Several overriding rules control the creation and application of Medicaid eligibility criteria by the states. These rules are applicable to all mandatory and optional coverage groups, as well as all medically needy individuals. First, a state may not impose any eligibility requirements prohibited by Title XIX. Next, the state must base coverage or optional coverage groups on reasonable classifications that do not result in arbitrary or inequitable treatment of individuals or groups, and the coverage must in consistent with the objectives of Title XIX. For optional coverage of families and children, a state can not use eligibility requirements more restrictive than those used in the state’s AFDC program. Finally, for optional coverage of the aged, blind, and disabled, a state can not use eligibility requirements more restrictive than those of the SSI program, unless the state has elected the § 209(b) option of applying more restrictive reqmrements. The applicable code sections are 42 U.S.C. § 1396a(a)(10)(C)(i) and § 1396a(r)(2)(A) & (B). (See text below).
The following is a non-exhausting list of cases citing these limitations with results being mixed. Some court cite these sections as absolute bars to more restrictive eligibility criteria in non-209(b) States, while others find they do not apply to MCCA protections for the Community Spouse.
Gardner v. Ohio Dep’t of Job and Family Services (Ohio Ct. App., Appeal No. C-210376 (6/15/2022)
42 U.S.C. 1396a(r)(2)(a) provides, The methodology to be employed in determining income and resource eligibility for individuals under subsection * * * (a)(10)(A)(ii) * * * may be less restrictive, and shall be no more restrictive, than the methodology— … “In other words, if an applicant would be eligible for SSI, but not for Medicaid, then the Medicaid regulations are too restrictive.”
Tex. HHS Comm’n v. Estate of Burt, 2022 Tex. App. LEXIS 2556
The methodology used in Medicaid calculations must be no more restrictive than that used in Social Security calculations, 42 U.S.C. § 1396a(r), and a “methodology is considered to be ‘no more restrictive’ if, using the methodology, additional individuals may be eligible for medical assistance and no individuals who are otherwise eligible are made ineligible for such assistance,” id. § 1396a(r)(2)(B).
In re Geyen v. Comm’r of Minn. Dep’t of Human Servs., 964 N.W.2d 639 (2021)
In addition to following federal rules regarding treatment of trust assets, a state’s methodology for determining Medicaid eligibility for the medically needy must be “no more restrictive” than the federal test used to determine eligibility for SSI. See 42 U.S.C. § 1396a(a)(10)(C)(i)(III) (providing requirements for a state’s standard for determining who is medically needy). A state’s methodology is “no more restrictive” than its federal counterpart “if, using the methodology, additional individuals may be eligible for medical assistance and no individuals who are otherwise eligible are made ineligible for such assistance.” Id. (r)(2)(B)….In Lewis v. Alexander, Pennsylvania government officials argued that a Pennsylvania statute governing so-called “special needs trusts” was not preempted by the “no-more-restrictive rule” established in 42 U.S.C. §§ 1396a(a)(10)(C)(i)(III) and 1396a(r)(2)(B) because the Pennsylvania statute was “not directed toward Medicaid eligibility but rather represent[ed] part of Pennsylvania’s general regulations of trusts.” 276 F.R.D. 421, 429, 437 (E.D. Pa. 2011), aff’d in part and rev’d in part on other grounds, 685 F.3d 325 (3d Cir. 2012).
Rose v. Brown, 14 F.4th 1129 (10th Cir. 2021)
Oklahoma must extend Medicaid eligibility at least as far as eligibility for Supplemental Security Income. 42 U.S.C. §§ 1396a(a)(10)(C)(i)(III), 1396a(r)(2); Houghton ex rel. Houghton v. Reinertson, 382 F.3d 1162, 1170 (10th Cir. 2004). So when identifying resources for the purposes of Medicaid, we consider the rules for Supplemental Security Income. 42 U.S.C. § 1382b.
Dermody v. Exec. Office of HHS, 2020 Mass. Super. LEXIS 5 (2020)
The court notes that there are Massachusetts regulations that mimic the federal Medicaid statutes; however, because Massachusetts must comply with the federal guidelines, for ease of analysis, the court refers only to the relevant federal statutes from here on out in its analysis. See generally 42 U.S.C. §1396a(r)(2)(A) (in determining income eligibility, states cannot be more restrictive than federal methodology).
G.C. v. Div. of Med. Assistance & Health Servs., 463 N.J. Super. 79 (2020)
The methodology used by a state to determine “eligibility for optional categorically needy applicants may be less restrictive, but may not be more restrictive, than the methodology used to determine eligibility for SSI applicants.” Mistrick, 154 N.J. at 168, 712 A.2d 188 (citing 42 U.S.C. § 1396a(r)(2)(A))…. As noted, while Title XIX prohibits any state from adopting more “restrictive” eligibility requirements, states are free to adopt less restrictive requirements that make additional individuals eligible for benefits. Mistrick, 154 N.J. at 168, 712 A.2d 188 (citing 42 U.S.C. § 1396a(r)(2)(B)). Subsequent appellate history at G.C. v. Div. of Medical Assistance and Health Services, 249 N.J. 20 (2021).
Cushing v. Jacobs, 2020 U.S. Dist. LEXIS 51351 (D. N.J. 2020)
Whether the Annuity at issue is considered “revocable” under the Federal SSI standards—the most restrictive standards permissible to determine Medicaid eligibility—is a strictly legal issue. See 42 U.S.C. § 1396a(r)(2)(A)…. But 42 U.S.C. § 1382b(e)(3)(B) explicitly applies to irrevocable trusts and “[t]he term ‘trust’ . . . includes an annuity only to such extent and in such manner as the [HHS] Secretary specifies.” 42 U.S.C. § 1396p(d)(6). “[B]ecause the Secretary to date has not so specified, it follows that [annuities] cannot be treated as trusts.” Zahner v. Sec’y Pa. Dep’t of Human Servs., 802 F.3d 497, 510 (3d Cir. 2015). Thus, the ALJ Decision erroneously relies on an inapplicable law.
Todd v. Jones, 2019 U.S. Dist. LEXIS 77361 (D. N.D. 2019)
Todd relies on 42 U.S.C. §§ 1396a(a)(10)(C)(i) and (r)(2)(B) to support her argument that the Department is violating federal law by considering a trust with a valid spendthrift provision as an available resource. Section 1396a(a)(10)(C)(i) requires Medicaid eligibility criteria be “no more restrictive” than the criteria used to determine SSI eligibility. Section 1396a(r)(2)(B) defines the term “no more restrictive” in this context. However, as explained below, Congress has provided states with a limited exception—termed the “209(b) option”—that exempts states from this requirement. See 42 U.S.C. § 1396a(f).
May v. Azar, 302 So. 3d 222 (2019)
In other words, the Agency “may not establish Medicaid resource and income methodologies which are more restrictive than those under SSI.” Primo, 579 So. 2d at 1358. As hereinafter discussed, however, the present case does not involve a resource standard established by the Agency; the present case involves a resource standard established by federal law, specifically § 1396r-5.
Ind. Family & Soc. Servs. Admin. v. Patterson, 119 N.E.3d 99 (2019)
The federal Department of Health and Human Services (“HHS”) has promulgated regulations establishing financial eligibility requirements for Medicaid applicants and recipients. A state may opt to use a less restrictive income methodology, so long as its methods do not result in granting Medicaid benefits to those whose income, as calculated using SSI standards, exceeds the “special income level.” See 42 U.S.C. § 1382a; 42 U.S.C. § 1396a(r)(2); 42 C.F.R. § 435.601(d)(1)(ii), (d)(2). A state’s plan must specify whether it will use the relevant federal standard or a less-restrictive standard. 42 C.F.R. § 435.601(f). Indiana has adopted the federal rule, not a less-restrictive option. Specifically, 405 Indiana Administrative Code section 2-1.1-5(a) states, “Individuals declared eligible for benefits by reason of age, disability, or blindness are subject to the income definition and exclusions set forth in 42 U.S.C. 1382a and 20 CFR Part 416, Subpart K Income.”
Kadingo v. Johnson, 2017 U.S. Dist. LEXIS 128778 (D. Colo 2017)
“In determining a person’s eligibility for Medicaid, states must use reasonable standards that only factor in income and resources which are available to the recipient and which would affect the person’s eligibility for [Supplemental Security Income (“SSI”)].” Brown ex rel. Brown v. Day, 555 F.3d 882, 885 (10th Cir. 2009) (citing 42 U.S.C. § 1396a(a)(17)); see also 42 U.S.C. § 1396a(r)(2)(A)(i) (forbidding states from employing eligibility methodologies that would render an individual ineligible for Medicaid where that individual is eligible for SSI).
Simonsen v. Bremby, 679 Fed. Appx. 57 (2nd Cir. 2017)
Federal law requires that state Medicaid plans adopt eligibility methodologies that are no more restrictive than that used for the federal SSI program. See 42 U.S.C. § 1396a(r)(2)(A)(i); id. § 1396a(r)(2)(B) (explaining that no-more-restrictive requirement is met if, “using the methodology, additional individuals may be eligible for medical assistance and no individuals who are otherwise eligible are made ineligible for such assistance”).
Simonsen v. Bremby, 2015 U.S. Dist. LEXIS 171099 (d. Conn. 2015)
The Medicaid Act prohibits DSS from employing a methodology for determining income and resource eligibility that is more restrictive than the methodology which would be employed under the SSI program, as administered by the United States Social Security Administration (the “SSA”). See 42 U.S.C. §§ 1396a(a)(10)(C)(i), 1396a(r)(2).
Zahner v. Sec’y Pa. Dep’t of Human Servs., 802 F.3d 497 (3rd Cir. 2015)
States that elect to participate in the Medicaid program must comply with eligibility requirements set by the federal government. The Medicaid Act permits states to establish eligibility requirements that are more liberal than those of the federal government, however states may not create more restrictive requirements. 42 U.S.C. § 1396a(a)(10)(C)(i)(III). A state law is considered “no more restrictive” if “additional individuals may be eligible for medical assistance and no individuals who are otherwise eligible are made ineligible for such assistance.” Id. § 1396a(r)(2)(B). “[O]nce the state voluntarily accepts the conditions imposed by Congress, the Supremacy Clause obliges it to comply with federal requirements.” Lankford v. Sherman, 451 F.3d 496, 510 (8th Cir. 2006) (citations omitted); see also Lewis, 685 F.3d at 332 (“No State is obligated to join Medicaid, but if they do join, they are subject to federal regulations governing its administration.” (citation omitted)).
Aplin v. McCrossen, 2014 U.S. Dist. LEXIS 119682 (W.D. N.Y. 2014)
“New Medicaid Transfer of Asset Rules under the Deficit Reduction Act of 2005”; (2) § 3258.10(c)(3),14Link to the text of the note a provision of the CMS Medicaid Manual, a policy compendium binding on State Medicaid programs, provides that “When a penalty has been assessed…a return of the assets requires a retroactive adjustment, including erasure of the penalty, back to the beginning of the penalty period…” (emphasis supplied by Plaintiffs); and (3) 42 U.S.C. § 1396a(a)(10)(C)(i)(III)15Link to the text of the note and 1396a(r)(2)(B)16Link to the text of the note require State Medicaid programs to use methodologies for evaluating resources that are no more restrictive than those used by the Supplemental Security Income (“SSI”) program policy as set forth in 42 U.S.C. §§ 1396a(a)(10)(C)(i)(III) and 1396a(r)(2)(B).
Galletta v. Velez, 2014 U.S. Dist. LEXIS 75248 (D. N.J. 2014)
Pursuant to 42 U.S.C. § 1396a(r)(2), the definition of income for purposes of SSI eligibility also applies to Medicaid eligibility. See Sherman v. Griepentrog, 775 F. Supp. 1383, 1385 (D. Nev. 1991) (“the term ‘income’ is not defined in the Medicaid statute itself (42 U.S.C. § 1396a et seq.) but instead by reference to the related financial assistance program, Supplemental Security Income.”) (citing 42 U.S.C. § 1396a(r)(2)).
Ark. Dep’t of Human Servs. v. Pierce, 2014 Ark. 251 (2014)
“[S]tate methodologies for determining eligibility must be ‘no more restrictive’ than the federal methodology that would be employed under the supplemental security income [SSI] program.” Geston v. Anderson, 729 F.3d 1077, 1079 (8th Cir. 2013); 42 U.S.C. § 1396a(a)(10)(C)(i). “A State’s methodology is considered ‘no more restrictive’ if ‘additional individuals may be eligible for medical assistance and no individuals who are otherwise eligible are made ineligible for such assistance.'” Geston, 729 F.3d at 1079; § 1396a(r)(2)(B). (Then concluding that MCCA supersedes the “no more restrictive” provision).
Gragert v. Lake, 541 Fed. Appx. 853 (10th Cir. 2013)
The MCCA directs that in determining Medicaid eligibility, state agencies must use criteria that are “‘no more restrictive’ than the eligibility requirements under the Supplemental Security Income (SSI) Act.” Houghton, 382 F.3d at 1170 (quoting 42 U.S.C. § 1396a(r)(2)(A)); see also Lopes, 696 F.3d at 182-83 (noting the same directive in 42 U.S.C. § 1396a(a)(10)(C)(i)); James, 547 F.3d at 218 (same). Thus, the SSI regulation that defines what constitutes a resource, 20 C.F.R. § 416.1201, properly guides the analysis here. See Lopes, 696 F.3d at 183; James, 547 F.3d at 218; see also Morris, 685 F.3d at 930, 932-33. Under that regulation, “[i]f the individual has the right, authority or power to liquidate the property . . . , it is considered a resource,” but if not, “the property will not be considered a resource.” 20 C.F.R. § 416.1201(a)(1). Property is “liquid” and thus a “resource” if it “can be converted to cash within 20 days.” Id. § 416.1201(b).
Geston v. Anderson, 729 F.3d 1077 (8th Cir. 2013)
Medicaid provides federal funding to States that assist certain needy individuals in obtaining medical care. See 42 U.S.C. § 1396a(a)(10). “[D]esigned to advance cooperative federalism,” the federal Medicaid program not only gives States the option of participating but also gives participating States significant flexibility in defining many facets of their systems. Wisc. Dep’t of Health & Family Servs. v. Blumer, 534 U.S. 473, 495, 122 S. Ct. 962, 151 L. Ed. 2d 935 (2002). But to receive funding, participating States must comply with federal statutes and regulations promulgated by the Secretary of the Department of Health and Human Services governing such aspects as who is eligible for care, what services are available, and at what cost those services are provided. Nat’l Fed’n of Indep. Bus. v. Sebelius, 132 S. Ct. 2566, 2581, 183 L. Ed. 2d 450 (2012). One such requirement is that state methodologies for determining eligibility must be “no more restrictive” than the federal methodology that would be employed under the supplemental security income program. 42 U.S.C. § 1396a(a)(10)(C)(i). A State’s methodology is considered “no more restrictive” if “additional individuals may be eligible for medical assistance and no individuals who are otherwise eligible are made ineligible for such assistance.” Id. § 1396a(r)(2)(B).
A.C. v. E.C., 68 A.3d 265 (2013)
States that participate in the Medicaid program have the option of developing their own methodologies for determining available income, but their methodologies can be “no more restrictive than the methodology…under the Supplemental Security Income [SSI] program under Title XVI.” 10Link to the text of the note There is no federal statute or regulation which grants an explicit exemption from available income for court-ordered maintenance payments, 11Link to the text of the note however, under the SSI statutes, court-ordered maintenance payments may be considered available income to the payor, as nothing in the Federal Medicaid statute precludes a state from being less restrictive in requirements than the SSI program. 12Link to the text of the note Therefore, while federal law does not explicitly exempt alimony from available income, a state may choose to exempt alimony from its determination of available income in the standards set forth by the state for determining income under the state’s Medicaid program.
M.F. v. Div. of Med. Assistance, 2013 N.J. Super. Unpub. LEXIS 2069 (2013)
However, the State may not apply a more restrictive methodology for evaluating eligibility than is provided in federal law, 42 U.S.C.A. § 1396a(r)(2)(A), or take any actions regarding Medicaid that are inconsistent with the federal law and regulations. See, e.g., F.K., supra, 374 N.J. Super. at 133.
Holmes v. R.I. Dep’t of Human Servs., 2012 R.I. Super. LEXIS 138 (2012)
“The purpose of the Medicaid program is to furnish medical assistance to disabled individuals who are without funding to meet the necessary medical costs.” Social Security Act, § 1910, as amended, 42 U.S.C. § 1396. Title XIX requires states to establish a plan to be approved by the United States Department of Health and Human Services in order for the state to qualify for federal funding. 42 U.S.C. § 1396 et seq.; §§ 40-8-1(c), 40-8-5. Thus, DHS is bound by the guidelines of the Supplemental Security Income (SSI) program as established by the federal government. See 42 U.S.C. § 1396, et seq.; Social Security Act § 1902(R)(2)(a); Tierney v. Dep’t of Human Services, 793 A.2d 210, 211 (R.I. 2002).
Joyner v. N.C. HHS, 214 N.C. App. 278 (2011)
In his brief, Mr. Joyner argues that DHHS was prohibited from utilizing an approach to determining whether a particular transfer was uncompensated that was more restrictive than the rules applied in determining eligibility for the Supplemental Security Income (SSI) program, 42 U.S.C. § 1396a(a)(10)(C)(i)(III), and that the calculation of the lump sum amount specified in the agreement between Ms. Joyner and Mr. Joyner was calculated consistently with the Program Operations Manual System employed by that program. However, the rules upon which this aspect of Mr. Joyner’s argument rely only apply to the determination of “income and resource eligibility.” 42 U.S.C. § 1396a(r)(2)(B). As a result of the fact that the methodology utilized in connection with the imposition of a transfer sanction is not relevant to the determination of Medicaid “income and resource eligibility,” this aspect of Mr. Joyner’s argument lacks merit.
Sable v. Velez, 388 Fed. Appx. 235 (3rd Cir. 2010)
Appellants claim the District Court committed legal error when it held the promissory notes can be treated as trust-like devices under Medicaid. They argue such treatment violates the Medicaid statute’s comparability provisions, which require a state’s methodology for calculating income and resource eligibility to be “no more restrictive” than the methodology used for Supplemental Security Income (SSI). 42 U.S.C. §§ 1396a(a)(10)(C)(i)(III), 1396a(r)(2). A methodology is “considered to be ‘no more restrictive’ if, using the methodology, additional individuals may be eligible for medical assistance and no individuals who are otherwise eligible are made ineligible for such assistance.” § 1396a(r)(2)(B). The Department may employ a different methodology, as long as it is no more restrictive.
J.P. v. Mo. State Family Support Div., 318 S.W.3d 140 (2010)
Federal regulations provide that “[i]n determining the eligibility of individuals under the income standards established under this section, the agency must not take into account income that would be disregarded in determining eligibility for SSI or for an optional State supplement.” 42 C.F.R. § 435.622(b). Federal statutory law further provides that “[t]he methodology utilized to determine eligibility for services by the state cannot be more restrictive than the methodology utilized by the federal government.” Plumb v. Mo. Dept. of Soc. Servs., Family Support Div., 246 S.W.3d 475, 479 (Mo. App. E.D. 2007) (citing 42 U.S.C. § 1396a(r)(2)(A)).
E.S. v. Division of Medical Assistance & Health Services, 412 N.J. Super. 340 (2010)
Petitioner also contends that the State cannot adopt a methodology more restrictive for Medicaid purposes than that which is authorized for payment of SSI benefits. This argument also lacks merit. SSI statutes and regulations do not address nursing home care benefits for persons over sixty-five. 42 U.S.C.A. § 1381a; 42 U.S.C.A. § 1382c. Therefore, the fact that 42 U.S.C.A. § 1396a(r)(2)(A) states that methodologies employed in determining income and resource eligibility may not be more restrictive than those for SSI is not relevant to these issues. Furthermore, the argument was not made either before the ALJ or the Director. We therefore do not address it further. Nieder v. Royal Indem. Ins. Co., 62 N.J. 229, 234, 300 A.2d 142 (1973).
Plumb v. Mo. Dep’t of Soc. Servs., 246 S.W.3d 475 (2007)
The methodology utilized to determine eligibility for services by the state cannot be more restrictive than the methodology utilized by the federal government. 42 U.S.C. § 1396a(r)(2)(A). The state is permitted, however, to employ methodologies which are less restrictive than those utilized by the federal government. Id. Missouri has elected to participate in the federal Medicaid program. Maples v. Dep’t. of Soc. Serv., 11 S.W.3d 869, 872 n.3 (Mo. App. S.D. 2000).
Rome v. Wilson-Coker, 2007 Conn. Super. LEXIS 2779 (2007)
A succinct explanation of the interrelationship between the eligibility requirements of Title XIX, Medicaid, and SSI is set forth in a recent United States District Court case, Brown v. Day, 434 F.Sup.2d 1035 (D.Kan. 2006). The court stated: “In determining income and resource eligibility for Medicaid, states may not employ a methodology which renders an individual ineligible for Medicaid where that individual would be eligible for SSI. See 42 U.S.C. § 1396a(r)(2)(A)(i). In addition, states must use reasonable standards for determining eligibility which only take into account income and resources which are available to the recipient and which would not be disregarded in determining eligibility for SSI. 42 U.S.C. § 1396a(a)(17). For SSI purposes, if an individual has no authority to liquidate a property right, it is not considered an ‘available resource.’ 20 C.F.R. § 416.1201(a)(1). Social Security Administration guidance further explains that a trust is an ‘available resource’ only if the beneficiary has the legal authority to compel the use of trust assets for her own support and maintenance. See Social Security Administration, Program Operating Manual System (‘POMS’) § S01120.200(D)(2).” Brown, 434 F.Sup.2d at 1037-38.
I.G. v. Department of Human Services, Div. of Medical Assistance and Health Services, 386 N.J. Super. 282 (2006)
It is well accepted that DMAHS may not take any actions regarding Medicaid that are inconsistent with the federal law and regulations. See, e.g., Estate of F.K. v. Div. of Med. Assistance and Health Servs., 374 N.J. Super. 126, 133, 863 A.2d 1065 (App.Div.), certif. denied, 184 N.J. 209, 876 A.2d 283 (2005). States administering Medicaid may not apply a more restrictive methodology for evaluating eligibility than is provided in federal law. 42 U.S.C.A. § 1396a(r)(2)A.
Mulder v. S.D. Dep’t of Soc. Servs., 2004 SD 10 (2004)
The Medicaid act allows the State the option of developing its own methodology for determining income eligibility, but requires that the methodology be “no more restrictive than the methodology . . . under the Supplemental Security Income [SSI] program under Title XVI.” 42 USCA § 1396a(r) (2) (A) and (B).
Keip v. Wis. Dep’t of Health & Family Servs., 2001 Wisc. App. LEXIS 1223 (2001)
States providing assistance to the medically needy must prescribe eligibility standards that are “reasonable” and “comparable for all groups.” 42 U.S.C. § 1396a(a)(17) (1994). Every state plan must include a single standard to be employed in determining income and resource eligibility “which shall be no more restrictive than the methodology which would be employed under the [SSI] program.” 42 U.S.C. § 1396a(a)(10)(C)(i); see also 42 U.S.C. § 1396a(r)(2)(A) (providing that the methodology for determining eligibility for categorically needy applicants may be less restrictive, but no more restrictive, than the methodology used to determine eligibility for SSI applicants). A methodology is “no more restrictive” if, in using the methodology, “additional individuals may be eligible for medical assistance and no individuals who are otherwise eligible are made ineligible for such assistance.” 42 U.S.C. § 1396a(r)(2)(B).
Keip v. Wisconsin Dep’t of Health & Family Servs., 232 Wis. 2d 380 (1999)
Under 42 U.S.C. § 1396a(a)(10)(C)(i) and 42 U.S.C. § 1396a(r)(2)(A), state MA programs are required to be “no more restrictive” in their methodology for determining MA eligibility than are the federal SSI regulations. That is, a state may establish different MA eligibility criteria, so long as under the state criteria, “additional individuals may be eligible for medical assistance and no individuals who are otherwise eligible are made ineligible for such assistance.” See 42 U.S.C. § 1396a(r)(2)(B) (1994). And, because a federal regulation excludes IRAs owned by an ineligible spouse from being deemed a resource of his or her SSI-eligible spouse, 8Link to the text of the note Keip argues that her IRA must likewise be excluded as a resource in determining Walter’s eligibility for MA. Keip contends further that there is nothing in the spousal impoverishment provisions that is “inconsistent” with the exclusion of her IRA, and neither is there language in 42 U.S.C. § 1396r-5 which “specifically provides” that the IRA exclusion is superseded…. In summary, we conclude that the more reasonable interpretation of 42 U.S.C. § 1396r-5 is that the statute does not remove the exclusion for an IRA held by a community spouse when an institutionalized spouse applies for MA. The ineligible spouse’s IRA would be excluded in determining whether the applying spouse would be eligible for SSI, and Wisconsin’s MA eligibility criteria may not be more restrictive than federal SSI eligibility requirements.
Mistrick v. Division of Medical Assistance and Health Services, 299 N.J. Super. 76 (1997)
The whole point of §§ 1396a(a)(10)(C)(i)(III) and 1396a(r)(2) is to require the same treatment for the medically needy as for the categorically needy in respect of the methods by which their respective eligibilities are determined. Excludability of assets is part of that method. There may be no disparity.
Mistrick v. Div. of Med. Assistance & Health Servs., 154 N.J. 158 (1998)
For purposes of determining medically needy or optionally categorically needy eligibility, application of a methodology “no more restrictive” than the SSI methodology set forth in 20 C.F.R. § 416.1202, which excludes IRAs, would clearly be inconsistent with MCCA, which specifies by reference to 42 U.S.C.A. 1382b(a) and (d) what items are excluded from the determination of resources, without excluding IRAs. In that context, the conclusion is inescapable that MCCA supersedes the “no more restrictive” provision. See 42 U.S.C.A. §§ 1396a(a)(10)(C)(i)(III), 1396a(r)(2)(A). Thus, MCCA requires the inclusion of the community spouse’s IRA in the determination of the institutionalized spouse’s resources.
FRANCISCO v. RHODE ISLAND DEP’T OF HUMAN SERVS., 1997 R.I. Super. LEXIS 61 (1997)
In the creation of the Medicaid eligibility criteria, the state is obligated to follow the methodology determinations of the Supplemental Security Income (“SSI”) program. See, 42 USC § 1396 et seq.; and Social Security Act § 1902(R)(2)(a).
Matarazzo v. Rowe, 225 Conn. 314 (1993)
Even if we were to agree with the defendant’s contention that resource spend down is not permitted under SSI — that is, the “categorically needy” program” — Congress has amended Title XIX to make clear that states could use income and resource methodologies in their medically needy programs that are more liberal than those used in the corresponding cash assistance programs. The Medicaid Catastrophic Care Act of 1988 (MCCA) states in relevant part: “(2) (A) The methodology to be employed in determining income and resource eligibility . . . may be less restrictive, and may be no more restrictive, than the methodology —
“(i) in the case of groups consisting of aged, blind or disabled individuals, under the supplemental security income program . . . .
“(B) For purposes of this subsection . . . [a] methodology is considered to be ‘no more restrictive’ if, using the methodology, additional individuals may be eligible for medical assistance and no individuals who are otherwise eligible are made ineligible for such assistance.” Pub. L. No. 100-360, § 303 (e) (5), 102 Stat. 683, 763 (1988), as amended by Pub. L. No. 100-485, § 608 (d), 102 Stat. 2343, 2418 (1988), codified at 42 U.S.C. § 1396a (r) (2).
Congress’ intent to liberalize the methodology utilized in the medically needy programs is supported by the MCCA’s legislative history: “In the view of the Committee, there is no justification for the rigid application of SSI eligibility rules to Medicaid medically needy programs. . . . To avoid any possible ambiguity, the bill provides that a methodology is considered to be ‘no more restrictive’ if, using the methodology, individuals qualify for Medicaid even though they would not be eligible were the SSI methodology used, and individuals who would be eligible for Medicaid under the SSI methodology would not be ineligible under the State’s medically needy methodology.” H. Rep. No. 105 (II), 100th Cong., 2d Sess. 74-75, reprinted in 1988 U.S. Code Cong. & Admin. News 857, 898.
Accordingly, because the MCCA would permit a less restrictive methodology in the medically needy program, assuming, of course, that SSI in fact prohibits resource spend down, federal law would not prohibit a state from applying such a methodology. If not otherwise prohibited by federal law, a § 209 (b) state may not adopt eligibility requirements that are more restrictive than those that the state applied on January 1, 1972, under the state plan. See footnote 12; Foley v. Suter, [1989-1 Transfer Binder] Medicare & Medicaid Guide (CCH), P37,695, p. 19,704 (N.D. Ill. 1988); see also Brogan v. Miller, 537 F. Supp. 139, 144 n.12 (N.D. Ill. 1982); Indiana Department of Public Welfare v. Payne, 592 N.E.2d 714, 37 Soc. Sec. Rep. Serv. 210 (Ind. App. 1992).
(C) that if medical assistance is included for any group of individuals described in section 1905(a) who are not described in subparagraph (A) or (E), then—
(i) the plan must include a description of (I) the criteria for determining eligibility of individuals in the group for such medical assistance, (II) the amount, duration, and scope of medical assistance made available to individuals in the group, and (III) the single standard to be employed in determining income and resource eligibility for all such groups, and the methodology to be employed in determining such eligibility, which shall be no more restrictive than the methodology which would be employed under the supplemental security income program in the case of groups consisting of aged, blind, or disabled individuals in a State in which such program is in effect, and which shall be no more restrictive than the methodology which would be employed under the appropriate State plan (described in subparagraph (A)(i)) to which such group is most closely categorically related in the case of other groups;
(r) (2)(A) The methodology to be employed in determining income and resource eligibility for individuals under subsection (a)(10)(A)(i)(III), (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10)(A)(i)(VII), (a)(10)(A)(ii), (a)(10)(C)(i)(III), or (f) or under section 1905(p) may be less restrictive, and shall be no more restrictive, than the methodology—
(i) in the case of groups consisting of aged, blind, or disabled individuals, under the supplemental security income program under title XVI, or
(ii) in the case of other groups, under the State plan most closely categorically related.
(B) For purposes of this subsection and subsection (a)(10), methodology is considered to be “no more restrictive” if, using the methodology, additional individuals may be eligible for medical assistance and no individuals who are otherwise eligible are made ineligible for such assistance.
(a)(10)(A)(i)(III): who are qualified pregnant women or children as defined in section 1905(n).
(a)(10)(A)(i)(IV): who are described in subparagraph (A) or (B) of subsection (l)(1) and whose family income does not exceed the minimum income level the State is required to establish under subsection (l)(2)(A) for such a family
(a)(10)(A)(i)(VI): who are described in subparagraph (C) of subsection (l)(1) and whose family income does not exceed the income level the State is required to establish under subsection (l)(2)(B) for such a family
(a)(10)(A)(i)(VII): who are described in subparagraph (D) of subsection (l)(1) and whose family income does not exceed the income level the State is required to establish under subsection (l)(2)(C) for such a family
(a)(10)(A)(ii): at the option of the State, to any group or groups of individuals described in section 1905(a) (or, in the case of individuals described in section 1905(a)(i), to any reasonable categories of such individuals) who are not individuals described in clause (i) of this subparagraph but—
(I) who meet the income and resources requirements of the appropriate State plan described in clause (i) or the supplemental security income program (as the case may be),
(II) who would meet the income and resources requirements of the appropriate State plan described in clause (i) if their work-related child care costs were paid from their earnings rather than by a State agency as a service expenditure,
(III) who would be eligible to receive aid under the appropriate State plan described in clause (i) if coverage under such plan was as broad as allowed under Federal law,
(IV) with respect to whom there is being paid, or who are eligible, or would be eligible if they were not in a medical institution, to have paid with respect to them, aid or assistance under the appropriate State plan described in clause (i), supplemental security income benefits under title XVI, or a State supplementary payment;
(V) who are in a medical institution for a period of not less than 30 consecutive days (with eligibility by reason of this subclause beginning on the first day of such period), who meet the resource requirements of the appropriate State plan described in clause (i) or the supplemental security income program, and whose income does not exceed a separate income standard established by the State which is consistent with the limit established under section 1903(f)(4)(C),
(VI) who would be eligible under the State plan under this title if they were in a medical institution, with respect to whom there has been a determination that but for the provision of home or community-based services described in subsection (c), (d), or (e) of section 1915 they would require the level of care provided in a hospital, nursing facility or intermediate care facility for the mentally retarded the cost of which could be reimbursed under the State plan, and who will receive home or community-based services pursuant to a waiver granted by the Secretary under subsection (c), (d), or (e) of section 1915,
(VII) who would be eligible under the State plan under this title if they were in a medical institution, who are terminally ill, and who will receive hospice care pursuant to a voluntary election described in section 1905(o);
(VIII) who is a child described in section 1905(a)(i)—
(aa) for whom there is in effect an adoption assistance agreement (other than an agreement under part E of title IV) between the State and an adoptive parent or parents,
(bb) who the State agency responsible for adoption assistance has determined cannot be placed with adoptive parents without medical assistance because such child has special needs for medical or rehabilitative care, and
(cc) who was eligible for medical assistance under the State plan prior to the adoption assistance agreement being entered into, or who would have been eligible for medical assistance at such time if the eligibility standards and methodologies of the State’s foster care program under part E of title IV were applied rather than the eligibility standards and methodologies of the State’s aid to families with dependent children program under part A of title IV;
(IX) who are described in subsection (l)(1) and are not described in clause (i)(IV), clause (i)(VI), or clause (i)(VII);
(X) who are described in subsection (m)(1);
(XI) who receive only an optional State supplementary payment based on need and paid on a regular basis, equal to the difference between the individual’s countable income and the income standard used to determine eligibility for such supplementary payment (with countable income being the income remaining after deductions as established by the State pursuant to standards that may be more restrictive than the standards for supplementary security income benefits under title XVI), which are available to all individuals in the State (but which may be based on different income standards by political subdivision according to cost of living differences), and which are paid by a State that does not have an agreement with the Commissioner of Social Security under section 1616 or 1634;
(XII) who are described in subsection (z)(1) (relating to certain TB-infected individuals);
(XIII) who are in families whose income is less than 250 percent of the income official poverty line (as defined by the Office of Management and Budget, and revised annually in accordance with section 673(2) of the Omnibus Budget Reconciliation Act of 1981[18]) applicable to a family of the size involved, and who but for earnings in excess of the limit established under section 1905(q)(2)(B), would be considered to be receiving supplemental security income (subject, notwithstanding section 1916, to payment of premiums or other cost–sharing charges (set on a sliding scale based on income) that the State may determine);
(XIV) who are optional targeted low-income children described in section 1905(u)(2)(B);
(XV) who, but for earnings in excess of the limit established under section 1905(q)(2)(B), would be considered to be receiving supplemental security income, who is at least 16, but less than 65, years of age, and whose assets, resources, and earned or unearned income (or both) do not exceed such limitations (if any) as the State may establish;
(XVI) who are employed individuals with a medically improved disability described in section 1905(v)(1) and whose assets, resources, and earned or unearned income (or both) do not exceed such limitations (if any) as the State may establish, but only if the State provides medical assistance to individuals described in subclause (XV);
(XVII) who are independent foster care adolescents (as defined in section 1905(w)(1)), or who are within any reasonable categories of such adolescents specified by the State;
(XVIII) who are described in subsection (aa) (relating to certain breast or cervical cancer patients);
(XIX) who are disabled children described in subsection (cc)(1);
(XX)[19] beginning January 1, 2014, who are under 65 years of age and. are not described in or enrolled under a previous subclause of this clause, and whose income (as determined under subsection (e)(14)) exceeds 133 percent of the poverty line (as defined in section 2110(c)(5)) applicable to a family of the size involved but does not exceed the highest income eligibility level established under the State plan or under a waiver of the plan, subject to subsection (hh);
(XXI)[20] who are described in subsection (ii) (relating to individuals who meet certain income standards); or
(XXII) who are eligible for home and community-based service under needs-based criteria established under paragraph (1)(A) of section 1915(i), or who are eligible for home and community-based services under paragraph (6) of such section, and who will receive home and community-based services pursuant to a State plan amendment under such subsection.
(a)(10)(C)(i)(III): such medical assistance must include (I) with respect to children under 18 and individuals entitled to institutional services, ambulatory services, and (II) with respect to pregnant women, prenatal care and delivery services
Section 1902(f): Notwithstanding any other provision of this title, except as provided in subsection (e) and section 1619(b)(3) and section 1924, except with respect to qualified disabled and working individuals (described in section 1905(s)), and except with respect to qualified medicare beneficiaries, qualified severely impaired individuals, and individuals described in subsection (m)(1), no State not eligible to participate in the State plan program established under title XVI shall be required to provide medical assistance to any aged, blind, or disabled individual (within the meaning of title XVI) for any month unless such State would be (or would have been) required to provide medical assistance to such individual for such month had its plan for medical assistance approved under this title and in effect on January 1, 1972, been in effect in such month, except that for this purpose any such individual shall be deemed eligible for medical assistance under such State plan if (in addition to meeting such other requirements as are or may be imposed under the State plan) the income of any such individual as determined in accordance with section 1903(f) (after deducting any supplemental security income payment and State supplementary payment made with respect to such individual, and incurred expenses for medical care as recognized under State law regardless of whether such expenses are reimbursed under another public program of the State or political subdivision thereof) is not in excess of the standard for medical assistance established under the State plan as in effect on January 1, 1972. In States which provide medical assistance to individuals pursuant to paragraph (10)(C) of subsection (a) of this section, an individual who is eligible for medical assistance by reason of the requirements of this section concerning the deduction of incurred medical expenses from income shall be considered an individual eligible for medical assistance under paragraph (10)(A) of that subsection if that individual is, or is eligible to be (1) an individual with respect to whom there is payable a State supplementary payment on the basis of which similarly situated individuals are eligible to receive medical assistance equal in amount, duration, and scope to that provided to individuals eligible under paragraph (10)(A), or (2) an eligible individual or eligible spouse, as defined in title XVI, with respect to whom supplemental security income benefits are payable; otherwise that individual shall be considered to be an individual eligible for medical assistance under paragraph (10)(C) of that subsection. In States which do not provide medical assistance to individuals pursuant to paragraph (10)(C) of that subsection, an individual who is eligible for medical assistance by reason of the requirements of this section concerning the deduction of incurred medical expenses from income shall be considered an individual eligible for medical assistance under paragraph (10)(A) of that subsection
Section 1905(p): Relates to “qualified medicare beneficiary”.
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