Medicaid Policy
Medicaid Policy
After deciding that an individual, or married couple, fails eligibility for the 100% FPL Medicaid group, look at MWI Medicaid for a working disabled individual. (314)
A. 250% FPL Income Test
To qualify for the MWI program, household income must not exceed 250% of the FPL. Use the following policy to determine if the individual passes the 250% FPL income test.
1. Household Composition:
For the Medicaid Work Incentive program 250% FPL test, the household size includes the following people living with the MWI applicant or recipient. [Do not include household members eligible for an HCB waiver.]:
a. The individual.
b. The spouse of the individual.
c. Parents of a individual under 18.
d. Children of the individual or spouse, if the children are under 18, or are 18 up to 21 and full-time students.
e. Siblings of a individual under age 18, if the siblings are under 18, or are 18 up to 21 and full-time students.
2. Whose income to count:
a. The individual's,
b. The individual's spouse if living together,
c. The parents living with the working disabled child who is under age 18.
[Do not use the spouse or parent deeming rules in 427-2 and 427-3 Instead, count all income of a spouse, and all income of the parents' of a minor individual.]
d. Do not count income that is exempt under policies in 403 for aged, blind and disabled individuals.
3. Income deductions:
a. Deduct the $20 general disregard from unearned income. (409-6)
b. Allow earned income deductions in 431-2.
· If the individual is a minor child, first allow the earned income exclusions in 405-4. This exclusion only applies to the child's income. Even if this deduction reduces the child's countable earnings to zero, the child may qualify for MWI.
· Deduct impairment related work expenses not payable by a third party only from the earnings of the disabled person. Deduct these before the other deductions.
c. Combine remaining unearned income with remaining earned income.
d. Compare the remaining income to 250% of the FPL for the household size determined in A.1.
e. If income does not exceed 250% FPL, the individual can be eligible for the MWI program.
4. When countable household income is over 250% of the FPL, the individual does not pass the income test for the MWI program. Determine eligibility under another Medicaid program, such as Disabled Medically Needy program. The individual must pass the asset test for the Disabled Medically Needy program.
B. MWI Premium Calculation
1. 100% FPL Test
Most individuals on the MWI program will pay a premium to receive coverage. The individual must pay a premium when income of the individual, the individual and the spouse, or the minor individual and the parents' countable income exceeds 100% of the FPL. This would be the countable income used to decide if the individual or couple was eligible for the Aged and Disabled 100% FPL program.
a. Follow the rules in 414 to determine countable income for the premium test.
b. To decide if income exceeds 100% of poverty, deem income from a spouse or parents according to the deeming policies in 410.
· This income test is different than the one used for the 250% FPL test.
c. Household size will be either 1 or 2 when doing the 100% FPL test.
· For a married couple, the household size will be 2 when both are aged, blind or disabled. It will also be a household of 2 when the ineligible spouse has deemable income.
· Household size will be 1 when the ineligible spouse has no deemable income.
· A minor child's household size will always be 1.
d. When the household income following policies in 410 and 443 exceeds 100% of the FPL, the individual is subject to the MWI Premium calculation process.
2. Premium Percentages
The MWI premium structure has three tiers. Determine the countable income as shown in B.1.
· Compare that countable income to percentages of the FPL to determine the multiplier to use to calculate the premium. Table VII-A. Use the household size used in B.1.
· It does not matter whether one or both members of a married couple are disabled and working. We still compare the couple's income to the FPL amounts to decide what percent to use in the premium calculation.
· The multipliers are shown below.
Countable Income Is: |
Multiply Income By |
More than 100% but not over 110% of FPL |
5% |
More than 110% but not over 120% of FPL |
10% |
Over 120% of FPL |
15% |
3. Calculate the Premium
To calculate the MWI premium, use only the eligible individual's income. If both members of a married couple are disabled and working, use the couple's combined income and apply the following deductions.
a. Deduct the unearned and earned income disregards in 431-2 and 431-5 from the individual's income. Allow the earned income exclusion of a minor child found in 405-4. This could reduce the child's countable income to zero, in which case, the child will not owe a premium.
i. Deduct impairment related work expenses only from the earned income of the working disabled individual.
ii. For a minor working disabled child, do not include any of the parents' income in this calculation.
b. Deduct Health Insurance Premiums the individual pays for health insurance covering the individual, the spouse or any dependents of the individual or spouse. The health insurance premiums a individual pays reduces the countable income before we multiply income by the applicable percentage to arrive at the MWI premium.
i. Deduct the whole premium amount only in the month payment is due. Do not pro-rate the deduction over the months the insurance is intended to cover. [NOTE: Carefully enter effective dates into erep to assure premiums are counted in the correct month.]
ii. Only deduct health insurance premiums paid in retroactive months in the month it is due if you are approving MWI for such months. Do not count them in any other MWI month.
iii. Do not deduct Medicare Part B premiums. Review the individual's eligibility for Medicare Cost Sharing programs for retroactive and ongoing months.
iv. Deduct a Part D premium the individual pays in the month it is due. Do not deduct Part D premiums paid in retroactive months in any month except the month it is due. [NOTE: The individual's Part D premium may go down after Medicaid eligibility is approved. Continue to deduct the actual Part D premiums the individual pays.]
v. Treatment of health insurance premiums paid in retroactive months is different from what is allowed for medically needy programs. The MWI program does not allow amounts paid to be carried forward to any other month.
c. Multiply the individual's income remaining after allowing the above deductions by the applicable percentage as determined in Subsection B. above. [NOTE: Remember in this calculation, you are not including deemed income from an ineligible spouse or ineligible parents.]
d. The individual must pay this premium amount to receive Medicaid coverage.
[NOTE: We do not use health insurance premiums or medical bills to meet the MWI premium.]