XIX of the Social Security Act, Federal financial participation is available in the costs of medical care and services provided under such a plan to a spouse of a recipient of financial assistance under another plan of the State approved under title I, X, XIV, or XVI of the Act, who is living with and has been determined, in accordance with such other plan, to be essential to the well-being of such recipient, and whose needs are taken into account in determining the amount of financial assistance provided to such recipient. [34 F.R. 1320, Jan. 28, 1969]

§ 248.21 Financial eligibility-medical assistance programs.

(a) State plan requirements. A State plan under title XIX of the Social Security Act must:

(1) With respect to the categorically needy:

(i) Specify that the financial eligibility conditions of the pertinent financial assistance plan will apply;

(ii) Provide for the application of income first to maintenance costs.

(2) With respect to both the categorically needy and, if they are included in the plan, the medically needy:

(i) Provide that only such income and resources as are actually available will be considered and that income and resources will be reasonably evaluated;

(ii) Provide that financial responsibility of any individual for any applicant or recipient of medical assistance will be limited to the responsibility of spouse for spouse and of parents for children under age 21, or blind, or permanently and totally disabled;

(iii) Specify the extent to which the financial responsibility of any such relatives is taken into account.

(3) With respect to the medically needy, if they are included in the plan:

(i) Provide levels of income and resources for maintenance, in total dollar amounts, as a basis for establishing fi

nancial eligibility for medical assistance. Under this requirement:

(a) Such income levels must be comparable as among individuals and families of varying sizes;

(b) The income levels for maintenance must be, as a minimum, at the levels of the most liberal money payment standard used by the State, at any time on or after January 1, 1966, as a measure of financial eligibility in any categorical money payment program in the State, or at the level for which Federal financial participation is available pursuant to paragraph (b) of this section, whichever is less. Where a State imposes any deduction, cost sharing, enrollment fee, premium, or similar charge under the plan with respect to any medical assistance furnished to an individual thereunder, such charge may not be imposed to the extent that it would reduce the individual's income below the most liberal money payment standard referred to in the preceding sentence;

(c) A lower income level for maintenance must be used for individuals not living in their own homes but receiving care in nursing homes, institutions for tuberculosis or mental diseases or other medical facilities providing long-term care. This lower income level must be reasonable in amount for clothing and personal needs for such individuals. When such an individual's home is maintained for a spouse or other dependents, the appropriate income level for such dependents, plus the individual's income level for maintenance in a long-term care facility, is applicable;

(d) Resources which may be held must, as a minimum, be at the most liberal level used in any money payment program in the State on or after January 1, 1966, and the amount of liquid assets which may be held must increase with an increase in the number of individuals in the family. There must be separate levels established for

resources.

(ii) Provide that there will be a flexible measurement of available income which will be applied in the following order of priority:

(a) First, for maintenance, so that any income in an amount at or below the established level will be protected for maintenance;

(b) Next, income in excess of that needed for maintenance will be applied to costs incurred for medical insurance premiums and for necessary medical or

remedial care recognized under State law and not encompased within the State plan for medical assistance. States may set reasonable limits on such medical services for which excess income may be applied.

(c) All of the remaining excess income will be applied to costs of medical assistance included in the State plan.

(iii) Provide that all income and resources (after all State policies governing the disregard, or setting aside for future needs, of income and resources in the State's approved plans under titles I, IV-A, X, XIV, and XVI have been applied) will be considered in establishing eligibility, and in the flexible application of income to medical costs not in the State plan, and payment toward the medical assistance costs.

(iv) Provide that only such income and resources will be considered as will be "in hand" within a period, preferably of not more than 3 months, but not in excess of 6 months, ahead, including the month in which medical services were rendered, for which payment would be made under the plan.

participation.

(b) Federal financial (1) Federal financial participation is available in payments made in behalf of categorically needy individuals.

(2) Payments in behalf of medically needy individuals are subject to Federal financial participation only to the extent that they are made for a member of a family the annual income of which is within the income levels established in the following:

(i) In the case of any State, the applicable income levels with respect to periods after December 31, 1969 are 1333 percent of the amounts specified in subdivision (ii) of this subparagraph. Any total yearly income levels established by applying the above percentage which are not multiples of $100 shall be rounded to the next higher multiple of $100. Federal financial participation is available for a person whose annual income exceeds this level to the extent that medical expenses exceed the income excess (see subdivision (ii) (c) of this subparagraph).

(ii) The amounts to be applied in calculating the income levels referred to in subdivision (i) of this subparagraph are the highest amounts which would ordinarily be paid to a family of the same size without any income or resources in the form of money payments, under the

approved AFDC plan of the State, subject to the following modifications:

(a) In the case of a single individual the amount of the income level shall be reasonably related to the amounts payable under such plan to families consisting of two or more individuals who are without income or resources.

(b) If the amounts established under such plan are subject to a maximum family limit, the income level for families which exceed such limit will be determined by adding an amount for each member of the family to such limit. The amounts to be added shall be reasonably related to those established under the plan for families which are within the maximum family limit.

(c) In computing a family's or individual's income for purposes of subdivisions (i) and (ii) of this subparagraph, there shall be excluded any costs (whether in the form of insurance premiums or otherwise) incurred by such family or individual for medical care or for any other type of remedial care recognized under State law.

(3) If a State furnishes medical assistance on the basis of income levels which are higher than those specified in this section, the State agency must submit to the Department of Health, Education, and Welfare for its approval income levels which are calculated on the basis provided in this section, and must establish procedures to assure that claims for Federal financial participation are limited accordingly.

[36 F.R. 3871, Feb. 27, 1971]

(a) Conditions for plan approval. A State plan under title XIX of the Social Security Act may not impose:

(1) Any age requirement of more than 65 years;

(2) Any age requirement which excludes any individual who has not attained the age of 21 and is or would, except for the provisions of section 406 (a) (2) of the Act (regarding attendance at school or a training course), be a dependent child under the State's AFDC plan; or

(3) Age requirements more stringent than are imposed in the State's approved plans for financial assistance.

(b) Federal financial participation. (1) Federal financial participation is available in medical assistance provided to otherwise eligible persons who were, for any portion of the month in which

they received medical care or services, under 21 years of age, or 65 years of age or over, or 18 years of age or over and permanently and totally disabled. There is no Federal requirement as to age for blind persons.

(2) Federal determination of whether an individual meets the age requirements of the Social Security Act will be made according to the common-law method (under which a specific age is attained the day before the anniversary of birth), unless the State plan specifies that the popular usage method (under which an age is attained on the anniversary of birth) is used.

(3) The State agency may adopt an arbitrary date such as July 1 as the point from which age will be computed in all instances where the month of an individual's birth is not available, but the year can be established.

[36 F.R. 3872, Feb. 27, 1971] § 248.40

Residence.

(a) State plan requirements. A State plan under title XIX of the Social Security Act must provide that:

(1) Medical assistance will be furnished to eligible individuals who are residents of the State but are absent therefrom to the same extent that such assistance is furnished under the plan to meet the cost of medical care and services rendered to eligible individuals in such State, at least to the extent that medical care and services are needed in any other State (as defined in section 1101(a)(1) of the Social Security Act, as amended, 42 U.S.C. 1301(a)(1)), under any of the following circumstances:

(i) Where an emergency arises from accident or illness;

(ii) Where the health of the individual would be endangered if the care and services are postponed until he returns to the State in which he resides; or

(iii) Where his health would be endangered if he undertook travel to return to such State.

(2) Medical care and services will be provided outside the State to eligible residents of the State, at least in the following situations:

(i) When it is general practice for residents of a particular locality to use medical resources outside the State; or (ii) When the medical care and services available, or the availability of needed supplementary resources, make it desirable for the individual to use medical facilities outside the State for

short or long periods, in accordance with plans developed jointly by the agency and the individual, consistent with medical advice.

(3) The State agency will facilitate the meeting of medical needs within the State for residents from other States.

(b) Condition for plan approval. A State plan under title XIX of the Act may not impose any resident requirement which excludes any individual who is a resident of the State. For purposes of this section:

(1) A resident of a State is one who is living in the State voluntarily with the intention of making his home there and not for a temporary purpose. A child is a resident of the State in which he is living other than on a temporary basis. Residence may not depend upon the reason for which the individual entered the State, except insofar as it may bear upon whether he is there voluntarily or for a "temporary purpose."

(2) Residence is retained until abandoned. Temporary absence from the State, with subsequent returns to the State, or intent to return when the purposes of the absence have been accomplished, does not interrupt continuity of residence.

(Sec. 2, 49 Stat. 620, 74 Stat. 987, sec. 402, 49 Stat. 627, sec. 1002, 49 Stat. 645, sec. 1402, 64 Stat. 555, sec. 1602, 76 Stat. 198, sec. 1902, 79 Stat. 344; 42 U.S.C. 302, 602, 1202, 1352, 1382, 1396a) [35 F.R. 17719, Nov. 18, 1970] § 248.50 Citizenship.

Conditions for plan approval:

(a) A State plan under title XIX of the Social Security Act may not exclude an otherwise eligible citizen of the United States, regardless of how (by birth or by naturalization), or when, citizenship was obtained.

(b) A State plan which includes the medically needy must include all otherwise eligible individuals, regardless of citizenship status, unless all of the State's approved financial assistance plans require citizenship as a condition of eligibility.

(c) A State plan may include persons without regard to citizenship status, even though all of the State's financial assistance plans contain such a requirement. [36 F.R. 3872, Feb. 27, 1971]

§ 248.60 Institutional status.

(a) Federal financial participation. (1) Federal financial participation under title XIX of the Social Security