5220-2 ELIGIBILITY DETERMINATION
To be eligible for Transitional Medicaid a household must have:
Lost FM eligibility solely because of an increase in the earnings of a specified relative, either from more hours or higher pay.
When more than one change in the household occurs in the same month, a careful look at those changes is necessary to determine which change had a “causative effect” on the loss of Family Medicaid eligibility. Initially, you should determine if the increase in income or hours of employment would have resulted in loss of FM eligibility if all other factors in the case remained the same (i.e., there were no other changes in income, no changes in household composition, no change in the FM standards, etc.). If all other factors remained the same, the household is eligible to receive Transitional Medicaid benefits. If other factors in the case change that do not, when considered individually, result in loss of FM eligibility, but when combined with increased earnings do cause loss of eligibility, the household is eligible to receive Transitional Medicaid benefits.
When two factors of eligibility change and either one could cause ineligibility, give preference to the increased earnings so that the household will qualify for Transitional Medicaid. See Example 4.
Below are four examples of different household situations and how Transitional Medicaid eligibility is affected:
Example 1:
The Family Medicaid household consists of Mom and her two children. The
household has been on Family Medicaid for the last four months. Mom
has been working those four months at a constant rate of pay. In
January, Mom receives a raise in her hourly wage that puts her household
over income for FM in February. Nothing
else in the household changes. Since
the reason the household lost FM eligibility is the increased earnings
of a specified relative, the household is eligible for Transitional Medicaid.
Example 2:
The Family Medicaid household consists of Mom and her two children. The
household has been on Family Medicaid for three of the last six months.
Mom has
been unemployed the whole time. In
September, Mom’s grandfather dies and leaves her a small investment that
will pay her $100 per month. Also
in that month, Mom gets a job. The
countable income from her job alone is just below the household Medicaid
need standard, but when combined with the $100 income from her grandfather’s
investment, the household is over income. Even though her increased earnings
alone were not enough to cause ineligibility for FM , when combined with
the $100, her increased wages still had a “causative effect” on the loss
of FM ; therefore, the household is eligible for Transitional Medicaid.
Example 3:
The Family Medicaid household consists of Mom and her three children. The
household has been on FM for four months. In
December, Dad returns to the household. Dad
already has a job before he returns. With
Dad back, his income combined with Mom’s income causes the countable household
income to exceed the FM need standard for a household of five. While
the income available to the household has increased, neither of the specified
relatives had increased earnings or hours. The
household is considered to have lost FM eligibility because deprivation
no longer exists. This
household is not eligible for
Transitional Medicaid.
Example
4:
The Family Medicaid household consists of Mom and her two children. They
have been on FM for six months. In
January, Dad returns home. When
he first returned home he was working part-time. Later
in the same month, he goes to work full-time. Two
factors of eligibility have changed in the same month: (1)
the children are no longer deprived of a parent, since both are now living
in the home; and (2) a specified
relative (in this case, Dad) has increased earnings in the month. This
household is eligible for Transitional Medicaid.
5220-2 B. DETERMINING THE FIRST MONTH OF TRANSITIONAL MEDICAID
An adverse action notice must be sent before closing a Family Medicaid case. Regardless of when the adverse action notice was sent, Transitional Medicaid begins the first month after the Family Medicaid case closes or should have closed. A household is not entitled to receive more months of coverage because they were late in reporting a required change (such as beginning or ending a job, a change in rate of pay or employment changing from part-time to full-time, etc.). See Section 5185-1.
Example
5:
The Family Medicaid household consists of Dad and his two children. Dad
has been working part-time for several months. When
the Family Medicaid review is received in October, the caseworker discovers
that Dad’s hours increased on July 5th, changing his employment from part-time
to full-time. This
increase in earnings put his household over income for FM in August. The
caseworker sets up Transitional Medicaid backdating the Post Med start
month to August and sets the six-month cert thru date for January.
5220-2 D. ADDING HOUSEHOLD MEMBERS TO THE TRANSITIONAL MEDICAID CASE
In Example 4 above, Dad can be added to the Transitional Medicaid case even though he personally did not receive FM in three of the last six months. This is because Transitional Medicaid eligibility is available to households who lose Family Medicaid due to employment. In addition to adding household members to the FM household, you can add anyone to the Transitional Medicaid household whose needs and income you would consider if you were determining eligibility for the household for the first time.
Anyone who could potentially be included in the Family Medicaid case (whether they would eventually qualify or not) may be included in the Transitional Medicaid case. Contact DPA Policy at DPAPolicy@health.state.ak.us for instructions on how to apply this policy in a particular case.
Example 6:
Mom and her three children have been on Family Medicaid for six months.
Dad is
also in the household, but is excluded from FM because he is disabled
and receives SSI Supplemental Security Income
and APA . The
household consists of Mom and her three children. Mom
has been working off and on, but in April gets a full-time job. A
Transitional Medicaid case is opened for Mom and the children. Because
of the increased earnings, Dad is now over income for SSI Supplemental Security Income
and APA and his case closes. Dad
can be added to the Transitional Medicaid case because, if this household
were applying for Family Medicaid in the current month, dad’s needs and
income would be considered since he is no longer receiving SSI Supplemental Security Income
or APA .
Example 7:
Mom is divorced and lives with her two children. They
have been on Family Medicaid for over five months. Mom
remarries and her new spouse, who is unemployed at the time, moves into
the home. The
following month the new spouse gets a job and begins making enough money
to cause the mother’s income, under spouse-to-spouse deeming rules, to
exceed the Family Medicaid need standard. Because
the income deemed to her was from increased earnings, the mother is eligible
for Transitional Medicaid. Medicaid
does not deem stepparent income, so the children continue on Family Medicaid.
The stepparent
cannot be added to the spouse’s Transitional Medicaid case because, unless
there was a common child, there is no situation in which we would consider
the stepparent’s needs and income
in making a new Family Medicaid eligibility determination for the specified
relative’s household.
5220-2 E. COUNTING RETROACTIVE FAMILY MEDICAID
Because a household can apply for Medicaid for up to three months prior to the date of application (see Section 5008 - Retroactive Medicaid), it is possible that those three retroactive months will meet or help meet the Transitional Medicaid requirement that a household be eligible for and have received Family Medicaid in three of the last six months. A household will meet the Transitional Medicaid requirement even if their only months of Family Medicaid were the three months before the month of application in which Retroactive Family Medicaid was issued.
Coupons must be issued for each month(s) used even if there are no unpaid medical bills for that month. This is the only situation in which unpaid medical bills for each retroactive month is not required.
5220-2 F. MEDICAID RECIPIENTS IN OTHER CATEGORIES
Do not count any month that benefits were:
Note:
The caseworker should not issue
Family Medicaid coupons. All
that is required is that Family Medicaid eligibility be documented in
the case file.
|
|
||
|
|
|