full-benefit eligible individual

(2) Application (A) In general Except as provided in subparagraph (B), a State may require that a full-benefit eligible individual (as defined in subparagraph (C)) within a group obtain benefits under this subchapter through enrollment in coverage described in paragraph (1)(A). A State may apply the previous sentence to individuals within 1 or more groups of such individuals. (B) Limitation on application A State may not require under subparagraph (A) an individual to obtain benefits through enrollment described in paragraph (1)(A) if the individual is within one of the following categories of individuals: (i) Mandatory pregnant women The individual is a pregnant woman who is required to be covered under the State plan under section 1396a(a)(10)(A)(i) of this title . (ii) Blind or disabled individuals The individual qualifies for medical assistance under the State plan on the basis of being blind or disabled (or being treated as being blind or disabled) without regard to whether the individual is eligible for supplemental security income benefits under subchapter XVI on the basis of being blind or disabled and including an individual who is eligible for medical assistance on the basis of section 1396a(e)(3) of this title . (iii) Dual eligibles The individual is entitled to benefits under any part of subchapter XVIII. (iv) Terminally ill hospice patients The individual is terminally ill and is receiving benefits for hospice care under this subchapter. (v) Eligible on basis of institutionalization The individual is an inpatient in a hospital, nursing facility, intermediate care facility for the mentally retarded, or other medical institution, and is required, as a condition of receiving services in such institution under the State plan, to spend for costs of medical care all but a minimal amount of the individual’s income required for personal needs. (vi) Medically frail and special medical needs individuals The individual is medically frail or otherwise an individual with special medical needs (as identified in accordance with regulations of the Secretary). (vii) Beneficiaries qualifying for long-term care services The individual qualifies based on medical condition for medical assistance for long-term care services described in section 1396p(c)(1)(C) of this title . (viii) Children in foster care receiving child welfare services and children receiving foster care or adoption assistance The individual is an individual with respect to whom child welfare services are made available under part B of subchapter IV on the basis of being a child in foster care or with respect to whom adoption or foster care assistance is made available under part E of such subchapter, without regard to age, or the individual qualifies for medical assistance on the basis of section 1396a(a)(10)(A)(i)(IX) of this title . (ix) TANF and section 1396u–1 parents The individual qualifies for medical assistance on the basis of eligibility to receive assistance under a State plan funded under part A of subchapter IV (as in effect on or after the welfare reform effective date defined in section 1396u–1(i) of this title ). (x) Women in the breast or cervical cancer program The individual is a woman who is receiving medical assistance by virtue of the application of sections 1396a(a)(10)(A)(ii)(XVIII) and 1396a(aa) of this title . (xi) Limited services beneficiaries The individual— (I) qualifies for medical assistance on the basis of section 1396a(a)(10)(A)(ii)(XII) of this title ; or (II) is not a qualified alien (as defined in section 1641 of title 8 ) and receives care and services necessary for the treatment of an emergency medical condition in accordance with section 1396b(v) of this title . (C) Full-benefit eligible individuals (i) In general For purposes of this paragraph, subject to clause (ii), the term “full-benefit eligible individual” means for a State for a month an individual who is determined eligible by the State for medical assistance for all services defined in section 1396d(a) of this title which are covered under the State plan under this subchapter for such month under section 1396a(a)(10)(A) of this title or under any other category of eligibility for medical assistance for all such services under this subchapter, as determined by the Secretary. (ii) Exclusion of medically needy and spend-down populations Such term shall not include an individual determined to be eligible by the State for medical assistance under section 1396a(a)(10)(C) of this title or by reason of section 1396a(f) of this title or otherwise eligible based on a reduction of income based on costs incurred for medical or other remedial care.


42 USC § 1396u-7(a)(2)

Scoping language

For purposes of this paragraph
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