Medicaid Policy
Medicaid Policy
A. Deducting Health Insurance Premiums from Cost of Care Contributions
1. For institutionalized and waiver eligible members, deduct only the amount of the health insurance premium that covers the member when determining the cost of care contribution. The member must pay the premium with their funds, or reimburse their spouse.
a. Deduct premiums due in retroactive months in that retroactive month, or a later retroactive month through the application month as defined in 431-1.1.
· Do not deduct such past premiums in months after the application month.
· If a member is ineligible in the application month, but will be eligible the following month, that month becomes the new application month. Allow past premiums from the three retroactive months not already used as deductions through that new application month. If approving any retroactive months, deduct premiums paid in such month from the cost-of-care owed for that month. Carry forward any unused portion only when they are not used in the month paid.
b. Deduct Part B Medicare premiums paid in retroactive months if the member is not eligible for Medicaid, QMB, SLMB or QI in those months as defined in 431-1.1.
c. Do not deduct any Medicare Part B premiums the member paid for any month the member will be eligible for Medicaid, QMB, SLMB or QI coverage. The state will pay them after eligibility is approved.
d. Deduct Part A or Part D Medicare premiums paid by the member as defined in 431-1.1.
i. If a member pays a premium to receive Part A Medicare, deduct the amount of the premium paid like any other health insurance premium.
ii. If another state is paying the premium, contact the Program Specialist for help. (223-1-Resource-Medicare)
e. Do not allow health insurance premiums, or the portion of a premium, that covers other family members.
· If the spouse pays a premium that covers the member and the spouse manages the member's income, assume the spouse uses the member's income to pay the premium.
· Deduct the health insurance expense from the member's income, unless you have information suggesting someone else pays the expense.
f. If both spouses are eligible for Medicaid, only deduct from each individual's income the portion of health insurance premiums covering that individual. Each spouse must pay their share of the premium. Absent conflicting information, accept client statement that one spouse pays back the other spouse when the premium is paid from one spouse's income.
2. For the New Choices Waiver, the following apply:
a. Do not deduct health insurance premiums for New Choices waiver members to determine if they qualify under either the 100% FPL group or the 300% of the SSI rate-special income group.
· For Special Income Group members, deduct premiums paid as part of the post-eligibility process to determine the cost of care contribution.
b. If a NCW member qualifies under the Medicaid Work Incentive, follow the policy in 431-1.2 and section 463-2 for health insurance premiums.
c. For NCW medically needy (spenddown) members, follow the policies in 431-1.1. The exception is that we only allow the portion of a premium covering the waiver recipient. The recipient must pay the premium, or reimburse their spouse.
B. Physical Disabilities Waiver (PDW) and Community Transitions Waiver (CTW)
1. Special Income Group.
PDW and CTW members do not owe a cost-of-care contribution when their income does not exceed 300% of the SSI payment rate. Do not deduct health insurance premiums to determine their total income for the 300% test.
2. Medically Needy (Spenddown) Group.
PDW and CTW members whose income exceeds 300% of SSI are medically needy. To determine the spenddown amount, these individuals receive a deduction for health insurance premiums. In this case, follow the policy in 431-1.1. The exception is that we only allow the portion of a premium covering the waiver recipient. The recipient must pay the premium or reimburse their spouse.