The Division of Family Assistance (DFA) determines Medicaid financial eligibility and all non-financial eligibility, with the exception of medical necessity determinations, for the following:
- Modified Adjusted Gross Income (MAGI) groups: children under the age of 20, pregnant women, parents/caretaker relatives, former foster care children, non-disabled adults between the ages of 19 and 65, and family planning expansion category (limited coverage); and
- Non-MAGI groups: blind individuals, refugees, non-citizens, seniors, disabled adults, and individuals requiring long-term care services.
There are three basic areas of criteria that DFA evaluates to make an eligibility determination for Medical Assistance:
- resources (for the non-MAGI groups only),
- and non-financial criteria.
Specific income and resource limits are used to determine eligibility for each Medicaid group. While non-financial information is generally the same for each Medicaid group, there are some differences – for example, an application for services under the Aid to the Needy Blind program requires an individual to have a medical necessity determination of legally blind, while an application for services for seniors has no medical necessity requirement, but does have an age requirement. Specific details regarding income, resource, and non-financial requirements are explained for each kind of medical assistance on the pages reserved for eligibility for Medical Assistance. DFA coordinates eligibility determinations with the Office of Medicaid Business and Policy (OMBP), the Bureau of Elderly and Adult Services (BEAS) and the Disability Determination Unit (DDU).
How to Apply for Assistance.
The DDU is responsible for making medical necessity determinations for Aid to the Permanently and Totally Disabled, Child Severely Disabled, Home Care for Child Severely Disabled, Aid to the Needy Blind, emergency medical assistance to non-citizens, and Medical Eligibility for Adults with Disabilities. The Bureau of Elderly and Adult Services provides and coordinates services for Nursing Facility Assistance and Home and Community Based Care Choices for Independence (HCBC-CFI) as well as making the medical necessity determination for these two programs.
In and Out Medical Assistance
In and Out Medical Assistance (Medicaid) helps individuals whose income is not enough to pay their medical bills but is too much to qualify for Medicaid. Individuals are given a Spenddown, similar to a car insurance deductible. When qualifying medical expenses add up to the spenddown amount, Medicaid can then help pay for bills incurred for the duration of the Spenddown period. For more information about In and Out Medical Assistance read, "In and Out Medical Assistance?" (Form 77j) (English) (Nepali) (Spanish)
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