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Code of Federal Regulations (Last Updated: November 8, 2024) |
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Title 42 - Public Health |
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Chapter IV - Centers for Medicare & Medicaid Services, Department of Health and Human Services |
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SubChapter C - Medical Assistance Programs |
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Part 435 - Eligibility in the States, District of Columbia, the Northern Mariana Islands, and American Samoa |
Part 435 - Eligibility in the States, District of Columbia, the Northern Mariana Islands, and American Samoa
| Subpart A - General Provisions and Definitions |
| § 435.2 - Purpose and applicability. |
| § 435.3 - Basis. |
| § 435.4 - Definitions and use of terms. |
| § 435.10 - State plan requirements. |
| Subpart B - Mandatory Coverage |
| § 435.100 - Scope. |
| Mandatory Coverage of Families and Children |
| § 435.110 - Parents and other caretaker relatives. |
| § 435.112 - Families terminated from AFDC because of increased earnings or hours of employment. |
| § 435.113 - Individuals who are ineligible for AFDC because of requirements that do not apply under title XIX of the Act. |
| § 435.114 - Individuals who would be eligible for AFDC except for increased OASDI income under Pub. L. 92-336 (July 1, 1972). |
| § 435.115 - Families with Medicaid eligibility extended because of increased collection of spousal support. |
| Mandatory Coverage for Individuals Age 19 Through 64 |
| § 435.119 - Coverage for individuals age 19 or older and under age 65 at or below 133 percent FPL. |
| Mandatory Coverage of the Aged, Blind, and Disabled |
| § 435.120 - Individuals receiving SSI. |
| § 435.121 - Individuals in States using more restrictive requirements for Medicaid than the SSI requirements. |
| § 435.122 - Individuals who are ineligible for SSI or optional State supplements because of requirements that do not apply under title XIX of the Act. |
| § 435.123 - Individuals eligible as qualified Medicare beneficiaries. |
| § 435.124 - Individuals eligible as specified low-income Medicare beneficiaries. |
| § 435.125 - Individuals eligible as qualifying individuals. |
| § 435.126 - Individuals eligible as qualified disabled and working individuals. |
| § 435.130 - Individuals receiving mandatory State supplements. |
| § 435.131 - Individuals eligible as essential spouses in December 1973. |
| § 435.132 - Institutionalized individuals who were eligible in December 1973. |
| § 435.133 - Blind and disabled individuals eligible in December 1973. |
| § 435.134 - Individuals who would be eligible except for the increase in OASDI benefits under Pub. L. 92-336 (July 1, 1972). |
| § 435.135 - Individuals who become ineligible for cash assistance as a result of OASDI cost-of-living increases received after April 1977. |
| § 435.136 - State agency implementation requirements for one-time notice and annual review system. |
| § 435.137 - Disabled widows and widowers who would be eligible for SSI except for the increase in disability benefits resulting from elimination of the reduction factor under Pub. L. 98-21. |
| § 435.138 - Disabled widows and widowers aged 60 through 64 who would be eligible for SSI except for early receipt of social security benefits. |
| Mandatory Coverage of Pregnant Women, Children Under 8,and Newborn Children |
| Mandatory Coverage of Pregnant Women, Children Under 19, and Newborn Children |
| § 435.116 - Pregnant women. |
| § 435.117 - Deemed newborn children. |
| Mandatory Coverage of Qualified Family Members |
| § 435.118 - Infants and children under age 19. |
| Mandatory Coverage of Adoption Assistance and Foster Care Children |
| § 435.145 - Children with adoption assistance, foster care, or guardianship care under title IV-E. |
| § 435.150 - Former foster care children. |
| Mandatory Coverage of Certain Aliens |
| § 435.139 - Coverage for certain aliens. |
| Mandatory Coverage of Pregnant Women, Children Under 8, and Newborn Children |
| Mandatory Coverage of Special Groups |
| § 435.170 - Pregnant women eligible for extended or continuous eligibility. |
| § 435.172 - Continuous eligibility for hospitalized children. |
| Subpart C - Options for Coverage |
| § 435.200 - Scope. |
| § 435.201 - Individuals included in optional groups. |
| Options for Coverage of the Aged, Blind, and Disabled |
| § 435.230 - Aged, blind, and disabled individuals in States that use more restrictive requirements for Medicaid than SSI requirements: Optional coverage. |
| § 435.232 - Individuals receiving only optional State supplements. |
| § 435.234 - Individuals receiving only optional State supplements in States using more restrictive eligibility requirements than SSI and certain States using SSI criteria. |
| § 435.236 - Individuals in institutions who are eligible under a special income level. |
| Options for Coverage of Families and Children and the Aged, Blind, and Disabled |
| § 435.210 - Optional eligibility for individuals who meet the income and resource requirements of the cash assistance programs. |
| § 435.211 - Optional eligibility for individuals who would be eligible for cash assistance if they were not in medical institutions. |
| § 435.212 - Individuals who would be ineligible if they were not enrolled in an MCO or PCCM. |
| § 435.213 - Optional eligibility for individuals needing treatment for breast or cervical cancer. |
| § 435.214 - Eligibility for Medicaid limited to family planning and related services. |
| § 435.215 - Individuals infected with tuberculosis. |
| § 435.217 - Individuals receiving home and community-based services. |
| § 435.218 - Individuals with MAGI-based income above 133 percent FPL. |
| § 435.219 - Individuals receiving State plan home and community-based services. |
| Options for Coverage of Families and Children |
| § 435.220 - Optional eligibility for parents and other caretaker relatives. |
| § 435.221 - [Reserved] |
| § 435.222 - Optional eligibility for reasonable classifications of individuals under age 21 with income below a MAGI-equivalent standard in specified eligibility categories. |
| § 435.223 - Other optional eligibility for reasonable classifications of individuals under age 21. |
| § 435.225 - Individuals under age 19 who would be eligible for Medicaid if they were in a medical institution. |
| § 435.226 - Optional eligibility for independent foster care adolescents. |
| § 435.227 - Optional eligibility for individuals under age 21 who are under State adoption assistance agreements. |
| § 435.229 - Optional targeted low-income children. |
| Subpart D - Optional Coverage of the Medically Needy |
| § 435.300 - Scope. |
| § 435.301 - General rules. |
| § 435.308 - Medically needy coverage of individuals under age 21. |
| § 435.310 - Medically needy coverage of parents and other caretaker relatives. |
| § 435.320 - Medically needy coverage of the aged in States that cover individuals receiving SSI. |
| § 435.322 - Medically needy coverage of the blind in States that cover individuals receiving SSI. |
| § 435.324 - Medically needy coverage of the disabled in States that cover individuals receiving SSI. |
| § 435.326 - Individuals who would be ineligible if they were not enrolled in an MCO or PCCM. |
| § 435.330 - Medically needy coverage of the aged, blind, and disabled in States using more restrictive eligibility requirements for Medicaid than those used under SSI. |
| § 435.340 - Protected medically needy coverage for blind and disabled individuals eligible in December 1973. |
| § 435.350 - Coverage for certain aliens. |
| Subpart E - General Eligibility Requirements |
| § 435.400 - Scope. |
| § 435.401 - General rules. |
| § 435.402 - [Reserved] |
| § 435.403 - State residence. |
| § 435.404 - Applicant's choice of category. |
| § 435.406 - Citizenship and noncitizen eligibility. |
| § 435.407 - Types of acceptable documentary evidence of citizenship. |
| § 435.408 - Categories of aliens who are permanently residing in the United States under color of law. |
| Subpart F - Categorical Requirements for Eligibility |
| § 435.500 - Scope. |
| Age |
| § 435.520 - Age requirements for the aged. |
| § 435.522 - Determination of age. |
| Blindness |
| § 435.530 - Definition of blindness. |
| § 435.531 - Determinations of blindness. |
| Dependency |
| § 435.510 - Determination of dependency. |
| Disability |
| § 435.540 - Definition of disability. |
| § 435.541 - Determinations of disability. |
| Subpart G - General Financial Eligibility Requirements and Options |
| § 435.600 - Scope. |
| § 435.601 - Application of financial eligibility methodologies. |
| § 435.602 - Financial responsibility of relatives and other individuals. |
| § 435.603 - Application of modified adjusted gross income (MAGI). |
| § 435.604 - [Reserved] |
| § 435.606 - [Reserved] |
| § 435.608 - [Reserved] |
| § 435.610 - Assignment of rights to benefits. |
| § 435.622 - Individuals in institutions who are eligible under a special income level. |
| § 435.631 - General requirements for determining income eligibility in States using more restrictive requirements for Medicaid than SSI. |
| § 435.640 - Protected Medicaid eligibility for individuals eligible in December 1973. |
| Subpart H - Specific Post-Eligibility Financial Requirements for the Categorically Needy |
| § 435.700 - Scope. |
| § 435.725 - Post-eligibility treatment of income of institutionalized individuals in SSI States: Application of patient income to the cost of care. |
| § 435.726 - Post-eligibility treatment of income of individuals receiving home and community-based services furnished under a waiver: Application of patient income to the cost of care. |
| § 435.733 - Post-eligibility treatment of income of institutionalized individuals in States using more restrictive requirements than SSI: Application of patient income to the cost of care. |
| § 435.735 - Post-eligibility treatment of income and resources of individuals receiving home and community-based services furnished under a waiver: Application of patient income to the cost of care. |
| Subpart I - Specific Eligibility and Post-Eligibility Financial Requirements for the Medically Needy |
| § 435.800 - Scope. |
| Medically Needy Income Eligibility |
| § 435.831 - Income eligibility. |
| § 435.832 - Post-eligibility treatment of income of institutionalized individuals: Application of patient income to the cost of care. |
| Medically Needy Income Standard |
| § 435.811 - Medically needy income standard: General requirements. |
| § 435.814 - Medically needy income standard: State plan requirements. |
| Medically Needy Resource Standard |
| § 435.840 - Medically needy resource standard: General requirements. |
| § 435.843 - Medically needy resource standard: State plan requirements. |
| Determining Eligibility on the Basis of Resources |
| § 435.845 - Medically needy resource eligibility. |
| §§ 435.850--435.852 - [Reserved] |
| Subpart J - Eligibility in the States and District of Columbia |
| § 435.900 - Scope. |
| Redeterminations of Medicaid Eligibility |
| § 435.916 - Regularly scheduled renewals of Medicaid eligibility. |
| § 435.917 - Notice of agency's decision concerning eligibility, benefits, or services. |
| § 435.918 - Use of electronic notices. |
| § 435.919 - Changes in circumstances. |
| § 435.920 - Verification of SSNs. |
| § 435.923 - Authorized representatives. |
| § 435.926 - Continuous eligibility for children. |
| § 435.927 - Requirements for States to submit certain data on redeterminations. |
| § 435.928 - Reduction in FMAP for failure to submit certain data. |
| Determination of Medicaid Eligibility |
| § 435.911 - Determination of eligibility. |
| § 435.912 - Timely determination and redetermination of eligibility. |
| § 435.913 - Notice of agency's decision concerning eligibility. |
| § 435.914 - Case documentation. |
| § 435.915 - Effective date. |
| Income and Eligibility Verification Requirements |
| § 435.940 - Basis and scope. |
| § 435.945 - General requirements. |
| § 435.948 - Verifying financial information. |
| § 435.949 - Verification of information through an electronic service. |
| § 435.952 - Use of information and requests of additional information from individuals. |
| § 435.953 - Identifying items of information to use. |
| § 435.955 - Additional requirements regarding information released by a Federal agency. |
| § 435.956 - Verification of other non-financial information. |
| § 435.960 - Standardized formats for furnishing and obtaining information to verifying income and eligibility. |
| § 435.965 - Delay of effective date. |
| Applications |
| § 435.905 - Availability and accessibility of program information. |
| § 435.906 - Opportunity to apply. |
| § 435.907 - Application. |
| § 435.908 - Assistance with application and renewal. |
| § 435.909 - Automatic entitlement to Medicaid following a determination of eligibility under other programs. |
| § 435.910 - Use of social security number. |
| General Methods of Administration |
| § 435.901 - Consistency with objectives and statutes. |
| § 435.902 - Simplicity of administration. |
| § 435.903 - Adherence of local agencies to State plan requirements. |
| § 435.904 - Establishment of outstation locations to process applications for certain low-income eligibility groups. |
| Furnishing Medicaid |
| § 435.930 - Furnishing Medicaid. |
| Subpart K - Federal Financial Participation |
| § 435.1000 - Scope. |
| Requirements for State Supplements |
| § 435.1011 - Requirement for mandatory State supplements. |
| § 435.1012 - Requirement for maintenance of optional State supplement expenditures. |
| FFP for Premium Assistance |
| § 435.1015 - FFP for premium assistance for plans in the individual market. |
| Limitations on FFP |
| § 435.1005 - Beneficiaries in institutions eligible under a special income standard. |
| § 435.1006 - Beneficiaries of optional State supplements only. |
| § 435.1007 - Categorically needy, medically needy, and qualified Medicare beneficiaries. |
| § 435.1008 - FFP in expenditures for medical assistance for individuals who have declared citizenship or nationality or satisfactory immigration status. |
| § 435.1009 - Institutionalized individuals. |
| § 435.1010 - Definitions relating to institutional status. |
| FFP in Expenditures for Determining Eligibility and Providing Services |
| § 435.1001 - FFP for administration. |
| § 435.1002 - FFP for services. |
| § 435.1003 - FFP for redeterminations. |
| § 435.1004 - Beneficiaries overcoming certain conditions of eligibility. |
| Subpart L - Options for Coverage of Special Groups under Presumptive Eligibility |
| § 435.1100 - Basis for presumptive eligibility. |
| § 435.1101 - Definitions related to presumptive eligibility. |
| § 435.1102 - Children covered under presumptive eligibility. |
| § 435.1103 - Presumptive eligibility for other individuals. |
| § 435.1110 - Presumptive eligibility determined by hospitals. |
| Presumptive Eligibility for Children |
| Subpart M - Coordination of Eligibility and Enrollment Between Medicaid, CHIP, Exchanges and Other Insurance Affordability Programs |
| § 435.1200 - Medicaid agency responsibilities for a coordinated eligibility and enrollment process with other insurance affordability programs. |
| § 435.1205 - Alignment with exchange initial open enrollment period. |