In addition to the financial eligibility determination for Medicaid services made by the Division of Family Assistance (DFA), specific service categories also require a determination of medical eligibility.

Determining that an applicant is medically eligible for Medicaid services involves an assessment made by a DHHS medical review team of an applicant's medical condition.  This review is based on an applicant's medical records and other medical documentation specifically related to an applicant's medical condition.  The DHHS medical review team consists of professional individuals including nurses, medical physicians, psychiatrists and clinical psychologists, as well as para-professionals and administrative staff.

The length of time required to complete the medical determination process depends on the clarity of information received from an applicant, the responsiveness of an applicant's healthcare provider to return information requested by the medical review team, the volume and comprehensiveness of information received, and the need for an applicant to have additional examinations or testing.

When a determination of medical eligibility is made, an applicant and DFA are notified in writing.   If an applicant is found eligible, DFA may then initiate financial or medical assistance.  When a determination of ineligibility is made, an applicant is notified of his or her right to a Fair Hearing.   DFA provides specific and detailed financial eligibility information on their Medical Assistance pages.

SERVICES THAT REQUIRE FINANCIAL & MEDICAL

ELIGIBILITY DETERMINATION

Aid to the Needy Blind (ANB):  a category of eligibility that requires an individual to be diagnosed as legally blind.  The visual acuity in the better eye can be no greater than 20/200. 

Aid to the Permanently and Totally Disabled (APTD):  an adult service category that requires individuals between ages 18 to 64 to meet the Social Security impairment severity requirements and to be unable to perform substantial gainful activity for 48 consecutive months as a result of the impairment.

Children with Severe Disability (CSD):  requires a severe disability but does not require institutional level of care.  Family income and resources are considered for financial eligibility.

Home Care for Children with Severe Disability (HC-CSD), commonly referred to as Katie Beckett:  requires children to meet an institutional (nursing facility) level of care requirement and only considers a child's income and resources for financial eligibility.

Medicaid for Employed Adults with Disabilities (MEAD):  allows certain employed individuals with impairments that meet the Social Security severity requirements to receive Medicaid coverage with a sliding scale buy-in component.

Temporary Assistance to Needy Families - Incapacitated (TANF-Incap):  a category of eligibility that requires an individual to have a condition that impedes his or her ability to take care of his or her children and family.