23 Miss. Code. R. 200-3.1

Current through December 10, 2024

Rule 23-200-3.1 - Eligibility Groups

A. Persons eligible for Full Medicaid Benefits

1. Low-income families with children under age eighteen (18) who meet pre-reform Aid to Families with Dependent Children (AFDC) and income criteria, as certified by the Division of Medicaid.

2. Children in licensed foster family homes or private child care institutions for which public agencies in the State of Mississippi are assuming financial responsibility as certified by the Department of Human Services (DHS). Children in foster care on their eighteenth (18th) birthday are certified as eligible by the Division of Medicaid until their twenty-first (21st) birthday.

3. Children receiving subsidized adoption payments as certified by DHS.

4. Children under the age of six (6) whose family income is equal to or below 133% of the federal poverty level (FPL) as certified by the Division of Medicaid.

5. Infants born to Medicaid-eligible mothers are eligible for the first (1st) year of the infant's life provided the mother was eligible during her pregnancy and the child lives with her.

6. Children under age nineteen (19) who have family income below 100% of the FPL as certified by the Division of Medicaid.

7. Certain disabled children age eighteen (18) or under who live at home but who would be eligible if in a medical institution and who receive medical care at home that would be provided in a medical institution, as certified by the Division of Medicaid.

8. Persons age sixty-five (65) or over, blind or disabled, and who receive Supplemental Security Income (SSI) grants as certified by the Social Security Administration (SSA).

9. Persons in medical facilities who meet long term care criteria as certified by the Division of Medicaid.

10. Certain former SSI beneficiaries who continue to meet SSI criteria except for income, as certified by the Division of Medicaid.

11. Persons provided home and community based waiver services that are physically disabled and certified by the Division of Medicaid as eligible by applying the eligibility requirements as if they are institutionalized.

12. Working disabled persons whose earnings do not exceed 250% of the FPL, as certified by the Division of Medicaid.

13. Women under age sixty-five (65) who are uninsured and have been screened and diagnosed for breast and/or cervical cancer under the Centers for Disease Control (CDC) screening program administered by the Mississippi State Department of Health are covered during the course of their cancer treatment.

14. Medicaid-eligible children under age eighteen (18) remain eligible for Medicaid for twelve (12) continuous months, provided eligibility has been correctly established.

15. Evidence of eligibility is demonstrated by the Medicaid identification (ID) card. Payment of claims can only be made for person's certified as eligible by DHS, SSA or the Division of Medicaid.

B. Persons Eligible for Medicare Cost Sharing or Premium Payment

1. Qualified Medicare beneficiaries (QMBs) who are entitled to Medicare Part A, whose income does not exceed 100% of the federal poverty level as certified by the Division of Medicaid, are only eligible for payment of Medicare cost sharing expenses.

2. Specified low-income Medicare beneficiaries (SLMBs) whose income does not exceed 120% of the FPL only receive payment from Medicaid for the Medicare Part B premium. These individuals must be entitled to Part A Medicare benefits under their own coverage, as Medicaid does not pay the Part A premium for them.

3. Qualifying individuals (QIs) certified by the Division of Medicaid, with an income of 120% -135% of the FPL, receive full payment of Medicare Part B premium, provided the beneficiary has Medicare Part A.

4. The Division of Medicaid qualifies certain qualified working disabled persons who are only eligible for Medicaid to pay their Medicare Part A premiums.

C. Persons Eligible for Limited Medicaid Benefits

1. Pregnant Women, and Children Under the Age of Twenty-One (21)

Pregnant women and children under the age of twenty-one (21) whose family income is equal to or below 185% of the FPL as certified by the Division of Medicaid qualify for limited benefits.

b) Eligible pregnant women remain eligible for sixty (60) days after pregnancy ends.

2. Family Planning Waiver

a) Women of childbearing age, defined as ages thirteen (13) to forty-four (44), whose income does not exceed 185% of poverty and who are not otherwise Medicaid-eligible, qualify for Medicaid covered family planning services only. The Division of Medicaid certifies eligibility for family planning services under a federal waiver.

b) Women covered under the family planning waiver are only eligible for family planning services outlined in Part 221, Chapter 2. Women who are otherwise eligible for full services under Medicaid also qualify for family planning services as a covered state plan service.

3. Healthier Mississippi Waiver

a) Eligibility for the Healthier Mississippi Waiver is dependent upon all of the following criteria:

1) The person's income is below 135% of the federal poverty level,

2) The person's resources are under $4,000 for an individual or $6,000 for a couple, and

3) The person is not eligible for Medicare coverage.

b) If, at any time, the beneficiary does not meet the criteria as stated above, eligibility for the November 1, 2010. Prior to November 1, 2010, the enrollment cap was 5,000.

c) Covered Services

1) The following services are covered for all beneficiaries, adult and children enrolled in the Healthier Mississippi Waiver Program:

i) Inpatient hospital services,

ii) Outpatient hospital services,

iii) Laboratory and radiology services,

iv) Physician services,

v) Pharmacy services,

vi) Home health services,

vii) Hospice services,

viii) Transportation services,

ix) Dialysis services,

x) Community mental health services, and

xi) Federally Qualified Health Center (FQHC) services.

2) Service limits and beneficiary cost sharing (co-pay) requirements apply. Beneficiaries under age twenty-one (21) may be eligible for additional visits/services with an approved plan of care under the expanded EPSDT benefits.

d) Excluded Services

1) All of the following services are excluded:

i) Chiropractic services,

ii) Podiatry services,

iii) Dental services,

iv) Vision services (eye exams are covered under physician services but eyeglass frames, eyeglass lenses and contact lenses are not covered),

v) Long term care services including but not limited to, nursing facilities, Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID), and home and community based waivers.

2) Beneficiaries under age twenty-one (21) may be eligible for these services with an approved plan of care.

23 Miss. Code. R. 200-3.1

42 USC 1396 A(a)(10) and (17); Miss. Code Ann. §§ 43-13-115, 121.

Removed 3.c.2.d.v) to reflect CMS waiver (eff. 04/01/2004) eff. 12/01/2013.