Mont. Admin. r. 37.82.701 - GROUPS COVERED, NONINSTITUTIONALIZED FAMILIES AND CHILDREN
(1) Medicaid will be provided to:
(a) Individuals under age 19 who currently
reside in Montana and are receiving foster care, guardianship, or adoption
assistance under Title IV-E of the Social Security Act, whether or not such
assistance originated in Montana. Eligibility requirements for Title IV-E
foster care and adoption assistance are found in ARM
37.50.101,
37.50.105,
37.50.106, and 45 CFR part
233.
(b) Individuals who have been
receiving assistance in the nonmedically needy family Medicaid program and
whose assistance is terminated because of earned income. These individuals may
continue to receive Medicaid for any or all of the 6 calendar months
immediately following the month in which nonmedically needy family Medicaid is
last received, providing:
(i) in cases where
assistance was terminated due to earned income, a member of the assistance unit
continues to be employed during the 6 months; however, eligibility may continue
even though no member of the assistance unit is employed if there was a good
cause as defined in the family-related Medicaid Manual, section 1508-1, as
incorporated by reference in ARM
37.82.101, for the termination or
loss of employment;
(ii) they
received nonmedically needy family Medicaid for three of the six months
immediately prior to the month they became ineligible for nonmedically needy
family Medicaid coverage; and
(iii)
there continues to be an eligible child in the assistance unit. This coverage
group is known as the "family-transitional."
(c) Individuals under age 19 who live with a
specified caretaker relative as defined in the family- related Medicaid manual,
section 201-1, as incorporated by reference in ARM 37.82.101, and who meet all
other eligibility requirements.
(d)
A pregnant woman whose pregnancy has been verified and whose family income and
resources meet the requirements listed in ARM
37.82.1106,
37.82.1107, and
37.82.1110. This coverage group is
known as the "qualified pregnant woman group." The unborn child shall be
considered an additional member of the filing unit for purposes of determining
eligibility.
(e) A pregnant woman
whose pregnancy has been verified, whose family income does not exceed 157% of
the federal poverty guidelines. This coverage group is known as the "pregnancy
group."
(i) The unborn child shall be
considered an additional member of the filing unit for purposes of determining
eligibility.
(ii) Newborn children
are continuously eligible through the month of their first birthday, provided
they continue to reside in Montana. This coverage group is known as the
"child-newborn group."
(f) A pregnant woman during a period of
presumptive eligibility.
(i) Presumptive
eligibility is established by submission of an application by the applicant on
the form specified by the department, to a qualified presumptive eligibility
provider, verification of pregnancy and a determination by the qualified
presumptive eligibility provider that applicant's household income and
resources do not exceed the income and resource standards specified in (1)(e).
(A) A qualified presumptive eligibility
provider is an entity which meets the requirements specified in section 3570 of
the state Medicaid Manual, published by the Centers for Medicare and Medicaid
Services (CMS) of the U.S. Department of Health and Human Services and who is
enrolled with the department as a qualified presumptive eligibility provider
under the presumptive eligibility program. Section 3570 of the state Medicaid
Manual is adopted and incorporated by this reference. A copy of the manual
section may be obtained from the Department of Public Health and Human
Services, Human and Community Services Division, 111 N. Jackson St., P.O. Box
202925, Helena, MT 59620-2925.
(B)
Presumptive eligibility determinations shall be effective through the earlier
of the date the department makes a determination of eligibility or
ineligibility based upon a Medicaid application, or the last day of the month
following the month of the presumptive eligibility determination, if no
Medicaid application is filed within such period. An individual is limited to
one presumptive eligibility period per pregnancy.
(C) The applicant or recipient shall be
entitled to a fair hearing with respect to a determination by the department
based upon a Medicaid application.
(ii) During a period of presumptive
eligibility, a pregnant woman is limited to ambulatory prenatal care services
covered under the Montana Medicaid program. Such services may be provided by
any Medicaid provider eligible to receive Medicaid reimbursement for such
services under applicable law and regulations.
(g) A pregnant woman who becomes ineligible
for Medicaid due solely to increased income and whose countable resources do
not exceed $3,000 and whose pregnancy is disclosed to the department prior to
the effective date of Medicaid closure. This coverage group is known as the
"continuous pregnant woman group." Eligibility shall be continuous without
lapse in Medicaid eligibility from the prior Medicaid eligibility and shall
terminate on the last day of the month in which the 12-month postpartum period
ends.
(h) A child who has not yet
reached age 19, whose family income does not exceed 143% of the federal poverty
guidelines. This coverage group is known as the "Healthy Montana Kids (HMK)
Plus" group. Children determined eligible under the Healthy Montana Kids Plus
program will receive up to 12 months of continuous coverage.
(i) Individuals under the age of 21 who are
receiving foster care or subsidized adoption payments through child welfare
services. These individuals must have full or partial financial responsibility
assumed by public agencies and must have been placed in foster homes, private
institutions, or private homes by a nonprofit agency.
(j) A child of a minor custodial parent when
the custodial parent is living in the child's grandparent's home and the
grandparent's income is the sole reason rendering the child ineligible for
nonmedically needy family Medicaid.
(k) Needy caretaker relatives as defined in
the family-related Medicaid Manual, section 201-1, as incorporated by reference
in ARM 37.82.101, who have in their care an individual under age 19 who is
eligible for Medicaid, and whose countable income does not exceed the state's
family Medicaid standards as defined in the family-related Medicaid Manual,
section 002.
(l) A child through
the month of the child's 19th birthday, who lives in a household whose income
exceeds the categorically needy standards and resources do not exceed the
resource standards specified in ARM 37.82.1106, 37.82.1107, and 37.82.1110.
This coverage group is known as the "family medically needy group."
(m) Individuals, under the age of 65 who have
been screened through the Montana Breast and Cervical Health Program who:
(i) have been diagnosed with cancer or
precancer of the breast or cervix;
(ii) do not have creditable coverage to pay
for their cancer/precancer treatment;
(iii) have countable income that does not
exceed 250% of the federal poverty level at the time of screening and
enrollment into the Montana Breast and Cervical Health Program; and
(iv) are not eligible for any other
nonmedically needy Medicaid coverage group. This coverage group is known as
"breast and cervical cancer treatment."
(n) Families who, due to receipt of new or
increased spousal support, lose eligibility for nonmedically needy family
Medicaid. To be eligible the family must:
(i)
receive new or increased spousal support in an amount great enough to cause
their nonmedically needy family Medicaid eligibility to end; and
(ii) have received nonmedically needy family
Medicaid in Montana for three of six months prior to the closure of
nonmedically needy family Medicaid. The coverage will continue for four
consecutive months. This program is known as the "family-extended
group."
(o) Women ages 19
through 44, who have not been otherwise determined eligible for Medicaid under
this title, who are able to become pregnant but are not now pregnant, whose
household income does not exceed 211% of the federal poverty level. Services
are limited to those family planning services defined at ARM 37.86.1707 and not
covered by third party health coverage. This program is limited to 4,000 women
at any given time and is known as Plan First. Plan First will not pay any copay
or deductible required by a member's third party health coverage.
(2) Medicaid will continue until
the last day of the month in which the 12-month postpartum period ends for
pregnant women as long as the pregnant woman was eligible for and receiving
Medicaid on the date pregnancy ends.
(3) Medicaid may be provided for up to three
months prior to the date of application for individuals listed in (1)(a),
(1)(c), (1)(d), (1)(g), (1)(h), (1)(i), (1)(j), (1)(k), (1)(l), and (1)(m) if
all financial and nonfinancial eligibility criteria are met as of the date
medical services were received in each of those months.
Notes
AUTH: 53-4-212, 53-4-1105, 53-6-113, MCA; IMP: 53-4-231, 53-4-1104, 53-4-1105, 53-6-101, 53-6-131, 53-6-134, MCA
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