816-1 MAGI MEDICAID CATEGORY ELIGIBILITY FACTORS
Each MAGI Medicaid category has specific eligibility criteria. The criteria for the categories below are listed in the order that should be used when determining which category of MAGI Medicaid to authorize.
Children born to a woman eligible for and receiving Alaska Medicaid in the month of delivery are automatically eligible for Medicaid without application. The newborn's eligibility is not dependent on the continuation of the mother's Medicaid eligibility. This includes a child born to an alien under the Emergency Treatment for Aliens category and a pregnant woman receiving retroactive Medicaid in the birth month.
Children born to women during the HPE Medicaid period are not automatically eligible for Newborn Medicaid as they were not born to women eligible for and receiving Pregnant Women Medicaid in the month of delivery.
This period of automatic Medicaid eligibility for the newborn continues through the last day of the month of the child's first birthday. There are 2 exceptions. If an individual was issued Pregnant Women Medicaid in error, there is not automatic eligibility for the newborn. Secondly, if the newborn loses Alaska residency, eligibility ends. For both exceptions, the case must be closed with timely notice of adverse action.
The newborn's medical bills cannot be paid until the newborn has been assigned a Medicaid Identification number. Therefore, it is very important that the birth of the newborn be verified as soon as possible. The birth may be verified by a written or verbal statement from the mother, hospital, doctor, or any other contact the ET determines to be reasonable verification of birth. Some hospitals will notify district offices of births in order to facilitate their billing process. When a baby will not remain in the birth mother's household, a hospital may turn in the Request for Newborn Medicaid Identification Number (Med 45) to report a birth of the baby.
Example 1:
The household consists of a mother, her spouse, and a newborn infant. The mother received Pregnant Women Medicaid coverage throughout her pregnancy and was covered on the date of delivery, making the child automatically eligible for Newborn Medicaid coverage. After the mother's postpartum period, the mother is determined ineligible for Medicaid. Newborn Medicaid eligibility for the child continues until the end of the month in which the child turns one year old.
Example 2:
Terry, a Pregnant Women Medicaid recipient, gives birth to a baby girl. Terry gives up the newborn for adoption. Even though the newborn does not stay in Terry's household, the newborn is eligible for the full 13 months of Newborn Medicaid. As the newborn is no longer in Terry's house, the newborn should not be on Terry's Medicaid case.
Example 3:
Lisa doesn't have regular Medicaid when she gives birth, so she applies for and is determined eligible for HPE coverage for herself and her newborn. Newborn Medicaid is not a category of HPE Medicaid. The newborn is determined eligible for HPE Medicaid using the Children Under 19 coverage. Later, Lisa applies for regular Medicaid for herself and her newborn. She is determined eligible for Pregnant Women coverage. As she is eligible for and receiving Pregnant Women Medicaid, her baby is eligible for Newborn Medicaid.
This category is for women who are pregnant. Once determined eligible, including retroactively, a pregnant woman is deemed eligible until the last day of the month of the pregnancy due date or termination. Termination includes birth, miscarriage, and abortion. The individual must notify DPA at the end of the pregnancy.
Verification of pregnancy is only required for multiple births and when questionable. If verification of pregnancy is necessary, a licensed medical provider such as a MD, PHN, PA, or nurse-midwife must confirm the EDD and number of children expected. If a licensed medical professional is not available in the client's home community, a village health aide may verify pregnancy.
An individual remains eligible until the end of the pregnancy unless benefits are authorized in error, the individual loses Alaska residency, or citizenship or qualified alien status has not been verified after the reasonable opportunity period.
Note:
A pregnant woman is not eligible for PW Medicaid at the 201 - 225 % income level if they are eligible for Medicaid in another category or if their dependent children (as defined in MAGI MS 816-1 D) are not receiving Medicaid benefits or enrolled in minimum essential coverage. Being eligible for IHS services alone does not meet essential coverage requirement.
Note:
For an ongoing Medicaid case, pregnancy coding cannot be provided earlier than the month in which the report of change was received.
Example:
A woman receiving Medicaid benefits in the Expansion Group category reports a pregnancy on October 5th. She is expecting one child and indicates that her estimated due date is December 24th. Assuming all other eligibility criteria are met, Pregnant Women Medicaid coverage should be authorized from October 1st through December 31st.
1) PREGNANT WOMEN POSTPARTUM ELIGIBILITY
Coverage begins on the day the pregnancy ends through the last day of the month in which the 12 month ends. The date of pregnancy termination must be verified in order to calculate the postpartum eligibility. The date may be verified by a written or verbal statement from the mother, hospital records, birth certificate, or any other contact the caseworker determines to be a reasonable verification.
A pregnant woman who was eligible for and receiving Medicaid coverage under any eligibility category on the last day of pregnancy, including retroactively is eligible for 12-month postpartum coverage.
Example:
The household consists of Jaquette and her newborn child. Jaquette was receiving Medicaid coverage on the date of delivery, which was June 5th, 2024. She is guaranteed Postpartum Medicaid coverage until the 4th of June 2025 (12 months of postpartum coverage). However, because of the one day-one month principle, Jaquette remains eligible through June 30th.
The only conditions of eligibility for postpartum coverage are Alaska residency and cooperation for TPL. As long as these conditions are met, the individual is deemed eligible until the end of the postpartum period. If the individual is not meeting these conditions, the case will close with timely notice of adverse action.
2) CONTINUATION OF PREGNANT WOMEN AND POSTPARTUM COVERAGE FROM OTHER CATEGORIES OF MEDICAID
A pregnant woman eligible under any Medicaid eligibility category, such as ADLTC Medicaid who loses eligibility for that Medicaid category because of a change in her household's income or due to a requirement that is not a criterion of MAGI Medicaid may remain eligible for Medicaid coverage under MAGI Medicaid throughout her pregnancy and postpartum period.
816-1 C. CHILDREN UNDER THE AGE OF 19
Children Under 19 Medicaid is available to children through the end of the month in which the child turns age 19.
An uninsured child is eligible if the household's countable income is at or below the income standard for uninsured children. An insured child is eligible if the household’s countable income is at or below the income standard for insured children.
A child is considered insured if the child has health coverage from one of the following, even if the coverage requires a co-pay or deductible or does not cover a particular illness or procedure the child needs:
1) A group health plan (including a governmental or church plan);
2) A group or individual health insurance;
3) Medicare;
4) A military-sponsored health care program such as TRICARE;
5) A state high risk insurance pool;
6) The Federal Employees Health Benefit Program;
7) Public health plan established or maintained by a state or local government; and
8) A health benefit plan provided for Peace Corps members.
Health insurance coverage does not include:
1) Coverage limited to a specific service (e.g. dental care or vision care);
2) Tribal health services (IHS);
3) Worker’s Compensation;
4) Medicaid.
1) CONTINUOUS ELIGIBILITY FOR CHILDREN
All children under the age of 19 who are eligible for Medicaid (except Newborn, Transitional, Post Medicaid, and Retroactive Medicaid) remain eligible for those benefits for a continuous 12-month period, called the continuous eligibility period (CEP).
In application situations, the CEP begins with the first month of eligibility. In a renewal or re-determination situation, the new 12-month CEP begins the month after the renewal is processed and interfaces checked.
During this 12-month period a child continues to be eligible regardless of changes in income, family status, or household composition.
The CEP ends:
1) at the end of the twelfth month of continuous eligibility;
2) at the end of the month the child reaches age 19;
3) with the death of the child;
4) with written request from the recipient requesting case closure;
5) when there is loss of contact and the case is closed with 10 day notice of adverse action;
6) when child loses Alaska residency and the case is closed with 10 day notice of adverse action;
7) the eligibility was approved in error and the case is closed with 10 day notice of adverse action.
Example:
Mathias is 18 years old and receiving Children Under 19 Medicaid. He reports employment. The ET receives verification of his earnings and he is now over the income limit. The Medicaid case cannot be closed because he is under age 19. Mathias remains eligible for Medicaid through the previously authorized CEP or until the end of the month he reaches age 19, whichever is sooner.
816-1 D. PARENT/CARETAKER RELATIVE
The Parent/Caretaker Relative category is for parents and relatives who have primary responsibility for the care of a dependent child in their household. Primary responsibility means the parent/caretaker relative has the child in the household at least 51% of the time. The parent or caretaker’s statement regarding their relationship to a dependent child will be accepted unless the agency has credible evidence or documentation that contradicts the parent/caretaker relative's statement.
To be eligible under this category, the parent or caretaker relative must be within the 5th degree of kinship of the child, as defined below. The relationship can be based on blood, half-blood, adoption, or marriage.
1st degree: mother, step-mother, father, step-father
2nd degree: sister, half-sister, brother, half-brother, grandparent, step-grandparent
3rd degree: great-grandparent, uncle, aunt, nephew, niece
4th degree: great-great grandparent, great uncle, great aunt, first cousin
5th degree: great-great-great grandparent, great-great uncle, great-great aunt, first cousin once removed (child of first cousin)
The category also includes the spouse of such parent or relative, even after the marriage is terminated by death or divorce.
If a biological parent has had legal rights to a child severed due to an adoption, the biological parent cannot be considered a parent/caretaker relative for the child.
Dependent child means a child who is under the age of 18, or is age 18 and a full-time student in high school, GED, or equivalent vocational or technical training. The 18-year-old must be expected to complete school or training before reaching age 19. Client statement of student status is accepted unless questionable.
An 18-year-old’s eligibility as a dependent child ends effective the end of the month in which (whichever occurs first):
1) High school or GED graduation occurs;
2) Vocational or technical training ends;
3) The child withdraws from enrollment; or
4) The child reaches age 19.
Example 1:
Child Graduates Before 19:
Herman and his son Joe are MAGI Medicaid recipients. Herman is 67 years old. Joe will turn 18 on May 10. Herman reports Joe will graduate June 5. Because Joe will graduate high school before turning 19 he continues to be considered a dependent child for the Parent/Caretaker Relative category until the month he graduates. Herman’s Parent/Caretaker Relative Medicaid eligibility will end June 30. As Herman is over 65 years old, he is no longer eligible for MAGI Medicaid, as he is no longer a parent/caretaker and does not meet the eligibility factors for any other category. Herman may be eligible for Old Aged Medicaid. Joe’s eligibility for the Children Under 19 category continues until he turns 19 next May.
Example 2:
Child Graduates After 19:
Nicole and her daughter, Gabi, receive MAGI related Medicaid. Gabi is currently 17 years old and a junior in high school. She will turn 18 years old during her junior year and is expected to graduate the following year, when she is 19 years old. Because Gabi will not graduate before she turns 19, Nicole’s Parent/Caretaker Relative Medicaid eligibility will end once Gabi turns 18 because she will no longer be considered a dependent child for the Parent/Caretaker Relative category. Gabi continues coverage under the Children Under 19 category until she turns 19. At that time, her eligibility for Under 21 Medicaid will be determined.
1) TWO RELATIVES CLAIMING PARENT/CARETAKER RESPONSIBILITY
In most cases, the applying caretaker relative may be assumed to be exercising this responsibility. If two separate parent/caretaker relatives, living together or apart, claim being the parent/caretaker relative of the same child, the ET would have to determine who has the child the majority of the time.
For MAGI Medicaid if the child lives part of the time with each parent, the parent with whom the child spends at least 51% of the time in the home will be the eligible parent/caretaker relative. See section 817 to determine whose income to count.
2) DEFINITION OF THE HOME
To be considered a parent/caretaker relative, the dependent child must be living in the same household, or home as the parent/caretaker relative.
There is no requirement that the place of residence, or home, meet standards as to type or expected duration. An owned or rented house, a motor home, an apartment, a motel room, shelter, or even a tent can be considered a residence, even if they are only temporary dwelling places.
Federal regulations define a home as "the family setting maintained or in process of being established as evidenced by assumption and continuation of responsibility for day-to-day care of the child by the relative with whom the child is living. A home exists so long as the parent/caretaker relative exercises responsibility for the care and control of the child, even though either the child or the parent/caretaker relative is temporarily absent from the customary family setting." Within this interpretation, the child is considered to be living with the parent/caretaker relative even though:
1) He or she is under the jurisdiction of the court (such as receiving probation services or protective supervision); or
2) Legal custody is held by an agency that does not have physical custody of the child.
The definition of a home allows MAGI Medicaid eligibility to exist even if a home is in process of being established. In cases in which a child is intended to enter the home of a parent/caretaker relative, if the child is otherwise eligible except for not yet residing with the parent/caretaker relative, MAGI Medicaid eligibility will exist if these two conditions are met:
1) The child actually comes to live with the parent/caretaker relative within 30 days after the parent/caretaker relative receives the first MAGI Medicaid month; and
2) The child has not received State Title IV-E Foster Care benefits or MAGI Medicaid benefits in the home of another parent/caretaker relative for the same month covered by the initial MAGI Medicaid benefit.
Note:
When a child in OCS custody returns home for a trial home visit, they are considered part of the MAGI Medicaid household, but are not eligible for MAGI Medicaid coverage because they will continue to receive Title IV-E Medicaid. See Administrative Procedures Manual Section 124-5.
3) TEMPORARY ABSENCE FROM HOME
This section is used to determine if a parent/caretaker relative can continue to meet parent/caretaker relative criteria when either the child or parent/caretaker relative is absent from the home.
If a child or parent/caretaker relative is absent for any reason not allowed, that individual may not be included in the household for Medicaid. However, the caseworker should continue to determine the individual's eligibility for MAGI Medicaid. Parents' income may affect the child's eligibility for Medicaid, even though the child is not living with them. See section 817 for more information about household composition and income counting rules.
The federal definition of home allows for a child and parent/caretaker relative to be considered to be living together even if "either the child or the parent/caretaker relative is temporarily absent from the customary family setting." Under the one day-one month principle, as long as the child and the parent/caretaker relative are both in the home one day of the calendar month, Parent/Caretaker Relative category eligibility exists on this factor.
There are certain special circumstances in which Parent/Caretaker Relative Medicaid eligibility can exist if an absence lasts an entire calendar month or longer.
Parents' income may affect the child's eligibility for Medicaid, even though the child is not living with them due to an absence. If the application states that the parents will claim the child as a tax dependent next year, their income counts for the child. If the parents do not plan on claiming the child as a tax dependent or if tax filing information is not known at the time of application processing, non-filer rules apply. See section 817 for more information about household composition and income counting rules.
Either the child or the relative is being cared for in a hospital or other public or private institution. Parent/Caretaker Relative category eligibility can exist as long as the illness is such that a return to the household can be expected and the parent/caretaker relative responsibility for the child continues. A drug and alcohol treatment center is considered hospitalization in a public or private institution.
b. Court Ordered Visitation
The child is absent because a court order specifies that he is to visit a parent who resides away from the child's customary home. Parent/Caretaker relative eligibility can exist as long as:
1) The parent/caretaker relative maintains a home for the child to return to;
2) The intent is for the child to return to the MAGI Medicaid home at the end of the visit;
3) The child does not receive Medicaid while in the care of the parent he is visiting; and
4) The absence does not last longer than three calendar months.
Either the child or the caretaker relative is absent because of a need for education or training which is not available in the home community. This absence includes a child who has left home to attend an educational institution, National Guard Youth Corps, or other educational training or treatment environment that involves a residential living arrangement. Parent/Caretaker Relative category eligibility can exist as long as:
1) The absent student returns to the home at least once each year;
2) The absent student is not receiving Medicaid in another household;
3) The absent student intends to return to the home at the completion of his education or training; and
4) The parent/caretaker relative is maintaining a home to which either he or the child intends to return.
A parent/caretaker relative is temporarily absent from the home for a planned temporary absence, including but not limited to: employment, seeking employment, and military assignment. A parent remains a mandatory household member while absent.
Note:
Parent/Caretaker Relatives may be eligible for Expansion Medicaid as long as they meet the following requirements;
1. Are age 19 or older and under age 65;
2. Are not pregnant;
3. Are not entitled to or enrolled in Medicare;
4. Are not eligible for any other Medicaid category;
5. Have household income that is at or below 133% of FPL; and
6. Their dependent children (as defined in MAGI MS 816-1 D) are receiving Medicaid benefits or enrolled in minimum essential coverage. Being eligible for IHS services alone does not meet the minimum essential coverage requirement.
If a Parent/Caretaker Relative has countable income above the Parent/Caretaker Relative income standard for their household size but their countable income is below the Expansion Group income standard for their household size, then they are eligible for Medicaid in the Expansion Group as "newly eligible" as long as they meet all of the requirements listed above.
A Parent/Caretaker Relative who is being approved for Medicaid in the Expansion Group category must cooperate with the Child Support Services Division (CSSD) unless they are exempt as explained in MAGI MS 812 (B) or have good cause as outlined in MAGI MS 812-4 B. In order to be considered a Parent/Caretaker Relative the individual must be within 5th degree of kinship of the child and have primary responsibility for their care as explained in MAGI MS 816-1 D.
To be eligible for Under 21 Medicaid, the individual must be age 19 or 20. Eligibility ends the end of the month in which the individual reaches the age of 21.
816-1 F. FORMER FOSTER CARE (FFC)
Individuals who meet the following 2 requirements are categorically eligible for Former Foster Care Medicaid.
1) Be at least age 18 and under the age of 26; and
2) Individuals who received state or tribal foster care in any state and was enrolled in Medicaid upon reaching age 18.
Eligibility for this category ends at the end of the month in which the individual reaches age 26.
The eligibility determination for the FFC category is not automatic. When a foster care child ages out of foster care, he or she will need to apply for Medicaid if they want continued benefits.
In Alaska, this can be done by checking the eligibility system to confirm if the individual was receiving Title IV-E Medicaid in the month he or she reached age 18. If the caseworker is unable to determine receipt of Medicaid and foster care at age 18, they should contact OCS by sending an email to brooke.katasse@alaska.gov.
Example:
Josie applied for Medicaid 2/12/22. On her application she reported that she was in foster care when she turned 18. The caseworker confirms she was in Alaska foster care and receiving Medicaid when she turned 18. She is over income for Under 21 Medicaid. Her FFC Medicaid case is opened and certified through 1/23. In July, she reports she is pregnant. Since she meets all eligibility factors for Pregnant Women Medicaid, coverage is authorized through the month of her estimated due date.
Note:
If the FFC child is potentially eligible for a Medicaid category higher on the hierarchy list outlined in MAGI MS 816, the applicant must be asked to provide all of the information needed to make an eligible decision in that category.
If the FFC child fails to provide the needed verification by the due date or is found ineligible for that category of Medicaid, the caseworker should then authorize Medicaid benefits in the FFC category.
Effective January 1, 2023, if we have verification that an individual is eligible for the FFC category but do not have the verification needed for another category higher on the hierarchy list, we should authorize benefits in the FFC category without asking the individual to provide any information needed to make an eligibility decision in another category.
The Expansion Group covers adults between ages 19 and 64. This category does not include individuals who are pregnant, entitled to or enrolled in benefits under Medicare Part A or Part B, or SSI recipients.
Note:
Eligibility in this category continues through the month an individual turns 65, even if they start to receive Medicare coverage on the first of the month in which they turn 65.
1) Newly and Not-Newly Eligible
DPA must determine if an individual in the Expansion Group category is considered Newly Eligible or Not-Newly Eligible. Whether benefits are Newly or Not-Newly Eligible determines the amount of federal reimbursement. ARIES determines this automatically. ETs will make this determination when processing Expansion Group Medicaid in EIS.
To make this determination, use the following steps.
1) Determine Expansion Group category eligibility. If the individual does not meet the criteria for Expansion Group Medicaid, do not continue. If so, continue to step 2.
2) Does the individual have a current and favorable disabled or blind decision from SSA or DDS?
No? The individual is Newly Eligible.
Yes? Continue to Step 3.
3) Did the individual meet all eligibility criteria for Disabled Medicaid but was denied due to being over resource limit for the household size?
No? The individual is Newly Eligible.
Yes? Continue to Step 4.
4) Is the gross monthly income for a single person at or above $1252 or the gross monthly income for a married couple at or above $1504?
Yes? The individual is Newly Eligible.
No? Continue to Step 5.
5) Is the gross monthly income for a single person is below $1252 or the gross monthly income for a married couple below $1504?
Yes? The individual is Not-Newly Eligible.
Examples:
1) Lgeik'i is receiving Social Security Early Retirement income of $1,000/month. She is not disabled. She meets the eligibility criteria for Expansion Group Medicaid. L'geik'i is considered Newly Eligible.
2) Jeffry is a single adult with no dependent children. He is disabled and receiving Medicare. He has income of $1100/month and $10,000 of savings in the bank. He is over resource for Disabled Medicaid. Jeffry is also ineligible for Expansion Group Medicaid as he is a Medicare recipient. There is no need to determine if Jeffry is Newly or Not-Newly Eligible as he does not meet Expansion Group criteria.
3) Anastacio has a state only disability decision and no income or resources. He is ineligible for SSA benefits and does not want Disabled Medicaid. Anastacio meets Expansion Group Medicaid criteria. Anastacio is considered Newly Eligible.
4) Mable just received a favorable disability decision from SSA and has 2 years to wait for her Medicare to begin. She receives $1300/month in income. She is denied Disabled Medicaid as her resources are over the limit. Mable meets all the criteria for Expansion Group Medicaid. As her income is above $1252/month and she was denied Disabled Medicaid because of resources, she is considered Newly Eligible.
5) Kristen just received a favorable disability decision from SSA and has 2 years to wait for her Medicare to begin. She is receiving $900/month from SSA benefits. Kristen has an unused fishing boat that puts her over resource for Disabled Medicaid. She is eligible for Expansion Group Medicaid. As her income is below $1252/month and she was denied Disabled Medicaid due to resources, she is considered Non-Newly eligible.
Refer to Addendum 2 for the correct Medicaid Subtypes.
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