1805.000.00 Eligibility and Verification

1805.030.15 Reasonable Compatibility

IM-100 July 11, 2022; IM-94 June 30, 2022; IM-39 March 15, 2019; IM-96 July 13, 2017; IM-46 May 12, 2017; IM-07 January 27, 2017; IM-97 November 9, 2015

Definitions

Reasonable Compatibility (RC) is defined as the allowable difference between the self-attested income and the income reported by the Electronic Data Sources (EOI).

A program threshold is the maximum income limit for the Title XIX or CHIP program.

An eligibility level is a point of eligibility within a program threshold. For example, CHIP 73 and 74 are eligibility levels within the CHIP program threshold. MO HealthNet for Families (MHF) and Adult Expansion Group (AEG) are eligibility levels within the Medicaid program threshold.

RC Process

RC is used to confirm the self-attestation of income. When the self-attested income is not RC with the EOI, further clarification is required from the individual to substantiate the self-attested income.

NOTE: RC’s primary purpose is to determine if further clarification should be requested from the individual. When the income is not RC, the EOI returns no response or an error, or when the self-attested/EOI information is questionable, request further clarification.

Income is considered RC when:

  • both the self-attested household income and the EOI fall within the same MO HealthNet (MHN) program eligibility level

OR

  • the self-attested income is below an eligibility level and EOI falls in a different eligibility level above the self-attested eligibility level, but the EOI is within 10% or less of the self-attested income.

The eligibility determination is based on the self-attested income. Neither RC nor the EOI amounts are used to make an eligibility determination.

Income is NOT considered RC when:

  • The self-attested income is above the eligibility level and EOI falls in a different eligibility level below the self-attested eligibility level.

In this circumstance, do not consider the income RC whether it is within 10% or not. Request clarification from the participant.

NOTE: If total household income is not RC, complete an RC comparison for income of each individual. Refer to 1805.030.15.10 Reasonable Compatibility with More Than One Income in the Household for more information.

Change in Circumstance (CIC)

Whenever a Change in Circumstance (CIC) affects the budget, apply RC to determine if further clarification is needed from the participant. Apply RC in the following situations, as appropriate:

  • Application
  • Annual Renewal
  • Ex-parte Review
  • Add/Remove a Person
  • Marriage/Divorce
  • Income Change

When self-attestation of the employer, or the income source, is different than what is received from the EOI, determine if the sources are compatible. The sources are considered compatible when:

  • income from both sources fall within the same eligibility level

    OR

  • the self-attested income is below the eligibility level and the EOI amount is above the self-attested eligibility level but is within 10% of the self-attested amount

If the employers/income sources are compatible accept self-attestation for the income source.

NOTE:  If our records indicate a different employer/income source than what is self-attested, and the employers/income sources are compatible, do not request verification that the income source in our records has ended. Accept self-attestation in this situation.

Paystubs are considered the individual’s self-attestation and the verification of income. Paystubs trump the information returned by an EOI. Use the pay stubs as verified income evidence.

EXAMPLE:  Sue provided her weekly pay stubs for the past 4 weeks with her application. Her pay stubs are used as Sue’s attestation and verification of her income. With Sue’s pay stubs/self-attestation, Sue’s income is below the eligibility level for MHK (148% of FPL). The EOI shows income above the eligibility level for MHK and more than 10% difference from the pay stubs.

Outcome: Based on her self-attestation, Sue is MHK eligible. RC does not need to be explored as the pay stubs are considered verified and reflect information more recent than the EOI.

When pay stubs are provided, RC does not need to be completed.

When no pay stubs are provided, explore RC with all available EOI before requesting additional information/clarification from the individual.

Applying Reasonable Compatibility

To determine if the income is RC gather the following information:

  • household size
  • MHN program’s income eligibility levels and program thresholds
  • self-attested income
  • electronic data source income

The MHN program levels are grouped together as listed below.

Title XIX Program Threshold

For Adults—

  • MHF – MHF income limit for household size
  • AEG for adults age 19 through age 64 – 133% of the FPL
  • MPW – 196% of the FPL

For Kids—

  • Children under the age of 1 – 196% of the FPL
  • MHK for children age 1 through age 18 – 148% of the FPL

State Only Program Threshold

  • UWHS – 201% of the FPL

CHIP Program Threshold

For Adults—

  • SMHB – 150% to 300% of the FPL

For Kids—

  • CHIP 4M age 1 through age 18 – 153% of the FPL
    • NOTE: Eligibility for CHIP 4M for children ages 6 through 18 starts at 110% of the FPL
  • CHIP 71/72 – 150% of the FPL
  • CHIP 73 – 185% of the FPL
  • CHIP 74 – 225% of the FPL
  • CHIP 75 – 300% of the FPL

Determine if the participant may be eligible in any of the program thresholds. Apply RC to each eligibility level based upon the participant’s circumstances.

EXAMPLE: Mary applied for MHN and reports a pregnancy.  Explore eligibility for MO HealthNet for Pregnant Women (MPW); if ineligible for MPW, explore eligibility for Show Me Healthy Babies (SMHB).

EXAMPLE:  Mary applied for MHN.  She is the only person in the home.  As she has no children, a determination at the MHF eligibility level is not necessary. As she is not pregnant, a determination for SMHB within the CHIP threshold is not necessary.  Explore eligibility for Adult Expansion Group (AEG) coverage.

EXAMPLE:  Scott applied for MHN for his two uninsured children.  Eligibility for them is explored in each program threshold and each eligibility level for which they may be eligible.

Applying the 10% Reasonable Compatibility Test

The income is RC when the self-attested income falls below the eligibility level and EOI falls above, and the EOI is within 10% of the self-attested amount. This is called the 10% Reasonable Compatibility Test.

To apply the 10% RC Test, complete the following steps for each individual in the household with income:

  • If the self-attested income is below the eligibility level and the EOI is above, compare the individual’s self-attested income to the individual’s EOI.
  • Determine if the EOI is within 10% of the self-attested income.

    NOTE:  MHN eligibility is determined for each individual by the individual’s household size and applicable income. Since households are determined by the tax filing unit, each person in the household could potentially have a different household size.

If the self-attested income is below the eligibility level and the EOI is within 10% of self-attested, the individual’s income is reasonably compatible.  Use the self-attested income for the budget and eligibility determination.

If the self-attested income is below the eligibility level and the EOI is above but not within 10% of each other, or the self-attested income is above the eligibility level while the EOI is below, the individual’s income is not reasonably compatible.  Request a reasonable explanation to clarify the difference between the self-attested income and the EOI.

If a reasonable explanation is not given or the explanation given is not reasonable, request further verification.

EXAMPLE:  George self-attested his income at within the CHIP 4M eligibility level (149% of the FPL), the electronic data source income for George was within CHIP 73 eligibility level (155% of the FPL), but his self-attested income and the electronic data income were within 10% of each other.  George’s income is reasonably compatible.  He is eligible at the CHIP 4M eligibility level based on his self-attestation.

NOTE: When applying the 10% Reasonable Compatibility Test and one of the household member’s income passes the 10% Reasonable Compatibility Test and another household member’s income fails, only request a reasonable explanation/clarification for the income that failed the test.

Self-Attested Income is above the Program Threshold

Accept self-attested income if it is above the program threshold.  Do not compare the participant’s self-attested income amount to EOI.  Do not seek clarification from the participant to confirm the self-attested income.  Participants ineligible for coverage due to income are systematically referred to the Federally Facilitate Marketplace (FFM) to explore coverage.

EXAMPLE:  Jason is an adult and self-attests to income at 150% FPL.  He does not have children.  His only eligibility can be found in the Title XIX programs. His EOI indicates his income may vary, but as his self-attested income is above the program threshold for Title XIX, his self-attested income is accepted and he is found ineligible for coverage. Eligibility in the CHIP levels is not explored.

EXAMPLE:  Tasha has 3 children.  She self-attests that her income is 243% FPL and her children are insured. Because they are insured, the children could only be eligible for Title XIX, or MO HealthNet for Kids at 148%.  As their income exceeds that program threshold, Tasha’s self-attested income is accepted and the children are found ineligible for coverage.

EXAMPLE:  Randa is pregnant and reports income at 307% FPL.  Her IMES returns no data; however, her self-attestation is accepted and she is denied coverage for MPW and SMHB.

Attested Income Electronic Data Source Outcome
Is below the income eligibility level. Is below the eligibility level. Self-attested income is used.  Individual is eligible.  10% Reasonable Compatibility Test is not required.
Is below the income eligibility level. Is above the eligibility level. The 10% Reasonable Compatibility Test is required.
Is below the income eligibility level. Is not available. Request additional verification/clarification.
Is above the income eligibility level. Is below the income eligibility level.

Request additional verification/clarification.

Is above the income eligibility level. Is not available.

Request additional verification/clarification.

Is above the program threshold. N/A

Individual is ineligible. 10% Reasonable Compatibility Test is not required. Refer to the FFM

Refer to the Reasonable Compatibility Calculator within the MAGI Policy Manual, Appendix B.