• Families with Children: Children and their parents, step-parents or caretakers can be eligible for Medicaid if they meet one of the following criteria (individuals receiving TANF are categorically eligible for Medicaid; see Chapter 12: Categorical Eligibility in Part IV).
  
  
  • TANF Standard: Individuals receiving TANF or children under age 19, their parents, step-parents, or caretakers who meet the TANF income and asset standards but are not receiving TANF;
    
    
  • Foster Care/Department Ward/Adoption Assistance Recipient : Children under age 18 placed in foster care (but not in institutions) and children receiving IV-E foster care payments or IV-E adoption assistance benefits are categorically eligible for Medicaid (see Chapter 12: Categorically Eligible in Part IV);
    
    
  • Medically Needy Families & Children: Children under the age of 21 and parents, and/or caretaker relatives with incomes below the MNIL;
    
    
  • Poverty Level Children and Pregnant Women: Pregnant women and infants (children under age one) with net incomes below 185 percent of the federal poverty level (FPL), children under age six with net incomes below 133 1/3 percent of the FPL, children ages six and over provided they were born after September 30, 1983 with net incomes below 100 percent of the FPL, and children 19 and 20 with net incomes under 200% of the FPL. When determining if the pregnant woman's income is below 185 percent of the FPL, the unborn child is included as a group member (i.e., if the applicant is a pregnant woman with no other children, the poverty level for a group of two is used).
    
    Pregnant women with net incomes below 185 percent of the FPL and a medically-verified pregnancy are eligible for prenatal care during a presumptive eligibility period while their ongoing eligibility for medical services is determined.
    
    
  • Children with Other Health Insurance: Pregnant women and children under 19 who have other health insurance are eligible for Medicaid if their incomes are below 300 percent of the FPL;
    
    
  • DC Healthy Families Expansion Group for Pregnant Women and Children : Pregnant women and children under age 19 whose gross income is below 300 percent of the FPL, have no other health insurance, and are ineligible for Medicaid under the TANF Standard, Poverty Level Families and Children, and Medically Needy Families and Children criteria described above (the federal government will pay a larger share of the cost of providing health care coverage to these children because extending Medicaid to this group was done as part of the Child Health Insurance Program (CHIP);
    
    
  • DC Healthy Families Expansion Group for Parents/Caretaker Relatives : Parents except for pregnant women, and/or caretaker relatives of a child(ren) eligible for Medicaid whose income is below 200 percent of the FPL and who is ineligible for Medicaid under the TANF Standard and Medically Needy Families & Children Criteria; and
    
    
  • Transitional Medicaid: Parents, caretakers, pregnant women, and/or children under 19 who become ineligible for Medicaid under any category listed above because of an increase in earnings or child support are eligible for Transitional Medicaid Assistance (TMA). TMA is only available if increased earnings or child support cause persons in the group to exceed the income standard of 200 percent of FPL for parents and caretakers, and 300 percent of FPL for pregnant women and children under 19. Persons ineligible due to an increase in earnings are eligible for six months of TMA. Persons ineligible due to an increase in child support are eligible for four months of TMA
    
    
• Elderly/Disabled: The elderly or disabled can be eligible for full coverage if they meet one of the following criteria:
  
  
  • SSI Recipient: Supplemental Security Income (SSI) recipients (individuals receiving SSI are categorically eligible for Medicaid; see Chapter 12: Categorical Eligibility in Part IV);
    
    
  • Aged/Disabled: Individuals who are age 65 or older, blind, or disabled whose income is below 100 percent of the FPL and whose assets do not exceed twice the SSI standard (see Section 12.3: Who is Categorically Eligible in Part IV, and Section 1.6: Pickle Amendment, Section 1.7: Disabled Widow(er)s, and Section 1.8: Early Widowers in Part VII for a more extensive discussion); and
    
    
  • Individuals in a Long-Term Care (LTC) Facility: Medicaid pays some or all of the cost of a LTC facility for some low-income individuals.
    
    
• Medicare Beneficiaries: Some low-income Medicare beneficiaries, including persons receiving Title II benefits (Social Security), can receive assistance paying for some or all of their Medicare premiums, etc. Medicare beneficiaries eligible for this type of assistance are often referred to as participating in the 'Buy In' program, i.e. the Medicaid program is helping the individual 'buy into' the Medicare program. If not otherwise eligible for Medicaid (such as through the Aged/Disabled criteria above or based on their serving as a caretaker relative for a child), these individuals do not receive other Medicaid benefits or services.
  
  
  • QMB: A Medicare beneficiary whose income does not exceed 300 percent of the Federal Poverty Level is called a Qualified Medicare Beneficiary (QMB). For an individual eligible for Medicaid in the QMB category, the Medicaid program pays the following:
    
    
    • Medicare Part A deductible*,
    • Medicare Part B premium,
    • Annual Part B deductible*, and
    • Annual Part B Copayments*

* The District's policy restricts reimbursement to those infrequent situations where the total Medicare payment is less than the Medicaid fee schedule. Consequently, Medicaid rarely if ever pays these amounts. 

 

Note that effective November 1, 2008, there is no asset limit for QMB.

• SLIMB: A Medicare beneficiary whose income is at least 100 percent of the FPL and less than 300 percent of the Federal Poverty Level is called a Special Low-Income Medicare Beneficiary (SLIMB). For an individual eligible for Medicaid in the SLIMB category, the Medicaid program pays the Medicare Part B premium. (Note that effective July 1, 2005, SLIMB eligibility applies only to the month of application and the three months prior to the month of application, since the QMB income limit has been increased to include these customers for the period beginning with the month following the month of application.)

Note that effective November 1, 2008, there is no asset limit for SLIMB.

• QI-1: A Medicare beneficiary whose income is at least 120 percent of the FPL and less than 135 percent of the FPL and whose resources are no more than twice the SSI resource standard is called a QI-1. For an individual eligible for Medicaid in the QI-1 category, the Medicaid program pays the Medicare Part B premium. (Note that effective July 1, 2005, there are no QI-1 eligible customers, since the QMB and SLMB income limits have been increased to include these customers.)

For an individual eligible for MA as a QDWI, the Medicaid program pays the Medicare

Part A premium.

A Medicare beneficiary who is eligible under one of the above categories and is also eligible for Medicaid based on another eligibility criteria, such as an individual who is 65 years of age or older and has income below the poverty line, will receive assistance paying for Medicare premiums, etc. and will also receive Medicaid-provided services not covered under the Medicare program.

• Immigrants: Depending on their status, immigrants may be eligible for full-coverage Medicaid or emergency Medicaid services.
  
  
  • Refugee-Related Medicaid: Refugees, asylees, and certain other immigrants in their first eight months in the country are eligible for Medicaid if their income and assets are below the Medically Needy income and resource scales. IMA first determines eligibility under the AR/AX or SR programs and, if necessary, considers such persons under the Refugee-Related Medicaid program. Also, all persons receiving Refugee cash assistance are eligible for Refugee-Related Medicaid if they are not eligible for the AR/AX or SR programs.
    
  • Non-Qualified Immigrants: Immigrants ineligible for Medicaid due only to their immigration status are eligible for emergency Medicaid services. These services are described in Section 2.2.4: Benefit Provision in this Chapter.

Individuals who meet all non-financial Medicaid requirements and asset limits, if applicable, but whose income exceeds the Medicaid income eligibility limit may qualify for partial coverage of medical bills if they have unpaid medical bills. Such individuals are eligible through the 'spend down' Medicaid provisions (see Chapter 7: Spend-Down in Part VI).