All Medicaid Programs |
Obsolete 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.
Single clients 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.
For married clients, apply the spousal resource assessment to determine resource eligibility. The client must then pass the income test for the applicable community Medicaid coverage group. A married client who meets the eligibility income and asset tests for a community group, except for an MWI eligible client, will have a post eligibility test to determine the contribution to the cost of care.
Transfer of asset rules do not apply when the client is eligible under a community coverage group.
Income Eligibility for SSI recipients, SSI Protected Groups and Aged and Disabled 100% FPL group.
SSI recipients
A client is income eligible if the client meets the criteria found in section 329.
SSI protected groups
A client is income eligible if the client 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 client's income. Do not deem income from a spouse.
The SSI protected groups are:
Disabled Adult Children (331)
1619(a) and 1619(b) (329-1)
Eligible because of the Pickle Amendment (336)
Widows and Widowers (337)
100% of Poverty, Aged or Disabled (does not include spenddown group)
Clients 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 client meets income eligibility if the client's countable income is at or below the 100% Poverty limit. See section 305 to determine countable income.
For married clients, count only the client's income to determine eligibility. See section 305 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.
If the countable income of the client exceeds 100% of the FPL and the client has earned income, determine eligibility for the Medicaid Work Incentive. The client may owe a premium to be eligible.
If the client's countable income exceeds 100% of the FPL and the client does not have earned income, decide if the client 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 client 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 client 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 client must pay to be eligible for Medicaid.
If the client does not qualify for the Medicaid Work Incentive, determine eligibility under the Special Income Group or the Spenddown Waiver group.
Post-Eligibility test for married clients (does not apply to clients eligible under MWI)
Count only the client's total income. Do not count the spouse's income. (372-1)
Deduct from client's total income the deductions allowed in 409-16.
The remaining amount is the client's contribution to cost-of-care.
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.
Resources
For single clients, use the applicable resource limit found in section 503-3 for a one person ABD household size.
For a married client, apply the spousal impoverishment asset rules found in section 373.
Transfer of Assets rules apply to the Special Income coverage group. See policy 386-2 and 371 for specifics.
Income eligibility test
A client is eligible in the special income group if the client's countable income does not exceed 300% of the SSI payment rate. The client must pass the resource test. 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 403 or 405.
Deduct $20 general disregard from unearned income. Any remaining amount of the deduction can then be deducted from earned income.
Deduct from earned income only, impairment-related work expenses, if applicable.
Deduct from earned income only, $65 and 1/2 of the remainder.
Compare countable income to 300% of the SSI payment rate for one person.
The client is eligible if income does not exceed 300% of the SSI payment rate.
Post-Eligibility income process:
After deciding a client's eligibility for the special income group, the post eligibility test is used to decide how much a client must pay toward the cost-of-care, if any.
Count only the individual's total income. Do not deem income from the spouse of a married client. (see 372-1)
Deduct from total income the post eligibility deductions listed in section 409-16.
The remaining amount is the client'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 clients, use the applicable resource limit found in section 503-3 for a one person ABD household size.
For a married client, apply the spousal impoverishment asset rules found in section 373.
Transfer of asset rules do not apply to this Medicaid group.
Income
Count only the client's income. A client can qualify for the spenddown group if the client's medical expenses would exceed the amount the client would have to pay. Determine what the client must pay to be eligible as follows:
For single clients, deduct from client's income, the ABD disregards in section 409-2, a deduction equal to 100% of the FPL and health insurance premiums described in 409-1. The remaining amount is the client's spenddown. The client may use medical bills as described in 415-5 to reduce or meet the spenddown.
For a married client, count only the client's total income. Do not deem income from the spouse. (see 372-1) Deduct from total income the post eligibility deductions listed in section 409-16. The remaining amount is the client's contribution to cost-of-care.