DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland  21244-1850 
 
 
Center for Medicaid and State Operations 
 
SHO # 05-001 
 
 
 
September 16, 2005 
Dear State Medicaid Directors and State Childrens Health Insurance Program Directors: 
As we work to recover from one of the worst natural disasters in the history of the United 
States, our hearts, thoughts, and prayers go out to those suffering and those who are 
assisting in rescue efforts.  With the massive displacement of thousands of residents in 
the affected areas of Louisiana, Mississippi, Alabama, and Florida to other States, the 
Centers for Medicare & Medicaid Services (CMS) thanks you for your tireless work on 
behalf of all people affected, and we are working to ensure that you can provide Medicaid 
and State Childrens Health Insurance Program (SCHIP) health care services for 
evacuees. 
 
In an effort to ensure the continuity of health care services for the victims of Hurricane 
Katrina, CMS has developed a new section 1115 demonstration initiative.  Under this 
program, States may apply to be part of a unique cooperative demonstration that allows 
coverage of evacuees from the affected geographic areas of Louisiana, Mississippi, 
Alabama, and Florida1 in which a Natural Disaster has been declared. 
 
Under this demonstration, effective retroactively to August 24, 2005, evacuees who have 
been displaced from his or her home as a result of Hurricane Katrina will be provided the 
opportunity to enroll to receive services under the Medicaid or SCHIP programs in 
whatever State they now reside.  States may provide a period of temporary eligibility for 
up to 5 months.  Evacuees will apply through a simplified application within the Host 
State through January 31, 2006.  Applicants may provide self-declaration of information 
needed for an eligibility determination if the individual is unable to produce necessary 
verification.  There is no obligation on the Host State to redetermine eligibility for 
evacuees at the end of this period.  The evacuee must apply, and States are encouraged to 
assist individuals in applying for assistance in the State in which they are currently 
residing.  This demonstration allows for self-attestation for items such as displacement, 
income, residency, resources, and immigration status if the evacuee is unable to provide 
documentation. 
 
 
 
 
 
 
1    Pursuant to the Robert T. Stafford Disaster Relief and Emergency Assistance Act, Section 408:  Federal 
Assistance to Individuals and Households. As of September 15, 2005, no Florida counties have Individual 
Assistance Designation pursuant Section 408.  Other affected National Disaster States/areas could be added 
at a later date.  This demonstration initiative permits Host States to offer Medicaid and SCHIP benefits to 
parents, pregnant women, children under age 19, individuals with disabilities, low income 
Medicare recipients, and low income individuals in need of long term care within certain 
income parameters using a simplified eligibility chart or the eligibility levels from the 
affected States.  As an evacuee, an individual is required to attest that he/she is displaced 
from certain geographic regions and to cooperate in demonstrating evacuee status. This 
initiative will not impact any other demonstration the State may have under title XIX or 
title XXI.  Benefits for evacuees will be those of the State Plan for the Host States title 
XIX and title XXI programs. 
 
States will not be required to meet budget neutrality tests under these unique 
demonstration programs.  The Department agrees that individuals participating in the 
demonstration are presumed to be otherwise eligible for Medicaid in their respective 
Home State and costs to the Federal Government would have otherwise been incurred 
and allowable.  Therefore, States participating in the demonstration program will not be 
required to provide or demonstrate budget neutrality through without waiver and with 
waiver expenditure data.  Additionally, States have the option to exempt evacuees from 
cost sharing. 
 
Attached is a template that States may use to request a section 1115 demonstration 
program to provide coverage to individuals who have been displaced due to Hurricane 
Katrina.  In completing the template, States should provide contact information in order 
that CMS can contact key State officials to discuss demonstration proposals.  The 
electronic version of the template will be available on the CMS Web site at 
http://www.cms.hhs.gov. 
 
Any questions related to this initiative or the template should be addressed to Ms. Jean 
Sheil, Director of the Family and Childrens Health Programs Group at (410) 786-5647. 
Applications should be addressed to: 
 
Centers for Medicare & Medicaid Services 
Center for Medicaid and State Operations 
Family and Childrens Health Programs 
7500 Security Boulevard 
Mail Stop S2-01-16 
Baltimore, MD  21244-1850  Page 3State Medicaid Directors and State Health Officials 
 
 
 
We appreciate the recovery efforts made by all the States in the aftermath of Hurricane 
Katrina.  Toward that end, CMS will work expeditiously with States to ensure that 
Americas most vulnerable populations continue to receive the care they need. 
 
Sincerely, 
 
/s/ 
 
Dennis G. Smith 
Director 
Enclosures 
cc: 
CMS Regional Administrators 
 
CMS Associate Regional Administrators 
for Medicaid and State Operations 
 
Martha Roherty 
Director, Health Policy Unit 
American Public Human Services Association 
 
Joy Wilson 
Director, Health Committee 
National Conference of State Legislatures 
 
Matt Salo 
Director of Health Legislation 
National Governors Association 
 
Brent Ewig 
Senior Director, Access Policy 
Association of State and Territorial Health Officials 
 
Trudi Matthews 
Senior Health Policy Analyst 
Council of State Governments 
 
Sandy Bourne 
Legislative Director 
American Legislative Exchange Council  Multi-State Section 1115 Demonstration Application Template 
Medicaid and SCHIP Coverage for Evacuees of Hurricane Katrina 
 
 
 
The State of  , Department of  proposes 
emergency relief as an affected State, through the use of section 1115 demonstration 
authority, as outlined in the Social Security Act (the Act), which sets forth a multi-State 
demonstration project including all signatory States (described below as Home States and 
Host States). 
 
I.  GENERAL DESCRIPTION OF PROGRAM 
 
Effective retroactively to August 24, 2005, States will be allowed to provide Medicaid and 
SCHIP coverage to a new demonstration population of evacuees consisting of parents, 
pregnant women, children under age 19, individuals with disabilities, low income 
Medicare recipients, and low income individuals in need of long term care with incomes 
up to and including the levels listed on the attached simplified eligibility chart. Host 
States may also provide Medicaid and SCHIP coverage to evacuees using eligibility 
determinations based on eligibility levels in the Home State of an evacuee. 
 
State information is provided in order that the Centers for Medicare & Medicaid Services 
(CMS) can contact States on an individual basis to discuss demonstration proposals. 
 
State Name: 
State Medicaid Director Name: 
Telephone Number: 
E-mail Address: 
Other Key Contacts: 
 
II.  DEFINITIONS AND CONDITIONS 
 
Emergency Area: Refers to a geographic area or region in which a National Disaster has 
been declared.  In the case of Hurricane Katrina this refers to the States of Louisiana, 
Mississippi, Alabama, and Florida.  The affected counties/parishes below have been 
declared by FEMA as designated counties requiring Individual Assistance as a result of 
Hurricane Katrina.  Evacuees from these counties are eligible under this waiver consistent 
with the Individual Assistance Program designation pursuant to the Robert T. Stafford 
Disaster Relief and Emergency Assistance Act, Section 408: Federal Assistance to 
Individuals and Households1. 
 
 
 
 
 
 
 
1    
As of September 15, 2005, no Florida counties have Individual Assistance Designation pursuant to 
Section 408.  Other affected National Disaster States/areas could be added at a later date. 
  1  Louisiana: 
Acadia, Ascension, Assumption, Calcasieu, Cameron, East Baton Rouge, East Feliciana, 
Iberia, Iberville, Jefferson, Jefferson Davis, Lafayette, Lafourche, Livingston, Orleans, 
Pointe Coupee, Plaquemines, St. Bernard, St. Charles, St. Helena, St. James, St. John, 
St. Mary, St. Martin, St. Tammany, Tangipahoa, Terrebonne, Vermilion, Washington, 
West Baton Rouge, and West Feliciana parishes. 
 
Mississippi: 
Adams, Amite, Attala, Claiborne, Choctaw, Clarke, Copiah, Covington, Forrest, Franklin, 
George, Greene, Hancock, Harrison, Hinds, Jackson, Jasper, Jefferson, Jefferson Davis, 
Jones, Kemper, Lamar, Lauderdale, Lawrence, Leake, Lincoln, Lowndes, Madison, 
Marion, Neshoba, Newton, Noxubee, Oktibbeha, Pearl River, Perry, Pike, Rankin, Scott, 
Simpson, Smith, Stone, Walthall, Warren, Wayne, Wilkinson, Winston, and Yazoo 
Counties. 
 
Alabama: 
Baldwin, Mobile, Pickens, Greene, Hale, Tuscaloosa, Washington, Choctaw, Clarke, and 
Sumter Counties. 
 
Florida: 
 
As of September 15, 2005, no Florida counties have Individual Assistance Designation 
pursuant to Section 408. 
 
Other affected National Disaster States/areas could be added at a later date by CMS. 
 
Evacuee:  Refers to an individual who is a resident of the emergency area affected by a 
National Disaster as declared by the President of the United States pursuant to the 
National Emergencies Act or the Robert T. Stafford Disaster Relief and Emergency 
Assistance Act and has been displaced from his or her home by the emergency (see 
emergency area), and is not a non-qualified alien and meets the definition of eligible 
population. 
 
Evacuee Status:  Refers to a temporary eligibility status, not to exceed 5 months, during 
which evacuees will be able to access Medicaid or SCHIP services. 
 
Evacuee Status Eligibility Determination:  Applications for eligibility for evacuee 
status will be accepted from August 24, 2005 through January 31, 2006, and may be 
retroactive to August 24, 2005.  Any eligibility time period prior to September 1, 2005, 
will not count against an evacuees eligibility period. Evacuee status will be limited to 
parents, pregnant women, children under age 19, individuals with disabilities, low income 
Medicare recipients, and low income individuals in need of long term care:  (1) with 
incomes up to and including the levels listed on the attached eligibility simplification 
chart, or (2) with eligibility that meets the eligibility levels in the applicants Home State. 
Evacuee status can be established by self-attestation of displacement, income, and 
immigration status, but evacuees must be required to cooperate in demonstrating evacuee 
and eligibility status.  If the Host State uses the simplified eligibility chart in determining 
  2  eligibility, the Host State may apply or waive the Host State resource test criteria 
applicable to the applicants eligibility category.  If the Host State uses the Home State 
eligibility criteria for determining eligibility, the Host State must apply the Home State 
resource test criteria.  CMS will consider waivers of the resource tests. 
 
Home State:  Refers to the State in which the National Disaster has been declared and 
from which the individuals have been displaced. 
 
Host State:  Refers to the State in which evacuees are temporarily residing.  A Home 
State can also be a Host State with respect to evacuees whether displaced from homes 
within its borders or outside its borders. 
 
Temporary Eligibility Period: A period of eligibility for up to 5 months is provided for 
all eligibility groups who are evacuees.  If they wish to be determined eligible for regular 
Medicaid/SCHIP, at the end of the temporary eligibility period individuals must reapply 
for eligibility under a permanent eligibility category in the State in which they are 
permanently residing.  Neither the Host State nor the Home State is obligated to 
redetermine eligibility before the termination of the temporary period, but either State may 
elect to redetermine whether the individual is eligible under a permanent eligibility 
category under its State plan.  No applications for evacuee status may be accepted after 
January 31, 2006. 
 
Host State Assurances:  Host States assure that they will, to the greatest extent possible: 
(1) verify circumstances of eligibility, (2) verify residency and citizenship of the evacuees, 
and (3) prevent fraud and abuse.  Host and Home States may be subject to audit by other 
Federal agencies including the Office of the Inspector General.  The purpose of the audit 
will be to assure only evacuee expenses are claimed by the State under the terms of the 
waiver and to detect provider or client fraud and abuse. Any provider or client fraud and 
abuse will require recovery efforts on the part of the State; however, the States will not be 
held liable for such fraud and abuse.  Additionally, there is a reciprocal obligation for 
Home/Host States in obtaining necessary information to determine eligibility for this 
waiver program. 
 
Duration of the Demonstration Program:  The duration of the program will be from 
August 24, 2005 through June 30, 2006. 
 
Eligible Populations:  The demonstration population will consist of evacuees who are 
parents, pregnant women, children under age 19, individuals with disabilities, low income 
Medicare recipients, and low income individuals in need of long term care with incomes 
up to and including the levels listed on the attached simplified eligibility chart or the 
eligibility levels in the affected States.  A new category of evacuee will be created to 
capture the displaced individuals for reporting purposes.  States must report enrollment in 
these eligibility categories monthly. 
 
Benefits:  The benefits for evacuees will be those of the State plan title XIX and title XXI 
programs in the Host State.  The cost of services provided to evacuees deemed eligible are 
  3  not counted against any other section 1115, section 1915(b) or (c) waiver the State may 
have, including Home and Community Based Services waiver slots. 
 
Effective Date:  The demonstration project will be effective upon approval by the 
Secretary with respect to evacuees.  Eligibility and payments under such a demonstration 
may be retroactive to August 24, 2005. 
 
FFP Claiming:  Host States will submit claims directly to CMS rather than submitting 
claims to Home States as would occur under regular procedures.  The Host State will 
report expenditures related to this demonstration on the CMS-64 and/or the CMS-21 in 
accordance with instructions provided by CMS. 
 
Reporting Requirements:  Unless otherwise waived, States will be required to comply 
with reporting requirements including reporting of enrollee member months monthly and 
reporting of progress on the demonstration monthly and financial reporting under titles 
XIX and XXI for evacuees enrolled in this demonstration program quarterly.  States will 
be required to track separately all expenditures associated with this waiver, 
including but not limited to, administrative costs and program expenditures in 
accordance with instructions provided by CMS for this population. 
 
Notice to Applicants:  Host States shall provide notice to evacuees that this is a limited 
benefit for 5 months from the date of application.  Applicants should be given notice that 
at the end of the temporary eligibility period individuals must reapply for eligibility under 
a permanent eligibility category. 
 
Fair Hearings and Appeals:  No fair hearings and/or appeals are provided as part of this 
demonstration program. 
 
Final Report:  No later than December 31, 2006, Host States will be required to submit a 
final report to CMS to describe the impact of this program, including but not limited to, 
the impact on evacuees, the Host States, etc. CMS will provide guidance on the submittal 
of the final report. 
 
III.  CURRENT ELIGIBILITY COVERAGE IN MISSISSIPPI , LOUISIANA, 
ALABAMA, AND FLORIDA. 
 
See attached charts for the Medicaid eligibility levels in the affected Home States.  States 
will be provided the opportunity to use the eligibility levels in the affected Home States or 
can use the simplified eligibility chart attached.  In the case of Mississippi, Louisiana, 
Alabama, and Florida, the eligibility levels for SCHIP are up to and including 200 percent 
of poverty for children. 
 
_/ Eligibility will be based on the eligibility levels in the affected Home States.  Please 
indicate which State(s) will be used. 
 
_/ Eligibility will be based on the simplified eligibility chart. 
  4   
IV.   BENEFITS 
 
_/  Benefits covered will include current Host State plan services. 
 
_/  Other 
 
 
 
V.  FINANCIAL REQUIREMENTS 
 
States will not be required to meet budget neutrality tests under these demonstration 
programs.  The Department agrees that individuals participating in the demonstration are 
presumed to be otherwise eligible for Medicaid in their respective Home State and costs to 
the Federal Government would have otherwise been incurred and allowable.  Therefore, 
States participating in the demonstration program will not be required to provide or 
demonstrate budget neutrality through without waiver and with waiver expenditure 
data. 
 
VI.  STANDARD FEATURES 
A.  Health care providers that furnish medical services in good faith, but who 
cannot comply with normal program requirements because of Hurricane 
Katrina, will be paid for services provided and will be exempt from sanctions 
for noncompliance, unless it is discovered that fraud and abuse occurred. 
B.  Crisis services provided to Medicaid and SCHIP patients who have been 
transferred to facilities not certified to participate in the programs will be paid. 
C.  Programs will reimburse facilities for providing services to patients in 
alternative settings, e.g., providing dialysis to patients with kidney failure in 
alternative settings. 
D.  Normal prior authorization and out-of-network requirements may also be 
waived for enrollees of Medicaid or SCHIP managed care plans. 
E.  Normal provider requirements for doctors, nurses, and other health care 
professionals who cross State lines to provide emergency care in stricken areas 
will be waived as long as the provider is licensed in their Home State. 
 
 
 
VII.  COST SHARING 
 
States may choose to exempt evacuees from cost-sharing. 
 
_/  Cost Sharing will not be imposed on evacuees by the Host State. 
 
_/  Cost Sharing will be imposed by the Host State consistent with the requirements 
outlined in title XIX. 
 
_/ Cost Sharing will be imposed by the Host State consistent with the requirements 
outlined in title XXI. 
  5   
 
VIII.  WAIVERS, REQUIREMENTS NOT APPLICABLE, AND EXPENDITURE 
AUTHORITIES 
 
A list of typical waivers and expenditure authorities has been provided for your 
convenience; however, States have the flexibility to request additional waivers and 
expenditure authorities as necessary to operate their programs.  If additional waivers or 
expenditure authorities are desired, please include a detailed request and justification as an 
attachment. 
 
All requirements of the Medicaid and SCHIP program expressed in law, regulation, and 
policy statement, not expressly waived or identified as not applicable shall apply to this 
demonstration program. 
 
A.  Waivers and Requirements Not Applicable to the Demonstration 
 
The following waivers and requirements that would not be applicable to the demonstration 
are requested pursuant to the authority of section 1115(a)(1) of the Act.  (Please check all 
that are applicable): 
 
Title XIX: 
 
   Statewideness and Eligibility Methods and Standards  Section 1902(a)(1) 
and 1902(a)(17) 
To enable the Host State to implement a program to provide benefits to evacuees who are 
determined to be eligible under a Home State Medicaid program on less than a Statewide 
basis.  In addition, to enable the Host State to use eligibility methods, benefit levels, and 
benefit delivery methods for evacuees that are different from those otherwise used within 
the Home State. 
 
   Comparability  Section 1902(a)(10)(B) 
To enable Host States to offer benefits to evacuees that are not comparable to the benefits 
offered by the Home or Host States to categorically needy individuals or to other 
individuals in the same eligibility group. 
 
   Fair Hearings and Notices  Section 1902(a)(3) 
To enable a Host State to make determinations of temporary status in the Host State 
Medicaid program for a period of up to 5 months without according the right to fair 
hearings or appeals of adverse determinations that would be available for determinations 
with respect to permanent eligibility status.  Nothing in this waiver limits the rights of 
such individuals to seek a determination of permanent eligibility status in the Home State 
with the right to fair hearings or appeals of adverse determinations. 
  6   
Cooperation in Establishing Paternity  Section 1902(a)(45) 
To permit the Host State to determine eligibility for evacuees under the Home State 
program without requiring applicants to comply with paternity cooperation requirements 
of section 1912. 
 
   Freedom of Choice - Section 1902(a)(27) 
To enable the Host State to restrict the choice of provider. 
 
              Provider Agreements - Section 1902(a)(32) 
To permit the provision of care in the Host State by individuals or entities who have not 
executed a Provider Agreement with the Home State Medicaid Agency but have such an 
agreement with the Host State. 
 
   Annual Redeterminations of Eligibility  Sections 1902(a)(4) and 1902(a)(19) 
To permit delay of otherwise required redeterminations for the Home/Host States title 
XIX program between August 24, 2005 and February 28, 2006, for recipients living in an 
emergency area of Mississippi, Louisiana, Alabama, and Florida for those recipients who 
were displaced by Hurricane Katrina. 
 
   Amount, Duration, and Scope  Section 1902(a)(10)(B) 
To permit the provision of different services to evacuees within the Host State than to 
other populations in either the Home or Host States. 
 
   Retroactive Eligibility  Section 1902(a)(34) 
To enable the Home State to waive the requirement to provide medical assistance for up to 
3 months prior to the date that application for assistance under a temporary eligibility 
period is made for evacuees. 
 
Title XXI: 
 
   Eligibility Screening  Section 2102(a) 
The State child health plan of the Host State does not have to reflect the evacuee 
population. 
 
   Eligibility Screening  Section 2103(a) 
The title XXI income eligibility guidelines of Mississippi, Louisiana, Alabama, and 
Florida, or the simplified eligibility chart criteria will be followed when enrolling evacuee 
children from these States. 
 
Federal Matching Payments  Section 2105 
To permit Federal Matching Payment for the provision of medical assistance on behalf of 
an evacuee child during a temporary eligibility period that is not implemented in 
accordance with section 1920A. 
  7   
Annual Reporting Requirements  Section 2108 
To permit not applying annual reporting requirements to this evacuee population. 
 
Annual Redeterminations - Section 2102 
To permit delay of otherwise required annual redeterminations for the Home/Host States 
title XXI program between August 24, 2005 and February 28, 2006, living in an 
emergency area of Mississippi, Louisiana, Alabama, and Florida who were displaced by 
Hurricane Katrina. 
 
B.  Expenditure Authority 
 
Expenditure authority is requested under section 1115(a)(2) of the Act to allow the 
following expenditures which are not otherwise included as expenditures, under section 
1903 or section 2105, to be regarded as expenditures under the Host States title XIX or 
title XXI plan. 
 
Note:  Checking the appropriate box(es) will allow the State to claim Federal financial 
participation for expenditures that otherwise would be ineligible for Federal match. 
 
Title XIX: 
 
Host State expenditures including both administrative and benefit costs of 
extending benefits during a temporary eligibility period to evacuees who are determined 
to be eligible under a Home State Medicaid program. 
 
Expenditures for Home and Community Based Services for evacuees including 
administrative and benefit costs. 
 
Expenditures for medical care, under payment methodologies set forth in the 
approved State plan, excluding any supplemental payments and without regard to the State 
disproportionate share hospital allotment, for evacuees who do not have health insurance 
coverage. 
 
Title XXI: 
 
Host State expenditures including both administrative and benefit costs of 
extending benefits during a temporary eligibility period to evacuees who are determined 
to be eligible under a Home State SCHIP program. 
 
Expenditures to permit delay of otherwise required redeterminations between 
August 24, 2005 and January 31, 2006 for evacuees enrolled in the Host States Title XXI 
program. 
  8   
IX.   SIGNATURE 
 
Date:      Authorizing Official (Typed):    
 
 
 
Authorizing Official (Signature):     
 
Attachments 
  9   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
   
   
Section 1115 Demonstration Relief From Hurricane Katrina   
Evacuee Eligibility Simplification Based on Home State Eligibility Rules 
   
Simplified Eligibilty Groups  Family FPL Levels 
Children Under Age 19  up to and including 200% FPL 
Pregnant Women from Louisiana, Mississippi and Florida  up to and including 185% FPL 
Pregnant Women from Alabama  up to and including 133% FPL 
Individuals with Disabilities  up to and including 300% SSI 
Low-income Medicare Recipients  up to and including 100% FPL 
Low-income Individuals in need of Long Term Care  up to and including 300% SSI 
Low-income Parents of Children Under Age 19  up to and including 100% FPL 
   
  Alabama 
 
Medicaid Eligibility Groups  Income and Resource Limits 
 
Eligibility Group  Income Limit  Resource Limit 
Section 1931 (Low Income  FS 1 = $111/month  $1,000 
Families with Children)  FS 2 = $137/month 
FS 3 = $164/month 
FS 4 = $194/month 
FS 5 = $225/month 
Poverty-level pregnant  133% of the FPL  No resource test 
women and infants 
Children ages 1 to 6  133% of the FPL  No resource test 
Children ages 6 to19  100% of the FPL  No resource test 
SSI Recipients  $579 individual/month,  $2,000 individual, 
$869 couple/month  $3,000 couple 
Qualified severely impaired  $20,553 annual earned  $2,000 
blind or disabled under age  income; $579 monthly 
65  unearned income 
Disabled adult children  $579/month  $2,000 
Individuals who would be  $579/month  $2,000 
eligible for SSI except for 
OASDI COLAs after April 
1977 
Disabled  $579/month  $2,000 
Widows/Widowers 
Early Widows/Widowers  $579/month  $2,000 
Disabled children who lost  $579/month  $2,000 
SSI due to change in 
definition of disability 
(section 4913 children) 
Qualified Medicare  100% of the FPL or  $4,000 individual, 
Beneficiaries  $798 individual, $1,079  $6,000 couple 
couple 
Special Low Income  100-120% of the FPL or  $4,000 individual, 
Medicare Beneficiaries  $798-$957 individual,  $6,000 couple 
$1,070-$1,283 couple 
Qualifying Individuals  120-135% of the FPL or  $4,000 individual, 
$957-$1,077 individual,  $6,000 couple 
$1,283-$1,444/couple 
Qualified Disabled Working  200% of the FPL or $1,595  $4,000 individual, 
Individuals  individual, $2,139 couple  $6,000 couple 
Special Income Level group  300% of the SSI Federal  $2,000 
Benefit Rate or $1,737 
  Florida 
Medicaid Eligibility Groups  Income and Resource Limits 
(as of August 24, 2005) 
 
Eligibility Group  Income Limit  Resource Limit 
Section 1931 (Low-Income  FS 1 = $180/month  $2,000 
Families with Children)  FS 2 = $241/month 
FS 3 = $303/month 
FS 4 = $364/month 
FS 5 = $426/month 
Poverty-level pregnant  185% of the FPL  No resource test 
women and infants 
Children ages 1 to 6  133% of the FPL  No resource test 
Children ages 6 to19  100% of the FPL  No resource test 
Medically Needy  FS 1 = $180/month  FS 1 = $5,000 
FS 2 = $241/month  FS 2 = $6,000 
FS 3 = $303/month  FS 3 = $6,000 
FS 4 = $364/month  FS 4 = $6,500 
FS 5 = $426/month  FS 5 = $7,000 
SSI Recipients  $579 individual/month,  $2,000 individual 
$869 couple/month  $3,000 couple 
Qualified severely impaired  $23,991 annual earned  $2,000 
blind or disabled under age  income; $579 monthly 
65  unearned income 
Disabled adult children  $579/month  $2,000 
Individuals who would be  $579/month  $2,000 
eligible for SSI except for 
OASDI COLAs after April 
1977 
Disabled  $579/month  $2,000 
Widows/Widowers 
Early Widows/Widowers  $579/month  $2,000 
Disabled children who lost  $579/month  $2,000 
SSI due to change in 
definition of disability 
(section 4913 children) 
Qualified Medicare  100% of the FPL or  $4,000 individual 
Beneficiaries  $798 individual, $1,079  $6,000 couple 
couple 
Special Low Income  100-120% of the FPL or  $4,000 individual 
Medicare Beneficiaries  $798-$957 individual,  $6,000 couple 
$1,079-$1,283/couple 
Qualifying Individuals  120-135% of the FPL or  $4,000 individual 
$957-$1,077 individual,  $6,000 couple 
$1,283-$1,444 couple 
   
Eligibility Group  Income Limit  Resource Limit 
Qualified Disabled Working  200% of the FPL or $1,595  $4,000 individual 
Individuals  individual, $2,139 couple  $6,000 couple 
Special Income Level group  300% of the SSI Federal  $2,000 
Benefit Rate or $1,737 
Optional State Supplement  $657.40-$764.00 individual,  $2,000 individual 
$1,314.80-$1,528.00 couple  $3,000 couple 
Individuals Receiving  $1,737 individual  $2,000 individual 
Hospice Care  $3,474 couple  $3,000 couple 
Optional Aged and  88% of the FPL or  $5,000 individual 
Disabled Poverty Level  $702 individual,  $6,000 couple 
Worki ng Disabled Buy-In  $1,59 5 indiv idual,  $5,000 individual 
Group  $2,139 couple  $6,000 couple 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Page 2 - Florida 
  Louisiana 
Medicaid Eligibility Groups  Income and Resource Limits 
(as of August 24, 2004) 
 
Eligibility Group  Income Limit  Resource Limit 
Section 1931 (Low-Income  FS 1 = $72/month  No resource test 
Families and Children)  FS 2 = $138/month 
FS 3 = $190/month 
FS 4 = $234/month 
FS 5 = $277/month 
Poverty-level pregnant  185% of the FPL  No resource test 
women and infants 
(LaMOMS) 
Children ages 1 to 6  133% of the FPL  No resource test 
(CHAMP children) 
Children ages 6 to19  100% of the FPL  No resource test 
(CHAMP children) 
Medically Needy  FS 1 = $100/month  No resource test for AFDC- 
FS 2 = $192/month  related 
FS 3 = $258/month  For SSI-related: 
FS 4 = $317/month  $2,000 individual 
FS 5 = $375/month  $3,000 couple 
SSI Recipients  $579 individual/month,  $2,000 individual 
$869 couple/month  $3,000 couple 
Qualified severely impaired  $23,580 annual earned  $2,000 
blind or disabled under age  income; $579 monthly 
65  unearned income 
Disabled adult children  $579/month  $2,000 
Individuals who would be  $579/month  $2,000 
eligible for SSI except for 
OASDI COLAs after April 
1977 
Disabled  $579/month  $2,000 
Widows/Widowers 
Early Widows/Widowers  $579/month  $2,000 
Disabled children who lost  $579/month  $2,000 
SSI due to change in 
definition of disability 
(section 4913 children) 
Qualified Medicare  100% of the FPL or  $4,000 individual 
Beneficiaries  $798 individual, $1,079  $6,000 couple 
couple 
Special Low Income  100-120% of the FPL or  $4,000 individual 
Medicare Beneficiaries  between $798-$957  $6,000 couple 
individual, $1,079-$1,283 
couple 
   
Eligibility Group  Income Limit  Resource Limit 
Qualifying Individuals  120-135% of the FPL or  $4,000 individual 
$957-$1,077 individual,  $6,000 couple 
Qualified Disabled Working  200% of the FP L or $1 ,595  $4,000 individual 
Individuals  individual, $2,139 couple  $6,000 couple 
Special Income Level group  300% of the SSI Federal  $2,000 individual 
Benefit Rate or $1,737  $4,000 couple 
individual, $3474 couple 
TB-infected individuals  $579 individual/month  $2,000 individual 
$869 couple/month  $3,000 couple 
Breast and Cervical Cancer  None (declared income  No resource test 
must be < 250% of the FPL 
at CDC screening) 
TWWIIA  250% of the FPL (including  $25,000 
a disregard) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Page 2  Louisiana 
  Mississippi 
Medicaid Eligibility Groups  Income and Resource Limits 
(as of August 24, 2005) 
 
Eligibility Group  Income Limit  Resource Limit 
Section 1931 (Low Income  FS 1 = $218/month  No resource test 
Families with Children)  FS 2 = $293/month 
FS 3 = $368/month 
FS 4 = $443/month 
FS 5 = $518/month 
Poverty-level pregnant  185% of the FPL  No resource test 
women and infants 
Children ages 1 to 6  133% of the FPL  No resource test 
Children ages 6 to19  100% of the FPL  No resource test 
SSI Recipients  $579 individual/month,  $2,000 individual 
$869 couple/month  $3,000 couple 
Qualified severely impaired  $23,991 annual earned  $2,000 
blind or disabled under age  income, $579 monthly 
65  unearned income 
Disabled adult children  $579/month  $2,000 
Individuals who would be  $579/month  $2,000 
eligible for SSI except for 
OASDI COLAs after April 
1977 
Disabled  $579/month  $2,000 
Widows/Widowers 
Early Widows/Widowers  $579/month  $2,000 
Disabled children who lost  $579/month  $2,000 
SSI due to change in 
definition of disability 
(section 4913 children) 
Qualified Medicare  100% of the FPL or  $4,000 individual 
Beneficiaries  $798 individual, $1,079  $6,000 couple 
couple 
Special Low Income  100-120% of the FPL or  $4,000 individual 
Medicare Beneficiaries  $798-$957 individual,  $6,000 couple 
$1,079-$1,283 couple 
Qualifying Individuals  120-135% of the FPL or  $4,000 individual 
$957-$1,077 individual,  $6,000 couple 
$1,283-$1,444 couple 
Qualified Disabled Working  200% of the FPL or $1,595  $4,000 individual 
Individuals  individual, $2,139 couple  $6,000 couple 
Special Income Level group  300% of the SSI Federal  $2,000 
Benefit Rate or $1,737 
   
Eligibility Group  Income Limit  Resource Limit 
Individuals Receiving  $1,737 individual  $2,000 
Hospice Care 
Optional Aged and  100% of the FPL or  $2,000 individual 
Disabled Poverty Level  $798 individual,  $3,000 couple 
Group  $1,079 couple 
Working Disabled Buy-In  $4,053 earned  $24,000 individual 
Group  income/individual, $5,411  $26,000 couple 
earned income/couple; 
$1,127 unearned 
income/individual, $1,494 
unearned income/couple 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Page 2  Mississippi