Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.7 - Eligibility Requirements for the Noninstitutionalized Categorically Needy: AFDC-Related Families and Children › Rule 37.82.701 - GROUPS COVERED, NONINSTITUTIONALIZED FAMILIES AND CHILDREN

Current through Register Vol. 13, July 5, 2024
(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 and
				verified 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 60th postpartum day occurs.
(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
				and resources do not exceed the medically needy income and resource standards
				specified in ARM 37.82.1106, 37.82.1107, and 37.82.1110, provided that the
				child does not live with a parent or specified caretaker relative as defined in
				the family-related Medicaid Manual, section 201-1. This coverage group is known
				as the "child-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
				37.86.1701
				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 member's third party health
				coverage.