Application for a §1915 (c) hcbs waiver Submitted by


Appendix B-4: Medicaid Eligibility Groups Served in the Waiver



Download 1.76 Mb.
Page3/23
Date conversion03.05.2018
Size1.76 Mb.
1   2   3   4   5   6   7   8   9   ...   23



Appendix B-4: Medicaid Eligibility Groups Served in the Waiver

a. State Classification. The State is a (select one):


X

§1634 State




SSI Criteria State



209(b) State

b. Medicaid Eligibility Groups Served in the Waiver. Individuals who receive services under this waiver are eligible under the following eligibility groups contained in the State plan. The State applies all applicable federal financial participation limits under the plan. Check all that apply:

Eligibility Groups Served in the Waiver (excluding the special home and community-based waiver group under 42 CFR §435.217)



Low income families with children as provided in §1931 of the Act

X

SSI recipients




Aged, blind or disabled in 209(b) states who are eligible under 42 CFR §435.121



Optional State supplement recipients



Optional categorically needy aged and/or disabled individuals who have income at: (select one)






100% of the Federal poverty level (FPL)



%

of FPL, which is lower than 100% of FPL




Working individuals with disabilities who buy into Medicaid (BBA working disabled group as provided in §1902(a)(10)(A)(ii)(XIII)) of the Act)



Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as provided in §1902(a)(10)(A)(ii)(XV) of the Act)


Working individuals with disabilities who buy into Medicaid (TWWIIA Medical Improvement Coverage Group as provided in §1902(a)(10)(A)(ii)(XVI) of the Act)




Disabled individuals age 18 or younger who would require an institutional level of care (TEFRA 134 group as provided in §1902(e)(3) of the Act)



Medically needy (42 CFR §435.320, §435.322, §435.324 and §435.330)



Other specified groups (include only the statutory/regulatory reference to reflect the additional groups in the State plan that may receive services under this waiver) specify:



Special home and community-based waiver group under 42 CFR §435.217) Note: When the special home and community-based waiver group under 42 CFR §435.217 is included, Appendix B-5 must be completed



All individuals in the special home and community-based waiver group under 42 CFR 435.217

X

Only the following groups of individuals in the special home and community-based waiver group under 42 CFR §435.217 (check each that applies):


X


A special income level equal to (select one):




X

300% of the SSI Federal Benefit Rate (FBR)



%

of FBR, which is lower than 300% (42 CFR §435.236)



$

which is lower than 300%



Aged, blind and disabled individuals who meet requirements that are more restrictive than the SSI program (42 CFR §435.121)




Medically needy without spenddown in States which also provide Medicaid to recipients of SSI (42 CFR §435.320, §435.322 and §435.324)



Medically needy without spend down in 209(b) States (42 CFR §435.330)



Aged and disabled individuals who have income at: (select one)




100% of FPL




%

of FPL, which is lower than 100%



Other specified groups (include only the statutory/regulatory reference to reflect the additional groups in the State plan that may receive services under this waiver) specify:



Appendix B-5: Post-Eligibility Treatment of Income

In accordance with 42 CFR §441.303(e), Appendix B-5 must be completed when the State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217, as indicated in Appendix B-4. Post-eligibility applies only to the 42 CFR §435.217 group. A State that uses spousal impoverishment rules under §1924 of the Act to determine the eligibility of individuals with a community spouse may elect to use spousal post-eligibility rules under §1924 of the Act to protect a personal needs allowance for a participant with a community spouse.

a. Applicability (select one):

X

Yes. As provided in Appendix B-4, the State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217. Complete item B-5-b and other related items.




No. The State does not furnish waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217. Do not complete the remainder of this Appendix.

b. Use of Spousal Impoverishment Rules. Indicate whether spousal impoverishment rules are used to determine eligibility for the special home and community-based waiver group under 42 CFR §435.217 (select one):

X

Spousal impoverishment rules under §1924 of the Act are used to determine the eligibility of individuals with a community spouse for the special home and community-based waiver group. In the case of a participant with a community spouse, the State elects to (select one):



Use spousal post-eligibility rules under §1924 of the Act. Complete ItemsB-5-c-2 (SSI State) or B-5-d-2 (209b State) and Item B-5-e.

X

Use regular post-eligibility rules under 42 CFR §435.726 (SSI State) (Complete Item B-5-c-1) or under §435.735 (209b State) (Complete Item B-5-d-1)



Spousal impoverishment rules under §1924 of the Act are not used to determine eligibility of individuals with a community spouse for the special home and community-based waiver group. The State uses regular post-eligibility rules for individuals with a community spouse. Complete Item B-5-c-1 (SSI State) or Item B-5-d-1 (209b State).

[Items B-5-c-1 and B-5-d-1 are for use by states that do not use spousal eligibility rules or use special post eligibility rules but elect to use regular post-eligibility rules].

c-1. Regular Post-Eligibility Treatment of Income: SSI State. The State uses the post-eligibility rules at 42 CFR 435.726. Payment for home and community-based waiver services is reduced by the amount remaining after deducting the following allowances and expenses from the waiver participant’s income:

i. Allowance for the needs of the waiver participant (select one):




X

The following standard included under the State plan (select one)










SSI standard






Optional State supplement standard






Medically needy income standard




X

The special income level for institutionalized persons (select one):







X

300% of the SSI Federal Benefit Rate (FBR)






%

of the FBR, which is less than 300%






$

which is less than 300%.




%

of the Federal poverty level






Other (specify):











The following dollar amount:

$

If this amount changes, this item will be revised.






The following formula is used to determine the needs allowance:









ii. Allowance for the spouse only (select one):



SSI standard



Optional State supplement standard



Medically needy income standard

The following dollar amount:


$

If this amount changes, this item will be revised.



The amount is determined using the following formula:



X

Not applicable (see instructions)

iii. Allowance for the family (select one):



AFDC need standard



Medically needy income standard



The following dollar amount:

$

The amount specified cannot exceed the higher

of the need standard for a family of the same size used to determine eligibility under the State’s approved AFDC plan or the medically needy income standard established under
42 CFR §435.811 for a family of the same size. If this amount changes, this item will be revised.



The amount is determined using the following formula:





Other (specify):



X

Not applicable (see instructions)

iv. The State also will deduct medical and remedial care expenses specified in 42 CFR §435.726.




1   2   3   4   5   6   7   8   9   ...   23


The database is protected by copyright ©hestories.info 2017
send message

    Main page