DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
Center for Medicaid, CHIP and Survey & Certification 
 
CMCS Informational Bulletin 
  
 
DATE:  June 16, 2011 
     
FROM:  Cindy Mann  
  Director 
   
SUBJECT:  State Option to Enroll Tuberculosis (TB) Infected Individuals into the 
Medicaid Program 
 
This Informational Bulletin reminds States about the option that is available to extend Medicaid 
eligibility to low-income individuals infected with tuberculosis (TB), with Federal financial 
participation.  This option was made available by the Omnibus Budget Reconciliation Act of 
1993 (OBRA 93).  At the time this provision was enacted, there had been a resurgence of TB 
across the country, particularly multi-drug resistant TB.   
 
Although U.S. incidence of both drug susceptible and drug resistant TB has declined since the 
1990s, TB remains an important public health concern both in the U.S. and globally.  In 2010, 
The Centers for Disease Control and Prevention (CDC) reported 11,181 cases of TB disease in 
the U.S. The continued concern is that because TB is transmitted through the air, individuals 
with untreated TB disease can spread it to others.  For every person with TB disease, CDC 
estimates that another 10 need to be evaluated because they may have unknowingly contracted 
the disease.  The good news is that TB is curable with antibiotic treatment.   Medicaid coverage 
can help ensure that individuals, including those who are not otherwise Medicaid-eligible, can 
receive treatment that can help improve their health and limit the spread of the disease. 
 
The CDC provides Federal funding to State and local health departments for TB diagnosis, case 
management, contact investigations, surveillance, education, and outreach, but provides very 
limited support for TB treatment or prescription drugs.  In these tough budgetary times, electing 
Medicaid coverage for TB-related services would provide Federal support for States to help 
cover the cost of curative and life-saving TB drugs, as well as prevent the further spread of TB 
into the community.   
 
The CMS and CDC are encouraging States to consider this coverage opportunity and to work 
with their counterparts in public health agencies to achieve the common goal of eliminating TB. 
 
Background 
  
As noted above, OBRA 93 gave States the option to extend Medicaid eligibility to low-income 
individuals infected with TB who are not otherwise eligible for Medicaid.  These TB-infected 
individuals must have income and resources which do not exceed the maximum amount of 
income and resources for disabled individuals in a mandatory group eligible for Medicaid.        
  Page 2  Informational Bulletin 
 
For 2011, the income standard is $1,433 a month for an individual (159 percent of Federal 
Poverty Level (FPL)) and $2,107 a month for a couple (234 percent of FPL).  The resource 
standard is $2,000 for an individual and $3,000 for a couple.  
 
States that elect this option provide certain outpatient services related to the TB infection, 
including prescribed drugs; physician, outpatient hospital, rural health center and Federally 
qualified health center services; laboratory and X-ray services including services to confirm the 
presence of infection; clinic services; targeted case management services; and services designed 
to encourage completion of regimens of prescribed drugs, including services to directly observe 
the intake of prescribed drugs (also known as Directly Observed Therapy (DOT)),  although 
room and board costs are excluded.   Case management and DOT, as well as other services, can 
help promote compliance with treatment regimens.  Prevention and early intervention related to 
TB treatment can avert much more extensive service needs that might emerge if the disease is 
allowed to progress.   
 
The TB coverage option offers States a means to ensure that TB infected individuals obtain 
treatment and to reduce the likelihood of transmission.  To help States complete a Medicaid State 
Plan Amendment (SPA) to elect this option, we have attached instructions and a pre-print page 
for use in completing the SPA request.  Questions regarding the TB option may be directed to 
Jerry Zelinger, M.D., Technical Director, Division of Benefits and Coverage at 
gerald.zelinger@cms.hhs.gov or (410) 786-5929.   
 
We hope you will find this information helpful.   
 
 
 
 
  Attachment 1 
 
Completing the State Plan Amendment Preprint Templates 
 
States electing to enroll TB-infected individuals into the Medicaid program under this option 
should complete the attached templates describing the eligibility and coverage parameters under 
the Medicaid State plan.   
 
Eligibility 
 
  Complete the Eligibility preprint Attachment 2.2-A, page 21, item 18.  The State should 
simply check the box to indicate its intent to elect the option. 
 
  As referenced in item 18 above, also submit Supplement 14 to Attachment 2.6-A, page 1. 
 
Coverage 
 
Note that a State electing to extend eligibility to this TB-infected group must cover the 
following TB-related services  (i.e., prescribed drugs; physician, outpatient hospital, rural 
health center and Federally qualified health center services; laboratory and X-ray services 
including services to confirm the presence of infection; and clinic services) to the same extent 
as these services, which are identified at section 1905(a) of the Social Security Act are 
otherwise covered/available to other categorically needy individuals under the State plan but 
only if the service is related to diagnosis, treatment or management of the eligible individuals 
TB.  The services described at 1902(z)(2)(E-F) (Targeted Case Management and Directly 
Observed Therapy (DOT)), which are designed to encourage patients to complete their drug 
regimens, are optional services and can be covered in addition to the services described in 
1902(z)(2)(A-D).  If the State wants to cover services in E and F they would elect these 
service(s) in item 19.a and or 19.b of the coverage preprint. 
 
  On the Coverage preprint Attachment 3.1-A, page 8, item 19.a, the State should indicate 
whether targeted case management for TB-infected individuals will be provided/covered. 
If provided/covered, the State should also indicate in a narrative attachment to 
Attachment 3.1-A (i.e., Supplement 1) whether these services will be covered for just 
those TB-infected individuals who are eligible under the State option to enroll TB-
infected individuals into the Medicaid program (1902(a)(10)(A)(ii)(XII)) or will more 
broadly cover targeted case management services for TB-infected individuals in other 
categorically needy groups as well.  The State should describe the nature of the targeted 
case management services they propose to cover along with any limitations. (Please note 
that item 19.a of the preprint refers to targeted case management as a discrete Medicaid 
service, and is not necessarily limited to individuals with TB.)  
 
  For item 19.b, Attachment 3.1-A, page 8, the State should indicate whether it will cover 
DOT services as described in 1902(z)(2)(F) for TB-infected individuals and include a 
narrative that describes the nature of these services.  Note that DOT is described more 
fully in the latest TB Treatment Guidelines (2003) accessible at this website:  
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm
   
Attachment 2                      
                     
Revision:                    ATTACHMENT 2.2-A 
                  Page 21 
 
      State:  ________________________________                                                          
                                                                                                                                         
Agency  Citation(s)        Groups Covered 
                                                                                                                                         
 
B.  Optional Groups Other Than the Medically Needy (Continued) 
 
           Children who are born after September 30, 1983 and who have 
attained 6 years of age but have not attained age 19* 
 
              7 years of age; or 
              8 years of age. 
 
          *A mandatory coverage group under OBRA 1990. 
 
1902(a)(10)(A)(ii)      17.  Individuals-- 
(X) and 1902(m) 
(1) and (3) of        a.  Who are 65 years of age or older or are disabled, as  
The Act          determined under section 1614(a)(3) of the Act.  Both aged 
and disabled individuals are covered under this eligibility 
group. 
 
a. Whose income does not exceed the income level (established at 
an amount up to 100 percent of the Federal income poverty 
level) specified in Supplement 1 to ATTACHMENT 2.6-A 
for a family of the same size; and 
 
b.Whose resources do not exceed the maximum amount allowed 
under SSI, or under the State's medically needy program as 
specified in ATTACHMENT 2.6-A. 
 
1902(a)(10)(A)(ii)      18.  Individuals not described in section 1902(a)(10)(A)(i) of the Act  
(XII) and 1902(z)    who are infected with tuberculosis whose income and resources  
of the Act    do not exceed the maximum amounts described in Supplement 
14 to ATTACHMENT 2.6-A. 
 
 
                                                                                                                                                    
 
TN No:                 Approval Date                 Effective Date             
Supersedes TN No.  
          Revision:                                 
   
 
  SUPPLEMENT 14  
TO ATTACHMENT 2.6-A 
    Page 1 
 
  STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT 
 
  State: _______________________________________                                                                 
 
 
INCOME AND RESOURCE REQUIREMENTS FOR 
TUBERCULOSIS (TB) INFECTED INDIVIDUALS 
 
 
For TB infected individuals under section 1902(z)(1) of the act, the income and resource 
eligibility levels are as follows: 
 
1.  Income:  The SSI breakeven point for earned income. 
 
2.  Resources:  The SSI resource standard. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 __________________________________________________________________________                                                                                                                                                    
TN No.                Approval Date                 Effective Date________              
Supersedes TN No.            
   
   
ATTACHMENT 3.1-A 
                   Page 8 
             
 
State: ___________________________ 
   
 
AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE 
AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY  
________________________________________________________________________ 
 
19.   Case management services and Tuberculosis related services 
 
a.     Case management services as defined in, and to the group specified in, 
Supplement 1 to Attachment 3.1-A (in accordance with section 1905(a)(19) or 
section 1915(g) of the Act).  
 
             Provided:              With limitations           _____   Not provided.  
 
b.     Special tuberculosis (TB) related services under section 1902(z)(2)(F) of 
           the Act.        
 
             Provided:              With limitations*         _____   Not provided.