56-254. ELIGIBILITY FOR MEDICAL ASSISTANCE. The department shall make payments for medical assistance to, or on behalf of, the following persons eligible for medical assistance.

(1) The benchmark plan for low-income children and working-age adults with no special health needs includes the following persons:

(a) Children in families whose family income does not exceed one hundred eighty-five percent (185%) of the federal poverty guideline and who meet age-related and other eligibility standards in accordance with department rule;

(b) Pregnant women of any age whose family income does not exceed one hundred thirty-three percent (133%) of the federal poverty guideline and who meet other eligibility standards in accordance with department rule, or who meet the presumptive eligibility guidelines in accordance with section 1920 of the social security act;

(c) Infants born to medicaid-eligible pregnant women. Medicaid eligibility must be offered throughout the first year of life as long as the infant remains in the mother’s household and she remains eligible, or would be eligible if she were still pregnant;

(d) Adults in families with dependent children as described in section 1931 of the social security act, who meet the requirements in the state’s assistance to families with dependent children (AFDC) plan in effect on July 16, 1996;

(e) Families who are provided six (6) to twelve (12) months of medicaid coverage following loss of eligibility under section 1931 of the social security act due to earnings, or four (4) months of medicaid coverage following loss of eligibility under section 1931 of the social security act due to an increase in child or spousal support;

(f) Employees of small businesses who meet the definition of "eligible adult" as described in section 56-238, Idaho Code, whose eligibility is limited to the medical assistance program described in section 56-241, Idaho Code;

(g) All other mandatory groups as defined in title XIX of the social security act, if not listed separately in subsection (2) or (3) of this section.

(2) The benchmark plan for persons with disabilities or special health needs includes the following persons:

(a) Persons under age sixty-five (65) years eligible in accordance with title XVI of the social security act, as well as persons eligible for aid to the aged, blind and disabled (AABD) under titles I, X and XIV of the social security act;

(b) Persons under age sixty-five (65) years who are in need of the services of a licensed nursing facility, a licensed intermediate care facility for the developmentally disabled, a state mental hospital, or home-based and community-based care, whose income does not exceed three hundred percent (300%) of the social security income (SSI) standard and who meet the asset standards and other eligibility standards in accordance with federal law and regulation, Idaho law and department rule;

(c) Certain disabled children described in 42 CFR 435.225 who meet resource limits for aid to the aged, blind and disabled (AABD) and income limits for social security income (SSI) and other eligibility standards in accordance with department rules;

(d) Persons under age sixty-five (65) years who are eligible for services under both titles XVIII and XIX of the social security act;

(e) Children who are eligible under title IV-E of the social security act for subsidized board payments, foster care or adoption subsidies, and children for whom the state has assumed temporary or permanent responsibility and who do not qualify for title IV-E assistance but are in foster care, shelter or emergency shelter care, or subsidized adoption, and who meet eligibility standards in accordance with department rule;

(f) Eligible women under age sixty-five (65) years with incomes at or below two hundred percent (200%) of the federal poverty level, for cancer treatment pursuant to the federal breast and cervical cancer prevention and treatment act of 2000;

(g) Low-income children and working-age adults under age sixty-five (65) years who qualify under subsection (1) of this section and who require the services for persons with disabilities or special health needs listed in section 56-255(3), Idaho Code;

(h) Persons over age sixty-five (65) years who choose to enroll in this state plan; and

(i) Effective January 1, 2018, children under eighteen (18) years with serious emotional disturbance, as defined in section 16-2403, Idaho Code, in families whose income does not exceed three hundred percent (300%) of the federal poverty guideline and who meet other eligibility standards in accordance with department rule.

(3) The benchmark plan for persons over twenty-one (21) years of age who have medicare and medicaid coverage includes the following persons:

(a) Persons eligible in accordance with title XVI of the social security act, as well as persons eligible for aid to the aged, blind and disabled (AABD) under titles I, X and XIV of the social security act;

(b) Persons who are in need of the services of a licensed nursing facility, a licensed intermediate care facility for the developmentally disabled, a state mental hospital, or home-based and community-based care, whose income does not exceed three hundred percent (300%) of the social security income (SSI) standard and who meet the assets standards and other eligibility standards in accordance with federal and state law and department rule;

(c) Persons who are eligible for services under both titles XVIII and XIX of the social security act who have enrolled in the medicare program; and

(d) Persons who are eligible for services under both titles XVIII and XIX of the social security act and who elect to enroll in this state plan.

History:

[56-254, added 2006, ch. 278, sec. 1, p. 856; am. 2007, ch. 200, sec. 4, p. 612; am. 2017, ch. 66, sec. 1, p. 155.]