South Carolina Code of Regulations
Chapter 126 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
Article 3 - MEDICAID
Subarticle 2 - ELIGIBILITY FOR THE MEDICAL ASSISTANCE (MEDICAID) PROGRAM
Section 126-365 - Categorically Needy Eligible Groups

Universal Citation: SC Code Regs 126-365

Current through Register Vol. 48, No. 9, September 27, 2024

A. Medicaid eligible persons through the Aid to Families With Dependent Children (AFDC) program are:

(1) All persons in the AFDC budget group.

(2) All children for whom the State makes an adoption assistance or foster care maintenance payment under Title IV E of the Social Security Act.

(3) Families terminated from AFDC because of increased earnings or hours of employment as provided for and limited by Title XIX of the Social Security Act and the federal regulations promulgated in accordance therewith.

(4) Individuals who are denied a cash payment solely because the amount of the AFDC payment would be less than $10.

(5) Pregnant women who would be eligible for an AFDC cash payment if the child had been born and was living with her in the month of payment and the pregnancy has been medically verified. Income shall be measured against the AFDC total requirements standard for one person.

(6) Individuals who are ineligible for AFDC because of requirements that do not apply under Title XIX of the Social Security Act. These individuals are identified in the Title XIX State Plan for Medical Assistance.

B. Individuals Under Twenty-one (21) With Special Living Arrangements.

(1) Medicaid is available to individuals who are younger than twenty-one (21) years of age, residing within or outside the State in foster homes or private institutions licensed by the Department of Social Services, or who live in foster care homes or institutions licensed by other state agencies, but whose standards have been approved by the Department of Social Services. To be Medicaid eligible, the individual must receive a regular foster care board payment, or a payment for maintenance under a Social Services Block Grant (SSBG) contract, or be supported fully or partially from public funds of any State or local agency. The income and resources available to the individual shall not exceed the appropriate foster home care board payment standard for the individual's age and the AFDC resource limitation.

(2) Hospitalization prior to placement in a substitute care facility may be necessary in certain situations. As long as it is planned for the individual to enter foster care upon release from the hospital and the individual meets all other eligibility criteria for Medicaid as an individual under twenty-one (21) with special living arrangements, the individual may be certified for Medicaid while in the hospital.

(3) An individual who is placed in foster care in emergency placement status under SSBG may be eligible for Medicaid while in the emergency placement, public or private, as long as all eligibility criteria for Medicaid as an individual under twenty-one (21) with special living arrangements are met.

(4) Individuals who are younger than twenty-one (21) years of age and who reside in a public institution or who are inmates of a penal or correctional institution, or of institutions licensed by penal or correctional agencies, are not eligible for Medicaid. Such individuals are not eligible for Medicaid when they are temporarily absent from such institution while residing in a maternity home, foster care home or facility, or a medical facility.

C. Supplemental Security Income (SSI) Recipients.

(1) All individuals, including their categorically eligible spouses, who receive SSI benefits are eligible for Medicaid.

(2) Individuals eligible as essential spouses in December 1973 are eligible for Medicaid. Eligibility is determined in accordance with Title XIX of the Social Security Act and the federal regulations promulgated in accordance therewith.

(3) SSI recipients who are in suspense status due to the development of a representative payee for the individual are eligible for Medicaid.

D. Optional State Supplement (OSS) Recipients. All individual who receive an OSS payment are eligible for Medicaid.

E. Refugee Assistance Recipients.

(1) All persons whose needs are included in a Refugee Assistance payment are eligible for Medicaid.

(2) All persons who are eligible to be included in a Refugee Assistance payment because of limited income and resources, but who desire to receive medical assistance only are eligible for Medicaid.

(3) Refugees who are determined to be medically needy by the "spend-down" method are eligible for Medicaid.

F. 1977 Title II Pass-Along Provision of the Social Security Act. Medicaid is available under this provision to those individuals who lost their eligibility for cash assistance due to a Social Security cost-of-living increase and who meet the requirements of Title XIX of the Social Security Act and the federal regulations promulgated in accordance therewith.

G. Individuals Who Would Be Eligible for Cash Assistance If Outside the Institution.

(1) Medicaid is available to individual who would be eligible for cash assistance if they were not residing in an institution provided they meet the eligibility requirements of Title XIX of the Social Security Act and the federal regulations promulgated in accordance therewith.

(2) Individuals who have no income may also be eligible under this provision provided they have applied for and are awaiting receipt of payment under the SSI program.

H. Institutionalized Individuals Who Are Eligible Under a Special Income Level.

(1) An individual may be eligible for MAO, including a medical institution vendor payment, if he meets all of the following requirements:
(a) Resides in a Title XIX certified medical facility and meets the requirements to be considered institutionalized as defined by Title XIX of the Social Security Act and the federal regulations promulgated in accordance therewith;

(b) Meets SSI criteria for either age, disability or blindness;

(c) Meets all SSI financial eligibility criteria except for the income limitation;

(d) Has been certified by CLTC for the level of care in which he resides.

(2) SSI categorical and financial eligibility criteria are found in Title XVI of the Social Security Act and in the Program Operations Manual System published by the Social Security Administration, U.S. Department of Health and Human Services.

(3) To be eligible for MAO as an aged, blind or disabled person, an individual's or couple's gross monthly income shall not exceed the Medicaid Cap. Gross monthly income is the individual's or couple's total earned and unearned income as defined under the federal regulations of the SSI Program.

(4) An income averaging procedure shall be used for individuals who receive Medicaid and who receive variable income.

I. Individuals receiving Home and Community based Services Who Are Eligible Under a Special Income Level.

(1) An individual living in the community may be eligible for MAO if he meets all of the following requirements:
(a) Meets SSI criteria for either age, disability or blindness;

(b) Meets all SSI financial eligibility criteria except for the income limitation;

(c) Has been certified by CLTC to be eligible for skilled or intermediate nursing care;

(d) Receives home and community based services provided under a home and community-based waiver.

(2) The criteria found in 126.365 H. (2) through (4) apply to these individuals.

(3) An individual must apply all available income, less allowable exclusions to the cost of waivered services. The amount of income to be applied to the cost of waivered services shall be determined in accordance with Title XIX of the Social Security Act and the federal regulations promulgated in accordance therewith.

J. Pregnant women and children with family income below the poverty level.

(1) An individual eligible for Medicaid under this category is one who--
(a) is a pregnant woman whose pregnancy has been medically verified; or, is a child under the age of one year (or as otherwise specified in the Title XIX State Plan); and

(b) has a countable family income, as determined in accordance with Title XIX of the Social Security Act and federal regulations promulgated in accordance therewith, which is below 100 percent of the federal poverty level (or as otherwise specified in the Title XIX State Plan) for the appropriate family size; and

(c) meets all non-financial criteria required by Title XIX of the Social Security Act and federal regulations promulgated in accordance therewith.

(2) A pregnant woman who is determined eligible under this category is eligible throughout the term of her pregnancy and remains eligible for sixty (60) days after the end of her pregnancy, regardless of changes in income.

K. Medicaid is available to children under age eighteen (18) who meet AFDC income and resource standards. Eligibility is determined in accordance with Title XIX of the Social Security Act and the federal regulations promulgated in accordance therewith.

L. Children for whom there is in effect a State adoption assistance agreement. An individual eligible for Medicaid under this category is one whom:

(1) the State adoption agency has determined cannot be placed for adoption without medical assistance because of special needs for medical or rehabilitative care; and

(2) before the execution of the agreement, had such special need and would have been eligible for Medicaid if the standards and methodologies of the Title IV-E foster care program were applied.

M. Aged, blind and disabled individuals with income below the poverty level.

(1) An individual eligible for Medicaid under this category is one who:
(a) meets SSI criteria for either aged, disability or blindness;

(b) has countable income, as determined in accordance with Title XIX of the Social Security Act and federal regulations promulgated in accordance therewith, which is below 100 percent of the federal poverty level (or as otherwise specified in the Title XIX State Plan);

(c) has countable resources, as determined in accordance with Title XIX of the Social Security Act and federal regulations promulgated in accordance therewith, which is below the level specified in the Title XIX State Plan; and

(d) meets all non-financial criteria required by Title XIX of the Social Security Act and federal regulations promulgated in accordance therewith.

(2) As allowed by Section 1902(r)(2) of the Social Security Act, the State has elected to use special methodologies to determine income and resource eligibility. These methodologies are specified in the Title XIX State Plan.

N. Certain disabled children age 18 or under who are living at home.

(1) Children eligible for Medicaid under this category are children who:
(a) live at home;

(b) would be eligible for Medicaid under the plan if they were in a medical institution;

(c) meet the Supplemental Security Income definition of disability; and

(d) have been determined by the State to meet the requirements of Section 1902(e)(3)(B) of the Social Security Act regarding the appropriateness and cost effectiveness of care.

(2) Only the income and resources of the children are considered in the financial eligibility determination. Financial eligibility is determined in accordance with Title XIX of the Social Security Act and federal regulations promulgated in accordance therewith.

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