D.C. Mun. Regs. tit. 29, r. 29-9515

Current through Register Vol. 72, No. 2, January 10, 2025

Rule 29-9515 - MEDICALLY NEEDY

9515.1

This section establishes the conditions of medically needy eligibility for individuals, identified in Subsection 9515.3, who have income in excess of District Medicaid or Medicaid Waiver standards at the time of application, renewal, or redetermination.

9515.2

The medically needy eligibility category shall be subject to the spend down provisions of Section 9516 and all other requirements applicable to District of Columbia Medicaid or Medicaid Waiver programs, including but not limited to, application requirements set forth under Section 9501, and Chapters 19 and 42 (as applicable) of Title 29 DCMR, and DHCF policy.

9515.3

The following Modified Adjusted Gross Income (MAGI) eligibility coverage groups may be eligible for District Medicaid under this Section:

(a) Parents and caretaker relatives with household income above the amount determined in accordance with Subsection 9506.2;

(b) Individuals under age nineteen (19) with household income above the amount determined in accordance with Subsection 9506.6;

(c) Individuals aged nineteen (19) or twenty (20) with household income above the amount determined in accordance with Subsection 9506.7; and

(d) Pregnant women with household income above the amount determined in accordance with Subsection 9506.3.

9515.4

Individuals that are sixty-five (65) or older, blind or disabled with household income above the amounts determined in accordance with Section 9511 of this chapter and have resources at or below four thousand dollars ($4,000) for an individual and six thousand dollars ($6,000) for a couple may be eligible for District Medicaid under this section. This eligibility coverage group includes individuals applying for or receiving long-term services and supports.

9515.5

MAGI and non-MAGI eligibility coverage groups identified at Subsections 9515.3 and 9515.4 shall meet the following non-financial eligibility criteria, where applicable, as a condition of medically needy Medicaid or Medicaid Waiver eligibility:

(a) Non-financial categorial requirements as identified at Subsection 9506.9, which are as follows:

(1) District residency pursuant to 42 CFR § 435.403;

(2) Provision of a Social Security Number (SSN) or proof of exemption pursuant to 42 CFR § 435.910 and Subsection 9504.7; and

(3) U.S. citizenship or nationality, or satisfactory immigration status;

(b) Non-financial technical requirements for long-term care services, waiver services, or to establish medical or functional level of need as follows:

(1) Federal requirements set forth under 42 USC § 1382c for individuals that are aged sixty-five (65) or older, blind, or disabled;

(2) Non-financial requirements set forth under Chapter 19 for individuals applying for services under the Home and Community Based Services (HCBS) Waiver for Individuals with Intellectual and Developmental Disabilities (ID/DD);

(3) Non-financial requirements set forth under Section 989 for individuals applying for services in nursing facilities;

(4) Non-financial requirements set forth under Chapter 41 for individuals applying for services in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID); and

(5) Non-financial requirements set forth under Chapter 42 for individuals applying for services under the HCBS Waiver for Persons Who Are Elderly and Individuals with Physical Disabilities (EPD).

9515.6

When applying for Medicaid, applicants shall comply with the application requirements set forth under Section 9501 of this chapter, and individuals applying for or enrolled in the HCBS Waiver programs under Subsection 9515.4 shall also comply with the application requirements set forth under Chapters 19 and 42 (as applicable for the HCBS Waivers for ID/DD and EPD, respectively) of Title 29 DCMR, and DHCF policy.

9515.7

After the Department determines that an individual meets all non-financial and medical or functional (if applicable) eligibility factors as described in this section but is over the applicable income limit, the individual may become eligible for medically needy Medicaid through the spend down process, pursuant to the requirements set forth under Section 9516.

D.C. Mun. Regs. tit. 29, r. 29-9515

Final Rulemaking published at 69 DCR 12069 (10/7/2022)