§ 435.554 Specified excluded individuals.
(a) For purposes of this section—
Caretaker relative means a relative of a dependent child or a disabled individual, as those terms are defined in this section, by blood, adoption, or marriage with whom the child or disabled individual is living, who assumes primary responsibility for the dependent child's or disabled individual's care, and who is one of the following—
(i) The dependent child's or disabled individual's father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece.
(ii) The disabled individual's husband, wife, son, daughter, stepson, stepdaughter, grandson, or granddaughter.
(iii) The spouse of such parent or relative, even after the marriage is terminated by death or divorce.
(iv) At State option, another relative of the dependent child or disabled individual based on blood (including those of half-blood), adoption, or marriage; the domestic partner of the parent or other caretaker relative; or an adult with whom the dependent child or disabled individual is living and who assumes the primary responsibility for the dependent child or disabled individual's care. To the extent a State has elected to include any of these relationships for the purpose of eligibility for the group at § 435.110, the same elections shall apply for this definition for such State.
Dependent child means a child 13 years of age or under who relies on another individual for care.
Disabled individual means an individual who meets the Americans with Disabilities Act definition of disability at 28 CFR 35.108. An individual need not be eligible for Medicaid or other Federal programs on the basis of a disability to be a disabled individual under this definition.
Family caregiver means an adult family member or other individual who has a significant relationship with, and who provides care within a broad range of assistance to, a dependent child or a disabled individual as both terms are defined in this section.
Guardian means an adult appointed by a court to care for and make personal decisions for a dependent child or disabled individual, as defined in this section, who cannot care for themselves, in accordance with applicable State law.
Parent means an individual with the legal status of a mother or father, including by adoption, in accordance with applicable State law, who provides some level of care to a dependent child or disabled individual, as defined in this section.
(b) An individual who meets the criteria for one or more of the categories described in paragraph (c) of this section is excluded from the definition of an applicable individual as defined at § 435.551. Community engagement is not a condition of eligibility for specified excluded individuals.
(c) An individual is a specified excluded individual if he or she meets one of the following:
(1) The individual meets the definition of the eligibility group serving former foster care children, described at section 1902(a)(10)(A)(i)(IX) of the Act as amended by Public Law 115-271, regardless of whether the individual turned age 18 on or after January 1, 2023.
(2) The individual meets the definition of Indian at § 447.51 of this subchapter.
(3) The individual is a parent, guardian, caretaker relative, or family caregiver, as each is defined in this section, and for family caregivers, meets one of the criteria identified at paragraphs (c)(1)(i)(A) through (C) of this section. For purposes of this exclusion:
(i) An individual who is a family caregiver as defined in this section is a specified excluded individual if he or she meets one of the following criteria:
(A) The individual primarily resides with a dependent child or disabled individual, as these terms are defined in this section, for whom he or she provides assistance that occurs on a regular basis and is not solely incidental in nature.
(B) The individual is a relative (as specified in the “caretaker relative” definition in this section, without regard to the requirements to live with and to assume primary responsibility) of a dependent child or disabled individual, as these terms are defined in this section, for whom he or she provides assistance that occurs on a regular basis and is not solely incidental in nature, and with whom he or she does not reside.
(C) The individual does not reside with and is not a relative (as specified in the “caretaker relative” definition in this section, without regard to the requirements to live with and to assume primary responsibility) of a dependent child or disabled individual, as these terms are defined in this section, for whom he or she provides not less than 80 hours of assistance that is not solely incidental in nature per month.
(ii) In residences with more than one parent, guardian, caretaker relative, or family caregiver, multiple individuals who meet the relevant definitions at paragraph (a) of this section may qualify as a specified excluded individual as described in this section.
(4) The individual is a veteran with a temporary or permanent disability from the Department of Veterans Affairs, rated as 100 percent (total) under 38 U.S.C. 1155.
(5) The individual is medically frail or otherwise has special medical needs. For purposes of this exclusion:
(i) An individual who is medically frail or otherwise has special medical needs is defined as an individual whose physical, mental, or other behavioral health condition significantly impairs the individual's ability to comply with the community engagement requirement in this subpart and is an individual:
(A) Who is blind or disabled (as defined in section 1614 of the Social Security Act);
(B) With a substance use disorder, excluding an individual in stable recovery (which means, an individual who is in recovery for 5 or more years);
(C) With a disabling mental disorder;
(D) With a physical, intellectual, or developmental disability that significantly impairs their ability to perform one or more activities of daily living; or
(E) With a serious or complex medical condition which is a medical condition that is life threatening, seriously disabling without necessarily being life threatening, causing significant pain or discomfort that can cause serious interruptions to life activities, requiring a major time or effort commitment from caregivers for a substantial period of time, requiring frequent monitoring, associated with severe consequences or negative consequences for someone else, affecting multiple organ systems, requiring management to tight physiological parameters, requiring coordination of multiple specialties, requiring treatment that carries a risk of serious complications, or requiring adjustment in non-medical environments.
(ii) The State must develop a list of diseases, diagnoses, disorders, or other health conditions to identify individuals who meet the criteria in paragraphs (a)(5)(i)(A) through (E) of this section.
(A) The list must be auditable, justifiable, and consistent with the definitions established in paragraphs (a)(5)(i)(A) through (E) of this section.
(B) The State must revise this list on a regular basis to add or remove diseases, diagnoses, disorders, or health conditions based on the State's experience applying this exclusion.
(C) If an individual does not have a disease, diagnosis, disorder, or health condition on this list, the State must have reasonable processes and criteria in place for such individual to request consideration for the exclusion for individuals who are medically frail or otherwise have special medical needs.
(6) The individual is compliant with any requirements imposed by the State, in accordance with section 407 of the Act.
(7) The individual is a member of a household that receives Supplemental Nutrition Assistance Program (SNAP) benefits under 7 U.S.C. 2015 and is not exempt from a work requirement under such Act.
(8) The individual is participating in a drug addiction or alcoholic treatment and rehabilitation program, as defined in section 3(h) of the Food and Nutrition Act of 2008 (7 U.S.C. 2012(h)). States may establish a minimum time commitment, consistent with appropriate clinical guidelines, for participation in such a program.
(9) The individual is an inmate of a public institution, as defined at § 435.1010.
(10) The individual is pregnant or entitled to postpartum medical assistance under section 1902(e)(5) or (16) of the Act.