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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 29. PUBLIC WELFARE |
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Chapter 29-95. MEDICAID ELIGIBILITY |
Section 29-9511. SUPPLEMENTAL SECURITY INCOME-BASED METHODOLOGY FOR CERTAIN NON-MAGI ELIGIBILITY GROUPS
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9511.1 The Department shall determine financial eligibility for Medicaid using a Supplemental Security Income (SSI)-based methodology pursuant to 42 C.F.R. Section 435.601 for the following non-modified adjusted gross income (non-MAGI) eligibility groups:
(a) Individuals who are aged sixty-five (65) years or older, or disabled (AD);
(b) Individuals enrolled in the Qualified Medicare Beneficiary (QMB) program;
(c) Individuals enrolled in the QMB Plus program;
(d) Individuals with long-term medical needs;
(e) Individuals receiving Medicaid through the Katie Beckett eligibility group; and
(f) Individuals, described in Subsection 9500.15, who are medically needy.
9511.2The following income requirements shall apply to the non-MAGI eligibility groups set forth under Subsection 9511.1:
(a) AD - Applicants and beneficiaries shall have income at or below one hundred percent (100%) of the federal poverty level (FPL);
(b) QMB program - Applicants and beneficiaries shall have income at or below one hundred percent (100%) of the FPL. For applicants and beneficiaries that have income up to three hundred percent (300%) of the FPL, the Department shall disregard income in excess of one hundred percent (100%) of the FPL;
(c) QMB Plus program – Applicants and beneficiaries shall have income at or below one hundred percent (100%) of the FPL, and shall be entitled to full Medicaid coverage and benefits under the QMB program;
(d) Long-term care - Applicants and beneficiaries shall have income at or below three hundred percent (300%) of the SSI Federal Benefit Rate (FBR);
(e) Katie Beckett eligibility group - Applicants and beneficiaries shall have income at or below three hundred percent (300%) of the SSI FBR; and
(f) Medically Needy - Applicants and beneficiaries shall use a medically needy (MN) spend-down process, in which the Department shall deduct the amount of medical expenses incurred by the individual or family or financially responsible relatives that are not subject to payment by a third party from countable income. The District shall disregard countable earned and unearned income in an amount equal to the difference between fifty percent (50%) of the FPL, and the District's medically needy income limit (MNIL) for a family of the same size, except the disregard for a family of one (1) will be equal to ninety-five percent (95%) of the disregard for a family of two (2).
9511.3The SSI-based income methodology shall use monthly gross countable income to determine financial eligibility for Medicaid, which shall be calculated in accordance with Subsection 9511.11. The methodology under Subsection 9511.11 shall incorporate the following:
(a) Countable earned income as set forth under Subsection 9511.4;
(b) Countable unearned income as set forth under Subsection 9511.5;
(c) Exclusions of gross countable income as set forth under Subsection 9511.6;
(d) Deeming of income calculations as set forth under Subsection 9511.7; and
(e) General income deductions and exclusions as set forth under Subsection 9511.10.
9511.4An individual’s countable earned income shall include:
(a) Wages, salaries, tips, overtime, and bonuses;
(b) Net income from a business or self-employment;
(c) Payments for services performed in a sheltered workshop or work activities center;
(d) Royalties earned by an individual in connection with any publication of his or her work and any honoraria received for services rendered; and
(e) Any other earnings from a job or work in which the individual receives payment.
9511.5An individual’s countable unearned income shall be defined as all other income which does not coincide with income delineated under Subsection 9511.4 and which is not excluded under 20 C.F.R. § 416.1124, and shall include but not be limited to:
(a) Social Security benefits;
(b) Interest, dividends, and other income from investments;
(d) Department of Veterans Affairs benefits;
(e) Railroad retirement and civil service retirement benefits;
(f) Annuities and pensions from government or private sources;
(g) Workers’ compensation, unemployment insurance benefits, and black lung benefits;
(h) Prizes, settlements, and awards, including court-ordered awards;
(i) Proceeds of life insurance policies;
(j) Gifts and contributions;
(k) Child support and alimony payments;
(l) Inheritances in cash or property;
(m) Rental income; and
(n) Strike pay and other benefits from unions.
9511.6An individual’s gross countable income shall exclude the following income or payments:
(a) Children’s earnings (earnings from an unmarried child who is living with a person who provides care or supervision, or earnings from a child who is a student in college or vocational training);
(b) Adoption subsidy;
(c) AmeriCorps/VISTA income received under the National and Community Service Trust Act of 1993, effective September 21, 1993 (107 Stat. 787; 12 U.S.C. §§ 12501 et seq.), as amended by the Serve America Act of 2009, effective April 21, 2009 (123 Stat. 1463; 42 U.S.C. §§ 12501 et seq.);
(d) Child nutrition payments;
(e) Payments received under the Domestic Volunteer Service Act of 1973, effective October 1, 1973 (87 Stat. 396; 42 U.S.C. §§ 4950 et seq.), as amended by the Domestic Volunteer Service Act Amendments of 1984, effective May 21, 1984 (98 Stat. 189; 42 U.S.C. §§ 4951 et seq.), as amended by the National and Community Service Trust Act of 1993, effective September 21, 1993 (107 Stat. 899; 12 U.S.C. §§ 12501 et seq.), as amended by the Serve America Act of 2009, effective April 21, 2009 (123 Stat. 1581; 42 U.S.C. §§ 12501 et seq.);
(f) Earned income tax credits;
(g) Educational benefits (for example, Department of Education (DOE) Bureau of Indian Affairs Benefits, DOE Title IV Benefits, DOE Perkins Vocational and Applied Technology Education Act, DOE work study wages, and other any education benefits work study);
(h) Energy assistance payments;
(i) Foster care payments;
(j) Housing assistance provided by the federal or District of Columbia government or non-profit organizations;
(k) Incentive payments for prenatal and well-baby care, and from the work incentive programs for current or former recipients of Temporary Assistance for Needy Families (TANF) under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, effective August 22, 1996 (110 Stat. 2105; 42 U.S.C. §§ 1305 et seq.);
(l) Non-cash benefits in the form of a voucher, commodity, or service;
(m) Jury duty payments;
(n) Money received by a third party for an applicant, beneficiary, or community spouse, unless an applicant, beneficiary, or community spouse has or will have access to the funds;
(o) Money received by an applicant, beneficiary, or community spouse, on behalf of any third party;
(p) Nutrition payments;
(q) Rehabilitation Service Administration (RSA) payments received under the Rehabilitation Act of 1973, effective September 26, 1973 (87 Stat. 355; 29 U.S.C. §§ 701 et seq.);
(r) Reimbursements received from an individual or organization to cover past, current, or future expenses, if all the following conditions are met:
(1)The reimbursement is for actual expenses;
(2)The reimbursement is earmarked to cover those expenses; and
(3)The reimbursement is paid or documented separately from any other payment such as wages;
(s) Payments received from roommates to cover their share of household expenses such as rent and utilities and which are paid by the applicant or beneficiary to the landlord or utility company;
(t) Senior Community Service Employment Program (SCSEP) income received under the Older Americans Act of 1965, approved July 14, 1965 (79 Stat. 218; 42 U.S.C. §§ 3001 et seq.), as amended by the Older Americans Act Amendments of 2000, approved November 13, 2000 (114 Stat. 2226; 42 U.S.C. §§ 3001 et seq.), as amended by the Older Americans Act Amendments of 2006, approved October 17, 2006 (120 Stat. 2522; 42 U.S.C. §§ 3001 et seq.);
(u) TANF underpayments received;
(v) Training income, such as training expense allowances and stipends;
(w) Utility allowances received through a federal or District government housing assistance program; and
(x) Other uncommon unearned income exclusions required under federal statute.
9511.7With the exception of individuals with long-term medical needs and Katie Beckett eligibility group applicants and beneficiaries, the following deeming of countable earned and unearned income shall apply to the individual pursuant to Section 1614(f) of the Social Security Act (42 U.S.C. § 1382c(f)):
(a) For an individual with a spouse who is ineligible for SSI benefits and is living with the individual, the income of an ineligible spouse shall be deemed to the individual and counted towards the individual’s gross countable income;
(b) For a child under the age of eighteen (18) that lives with a parent(s), the income of the parent(s) is deemed to the child and counted towards the child’s gross countable income, unless deeming is determined to be inequitable pursuant to the circumstances described in Section 1614(f)(2)(B) of the Social Security Act (42 U.S.C. § 1382c(f)(2)(B)); and
(c) For an individual who is an alien that meets citizenship requirements described under Subsection 9503.2, the individual’s income and resources shall be deemed to include the income and resources of the individual’s sponsor and the sponsor’s spouse.
9511.8The Department shall only consider the income and assets of the child applying for or currently receiving Medicaid through the Katie Beckett eligibility group in calculating income under Subsection 9511.3. The parents’ income and resources shall not be deemed to be income and assets of the Katie Beckett eligibility group applicant or beneficiary.
9511.9The Department shall determine the income and resources of individuals with long-term medical needs applying for or currently receiving Medicaid pursuant to Chapter 98 (Financial Eligibility for Long Term Care Services) of Title 29 DCMR.
9511.10General income deductions and exclusions may apply as follows:
(a) Individuals with unearned income may deduct up to twenty dollars ($20) as an unearned income deduction from their gross countable unearned income. If an individual has less than twenty dollars ($20) of unearned income in a month and also has earned income in that month, the remainder of the twenty dollar ($20) exclusion shall reduce the amount of the earned income;
(b) An individual with earned income may deduct up to sixty-five dollars ($65) as an earned income deduction from their gross countable earned income;
(c) One half of the remaining earned income in a month may be deducted; and
(d) Exclusions from general earned income may include:
(1) Earned income tax credit payments (effective January 1, 1991) and child tax credit payments;
(2) Up to thirty dollars ($30) of earned income or sixty dollars ($60) of unearned income in a calendar quarter if it is infrequent or irregular;
(3) Earned income of blind or disabled student children up to the student earned income exclusion (SEIE) monthly limit, but not more than the SEIE yearly limit as determined by the U.S. Social Security Administration;
(4) Earned income of disabled individuals used to pay impairment-related work expenses;
(5) Earned income of blind individuals used to meet work expenses; and
(6) Any earned income used to fulfill an approved plan to achieve self-support (PASS).
9511.11When applying SSI-based methodology to determine financial eligibility for Medicaid, an individual’s countable income shall be calculated as follows:
(a) All countable unearned income sources, as determined under Subsection 9511.5, shall be added to deemed income, if any, as determined under Subsection 9511.7;
(b) If the individual has up to twenty dollars ($20) of an unearned income deduction as determined under Subsection 9511.10(a), the amount of unearned income (up to twenty dollars ($20)) shall be deducted from the amount derived under paragraph (a) of this subsection. This derived amount shall be the net unearned income;
(c) The individual’s countable gross earned income, as determined under Subsection 9511.4, shall be added to deemed income, if applicable, as determined under Subsection 9511.7;
(d) If the household has earned income, the earned income deduction, if applicable as determined under Subsection 9511.10(b), shall be deducted from the amount calculated in paragraph (c) of this subsection. If a portion of the unearned income deduction was unused because the unearned income was less than twenty dollars ($20), as determined under Subsection 9511.10(a), the remaining amount shall be subtracted from paragraph (c) of this subsection;
(e) Sixty-five dollars ($65) shall be deducted from the amount derived from paragraph (d) of this subsection. If paragraph (d) of this subsection is not applicable as determined under Subsection 9511.10(b), then sixty-five dollars ($65) shall be deducted from the amount derived in paragraph (c) of this subsection;
(f) One half of the remaining earned income, as described under Subsection 9511.10(c), shall be deducted from the amount determined under paragraph (e) of this subsection. The exclusions to general earned income, delineated under Subsection 9511.10(d), shall then be applied. This amount shall be the net earned income; and
(g) The household's total net unearned income derived in paragraph (b) of this Subsection shall be added to the total net earned income derived under paragraph (f) to determine the household's total gross income. This amount shall be the non-MAGI countable income.
9511.12Each applicant described under Subsection 9511.1 shall report at the time of application all earned and unearned income, as described in this section, to the Department, including any income that the applicant receives periodically (less frequently than once a month) or anticipates receiving prior to the time of renewal. Each current Medicaid beneficiary described under Subsection 9511.1 shall continually report any new or significant changes of earned or unearned income to the Department.
9511.13Recipients of SSI and state supplemental payments (SSP) are categorically eligible for Medicaid. The income of recipients of SSI and state supplemental payments (SSP) shall be determined pursuant to 20 C.F.R. Part 416 and in accordance with the District’s Section 1634 of the Social Security Act Agreement with the federal Social Security Administration (SSA). The methodology set forth in this section shall not be applied when determining income of recipients of SSI and SSP.