Title 16
15000 AFDC-TANF Related Programs
Federal Regulation 42 CFR 435.116
On 10/1/84, Medicaid coverage for certain pregnant women became mandatory effective upon medical verification of their pregnancy. The pregnancy must be verified by a medical professional authorized under State law to make such a determination. A medical professional includes a physician, nurse, or lab technician. Eligibility is based on whether the woman would be eligible for AFDC if her child was born and living with her.
15130.1 Composition of Assistance Unit
The determination of Medicaid eligibility must take into account the needs, income, and resources that would be taken into account under the cash assistance program, A Better Chance Welfare Reform Program, if the child were born and living with her. Therefore, include the needs, income, and resources of:
• the pregnant woman;
• the unborn child (or children when it is medically verified that there is more than one unborn);
• the unborn child's father (if living in the household); and
• siblings who would otherwise be eligible.
Deprivation is no longer a technical eligibility requirement under the cash assistance rules for A Better Chance Welfare Reform Program. Use the income and resource standards under A Better Chance Welfare Reform Program.
15130.2 Presumptive Eligibility
Pregnant women under this coverage group may be found presumptively eligible. See DSSM 16100.1 for the rules on presumptive eligibility.
15130.3 Limitations on Retroactive Coverage
Eligibility is available for up to 3 months prior to the month of application. In order to be eligible during this retroactive period, the woman must have been pregnant in the month that eligibility is determined. Effective January 1, 1996, individuals who are eligible for enrollment in managed care in the month that they apply for Medicaid cannot receive retroactive Medicaid.
15130.4 Post Partum Extension
The pregnant woman is eligible for 90 days post partum. Medicaid eligibility related to the post partum extension ends on the last day of the month in which the 90 day period ends. A redetermination will be completed prior to closing. If the woman is not eligible for Medicaid on another basis, she can receive Family Planning services only. (See DSSM 16500)
