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All Medicaid Programs |
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Obsolete Policy |
General rules for determining income
Determine a household's Medicaid eligibility, spenddown amount, or MWI premium if applicable, by "best estimating" income for the current month and in some cases, anticipating any expected changes in income over the certification period to arrive at a monthly income amount. The determination is based on:
What income is being received or is expected to be received in the future months
Historical patterns such as recurring income or regular seasonal income that are expected to continue in the future
Any future change that can be documented, or that has a recurrent pattern and that is expected to occur in the future
The client's current circumstances and expectation about future income
Prospective budgeting
Use prospective budgeting for MAGI-based coverage groups as well as non-MAGI-based coverage groups to determine the monthly income for each person in an individual's household whose income must be counted.
The types of income counted for MAGI-based and non-MAGI-based coverage groups and deductions that are allowed are different. These differences may cause the countable income to be different when someone fails a MAGI group and eligibility is determined for a non-MAGI medically needy group.
The best estimate will be done differently for MAGI-based groups than it is for non-MAGI-based groups. Refer to C. and D. below.
For non-MAGI-based medically needy Family, Child and Pregnant Women groups, factor income being received every week or every other week to arrive at a monthly amount from that income source. Do not factor income for aged, blind and disabled Medicaid coverage groups or MAGI-based groups.
Use the techniques of anticipating, averaging or annualizing income to determine an appropriate monthly income amount. The method used to determine the best estimate is based on the type of income, the frequency of receipt, the individual’s earnings history and any anticipated changes in circumstances. Determine which method to use based upon the individual client's history and current circumstances.
For self-employment income, determine the expected net annual income, and prorate that over 12 months to determine a monthly amount. Some other types of income such as contract or commission income may also need to be annualized.
For non-MAGI-based family, child and pregnant woman coverage groups, contract income may be averaged over the period of time it is expected to cover, or for the whole certification period when sufficient history is available to show the average monthly income. Seasonal income that is intended to cover the whole year may be annualized. When seasonal income is only intended to cover the period of time during which it is being earned, it may be counted only for the months in which it is being received.
MAGI-based groups
In the MAGI-based methodology, the best estimate of income is used to arrive at a monthly amount. That amount is used to conduct a reasonable compatibility test and to determine eligibility for the certification period.
Stable income: For MAGI-based groups, when a person receives stable income, to arrive at a monthly income figure, determine how much an individual will receive each pay period. Multiply that amount by the number of pay periods in the year and divide by 12.
Infrequent income: Prorate over the 12-month certification period, infrequent income that is expected to reoccur sometime during the certification period. Also prorate over the 12-month certification period seasonal income, fluctuating income, and other countable income that is received only sporadically during the year. Add the prorated amount to the monthly income.
Temporary income: Prorate over the certification period, income that will be received for only a set time during the certification period, but not for the entire certification period, to arrive at a monthly amount from that source. For example, if someone will receive 14 weeks of unemployment during the certification period, divide the total expected unemployment to be received in those 14 weeks by 12 months. This takes into account the expected months when this income will not be received.
Seasonal or contract income: Income that will start during the certification period, such as from a seasonal job or because the client has a signed contract for work to begin on a specific date should be prorated over the certification period.
When prorating seasonal income, or infrequent income, total the amount expected to be received during the certification period and divide it by the number of months in the certification period.
Add the prorated amount to the monthly income.
Terminated income: If an individual will receive some income from a terminated source during the certification period for which you are making a best estimate of income, determine the total actual amount the individual will receive during the certification period. Divide that amount by 12 and add the prorated amount to other monthly income. If the terminated income was received in the retroactive months, count the actual income received.
Changes: If a change is reported during the certification period, decide if that change has been accounted for in the original best estimate.
If the reported change has been accounted for in the original best estimate, do not adjust the best estimate.
If it has not been accounted for, modify the best estimate.
Reasonable compatibility: Determine if the reported income is reasonably compatible with electronic verification sources. The reasonable compatibility test compares the best estimate of countable income that the agency derives based on the client's statement with the best estimate of countable income derived from available electronic income sources. Compare those amounts against the income limit for the applicable MAGI-based coverage group.
If both the client's statement and the electronic income match are at or below the income limit for the applicable MAGI-based coverage group, the individual is eligible.
If both the client statement and the electronic income match are above the income limit for the applicable MAGI-based coverage group, the individual is ineligible for the MAGI-based coverage group. Determine eligibility for any other medical assistance program.
If one income amount is above and one income amount is below the income limit, request additional verification from the client. Sec. 731.
Budgeting for non-MAGI-based family, child and pregnant women groups (i.e., medically needy)
Use prospective budgeting for non-MAGI-based coverage groups to determine the monthly income. Budget based on the client's current circumstances.
The household size may change (in some cases) and whose income is counted is different between MAGI-based and non-MAGI-based groups and can result in a different best estimate.
For non-MAGI-based family, child and pregnant women groups, determine the best estimate of expected current income to determine eligibility and the amount of the monthly spenddown, if applicable.
Terminated income: If income terminates in the application month, do not count that income for future months.
If the income terminates in the application or renewal month, count the actual amount received in that month. Complete a new best estimate for the following months.
For non-MAGI-based family, pregnant women and child groups, do not factor terminated income.
Infrequent or seasonal income: For non-MAGI-based coverage groups, you can prorate certain infrequent or seasonal income that is expected to be received in future months over the period of time it is expected to cover, which may be less than 12 months. Do not prorate future expected income unless there is a high expectation that it will actually be received.
Temporary income: When income will be received for a set time period during the certification period, but not for the entire certification period, set a review about the time of the expected change to do a new best estimate of income. For example, if someone will receive 14 weeks of unemployment during the certification period, schedule a review to occur just before the end date of the income and do a new best estimate based on the client's current circumstances at that time.
Expected changes: If a change is expected but not certain, such as income from a seasonal job, set a shorter review period to check on the expected change. Do a new best estimate based on the actual change.
Budgeting for Aged, Blind and Disabled Medicaid, and long-term care groups
Use the same prospective budgeting process for aged, blind and disabled categories (generally referred to as Disabled Medicaid) and Long-term Care/Waiver groups as you would for any other Medicaid program. The only difference requires you to count actual monthly income received, or expected to be received, rather than factoring the income. Count the third or fifth paycheck in a month to determine Medicaid eligibility for aged, blind and disabled Medicaid cases for such months. If changes are expected in the future, control for those changes through the review process.
Self-employment income can be annualized for aged, blind and disabled cases.
For Waiver Medicaid Programs, if the client's statement of total earned income is below $65 per month, waive the requirement to request verification of actual income from the client when electronic match data is unavailable, and there is no other information that indicates the client statement is incorrect.
Factoring Income--Non-MAGI-Based Family, Pregnant Women ans Child
Factor income received weekly or every two weeks. First determine the most accurate best estimate of income a client receives each pay period.
To factor weekly income, multiply the weekly best estimate amount by 4.3 to determine a monthly amount.
When income is received every two weeks, multiply the two-week best estimate by 2.15 to determine a monthly rate.
Do not factor income for Retroactive Medicaid months. See section 445-2 to determine what income to count for the retroactive month.
Do not factor income for Aged, Blind or Disabled Medicaid programs, or MAGI-based coverage groups.
Do not factor new income in months when the client does not receive the full number of paychecks for that month.
Do not factor terminated income.
Documentation and Changes
Document the method of determining the best estimate.
Refer to Section 815-5 when a change has occurred that results in the best estimate needing to be changed. For residents of nursing homes, Utah State Hospital, and Utah Developmental Center follow the policy in 833.