IM-56 3/19/01 UPDATE OF POVERTY INCOME GUIDELINES IM M.R.# 11
| SUBJECT: | ||||||||||||||||||||||||||||||||
| UPDATE OF POVERTY INCOME GUIDELINES
IM MANUAL REVISION # 11 |
||||||||||||||||||||||||||||||||
| DISCUSSION: | ||||||||||||||||||||||||||||||||
| Effective April 1, 2001, the Federal Poverty
Level is increased. This memo updates the poverty income guidelines for
MC+ and Transitional Medical Assistance. Also increased are the income
standards for the QMB program, the SLMB program, the QDWI program, and
the support capability determination figures for General Relief.
New poverty figure amounts for TEMP eligibility will be provided to qualified
providers by State Office.
On the weekend of March 17, 2001, the Division of Data Processing will adjust the expense and deficit fields of active MC+ cases for children, parents and pregnant women, and the income standard and OASDI amounts (if applicable) for active QMB and SLMB cases. QMB cases were not included in the COLA adjustments in December 2000, due to federal legislation requiring that OASDI COLA increases not be considered on QMB budgets until the effective date of the new Federal Poverty guidelines. This federal legislation is also applicable to SLMB cases. The OASDI amounts for QMB and SLMB cases are increased based on cost of living with this adjustment. MC+ for Children, Parents and Pregnant Women Program For IMU5 transactions entered on or after March 19, 2001, use the new poverty income amounts, effective for April 2001 (attached). Use the new amounts even if eligibility was established for March or earlier months based on the old amounts. This is necessary to prevent edits. Eligibility for months prior to April 2001 must be based on the old poverty standards. Also, effective March 19, 2001, IBCA will be updated with the new standards. The IM-30 has been revised. New supplies can be ordered from the warehouse. o For
March 2001 and prior months, use the old poverty figures in effect during
o For April 2001 and later, use the amounts on the attached page. No IM-5 forms or listing will be generated from this adjustment. When using the last IM-5 in the case record for a subsequent action, update Fields 33-35 only if one of these fields is different than the adjusted figures. The adjusted figures will appear on the ICAS screen effective March 19, 2001. For this adjustment, we are bypassing edit Error Code 382 - Poverty, Incorrect Expense on the poverty cases. If a case currently has poverty figures (whether correct or in error), the case will be updated with the new poverty figures. After the adjustments are made the edit will be reactivated. Some children may have a change in LOC because of the increase in FPL. These cases will be adjusted and the recipient notified of the change in their level of care. QMB Income Standard Increase Below are the new QMB income standards.
Use these standards for all QMB eligibility determinations completed for
April or later months.
QMB material in Chapter VI is revised to include the new figures. SLMB Income Standard Increase Below are the new SLMB income standards.
Use these standards for all SLMB eligibility determinations completed for
April or later months. NOTE: Because SLMB eligibility can include prior
quarter determinations, use the previous standards for months prior to
April 1, 2001.
QMB/SLMB Adjustment For the mass adjustments, Data Processing will match each QMB only or SLMB only individual to BENDEX to determine current OASDI amounts. This amount includes the COLA increase received in January 2001. If the individual matches to BENDEX, the new OASDI amount is entered in Field 13J and the difference between the old OASDI amount and the new OASDI amount is added to the gross and net income fields. The new QMB or SLMB standard for household size is entered in the expense field and a deficit or surplus is calculated. Adjusted cases appear on ICAS with the new budget figures on the first working day after the mass adjustment. No turnaround IM-5 forms are produced with this adjustment. On the day of the mass adjustment, if the figure in Field 33 (Expense) is not a previous QMB, SLMB, or MA expense figure the case will not be adjusted. Additionally, if the new Field 35 is calculated to be a surplus, the case will not be adjusted. (MA expense figures correctly appear when an MA spenddown automatic close generates a QMB or SLMB automatic open.) Cases not adjusted appear on a listing entitled "QMB/SLMB Cases Needing Review for Adjustment", sent to the counties for review. The listing contains explanatory captions for each case not adjusted. NOTE: Check for SLMB eligibility for QMB cases where a surplus is calculated. Some cases will be adjusted by a percentage method based on information in the IM database if BENDEX information is not available. Any case adjusted by the percentage method will be identified with an asterisk (*) at its caption. In previous adjustments, these cases were not adjusted, with reason "IM NO BENDEX." If a case does not appear on BENDEX but shows OASDI on the IM database, the case may be adjusted. Other cases will be adjusted by applying the 3.5% increase to the OASDI amount shown in 13J. For these cases, if the amount in 13J is wrong, the adjustment will be wrong. The worker is responsible for correcting 13J and any other affected figures. Because SMI premium information will not be available from BENDEX on percentage-adjusted cases, the program will attempt to identify premium payers and will assume the premium was $45.50 as of December 2000. Because not every premium is $45.50, a small portion of percentage-adjusted cases may be wrong due to this assumption. Therefore, each percentage-adjusted case is marked on the listings with an asterisk (*) to help caseworkers identify them in case of incorrect adjustments. After the adjustment, IMU5 will accept only the new QMB or SLMB standard expense figures. Therefore, effective March 19, enter QMB or SLMB IM-5/IMU5 transactions using the new figures. County Office Responsibility Using the listing "QMB/SLMB Cases Needing Review for Adjustment", review listed cases as follows: QMB SURP - These cases have a surplus calculated in Field 35. Review for continuing eligibility, including eligibility under the SLMB program. SLMB SURP - These cases have a surplus calculated in Field 35. Review for continuing eligibility. IM NO BNDX - These cases have an OASDI amount in Field 13J of IMU5 but no OASDI amount appearing on the BENDEX tape file. Review for accuracy of information in the IM database and make necessary corrections. IM > BNDX - These cases have an OASDI amount in Field 13J of IMU5 that is greater than the amount appearing on the BENDEX tape file. Review for accuracy of information in the IM database and make necessary corrections. INCOR EXP - These cases appear as the result of a computer generated opening (i.e., the QMB/SLMB only case was opened when an MA spenddown case was auto closed, and the MA budget figures remain in Fields 33 through 35.) These are for information only. Correct the budget figures at the next regular handling. Adjust any cases not adjusted by state office as necessary. General Relief and QDWI Manual Updates The General Relief chapter and the QDWI material in Chapter VI are revised to include the new poverty figures. Use the figures in Chapter II for support capability determinations effective for April 1, 2001 and later. Use the updated QDWI expense standards in Chapter VI for eligibility determinations made for April 1, 2001 and later. Chapter II, Section
III, page 2a
grant for the GR claimant. Specified
relatives are defined as mother and father of children age twenty-one (21)
or over, sister, brother, son, daughter and grandparents of the claimant,
as well as the spouses of these relatives if living in the home.
The poverty level in effect at this time is: Family Size Monthly Income Level
1
$ 716.00
For each additional person add $252.00. Thus, to determine eligibility when involved with a case with employed (including self-employed) specified relatives, a support capability determination must be completed to determine the specified relative's ability to support the GR claimant. This determination must be completed as follows: The gross income (both earned and unearned) of the specified relative and the specified relative's dependents would be subtracted from the poverty level for that number of people. The specified relative's dependents would include his spouse and his children under age 21 living in the home. Gross income is total earned and unearned income minus "Overhead Expenses of Producing Income" as defined in this section. Taxes and other expenses of producing income are not subtracted. If a deficit is computed, the specified relatives are considered to not have sufficient income to support the GR claimant. If a surplus is computed, the specified relatives are considered to have sufficient income to support the GR claimant and the amount of the surplus must be included as unearned income in the GR claimant's budget to determine need and amount of grant. The GR claimant's need and amount of grant determination will then be completed with the added provision of including as unearned income the surplus amount from the specified relative's support capability determination. Example: The household consists of the GR claimant, his spouse, his employed brother and sister-in-law and their three children. The income in the household consists of the brothers' gross monthly wages of $1,756.00. To determine the GR claimant's eligibility: 1. Complete the specified relative's support
capability determination by subtracting $1,756.00 (gross monthly wages)
from $1,723.00 (poverty level for five). This equals a surplus of
$33.00.
March 2001
Chapter II, Section III,
page 2b
2. Complete the GR need and amount of grant
determination, the need standard for two, ($256) would be used for the
GR claimant and his spouse. The $33 surplus from the specified relative
support capability determination will be shown as unearned income.
Thus, a deficit of $223.00 exists. If otherwise eligible, the GR
claimant would be eligible for a GR grant of $80.
For any case involving a specified relative who is not employed,
a support
For any case in which the specified relative is receiving AFDC, GR, SAB,
BP,
Since it is necessary to know the specified relative's income, refusal
to provide
Examples of assistance groups:
1. Household consists of Gary Smith,
age 19, and his
If Gary is the applicant, the assistance group must consist of Gary and
If Mrs. Smith is the applicant, Mrs. Smith may choose to include or
If Gary is included, he and Mrs. Smith must meet all eligibility
If Gary is excluded and is employed, a support capability
March 1995
Chapter VI, Page 73
State Office will obtain verification of enrollment
in Medicare Part A and the date of the change to premium Part A at the
same time SSA QDWI status is verified.
3. Need a. Income Standards The QDWI income standard
is 200% of the Federal Poverty level for the size of the
Assistance Group Size QDWI Income Standard
1
$1432.00
The QDWI income standard
is absolute. An individual cannot "spend down" to
Include in the assistance
group the claimant and the claimant's spouse (if living
NOTE: For married
couples living together, include both in the assistance group even if
b. Budgeting Procedures Budgeting for QDWI eligibility
follows budgeting guidelines for QMB on the IM-30A. Use
EXAMPLE: Mr. Lawrence is a 56
year old single person who has been receiving Social Security
March 2001
Chapter VI, Page 74
Gross Income (Line 1)
($250 x 4.333) $1083.25 Earned Income Exemption (Line 2) 65.00 Total (Line 2a) 1148.25 Divide by 2 (Line 2b) 574.13 Total Exemptions (Line 2d) 574.13 Adjusted Earned Income (Line 3) 509.12 Non-earned Income (Line 4) 00.00 Total Adjusted Income (Line 5) 509.12 Personal Deduction (Line 6) 20.00 Total Exemptions (Line 8) 20.00 Adjusted Gross Income (Line 9) 489.12 QDWI Standard (Line 10) 1432.00 Mr. Lawrence is income eligible for the QDWI program. EXAMPLE: Mrs. Jones is 47 year old and lives with her spouse. She has been receiving Social Security Disability for 4 years. Mr. Jones earns $1500.00 per month. Mrs. Jones became employed on April 19, 1993 earning $6.00 per hour, 40 hours per week and she is paid every 2 weeks. Social Security has determined that Mrs. Jones remains disabled and continues to be eligible for Medicare Part A with a premium. The Jones' have available resources totaling $2950.00. Gross Earned Income (Line 1)
Mrs. Jones is income eligible for the QDWI program. EXAMPLE: Mrs. Cree is 55 years old and lives with
her 67 year old spouse. Mr. Cree receives Social Security retirement
of $777.00 per month. Mrs. Cree has been receiving Social Securi-ty
Disability for 5 years. Mrs. Cree became employed on April 2, 1993.
She earns $1600 per month. Social Security has determined that Mrs.
Cree remains disabled and is eligible for Medicare Part A with a premium.
March 2001
Chapter VI, Page 75
Gross Earned Income (Line 1)
$1600.00
Earned Income Exemption (Line 2) 65.00 Total (Line 2a) 1665.00 Divide by 2 (Line 2b) 832.50 Total Exemptions (Line 2d) 832.50 Adjusted Earned Income (Line 3) 767.50 Non-Earned Income (Line 4) 777.00 Total Adjusted Income (Line 5) 1544.50 Personal Exemption (Line 6) 20.00 Total Exemptions (Line 8) 20.00 Adjusted Gross Income (Line 9) 1524.50 QDWI Standard (Line 10) 1935.00 Mrs. Cree is QDWI eligible. 4. Resources The QDWI resource
maximums are twice the SSI maximums. Currently, the QDWI
Single $4,000
Determine as resources
anything that is considered available under the December
5. Eligibility for Other Assistance QDWI eligibles
must not be otherwise eligible for Medicaid. When an individual
NOTE: If
it appears the claimant is MA eligible, a disability determination by MRT
is
6. Transfer of Property Transfer of property is not an eligibility factor for the QDWI program. 7. Citizenship, Residency, Social Security Number Use the
guidelines in Chapter XI to determine eligibility on the factors of citizenship,
March 2001
B. Procedures
Chapter VI, Page 76 1. General Instructions Enter the application in the name of the applicant for "W" type of assistance. Only one individual may be registered on a "W" type of assistance. Register a separate application for each spouse if both apply for QDWI benefits. The federal time limit for processing QDWI applications is 45 days. When pending applications for QDWI become delinquent, workers will receive a notice through the S020 print subsystem. Workers must enter one of the following delay codes in Field 11 (Presumptive Eligibility) of IMU5: a. A - Agency Delay. Use this code when the case is not processed timely due to an agency delay. b. C - Client Delay. Use this code when the case is not processed timely due to a delay that is strictly the fault of the claimant. c. H - Hearing or Court Decision Delay. Use this code only when an administrative hearing or court decision orders that an application be registered back to the original date of application. Enter delay codes on pending applications using case action code 96 in Field 5 (Case Action). The only entry required is the appropriate delay code. Do not approve the claimant for benefits when the only action taken is to enter a delay code. When a delay code has not been entered on a delinquent application, the appropriate delay code is mandatory for applications processed delinquent. If the application is pending delinquent and the case action code for Field 5 (Case Action) is 08, 11 or 20, entry of a delay code is required. 2. Applications - If a claimant applies for QDWI benefits, the worker will: a. Complete an IM-1 in the applicant's name. b. Have the applicant complete pages 1 through 7 of the IM-2. c. Have the applicant read and sign the IM-3. d. Send an IOC to the Program
and Policy Unit in State Office requesting verification of SSA QDWI status
and the date of the change to premium Part A.
October 1992
Chapter VI, Page 91
For conditional enrollment cases, if the TPQY is returned showing no Part
A
entitlement, the caseworker must contact the local SSA office for clarification before the QMB application is rejected for no participation in Part A Medicare.
Make a determination of QMB eligibility on all factors including Part A
E. NEED 1. Assistance Group
Although QMB eligibility is determined on an individual basis, the income
and
Those whose income and resources are to be considered are:
the claimant;
NOTE: Dependent children are not considered in the assistance group
with a
Part A Medicare eligible dependent children (under age 18) of parents who
are
For married couples living together, include both in the assistance group,
2. QMB Income Standard
The QMB income standard is 100% of the Federal Poverty Level for the size
of
Assistance Group Size QMB Income Standard
1
$ 716.00
For each additional person, add $252.00.
The QMB income standard is absolute and a person may NOT "spend down"
March 2001
3. Income considered
Chapter VI, Page 92 All income, earned and unearned, that is considered for the Medical Assistance program is also considered for QMB. Refer to pp. 5b-14 of this chapter for specific inclusions. Additionally, BP grants received by the claimant or his/her spouse are included in the QMB budget. 4. Income Exemptions/Deductions All income exemptions used for Medical Assistance budgeting apply for the QMB program. Also exclude the following cash grants: AFDC, SP, SAB, GR, and SNC. In addition, as a result of federal legislation, effective January 1, 1991, cost of living (COLA) increases in OASDI and SSI which are received in January of each year cannot be considered on the QMB budget until the effective date of the Federal Poverty guidelines in April of the same year. This means, for QMB budgets only, use the old amount of OASDI or SSI for January through March of each year. Use the increased amounts of OASDI and SSI beginning in April of each year, at the same time the increased income standards are effective. 5. Completion of the QMB budget Compute the QMB budget using the IM-30A. QMB budgeting procedures follow those of Medical Assistance (found in this chapter) with the following exception: No deduction from income is allowed for medical insurance premiums on the QMB budget. This includes the SMI premiums for Medicare. For each applicant, the worker must consider gross income of the assistance group, minus all allowable deductions. The resulting net income is compared to the QMB standard (based on assistance group size) to determine eligibility. If net income exceeds the standard, the claimant is not eligible. If net income is equal to or less than the standard, the claimant is eligible. Following are representative examples of QMB budgeting situations: EXAMPLE #1 Mr. Smith is age 67. His only income is Social Security of $470.00 per month. He is enrolled in Part A Medicare. His SMI premium of $50.00 per month is deducted from his Social Security check for a net check of $420.00. His wife, age 56, lives with him in the home. She has no income of her own and there are no other household members. Gross Income
$470.00
QMB Standard (2) $968.00
Mr. Smith is income eligible for the QMB program. EXAMPLE #2 Mrs. Jones receives Social Security disability payments of $516.00 per month. She is enrolled in Part A Medicare. Her Part B premium of $50.00 per month is deducted from her check for a net check of $466.00. Mr. Jones and their two children, ages 12 and 14, reside in the home. Mr. Jones is employed earning $1100.00 per month. He pays a medical insurance premium of $159.00 per month for himself and Mrs. Jones. The children each receive a Social Security benefit of $68.00 per month. Earned Income
$1100.00
Subtotal
$1033.50
QMB Standard (2)
$968.00
Mrs. Jones is not QMB eligible. The needs and income of ineligible children are not considered. Mrs. Jones cannot "spenddown" or use the medical insurance premium to become QMB eligible. EXAMPLE #3 Mr. and Ms. Black are both over age 65. They are both enrolled in Part A Medicare. Mr. Black has Social Security of $500.00. Ms. Black has Social Security of $490.00. The SMI premiums are deducted from their checks for net checks of $450.00 and $440.00 respectively. There are no other household members. Gross Income $990.00
($500.00 + $490.00)
QMB Standard (2) $968.00
Neither Mr. nor Mrs. Black is eligible
for QMB coverage.
March 2001
F.
RESOURCES
Chapter VI, Page 94 1. Resource maximums The QMB resource maximums are:
$4000 for a single individual, and
2. What resources are to be considered
Resources for the QMB program include anything considered as
NOTE: In Medicaid vendor cases, where the claimant is eligible due
to
3. Whose resources are to be considered
Consider the resources of all members of the assistance group. For
4. Transfer of Property
Penalties for transfer of property will be imposed for QMB as for
a. Transfers prior to July 1, 1989
When making a determination of penalty for transfers that
b. Transfers after July 1, 1989
Transfers occurring July 1, 1989, or later do not affect QMB
G. CITIZENSHIP, RESIDENCY, SOCIAL SECURITY NUMBER
The eligibility factors of citizenship, residency, and social security
number for
NOTE: Lawful Temporary Residents (LTR) are not eligible as QMB recipients. January 1992
|
||||||||||||||||||||||||||||||||
| NECESSARY ACTION: | ||||||||||||||||||||||||||||||||
Distribution #2 |