COD E R E D

Mandatory and Optional Covered PopulationsFederal guidelines specify mandatory populations to cover and services to offer at a minimum toreceive funds for the Medicaid program, and states can cover more people and/or offeradditional services if they wish. The mandatory population is most people who receive federalassistance payments, as well as some related groups that do not receive cash payments.These groups are called “categorically needy” and include the following:• Low-income families with children (described in Section 1931 of the Social Security Act,who meet certain eligibility requirements of the state’s AFDC plan in effect on July 16,1996, now called TANF, or Temporary Aid to Needy Families). Since 1996, Section1931 has allowed states to define “low-income” by giving them flexibility to increaseincome disregards and assets limits by amending the state’s Medicaid State Plan(instead of applying for a federal waiver).• Supplemental Security Income (SSI) recipients.• Infants born to Medicaid-eligible pregnant women (up to one year old as long as theinfant remains in the mother’s household and she remains eligible, or would be eligible ifshe were still pregnant).• Children under age 6 and pregnant women whose family income is at or below 133percent of the federal poverty level (FPL). Once eligibility is established, pregnantwomen remain eligible for Medicaid through the end of the calendar month in which the60th day after the end of the pregnancy falls, regardless of any change in family income.• Children ages 6 to 19 with family incomes up to 100 percent FPL.• Recipients of adoption assistance and foster care under Title IV-E of the Social SecurityAct.• Certain low-income Medicare beneficiaries with limited resources (Medicare pays first,and Medicaid supplements the out-of-pocket medical expenses of these “dual eligibles”).• Special protected groups who may keep Medicaid for a period of time. (For example,people who lose SSI payments due to earnings from work or increased Social Securitybenefits; and families who are provided from 4 to 12 months of Medicaid coveragefollowing loss of eligibility under Section 1931 due to increases in various types ofincome). 10States have the option to extend Medicaid to other categorically needy groups who are similarto the mandatory groups using somewhat more liberal eligibility criteria. States will receive thefederal matching funds for covering these groups if they choose to do so. Following areexamples of these optional groups:• Infants up to age 1 and pregnant women not covered under the mandatory rules whosefamily income is below 185 percent of FPL (or other percentage set by each state).• Optional targeted low-income children.• Certain aged, blind or disabled adults who have incomes above the mandatory coveragebut below the FPL.• Children under age 21 who meet income and resources requirements for AFDC, but whootherwise are not eligible (AFDC now called TANF).B-4