Title 7 . Health and Social Services

Chapter 43 . Hearings

Section 20. Eligibility

7 AAC 43.020. Eligibility

(a) To be eligible for Medicaid coverage, a person must meet one of the following conditions:

(1) be eligible to receive a cash assistance payment under the APA program; a person need not receive a cash assistance payment, but he or she must be eligible to receive one;

(2) be a juvenile who is in the protective custody of the department, whose available financial resources do not exceed the need standard for a single person eligible for medical assistance under (11) of this subsection;

(3) be an aged, blind, or disabled person who is not eligible for assistance under the APA or SSI programs because of that person's income, but whose income does not exceed the amount established in AS 47.07.020 (b)(6) and who

(A) has been an inpatient in a health care facility for at least 30 days; or

(B) is not an inpatient in a health care facility, but who has been approved by the department to receive services under a home and community-based services waiver under 7 AAC 43.1000 - 7 AAC 43.1110;

(4) be an individual under age 21 who would be, except for age or school attendance requirements, a dependent child eligible for medical assistance under (11) of this subsection;

(5) be a family that became ineligible for medical assistance under (11) of this subsection due to increased earnings or child support; the family must have been eligible for Medicaid under (11) of this subsection in at least three of the preceding six months; if loss of eligibility was due to increased earnings, the family may have Medicaid eligibility extended up to 12 months in accordance with 42 U.S.C. 1396r-6; if loss of eligibility was due to receipt of increased child support payments, the family will have Medicaid eligibility extended up to four months;

(6) be an individual, age 21 and under, who is receiving active treatment in an inpatient psychiatric hospital facility or a residential psychiatric treatment center;

(7) be a reasonably classified individual under age 21 who is in an intermediate care facility for the mentally retarded or person with related conditions;

(8) be an individual under age 18 who meets the SSI eligibility requirements;

(9) be an individual who is deemed to be a recipient of supplemental security income under 42 U.S.C. 1396a(e)(3) because the individual meets all of the following criteria:

(A) the individual is 18 years of age or younger and qualifies as a disabled individual under 42 U.S.C. 1382c(a);

(B) the department has determined that

(i) the individual requires a level of care provided in a hospital, including an inpatient psychiatric hospital, nursing facility, or intermediate care facility for the mentally retarded in accordance with 7 AAC 43.170 - 7 AAC 43.190, 7 AAC 43.300, or (h) of this section;

(ii) it is appropriate to provide care for the individual outside of an institution; and

(iii) the estimated amount that would be spent for medical assistance for the individual for care outside of an institution is not greater than the estimated amount that would otherwise be spent for the individual for medical assistance within an appropriate institution;

(C) if the individual were in a medical institution, the individual would be eligible for medical assistance under (3) of this subsection; and

(D) the department has determined that home and community-based waiver services are not available or are inappropriate in accordance with AS 47.07.020 (b)(11)(D);

(10) be an individual under age 21

(A) for whom there is in effect an adoption assistance agreement under AS 25.23.190 - 25.23.220, other than an agreement under Title IV-E of 42 U.S.C. 670 - 676 (Social Security Act) between the state and an adoptive parent or parents;

(B) who the state agency responsible for adoption assistance determined could not be placed with adoptive parents without medical assistance because the child has special needs for medical or rehabilitative care; and

(C) who was eligible for medical assistance under the other provisions of this subsection before the effective date of the adoption assistance agreement under AS 25.23.190 - 25.23.220, or who would have been eligible for medical assistance under (1) of this subsection.

(11) be an individual who is eligible for medical assistance under 42 U.S.C. 1396u-1(b) (sec. 1931(b), Social Security Act);

(12) be a pregnant woman whose household income does not exceed the amount established in AS 47.07.020 (b)(14);

(13) be a child under 19 years of age whose household income does not exceed 150 percent of the federal poverty guideline for Alaska;

(14) be a child under 19 years of age whose household income exceeds 150 percent of the federal poverty guideline but does not exceed the amount established in AS 47.07.020 (b)(13) and who

(A) is not currently covered by health insurance of any kind; and

(B) did not have private or employer-sponsored health insurance coverage end less than 12 months before the determination of eligibility, unless the department determines under (i) of this section there was good cause for ending coverage;

(15) be a woman under age 65 who

(A) has been screened for breast or cervical cancer under the Center for Disease Control and Prevention's Breast and Cervical Cancer Early Detection Program established under 42 U.S.C. 1396(a)(10)(A)(ii)(XVIII) and is found to need treatment for either breast or cervical cancer;

(B) does not have creditable coverage for the treatment of breast or cervical cancer; and

(C) has not been determined eligible for any of the other Medicaid eligibility groups described in this section.

(b) Persons whose application or eligibility for Medicaid is denied, suspended, terminated, or reduced have the right to a hearing under 7 AAC 49.

(c) To be eligible for services provided exclusively under the EPSDT program, a recipient must be under age 21 and must be screened according to the screening schedule established by the department.

(d) The eligibility status of a recipient is of critical importance to the provider of medical care in planning treatment with both the recipient and the division. It is the provider's responsibility to secure a current medical assistance coupon or view a medical identification card in possession of the patient at least once each month to verify that eligibility exists at the time medical service is rendered and in order to receive payment from the division. Failure to verify current eligibility at the time of service may result in denial of the claim if the provider is unable to document at the time of billing that the patient was eligible for Medicaid during the month of service.

(e) Medicaid eligibility is available to applicants on a retroactive basis for the three months before the month of application. The applicant need not be eligible for Medicaid at the time of application but must meet the income and categorical eligibility criteria described in (a) of this section during each month in which retroactive eligibility is desired. An applicant may be eligible during any one or more months during the three-month retroactive period.

(f) For the purposes of determining Medicaid eligibility under this section, AFDC eligibility is based on the eligibility criteria as described in the AFDC state plan for Alaska in effect on July 16, 1996, except for the following:

(1) the value of a vehicle excluded as a resource is the same as for a vehicle excluded under 7 AAC 45.300(n) (Alaska Temporary Assistance Program (ATAP)); and

(2) a diversion payment made under AS 47.27.026 is not counted as income.

(g) For the purposes of determining eligibility for Medicaid under (a)(11) of this section

(1) income eligibility is determined

(A) for an applicant, using an earned income disregard of $90 per month; or

(B) for a recipient, using a monthly earned income disregard of $150 plus 33 percent of any remaining earned income; and

(2) a child is considered to be deprived of the support of one or more parents by reason of unemployment if the combined income of both parents living in the household is equal to or less than the federal poverty guideline for this state that is applicable to the household size.

(h) For the purposes of determining eligibility under (a)(9) of this section, an individual requires a level of care provided in an inpatient psychiatric hospital if the individual

(1) has a mental illness or severe emotional disturbance diagnosed by a psychiatrist or mental health professional clinician that has persisted six months and is expected to persist for a total of 12 months or longer;

(2) has at least one of the following mental health symptoms:

(A) psychotic symptoms, characterized by defective or lost contact with reality, hallucinations, or delusions;

(B) suicidal behavior, in the 90 day period before the date of application, as demonstrated by the individual having made a suicide attempt;

(C) significant suicidal thoughts, in the 30 day period before the date of application, that include a plan for suicide; or

(D) violent behavior, in the 30 day period before the date of application, as characterized by a documented attempt by the individual to cause injury to a person or substantial property damage as the result of an emotional disturbance;

(3) has functional impairments, relative to expected developmental levels for that age and at a level that qualifies the child to receive inpatient psychiatric hospitalization, in at least three of the following areas:

(A) self-care;

(B) interaction with the community;

(C) social relationships;

(D) family relationships;

(E) functioning at school or work;

(4) absent appropriate intervention in the home and community, requires psychiatric hospitalization as documented by a mental health professional, as that term is defined in AS 47.30.915 ;

(5) requires a level of care in the home that is typically provided in a psychiatric hospital because the child is suffering from a mental illness or emotional disturbance that is likely to result in serious harm to self or others; and

(6) can be expected to functionally improve or can avoid further deterioration if care is provided in the home and community.

(i) For the purposes of determining "good cause" under (a)(14) of this section, the following circumstances constitute good cause:

(1) death of the dependent's insured parent;

(2) expiration of coverage under a COBRA continuation provision, as defined in 42 U.S.C. 300gg-91;

(3) involuntary termination of health benefits due to long-term disability or another medical condition;

(4) changing to a new employer who does not provide an option for dependent coverage;

(5) the likelihood that the cost of continuing coverage would have caused a severe economic hardship on an employee or self-employed individual.

(j) In this section, "federal poverty guidelines" means the United States Department of Health and Human Services poverty guidelines for this state established in 68 Fed. Reg. 6456 - 6458, as revised as of February, 7, 2003, and adopted by reference as amended from time to time.

(k) For the purposes of determining eligibility for Medicaid under (a)(15) of this section, "creditable coverage" has the meaning given the term in 42 U.S.C. 300gg(c)(1) (Health Insurance Portability and Accountability Act), except that "creditable coverage" includes coverage for the type of cancer for which the beneficiary needs treatment.

( l ) A woman eligible for Medicaid under (a)(15) of this section continues to be eligible as long as she is receiving treatment for breast or cervical cancer, is under age 65, and is not otherwise covered under creditable coverage. A woman is presumed to be receiving treatment for the duration of the period in the treatment plan established by the treating health care professional. The department will review each recipient's eligibility annually for compliance with this subsection. If, during an ongoing period of eligibility, a metastasized cancer is found in another part of her body that is a known or presumed complication of the breast or cervical cancer, her eligibility for Medicaid will be extended to cover treatment of that cancer. If additional breast or cervical cancer is found after a treatment period has ended and Medicaid eligibility terminated, a woman must be recertified as eligible for the screening program described in (a)(15)(A) of this section before Medicaid eligibility can be reestablished.

History: Eff. 8/18/79, Register 71; am 1/4/85, Register 93; am 5/31/85, Register 94; am 3/26/93, Register 126; am 12/19/93, Register 128; am 1/26/94, Register 129; readopt 8/7/96, Register 139; am 7/1/97, Register 142; am 11/13/97, Register 144; am 2/12/99, Register 149; am 3/3/2001, Register 157; am 7/1/2001, Register 159; am 10/27/2001, Register 160; am 10/26/2003, Register 168; am 5/15/2004, Register 170; am 1/7/2005, Register 173

Authority: AS 47.05.010

AS 47.05.020

AS 47.07.040

AS 47.07.050

Editor's note: Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.020 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department.

As of Register 160 (January 2002), the regulations attorney made a technical revision under AS 44.62.125 (b)(6), to 7 AAC 43.020(a) (13).

On March 3, 2003, as required by AS 44.62.245 and AS 47.05.012 , the department gave notice that the following amended version of material, previously adopted by reference in 7 AAC 43.020, would be in effect on April 1, 2003: the United States Department of Health and Human Services poverty guidelines established in 68 Fed. Reg. 6456-6458 (February 7, 2003). The amended version may be reviewed at the Department of Health and Social Services, Division of Medical Assistance, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska, 99503-7167.