SECTION 5, Coverage Groups

01. Individual Countable Monthly Income. Countable monthly income and resources for each individual are compared to the income and resource payment standard for Title XIX Medicaid AFDC-related coverage groups. When income or resources exceed the AFDC-related coverage groups standards, the individual is ineligible for Title XIX AFDC-related coverage groups. (7-1-04)T

02. Child or Pregnant Woman Countable Monthly Income. If the individual is a child or pregnant woman, the individual’s countable monthly income and resources are compared to the income and resource limits for the Title XIX Medicaid FPG-related coverage groups. If the individual’s countable monthly income or resources exceed the income and resource standards for both the Title XIX Medicaid AFDC and FPG-related coverage groups, the participant is ineligible for Title XIX AFDC and FPG-related coverage groups. (7-1-04)T

03. Child’s Title XXI CHIP A, CHIP B and Children’s Access Card Countable Monthly Income. If the individual is a child, his countable monthly income and resources are compared to the Title XXI CHIP A, CHIP B and Children’s Access Card coverage group’s income and resource standards. If the individual’s countable monthly income or resources exceed the income and resource standards for the Title XXI CHIP A, CHIP B and Children’s Access Card coverage groups, the child is not eligible. (7-1-04)T

03.01.401. AFDC related COVERAGE GROUP INCOME STANDARDS.

The AFDC standards are based on the number of budget unit members. The standards are listed in Table 401. (7-1-04)T

TABLE 401 - AFDC STANDARDS
NUMBER IN FAMILY	PAYMENT STANDARD	NEED STANDARD
1	$205	$643
2	$251	$786
3	$317	$991
4	$382	$1,196
5	$448	$1,401
6	$513	$1,606
7	$579	$1,811
8	$645	$2,016
9	$710	$2,221
10	$776	$2,426
OVER 10 PERSONS	ADD $65 EACH	ADD $205 EACH

Table 03.01.401 AFDC Related Coverage Group Income Standards(7-1-04)

Family Size For MA, MU, and QP – (Qualified Pregnant Women, or Low Income Families with Children)

-Ineligible Aliens are not counted in the family size and their income is deemed to the eligible family members.

-Disqualified parents are not counted in the family size and their income is counted in full (minus disregards) to the eligible family members. (7-1-04)

03.01.402. -- 03.01.409. (RESERVED).

03.01.410. TITLE XIX MEDICAID COVERAGE GROUPS RELATED TO AFDC STANDARDS.

Persons with countable income below the AFDC payment standard may be eligible for the Title XIX Medicaid coverage groups of Qualified Pregnant Women or Low Income Families with Children. (7-1-04)T

MU, MA and QP are Medicaid programs related to AFDC standards.

PW, PWC, and CHIP are Medicaid programs related to FPG

(7-1-04)

03.01.411. RESERVED.

03.01.412. QUALIFIED PREGNANT WOMAN.

A Qualified Pregnant Woman must meet non-financial and financial criteria for one of the Low Income Families with Children coverage groups. (7-1-04)T

03.01.413. LOW INCOME FAMILIES WITH CHILDREN.

Families with minor children in the home, who would be AFDC eligible if the program was in effect, are eligible if all non-financial, financial, and conditions listed in Subsections 413.01 through 413.03 of these rules are met. (7-1-04)T

.01 Living with a Relative. A child must live with an adult who is a relative of specified degree. (7-1-04)T

CARETAKER RELATIVE

A caretaker relative can be a:

Father, mother (natural or adoptive), child, grandfather or grandmother, brother or sister, stepfather or stepmother, stepbrother or stepsister, aunt or uncle, first cousin, first cousin once removed, niece, nephew, person of preceding generations denoted by grand, great or great-great; or the spouses of these relatives, even after the marriage is ended by death or divorce.

The relationship between a child and a caretaker declared on the application is proof of relationship. Do not request additional verification unless the declared relationship is questionable. If additional verifications are requested, document the reason for the request. (7-1-04)

02. Child. A child is expected to graduate from high school by his nineteenth (19th) birthday. (7-1-04)T

03. Financial Deprivation. A child is financially deprived when the individual’s income does not exceed the income limit for their budget unit size, as described in Section 401 of this rule. (7-1-04)T

03.01.414. (RESERVED).

03.01.415. EXTENDED MEDICAID FOR SPOUSAL SUPPORT INCREASE.

Participants in the Low Income Families with Children coverage groups are eligible for four (4) calendar months of Extended Medicaid (EM) if the individual’s spousal support income causes them to exceed the income limit for their budget unit size. The individual must have received Title XIX Medicaid in Idaho in at least three (3) of the six (6) months before the month the participant became income ineligible. (7-1-04)T

NOTE: If the participant becomes ineligible for AFDC related Medicaid wholly or partly because of the collection of or increase in the amount of child support or spousal support and have received MA or MU in at least 3 of 6 preceding months, they are eligible for EM

03.01.416. TRANSITIONAL MEDICAID (TM).

Individuals and families who were eligible for Title XIX Medicaid coverage under the Low Income Families with Children group (MA or MU) are eligible for Transitional Medicaid (TM) if the family income exceeds limits because of a reason listed in Subsections 416.01 through 416.03 of this rule. The family must have received Low Income Families with Children medical assistance in Idaho in three (3) of the six (6) months before the month they became ineligible unless the family meets the condition in subsection 416.01 of this rule. Eligible families may get TM for up to twelve (12) months. (7-1-04)T

Retroactive Medicaid months count toward the TM requirement of receiving Medicaid for three of the last six months. (7-1-04)

01. Idaho TAFI Income And Income From Employment. Family income exceeds limits because they have Idaho TAFI income and income from employment. (3-20-04)

02. Employment Income Increased. Family income exceeds limits because employment income increased. (4-5-00)

03. Disregard Expired. Family income exceeds limits because the thirty dollar ($30) plus one-third (1/3) or the thirty dollar ($30) disregard expired. (4-5-00)

Refer to .03.01.422 for adding new household members to TM (1/31/04)

Example 1:

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.

03.01.417. TM NOTICE REQUIREMENTS.

The participant must be provided notice during TM as described in Subsections 417.01 through 417.02. (11-1-99)

01. Required Notice During First Six (6) Months of TM. Notify the participant of the reporting requirements and the option for months seven (7) through twelve (12) of TM. Send the notice and the report form in month three (3) and month six (6) of TM. (11-1-99)

02. Required Notice During Second Six (6) Months of TM. Notify the participant of reporting requirements. Send the notice and the report form in month nine (9) of TM. (11-1-99)

03.01.418. TM REPORTING REQUIREMENT.

Families receiving TM are mailed three (3) report forms during the twelve (12) TM months. Families must complete and return the reports as listed in Subsections 418.01 through 418.03. (11-1-99)

01. First Report. The family must complete and return the report only if changes have occurred in earnings, household composition or work-related child care costs. The first report is due by day twenty-one (21) of TM month four (4). The report covers TM months one (1) through three (3). (11-1-99)

02. Second Report. The family must complete and return the report only if changes have occurred in earnings, household composition or work-related child care costs. The second report is due by day twenty-one (21) of TM month seven (7). The report covers TM months four (4) through six (6). (11-1-99)

03. Third Report. The family must complete and return the report only if changes have occurred in earnings, household composition or work-related child care costs. The third report is due by day twenty-one (21) of TM month ten (10). The report covers TM months seven (7) through nine (9). (11-1-99)

03.01.419. INCOME TESTS FOR TM.

When a family reports changes in earnings, household composition or child care costs, eligibility to receive months seven (7) through twelve (12) of TM must be evaluated using the income tests listed in this Section. Use the steps in Table 419.01 for the first income test, done at the end of month seven (7) of TM. Use steps in Table 419.02 for the second income test, done at the end of month ten (10) of TM. (11-1-99)

TABLE 419.01

FIRST TM INCOME TEST,

Done at the end of month seven (7)

STEP

ACTION

Step 1

Add the gross monthly earnings reported for months four (4) through six (6) of TM.

Step 2

Subtract allowable reported child care costs from months four (4) through six (6) of TM from the total gross earnings. Allowable child care costs are costs necessary for the employment of the caretaker relative, not paid by another party.

Step 3

Divide the result of the computation in Step 2 by three (3). The result is the average monthly earnings.

Step 4

Select the Federal Poverty Guideline amount for the family size and multiply that amount by one hundred eighty-five percent (185%).

Note: For the current Federal Poverty Guidelines follow this link.

Step 5

Compare the average monthly earnings from Step 3 with the product of Step 4. If the average monthly earnings in Step 3 exceed the amount computed in Step 4, close TM. Adequate notice is required.

TABLE 03.01.419.01 First TM Income Test (11-1-99)

TABLE 419.02

SECOND TM INCOME TEST,

Done at the end of month ten (10)

STEP

ACTION

Step 1

If the caretaker relative reports earnings in each of months seven (7) through nine (9) TM eligibility continues. If no earnings are reported go to Step 2.

Step 2

If no earnings are reported for any of months seven (7) through nine (9) of TM, determine if the caretaker relative has good cause for the lack of earnings. Use the criteria in Subsection 419.03. If good cause does not exist, close TM. Ten (10) day advance notice is required.

TABLE 03.01.419.02 Second TM Income Test (11-1-99)

If the participant does not return report forms, assume no changes have occurred unless the Department learns of changes through other means. This includes changes reported for other programs. The family remains eligible for TM. (7-1-04)

03. Good Cause for Lack of Earnings. Good cause for lack of earnings includes, but is not limited to: (11-1-99)

a. Family crisis. (3-1-99)

b. Court required appearance or incarceration. (3-1-99)

c. Loss of transportation where no other means of transportation is readily accessible. (3-1-99)

d. Loss of child care arrangements. (3-1-99)

e. Involuntary loss of employment. (3-1-99)

f. Illness. (3-1-99)

03.01.420. REASONS TO END TM.

Reasons to end TM are listed in Subsections 420.01 through 420.05. (3-1-99)

01. Child Leaves Family Unit. The family unit ceases to include an eligible child. (3-1-99)

02. Not Residing in Idaho. The family unit ceases to reside in Idaho. (3-1-99)

03. Failure to Furnish SSN. The caretaker relative fails to furnish the SSN for a family unit member other than a newborn. That family unit member is not eligible for TM. (3-1-99)

04. Failure to Cooperate. The caretaker relative fails to cooperate in obtaining medical support and third party payments. In this case, the caretaker relative is ineligible for TM. (3-1-99)

05. Member Committing Fraudulent Acts. It is determined a member of the family unit committed fraud during the last six (6) months the unit got Medicaid, before receiving TM. The remaining members of the family unit remain eligible. (3-1-99)

03.01.421. TM FAMILY RETURNS TO IDAHO.

If TM is closed because the family left the state, reopen the TM if the family returns to Idaho during the twelve (12) month period. The family remains eligible for the rest of the original twelve (12) months if all eligibility requirements are met. Count the months of absence as if the family had actually received TM during those months. (3-1-99)

03.01.422. NEW PERSONS MOVE INTO TM HOME.

New persons moving into the home during the twelve (12) month TM period are eligible for Medicaid if they must be included in the budget unit as described in Section 303. (3-1-99)

PW and CHIP participants are not entitled to Extended or Transitional Medicaid. (7-1-04)

Note: When a mandatory budget unit member joins the household, add the new budget unit member and his/her income, with timely notice. When the newly added budget unit member's income would cause other budget unit members to lose eligibility for Medicaid, explore Individual Medicaid budgeting.

When the earned income of the newly added budget unit member would cause the MA/MU to close, the budget unit is eligible for Transitional Medicaid, providing the budget unit has received MA/MU in Idaho in at least 3 of the last 6 months.

All mandatory budget unit members are TM eligible, even if some individuals have not received MA/MU in Idaho in at least 3 of the last 6 months.

If a child has not received 12 month continuous eligibility when TM ends, they are entitled to continue to receive Medicaid for the balance of the 12-month period.

Close TM and enroll the child in the original coverage group in which they received benefits prior to TM. Count the months of regular Medicaid and the TM when calculating the child’s 12-month eligibility period.

Example: Carrie and her 2 children, James, and Lillian have been receiving MA for the past 5 months. They have no income. Bob, Carrie's husband and the children's father, moves into the home because he and Carrie have reconciled. Because Bob is a mandatory budget unit member, he and his income must be added to the budget unit, with timely notice. Bob's income is too high for the budget unit of 4 to receive MA. Carrie, Bob, James, and Lillian are eligible for TM. Even though Bob did not receive MA in Idaho in 3 of the last 6 months, because he is a mandatory budget unit member, he is eligible for TM.

03.01.423. -- 03.01.499. (RESERVED).

TABLE 419.01 FIRST TM INCOME TEST, Done at the end of month seven (7)
STEP	ACTION
Step 1	Add the gross monthly earnings reported for months four (4) through six (6) of TM.
Step 2	Subtract allowable reported child care costs from months four (4) through six (6) of TM from the total gross earnings. Allowable child care costs are costs necessary for the employment of the caretaker relative, not paid by another party.
Step 3	Divide the result of the computation in Step 2 by three (3). The result is the average monthly earnings.
Step 4	Select the Federal Poverty Guideline amount for the family size and multiply that amount by one hundred eighty-five percent (185%). Note: For the current Federal Poverty Guidelines follow this link.
Step 5	Compare the average monthly earnings from Step 3 with the product of Step 4. If the average monthly earnings in Step 3 exceed the amount computed in Step 4, close TM. Adequate notice is required.

TABLE 419.02 SECOND TM INCOME TEST, Done at the end of month ten (10)
STEP	ACTION
Step 1	If the caretaker relative reports earnings in each of months seven (7) through nine (9) TM eligibility continues. If no earnings are reported go to Step 2.
Step 2	If no earnings are reported for any of months seven (7) through nine (9) of TM, determine if the caretaker relative has good cause for the lack of earnings. Use the criteria in Subsection 419.03. If good cause does not exist, close TM. Ten (10) day advance notice is required.