Sec. 10.09.24.09. Determining Financial Eligibility for Noninstitutionalized Individuals

A. Basis.

(1) Financial eligibility is determined on the basis of the countable net income and resources of members of the MAGI exempt assistance unit and those individuals whose income and resource are considered pursuant to Regulations .06, .07, and .08 of this chapter for the period under consideration. For current eligibility under spend-down, a review to identify changes in the unit's financial and nonfinancial eligibility status shall be made before spend-down eligibility is established.

(2) The appropriate medically needy income level shall be the amount specified in Schedule MA-1 for the number of persons whose income is considered in determining financial eligibility.

(3) The appropriate medically needy resource level shall be the amount specified in Schedule MA-2 for the number of persons whose resources are considered in determining financial eligibility.

(4) Financial eligibility is determined on the basis of the countable income for members of the MAGI household unit and those individuals whose income are considered pursuant to Regulations .06-1 and .07 of this chapter for the period under consideration. For current eligibility under spend-down, a review to identify changes in the unit's financial and nonfinancial eligibility status shall be made before spend-down eligibility is established.

B. Retroactive Eligibility.

(1) When the countable net income and resources are equal to or less than the medically needy income and resource levels, eligibility exists as medically needy.

(2) When the countable net income is greater than the medically needy income level and the countable resources are equal to or less than the medically needy resource level, retroactive eligibility may exist under the spend-down provision as specified in §B(4) of this regulation.

(3) Excess Resources. Retroactive eligibility does not exist when the countable resources are greater than the medically needy resource level.

(4) Retroactive Spend-Down Eligibility.

(a) In determining retroactive spend-down eligibility, documented medical and remedial expenses incurred during the 3 months before the month of application of any person whose income and resources are considered in determining eligibility shall be considered if the incurred expenses:

(i) Have not been paid for by any third party, including a family member or an insurer; and

(ii) Are not required to be paid for by any third party, such as an insurer.

(b) The incurred medical expenses shall be considered on a month-by-month basis beginning with the earliest month in the period under consideration and shall be deducted from excess income in the following order:

(i) Medicare and other health insurance premiums, deductibles, or coinsurance charges;

(ii) Expenses incurred for necessary medical care or remedial services that are recognized under State law but are not covered under the State Plan;

(iii) Expenses incurred for necessary medical care or remedial services that are covered under the State Plan.

(c) Retroactive spend-down eligibility is established when the incurred medical expenses exceed the excess income.

(d) The medical expense used to establish retroactive spend-down eligibility may not be:

(i) Reimbursed by the Medical Assistance Program; or

(ii) Used for any subsequent eligibility determination.

(e) Retroactive spend-down eligibility is not established when the incurred medical expenses are equal to or less than the excess income.

C. Current Eligibility.

(1) When the countable net income and resources are equal to or less than the medically needy income and resource levels, eligibility exists as medically needy.

(2) When the countable net income is greater than the medically needy income level and the countable resources are equal to or less than the medically needy resource level, eligibility may exist under the spend-down provision as specified in §C(4) of this regulation. Spend-down eligibility is established when the amount of the incurred medical expenses equals or exceeds the excess income.

(3) Excess Resources. Eligibility does not exist when the countable resources are greater than the medically needy resource level.

(4) Spend-Down Eligibility.

(a) In determining spend-down eligibility, documented medical expenses incurred during the time periods and meeting the conditions specified in §C(4)(b)-(d) of this regulation shall be considered.

(b) Medical expenses incurred before the month of application shall be considered if:

(i) The expenses were not considered in any retroactive certification;

(ii) The expenses were not used to establish spend-down eligibility for a prior certification; and

(iii) The expenses are not paid for by any other person, remain the obligation of the person whose income and resources are considered in determining eligibility, and have not been forgiven by the provider of the services as evidenced by account statements dating up to 3 months before the month of application.

(c) Medical expenses incurred at any time during or after the month of application and before the end of the period under consideration by any person whose income and resources are considered in determining eligibility shall be considered if the medical expenses:

(i) Have not been paid for by any third party, including a family member or an insurer; and

(ii) Are not required to be paid for by any third party, such as an insurer.

(d) Each medical bill verifying expenses shall include a statement of the service and the date the service was rendered. For purchases of medicines and medical supplies or equipment, the statement from the provider shall include the item purchased and the date and cost of the purchase.

(e) Medical expenses incurred during the time periods specified in §C(4)(b) and (c) of this regulation shall be deducted from the excess income beginning with the earliest time period and in the following order:

(i) Medicare and other health insurance premiums, deductibles, or coinsurance charges;

(ii) Expenses incurred for necessary medical care or remedial services that are recognized under State law but are not covered under the State Plan;

(iii) Expenses incurred for necessary medical care or remedial services that are covered under the State Plan.

(f) Spend-down eligibility is established for the remainder of the period under consideration when the incurred medical expenses equal or exceed the amount of excess income. The medical expenses used to establish spend-down eligibility may not be:

(i) Reimbursed by the Medical Assistance Program; or

(ii) Used for any subsequent eligibility determination.

(g) When spend-down eligibility is not established during the application process, the applicant shall be notified of his ineligibility and advised of the spend-down provision. The application date shall be preserved for possible spend-down eligibility at any time during the established period under consideration.

(h) When the incurred medical expenses do not equal the amount of excess income during the period under consideration, eligibility does not exist. A new application date and period under consideration will be established when the applicant reapplies after the expiration of the established period under consideration.