5220-2 ELIGIBILITY DETERMINATION
To be eligible for Transitional Medicaid a household must have:
Been both eligible
for and in receipt of Family Medicaid coverage in any three of the
six months immediately preceding the month in which the household
became ineligible for Family Medicaid; (see Sections 5220-2E
and 5220-2F
for additional policy on receipt of Family Medicaid); and
Lost FM eligibility solely because of an increase in the earnings of a caretaker relative, either from more hours or higher pay.
The increased earnings or hours of one or both of the caretaker relatives must be verified. That increase must have a causative effect on the household’s loss of financial eligibility for Family Medicaid.
Transitional Medicaid is not available for the household who loses Family Medicaid for any other reason, including changes in the household size or the return of an absent parent.
A household does NOT qualify for Transitional Medicaid just because they go over income for the Temporary Assistance cash program. If Family Medicaid eligibility is in question, a Medicaid redetermination is necessary to determine whether eligibility for Transitional Medicaid exists.
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 caretaker 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 ”r;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 caretaker relatives had
increased earnings or hours. This household is not
eligible for Transitional Medicaid. The children's Medicaid continues
through their original CEP .
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. This
household is eligible for Transitional Medicaid because a caretaker relative's
earnings increased.
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 with adverse action (10 days), had the household reported timely (within 10 days), and had the agency acted on the report timely (within 10 days). 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.
The caseworker must evaluate Transitional Medicaid eligibility when a change is reported, verified, and processed timely. If the change was not reported, verified or processed timely, the caseworker must determine when Family Medicaid should have ended.
If there is a month in which the benefits were paid under Family Medicaid because of the recipient’s untimely reporting, the caseworker must backdate the Post Med start month on the EIS MERE screen to show the correct month Transitional Medicaid should have started. This will assure that only 12 months of Transitional Medicaid eligibility is allowed.
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 2009, 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
2009 and sets the 12-month certification thru date for July 2010. The
M702 is sent telling the client that Transitional Medicaid is opened and
the start month is August 2009.
Example 6:
The household reports timely on October 5, 2009 that Dad has a new job
and verifies his hours and wages with an employment statement. The
caseworker is backlogged and does not work this change report until November
15. Under normal circumstances, the caseworker would have until
October 15 to close Family Medicaid and open Transitional Medicaid by
November 1. On November 15, the caseworker is finally able to set
up Transitional Medicaid backdating the Post Med start date to November
and sets the 12 month certification thru date to October 2010. The
M702 notice is sent telling the client that Transitional Medicaid starts
November 1, 2009
Verification is required to confirm that the loss of Family Medicaid is due to increased earnings before eligibility for Transitional Medicaid can be established. The caseworker must receive verification of employment (i.e. start date, hours per week, rate of pay, and pay dates) earnings, before authorizing Transitional Medicaid.
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@alaska.gov 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
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 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 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 and her children are eligible
for Transitional 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 in making a new Family Medicaid eligibility determination for the
caretaker 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.
5220-2 F. MEDICAID RECIPIENTS IN OTHER CATEGORIES
Transitional Medicaid eligibility is based on a household’s eligibility for and receipt of Family Medicaid in any three of the last six months. If, when looking back six months, the caseworker finds that a household member received some other category of Medicaid, the caseworker should determine whether that household member could have been eligible for Family Medicaid for any of those months they received Medicaid under the other category. If that household member does meet FM eligibility criteria for a particular month, that month may count toward meeting the three of the last six months Transitional Medicaid requirement. This will allow household members to meet the Transitional Medicaid eligibility even if they received Medicaid under another eligibility category as long as Family Medicaid eligibility also existed for that month.
Do not count any month that benefits were:
issued but the
household was not eligible;
issued as the
result of a request for continued benefits for a Fair Hearing and
the decision is in favor of the agency;
not issued;
or
received in another state.
Note:
The caseworker should not issue
Family Medicaid coupons. All that is required is that Family Medicaid
eligibility be documented in the case file.
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