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The MA assistance group must consist of the person requesting assistance and certain relatives and caretakers of children (including unrelated caretakers) who live with the person, if these individuals also wish to receive assistance. Relatives/caretakers who do not want to apply for benefits for themselves are never required to be included in the MA assistance unit, though their income and/or resources may be considered when determining the applicant’s eligibility for MA (see Chapter 2: Whose Assets are Counted and Chapter 5: Whose Income is Counted in Part VI). Some relatives/caretakers also applying for MA may be included in the same MA unit, but they do not have to be. In fact, individuals living in the same household may be eligible under different MA program types (such as AR, AX, SR, or QM) or different eligibility categories within a program type (that is, one child may be eligible for MA based on the Poverty Level Families and Children criteria while a child age 20 may be eligible based on the Medically Needy Families and Children criteria). The SSR must explore all categories for each person who requests assistance (see Section 2.2.1: MA Program Eligibility Criteria in Part I for a discussion of categories of people who are eligible for MA). The SSR should designate the group(s) in the manner most beneficial to the applicants (that is, in the manner that allows as many applicants, related or not, to be determined eligible; see Section 1.4: Optional Group Members in this Chapter for an example).
Combination assistance units arise in households where some members are one type of unit and other members are a different type of unit. The SSR must determine all potential program types under which each individual applicant may be eligible for Medicaid and test each individual against each potential eligibility criteria.
AR: An AR assistance unit includes at least one child under age 21 (including an unborn child).
Non-disabled children ages 19 and 20 who are not themselves parents or caretakers can only be eligible for Medicaid based on the TANF Standard or the Medically Needy Families and Children category. Children under the age of 19 can be eligible for Medicaid based on the TANF Standard, Foster Care/Department Ward/Adoption Assistance Recipient category, the Medically Needy Families and Children category, or the Poverty Level Families and Children category. (Children under 19 whose incomes exceed the various AR standards may be eligible under the AX type.)
While parents residing in the home with a dependent child do not have to be included in the assistance unit, parents living in the home with a dependent child are provisionally included for purposes of determining financial eligibility (see Chapter 5: Whose Income is Counted and Chapter 2: Whose Assets are Counted in Part VI). Caretaker relatives and unrelated caretakers of minor children are not required to be in the group and are not included provisionally if they choose not to apply for benefits on their own behalf as a caretaker of a child.
FOSTER CARE/DEPARTMENT WARD/ADOPTION ASSISTANCE RECIPIENT
Department wards are automatically eligible for MA if they are not in penal institutions. A Department ward is any child who:
- has been committed to, or placed with, CFSA by a court order due to abuse or neglect, and
- has been placed in either a foster care home or a licensed child-care institution by the Department.
No other individuals are included in a unit with a Department ward.
Foster parents may apply on behalf of foster care children (see Section 1.6.2: Filing an Application/Accessing Benefits on Behalf of Another Individual or Group). They do not have the option of being included in the group with the foster care child but could otherwise be eligible.
Current MA eligibility for Department wards begins with the first day of the month the court order was received by the Department. Applications are not required for Department wards, (including those eligible for IV-E), for current MA, but applications are required for retroactive MA.
Any child for whom foster care maintenance payments are made is eligible for MA. The child is eligible for MA in the state where s/he is physically present even if the foster care payments are made by another state.
A foster child committed by the court to a juvenile penal facility can only receive Medicaid during an inpatient hospital stay.
Any child under age 21for whom there is an adoption assistance agreement in effect under Title IV-E of the Social Security Act is eligible for MA. The child is eligible for MA in the state where s/he is physically present even if the adoption assistance agreement is with another state. The adoption assistance agreement need not provide for an actual adoption assistance payment.
AX: An AX unit always contains a child under the age of 19, a parent or a caretaker (related or unrelated) of a child under the age of 19 who is eligible for Medicaid, or a pregnant woman. All parents, caretakers, pregnant women, and children under the age of 19 must first be evaluated to determine if they are eligible under the AR program type. If the individual is aged, disabled and/or an SSI recipient, s/he must be evaluated under the SR program type before determining eligibility as part of an AX unit.
There are no mandatory group members for this type of unit.
SR: A person eligible for MA in an SR unit must be
- Age 65 or older,
- Blind, or
- Permanently and totally disabled.
A person who is blind or permanently and totally disabled can be any age from newborn to age 65. After age 65, the person's medical condition is no longer relevant because the person meets the age criteria.
The only mandatory group member is a spouse if s/he is also aged, blind, or disabled. If only one spouse is aged, blind, or disabled, then the other spouse is not included in the SR unit.
There are never more than two people in an SR unit. The only time there are two in the unit is when the two people are married to each other, are living together, and are both aged, blind, or disabled. An SR unit always consists of either a married couple who are living together or an individual. An SR unit will never consist of a disabled parent and a disabled child. If a parent and a child are both disabled, they are considered two separate SR units.
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Mr. and Mrs. Drew have one daughter, Rebecca who is 14. Mrs. Drew is blind. All three family members apply for MA. Mrs. Drew has the option of being included in her own SR unit or in a unit with Rebecca. Mr. Drew should be included in a unit with Rebecca and, if she chooses, Mrs. Drew.
Suppose Mrs. Drew and Rebecca have no income, Mr. Drew earns $1,000 per month, and the family incurs no child care costs. If all three are included in the same assistance unit and tested under the AR category, Rebecca will be found eligible (since the family’s income is below 100 percent of the FPL for a family of three). If both Mr. and Mrs. Drew chose to be in the same unit with Rebecca, both would be tested under the AX criteria. Rebecca would be included provisionally in the AX unit, and Mr. and Mrs. Drew would be found eligible for Medicaid (since their family’s income is below 200 percent of the FPL).
Mrs. Drew could choose to be in her own SR unit. By doing so, she would not be placed in managed care because disabled Medicaid recipients are not required to enroll in the managed care system. Because the general managed care organizations may not meet the needs of disabled individuals, individuals with disabilities should be strongly encouraged to complete the medical evaluation form. If the MRT determines the individual disabled, the individual can be switched from an AR or AX unit to an SR unit. |
Couple status ceases for spouses who are no longer living together the month after the month of separation. The reason for the separation does not matter. (See Chapter 2, Part VII for information on the treatment of spouses in LTC cases).
An SSI recipient is always in an SR unit.
QM: Only Medicare beneficiaries can be included in a QM unit. Spouses who are both applying for assistance with Medicare premiums, deductibles, and co-payments must be included in the same QM unit. | 
