Financial Eligibility

ONLINE RESOURCE:

• Social Security Administration Benefits
• Sheltered Workshop Directory
• Prior Quarter Guide

REQUIREMENT:

The impact of financial need is viewed differently for MHABD – OAA/PTD/AB programs. The combined income of all EU members is captured in FAMIS. For MHABD programs, income for the EU determines if they must spend some of their income (spend down) to receive coverage, or do not (non-spend down). For QMB/SLMB the combined income of EU members cannot exceed the income limits. For TWHA, the income level determines whether a monthly premium is required and its amount.

For TWHA, the combined income of EU members cannot exceed the income limits. The income level determines eligibility and whether a monthly premium is required and its amount. There are two TWHA coverage groups, each having additional income related eligibility requirements:

• • For the Basic Coverage group, there are no minimum earnings. The applicant must have earned income which has taxes withheld for Medicare and Social Security. Self employment is allowed, but taxes must be paid.
  • For the Medically Improved Group, in addition to taxes withheld, the monthly earned income must be equal to or exceed 40 hours at federal minimum wage.
  • The tax withholdings and minimum earnings requirements must be verified. Entering a ‘Y’ or ‘N’ in the yellow ‘taxes withheld’ field on the Income screen initiates a TWHA determination. Entering a ‘Y’ indicates applicant meets the tax withholding and minimum earning requirement is met. Entering an ‘N’ indicates applicant does NOT meet the tax withholding and minimum earning requirement.

PROCEDURE:

FAMIS compares the countable income to the allowable maximums.

• Non-Spend Down – net income less than or equal to 85% of Federal Poverty Level (FPL)
• Spend Down – net income above 85% of FPL
• TWHA Non premium – income less than 100% of FPL
• TWHA Premium – income equal to or greater than 100% and up to and including 300% of FPL
• QMB – net income less than or equal to 100% of FPL
• SLMB group 1 – net income more than 100% FPL but less than 120% of FPL
• SLMB group 2 – net income more than 120% but less than 135% of FPL
• QDWI – net income less than or equal to 200% of FPL
• HCB – gross income limit is absolute; refer to Appendix E

Some types of income are excluded. Common exclusions include:

• Department of Mental Health Funds (DMH)
• Vocational Rehabilitation payments
• Energy Assistance payments
• Any income earned by individuals eligible for certified extended employment at a sheltered workshop, including income earned from employment at a sheltered workshop and from other employers. The Sheltered Workshop Directory is available under Online Resources section above.

VERIFICATION:

Verify countable income and determine if it is earned or unearned. If changes in income are anticipated, verify the change if possible.

NOTE: DO NOT scan/upload or print hard copies of the IIVE to the participant’s case record in the ECM. Continue to view the IIVE and document IIVE verification for each person in the Eligibility Unit (EU). Follow the steps below:

• view the IIVE
• make the appropriate system entries
• make detailed comment/notes

Verify Child Support Income received or paid in the State of Missouri via: Missouri Automated Child Support System Payment Information

IIVE should be viewed and document IIVE verification in the eligibility system by following these steps for each eligibility unit (EU) member/household member at the time of the interview or at the time the case is worked if no interview is held.

• view IIVE
• Make the appropriate system entries
• make a detailed comment/not

SOCIAL SECURITY COST OF LIVING ADJUSTMENTS (COLA):

MO HealthNet programs for which eligibility is based on the Federal Poverty Level (FPL) do not begin considering COLA adjustments until the FPL figures are updated in April of each year. See SOCIAL SECURITY COST OF LIVING ADJUSTMENTS (COLA) in this guide for details.

STANDARD DEDUCTIONS FROM GROSS EARNED INCOME: 0805.015.20

Gross earned income is the total amount of all non-excluded earned income, minus any allowable overhead expenses for income producing property. For details on calculating earned income, see Calculation Methods and Frequency Codes.

From the total gross income, the following deductions are applied:

• • The first $65.00 of the claimant’s (and spouse’s, if married and living together) earned income, plus 1/2 of the remainder.
  • If the claimant is approved for MA under AB eligibility requirements, subtract work expenses (see 0805.015.20).
  • For Students under age 22 approved for MA under AB or PTD eligibility requirements, subtract educational expenses (see 0805.015.20).

The gross earned income figure minus the allowable deductions shown above equals the adjusted earned income.

INCOME EXEMPTIONS/DEDUCTIONS:

MHABD Income Exemptions / Deductions – 0805.015.35

FAMIS allows exemptions/deductions to arrive at the adjusted gross income. For MHABD and QMB/SLMB programs exempt the following:

• Allow a $20 personal income exemption per case (even if income of a couple is being considered).
• SSI payments

For QMB/SLMB, FAMIS compares adjusted gross income to the individual or spouse QMB standard, as appropriate. If adjusted gross income is more than the appropriate QMB standard, FAMIS will roll down to determine SLMB eligibility.

For MHABD, FAMIS allows the following deductions (in addition to the MHABD exemptions) prior to determining Spend down /Non-spend down:

• Medicare Part B (if no QMB/SLMB)
• Medicare Part D
• Insurance premium

For TWHA, FAMIS allows the following deductions (in addition to the MHABD exemptions):

• Earned income of the disabled worker between 250%-300% FPL is excluded
• The first $50,000 annual earned income of a non-disabled spouse’s earned income
• Health insurance premiums including Medicare
• A $75 per month standard for the disabled worker’s dental and optical insurance. If the total dental and optical insurance premiums exceed $75, allow the actual premium
• The first fifty dollars ($50.00) of the disabled worker’s SSDI payments
• A standard deduction for impairment-related employment expenses equal to one-half of the disabled worker’s earned income. The disabled worker is entitled to this deduction even if the earned income is excluded from the gross income test as sheltered workshop income.

DETERMINING FINANCIAL ELIGIBILITY

FAMIS compares the adjusted gross income with the appropriate income standard to determine whether MHABD case is spend down, non-spend down or TWHA.

If new adjusted gross income is less than or equal to income standard, the case is non-spend down. If the adjusted gross income is greater than the income standard, the case is spend down.

For TWHA, if new adjusted income is less than or equal to the income standard, and the income is less than 100% of the FPL the case is a TWHA non premium. If the income is greater than 100% up to and including 300% of the FPL, the case is a TWHA premium. If new adjusted income is greater than 300% of the FPL, the participant is not eligible for TWHA.

Note: For combination MHABD spend down/QMB or MHABD spend down/SLMB cases, client must be given the option of declining QMB/SLMB and having a lower or no spend down.

July 2022