Medicaid Policy
Medicaid Policy
Previous Policy (All sections in 445 incorporated into 435-3 as of June 1, 2020)
Introduction
The retroactive period is the three calendar months immediately before the month an application is received.
Medicaid programs, other than presumptive eligibility and the UPP program allow an individual to receive coverage in one or more of the retroactive period months.
· Retroactive coverage applies to the Adult Expansion program, but not before the effective date of April 1, 2019.
· Eligibility for UPP cannot begin before the month of application. (See 1007)
· Presumptive eligibility coverage begins the date an eligibility determination is made by the qualified entity. If the applicant requests regular Medicaid, coverage may extend back to the retroactive period once the agency makes a full determination.
Two Medicare Cost-Sharing programs allow retroactive coverage. They are the SLMB (Specified Low-Income Medicare Beneficiary) and QI (Qualifying Individuals) programs.
The QMB (Qualified Medicare Beneficiaries) program does not allow for retroactive coverage. Eligibility for QMB does not begin until the month following the month in which the eligibility agency determines the individual meets all of the eligibility criteria.
A. General Requirements
1. Individuals must meet the eligibility criteria in the retroactive month or months for which they want coverage.
2. Use the actual income and circumstances that exist in the retroactive months to determine eligibility for all programs.
3. Use the eligibility policies in effect during the retroactive months when determining eligibility.
4. Determine eligibility the same for a partial month of coverage as you do for a full month of coverage, if the benefit effective date is not the first day of the month. Exceptions to starting eligibility on the first day of the month are found in 711.
B. Requirements for Medicare Cost-Sharing Programs
When an applicant has Medicare, always decide if the individual qualifies for either the SLMB or the QI program in the 3 retroactive months.
· The individual does not have to request this coverage, as most individuals are not aware of it.
· The individual does not have to have any medical expenses in the retroactive months to receive a Medicare Cost-Sharing program.
· If the individual fails eligibility for QMB, but is within the income limit for either SLMB or QI for one or more retroactive months, approve coverage for such months.
The individual will receive reimbursement from Social Security for the premiums paid in those months once the Medicare Buy-In occurs.
C. Income
Determine income for each month of the retroactive period. Each month's decision may be different based on income, circumstances, and policies.
1. Verify the income received in each month of the retroactive period.
a. Count actual income received unless the person was self-employed or was a contract worker during the retroactive period. Do not factor income for the months in the retroactive period for any program.
b. If the individual was self-employed, or worked under contract, in the same business during the retroactive period as they are at application, use the best estimate of self-employment income determined for the application and ongoing months for the retroactive months.
c. If the individual was self-employed, or worked under contract, during the retroactive months, but is no longer self-employed or working under contract, determine a best estimate of the actual income earned in the retroactive period to do eligibility for those months.
d. If the individual has just started self-employment at application or during the retroactive period, determine when this started. Do not count any self-employment income before the month the individual starts to realize a net profit. Do a new best estimate when net income changes.
e. Contract work may also be counted over the number of months it is intended to cover. In this case, divide the income by the number of months the contract income was intended to cover to determine a monthly amount. Count only the monthly amount for each month. This may include months in the retroactive period and ongoing months.
f. Subtract all allowable disregards, exemptions, deductions, and earned income expenses allowed for the appropriate program.
2. If countable income after deductions exceeds the limits for a non-spenddown program, determine eligibility for a medically needy (spenddown) group. Request additional information, if needed, such as asset information.
D. Eligibility Decision
1. For MAGI-based coverage groups, income cannot exceed the applicable income limit after allowable deductions. If income exceeds the applicable limit, review eligibility for a Family-Related medically needy program.
a. Determine a best estimate of income and household size based on the non-MAGI-based Medically Needy programs rules.
b. Request additional information, if necessary.
c. The amount of countable income (after deductions) in excess of the BMS is the spenddown amount.
2. For the 100% Poverty-Related Aged or Disabled programs, income cannot exceed the income limit for the applicable household size. If the income exceeds the applicable income limit, the person would have to pay a spenddown to be eligible for Medicaid.
3. For SLMB or QI benefits, income must be within the applicable limits each month of eligibility. The person cannot be under 100% of the FPL for a month during the retroactive period, for instance, and receive SLMB coverage in that month. Use the same budgeting methods to determine income as you would for aged, blind and disabled Medicaid coverage.
4. If the individual does not qualify for the 100% Aged or Disabled poverty-related program, determine eligibility for the Medically Needy Spenddown program, or the Medicaid Work Incentive program when the person is disabled and working.
a. Aged, blind and disabled persons will spend down to 100% of the poverty rate. The countable income and the household size for the spenddown program can be different than it is for the 100% poverty group. Follow policies in Sec. 443-2 for the spenddown group. See Sec. 461-2 on how to meet the spenddown.
b. A disabled person with earned income may qualify for the Medicaid Work Incentive. MWI premiums can only be met with cash. Follow policy in Sec. 462-1 on counting income, determining household size and calculating an MWI premium.
5. To receive medically needy Medicaid, the spenddown must be less than the cost of services received in that month. The cost of services means only those medical expenses that Medicaid covers for the individual.
a. Use health insurance premiums and medical bills for services in non-Medicaid months to reduce the spenddown amount. The remaining spenddown may then be less than the current month services that Medicaid will pay making it beneficial for the individual to meet the remaining spenddown.
b. Do not use bills a third party will pay.
c. The individual may also use current month medical bills to meet the spenddown. (See section 461-5)
6. The individual may choose the months in the retroactive period he wishes to be covered. When the individual owes a spenddown or MWI premium, the individual must meet the spenddown or pay the MWI premium for any retroactive month or partial month for which he wants to receive Medicaid eligibility.