0815.000.00 Vendor Eligibility

0815.030.05 Determining Adjusted Gross Income

IM-116 August 6, 2019; IM-81 May 17, 2019; IM-69 July 6, 2015; IM-33 March 29, 2012; IM-68 July 14, 2004

The first step of the vendor surplus computation is to review all gross income sources for the participant and members of the household.

  1. Determine the total gross income from all sources.
  • Use the gross eligibility amount for any Social Security programs. For Social Security recipients who receive Medicare, the gross amount includes the Supplemental Medical Insurance (SMI) premium.
  • The Federal SSI benefit for any month is limited to a maximum of $30 for an eligible individual, less any non-SSI income, when the individual is a resident in a vendor facility when Medicaid (MO HealthNet in Missouri) pays or is expected to pay over 50 percent of the cost of care for that month.
  • For participants receiving vendor benefits, SSI payments are reduced to zero ($0) if they have other income that is equal to, or greater than, $50 per month (as SSI does not count $20 of other income). If the only income is SSI, SSI payments are reduced to $30.

NOTE: The SSI payment amount is not reduced until after the participant has been in a vendor facility for a full calendar month, but the participant will be responsible to repay Social Security for any SSI overpayment received while residing in a vendor facility. FSD staff will adjust the budget using irregular amount disregards for the first full month of vendor eligibility to account for recovery of the overpayment by Social Security, even though the change may not have been verified by SSI or reflected on IIVE. If IIVE or other provided information verifies the updated payment amount at time of application or budget adjustment, enter the correct amount as the gross income and no irregular amount disregard is required.

EXAMPLE: Mr. Green received $771 in SSI income and this is his only income. He enters a vendor facility on May 15, 2019. The eligibility specialist enters a budget for June 2019 showing $771 gross income and an irregular disregarded amount of $741.His total counted income is $30 (SSI).

EXAMPLE: Ms. White receives $700 in SSD and $91 in SSI. She enters a vendor facility on June 5, 2019. The eligibility specialist enters a budget for her SSI for July 2019 showing $91 gross income and an irregular disregarded amount of $91, for a counted income of $0. Her SSD budget would not change. Her total counted income is $700 (SSD) + $0 (SSI) = $700.

EXAMPLE: Mr. Red receives $25 in child support and $766 in SSI. He enters a vendor facility on June 10, 2019. The eligibility specialist enters a budget for his SSI for July 2019 showing $766 gross income and an irregular disregarded amount of $741, for a counted income of $25. His child support budget would not change. His total counted income is $25 (SSI) + $25 (CS) = $50.

  • On-going payments by relatives, the Department of Mental Health (DMH), insurance policies, or other binding agreements intended to help meet the basic covered services must be counted as unearned income in the month received.

EXAMPLE: Mr. Brown has a long term care insurance policy which covers nursing facility care. According to the terms of the policy, the company will pay $15 per day for patient care while Mr. Brown is in the nursing facility. This payment will not be reduced if the participant’s income increases or if the nursing home is also paid from another source. Therefore, in addition to any other income, Mr. Brown has $456.25 ($15 X 365 days divided by 12 months) which must be counted as unearned income in determining the vendor surplus.  

  1. Exclude the following as income:
    • All income exclusions in 0805.015.10 Income Exclusions.
    • Income from employment in a sheltered workshop or income from employment as a patient worker at sub-minimum wage in an institution, per the Fair Labor Standards Act (Section 14, Regulation 29 CFR 529).
    • For veterans receiving reduced VA pension, an amount equal to their reduced pension up to $90. Budget the entire pension amount until verification is received confirming the pension is reduced as a result of residing in a nursing home.  If the VA pension amount remains at an unreduced rate after the veteran has entered a nursing home, the veteran is not liable to repay the United States if the failure to reduce the pension amount is not the result of willful concealment by the veteran of necessary information to make a reduction in pension.  38 U.S. Code 5503 
    • Payment by relatives, the DMH, etc. for non-covered services (newspaper, telephone, cable TV, rental, etc.).

NOTE: Payments by relatives, etc. to cover the difference between a facility’s semi-private and private room charge are not counted as income. MHN considers a private room a non-covered service, unless a private room is needed to isolate a participant due to a medical or social condition.