Revision 09-4; Effective December 1, 2009

Subchapter C, Division 6, Budgeting for Eligibility and Co-payment

§358.431. Definitions.

In this division, the following words and terms have the following meanings, unless the context clearly indicates otherwise.

(1) Child--Has the meaning given in 20 CFR §416.1856.

(2) Couple--Two persons who live together and:

(A) present themselves to the community as husband and wife, intend to be married, and are considered to be married under state law;

(B) are determined to be husband and wife for purposes of receiving Social Security benefits; or

(C) are recognized as husband and wife under state law.

(3) Dependent relative--A relative who was living in the home of an applicant or recipient before the applicant's or recipient's absence and who is unable to support himself or herself outside of the person's home due to medical, social, or other reasons.

(4) Parent--Has the meaning given in 20 CFR §416.1881.

§358.432. Eligibility Budgets.

The Texas Health and Human Services Commission (HHSC) prepares an eligibility budget to determine a person's financial eligibility for Medicaid. The type of eligibility budget HHSC prepares depends on:

(1) where the person lives and whether a person is married or not married at the beginning of each month;

(2) whether a person is considered a child; and

(3) whether a person is considered another person's parent.

§358.433. Special Income Limit.

The Texas Health and Human Services Commission uses a special income limit to determine income eligibility under circumstances established in this section. The special income limit for a person is equal to or less than 300 percent of the full individual Supplemental Security Income (SSI) federal benefit rate. The special income limit for a couple is twice the special income limit for an individual.

(1) To qualify for the special income limit, a person or couple must have countable income that exceeds the reduced SSI federal benefit rate; and:

(A) must:

(i) reside in:

(I) a Medicaid-certified long-term care facility for 30 consecutive days; or

(II) a Medicaid-certified institution for mental diseases for 30 consecutive days, if the person is 65 years of age or older; and

(ii) receive a level of care or medical necessity determination that qualifies the person or couple for Medicaid; or

(B) must be approved by a Texas health and human services agency to receive services under a §1915(c) waiver program and receive the services within one month after approval.

(2) The 30 consecutive days described in paragraph (1)(A) of this section are not disrupted if the person:

(A) makes a three-day therapeutic home visit with a planned return to the facility;

(B) is admitted to a hospital with a planned return to the facility; or

(C) moves from a facility described in paragraph (1)(A)(i) of this section:

(i) to a §1915(c) waiver program; or

(ii) to another Medicaid-certified facility.

(3) If a person dies before meeting the 30-consecutive-day requirement without moving to a noninstitutional setting, the person is considered to have met the requirement for application of the special income limit.

§358.434. Budget Types for a Noninstitutional Setting.

(a) Individual budget. The Texas Health and Human Services Commission (HHSC) prepares an individual budget for a person in a noninstitutional setting if the person is:

(1) single;

(2) widowed;

(3) divorced; or

(4) married and is:

(A) an applicant separated from his or her spouse at the time of application; or

(B) a recipient separated from his or her spouse during the previous month.

(b) Couple budget. HHSC prepares a couple budget for a couple in a noninstitutional setting if:

(1) the couple meets the definition of a couple in §358.431 of this division (relating to Definitions);

(2) each spouse is an applicant or a recipient; and

(3) both spouses are in the same coverage group.

(c) Companion budget. HHSC prepares a companion budget for a person in a noninstitutional setting who has an ineligible spouse if:

(1) the couple meets the definition of a couple in §358.431 of this division; and

(2) the person lives with the ineligible spouse during any part of a calendar month.

§358.435. Noninstitutional Eligibility Budgets.

(a) Scope. The Texas Health and Human Services Commission (HHSC) prepares a noninstitutional eligibility budget to determine financial eligibility for a person or couple in a noninstitutional setting, if the person or couple:

(1) applies for retroactive coverage;

(2) applies for or has eligibility redetermined under a federally mandated Medicaid-funded program for the elderly and people with disabilities as described in §358.107 of this chapter (relating to Coverage Groups); or

(3) applies for or has eligibility redetermined under §1929(b)(2)(B) of the Social Security Act.

(b) Individual budget. In preparing an eligibility budget for a person who meets the criteria in §358.434(a) of this division (relating to Budget Types for a Noninstitutional Setting), HHSC:

(1) counts the person's income in accordance with §1612 of the Social Security Act (42 U.S.C. §1382a);

(2) counts the person's resources in accordance with §1613 of the Social Security Act (42 U.S.C. §1382b);

(3) applies the individual resource limit in accordance with 20 CFR §416.1205; and

(4) applies the appropriate income limit, effective the month of eligibility determination, as follows:

(A) for a person who meets the criterion in subsection (a)(1) or (2) of this section, the income limit is the full individual Supplemental Security Income (SSI) federal benefit rate; and

(B) for a person who meets the criterion in subsection (a)(3) of this section, the income limit is the special income limit based on 300 percent of the full individual SSI federal benefit rate.

(c) Couple budget. In preparing an eligibility budget for a couple who meets the criteria in §358.434(b) of this division, HHSC:

(1) counts the income of both spouses in accordance with §1612 of the Social Security Act;

(2) counts the resources of both spouses in accordance with §1613 of the Social Security Act;

(3) applies the couple resource limit in accordance with 20 CFR §416.1205; and

(4) applies the appropriate income limit, effective the month of eligibility determination, as follows:

(A) for a couple who meets the criterion in subsection (a)(1) or (2) of this section, the income limit is the full couple SSI federal benefit rate; and

(B) for a couple who meets the criterion in subsection (a)(3) of this section, the income limit is twice the special income limit based on 300 percent of the full individual SSI federal benefit rate.

(d) Companion budget. In preparing an eligibility budget for a person who meets the criteria in §358.434(c) of this division, HHSC:

(1) counts the income of both spouses in accordance with §1612 of the Social Security Act;

(2) counts the resources of both spouses in accordance with §1613 of the Social Security Act;

(3) deems the ineligible spouse's income and resources;

(4) applies the couple resource limit in accordance with 20 CFR §416.1205; and

(5) applies the appropriate income limit, effective the month of eligibility determination, as follows:

(A) for a person who meets the criterion in subsection (a)(1) or (2) of this section, the income limit is the full individual SSI federal benefit rate; and

(B) for a person who meets the criterion in subsection (a)(3) of this section, the income limit is the special income limit based on 300 percent of the full individual SSI federal benefit rate.

§358.436. Budget Types for an Institutional Setting.

(a) Individual budget. The Texas Health and Human Services Commission (HHSC) prepares an individual budget for a person in an institutional setting if the person is:

(1) single;

(2) widowed;

(3) divorced; or

(4) married and meets the criteria in subsection (c) of this section, but the community spouse refuses to cooperate in providing information and circumstances indicate possible abuse or neglect by the community spouse.

(b) Couple budget. HHSC prepares a couple budget for a couple in an institutional setting if:

(1) the couple meets the definition of a couple in §358.431 of this division (relating to Definitions);

(2) each spouse is an applicant or a recipient; and

(3) both spouses are in the same coverage group.

(c) Institutional companion budget. HHSC prepares an institutional companion budget for a person in an institutional setting if:

(1) the person has a community spouse; and

(2) the couple meets the definition of a couple in §358.431 of this division, except the criterion that the couple live together does not apply.

§358.437. Institutional Eligibility Budgets.

(a) Scope. The Texas Health and Human Services Commission (HHSC) prepares an institutional eligibility budget to determine financial eligibility for a person or couple in an institutional setting, if the person or couple:

(1) applies for retroactive coverage; or

(2) applies for or has eligibility redetermined under a federally optional Medicaid-funded program for the elderly and people with disabilities as described in §358.107 of this chapter (relating to Coverage Groups).

(b) Individual budget. In preparing an eligibility budget for a person who meets the criteria in §358.433 of this division (relating to Special Income Limit) and §358.436(a) of this division (relating to Budget Types for an Institutional Setting), HHSC:

(1) counts the person's income in accordance with §1612 of the Social Security Act (42 U.S.C. §1382a);

(2) counts the person's resources in accordance with §1613 of the Social Security Act (42 U.S.C. §1382b);

(3) applies the individual resource limit in accordance with 20 CFR §416.1205; and

(4) applies the special income limit effective the month of eligibility determination.

(c) Couple budget. In preparing an eligibility budget for a couple who meets the criteria in §358.433 of this division and §358.436(b) of this division, HHSC:

(1) counts the income of both spouses in accordance with §1612 of the Social Security Act;

(2) counts the resources of both spouses in accordance with §1613 of the Social Security Act;

(3) applies the couple resource limit in accordance with 20 CFR §416.1205; and

(4) applies the special income limit, effective the month of eligibility determination.

(d) Institutional companion budget. In preparing an eligibility budget for a person who meets the criteria in §358.433 of this division and §358.436(c) of this division, HHSC:

(1) applies spousal impoverishment treatment of income and resources under 42 U.S.C. §1936r-5, counting income of both spouses in accordance with §1612 of the Social Security Act and resources of both spouses in accordance with §1613 of the Social Security Act;

(2) follows resource eligibility in accordance with 42 U.S.C. §1396r-5;

(3) bases income eligibility on the income of the person in the institutional setting; and

(4) applies the special income limit effective the month of determination.

(e) Less than 30 consecutive days. In preparing an eligibility budget for a person or couple in an institutional setting who does not meet the criteria in §358.433 of this division, HHSC applies the criteria in §358.435 of this division (relating to Noninstitutional Eligibility Budgets).

Revision 15-4; Effective December 1, 2015

A child is neither married nor a head of a household and is either:

• under age 18; or
• under age 22 and a student regularly attending school, college or training that is designed to prepare him/her for a paying job.

See Section D-1210, Definition of a Child, for more information.

A couple is two people who live together and:

• present themselves to the community as a married couple, intend to be married and are considered to be married under state law;
• are determined to be married for purposes of receiving Social Security benefits; or
• are recognized as married under state law.

A dependent relative is a relative who was living in the home of an applicant or recipient before the applicant's or recipient's absence and who is unable to support himself or herself outside of the person's home due to medical, social or other reasons.

A parent is:

• a natural or adoptive parent of the child, or
• the spouse of the natural or adoptive parent ("stepparent").

The stepparent must be the present spouse of the natural or adoptive parent. A person is not a stepparent if the natural or adoptive parent to whom the stepparent was married has died, or if the parent and stepparent have been divorced or their marriage has been annulled. See Section D-4213, Parent, for more information on the definition of a parent.

Revision 12-4; Effective December 1, 2012

The MEPD programs use income limits based on the Supplementary Security Income (SSI) limit up to the 300% of the federal poverty level. For a detailed list of the various income limits for the different programs, see Appendix XXXI, Budget Reference Chart.

G-1310 Community-Based Programs Using SSI Limits

Revision 23-1; Effective March 1, 2023

For programs being tested using the SSI federal benefit rate (FBR), use the following figures.

Income Limits

The monthly income limits for initial certification are:

Date Range	Individual	Couple
Jan. 1, 2023 to Present	$914	$1,371
Jan. 1, 2022 to Dec. 31, 2022	$841	$1,261
Jan. 1, 2021 to Dec. 31, 2021	$794	$1,191
Jan. 1, 2020 to Dec. 31, 2020	$783	$1,175
Jan. 1, 2019 to Dec. 31, 2019	$771	$1,157
Jan. 1, 2018 to Dec. 31, 2018	$750	$1,125
Jan. 1, 2017 to Dec. 31, 2017	$735	$1,103
Jan. 1, 2016 to Dec. 31, 2016	$733	$1,100
Jan. 1, 2015 to Dec. 31, 2015	$733	$1,100
Jan. 1, 2014 to Dec. 31, 2014	$721	$1,082
Jan. 1, 2013 to Dec. 31, 2013	$710	$1,066
Jan. 1, 2012 to Dec. 31, 2012	$698	$1,048
Jan. 1, 2011 to Dec. 31, 2011	$674	$1,011
Jan. 1, 2010 to Dec. 31, 2010	$674	$1,011

G-1320 Special Income Limits

Revision 23-1; Effective March 1, 2023

For programs being tested using the special income limit of 300 percent of the SSI-FBR, use the following figures.

Income Limits

The monthly income limits for initial certification are:

Date Range	Individual	Couple
Jan. 1, 2023 to Present	$2,742	$5,484
Jan. 1, 2022 to Dec. 31, 2022	$2,523	$5,046
Jan. 1, 2021 to Dec. 31, 2021	$2,382	$4,764
Jan. 1, 2020 to Dec. 31, 2020	$2,349	$4,698
Jan. 1, 2019 to Dec. 31, 2019	$2,313	$4,626
Jan. 1, 2018 to Dec. 31, 2018	$2,250	$4,500
Jan. 1, 2017 to Dec. 31, 2017	$2,205	$4,410
Jan. 1, 2016 to Dec. 31, 2016	$2,199	$4,398
Jan. 1, 2015 to Dec. 31, 2015	$2,199	$4,398
Jan. 1, 2014 to Dec. 31, 2014	$2,163	$4,326
Jan. 1, 2013 to Dec. 31, 2013	$2,130	$4,260
Jan. 1, 2012 to Dec. 31, 2012	$2,094	$4,188
Jan. 1, 2011 to Dec. 31, 2011	$2,022	$4,044
Jan. 1, 2010 to Dec. 31, 2010	$2,022	$4,044

Revision 09-4; Effective December 1, 2009

For the income eligibility budget, treatment of the following income exceptions is the same whether the person is in a noninstitutional or an institutional setting.

When calculating the total income for the income eligibility budget, do not consider receipt of those items detailed in Section E-1700, Things That Are Not Income. Some examples of things that are not income are:

• medical care and services that are not income;
• social services that are not income;
• sale of a resource;
• proceeds of a loan;
• mandatory payroll deductions; and
• cafeteria plan.

When calculating the total income for the income eligibility budget, do not consider receipt of those items detailed in Section E-2000, Exempt Income. Some examples of exempt income are:

• income exempt under federal laws;
• exempt income for Native Americans;
• earned income tax credits; and
• certain educational assistance.

When calculating the total income for the income eligibility budget, do not consider receipt of income that meets the definition of irregular or infrequent detailed in Section E-9000, Infrequent or Irregular Income. Take special note of interest and dividend treatment detailed in:

• Section E-3331, Interest and Dividends
• Section E-3331.1, Treatment of Interest/Dividends on Fully Countable Resources
• Section E-3331.2, Treatment of Interest/Dividends on Certain Excluded or Partially Excluded Resources
• Section E-3331.3, Treatment of Interest/Dividends on All Other Resources

Revision 09-4; Effective December 1, 2009

For the income eligibility budget, treatment of variable income is the same whether the person is in a noninstitutional or an institutional setting.

Average monthly income that is predictable but varies in amounts from month to month as detailed in Section E-5000, Variable Income.

Revision 09-4; Effective December 1, 2009

When the living arrangement is noninstitutional, income from support and maintenance and from deeming are considered in the eligibility budget. Refer to information in:

• Section E-8000, Support and Maintenance
• Section E-7000, Deeming Income

G-2310 Noninstitutional Deeming

Revision 09-4; Effective December 1, 2009

The term "deeming" identifies the process of considering another person's income and resources to determine available funds for meeting a person's basic needs of food and shelter.

G-2311 Spouse-to-Spouse Noninstitutional Deeming

Revision 09-4; Effective December 1, 2009

Use the following steps to prepare a budget for an individual when the person lives with an ineligible spouse in a non-institutional living arrangement.

G-2311.1 Pretest to Deeming

Revision 11-4; Effective December 1, 2011

For spouse-to-spouse deeming policy to apply, the person must first be eligible based on the person's own income in the pretest. To determine if the person meets the pretest, use the steps in Section G-5000, Noninstitutional Budget Steps, to determine the person's countable income and compare the person's countable income to the program's income limit for an individual.

If the individual is eligible in the pretest, Appendix XXIX, Special Deeming Eligibility Test for Spouse to Spouse, provides the manual steps used to calculate eligibility with deeming.

• Allocations — An allocation is an amount deducted from income that is subject to deeming, which is considered to be set aside for the support of certain individuals other than the eligible individual. Normally, the allocation amounts are based on the difference between the eligible couple and individual income limits for the program being tested.
  
  Example: The allocation for a Medicaid program that uses the SSI federal benefit rate (FBR) limit is the difference between the SSI FBR couple and SSI FBR individual income limits. See Appendix XXXI, Budget Reference Chart.
• The allocation for Qualified Medicare Beneficiaries (QMB) is the difference between the QMB couple and QMB individual income limits.
• The allocation amount when the Special Income Limit is used is the difference between the SSI FBR couple and SSI FBR individual income limits.
• When the Special Income Limit is used, the general income exclusion and the earned income exclusion are not allowed.

G-2311.2 Examples of Spouse-to-Spouse Deeming

Revision 23-1; Effective March 1, 2023

A couple lives together in their own home. Only one spouse is applying for Community Attendant Services (CAS). The applicant’s only income is gross monthly Retirement, Survivors, and Disability Insurance (RSDI) benefits of $675. The non-applicant spouse is working and earns $800 gross monthly wages. The non-applicant spouse also gets RSDI of $200, and their 16-year-old son gets RSDI of $211.

Deeming Pretest — Person must be eligible as an individual first.

Applicant's income:

Step	Description	Amount
Step 1:	Appropriate income limit	$2,742
Step 2:	Gross earned income	$0
Step 3:	Monthly unearned income	$675
Step 4:	Earned or unearned income exclusions	NA
Step 5:	Pickle RSDI COLA disregards	NA
Step 6:	Disabled Adult Child (DAC) RSDI exclusions	NA
Step 7:	Early Age Widow/Widower (W/W) RSDI exclusions	NA
Step 8:	Disabled W/W RSDI exclusions	NA
Step 9:	Remainder	$675

Remainder is less than the individual income limit for CAS. Continue with the deeming process.

Determining the ineligible spouse's income (this section and Appendix XXIX, Special Deeming Eligibility Test for Spouse to Spouse):

Step	Description	Amount	Comments
Step 1:	Appropriate income limit for couple	$5,484
Step 2:	Gross earned income	$800
	Gross unearned income	$200
Step 3:	$457 Allocation for ineligible child
	- $211 Son's RSDI
	$246 Allocation for ineligible child
	$200 Unearned income
	- $246 Allocation for ineligible child
	$0 Remaining unearned
Step 4:	Remaining unearned	$0
	Remaining earned	+ $800
		$800	> $457 Deeming allowance
			Proceed to Step 5
Step 5:	Non-applicant spouse's remaining unearned	$0
	Applicant's unearned	+$675
	Combined unearned	$675
	Non-applicant spouse's earned income	$800
	Applicant's earned income	+$0
	Combined earned	$800
Step 6:	No $20 general exclusion since the applicant is applying for CAS.
Step 7:	No earned income exclusions since the applicant is applying for CAS.
Step 8:	Remaining income =	$675	Unearned
		+ $800	Earned
		$1,475	< $5,484
	Eligible for CAS

A couple lives together in their own home. Only one spouse is applying for QMB. The applicant's only income is gross monthly RSDI of $780. The non-applicant spouse's gross monthly wages are $800. They have no children.

Deeming Pretest — Person must be eligible as an individual first.

Step	Description	Amount
Step 1:	Appropriate income limit	$1,133
Step 2:	Gross earned income	$0
Step 3:	Monthly unearned income	$780
Step 4:	Earned or unearned exclusions	− $20
Step 5:	Pickle RSDI COLA disregards	NA
Step 6:	DAC RSDI disregards	NA
Step 7:	Early Age W/W RSDI exclusions	NA
Step 8:	Disabled W/W RSDI disregards	NA
Step 9:	Remainder	$760

Remainder is less than the individual income limit for QMB. Continue with the deeming process.

Determining the ineligible spouse's income (this section and Appendix XXIX, Special Deeming Eligibility Test for Spouse to Spouse)

Step	Description	Amount	Comments
Step 1:	Appropriate income limit for couple	$1,526
Step 2:	Earned	$800
	Unearned	+ $0
	Total	$800
Step 3:	No ineligible children.
	$800 earned	$0	Allocation for ineligible children
		$800	Remaining earned
Step 4:	$800 Remaining income (earned and unearned) >		$393 Deeming allowance
			Proceed to Step 5
Step 5:	Non-applicant spouse's remaining unearned	$0
	Applicant's remaining unearned	+$780
	Combined remaining unearned	$780
	Non-applicant spouse's remaining earned	$800
	Applicant's remaining earned	+$0
	Combined remaining earned	$800
Step 6:	Combined unearned =	$780 − $20	general exclusion = $760
Step 7:	Combined earned =	$800 − $65 = $735	divided by 2 = $367.50
Step 8:	Remaining unearned	$760
	Remaining earned	+ $367.50
	Total	$1,127.50	< $1,526
	Eligible for QMB

G-2312 Parent-to-Child Noninstitutional Deeming

Revision 11-3; Effective September 1, 2011

The term deeming identifies the process of considering another person's income and resources to be available for meeting a person's basic needs of food and shelter.

Allocations — To consider that a portion of an ineligible parent's income is used to provide for the ineligible parent's own living expenses and those of any ineligible child/children living in the household. Based on this consideration, apply allocations for:

• ineligible parents; and
• ineligible children in the household.

Application of these allocations reduces the amount of income available for deeming.

Deem a parent's income to an eligible child beginning the month:

• after the month the child comes home to live with the parent(s) (for example, the month following the month the child comes home from the hospital); or
• of birth when a child is born in the parent's home; or
• after the month of adoption (the month of adoption is the month the adoption becomes final); or
• after the month of marriage (for example, when a natural or adoptive parent marries) or the month after the month a parent begins living in a relationship in which they hold themselves out as married.

Deeming applies from a parent to a child when they live together in the same household.

Exceptions:

An ineligible spouse or parent who is absent from a deeming household due solely to a duty assignment as a member of the Armed Forces on active duty will, in the absence of evidence to the contrary, be considered to be living in the same household as the Supplemental Security Income (SSI) claimant/recipient for income and resources deeming purposes.

This policy applies regardless of how long the deemor is absent from the household due to a duty assignment and regardless of when such absence began.

If a natural or adoptive parent is deceased or is divorced from the stepparent, and the child is living with the stepparent, the stepparent is not considered a parent or spouse of a parent of the eligible child for deeming purposes.

Deeming does not apply if one or both of the parents are eligible for Medicaid.

This deeming process does not apply to the Medicaid Buy-In for Children (MBIC) program. See Section N-6000, Budgeting, for consideration of parents' income in the eligibility budget for MBIC.

To determine the amount of a parent's (and the parent's spouse's, if any) income to be deemed to a disabled child under 18, use the following steps.

Step	Procedure
1.	Determine the gross earned and unearned nonexempt and nonexcludable income of the parent(s).
2.	Determine the total amount of allocations for ineligible children under 21 who live in the same household. The amount of a child's allocation is the difference between the couple and the individual limits for the program being tested, except when the Special Income Limit is used, less the amount of the child's own nonexempt income. When the Special Income Limit is used, the allocation equals the difference between the SSI federal benefit rate (FBR) couple and SSI FBR individual income limits, less the child's own nonexempt income.
3.	Subtract the total amount of allocations for ineligible children in the household from the unearned income of the parent(s). Any unmet remainder of the allocation is deducted from the earned income of the parent(s).
4.	If remaining income includes both earned and unearned income, deduct $20 from unearned income and then from earned income if unearned income is less than $20. From the remaining earned income, deduct $65 plus one-half of the remainder. Then, from the sum of remaining earned and unearned income, subtract an amount equal to the SSI FBR for an individual or a couple, as appropriate.
5.	Divide any remaining income from the calculation in Step 4 equally among all eligible children in the household to establish each child's deemed income.

G-2312.1 Examples of Parent-to-Child Deeming

Revision 23-1; Effective March 1, 2023

Example 1:

A child is 14 years old and is applying for Prior Medical for SSI (ME-SSI Prior). He lives with his ineligible parents. He has one ineligible 16 year old sibling. Neither child has any income. The parents' gross monthly earnings total $1,500 and their gross unearned income is $100.

Parent-to-Child Deeming

Steps	Description	Amount
Step 1:	Parents' gross earned =	$1,500
	Parents' gross unearned =	$100
Step 2:	Allocation for ineligible child	$457
	Sibling's income	- $0
	Allocation for ineligible child	$457
Step 3:	Parents' unearned income	$100
	Allocation for ineligible child	− $457
	Unmet remainder of the allocation	− $357
	Parents’ earned income	$1,500
	Unmet remainder of the allocation	− $357
	Remaining earned	$1,143
Step 4:	− $20 general exclusion =	$1,123
	$1,123 − $65 =	$1,058
	divided by 2 =	$529
	Remaining earned	$529
	Remaining unearned	+ $0
	Total	$529
	SSI FBR for couple	− $1,371
	Income deemed to applicant	$0

Determining the Applicant's Income

Step	Description	Amount	Comments
Step 1:	Appropriate income limit =	$914
Step 2:	Gross earned income =	$0
Step 3:	Monthly unearned income =	$0
Step 4:	$20 general exclusion =	− $20
Step 5:	Pickle RSDI COLA disregards =	NA
Step 6:	DAC RSDI disregards =	NA
Step 7:	Early Age W/W RSDI exclusions =	NA
Step 8:	Disabled W/W RSDI disregards =	NA
Step 9:	Remainder =	$894	< $914
	Eligible for Prior Medical for SSI (ME-SSI Prior)

Example 2:

A different child is 13 years old and is applying for Community Attendant Services (CAS). She lives with her ineligible parents. She has two ineligible brothers, 15 and 16 years old. She gets $700 per month in RSDI disability benefits. Her brothers have no income. The parents' gross monthly earned income is $2,000 and their gross monthly unearned income is $200.

Parent-to-Child Deeming

Step	Description	Amount	Comments
Step 1:	Parents' gross earned =	$2,000
	Parents' gross unearned =	$200
Step 2:	Allocation for ineligible child	$457
	First brother's income	− $0
	Allocation for first brother	$457
	Allocation for ineligible child	$457
	Second brother's income	− $0
	Allocation for second brother	$457
	Total allocation for ineligible children =	$457 x 2	= $914
Step 3:	Parents’ unearned income =	$200
	Allocation for ineligible children =	− $914
		− $714	Unmet remainder
	Parents’ earned income =	$2,000
	Unmet remainder of allocation =	− $714
		$1,286	Remaining earned
Step 4:	Remaining unearned	$0
	Remaining earned	$1,360
	General exclusion	− $20
		$1,286
		− $65
		$1,201	divided by 2 = $600.50
	Remaining earned and unearned	$600.50
	SSI FBR for couple	− $1,371
	Remainder	$0
Step 5:	Income deemed to applicant	$0

When parent-to-child deeming occurs for CAS, the $20 and the $65 plus one-half earnings exclusions are given to the parents in determining the amount to be deemed to the child. CAS does not allow these exclusions for the child who is the applicant or recipient.

Determining the Applicant's Income

Step	Description	Amount	Comments
Step 1:	Appropriate income limit =	$2,742
Step 2:	Gross earned income =	$0
Step 3:	RSDI	$700
	Deemed income	+ $0
	Total unearned income	$700
Step 4:	No $20 general exclusion since applicant is applying for CAS	NA
Step 5:	Pickle RSDI COLA disregards =	NA
Step 6:	DAC RSDI exclusions =	NA
Step 7:	Early Age W/W RSDI exclusions =	NA
Step 8:	Disabled W/W RSDI exclusions =	NA
Step 9:	Remainder =	$700	< $2,742
	Eligible for CAS

Revision 09-4; Effective December 1, 2009

Eligibility is determined for individuals and couples (in noninstitutional living arrangements) who:

• apply for retroactive Medicaid coverage;
• apply for or have eligibility redetermined under various federally-mandated MEPD programs; or
• apply for or have eligibility redetermined under the Community Attendant Services (CAS) program formerly known as 1929(b).

The income standard used and the income counted depend on whether the budget is for an individual, companion or couple case.

 

G-3110 Individual Noninstitutional Budget

Revision 09-4; Effective December 1, 2009

The full SSI federal benefit rate for an individual is the income standard or limit used for a person. Only the person’s income is considered. An individual budget is prepared if the person is single, widowed or divorced, or a married person who is:

• a person separated from his spouse at the time of application, or
• a person separated from his spouse during the previous month.

If the person is an individual and the MEPD program is Community Attendant Services (CAS), the institutional special income limit for an individual is the income standard or limit used.

See Appendix XXXI, Budget Reference Chart

 

G-3120 Companion Noninstitutional Budget (Person with Ineligible Spouse)

Revision 09-4; Effective December 1, 2009

The full SSI federal benefit rate for an individual is the income standard or limit used for a person, if a person lives with his ineligible spouse during any part of a calendar month. The income of the ineligible spouse may be deemed available to the person. See Section E-7000, Deeming Income, and Section G-2311, Spouse-to-Spouse Noninstitutional Deeming.

The institutional special income limit for an individual is the income standard or limit used for a person, if a person lives with his ineligible spouse during any part of a calendar month and the MEPD program is Community Attendant Services (CAS).

 

G-3130 Couple Noninstitutional Budget

Revision 15-4; Effective December 1, 2015

The following applies to couple budgets:

MEPD programs consider the income of both spouses against the full SSI payment standard for a couple (or the appropriate income limit for a couple if both spouses are clients in the same coverage group). A couple budget is prepared if an individual is living with an eligible spouse (i.e., a spouse who is aged or has a disability) and they are:

• presenting themselves to the community as a married couple,
• determined to be married for purposes of receiving Social Security benefits, or
• recognized as married under state law.

The institutional special income limit for a couple is the income standard or limit used for a couple, if the person lives with the eligible spouse during any part of a calendar month and the MEPD program is CAS.

Note: A couple budget is not prepared when only one member of an eligible couple enters a Title XIX long-term care facility and is entitled to vendor payment.

 

G-3131 Couple Budget Policy

Revision 09-4; Effective December 1, 2009

If both spouses are ineligible as a couple, redetermine the eligibility for each person on an individual basis. Use deeming procedures if appropriate. See Section E-7000, Deeming Income, and Section G-2311, Spouse-to-Spouse Noninstitutional Deeming.

Prepare an individual deeming budget for each spouse.

Perform the deeming pre-test for each member of the couple. Allow the exclusions, including the $20 dollar general exclusion, for each member of the couple during the deeming pre-test.

If only one member of the couple is eligible based on the deeming pre-test, complete a special deeming eligibility test worksheet using the steps found in Appendix XXIX, Special Deeming Eligibility Test for Spouse to Spouse, for the member found eligible in the pre-test.

If both members of the couple are eligible based on the deeming pre-test, complete a special deeming eligibility test worksheet using the steps in Appendix XXIX. Complete a worksheet for each member of the couple and follow the steps for each member as if one member of the couple was ineligible.

Revision 09-4; Effective December 1, 2009

After granting the applicable exemptions, apply appropriate exclusions to the remaining income of the person, including any income that is deemed as unearned income. See Section G-2000, Income Treatment, for exempt, variable and deemed income treatment.

An exclusion is not an exemption. An exclusion is applied to a type of income that would otherwise be counted in the eligibility determination. Income that is excluded in the eligibility test generally is considered when determining the amount that the person must pay for his care in a medical facility (see Chapter H, Co-Payment Budget.

 

G-4110 Twenty-Dollar General Exclusion

Revision 11-3; Effective September 1, 2011

For each month, the first $20 of unearned or earned income is excluded. This exclusion is applied first to unearned income, then to earned income if the unearned income is less than $20.

If no unearned income exists, the entire $20-exclusion is applied to the earned income.

See Section E-3000, Earned and Unearned Income.

Exceptions are as follows:

• Although this exclusion does not apply to VA pensions and parents' dependency and indemnity compensation (DIC), it does apply to VA compensation and insurance. If, however, a person receives income from a VA pension and another source, he retains the general exclusion.
• In the case of an eligible couple, only one $20-general exclusion is applied to the couple's combined income.
• The $20-general exclusion does not apply when determining eligibility for Community Attendant Services.
• The $20-general exclusion does not apply when determining eligibility for Medicaid Buy-In for Children (MBIC). See Section N-6320, MBIC Income Exclusion.

Example: The person receives $15 a month as a contribution from a relative. He also has $80 a month as gross earned income. The entire amount of the contribution is excluded because it is less than $20. The remaining $5 is then subtracted from the $80 gross earned income.

See Section E-4315, VA Aid and Attendance and Housebound Payments. Do not consider these payments in the eligibility budget.

 

G-4120 Earned Income Exclusion

Revision 18-4; Effective December 1, 2018

After applying the $20 general exclusion, exclude $65 of the remaining earned income plus one-half of the remaining earnings. In the case of an eligible couple, allow only one earned income exclusion for the couple's combined earned income.

Exceptions:

• The earned income exclusion does not apply when determining eligibility for Community Attendant Services.
• The earned income exclusion does not apply when determining eligibility for the Medicaid Buy-In for Children (MBIC) program.

Note: Do not apply the earned income exclusion when eligibility is determined using the special income limit.

Related Policy

MBIC Income Exclusion, N-6320
Institutional Eligibility Budget Steps, G-6300

 

G-4121 Examples of the Earned Income Exclusion

Revision 09-4; Effective December 1, 2009

• Bob Evans' monthly income is $350 in wages and $100 in pension payments.
   

  Description	Amount
  Unearned income	$100.00
  General income exclusion	– $20.00
  Remaining unearned income	$80.00
  Earned income exclusion:
  Gross earned income	$350.00
  First $65.00	– $65.00
  Remaining	$285.00
  One-half of remaining	$142.50
  Countable unearned income	$80.00
  Countable earned income	+ $142.50
  Total countable income	$222.50



• Ralph and Mary Teague are both receiving disability Social Security and SSI benefits. They were in an automobile accident in June, the month before they applied for SSI. Mr. and Mrs. Teague have applied for retroactive Medicaid to help with the payment of their hospital bills in June. In the month under consideration, Ralph received wages from the Senior Citizens' Center for preparing meals. Mary did part-time piecework sewing by hand at home for a local clothing manufacturer. She had no work-related expenses because the company supplied the materials.
   

  Description	Amount
  Unearned income
  Ralph's Social Security benefits	$200.00
  Mary's Social Security benefits	+ $100.00
  Gross unearned benefits for the couple	$300.00
  General income exclusion (only one allowed)	– $20.00
  Remaining unearned income	$280.00
  Earned income:
  Ralph's wages	$306.40
  Mary's wages	+ $109.90
  Total gross earned income	$416.30
  Earned income exclusion (only one allowed):
  First $65.00	$65.00
  Remaining	$351.30
  One-half of remaining	$175.65
  Countable unearned income	$280.00
  Countable earned income	+ $175.65
  Total countable income for the couple	$455.65

Revision 09-4; Effective December 1, 2009

The census is a count of everyone living in the United States and is mandated by the U.S. Constitution. The U.S. Census Bureau conducts the census every 10 years.

Wages paid by the Census Bureau for temporary employment related to census activities are excluded income for the Medicare Savings Programs (MSP). Do not include these wages in the eligibility budget for MSP.

These wages for temporary employment are not countable income in the month of receipt, but are considered a resource thereafter.

Wages paid by the Census Bureau for temporary employment related to census activities are included in eligibility or co-payment budgets for any other Medicaid for the Elderly and People with Disabilities (MEPD) program that is not an MSP.

Wages received from the Census Bureau for full-time employment are considered earned income and treated according to policy in Section E-3000, Earned and Unearned Income.

For cases with a combination of regular Medicaid benefits and an MSP, the wages are countable in the eligibility budget (and co-payment, if applicable) for the regular Medicaid program, but are excluded in the eligibility budget for MSP.

Example: Individual is being considered for Pickle with Qualified Medicare Beneficiary (QMB) benefits. The wages paid by the Census Bureau for temporary employment related to census activities are included in the eligibility budget for Pickle, but are excluded in the eligibility budget for QMB.

Revision 23-1; Effective March 1, 2023

G-4310 Computing Social Security Cost-of-Living Increases

Revision 23-1; Effective March 1, 2023

The following chart shows the Pickle (ME-Pickle) multiplier for Social Security cost-of-living adjustments.

Note: Additional information for prior years is available in Appendix XXXVIII, Pickle Disregard Computation Worksheet.

Last Check Received	Multiplier
Jan. 2022 to Dec. 2022	0.08
Jan. 2021 to Dec. 2021	0.0557
Jan. 2020 to Dec. 2020	0.0678
Jan. 2019 to Dec. 2019	0.0825
Jan. 2018 to Dec. 2018	0.1075
Jan. 2017 to Dec. 2017	0.125
Jan. 2016 to Dec. 2016	0.1276
Jan. 2015 to Dec. 2015	0.1363
Jan. 2014 to Dec. 2014	0.1507
Jan. 2013 to Dec. 2013	0.1632
Jan. 2012 to Dec. 2012	0.1772
Jan. 2011 to Dec. 2011	0.2058
Jan. 2010 to Dec. 2010	0.2137

Note: To calculate the Pickle (ME-Pickle) disregard, use the multiplier for the date the person received the last Supplemental Security Income check, and multiply by the current Retirement, Survivors and Disability Insurance benefit amount. Round the result to the nearest dollar amount. Subtract this disregard amount and all other available exclusions from the person's available income to determine the person's countable income.

Reference: For calculating manual budgets, see step 5 in Section G-5100, Individual and Couple Noninstitutional Budgets, or use Appendix XXXVIII, Pickle Disregard Computation Worksheet.

Also, follow this procedure for any family member whose income is considered in the eligibility determination.

G-4311 Pickle

Revision 13-1; Effective March 1, 2013

For persons who qualify for Pickle (ME-Pickle) and who received a 20% Social Security cost-of-living adjustment (COLA) increase in October 1972, exclude the amount of that increase in determining the person's eligibility.

For persons who qualify for Pickle (ME-Pickle) because of an SSI denial after April 1977, exclude Social Security COLAs received since the person last received both SSI and Social Security benefits in the same month. The person must have been entitled to both benefits in the same month. Because SSA processing procedures can be unpredictable, the person may not actually have received both checks/direct deposits in the same calendar month.

Note: Also exclude Social Security COLAs for the same period from the income of any family member whose income is deemed to the individual. The earliest increase that can be excluded is the July 1977 increase.

When an application for Pickle (ME-Pickle) assistance is received, verify the SSI denial date and current benefit and use the appropriate multiplier to calculate the disregard amount. Do not contact the Social Security office for this information.

Allow the COLA disregard after the date of denial. If the denial was sometime after the normal yearly December/January COLA, then the next available COLA would be available as the disregard.

Example: If denial is in May 2007, the next COLA disregard available to the person would be in January 2008 using Appendix XXXVIII, Pickle Disregard Computation Worksheet.

A variance to this may occur when a decision from SSA is delayed. Address entitlement, date of denial, and date of receipt of notice of denial when dealing with this.

Do not certify the person for Pickle (ME-Pickle) if the income before the COLA disregards is less than the SSI federal benefit rate (FBR). A person whose income, before the COLA exclusion, is less than the SSI FBR cannot be certified for the Social Security COLA programs.

• An SSI person who goes on and off SSI because of Social Security rounding is not eligible for Pickle (ME-Pickle) until he has been denied SSI because of a COLA increase.
• Persons who lose SSI eligibility because of a transfer of assets penalty do not qualify for Pickle (ME-Pickle) while the penalty period is in force. These individuals should be tested for potential eligibility under other MEPD programs, including Qualified Medicare Beneficiary.

Except in certain situations, a person cannot be eligible for the Pickle program.

G-4312 Ping-Pong

Revision 11-4; Effective December 1, 2011

In certain situations, a person whose income is less than the SSI federal benefit rate can be certified for the Social Security COLA programs.

In "ping-pong" cases, when a Pickle (ME-Pickle) person goes on and off SSI with a $1 check, maintain the case as an ongoing Pickle (ME-Pickle). This will stabilize receipt of Medicaid benefits.

G-4320 Special Income Exclusion for Disabled Adult Children

Revision 11-4; Effective December 1, 2011

ME-Disabled Adult Child. Individuals 18 and older who were denied SSI benefits on or after July 1, 1987, because of entitlement to or an increase in RSDI disabled adult children's benefits may be eligible for Medicaid if they otherwise would meet all current SSI eligibility criteria in the absence of those disabled adult children's benefits. Eligible individuals are also entitled to the exclusion of subsequent increase in those benefits.

After receiving an application for ME-Disabled Adult Child assistance, verify the amount of the appropriate disabled adult children's benefit or increase in order to determine the appropriate disabled adult children exclusion. If the person is in a vendor living arrangement, develop the case under the institutional guidelines.

G-4330 Special Income Exclusion for Widow/Widower

Revision 11-4; Effective December 1, 2011

ME-Early Aged Widow(er). Disabled individuals 60 and older who were denied SSI benefits because of entitlement to early aged widow's or widower's benefits may be eligible for Medicaid if they meet all current SSI eligibility criteria in the absence of those early aged widow's or widower's benefits.

Eligible individuals are also entitled to the exclusion of subsequent increases in these benefits. They may continue to receive Medicaid until they are eligible for Medicare. Medicaid benefits under Widow/Widower (ME-Early Aged Widow(er)) cannot begin before July 1, 1988, regardless of when an individual became eligible for or was denied SSI.

ME-Disabled Widow(er). Disabled individuals who were denied SSI benefits because of an increase in widow's or widower's disability benefits as a result of the relaxing of disability criteria may be eligible for Medicaid if they meet all SSI eligibility criteria in the absence of those widow's or widower's disability benefits.

Eligible individuals are also entitled to the exclusion of subsequent increases in these benefits. They may continue to receive Medicaid until they are entitled to Medicare. Medicaid benefits under this coverage group were not available before Jan. 1, 1991, regardless of when an individual became eligible for or was denied SSI.

Note: The widow's or widower's disability benefits under Social Security begin at age 50. ME-Disabled Widow(er).

After receiving an application for Widow/Widower (ME-Early Aged Widow(er), ME-Disabled Widower) assistance, verify the amount of the early aged/disabled widow's or widower's benefit. If the applicant/person is in a institutional living arrangement, develop the case as under the institutional guidelines.

Revision 11-1; Effective March 1, 2011

The development of other income exclusions related to work may be necessary when earned income is over the $65 per month earned income exclusion (or up to $85 per month if the $20 general exclusion has not been used up on unearned income) and the person is ineligible for Medicaid.

 

G-4410 Exclusion for Work Expenses for the Blind

Revision 09-1; Effective December 1, 2009

In addition to the earned income exclusion, a blind person's earned income is reduced by the amount of expenses that he can reasonably attribute to the earnings of the income.

 

G-4420 Exclusion for Impairment-Related Work Expenses

Revision 11-1; Effective March 1, 2011

In addition to the earned income exclusion, a disabled person's earned income is reduced by the amount of expenses that the person can reasonably attribute to the earnings of the income.

 

G-4430 Income Needed to Fulfill a Plan for Self-Support (Blind or Disabled)

Revision 11-1; Effective March 1, 2011

Earned or unearned income not excluded from consideration by the previous exclusions may be reduced to the extent that it is needed to fulfill an approved plan of a blind or disabled person for attaining self-support.

The plan must be submitted to MEPD, State Office, Mail Code 2090, for approval. The objectives of the plan and a time limit for achieving the objectives also must be designated. Each plan must describe the income that would be excluded in the case in addition to the previous income exclusions. Check the MEPD website for current MEPD staff contacts.

Revision 11-3; Effective September 1, 2011

In determining eligibility for the Medicaid Buy-In for Children (MBIC) program, allow a general income exclusion of $65 plus one-half of the remaining income. Deduct this exclusion at the end of the budget calculation. See Section N-6320, MBIC Income Exclusion.

Ineligible Siblings

Allow an exclusion from an ineligible sibling's income before counting the ineligible sibling's income in the budget. This exclusion is allowed for each ineligible sibling in the family unit. See Section N-6330, Ineligible Sibling Exclusion.

Revision 09-4; Effective December 1, 2009

Reminders:

• Monitor eligibility at least every three months if the client's total countable income is within $10 of the income limit.
• When income tax is withheld from retirement, pensions and disability benefits, use the gross amount for the eligibility calculation.
• If the person has VA, see Section E-4311.2, $90 VA Pension and Institutional Setting.

 

G-5110 COLA Disregard Programs

Revision 11-4; Effective December 1, 2011

Use the following steps to prepare a budget for an individual or an eligible couple in a noninstitutional living arrangement. Follow this procedure at application and for every redetermination.

Step	Procedure
1	Determine the appropriate income limit for either an individual or couple using the SSI federal benefit rate (FBR). See Appendix XXXI, Budget Reference Chart.
2	Determine monthly earned income. See the following: Section G-2000, Income Treatment Section E-3000, Earned and Unearned Income Section E-2000, Exempt Income Section E-2200, Earned Income Exemption Section E-1700, Things That Are Not Income Section E-1770, Mandatory Payroll Deductions
3	Determine monthly unearned income, including income from support and maintenance, if appropriate. See the following: Section G-2000, Income Treatment Section E-3000, Earned and Unearned Income Section E-1700, Things That Are Not Income Section E-2000, Exempt Income Section E-4000, Fixed Income Section E-5000, Variable Section E-7000, Deeming Income Section G-2310, Noninstitutional Deeming Section E-8000, Support and Maintenance Section E-9000, Infrequent or Irregular
4	Deduct earned and unearned income exclusions, as appropriate. See Section G-4000, Noninstitutional Exclusions. Compare the remainder to the appropriate SSI FBR to test for the income element of eligibility. Note: If the remainder is less than the SSI income limit, refer the person to SSA. See Section G-4312, Ping-Pong, for this exception.
5	Determine the amount of COLA disregard. See Section G-4300, Special Income Exclusion for COLA Disregard, for the MEPD group. See Chapter A, General Information and MEPD Groups, for the descriptions of the MEPD groups.
	For Pickle (ME-Pickle) type of assistance, deduct the amount of the RSDI increases received since the person last was eligible for and entitled to both SSI and Social Security in the same month. Reference: See Section G-4310, Computing Social Security Cost-of-Living Increases.
	For the Disabled Adult Children's (DAC) benefits type of assistance (ME-Disabled Adult Child), the amount of the appropriate RSDI disabled children's entitlement/increase(s) and any subsequent DAC increase. Reference: See Section G-4320, Special Income Exclusion for Disabled Adult Children.
	For Receipt of Early Aged Widow's or Widower's benefits type of assistance (ME-Early Aged Widow(er)), the amount of the appropriate Social Security early aged widow's or widower's benefits that resulted in SSI denial, and any subsequent RSDI COLAs. Reference: See Section G-4330, Special Income Exclusion for Widow/Widower.
	For Receipt of Disabled Widow's or Widower's benefits type of assistance (ME-Disabled Widow(er)), the full RSDI amount, including the appropriate amount of the disabled widow's or widower's benefits or surviving divorced spouse's benefits that resulted in SSI denial and any subsequent increases (whether COLA or not). Reference: See Section G-4330, Special Income Exclusion for Widow/Widower.
	Deduct the COLA disregard amount of the appropriate MEPD program.
9	The remainder is countable income. Compare the remainder to the appropriate income limit to test for the income element of eligibility.
	The remainder must be at least 1 cent less than SSI FBR.

 

G-5120 Community Attendant Services

Revision 09-4; Effective December 1, 2009

Use the following steps to prepare a budget for an individual or an eligible couple in a noninstitutional living arrangement. Follow this procedure at application and for every redetermination.

Step	Procedure
1	Determine the appropriate income limit for either an individual or couple using the special income limit. See Appendix XXXI, Budget Reference Chart.
2	Determine monthly earned income. See the following: Section G-2000, Income Treatment Section E-3000, Earned and Unearned Income Section E-2000, Exempt Income Section E-2200, Earned Income Exemption Section E-1700, Things That Are Not Income Section E-1770, Mandatory Payroll Deductions
3	Determine monthly unearned income, including income from support and maintenance, if appropriate. See the following: Section G-2000, Income Treatment Section E-3000, Earned and Unearned Income Section E-1770, Things That Are Not Income Section E-2000, Exempt Income Section E-4000, Fixed Income Section E-5000, Variable Section E-7000, Deeming Income Section G-2310, Noninstitutional Deeming Section E-8000, Support and Maintenance Section E-9000, Infrequent or Irregular
4	Do not subtract either the: $20-general exclusion, or earned income exclusion. See Section G-4000, Noninstitutional Exclusions. Compare the remainder to the appropriate SSI FBR to test for the income element of eligibility. Note: If the remainder is less than the SSI income limit, refer the person to SSA.
5	The remainder is countable income. Compare the remainder to the appropriate income limit to test for the income element of eligibility.
	The remainder must be equal to or less than the Special Income Limit.

 

G-5130 Medicare Savings Programs (MSP)

Revision 09-4; Effective December 1, 2009

Use the following steps to prepare a budget for an individual or an eligible couple in a noninstitutional living arrangement. Follow this procedure at application and for every redetermination.

Step	Procedure
1	Determine the appropriate income limit for either an individual or couple using the MSP income limits. See Appendix XXXI, Budget Reference Chart.
2	Determine monthly earned income. See the following: Section G-2000, Income Treatment Section E-3000, Earned and Unearned Income Section E-2000, Exempt Income Section E-2200, Earned Income Exemption Section E-1700, Things That Are Not Income Section E-1770, Mandatory Payroll Deductions
3	Determine monthly unearned income, including income from support and maintenance, if appropriate. See the following: Section G-2000, Income Treatment Section E-3000, Earned and Unearned Income Section E-1700, Things That Are Not Income Section E-2000, Exempt Income Section E-4000, Fixed Income Section E-5000, Variable Section E-7000, Deeming Income Section G-2310, Noninstitutional Deeming Section E-8000, Support and Maintenance Section E-9000, Infrequent or Irregular
4	Deduct earned and unearned income exclusions, as appropriate: $20-general income exclusion earned income exclusion See Section G-4000, Noninstitutional Exclusions. Compare the remainder to the appropriate SSI FBR to test for the income element of eligibility. Note: If the remainder is less than the SSI income limit, refer the person to SSA. See Section G-4312, Ping-Pong, for this exception.
5	Determine the amount of COLA disregard if appropriate. The RSDI COLA is disregarded in determining QMB/SLMB/QI-1 eligibility for the months of January through February.
6	Deduct the COLA disregard amount, if appropriate, for the QMB/SLMB/QI-1 program.
7	The remainder is countable income. Compare the remainder to the appropriate income limit to test for the income element of eligibility.
	QMB – The remainder must not exceed the limit.
	SLMB – The remainder must be less than the limit.
	QI-1 – Must be equal to or greater than the lower limit, but less than the upper limit.

 

G-5140 Reserved for Future Use

Revision 19-4; Effective December 1, 2019

 

G-5141 Reserved for Future Use

Revision 19-4; Effective December 1, 2019

 

G-5150 Medicaid Buy-In for Children Program (MBIC)

Revision 11-3; Effective September 1, 2011

See Section N-6300, Eligibility Income Budgeting, for budgeting steps for the MBIC program.

Revision 09-4; Effective December 1, 2009

Eligibility is determined for individuals and couples (in institutional living arrangements) who:

• apply for retroactive Medicaid coverage; or
• apply for or have eligibility redetermined under federally optional MEPD programs.

When a person not already eligible for Medicaid moves to an institutional setting, the income standard used and the income counted depend on whether the budget is for an individual, companion or couple case. Income is tested against the special income limit. See Appendix XXXI, Budget Reference Chart.

 

G-6110 Individual Institutional Eligibility Budget

Revision 09-4; Effective December 1, 2009

When a person applies for Medicaid, an individual budget is prepared if a person in an institutional setting is:

• single;
• widowed; or
• divorced.

Note: An individual budget is also used when a person is married and has a community spouse, but the community spouse refuses to cooperate in providing information and circumstances indicate possible abuse or neglect by the community spouse.

The income of the person is considered against the special income limit standard for an individual.

 

G-6120 Couple Institutional Eligibility Budget

Revision 18-3; Effective September 1, 2018

A couple budget is prepared when a person is residing in the same institutional setting with an eligible spouse (i.e., a spouse who is aged or has a disability) and they are:

• presenting themselves to the community as a married couple;
• determined to be married for purposes of receiving Social Security benefits; or
• recognized as married under state law.

The incomes of both spouses are considered against the special income limit standard for a couple.

Prepare two individuals budgets when a married couple:

• resides in different institutional settings; or
• is ineligible as a couple.

 

G-6130 Companion Institutional Eligibility Budget

Revision 09-4; Effective December 1, 2009

An institutional companion budget is prepared for a person in an institutional setting if:

• the person has a community spouse; and
• the couple meets the definition of a couple in Section G-6120, Couple Institutional Eligibility Budget, except the criterion that the couple live together does not apply.

Note: If the institutional setting is a waiver, the couple could be living together. If the institutional setting is a Medicaid certified facility, then the couple will not be living together since the criterion for a companion budget is a community spouse.

In preparing a companion institutional budget for a person, spousal impoverishment treatment of income and resources applies. See Chapter J, Spousal Impoverishment.

For the eligibility budget, the income of the person in the institutional setting is considered against the special income limit standard for an individual.

Revision 09-4; Effective December 1, 2009

A special income limit is used to determine income eligibility for a person in an institutional setting who is not already eligible for Medicaid or for a person who becomes ineligible for Medicaid because of the move to an institutional setting.

The special income limit for a person is equal to or less than 300% of the full individual Supplemental Security Income (SSI) federal benefit rate.

The special income limit for a couple is twice the special income limit for an individual.

To qualify for the special income limit, a person or couple must:

• have countable income that exceeds the reduced SSI federal benefit rate; and
• reside in a Medicaid-certified long-term care facility for 30 consecutive days;
• receive a level of care or medical necessity determination that qualifies the person or couple for Medicaid; or
• be approved by a Texas health and human services agency to receive services under a Home and Community-Based Services waiver program and receive the services within one month after approval.

Note: The special income limit is used if the person is 65 years of age or older and in a Medicaid-certified institution for mental diseases for 30 consecutive days.

 

G-6210 Thirty Consecutive Days and the Special Income Limit

Revision 09-4; Effective December 1, 2009

Eligibility under the special income limit is not effective until the person has been in an institutional setting for a period of 30 consecutive days. Once the person has been in the institutional setting for the 30 consecutive days, use the special income limit retroactively for the month in which the person started the 30 consecutive days period.

Note: When a full Medicaid-eligible recipient moves into an institutional setting, the recipient does not have to meet the 30 consecutive days requirement to be eligible for Medicaid in an institutional setting.

The 30 consecutive days are not disrupted if the person:

• makes a three-day therapeutic home visit with a planned return to the facility;
• is admitted to a hospital with a planned return to the facility;
• moves from a Medicaid-certified facility to another Medicaid-certified facility; or
• moves to a Home and Community-Based Services waiver program.

If a person dies before meeting the 30 consecutive days requirement without moving to a non-institutional setting, the person is considered to have met the requirement for application of the special income limit.

If the person does not complete the 30 consecutive days stay in an institutional setting, the special income limit is not used. The income limit for a non-institutional program must be used instead and the person must meet the criteria in another MEPD group as described in Chapter A, General Information and MEPD Groups.

Revision 09-4; Effective December 1, 2009

Step	Procedure
1	Determine the appropriate income limit for either an individual or couple using the special income limit. See Appendix XXXI, Budget Reference Chart.
2	Determine monthly earned income. See the following: Section G-2000, Income Treatment Section E-3000, Earned and Unearned Income Section E-2000, Exempt Income Section E-2200, Earned Income Exemption Section E-1700, Things That Are Not Income Section E-1770, Mandatory Payroll Deductions
3	Determine monthly unearned income, including income from support and maintenance, if appropriate. See the following: Section G-2000, Income Treatment Section E-3000, Earned and Unearned Income Section E-1700, Things That Are Not Income Section E-2000, Exempt Income Section E-4000, Fixed Income Section E-5000, Variable Section E-9000, Infrequent or Irregular
	If the person has VA, see Section E-4311.2, $90 VA Pension and Institutional Setting.
4	Do not subtract either the: $20-general exclusion, or earned income exclusion in Section G-4000, Noninstitutional Exclusions. Compare the remainder to the appropriate SSI FBR to test for the income element of eligibility Note: If the remainder is less than the reduced SSI federal benefit rate, refer the person to the Social Security Administration.
5	The remainder is countable income. Compare the remainder to the appropriate income limit to test for the income element of eligibility.
	The remainder must be equal to or less than the special income limit.

See Section G-5130, Medicare Savings Programs (MSP), for determination of a MSP program.

Revision 09-4; Effective December 1, 2009

When the applicant is obviously income ineligible based on the submitted application, see Section B-2500, Explaining Policy vs. Giving Advice, in determining the appropriate actions to take and the actions to avoid.

See Section F-6800, Qualified Income Trust (QIT), for policy information, and Appendix XXXVI, Qualified Income Trusts (QITs) and Medicaid for the Elderly and People with Disabilities (MEPD), for more information concerning a QIT and a sample.

The QIT option is not available for individuals in a noninstitutional setting such as Community Attendant Services.

Revision 18-3; Effective September 1, 2018

The Supplemental Security Income (SSI) application asks the individual about unpaid or reimbursable medical bills in the prior three months. An affirmative response is reported to the state using the State Data Exchange (SDX) system. A person claiming unpaid or reimbursable medical expenses incurred during the three months before the date of application receives a computer-generated notice to contact the Texas Health and Human Services Commission (HHSC) if they want their eligibility for prior coverage determined.

• Certified Recipients —For certified SSI recipients, Medicaid coverage automatically begins with the month prior to the first month of SSI payment. Prior coverage may be determined for  the preceding two months if the individual meets all Medicaid eligibility requirements.
• Denied Applicants — For denied SSI applicants who have medical expenses, the retroactive period remains the three months prior to the SSI application month.
• Deceased Applicants — For SSI applicants who die before the SSI eligibility decision by the Social Security Administration (SSA), and for whom SSA will not make a determination, the retroactive period is the three months prior to the receipt of an HHSC application from a bona fide agent. (see G-7210)

To apply for retroactive medical coverage, the individual must complete an HHSC application form. Use SSI program criteria when determining prior coverage eligibility.  

A person may be eligible for more than one retroactive period if the person applies for SSI more than once. Determination of eligibility on a month-to-month basis may result in non-sequential periods of eligibility.

When the eligibility determination for the open or close time-period is complete for the ME-SSI Prior, notify the individual of the decision using Form TF0001, Notice of Case Action.

Revision 12-3; Effective September 1, 2012

Applicants may be eligible for Medicaid coverage during any or all of the three months before the month of application for an ongoing MEPD program. An applicant must have unpaid or reimbursable charges or bills for Medicaid covered services during each month for which prior coverage is requested. He must meet all requirements applicable to the SSI or MEPD programs during each of the months he is eligible.

The department also explores possible three month's prior coverage based on the date of change in the individual's circumstances for an individual transferring from limited Medicaid programs, such as QMB or Community Attendant Services, to full Medicaid benefit programs.

Example: If a QMB individual entered a nursing facility on June 3, the eligibility specialist would explore possible three months prior coverage for March, April and May. The special income limit would potentially be used for June and the SSI income limit would be used for the prior months.

Note: For Title XIX facility payment only, it makes no difference whether the bill is paid or unpaid. Standards for participation mandate reimbursement if Medicaid is established.

 

G-7210 Prior Coverage for Deceased Applicants

Revision 18-3; Effective September 1, 2018

A bona-fide agent  may file an application with HHSC on behalf of a deceased person for Medicaid coverage for any or all of the three months before HHSC receives the application. During each month for which prior coverage is requested, the deceased person must:

• meet all eligibility requirements applicable to the MEPD program;
• meet SSI income and resource limits; and
• have unpaid or reimbursable charges or bills for Medicaid-covered services.

A bona fide agent is a person who is knowledgeable of the decedent's circumstances and can report the required information for eligibility determination accurately and under penalty of perjury. If the  information does not establish a date of onset covering the period for which eligibility is being determined, request a disability determination from the HHSC Disability Determination Unit (DDU). Indicate on Form H3034, Disability Determination Socio-Economic Report, that the individual is deceased.

The time period for which eligibility is determined is the three months before the month an HHSC application is received from the decedent's bona fide agent.

When the eligibility determination is complete for the ME-SSI Prior, notify the bona fide agent of the decision using Form TF0001, Notice of Case Action.

Revision 21-3; Effective September 1, 2021

A person ineligible for Medicaid due to undocumented status or not having an appropriate alien status may be eligible for Medicaid to cover an emergency medical condition in:

• the three months prior to the month of application only;
• the month of application only; or
• the month of application and up to three prior months.

More than one emergency medical period can be reported in the above time frames. Use Form H3038, Emergency Medical Services Certification, to verify treatment for an emergency medical condition and the dates of the emergency period. A new Form H3038 is needed for each emergency medical period.

The Form H3038 must:

• indicate the begin and end dates of the emergency condition;
• have the handwritten signature of the medical practitioner who provided the emergency treatment; and
• be signed and dated by the applicant on page 2.

Note: A stamped or electronic signature of the attending practitioner is not acceptable.

A medical practitioner is a person who holds a license to practice medicine, including the following:

• physician (MD);
• osteopathic medical physician (DO);
• advance nurse practitioner (ANP); or
• registered nurse (RN).

Note: A licensed practical nurse (LPN), a licensed vocational nurse (LVN), or a midwife do not meet the definition of medical practitioner.

Verification of unpaid medical bills is not required for prior coverage for emergency Medicaid. Provide Medicaid coverage for the duration of the emergency period as indicated on the Form H3038.