Assigning Category of Eligibility 510-03-30-15

(Revised 6/1/2015 ML #3441)

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IM 5330

IM 5327

There are six (6) major Categories of Eligibility (COE), each of which have related categories that fall under them. The six major categories are:

Children Under age 19;

Healthy Steps (CHIP);

Parents, caretaker relatives and their spouses;

Pregnant Women;

Adults.

Former Foster Care Children

The following rules determine how to assign the COE for eligible individuals:

Children Under Age 21

COE
COE

Description
Rule to Assign COE

61 Extended ACA Children
The Child:

• Is under age 18 (through the month the child attains age 18)

• Is deprived due to the absence, disability, incapacity, age or unemployment/ underemployment of a parent;

• Resides with one or both natural or adoptive parents, or one non-parent caretaker relative;

• Not eligible under the ACA Medicaid Children Poverty Levels; AND

The child’s parent(s) or caretaker relative:

• Lost eligibility under the Parents and Caretaker Relative and their spouses Category due to increased alimony or spousal support; and

• Was eligible under the Parent, Caretaker Relative and their Spouses Category in at least three of the six months immediately preceding the month in which the Parents or Caretaker Relatives lost coverage under the Parents, Caretaker Relatives and their Spouses Category.

67 Children ages 0 thru 18 (including month turn age 19) -- other than MOE, Foster Care, Transitional, Extended, Med Needy or Healthy Steps
The Child:

• Is age 0 to 6 (including the month the child attains age 6);

• Was found eligible for ACA Medicaid with income at or below 152% of the Federal Poverty Level (FPL).

OR

• Is age 6 (month following month attains age 6) thru age 18 (including the month the child attains age 19);

• Was found eligible for ACA Medicaid with income at or below 138% of the Federal Poverty Level (FPL).

OR

• The child’s mother applied for Medicaid before the child's birth;

• The child is deprived due to the absence, disability, incapacity or age of a parent;

• The child is age 0 to 1 (including the month the child attains age 1);

87
ACA

Transitional

Children

The Child:

• Is under age 18 (through the month the child attains age 18)

• Resides with one or both natural or adoptive parents, or one non-parent caretaker relative;

• Not eligible under the ACA Medicaid Children Poverty Levels;

AND

The child's parent(s) or caretaker relative:

• Lost eligibility under the Parents and Caretaker Relative and their spouses category due to increased earned income or hours of employment;

• Was eligible under the Parent, Caretaker Relative and their Spouses Category in at least three of the six months immediately preceding the month in which the Parents or Caretaker Relatives lost coverage under the Parents, Caretaker Relatives and their Spouses Category.

95
Maintenance of Effort Child Absence Deprived (Age 6 to 19)

Healthy Steps (CHIP) to Medicaid

The Child:

• Is age 6 to 19 (month following month attains age 6 through the end of the month the child attains age 19);

• Was found eligible for ACA Medicaid with income between 111% and 133% of the FPL.

98 State or Tribal Foster Care (Non-IV-E)
The Child:

• Meets the definition of a Foster Care Child;

• Is eligible under regular Foster Care (non-Title IV-E, tribal or state-funded).

80 Child Age 0 to 21 (Medically Needy)
The Child:

• Is age 0 to 21 (including the month the child attains age 21);

• Has income above 152% of the FPL;

• Has a medical need that exceeds the calculated Client Share (Recipient Liability);

Healthy Steps (CHIP Children)

COE
COE

Description
Rule to Assign COE

78
Healthy

Steps

The Child is:

• Age 0 through age 18 (through the last day of the month in which child turns age 19);

• Is not eligible for full Medicaid Coverage;

• Does not have current creditable health insurance coverage;

• Coverage is not available through the child’s parents’ or legal guardians’ employer at no additional cost;

• The child did not have creditable health insurance coverage within the past 90 days;

• Has income between 152% and 175% of the FPL

Parents, Caretakers and their Spouses

COE
COE

Description
Rule to Assign COE

63
Parents, Caretaker Relatives (& their Spouses) of Deprived Children

The Parent(s) or Caretaker:

• Is the natural or adoptive parent, or a caretaker/relative within the 5th degree of relationship to a child under age 18 (through the month the child attains age 18);

• Has a child residing with them who is deprived due to the absence, disability, incapacity, age or unemployment/ underemployment of a parent;

• Has income below 54% of the FPL.

86
ACA

Transitional Parents

and Caretakers

The Parent(s) or Caretaker relative:

• Has at least one child residing with them who is deprived due to the absence, disability, incapacity, age or unemployment/ underemployment of a child under age 18 (through the month the child attains age 18);

• Lost eligibility under the Parents and Caretaker Relative and their Spouses category due to increased earned income or hours of employment; and

• Was eligible under the Parent, Caretaker Relative and their Spouses category in at least three of the six months immediately preceding the month in which the Parents or Caretaker Relatives lost coverage under the Parents, Caretaker Relatives and their Spouses Category.

Pregnant Women

COE
COE

Description
Rule to Assign COE

66
Pregnant

Woman

(Categorically

Needy)

A woman who is:

• Pregnant and through the end of the month in which the 60th post-partum day fails;

• Has income at or below 152% of the FPL.

79
Pregnant

Woman

(Medically Needy)

A woman who is:

• Pregnant and through the end of the month in which the 60th post-partum day fails;

• Has income above 152% of the FPL;

• Has a medical need that exceeds the calculated Client Share (Recipient Liability).

Adults
1. Adult Expansion

COE
COE

Description
Rule to Assign COE

76
Adult

Expansion

Category

Individual is:

• Age 19 through age 64 (month following the month attained age 19 and month prior to attaining age 65);

• Not eligible under the Parent/Caretaker or Pregnant Woman Category;

• Not eligible under the Adults age 19 and 20 Category;

• Not eligible as Medically Frail;

• Has income at or below 138% of the FPL.

Adults age 19 and 20

COE
COE

Description
Rule to Assign COE

62
Adult

Age 19 and 20

The Adult:

• Must be age 19 or 20 (month following month attains age 19 through the month attains age 21);

• Is NOT pregnant;

• Has no children

• Pass the Adult Expansion Group BUT have income less than 90% of FPL

Medically Frail

COE
COE

Description
Rule to Assign COE

58
Adults Medically

Frail- Non-institutionalized

The Individual is:

• Age 19 through 64 (month following month attains age 19 through the month prior to the month attains age 65);

• Passes the Adult Expansion Group criteria;

• Determined Medically Frail;

• Not residing in an Institution;

• Income at or below 85% of FPL.

59
Adults Medically

Frail- Non-

Institutionalized

Individual is:

• Age 19 through 64 (month following month attains age 19 through the month prior to the month attains age 65);

• Passes the Adult Expansion Group criteria;

• Determined Medically Frail;

• Not residing in an Institution;

• Income above 85% of FPL.

60
Adults

Medically

Frail-

Institutionalized

Individual is:

• Age 19 through 64 (month following month attains age 19 through the month prior to the month attains age 65);

• Passes the Adult Expansion Group criteria;

• Determined Medically Frail;

• Residing in an Institution;

• Income at or below 85% of FPL.

65
Adults

Medically

Frail-

Institutionalized

Individual is:

• Age 19 through 64 (month following month attains age 19 through the month prior to the month attains age 65);

• Passes the Adult Expansion Group criteria;

• Determined Medically Frail;

• Residing in an Institution;

• Income above 85% of FPL.

77
Adults

Medically

Frail- Non-

Institutionalized

Managed Care

Individual is:

• Age 19 through 64 (month following month attains age 19 through the month prior to the month attains age 65);

• Passes the Adult Expansion Group criteria;

• Determined Medically Frail;

• Not residing in an Institution;

• Income at or below 85% of FPL.

89
Adults

Medically

Frail- Non-

Institutionalized

Managed Care

Individual is:

• Age 19 through 64 (month following month attains age 19 through the month prior to the month attains age 65);

• Passes the Adult Expansion Group criteria;

• Determined Medically Frail;

• Not residing in an Institution;

• Income above 85% of FPL.

Former Foster Care Children

COE
COE

Description
Rule to Assign COE

91
Former Foster

Care Child

The Child:

• Was in North Dakota Foster Care (including Tribal 638 children) and on ND Medicaid (Title IV-E, state-funded(non-IV-E) or tribal) in the month he/she turned age 18;

• Is under age 26 (through the month attaining age 26);

• Is not eligible for Medicaid under:

The Parent, Caretaker Relative and the Spouse coverage,

Pregnant Woman coverage, or

Children (up to age 19) coverage.

NOTE: An individual age 18 through 21 whom voluntarily sign him/herself back into Foster Care would also be assigned the COE of M091.

COE	COE Description	Rule to Assign COE
61	Extended ACA Children	The Child: • Is under age 18 (through the month the child attains age 18) • Is deprived due to the absence, disability, incapacity, age or unemployment/ underemployment of a parent; • Resides with one or both natural or adoptive parents, or one non-parent caretaker relative; • Not eligible under the ACA Medicaid Children Poverty Levels; AND The child’s parent(s) or caretaker relative: • Lost eligibility under the Parents and Caretaker Relative and their spouses Category due to increased alimony or spousal support; and • Was eligible under the Parent, Caretaker Relative and their Spouses Category in at least three of the six months immediately preceding the month in which the Parents or Caretaker Relatives lost coverage under the Parents, Caretaker Relatives and their Spouses Category.
67	Children ages 0 thru 18 (including month turn age 19) -- other than MOE, Foster Care, Transitional, Extended, Med Needy or Healthy Steps	The Child: • Is age 0 to 6 (including the month the child attains age 6); • Was found eligible for ACA Medicaid with income at or below 152% of the Federal Poverty Level (FPL). OR • Is age 6 (month following month attains age 6) thru age 18 (including the month the child attains age 19); • Was found eligible for ACA Medicaid with income at or below 138% of the Federal Poverty Level (FPL). OR • The child’s mother applied for Medicaid before the child's birth; • The child is deprived due to the absence, disability, incapacity or age of a parent; • The child is age 0 to 1 (including the month the child attains age 1);
87	ACA Transitional Children	The Child: • Is under age 18 (through the month the child attains age 18) • Resides with one or both natural or adoptive parents, or one non-parent caretaker relative; • Not eligible under the ACA Medicaid Children Poverty Levels; AND The child's parent(s) or caretaker relative: • Lost eligibility under the Parents and Caretaker Relative and their spouses category due to increased earned income or hours of employment; • Was eligible under the Parent, Caretaker Relative and their Spouses Category in at least three of the six months immediately preceding the month in which the Parents or Caretaker Relatives lost coverage under the Parents, Caretaker Relatives and their Spouses Category.
95	Maintenance of Effort Child Absence Deprived (Age 6 to 19) Healthy Steps (CHIP) to Medicaid	The Child: • Is age 6 to 19 (month following month attains age 6 through the end of the month the child attains age 19); • Was found eligible for ACA Medicaid with income between 111% and 133% of the FPL.
98	State or Tribal Foster Care (Non-IV-E)	The Child: • Meets the definition of a Foster Care Child; • Is eligible under regular Foster Care (non-Title IV-E, tribal or state-funded).
80	Child Age 0 to 21 (Medically Needy)	The Child: • Is age 0 to 21 (including the month the child attains age 21); • Has income above 152% of the FPL; • Has a medical need that exceeds the calculated Client Share (Recipient Liability);