SECTION 4, Financial Eligibility

01. Income And Resources. Sections 300 through 706, of these rules, describe the types of income and resources considered in the eligibility determination process and how they are considered for all family medical coverage groups. (7-1-04)T

02. Income Disregards. The income disregards described in Sections 357 through 362 and in Section 388, of these rules, do not apply to CHIP A, CHIP B or the Children’s Access Card program. (4-11-06)

03.01.301. FINANCIAL RESPONSIBILITY.

The income and resources of individuals who are financially responsible for the participant are counted in determining eligibility. Individuals are financially responsible for themselves. Parents are financially responsible for their adoptive and natural children but not step children. Spouses are financially responsible for each other. (7-1-04)T

FINANCIAL RESPONSIBILITY

Do not count income and resources of grandparents, step parents, aunts, uncles, siblings, etc., when determining eligibility for a family or for an individual, unless the person is included in the family size.

Only the participant's own income and resources, and the income and resources of a parent or spouse, can cause ineligibility for Medicaid. The income and resources of a family member, who is not a parent or spouse, do not cause an individual to be ineligible for Medicaid. (7-1-04)

Earned Income of Children Under Age 19

The earned income of children under age 19 is excluded for MA/MU and PW programs. The earned income of an 18 year old is counted for CHIP A and CHIP B. Unearned income of a child under 19 is countable for all programs. The non-excluded income of a child under age 19 is used to determine eligibility for any individual for whom the child is financially responsible.

Example #1

Steve, age 18 and Bonnie age 18 are married and have a common child, Chase (18 months). Steve works at the local convenience store and makes $800 per month. Bonnie stays home with Chase and receives $200 each month from her grandma. The family is applying for Medicaid. Steve is financially responsible for himself, Bonnie (his spouse), and Chase (his child). Steve has $0 countable income because his earned income is excluded. Bonnie is financially responsible for herself, Steve (her spouse), and Chase (her child). Bonnie has no earned income. Bonnie's unearned income is counted when determining eligibility for herself, Steve and Chase. The family is eligible for MU based on $200 per month countable unearned income for a Budget Unit of three.

Example #2

Household composition and age= MY - 55, SP - 56, CH - 17, CC - 6, CC - 1, SC - 12, GC - 2, NR - 13

The MY person has a spouse, children, children in common, a step-child, a grand-child, and a non-related child in her household. The MY person’s earned and unearned income will be counted for the CH, and both CC children, but not for the SC, GC, or NR children. The SP’s earned and unearned income will count for both CC children, and the SC child, but not for the CH, GC, or NR children. The unearned income for the children will be counted only in the budget unit they are a part of.

Example #3

Household composition = MY - 16, SP - 21, CH - 1, CC - 2, CC- 2, SC - 4

The MY person has a spouse, a child, children in common, and a step-child in her household. The MY person is a minor so only her unearned income will count in the budget units she is counted in. The MY person’s unearned income only will count for herself, the CH child, and for both CC children. The SP’s earned and unearned income will count for the MY child, both CC children, and the SC child.

Example #4

Household composition = MY - 17, NP - 18, CH - 2, CH - 2, CC - 1, NN- 3, PA - 43

The MY person has a non-married partner, 2 children, a child in common, a neice, and a parent. The household size will be calculated at 7 because of the inclusion of the parent. The MY and NP are both children for eligibility purposes, but only the MY person is a child for income purposes. The MY person’s unearned income only will count for herself, the CH children, and the CC child. The NP’s earned and unearned income will count for himself and the CC child. The PA person’s earned and unearned income will count for the MY. (7-1-04)

NOTE: 18 year old pregnant woman or 18 year old with minor child

An 18 year old who is pregnant or has a minor child in her home is considered a parent. A pregnant woman who is 18 years old can be a separate budget unit when living with her parents to determine Medicaid eligibility. An 18 year old who has a minor child in her home is also considered a separate budget unit from her parents. Therefore, the parent’s income is not deemed.

Example:

Julie is 18 years old and graduated from high school in May. She is pregnant and working. Since Julie is under the age of 19, her income is excluded per MS 03.01.355 for Title XIX Medicaid. Julie is considered a parent even though she is under the age of 19. Do not deem or include Julie’s parents in her budget unit when determining her eligibility for AFDC-related and FPG-related Medicaid.

Example:

Trisha is 18 years old and has a two-year old child. Trisha is living with her parents. Trisha applies for Medicaid for herself and her dependent child. Since Trisha is considered a parent, the Department would not deem income from Trisha’s parents. Trisha and her child are considered a separate budget unit from Trisha’s parents.

03.01.302. MEDICAID BUDGET UNIT.

A Medicaid budget unit is a person or group of persons living in the same home. Their needs, income, and resources are counted as a unit for Medicaid eligibility. Eligibility is based on the number of budget unit members. (3-1-99)

01. Medicaid Eligibility Requirements. All members of the budget unit must meet Medicaid eligibility requirements. (3-1-99)

02. Member of More than One (1) Budget Unit. No person may be a member of more than one (1) budget unit during the same month. (3-1-99)

NOTE: 1619B Medicaid recipients and children receiving Katie Beckett Medicaid are considered AABD participants

03. More than One (1) Medicaid Budget Unit in Home. If there is more than one (1) Medicaid budget unit in a home, each budget unit is considered a separate unit. (3-1-99)

04. Budget Units Not Separate. Budget units cannot be separate if any member is a required member of both units. The units must be combined and treated as one (1) unit. (3-1-99)

Individual Medicaid Budgeting: If a budget unit is ineligible due to income or resources, determine the eligibility of each individual member using individual Medicaid budgeting. (7-1-04)

JOINT CUSTODY
For PW/CHIP Medicaid a parent is allowed to apply for Medicaid on behalf of their children. There is no minimum visitation requirement. Eligibility is determined using the income and resources of the parent that applies first. In joint custody situations, children may move from one parent's home to the other parent's home during the month. If only one parent applies, the child may be included in that parent's Medicaid budget unit. If both parents apply, the parents should decide who will include the child in their household. When there is more than one child, the children may be a member of either but not both households. If the parents cannot agree on who will include the child in the household, include the child in the household of the first parent to apply.

For AFDC related MA/MU Medicaid, the child must be residing in the home of the parent that is applying.

03.01.303. PERSONS WHO MUST BE INCLUDED IN AN AFDC-RELATED MEDICAID BUDGET UNIT.

Persons in the home listed in Subsections 303.01 through 303.05 must be included in an AFDC-related Medicaid budget unit. (11-1-99)

01. Parents. A natural or adoptive parent must be included in the budget unit. Both parents must be included if: (3-1-99)

a. One (1) or both parents is incapacitated; (3-1-99)

b. One (1) parent is receiving AABD Medicaid based on the Community Property method and is not an SSI recipient; or (3-1-99)

c. One (1) or both parents is unemployed or underemployed. (11-1-99)

02. Disqualified Parents. Disqualified parents are members of the budget unit, but are not included in the family size. A disqualified parent's income and resources are counted in full. A person is disqualified if: (7-1-02)

a. He does not meet the financial eligibility criteria found in Sections 300 through 706. (7-1-02)

b. He does not meet the non financial eligibility criteria found in Sections 200 through 214 of these rules; or (7-1-02)

c. He fails to cooperate with Medicaid requirements found in Sections 215 through 220 of this rule. (7-1-02)

03. Siblings. A child's natural or adoptive brother or sister, including half siblings, must be included in the budget unit. (3-1-99)

04. Pregnant Woman With No Other Children. A pregnant woman, who does not have a child residing in the home, may receive Medicaid. (3-1-99)

a. The needs, income and resources of all persons in the home, who would be included in the budget unit if the child was born, must be counted for Medicaid eligibility. (3-1-99)

b. The father of the child, if living in the home, must be included in the budget unit if the couple is married. The father is not eligible for Medicaid until the child is born. (3-1-99)

05. Stepparent Incapacitated or Unemployed. A stepparent, who lives in the home and has a child in common with the parent, must be included in the budget unit if he is unemployed, or has a physical or mental incapacity expected to last at least thirty (30) days. (11-1-99)

Note: A non custodial parent (NCP) cannot receive AFDC related Medicaid (MA) unless there is an MA eligible dependant child living in the home for which they provide day to day care. Visitation with the NCP is not sufficient to meet the requirement of living in the home.

Example 1:
A pregnant woman applies for Medicaid. She lives with the father of the unborn but they are not married. She has no income. Because they are not married and have no common children, we cannot include the father of the unborn in the budget unit. Deprivation exists for the unborn. Dad's income cannot be used to determine eligibility for the pregnant woman. Approve the pregnant woman for MA.

The unborn is born. Paternity is established on the newborn. The newborn and dad is now a mandatory budget unit member of mom's MA budget unit. Determine if the budget unit is eligible for MU. If yes, process MU for all budget unit members. If dad's income makes the budget unit ineligible for MU, the entire budget unit is eligible for MU TM. Make sure the newborn receives one year continuous eligibility for Medicaid, should the MU TM case close prior to the end of the month in which the newborn's 1^st birthday falls.

When TM ends, if the budget unit is not MU eligible mom is not eligible, even though the income of someone who is not her spouse caused the ineligibility. This is because there are no eligible AFDC related children that could be in a separate budget unit with mom.

Example 2:
Cindy and Bob are not married. They live together with their common child, Ethan, age 2. Cindy has no income and Bob works full time. Ethan receives PW Medicaid. Cindy applies for Medicaid because she is pregnant. The budget unit is Cindy, Bob, Ethan, and the Unborn. Bob's income is too high for the family to be eligible for MU. Because Bob and Cindy are not married, the unborn is not considered a common child and paternity is an issue. Deprivation exists for the unborn. Cindy can receive MA for herself. Bob is not eligible for any Medicaid program and Ethan is PW eligible.

The unborn is born. Paternity is established on the newborn. Dad and Ethan are pulled into the budget unit with the newborn and Mom. Dad's income makes the budget unit over the income limit for MU so the entire budget unit is eligible for MU TM because mom received MA for at least 3 of the last 6 months. Make sure the children receive 1 year continuous eligibility at the time MU TM ends.

TM ends. Children are PW eligible. There are no deprived children. There are no AFDC related Medicaid eligible children who could be included in a budget unit with mom only. Mom is not eligible.

03.01.304. PERSONS WHO MAY BE INCLUDED IN AN AFDC-RELATED MEDICAID BUDGET UNIT.

Persons in the home listed in Subsections 304.01 through 304.05 may be included in an AFDC-related Medicaid budget unit. They may choose not to be included. (11-1-99)

01. Other Child in Home. A child, who is not a natural or adoptive child of a budget unit member and not a sibling or half-sibling of other children in the budget unit, can be included. The child must be under eighteen (18), or expected to graduate from high school by his nineteenth (19th) birthday. (3-1-99)

Include the child only when the child is related to the caretaker relative by specified degree. See Section 03.01.413.01. (7-1-04)

02. Child of Pregnant Woman. A pregnant woman's children can be included. If any children are included, all siblings must be included. (3-1-99)

03. Caretaker Relative Other Than Parent. A caretaker relative who is not a natural or adoptive parent, such as an aunt, uncle, or grandparent, can be included. (3-1-99)

A caretaker relative may be included only when both of the child's parents are absent from the home. (7-1-04)

04. Sibling Caretaker. A sibling over the age limit who is the caretaker relative, because the parents are absent, can be included. (3-1-99)

05. Stepparent Caretaker. A stepparent, who is the caretaker relative because the child's parent is absent, can be included. (3-1-99)

03.01.305. PERSONS WHO MUST NOT BE INCLUDED IN AN AFDC-RELATED MEDICAID BUDGET UNIT.

Persons listed in Subsections 305.01 through 305.06 must not be included in an AFDC-related Medicaid budget unit. (11-1-99)

01. SSI Recipient. Persons receiving SSI benefits must not be included. (3-1-99)

Note: Budgeting 18 yr olds for AFDC related Medicaid

Refer to sections 03.01.304 and 03.01.413 for budgeting 18 yr olds for AFDC related Medicaid (MA, MU). (8/1/05)

02. AABD Recipient. Persons receiving AABD benefits must not be included. (3-1-99)

Note: 1619B Medicaid recipients and children receiving Katie Beckett Medicaid are considered AABD participants

03. Stepparent Without Common Child. Stepparents must not be included, unless there is a common child and the child's parent is incapacitated or unemployed. (3-1-99)

04. Ineligible Non-citizen. Persons who are ineligible non-citizens must not be included. (3-1-99)

05. Title IV-E Foster Child. A child receiving foster care payments from the Department must not be included. (3-1-99)

06. Adoption Assistance. A child receiving adoption assistance payments from any federal, state or local agency providing adoption assistance payments must not be included. (3-1-99)

Note: Silent Foster Care
Silent Foster Care is another name for Adoption Assistance. Silent Foster Care is a federally or state funded program which provides monetary payments to the adoptive parents of special needs children to offset the cost of care. The payments are income to the adoptive parents, not the child. However, Silent Foster Care is excluded income regardless of whether it is state funded (FF in EPICS) or federally funded (FX in EPICS). Because the adopted children also receive Medicaid through Adoption Assistance, they are treated similarly to SSI children and cannot be included in the budget unit of other family members who apply for or receive AFDC related or Poverty Level Medicaid programs.

DOUBLE STEPPARENT
For AFDC-related Medicaid, a double stepparent household contains two parents without a common child. Each parent has a natural child not related by blood to the other parent.

Both parents may apply for Medicaid for their own children.

Each parent and their child are separate budget units. The income of each budget unit is separate and not deemed to the other parent's family unit if both units are eligible for Medicaid.

When one of the Medicaid family units is not eligible or is closed, deem the income from the stepparent the month following the month of closure to the Medicaid family unit remaining open. The deemed income only counts toward the spouse, not the child. Do not budget SSI recipients with either family unit. They are not counted for budgeting purposes. (7-1-04)

SSI PARENT
For both AFDC-related and FPG-related Medicaid, do not consider the needs of an SSI caretaker relative in determining eligibility for the child. When an SSI child is the only child in the home, one natural parent may get Medicaid if the child meets all the Medicaid eligibility criteria, other than receipt of SSI. Both parents can get Medicaid if the SSI child is deprived based on incapacity of a parent or unemployment of the principal wage earner. (7-1-04)

PREGNANT WOMAN
For AFDC-related Medicaid, a pregnant woman living with her husband and/or other children not related to her husband, may be in a Medicaid family unit by herself.

The pregnant woman is not required to apply for Medicaid for her other children. The other children are not mandatory Medicaid family unit members until the birth of the unborn.

If the woman applies for Medicaid for a child, include all siblings of that child in the Medicaid family unit.

To determine the pregnant woman's Medicaid eligibility, include the needs, income and resources of all persons living in the household who would be mandatory family unit members if the child was born. If this unit is eligible, the pregnant woman is Medicaid eligible.

The husband's needs, income, and resources are included in the eligibility determination, but he is not eligible for Medicaid until the birth of the unborn. (7-1-04)

To determine family size for Medicaid related to Federal Poverty Guidelines (FPG), refer to Sections 03.01.500 through 03.01.505. (7-1-04)

INDIVIDUAL MEDICAID BUDGETING

Individual Medicaid Budgeting can be applied to determine Medicaid eligibility for any individual. Determine individual Medicaid eligibility as follows:

CONDITION

DESCRIPTION

Family Size

To determine family size for individual Medicaid, use the family size for the family Medicaid coverage group.

Family coverage group is used to determine an income limit (FPG or AF related Medicaid) for an individual.

Financial Responsibility

A parent is financially responsible for himself and for his child.

A spouse is financially responsible for himself and for his spouse.

Do not count a parent or spouse, receiving SSI or AABD payments, as responsible for his spouse or child for determining Medicaid.

Any family member, other than a parent or spouse, is financially responsible only for himself.

Income Exclusions and Disregards

Count all non-exempt income of financially responsible persons in determining Medicaid eligibility.

Earned Income Disregard.

Subtract earned income disregards from each individual’s earned income.

$50 Child Support Disregard.

Subtract the first $50 from each child's support payment. Any unused portion of the child support disregard is not applied to any other child.

Do not allow earned or unearned income disregards for CHIP.

Income Limits

Income limits are based on family size and coverage group. To determine income eligibility for an individual, compare non-exempt gross income of the individual and of the financially responsible individuals to the income limit for the coverage group and family size.

AFDC-related Medicaid Coverage Group Income.

The individual is income eligible if total countable income from a financially responsible person is less than the income limit for the budget unit size. Countable income is income remaining after allowable disregards have been subtracted.

Poverty-related Medicaid Coverage Group Income (FPG). The Low Income Pregnant Woman, Low Income Child, or CHIP applicant is income eligible if total countable income is equal to, or less than, the Federal Poverty Guideline for the family size. Countable income is income remaining after allowable disregards have been subtracted.

Resource Limits

To determine resource eligibility for an individual, compare non-exempt resources of the individual and of financially responsible persons to the resource limit for the coverage group.

DETERMINING HOUSEHOLD SIZE STEP 1

AF Related Programs (MA, MU, QP)

Budget Unit

Federal Poverty Guideline (PW, CHIP) Family Size

The Budget Unit for AF related programs centers around the dependent child. The budget unit includes all MANDATORY household members. This includes parents and all minor siblings living in the home.

Exclude SSI/AABD participants in the Budget Unit determination.

Family size for Federal Poverty Guideline (FPG) programs includes all family members living with the child. This includes the child, child's children, parent(s), stepparent, minor siblings, minor half-siblings, and minor step-siblings.

Exclude SSI/AABD participants in the family size determination.

The Budget Unit is used to determine family Medicaid eligibility based on the AFDC income standards.

The family size is used to determine family Medicaid eligibility under the Federal Poverty Guidelines standards.

(7-1-04)

DETERMINING HOUSEHOLD SIZE STEP 2

INDIVIDUAL MEDICAID BUDGETING
Any participant, ineligible because of the income or resources of a person not a parent or a spouse, must have Medicaid eligibility determined as an individual. An individual may qualify for Medicaid under any coverage group. For Individual Medicaid budgeting only, the income and resources of a parent or a spouse can be used to determine Medicaid eligibility.

To determine household size when budgeting under individual Medicaid, use the same household size used to determine family Medicaid in STEP 1. (7-1-04)

03.01.306. DEEM INCOME FROM STEPPARENT, NON-PARENT CARETAKER OR NON-CITIZEN PARENT.

Use Table 306 to deem income for Medicaid related to the AFDC need standards in effect July 16, 1996. Do not use Table 306 for Medicaid related to Federal Poverty Guidelines. (3-1-99)

01. Stepparent or Non-Citizen Parent. Deem income from a stepparent or non-citizen parent to the budget unit. (3-1-99)

Deem income only when the stepparent or non-citizen parent is not included in the budget unit. (7-1-04)

02. Non-parent Caretaker. Count income from a non-parent caretaker choosing to be included in the budget unit. If there are two (2) non-parent caretaker relatives in the home, only one (1) can receive Medicaid. (11-1-99)

03. Two (2) Non-parent Caretaker Relatives. If two (2) non-parent caretaker relatives are a married couple and one (1) chooses to receive Medicaid, deem the income of the spouse not receiving Medicaid to the budget unit. (11-1-99)

TABLE 306

DEEMING INCOME FROM STEPPARENT,

NON-PARENT CARETAKER AND NON-CITIZEN PARENT

STEP

ACTION

Step 1

Subtract a ninety dollar ($90) work disregard from the total monthly earned income.

Step 2

Add the remaining earned income and unearned income to arrive at the total monthly income.

Step 3

Subtract child support payments made by a stepparent, non-parent caretaker or non-citizen parent from total monthly income in Step 2.

Step 4

Subtract payments made to a dependent not residing in the home from income in Step 3. The dependent must be claimed for income tax purposes before the payments can be subtracted. The amount remaining after the subtraction of the disregards is the net income.

Step 5

Subtract the Need Standard for the stepparent, non-parent caretaker or non-citizen parent and their dependent children from the net income in Step 4. The difference is the income deemed to the Medicaid family unit.

(11-1-99)

03.01.307. -- 03.01.308. (RESERVED).

03.01.309. DETERMINING RESOURCE ELIGIBILITY.

The following information is required to determine a participant’s resource eligibility: (4-6-05)

01. Countable Resources. The value of the participant’s calculated countable resources is compared to the resource limit for the appropriate Health Care Assistance coverage group. (4-6-05)

02. Initial Eligibility. For initial eligibility the value of their countable resources is determined as of the application date. (4-6-05)

03. Excess Countable Resources. Excess countable resources anticipated at any time during an upcoming month, affects the entire month’s eligibility. (4-6-05)

NOTE: TREATMENT OF RESOURCES FOR NON-HOUSEHOLD MEMBERS

SSI Participants.

Do not count resources owned by an SSI participant as available to the family, even if acquired after marriage.
Do not count vehicles owned only by an SSI recipient for Family Medicaid budgeting.

Stepparents. Do not count resources owned by a stepparent before marriage, unless he makes them available to the family. Count resources obtained by the stepparent after marriage as community property.

Sanctioned Parents. Count the resources of a sanctioned parent who would be included in the family size if the parent was not sanctioned.

Minor Parent's Parent. Do not count resources owned by the parent of a minor parent, unless the family unit includes the minor parent and his parents. The resources of the minor parent's parents are not counted, unless the minor parent's parents make them available to her.

Caretaker Relative. Do not count resources owned by a caretaker relative, unless the caretaker relative is included in the family size.

Alien Parent. Count all the alien parent's resources toward the family unit's resource limit. (8-1-05)

Example #1
Matt and Kristi are a married couple. Kristi has 3 children from a prior marriage. Matt and Kristi have 1 child in common. Matt owns 2 trucks, a travel trailer, a 4 wheeler and a homemade trailer used to haul the 4 wheeler. Matt and Kristy also purchased a car together.

Matt's vehicles count for himself, Kristi, and the common child. The vehicle Kristy and Matt purchased together counts for Matt, herself, and all the children. Do not count the value of Matt's vehicles for Kristi's children.

Example #2:
Steve and Melissa have 6 children. The children are income eligible for PW. Steve and Melissa have 2 vehicles that are exempt for work and family transportation. They also have a checking account with a balance of $250 and a savings account with a balance of $50. Each child has a savings account with a balance of $1000 that was set up by the grandmother. Steve and Melissa's bank accounts are used when determining the children's eligibility. Each child's savings account is also used when determining eligibility for that child. The children's savings accounts are not used to determine eligibility for their siblings. Each child has countable resources of $1300.00. All of the children are PW eligible.

NOTE: Excess countable resources reported after the initial approval or renewals apply only to pregnant women. Excess resources received or anticipated after an initial determination or renewal is completed do not affect children with continuous 12 month eligibility.

03.01.310. RESOURCE LIMITS.

The resource limit for AFDC-related coverage groups is one thousand dollars ($1,000). The resource limit for FPG-related coverage groups is five thousand dollars ($5,000). (7-1-04)T

Determining Resources:

1. Accept resource information provided on the application, or provided later by the participant, unless the information is incomplete or questionable.

2. If there is a discrepancy on the application, or information is not complete, contact the participant to obtain the information.

3. Contact collaterals ONLY when the participant cannot provide information needed to resolve the discrepancy.

4. If a participant provides additional verifications required by another program, use this information to determine resource eligibility.

5. Use information available through computer interface (such as ICSES and Department of Transportation) to verify resource information provided on the application.

6. Identify and evaluate resources as of the date of application. If the value of resources claimed on the application is less than the resource limit, the family is resource eligible.

7. If the value of resources claimed on the application is over the resource limit, contact the participant for information needed to determine if the resources are counted or excluded.

8. If resources owned by a person not financially responsible for the participant cause ineligibility, explore individual Medicaid eligibility.

9. If resources are anticipated any time during an upcoming month or months, determine if the resource affects eligibility for the month of receipt.

10. IRA funds and employment related retirement accounts are excluded and not considered against the resource limit. (7-1-04)

03.01.311. RESOURCE DEFINITION.

Resources are liquid assets, vehicles, and real property with a cash value upon disposition. Resources are available when the participant has the legal right to dispose of the resource and can do so in a reasonable length of time. (7-1-98)

03.01.312. LIQUID ASSETS.

Liquid assets include such things as cash, bank accounts, proceeds from the sale of a resource, stocks, bonds, mutual funds, promissory notes, mortgages, tax refunds, settlement of damage claims, trust funds, and other financial instruments that can be converted into cash. (11-1-99)

If a participant has a trust, refer to procedures regarding treatment of trusts, located in IDAPA 16, Title 3, Chapter 5, the Medicaid section of the AABD Handbook. Those procedures apply to all Medicaid groups. (7-1-04)

03.01.313. EQUITY VALUE OF RESOURCES.

Resources are counted according to their equity value. This is the value of the resource after all liens, mortgages and other encumbrances against the resource are subtracted. (7-1-97)

03.01.314. VEHICLES.

For both AFDC-related and FPG-related Medicaid coverage groups, one (1) vehicle, regardless of value, is excluded. In two (2) parent families, a second vehicle used for medical transportation, or seeking or retaining employment, is also excluded. The equity value of each additional vehicle, licensed or unlicensed, is a resource. The value of special equipment for the use or transportation of a disabled person is not counted when determining the equity value. (11-1-99)

NOTE: VEHICLE EQUITY AND FAIR MARKET VALUE

The equity value is the fair market value less any amount owed on the vehicle. Use the participant’s statement of a vehicles value, if reasonable.

Example #1: A participant states his car is valued at $5000. The amount of the loan at the time of application is $4000. The equity value is $1000.

Use the interface with the Department of Transportation to get information, including vehicle registrations. If there are discrepancies, ask the client for clarification. A vehicle registration provides detailed information that can be used to research trade-in value. Use one of the WEB bases automated resources (such as NADA, Kelly Blue Book, Edmonds, Car Pricing.com) to verify trade in value. Do not add vehicle options (such as cruise control, air conditioning, power windows, and 4-wheel drive) to the average trade-in value.

Example #2: A participant does not know how much his car is worth. The worker looks up the car using one of the automated resources. The low trade in is $400, the high is $1500 and the average is $1000. Use the average trade in value of $1000. (8-1-05)

NOTE: Do not count vehicles or resources owned only by an SSI recipient for Family Medicaid.

NOTE: In determining the value of vehicles for Family Medicaid, if the value listed puts the household over resources, the client can provide an estimate from a dealer that gives a more accurate value of the vehicle.

03.01.315. BANK ACCOUNTS.

Money deposited to a bank account by the participant is a countable resource. Income not spent in the month received is counted as a resource the next month. (7-1-98)

Deposits counted as income will not be counted as a resource in the same month. (7-1-04)

03.01.316. (RESERVED).

03.01.317. SALES CONTRACTS.

A mortgage, promissory note, or other form of sales contract that can be sold is a resource. (7-1-97)

03.01.318. RESOURCES EXCLUDED BY FEDERAL LAW.

A resource excluded by federal law is not counted in determining the resource amount available to the participant. (7-1-97)

EXCLUDED RESOURCES

One (1) burial plot for each family member.
One (1) funeral agreement for each family member up to $1,500 equity value.
Household goods.
Personal effects.
Home in which the participant lives.
Home replacement.
Family Self-Sufficiency Escrow Accounts established by HUD.
Educational income carried over from the month of receipt.
Retirement funds.
Cash value of life insurance policies.(7-1-04)

Note: If the home is temporarily unoccupied by the client, the home can remain exempt from resources as long as the client intends to return to the home. Temporary absences include, but are not limited to hospitalization, trips, following the migrant job stream, and attending school. If such absences are expected to exceed six months, the intent to return to the home must be evaluated and documented.

03.01.319. -- 03.01.329. (RESERVED).

03.01.330. CONDITIONAL BENEFITS.

A participant ineligible due solely to excess non liquid resources can receive Medicaid. Non liquid resources are non-cash resources not convertible to cash within twenty (20) working days. The participant must meet two (2) conditions. First, his countable liquid resources must not exceed three (3) times his Medicaid income limit. Second, the participant agrees, in writing, to sell excess non-liquid resources at their fair market value, within three (3) months. The value of excess real property is not counted as a resource, as long as the participant makes reasonable efforts to sell the property at its fair market value, and his reasonable efforts to sell are not successful. This exclusion is also used to compute deemed resources. (4-1-00)

01. Conditional Benefits Payments Disposal/Exclusion Period. The disposal period and exclusion period for excess non-liquid resources begins on the date the participant signs the Agreement to Sell Property. The disposal and exclusion periods can begin earlier for a participant who met all requirements to receive conditional benefits before his first opportunity to sign the Agreement to Sell Property. The participant must sign the Agreement to Sell Property before his application is approved. (4-1-99)

02. Time Period for Disposal of Excess Personal Property. The disposal period for excess non-liquid personal property is three (3) months. One (1) three (3) month extension, for sale of personal property, is allowed when good cause exists. (4-1-99)

03. Good Cause for Not Making Efforts to Sell Excess Property. The participant has good cause for not making efforts to sell property, when circumstances beyond his control prevent his taking the required actions. (11-1-99)

04. Participant Does Not Have Good Cause. If the participant does not have good cause for not making efforts to sell the property, the value of the property is counted as a resource back to the beginning of the conditional benefits period. If the resource value exceeds the limits, Medicaid is closed. Advance notice of closure is required. (11-1-99)

CONDITIONAL BENEFITS

Have the participant sign the Agreement to Sell form, HW 0455. The participant is not required to repay benefits for the conditional eligibility period. The Department will not place a lien on the property offered for sale. Property sold on a contract satisfies the terms of the agreement to sell. When the real or personal property is sold, the proceeds are a resource the month after the sale.

Tell the participant:

1. He must make continuing efforts to sell the property and report the sale.

2. He must not refuse a reasonable offer to buy and must report offers to buy.

3. The property must be offered for at least 2/3 of the fair market value and not more than the fair market value.

4. He can cancel the Agreement in writing and the property counts as a resource the following month.

Examples of Proof of Efforts to Sell Real Property:

1. Copy of the listing with the real estate agent.

2. Dated ads showing the property is for sale.

3. Contacts with the media for advertising the property.

4. Copies of flyers or posted notices.

5. Any other evidence of reasonable efforts to sell.

Evaluating Good Cause for Not Making Efforts to Sell:

1. If the SRS determines the participant is not making reasonable efforts, check for good cause.

2. Get the participant's statement about why the property has not been sold.

3. Have the participant provide evidence to support a claim of good cause.

4. Use evidence from collaterals if available.

The property is counted as a resource when the participant does not make reasonable effort to sell the property. End the conditional benefits the month after the month reasonable efforts stopped. Timely notice is required. (7-1-04)

03.01.331. PROPERTY Transfer.

When determining Medicaid eligibility for any family medical coverage group, there is no asset transfer penalty. (4-11-06)

03.01.332. -- 03.01.344. (RESERVED).

03.01.345. DETERMINING ELIGIBILITY FOR RETROACTIVE MEDICAL ASSISTANCE.

Calculate the participant’s countable income for each retroactive month, using actual, not converted income for that month. Determine eligibility for each retroactive month separately. Retroactive medical assistance is limited to Title XIX Medicaid and CHIP A coverage groups. (7-1-04)T

Retroactive Medical and CHIP B/Children’s Access Card applicants:

If an applicant requests a determination of eligibility for retroactive medical and is only eligible for CHIP B or Children’s Access card during the month of application, determine if the participant was eligible for Title XIX Medicaid or CHIP A. Issue retroactive Medicaid for any month the applicant was eligible for Title XIX or CHIP A.

(7-1-04)

03.01.346. DETERMINING INCOME ELIGIBILITY FOR THE MONTH OF APPLICATION.

Calculate the individual’s countable income for the application month. Compare the income against the income limits for the appropriate Health Care Assistance program. (7-1-04)T

If CHIP B and Children’s Access Card applicants are not eligible in the month of application, they must reapply.
(7-1-04)

Self Reliance Specialists (SRS) will compare the information that is declared on the application with the information on automated interfaces connected with other state and federal agencies, such as:

-Department of Transportation

            -Idaho Department of Commerce and Labor
            -The Work Number
            -SOLQ

Additional information will not be requested from the applicant when it can be verified through the above interfaces and is consistent with the declared income. When interface information is unavailable or inconsistent with declared income on the application, Department staff must contact the participant to provide the information needed or reconcile the discrepancy. If the income is still questionable after speaking with the participant, SRS staff will request additional documentation from the participant and give timely notice for the participant to provide that information. SRS staff must always narrate how they arrived at the income calculation. A few examples of situations in which income may be considered questionable:

-Out of state employment

-Participant with no Social Security number

-Change in income

-Self Employment Income is always considered questionable and written verification must be obtained from the applicant

Acceptable verification can include:

-Earned – pay stubs or a note from the employer

-Unearned – monthly payment stub or copy of an award letter

-Self Employment - Income tax returns

It is the participant’s responsibility to provide the information and employers should be contacted directly as a last resort. The Department may contact the issuing agency if the applicant requests assistance in getting the information.

Resources are self-declared but if the account balance or the value of the resource is close to the resource limit then the worker must contact the participant to clarify the information. Do not request further information if contact with the participant provides the information needed. Always narrate your findings. If the resource is considered questionable after speaking with the participant, request verification and give timely notice. (1/31/05)

03.01.347. Determining Available INCOME.

Income from financially responsible household members is considered available to the participant. Income is available when the participant has a legal interest in a liquidated sum. Income is available when action can be taken by the individual to obtain or use it. The participant must take all necessary steps to obtain program benefits for which he may be eligible. This includes RSDI, unemployment insurance, and worker's compensation. (7-1-04)T

03.01.348. DETERMINING INCOME Eligibility

Income from financially responsible household members is counted to determine an individual’s eligibility. The individual’s countable income must be calculated using actual income already received and anticipated income that can reasonably be expected. The individual’s calculated income is used to determine eligibility. The appropriate Health Care Assistance coverage group is determined by comparing the income against the income limit. (7-1-04)T

03.01.349. CALCULATING A FULL MONTH'S INCOME

The participant’s monthly income is calculated using actual income and anticipated income. Anticipated income is income the participant is reasonably expected to receive. The estimate of anticipated income must be based on the best available information. (7-1-04)T

01. Full Month's Income Anticipated. If no changes are anticipated, use the actual income received in the past thirty (30) days to calculate a full month’s income. If changes are anticipated, project the full month’s income with the new information. (7-1-04)T

02. Full Month's Income Not Anticipated. If a full month's income is not anticipated, count the actual income expected for the month. If the actual amount is unknown, project the anticipated income for that month. (7-1-04)T

03. Seasonal Income. If income changes seasonally, consider the household's income from the previous season and any anticipated pay changes to calculate the individual’s average monthly income. (7-1-04)T

04. Fluctuating Income. When income fluctuates each pay period, but the rate of pay remains the same, average the income from the past thirty (30) days to determine the average anticipated pay period amount. Convert the average anticipated pay period amount to a full month's income. (7-1-04)T

05. Income Paid As Salary. Count income paid as salary at the expected monthly salary rate. Do not count salary at an hourly rate. (3-30-01)

06. Income Paid under Contract. The earned income of an individual paid on a contractual basis is prorated over the term of the contract. (7-1-04)T

Anticipating income

Eligibility is determined for Health Care Coverage using the current month’s income. If the application is for March 3^rd, we don’t know what the income for March is.

Example: The application is for March 3^rd. As of the 3^rd of March we don’t know what the full month’s income will be. We must use the information that is available to “anticipate” what the March income is likely to be. Income from financially responsible household members is counted to determine an individual’s eligibility. Calculate the individual’s countable income using actual income already received and anticipated income that can reasonably be expected. The individual’s calculated income is used to determine eligibility. Compare the income against the income limit for the appropriate, Title XIX Medicaid, CHIP A, CHIP B or Children’s Access Card coverage group. (7-1-04)

03.01.350. CONVERTING INCOME TO A MONTHLY AMOUNT.

If a full month's income is expected, but income is received more often than monthly, convert the income to a monthly amount using the appropriate formula in Subsections 350.01 through 350.03. (11-1-2000)

01. Weekly Income. Multiply weekly income by 4.3. (11-1-2000)

02. Bi-Weekly Income. Multiply bi-weekly income by 2.15. (11-1-2000)

03. Semi-monthly Income. Multiply semi-monthly income by 2. (11-1-2000)

03.01.351. EARNED INCOME.

Earned income is derived from labor or active participation in a business. The income can be wages, tips, salary, commissions, advances, jury duty payments, sale of plasma, vacation pay, bonuses, living allowance or stipend from AmeriCorps and Senior Corps, or profit from employment or self-employment. Earned income is gross earnings before deductions for taxes or any other purposes. It is counted as income when it is received, or would have been received except for the decision of the participant to postpone receipt. Earnings over a period of time and paid at one (1) time, such as the sale of farm crops, livestock, or poultry, are annualized and self- employment expenses deducted. (11-1-99)

NOTE: Income is counted for the month it is intended to be paid. If mailing or payment cycles cause an extra payment to be received in one month, or one less payment in the next month, count the income for the month it is intended to be paid.

NOTE: Partnerships and Corporations

Partnerships, Limited Liability Corporations (LLCs), and S Corporations are regarded under the law as artificial persons with income and debts independent of their members or shareholders. Use appropriate legal or tax records to verify the type of business structure.

With these types of businesses, expenses are taken out prior to disbursing profits. Because of this, income from these businesses is not treated under typical self employment rules, and expenses are not allowed.

In LLCs and S-Corps, be aware that officers often receive a separate disbursement of income for that status, in addition to their income for being a member or shareholder. Disbursed income is treated as earned income.

If the disbursements come out less often than monthly, then average them over the period of time they are intended to cover.

If the participant has not taken any legal steps to turn their business into a Partnership, LLC, S Corp, assume it is a sole proprietorship and that normal self employment rules apply. If it is not clear from the legal paperwork provided which type of business structure is involved, utilize your local DAG to assist in the identification of the business structure.

03.01.352. SELF-EMPLOYMENT EARNED INCOME.

Income from self-employment is treated as earned income. Compute self-employment income using Table 352.06. (11-1-99)

01. Annualize Self-employment Income. Annualize the income if the participant has been self employed for more than one (1) year. (3-1-99)

02. Average Self-Employment Income. Average the income over the period of time the business has been operating if the participant has been self employed for less than one (1) year. (3-1-99)

03. Annualized or Averaged Income Not Accurate. If the annualized or averaged income does not reflect the participant's current or projected income from his business, anticipate self employment income and expenses. (3-1-99)

04. Allowable Costs of Producing the Self-employment Income. Allowable costs of producing the self-employment income include: (3-1-99)

a. The cost of labor paid to persons not in the home. (3-1-99)

b. The cost of stock. (3-1-99)

c. The cost of material. (3-1-99)

d. The cost for rent and utilities, advertising, shipping and legal fees. (3-1-99)

e. The cost of seed and fertilizer. (3-1-99)

f. Interest paid to purchase income-producing property, including real estate. (3-1-99)

g. Insurance premiums. (3-1-99)

h. Taxes paid on income-producing property. (3-1-99)

i. Transportation, when a vehicle is an integral part of business activity. (3-1-99)

j. Expenses directly related to producing the goods or services and, without which, the goods or services could not be produced. (4-11-06)

NOTE: OFFSETTING FARMING AND RANCHING SELF-EMPLOYMENT LOSSES

If a farmer's cost of producing self-employment income results in a loss, the loss must be subtracted from other countable income in the household.

·         First, subtract the loss from non-farm self-employment income. If any loss remains;

·         Subtract the remaining loss from the total of earned income. If any loss remains;

·         Subtract the remaining loss from the total of unearned income.

·         Net losses from the self-employment income of a farmer are prorated over the year.

Net losses do not carry over into the next year. (8-1-05)

05. Non-Allowable Costs of Producing the Self-employment Income. The non-allowable costs of producing the self-employment income are: (3-1-99)

a. Payments on the principal of the purchase price of income-producing real estate and capital assets, equipment, machinery, and other durable goods. (3-1-99)

b. Net losses from previous periods. (3-1-99)

c. Federal, State, and local income taxes. (3-1-99)

d. Money set aside for retirement. (3-1-99)

e. Personal expenses such as lunches and transportation to and from work. (4-11-06)

f. Personal business and entertainment expenses, and personal transportation costs. (4-11-06)

g. Depreciation. (3-1-99)

06. COMPUTING SELF EMPLOYMENT INCOME

Self-employment income is not self-declared. Verify self-employment income using current taxes or profit and loss statements. (7-1-04)

TABLE 352.06

COMPUTING SELF-EMPLOYMENT INCOME

STEP

DESCRIPTION

Step 1

Add all self-employment income.

Step 2

Add all capital gains to the self-employment income. The result is gross self-employment income.

Step 3

Use the method of determining net self-employment income that most benefits the participant. Either subtract fifty percent (50%) of total gross self-employment income or subtract allowable costs of producing the self-employment income. Allowable costs are listed in Subsection 352.04. Do not subtract the non-allowable costs listed in Subsection 352.05. The result is available self-employment income.

NOTE: When subtracting 50% of total gross self-employment income, use line number 7 on schedule C "total gross income". Do not use the figure on line number 1 "gross receipts or sales"

(4-11-06)

Apply allowable earned income disregards to self-employment income if:

1. The participant qualifies for the disregards.
2. The disregards are needed for eligibility. (7-1-04)

03.01.353. Offsetting Farm Self-Employment Losses.

If a farmer’s cost of producing self-employment income results in a loss, the loss must be subtracted from other countable income in the household. The losses from non-farm self-employment income must be subtracted first. If any loss remains, the remaining loss must be subtracted from the total of earned income. If any loss still remains, the remaining loss must be subtracted from the total of unearned income. Net losses from the self-employment income of a farmer are prorated over the year and do not carry over from year to year. (4-11-06)

Procedure:

First, subtract the loss from non-farm self-employment income. If any loss remains;
Subtract the remaining loss from the total of earned income. If any loss remains;
Subtract the remaining loss from the total of unearned income.

Remember:

Net losses from the self-employment income of a farmer are prorated over the year.
Net losses do not carry over into the next year. (4-11-06)

03.01.354. Income Paid Under Contract.

The earned income of an employee paid on a contractual basis is prorated over the period of the contract. (4-11-06)

03.01.355. JOB TRAINING PARTNERSHIP ACT (JTPA) INCOME.

Incentive income from the JTPA program is earned income. JTPA allowances are excluded if provided for specific goods and services. JTPA income, earned and unearned, paid to a minor child, is excluded with no time limits. (11-1-99)

03.01.356. CHILD'S INCOME.

A child's earned income is excluded for AFDC-related and FPG-related Medicaid coverage groups, other than the Children's Health Insurance Program (CHIP) coverage group. Earned income of a child eligible under CHIP between the ages of eighteen (18) and nineteen (19) is counted. (11-1-99)

Counting income of 18 year olds for CHIP programs.

Count the income of a child between the ages of 18 and 19 for CHIP A, CHIP B and Children’s Access Card. (7-1-04)

03.01.357. IN-KIND INCOME.

An individual receiving a service, benefit, or durable goods, instead of wages, is earning in-kind income. In-kind income is excluded. (11-1-99)

03.01.358. EARNED INCOME DISREGARDS.

Earned income disregards are subtracted from earnings after they are converted to a monthly amount, if the participant is not eligible without the disregards. The earned income disregards are the standard disregard, thirty dollars ($30) plus one-third (1/3) disregard, and the dependent care disregard. Disregards are subtracted in that order. (11-1-00)

Do not allow earned income disregards when determining CHIP A, B or Children’s Access Card eligibility.

03.01.359. STANDARD EARNED INCOME DISREGARD.

The first ninety dollars ($90) of earned income is disregarded. (11-1-99)

03.01.360. THIRTY PLUS ONE-THIRD DISREGARD.

Thirty dollars plus one-third ($30 + 1/3) is disregarded when the earned income belongs to a child, a single parent, a relative caretaker receiving Medicaid, a pregnant woman, or a parent in a two (2) parent family receiving Medicaid because of unemployment or incapacity. The disregard is allowed only if earned income, minus ninety dollars ($90) and allowable child care, is below the AFDC need standard for the family size. The disregard is not allowed after four (4) consecutive months. (7-1-97)

AFDC NEED STANDARDS -- JULY 16, 1996

NUMBER IN FAMILY

NEED STANDARD

1

$643

2

$786

3

$991

4

$1,196

5

$1,401

6

$1,606

7

$1,811

8

$2,016

9

$2,221

10

$2,426

OVER 10 PERSONS

ADD $205 EACH

(7-1-04)

APPLYING EARNED INCOME DISREGARDS
The 30 1/3 disregard is allowed only if the `applicant or recipient is receiving Medicaid or eligible to receive Medicaid and passes one of the following income tests. EPICS determines eligibility for the 30 1/3 disregard for clients with the following participation codes.

A child – earned income of a child under 19 yrs of age is excluded

A Pregnant woman – AP or EL

A single parent – MA/QP – a participation code of AP, EL, IP, and disqualified codes that begin with ‘D’

A caretaker relative applying for Medicaid – MA - participation code of AP or EL

Parents in a two parent family – MU - a participation code of AP, EL or IP and disqualified codes that begin with ‘D’

QC – There are no valid income disregards.

    Can be used to determine eligibility for retro-Medicaid
    Is not applied if the family is eligible without $30 1/3
    Can be used to determine individual Medicaid eligibility

First - Determine the FAMILIES total non-excluded earned and unearned income (include any deemed amounts.

Next – Determine the coverage group and use the following steps:

(8/1/2005)

FPG Related Coverage Groups ((PW and PWC).

INDIVIDUAL MEDICAID BUDGETING Individual Medicaid Budgeting can be applied to determine Medicaid eligibility for any individual. Determine individual Medicaid eligibility as follows:
CONDITION	DESCRIPTION
Family Size	To determine family size for individual Medicaid, use the family size for the family Medicaid coverage group. Family coverage group is used to determine an income limit (FPG or AF related Medicaid) for an individual.
Financial Responsibility	A parent is financially responsible for himself and for his child. A spouse is financially responsible for himself and for his spouse. Do not count a parent or spouse, receiving SSI or AABD payments, as responsible for his spouse or child for determining Medicaid. Any family member, other than a parent or spouse, is financially responsible only for himself.
Income Exclusions and Disregards	Count all non-exempt income of financially responsible persons in determining Medicaid eligibility. Earned Income Disregard. Subtract earned income disregards from each individual’s earned income. $50 Child Support Disregard. Subtract the first $50 from each child's support payment. Any unused portion of the child support disregard is not applied to any other child. Do not allow earned or unearned income disregards for CHIP.
Income Limits	Income limits are based on family size and coverage group. To determine income eligibility for an individual, compare non-exempt gross income of the individual and of the financially responsible individuals to the income limit for the coverage group and family size. AFDC-related Medicaid Coverage Group Income. The individual is income eligible if total countable income from a financially responsible person is less than the income limit for the budget unit size. Countable income is income remaining after allowable disregards have been subtracted. Poverty-related Medicaid Coverage Group Income (FPG). The Low Income Pregnant Woman, Low Income Child, or CHIP applicant is income eligible if total countable income is equal to, or less than, the Federal Poverty Guideline for the family size. Countable income is income remaining after allowable disregards have been subtracted.
Resource Limits	To determine resource eligibility for an individual, compare non-exempt resources of the individual and of financially responsible persons to the resource limit for the coverage group.

TABLE 306 DEEMING INCOME FROM STEPPARENT, NON-PARENT CARETAKER AND NON-CITIZEN PARENT
STEP	ACTION
Step 1	Subtract a ninety dollar ($90) work disregard from the total monthly earned income.
Step 2	Add the remaining earned income and unearned income to arrive at the total monthly income.
Step 3	Subtract child support payments made by a stepparent, non-parent caretaker or non-citizen parent from total monthly income in Step 2.
Step 4	Subtract payments made to a dependent not residing in the home from income in Step 3. The dependent must be claimed for income tax purposes before the payments can be subtracted. The amount remaining after the subtraction of the disregards is the net income.
Step 5	Subtract the Need Standard for the stepparent, non-parent caretaker or non-citizen parent and their dependent children from the net income in Step 4. The difference is the income deemed to the Medicaid family unit.

AFDC NEED STANDARDS -- JULY 16, 1996
NUMBER IN FAMILY	NEED STANDARD
1	$643
2	$786
3	$991
4	$1,196
5	$1,401
6	$1,606
7	$1,811
8	$2,016
9	$2,221
10	$2,426
OVER 10 PERSONS	ADD $205 EACH