Sec. 10.11.03.07. Financial Eligibility

A. An applicant's financial eligibility is based upon the composition and income of the family unit.

B. Family Unit. A family unit consists of one or more of the following members residing in the same household:

(1) The applicant;

(2) The natural or adoptive parents, stepparents, or legal guardian if the applicant is unmarried;

(3) The unmarried natural or adoptive siblings of the applicant who are younger than 22 years old;

(4) The lawful spouse of the applicant; or

(5) Other individuals who are not included in this regulation and who are dependents for federal income tax purposes.

C. Income.

(1) For the purpose of determining financial eligibility, the CMS Program shall treat the income of members of the family unit listed in §B of this regulation as the sole source for determining an applicant’s eligibility.

(2) The CMS Program shall determine the family’s income from the following sources:

(a) Wages, including sick or severance pay;

(b) Commissions and fees;

(c) Salaries and tips;

(d) Profit from self-employment, including income from the operation of a farm;

(e) The earned income tax credit (EITC);

(f) Social Security benefits;

(g) Veterans' Administration benefits;

(h) Workers' Compensation benefits;

(i) Black Lung or Agent Orange benefits;

(j) Railroad Retirement;

(k) Government, private, or company pensions and annuities;

(l) Unemployment insurance benefits;

(m) Payments from oil or mineral rights (leases);

(n) Government payments on land;

(o) Insurance benefits paid directly to an applicant;

(p) Trust funds;

(q) Individual retirement accounts (IRAs);

(r) Keough plans;

(s) Military allotments;

(t) Alimony or court-ordered and voluntary child support payments received from an absent spouse, or an absent natural or adoptive parent;

(u) Loan repayments made to the applicant or family member including, but not limited to, mortgage payments;

(v) Lump-sum benefits or other amounts of income received on a one-time-only basis;

(w) Profit from rental income;

(x) Cash assistance received from non-governmental social service agencies greater than the amount allowed by Medical Assistance;

(y) Sick pay which does not count as earnings for deduction purposes under Title II of the Social Security Act; and

(z) Any subsidy covering basic needs for food or shelter.

(3) If an individual in the family unit has recently resumed employment, the Program shall determine income for a 12-month period by averaging actual income for 6 months preceding resumption of employment and projected income for 6 months following resumption of employment.

(4) If additional CMS Program services are requested 6 months after resuming employment, the CMS Program may re-determine financial eligibility based on current income.

D. Medical Deductions. The applicant may deduct the following from the applicant’s income:

(1) Loan payments related to medical or medically related emergency debt;

(2) Payment to a hospital or other health care provider for a member of the family unit not covered by other third-party insurance entitlements, or the Program; and

(3) Payments for health insurance for a member of the family unit.

E. Effective Dates for Financial Eligibility.

(1) The CMS Program shall establish financial eligibility for a 12-month period from the date a completed application is received by the CMS Program.

(2) Exceptions to the 12-month financial eligibility period are:

(a) If financial eligibility was determined by averaging the previous 6 months, financial eligibility shall be reconsidered after 6 months;

(b) When an eligible applicant enrolled in the CMS Program informs the CMS Program of changes in family size, income, or expense, the CMS Program may reconsider eligibility as soon as possible if financial assistance is being given, or when the next request for services is made.

(3) Those receiving CMS Program financial assistance shall notify the CMS Program within 10 business days of any changes in circumstance which could affect continuing financial eligibility.