N.Y. Comp. Codes R. & Regs. Tit. 18 §§ 360-3.3

Current through Register Vol. 46, No. 45, November 2, 2024

Section 360-3.3 - Who is eligible for MA

Generally, an applicant is eligible for MA if he/she meets the conditions listed in section 360-3.2 of this Subpart and belongs to one of the groups listed below:

(a) Persons who are categorically needy. An applicant is categorically needy if:

(1) he/she is eligible for or receiving HR; or

(2) he/she is eligible for or receiving ADC; or

(3) he/she is eligible for or receiving SSI and/or State supplementary payments; or

(4) he/she is a child receiving foster care maintenance payments under title IV-E of the Social Security Act and living in the State; or

(5) he/she is a child living in the State on whose behalf an adoption assistance agreement is in effect under title IV-E of the Social Security Act, whether or not adoption assistance payments are provided for under the agreement or are being made pursuant to title IV-E; or

(6) he/she is an adopted child under age 21 provided that:

(i) there is a legally executed adoption assistance agreement in place between an authorized agency and the adoptive parents (other than an adoption assistance agreement subject to the provisions of title IV-E of the Social Security Act);

(ii) the child has a special need for medical or rehabilitative care that would have precluded placement with adoptive parents unless MA were provided to the child; and

(iii) the child was in receipt of MA in the three-month period prior to the adoption agreement being entered into, or the child would have been eligible for MA during such period if only the child's own income and resources were considered in determining eligibility.

(b) Persons who are medically needy. An applicant/recipient is medically needy if his/her net available income and resources do not meet the cost of necessary medical care and services available under the MA program, as determined in accordance with Subpart 360-4 of this Part, and he/she is:

(1) a person 65 years of age or older;

(2) a person who is certified blind or certified disabled;

(3) a person under 21 years of age, or under 22 years of age and receiving inpatient psychiatric services which he/she began receiving before reaching age 21;

(4) a pregnant woman;

(5) a person ineligible for ADC solely because his or her income and/or resources are above the amounts allowed for ADC eligibility. This category includes: parents or other relatives listed in section 369.1(b) of this Title who are living with and caring for a child under the age of 21 who is deprived of parental support; and persons who otherwise would be eligible for a continuation of an ADC grant pursuant to section 369.3(d)(1) of this Title;

(6) the spouse of a cash assistance recipient who is living with the recipient, who is essential to the recipient's welfare, and whose needs are included in determining the amount of the recipient's cash payment;

(7) a federally nonparticipating (FNP) person who is a parent of a dependent child under 21 years of age and who is ineligible for public assistance solely because his/her income and/or resources are above the amounts allowed for public assistance eligibility, provided that the child is living with such parent or is temporarily absent from the parent's household. An FNP person does not meet the categorical eligibility requirements for ADC or SSI; or

(8) a person who resides in a department-approved private facility which is funded through voluntary contributions and which provides for all maintenance and personal needs, provided that such person has no income or resources or that such person' s income and resources are applied toward the cost of maintenance in the facility. If such person is federally nonparticipating, he/she will be required to comply with the requirements of subdivision (5) of section 131 of the Social Services Law.

(c) Persons whose MA eligibility is extended. Certain persons will continue to receive MA benefits for a specified period of time after ceasing to be categorically needy or medically needy.

(1)

(i) A family which becomes ineligible for ADC or HR will remain eligible for MA for an extended MA coverage period of six calendar months following the month of ADC or HR ineligibility if:

(a) the family became ineligible for ADC or HR on or after April 1, 1990;

(b) the family was eligible for ADC or HR in at least three of the six months immediately preceding the first month of ADC or HR ineligibility; and

(c) the family became ineligible for ADC or HR due to the caretaker relative's hours of employment or income from employment, or the loss of the $30 plus one third of the remainder earned income disregard or the $30 earned income disregard, as provided in section 352.20 of this Title; and

(d) the family continues to have a dependent child.

(ii) When notifying a family of its ineligibility for ADC or HR for the reasons described in subparagraph (i)(c) of this paragraph, social services districts must give the family adequate notice of its rights to an extended MA coverage period under this paragraph, including notice of the reporting requirements for the additional extended MA coverage period under paragraph (2) of this subdivision and the circumstances described in subparagraph (iii) of this paragraph.

(iii) Social services districts also must give the families receiving MA under this paragraph adequate notice of the option for an additional extended MA coverage period in both the third and sixth months of the extended MA coverage period.

(iv) Upon adequate notice to the family, the extended MA coverage period under this paragraph must be terminated at the end of:

(a) the first month in which the family ceases to include a dependent child; or

(b) the month in which the department determines that a family member fraudulently received ADC or HR in any of the six months prior to the extended MA coverage period, except that the termination of coverage will apply only to such family member.

(v) With respect to a child who would cease to receive MA as a result of a termination of coverage pursuant to clause (iv)(a) of this paragraph, the child's coverage may not be terminated until the social services district has determined that the child is not otherwise eligible for MA.

(2)

(i) A family which received MA for the full six-month extended MA coverage period provided for under paragraph (1) of this subdivision may be eligible for an additional extended MA coverage period of six calendar months. In order to be eligible for the additional extended MA coverage period, the family must have submitted the first report required under subparagraph (ii) of this paragraph, or have good cause for failing to meet the reporting requirement.

(ii) A family must report to the social services district the family's gross monthly earnings and the family's costs for child care, which were necessary for the employment of the caretaker relative. These reports must include earnings and costs for each of the three preceding months. The reports must be submitted no later than the 21st day of the fourth month of the extended MA coverage period and the first and fourth months of the additional extended MA coverage period.

(iii) Social services districts must give families receiving MA coverage under this paragraph adequate notice of the reporting requirements of subparagraph (ii) of this paragraph in the third month of the additional extended MA coverage period.

(iv) Upon adequate notice to the family, the additional extended MA coverage period under this paragraph must be terminated at the end of:

(a) the first month in which the family ceases to include a dependent child;

(c) the first or fourth month of the additional extended MA coverage period if the family fails, without good cause, to meet the reporting requirements set forth in subparagraph (ii) of this paragraph in either the first or fourth month of the additional extended MA coverage period;

(d) the first or fourth month of the additional extended MA coverage period if the caretaker relative had no earnings in one or more of the previous three months, unless the lack of earnings was due to an involuntary loss of employment, illness, or other good cause; or

(e) the first or fourth month of the additional extended MA coverage period if the family's average gross monthly earnings during the previous three months, less the cost of child care necessary for the employment of the caretaker relative, exceed 185 percent of the Federal income official poverty line applicable to the family's size.

(3) A household which becomes ineligible for ADC due to the collection or increased collection of child or spousal support will remain eligible for MA for four calendar months beginning with the first month of ADC ineligibility if the family was eligible for ADC in at least three of the six months immediately preceding the first month of ADC ineligibility.

(4) [Reserved]

(5) A woman receiving MA on any day of her pregnancy remains eligible for MA for at least 60 days beginning on the last day of her pregnancy. Her eligibility will continue until the last day of the month in which the 60th day occurs, regardless of any change in her household's income.

(6) A child whose mother was eligible for and receiving MA on the date of the child's birth will be eligible for MA for up to one year from the date of birth so long as:

(i) the mother remains or, if pregnant, would remain eligible for MA; and

(ii) the child is a member of the woman's household.

(7) A person who becomes ineligible for SSI because he/she is no longer certified blind or certified disabled will remain eligible for MA for two months following the month in which the blindness or disability ends, provided the person continues to meet the financial eligibility requirements in Subpart 360-4 of this Part.

(8) Any certified blind or certified disabled person who is a qualified severely impaired individual will continue to be eligible for MA despite earnings that demonstrate his or her ability to engage in substantial gainful activity under the SSI program. A person is a qualified severely impaired individual if:

(i) he/she was eligible for MA and received SSI benefits, State supplementary payments, or benefits under section 1619(a) of the Social Security Act in the month preceding the first month in which the provision of this paragraph are applied; and

(ii) the Social Security Administration has determined that:

(a) the person continues to be blind or to have a disabling physical or mental impairment;

(b) the person continues to meet all other requirements for SSI eligibility except for earnings;

(c) the lack of MA coverage would seriously inhibit the person's ability to continue or to obtain employment; and

(d) the person's earnings are insufficient to provide a reasonable equivalent of the SSI, MA, and publicly funded attendant care benefits that would be available to the person if he/she were not employed.

(9) A person 60 years of age or older who applies for and receives early widow's or widower's insurance benefits under section 202(e) or (f) of the Social Security Act, or receives other benefits under section 202 of such act but is eligible for widow's or widower's insurance benefits, and who becomes ineligible for SSI or State supplementary payments as a result of receiving such benefits, will remain eligible for MA so long as:

(i) he/she would be eligible for SSI or State supplementary payments if he/she were not receiving such benefits; and

(ii) he/she is not entitled to Medicare part A hospital insurance benefits.

(10) A person who was receiving both SSI and Social Security benefits at any time after April 1977, and who subsequently became ineligible for SSI will be eligible for MA if:

(i) the person is currently eligible for and receiving social security benefits; and

(ii) the person would be eligible for SSI if social security cost-of-living increases received by the person and his/her spouse since the last month in which the person received both social security and SSI benefits were not counted as income.

(11) A person who was eligible for MA in December 1973, as a blind or disabled individual will remain eligible for MA so long as:

(i) the person still meets the December 1973 criteria for blindness or disability; and

(ii) the person meet all other current requirements for MA eligibility.

(12) A person eligible for MA in December 1973 as an essential spouse of a recipient of aid to the aged, blind, or disabled (AABD) remains eligible for MA so long as:

(i) the aged, blind or disabled individual still meets the December 1973 eligibility requirements for AABD; and

(ii) the person remains the spouse of the aged, blind or disabled individual.

(13) A person who was an inpatient in an institution participating in the MA program for all or any part of December, 1973 and who:

(i) would have been eligible for AABD except for being such an inpatient; or

(ii) was considered to be eligible for AABD, for the purpose of determining MA eligibility, on the basis of needing care in such an institution, remains eligible for MA so long as he/she continues to be in need of inpatient care.

(14) A person who was entitled to social security benefits and was eligible for or receiving cash assistance under ADC or AABD in August, 1972 will have his/her MA eligibility determined without regard to the October, 1972 social security increase. This provision also applies to a person who would have been eligible for ADC for AABD during August 1972 if he/she had not been in a medical institution or intermediate care facility.

(15) A person age 18 or older who was receiving SSI or State supplementary payments on the basis of blindness or disability which began before he or she reached the age of 22, and who on or after July 1, 1987 lost eligibility for SSI benefits because he or she became entitled to child's insurance benefits under 42 U.S.C. 402(d) (also known as Disabled Adult Child's benefits) or to an increase in the amount of such benefits, remains eligible for MA so long as he or she would be eligible for SSI benefits in the absence of such child's insurance benefits or the increase in such benefits.

(16) An infant who is receiving medically necessary in-patient care and services on his or her first birthday and who is eligible for MA because his or her household's income does not exceed 185 percent of the applicable Federal poverty line set forth in section 360-4.7(b) of this Part will remain eligible for such in-patient care and services until the end of his or her in-patient stay.

(17) A child who is receiving medically necessary in-patient care and services on his or her sixth birthday and who is eligible for MA because his or her household's income does not exceed 133 percent of the applicable Federal poverty line set forth in section 360-4.7(b) of this Part will remain eligible for such in-patient care and services until the end of his or her in-patient stay.

(18) A child who is receiving medically necessary in-patient care and services on his or her 19th birthday and who is eligible for MA because his or her household's income does not exceed 100 percent of the applicable Federal poverty line set forth in section 360-4.7(b) of this Part will remain eligible for such in-patient care and services until the end of his or her in-patient stay.

N.Y. Comp. Codes R. & Regs. Tit. 18 §§ 360-3.3