Medicaid Policy
Medicaid Policy
To be eligible for the NCW, an individual must meet the criteria for one of the six eligibility coverage groups described below. There are two main categories: Community Medicaid groups and Institutional Medicaid groups.
Community Groups
Determine eligibility under regular community Medicaid groups before moving to Institutional groups.
Individuals who meet the eligibility income and asset tests for a community group are eligible for NCW and will not have a post eligibility test to determine a contribution to the cost of care.
Income Eligibility for SSI recipients, SSI Protected Groups and Aged and Disabled 100% FPL group.
SSI recipients
A individual is income eligible if the individual meets the criteria found in section 329.
SSI protected groups
An individual is income eligible if the individual meets the criteria under an SSI protected group. Follow the income policies for the specific protected group as referenced below except that you only count the individual's income. Do not deem income from a spouse.
An individual eligible for an SSI protected group will not have a contribution to the cost of care.
The SSI protected groups are:
Disabled Adult Children (330-1)
1619(a) and 1619(b) (330-2)
Eligible because of the Pickle Amendment (330-3)
Widows and Widowers (330-4)
100% of Poverty, Aged or Disabled (does not include spenddown group)
Individuals who do not receive SSI and are not in an SSI protected group may qualify under the poverty-level group if income is at or below 100% FPL.
A single individual meets income eligibility if the individual's countable income is at or below the 100% Poverty limit. See section 443 to determine countable income.
For married individuals, count only the individual's income to determine eligibility. See section 443 to determine countable income except that you do not count the spouse's income. Countable income must be at or below the 100% Poverty limit for one person.
An individual eligible for the 100% FPL group will not have a contribution to the cost of care.
If the countable income of the individual exceeds 100% of the FPL and the individual has earned income, determine eligibility for the Medicaid Work Incentive. The individual may owe a premium to be eligible.
If the individual's countable income exceeds 100% of the FPL and the individual does not have earned income, decide if the individual is eligible under the Special Income group or the Spenddown Waiver group.
Income and Asset test for MWI (Medicaid Work Incentive - Individual must have earned income)
If the individual has earned income but does not receive SSI, does not meet SSI protected group eligibility, and does not pass the 100% FPL income tests, or does not pass the resource test for one of these groups, decide if the individual qualifies for the Medicaid Work Incentive.
Resources - Follow the resource rules in 314 to decide eligibility. Transfer of asset rules do not apply to this Medicaid group.
Income – Follow the income rules in 314 to decide eligibility and calculate the MWI premium. This is the amount the member must pay to be eligible for Medicaid.
If the individual does not qualify for the Medicaid Work Incentive, determine eligibility under the Special Income Group or the Spenddown Waiver group.
Institutional Groups
Special Income Group The special income group is for individuals who do not meet eligibility under community Medicaid groups, but would qualify if they were living in a medical institution because their income does not exceed the special income group limit.
Resource eligibility test
For single individuals, use the applicable resource limit found in section 503 for a one person ABD household size.
For a married individual, apply the spousal impoverishment asset rules found in section 573.
Transfer of Assets rules apply to the Special Income coverage group.
Income eligibility test An individual is eligible in the special income group if the individual's total income does not exceed 300% of the SSI payment rate. Determine income for the 300% of SSI test as follows:
Count only the individual's income. Do not deem income from the spouse.
Do not count income that is excluded income according to section 463-1.
Compare total income to 300% of the SSI payment rate for one person.
The individual is eligible if income does not exceed 300% of the SSI payment rate.
Post-Eligibility income process: After deciding a member's eligibility for the special income group, use the post eligibility test to decide how much a member must pay toward the cost-of-care.
Count only the individual's total income. Do not deem income from the spouse of a married member (463-1).
Deduct from total income the post eligibility deductions listed in section 431-14.
The remaining amount is the member's contribution to cost-of-care.
Spenddown Waiver Group The Spenddown Waiver group is for individuals who do not meet eligibility under regular community Medicaid groups or the Special Income Group.
Resources
For single individuals, use the applicable resource limit found in section 503 for a one person ABD household size.
For a married individual, apply the spousal impoverishment asset rules found in section 573.
Transfer of asset rules do not apply to this Medicaid group.
Income Count only the individual's income. The individual's total income must exceed 300% of the SSI payment level. An individual can qualify for the spenddown group if the individual's medical expenses would exceed the amount the individual would have to private pay. Deduct the following amounts to determine the individual's spenddown.
The ABD disregards in section 431-2,
A deduction equal to 100% of the FPL and health insurance premiums described in 431-1. The remaining amount is the individual's spenddown. The individual may use medical bills as described in 461-5 to reduce or meet the spenddown.