Family Related Medicaid In-Service Training

Transcription

1 Family Related Medicaid In-Service Training September 2013 The information contained in this document is current as of September 20,

2 Kaiser Video on Healthcare Reform The animated movie you are about to see explains the changes that are happening now, and the big changes coming in

3 The Affordable Care Act and Medicaid Eligibility An Overview The information contained in this document is current as of September 13,

4 Affordable Care Act (ACA) Flashcards

5 ACCESS ACA Implementation Web Page 5

6 Family Related In-Service Training Factors of eligibility include: Technical Assets Income Budgeting Standard Filing Unit (SFU) Coverage Groups 6

7 Technical Eligibility Factor Age Family-Related Overview Technical Factors of Eligibility Current Effective January 1, 2014 To be eligible on the factor of age, a child must be under age 21, if living with a parent or relative. The child also must be unmarried, not legally emancipated and under age 18 for Medicaid. For children living with nonrelatives, a child must be under age 19. No Change in the age factor. Social-Security Number Living Arrangements SSN must be provided for each individual. Must be living in a home with a parent or specified relative. A child under 19 years of age can be eligible living with non-relatives. No Change Note: SSN will be verified thru the Federal Data Services Hub (Hub) There is no requirement to live with an adult caretaker A parent/caretaker relative derives their eligibility from a child. No Change 7

8 Family-Related Overview Technical Factors of Eligibility (cont.) Technical Eligibility Factor Current Effective January 1, 2014 Citizenship Each applicant applying for public assistance must declare in writing whether each individual in the assistance group (AG) is an U.S. citizen, or a noncitizen in lawful immigration status. Citizenship information of those family members who are not applying for benefits is not required. Non-receiving members are to be asked only if they are citizens or noncitizens, not their U.S. Citizenship and Immigration Services status No Change. Note: Verified thru the Hub (when information is available in the Hub). When unavailable, a 90 day reasonable opportunity period is given to allow the customer to obtain required documentation. Identity The identity of each U.S. citizen applying for, or receiving Medicaid must be documented. No change. Note: Verified through the Hub (when information is available in the Hub). Residency Customer Statement No change. Pregnancy The pregnant woman s statement of pregnancy is accepted unless questionable. If the pregnant woman derives her eligibility from the unborn or expects multiple births, verification of pregnancy must be provided. Self-attestation accepted for pregnancy including the number of unborns 8

9 Technical Eligibility Factor Deprivation Family-Related Overview Technical Factors of Eligibility (cont.) Children must be deprived of the support of one or both parents due to one of the following reasons: death of one or both parents, existence of only one legal parent, continued absence of one or both parents, incapacity, or unemployment of one or both parents. Deprivation is not a factor of eligibility. CSE Cooperation Custodial parent or specified relative (if applying) must indicate willingness to cooperate with Child Support Enforcement to be eligible, unless good cause for noncooperation with CSE exists. CSE cooperation isn t a factor for Emergency MEDICAID for Non- Citizens (EMA), Transitional Medicaid and child only cases. CSE cooperation is completed post eligibility. Filing for Other Benefits Must apply for and diligently pursue an application for any other benefits for which they might be eligible. Verification is acceptable through electronic sources and customer statement. No Change 9

10 Family-Related Overview Asset Factors of Eligibility Asset Eligibility Factor Asset Limit Asset value No asset limit for MEDS category $2000 (1931 Medicaid) $5000 (Medically Needy) The value of all non-excluded assets are evaluated for a countable value and measured against the asset limit Assets are not a factor of eligibility. Lump Sum Counts as an asset in the month of receipt. Counts as income in the month of receipt. 10

11 Income Eligibility Factors Countable Income Child Support Deeming Family-Related Overview Income Factors of Eligibility All earned and unearned income is counted unless specifically excluded. Included as unearned income minus $50 disregard Stepparent deeming applies. Taxable earned and unearned income is counted as defined by the IRS. Excluded Stepparent deeming does not apply. Vendor Payments Earned Income Sponsor deeming applies Excluded Wages from the performance of work, including the sale of blood or plasma is counted. Federal Work Study, National and Community Services Trusts Act living allowances from Peace Corps, VISTA, AmeriCorps, etc. are excluded. No Change No Change No Change All taxable earnings are counted including Federal Work Study, National and Community Services Trusts Act living allowances from Peace Corps, VISTA, AmeriCorps, etc. 11

12 Income Eligibility Factor Self-Employment Expenses Dividends and Interest Scholarships, Fellowships & Grants Family-Related Overview Income Factors of Eligibility (cont.) Depreciation, labor and other expenses are not allowable. Excluded Excluded Depreciation, labor and other expenses are allowable. Included Include the income that exceeds qualified educational expenses. Qualified educational expenses include tuition, fees, books, supplies & equipment, which can be excluded. Room & board and travel are not qualified educational expenses, and must be counted. Foster Care & Adoption Subsidies Loans Income is counted for parent, if the child is included in the assistance group. Excluded Excluded No Change Contributions Included Excluded Veteran s Administration Benefits Workman s Compensation Included Included Excluded Excluded 12

13 Family-Related Overview Income Factors of Eligibility (cont.) Income Eligibility Factor Social Security Included No Change Supplemental Security Income (SSI) Unemployment Compensation Benefits Excluded Included No Change No Change 13

14 Family-Related Overview Budgeting Factors of Eligibility Budgeting Eligibility Factor Income Limit Budgeting Period Monthly Income Income Disregards and Deductions Established limits based on the coverage group. See Coverage Groups section for additional information. Prospective Budgeting: Future Month- anticipated income Past Month- actual income. When income is received more often than monthly, convert to a monthly amount. Use the 4 most recent consecutive weeks or best available information, when representative. First $90 for each individual s gross income is deducted in a regular and deeming budget. No Change No Change No Change Note: Wages from work will be verified through State Wage Information Collection Agency (SWICA). Children age 6 through 18 will not receive the standard disregard. $200 and ½ Disregard Child Care Disregard Incapacitated Adult Care Disregard All children will receive the MAGI disregard (5% of 100% FPL) if needed for full Medicaid. 14

15 Eligibility Factor CURRENT Effective January 1, 2014 Fluctuating Income Income Received More Often than Monthly Family-Related Overview Budgeting Factors of Eligibility (cont.) When averaging income, take the most recent four consecutive weeks or best available information, when representative. If received: Weekly- add 4 pay periods and divide by 4 to get the weekly average. Biweekly- add 2 pay periods and divide by 2 to get the biweekly average. Semimonthly- add 2 pay periods and divide by 2 to get the semimonthly average. The average income must be converted to a monthly amount. No Change Note: Request only if electronic verification is not received from SWICA. No Change Note: Request only if electronic verification is not received from SWICA. 15

16 Eligibility Factor Income Conversion Rounding Family-Related Overview Budgeting Factors of Eligibility (cont.) Weekly Income: Multiply by 4.3 Biweekly Income: Multiply by 2.15 Semimonthly income: Multiply by 2 Perform the division to 3 decimal positions. If the third decimal position is 5-9, round to the next higher cent. Weekly Income: Multiply by 4 Biweekly Income: Multiply by 2 Semimonthly income: no change No Change Medically Needy If the third decimal position is 4 or less, round to the next lower cent by dropping the third decimal position. Medically Needy Income Limit (MNIL) is based on TCA payment standard. MNIL will be based on MAGI 16

17 Family-Related Overview Standard Filing Unit of Eligibility Standard Filing Unit Eligibility Factor SFU Individual or group that share legal or blood relationship and/or live together. Based on expected tax filing status for each individual. May include tax dependent(s) outside of the household (OOTH). This includes filers and nonfilers. Definition of a Child A child is under the age of 21 who has never been married, or whose marriage was annulled. There is a requirement for the child to reside with a parent or caretaker. Parents Included if living in the home or meets the conditions of temporary absence. For the Child s Medicaid: A child is under the age of 21 who has never been married or whose marriage was annulled. There is no requirement for the child to reside with a parent or caretaker. For Individuals Who Derive Eligibility from a Child: A child is under the age of 18, never married and never emancipated. Included based on the expected tax filing group for the year. The parent is included if living in the home or out of the home based on the expected tax filing group. 17

18 Standard Filing Unit Eligibility Factor SSI Recipients Teen Parent Unmarried Parents Family-Related Overview Standard Filing Unit of Eligibility Excluded If living with a parent- must be included with their own child, unless eligible with their parent s SFU. If living with a specified relative- must be included with the teen parent s own child, unless the relative receives assistance for one or more siblings of the teen parent. Both parents are included in the SFU with the mutual child(ren). SSI Recipients are included in the SFU but their SSI income is excluded. If they have any other income, it is included, subject to tax rules. Teen Parents are not a factor of eligibility. Note: Children are Included in the SFU based on the expected tax filing group. No change. Note: Subject to tax rules 18

19 Family-Related Overview Standard Filing Unit of Eligibility (cont.) Standard Filing Unit Eligibility Factor Stepparent and stepsiblings Specified Relative Stepparents who have no eligible children of their own may not be included. Stepsiblings may be included or excluded. May be included or excluded. Must be within the 5 th degree of relationship (up to first cousin once removed). The SFU includes all natural, biological, step- and/or adoptive parents and children. No change Note: Subject to tax rules Pregnant Woman Needs of the Unborn Sibling Income Include the unborn child. Counted in the pregnant woman s assistance group. Income is excluded if it affects eligibility. Determined by the tax filer or non filer rules for the tax year. The unborn is included. Counted in the determination of eligibility for all household members. Income is included, subject to tax rules. 19

20 Coverage Group Eligibility Factor Infants and children Family-Related Overview Coverage Group Factors of Eligibility 200% FPL- infants to age 1 133% FPL- Children age % FPL- Children age 6-18 No Change. All children age 1 to 19 up to 133% FPL If the income is higher than the income limit, the child may be eligible for the Children s Health Insurance Program (CHIP) or the Federally Facilitated Marketplace (FFM). Pregnant Women 185% FPL Parents and caretaker relatives 1931 Medicaid Parents and Caretaker relatives living in the household derive their eligibility from a dependent child under age 18. Only one Caretaker Relative may be included in the coverage group. Step parents are not included. No Change. Parents (including step parents), caretaker relatives, and spouses living together may receive Medicaid coverage when household income is equal to or below the appropriate income limit. These individuals derive their eligibility from a child who is under the age of 18, never married and never emancipated. 20

21 Family-Related Overview Coverage Group Factors of Eligibility (cont.) Coverage Group Eligibility Factor Children years old CIC-Former foster care Medicaid is provided to individuals who are year olds. There is no requirement for school attendance must reside in the home of a specified relative. N/A Medicaid is provided to individuals who are 19 and 20 year olds. There is no requirement to reside in the home of parent or specified relative. May continue to receive Medicaid up to aged 26, if the individual was in foster care and receiving Medicaid at age 18 or when they age out in Florida. Medically Needy If the household s income exceeds the income limit for regular Medicaid programs. No change 21

22 Family-Related Overview Coverage Group Factors of Eligibility (cont.) Coverage Group Eligibility Factor Non-Title IV-E Foster care, Adoptions, Emergency Shelter and Independent Living Title IV-E Foster Care, Adoption assistance, Guardianship care Continuous Medicaid Eligibility Eligible up to age AFDC payment standard or highest income level (CNS). Eligible up to age AFDC eligible at the time of removal. Up to age 5: twelve months Age 6-19: six months No Change. Non-Title IV-E Foster Care will use the MAGI budgeting methodology. No Change No Change 22

23 Family-Related Overview Coverage Group Factors of Eligibility (cont.) Coverage Group Eligibility Factor Transitional Medicaid CURRENT Coverage must be extended for up to 12 months, beginning with the first month of ineligibility for 1931 Medicaid, when the assistance group becomes ineligible due to: 1. Initial receipt of earned income of the parent or caretaker relative, or 2. Receipt of increased earned income of the parent or caretaker relative. Additional Conditions: 1. At least one member of the assistance group was eligible for and received 1931 Medicaid in at least three of the preceding six months. 2. The assistance group must contain an eligible child under age 18. Effective January 1, 2014 No Change 23

24 Coverage Group Eligibility Factor Extended Medicaid Children living with non relatives Family-Related Overview Coverage Group Factors of Eligibility (cont.) Coverage must be extended for up to 4 months, beginning with the first month of ineligibility for 1931 Medicaid, if conditions are met: 1. Became ineligible due solely or in part to the receipt of, or increase in, state collected child support. 2. The assistance group was eligible for and received Medicaid in at least three of the preceding six months. The child s income must be under the TCA payment standard and assets cannot exceed $2,000. Child support income is excluded. Spousal support is included. All other criteria remain the same. The child s income must be equal to or below the appropriate Medicaid program limit. No asset limit. 24

25 Family-Related Overview Coverage Group Factors of Eligibility (cont.) Coverage Group Eligibility Factor Emergency Medical Assistance (EMA) for Noncitizens Retroactive Medicaid CURRENT Effective January 1, 2014 To be eligible for Emergency Medicaid Assistance (EMA) benefits, the noncitizen must meet all technical No change. (including residency) and financial requirements for a Medicaid coverage group, except: citizenship, child support enforcement cooperation, and Social Security number requirement. Retroactive Medicaid is available for any one or more No change. of the three months preceding the application month if all factors of eligibility are met and there are Medicaid reimbursable services. 25

26 Family-Related Crosswalk Overview 26

27 Technical Factors Current Effective January 1, 2014 Technical Factor - Age To be eligible on the factor of age, a child must be under age 21, if living with a parent or relative. The child also must be unmarried, not legally emancipated and under age 18 for Medicaid. For children living with nonrelatives, a child must be under age 19. Technical Factor - Living Arrangements Must be living in a home with a parent or specified relative. A child under 19 years of age can be eligible living with non-relatives. No Change in the age factor. There is no requirement to live with an adult caretaker. A child under 19 living with a non-relative, or A child who is homeless A parent/caretaker relative derives their eligibility from a child Note: A child can be eligible without an adult, but an adult cannot be eligible without a child. No Change 27

28 Technical Factors Current Effective January 1, 2014 Technical Factor Pregnancy The pregnant woman s statement of pregnancy is accepted unless questionable. If the pregnant woman derives her eligibility from the unborn or expects multiple births verification of pregnancy must be provided. Self-Attestation accepted for one unborn. If more than one unborn is expected and the woman would not be eligible without counting multiple unborns, the number of unborns must be verified. 28

29 Technical Factors Technical Factor Deprivation Deprivation is not a factor of eligibility. Children must be deprived of the support of one or both parents due to one of the following reasons: death of one or both parents, existence of only one legal parent, continued absence of one or both parents, incapacity, or unemployment of one or both parents. 29

30 Technical Factors Technical Factor CSE Cooperation Custodial parent or specified relative (if applying) must indicate willingness to cooperate with Child Support Enforcement to be eligible, unless good cause for non-cooperation with CSE exists. CSE cooperation isn t a factor for Emergency MEDICAID for Non-Citizens (EMA), Transitional Medicaid and child only cases. CSE cooperation is completed post eligibility. CSE will communicate with the department if customer is not cooperating. 30

31 Asset Factors Asset Limit No asset limit for MEDS category $2000 (1931 Medicaid) $5000 (Medically Needy) Asset Limit Assets are no longer a factor of eligibility. Asset Value The value of all non-excluded assets are evaluated for a countable value and measured against the asset limit. Lump Sum Counts as an asset in the month of receipt. Lump Sum Counts as income in the month of receipt. 31

32 Income Factors Countable Income Income Factor Countable Income All earned and unearned income is counted unless specifically excluded. Income Factor Taxable earned and unearned income is counted as defined by the IRS. Taxable Earned income is the receipt of wages, salary, commission, or profit from an individual's performance of work or services, or a self-employment enterprise. Taxable Unearned income is income for which there is no performance of work or services. Taxable unearned income may include: Retirement, disability payments, unemployment, etc. Annuities, pensions, and other regular payments; Alimony payments; Dividends, interest, and royalties; Prizes and awards; Social Security Award (SSA), and Social Security Disability Income (SSDI). 32

33 Income Factors Child Support Income Factor Child Support Included as unearned income minus $50 disregard Child Support Excluded Child support is excluded from the Medicaid Budget. 33

34 Income Factors Deeming Income factor Deeming Stepparent deeming applies. Sponsor deeming applies Deeming Stepparent deeming does not apply. No Change Stepparents income will now be included in the HH budget and there will be no deeming 34

35 Income Factors Earned Income Earned Income Wages from the performance of work, including the sale of blood or plasma is counted. No change. Wages from work will be verified through State Wages Information Collection Agency (SWICA). Federal Work Study, National and Community Services Trusts Act living allowances from Peace Corps, VISTA, AmeriCorps, etc. are excluded All taxable earnings are counted including: Federal Work Study, National and Community Services Trusts Act living allowances from Peace Corps, VISTA, AmeriCorps, ETC. 35

36 Income Factors Self Employment Expenses Self Employment Expenses Depreciation, labor and other expenses not allowable. Depreciation, labor costs and other expenses are allowable. Dividends and Interest Excluded Dividends and Interest Included Scholarships, Fellowships and Grants Excluded Scholarships, Fellowships and Grants Include the income that exceeds qualified educational expenses. Qualifying Expenses - educational expenses include tuition, fees, books, supplies & equipment. Non-qualifying - Room & board and travel. 36

37 Income Factors Foster Care & Adoption Subsidies Foster Care & Adoption Subsidies Counted as income for parent if child is included in the assistance group. Contributions Included Veteran s Administration Benefits Included Worker s Compensation Benefits Included Excluded Contributions Excluded Veteran s Administration Benefits Excluded Worker s Compensation Benefits Excluded 37

38 Budgeting Factors Income Disregards and Deductions Income Disregards and Deductions First $90 for each individual s gross income is deducted in a regular and deeming budget. $200 and ½ Disregard Child Care Disregard Incapacitated Adult Care Disregard Income Disregards and Deductions A standard disregard (as listed on Family Related Medicaid Income Limits Chart) will be applied, except for children 6-18 will NOT get a standard disregard. If an individual is not eligible, the MAGI disregard (5% of 100% FPL) may apply to test the individual for full Medicaid. 38

39 Budgeting Factors Income Conversion Weekly Income: Multiply by 4.3 Biweekly Income: Multiply by 2.15 Semimonthly income: Multiply by 2 Medically Needy Income Limit (MNIL) is based on TCA payment standard Income Conversion Weekly Income: Multiply by 4 Biweekly Income: Multiply by 2 Semimonthly income: no change MNIL will be based on MAGI 39

40 Standard Filing Unit of Eligibility SFU Individual or group that share legal or blood relationship and/or live together. SFU Based on expected tax filing status for each individual. May include tax dependent(s) outside of the household (OOTH). This includes filers and non-filers. 40

41 Standard Filing Unit of Eligibility SFU - Definition of a Child Current Effective January 1, 2014 For the Child s Medicaid: A child is under the age of 21 who has never been married, or whose marriage was annulled. There is a requirement for the child to reside with a parent or caretaker. A child is under the age of 21 who has never been married or whose marriage was annulled. There is no requirement for the child to reside with a parent or caretaker. For Individuals Who Derive Eligibility from the Child: A child is under the age of 18, never married and never emancipated. Parents Included if living in the home or meets the conditions of temporary absence. Parents Included based on the expected tax filing group for the year. The parent is included if living in the home or out of the home based on the expected tax filing group for the year. 41

42 Standard Filing Unit of Eligibility Teen Parent If living with a parent- must be included with their own child, unless eligible with their parent s SFU. If living with a specified relative- must be included with the teen parent s own child, unless the relative receives assistance for one or more siblings of the teen parent. Stepparent and stepsiblings Stepparent deeming may be included or excluded. Stepsiblings may be included or excluded. Teen Parent: Teen Parents are not a factor of eligibility. Note: Children are Included in the SFU based on the expected tax filing group Stepparent and stepsiblings: No stepparent deeming. The SFU includes all natural, biological, step- and/or adoptive parents and children. 42

43 Standard Filing Unit of Eligibility Pregnant Woman Pregnant Woman Determined by tax filer or non-filer rules for the tax year. Include the unborn child. The unborn is included. Needs of the Unborn Counted in the pregnant woman s assistance group. Sibling Income Income is excluded if it affects eligibility. Needs of the Unborn Counted in the determination of eligibility for all household members. Sibling Income Income is included subject to tax rules. 43

44 Coverage Group Factors of Eligibility Infants and children 200% FPL- infants to age 1 133% FPL- Children age % FPL- Children age 6-18 Parents and caretaker relatives 1931 Medicaid Parents and Caretaker relatives living in the household derive their eligibility from a dependent child under age 18. Only one Caretaker Relative may be included in the coverage group. Step parents are not included. Infants and children NO CHANGE All children age 1 through 18 up to 133% FPL. If the income is higher than the income limit, the child may be eligible for the Children s Health Insurance Program (CHIP) or the Federally Facilitated Marketplace (FFM). Parents and caretaker relatives Parents (including step parents), caretaker relatives, and spouses living together may receive Medicaid coverage when household income is equal to or below the appropriate income limit. These individuals derive their eligibility from a child who is under the age of 18, never married and never emancipated. 44

45 Coverage Group Factors of Eligibility Children years old Medicaid is provided to individuals who are years old. There is no requirement for school attendance. Children years old Medicaid is provided to individuals who are 19 and must reside in the home of a specified relative. CIC-Former foster care N/A There is no requirement to reside in the home of parent or specified relative. CIC-Former foster care May continue to receive Medicaid up to age 26, if the individual was in foster care and receiving Medicaid at age 18 or when they age out in Florida. 45

46 Coverage Group Factors of Eligibility Non-Title IV-E Foster care, Adoptions, Emergency Shelter and Independent Living Eligible up to age AFDC payment standard or highest income level (CNS). Non-Title IV-E Foster care, Adoptions, Emergency Shelter and Independent Living No Change. Non-Title IV-E Foster Care will use the MAGI budgeting methodology. 46

47 Coverage Group Factors of Eligibility Extended Medicaid Coverage must be extended for up to 4 months, beginning with the first month of ineligibility for 1931 Medicaid, if conditions are met: 1. Became ineligible due solely or in part to the receipt of, or increase in, state collected child support. Extended Medicaid Child support income is excluded. Spousal support income is included. All other criteria remain the same. 2. The assistance group was eligible for and received Medicaid in at least three of the preceding six months. 47

48 Coverage Group Factors of Eligibility Children living with non relatives Children living with non relatives The child s income must be under the TCA payment standard and assets cannot exceed $2,000. The child s income must be equal to or below the appropriate Medicaid program limit. No asset limit. 48

49 Modified Adjusted Gross Income (MAGI) Based Eligibility MAGI is the new method for determining eligibility for family- based Medicaid coverage. MAGI is adjusted gross income from the 1040 tax form, plus non-taxable interest and foreign earnings. MAGI looks at the income of all members included in an applicant s tax household. There are special rules depending on whether the individual is the taxpayer, a tax dependent, or someone who doesn t file federal income tax returns. 49

50 VERIFICATION REQUIREMENTS The Affordable Care Act requires that Medicaid applications be approved as quickly as possible, including real time, when all information needed to determine eligibility is available. The Department must use electronic data for verification whenever possible. Except where the law requires other procedures, such as identity, citizenship or immigration status, the Department must accept self attestation of information needed to determine an individual eligible for Medicaid, without requiring further information or documentation prior to approval for benefits. States are required to verify citizenship and immigration status through the hub, if possible. As part of the application process there will be a data request sent to the federal hub. Information available through the hub will include, at a minimum, SSA (including citizenship), the Department of Treasury, IRS and Homeland Security (for immigration status). Other resources are expected to be added over time. 50

51 VERIFICATION REQUIREMENTS Reasonable Compatibility If the information provided by the individual (whether at application, review or by some other means, such as a reported change) is reasonably compatible with the electronic information received by the Department, the Department must determine eligibility based on that information. The Department defines reasonable compatibility as this: If both customer statement and electronic verification are above or below the income limit, the customer s statement is acceptable. If not, and the customer s statement is not more than 10% below the electronically verified amount, the customer s statement is acceptable. 51

52 VERIFICATION REQUIREMENTS Citizenship As stated previously, states are required to verify citizenship and immigration status through the hub if possible. The Affordable Care Act requires that individuals applying for Insurance Affordability Programs make a declaration of citizenship or immigration status and states must verify citizenship through either an electronic data match with SSA, state vital statistic data matches, or with documentary evidence. Non-citizen status should be verified through the Department of Homeland Security. Both sources will be available through the hub with real time responses anticipated. Verification of citizenship is a one-time activity and must be maintained in the electronic case file. At review or future application states are prohibited from re-verifying citizenship. 52

53 VERIFICATION REQUIREMENTS Reasonable Opportunity Applicants declaring U.S. citizenship must be given a reasonable opportunity period to verify their citizenship or immigration status. CMS recommends this period be 90 days. As long as the individual is otherwise eligible, they must be furnished with Medicaid during this period while the state tries to resolve the discrepancy with SSA or the applicant, and request additional documentation from the applicant if the discrepancies cannot be resolved. Some examples of when the reasonable opportunity period might be needed: No SSN provided for a data match The hub, SSA or DHS data bases are down An inconsistency between an electronic source and the individual s declaration exists Electronic verification is unsuccessful even after the Department has made every effort to resolve 53

54 VERIFICATION REQUIREMENTS The basic plan is to: Accept self attestation when required Obtain electronic verification Ask the customer for a reasonable explanation of discrepancies Obtain paper documentation from the individual as a last resort 54

55 Draft - Family Based Medicaid Filing Unit 3 Rules- Draft Rule 1. If person being tested is a Tax Filer [& NOT claimed as a tax dependent] Apply the filer rule The Medicaid SFU = Tax payer + all their claimed dependents + spouse if living with tax payer or separated but filing jointly Notes 1. These rules are applied in order 1-3 until a is reached. 2. For the purpose of establishing a family based Medicaid SFU a child is defined as under 19 or 19 & 20 AND in school full time, never married and never emancipated.. Rule 2. If the person being tested is claimed as a tax dependent [& NOT a Tax Payer] Apply the filer rule The Medicaid SFU = Tax dependent + their claiming tax filer + any of the filer s claimed dependents + the spouse of the tax dependent if living with the tax dependent or separated but filing jointly Exceptions: 1. Is this person claimed by someone other than a spouse or a [biological, adopted, step] parent? 2. Is this person a child who lives with both parents, who are filing separately and only one parent claims child as a dependent? 3. Is this person a child who is claimed as a tax dependent by a noncustodial parent? If the answer to 1, 2 or 3, is Y move to rule 3, and apply Non-Filer rules Rule 3. If the person being tested is NOT tax filer and NOT claimed as a tax dependent Apply the non-filer rule The Medicaid SFU = person being tested + IF living with the person being tested the following: 1. Their spouse 2. Their [biological, adopted, step] children (<19 or 19 &20 and in school full time) 3. If the person is being tested as a child, include their parents (biological, adopted, step) and any siblings ([biological, adopted, step) if the sibling is<19 or 19 & 20 if in school full time. Draft 9/4/13 55 Florida MES SFU/EDBC Requirements Validation Sessions Copyright 2013 Deloitte Development LLC. All rights reserved.

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57 Family-Related Budget 57

58 Targeted Individual/AG: DRAFT ABMG: Family Related Medicaid/Medically Needy Benefit Determination Budget Earned Income: + SFU Size: Unearned Income: + Income Standard: MAGI: Income from Deemed Sponsor: + MNIL: - Total Reported Income: = SOC: = Allowed Tax Deductions: - Medical Ins Premium: - Modified Adjusted Gross Income: = Recurring Med. Expenses: - If MAGI is equal to or less than Income Standard Remaining SOC: = the AG is eligible; if not, apply the Standard Disregard. Standard Disregard: - If the AG is eligible after standard disregard, = = = the AG is eligible for full Medicaid. If not, apply the apply the MAGI disregard. MNIL--The Medically Needy Income Limit (MNIL) includes the appropriate standard disregard. No additional disregards should be applied to establish a share of cost. MAGI Disregard (5% of 100%FPL): - Budget Includes Income of OOTHs Countable Net Income: = If income is equal to or less than the Income Standard, then AG is eligible for full Medicaid, if not, compute the MNIL SOC. AG has the Family Related Medicaid/Medically Needy Benefit Determination Budget. Handout #4 58

59 Case Scenarios 59

60 Family Related Medicaid The End 60