Medicaid State Plan Eligibility PDF Forms
Documentation:
- Medicaid State Plan Eligibility Implementation Guides
- Medicaid MAGI Eligibility & Benefits State Plan Amendment
PDF Forms:
- A1-3: Medicaid Administration: Single State Agency
- S10: MAGI-Based Income Methodologies
- S14: AFDC Income Standards
- S14T: Income Standards - Territories
- S21: Presumptive Eligibility by Hospitals
- S25: Eligibility Groups - Mandatory Coverage: Parents and Other Caretaker Relatives
- S28: Eligibility Groups - Mandatory Coverage: Pregnant Women
- S28T: Eligibility Groups - Mandatory Coverage: Pregnant Women - Territories
- S30: Eligibility Groups - Mandatory Coverage: Infants and Children under Age 19
- S30T: Eligibility Groups - Mandatory Coverage: Infants and Children under Age 19 - Territories
- S32: Eligibility Groups - Mandatory Coverage: Adult Group
- S33: Eligibility Groups - Mandatory Coverage: Former Foster Care Children
- S50: Eligibility Groups - Options for Coverage: Individuals above 133% FPL
- S51: Eligibility Groups - Options for Coverage: Optional Coverage of Parents and Other Caretaker Relatives
- S52: Eligibility Groups - Options for Coverage: Reasonable Classification of Individuals under Age 21
- S53: Eligibility Groups - Options for Coverage: Children with Non IV-E Adoption Assistance
- S54: Eligibility Groups - Options for Coverage: Optional Targeted Low Income Children
- S55: Eligibility Groups - Options for Coverage: Individuals with Tuberculosis
- S57: Eligibility Groups - Options for Coverage: Independent Foster Care Adolescents
- S59: Eligibility Groups - Options for Coverage: Individuals Eligible for Family Planning Services
- S88: Non-Financial Eligibility: State Residency
- S89: Non-Financial Eligibility: Citizenship and Non-Citizen Eligibility
- S94: General Eligibility Requirements: Eligibility Process