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DMA ADMINISTRATIVE LETTER NO: 11-13, Hospital Provider Instructions for Determining Presumptive Eligibility

DATE:

November 3, 2014

SUBJECT:

Hospital Provider Instructions for Determining Presumptive Eligibility

DISTRIBUTION:

Enrolled Presumptive Eligibility Hospitals

County Directors of Social Services

Medicaid Eligibility Staff

I. background

II. a qualifed MEDICAL provider is a hospital that:

III. Provider enrollment process

IV. Medicaid applicant/Beneficiary Eligibility requirements

V. Qualifying groups for presumptive eligibility

VI. PROVIDER INSTRUCTIONS FOR DETERMINING ELIGIBILITY

Counting Income Tax Household

 

Tax Filer(s)

Tax Dependent – child of tax filer – does not meet an exception (Exceptions are listed on the MAGI household composition chart in DMA Administrative Letter No: 6-13)

Tax Household

Count income of tax filer and spouse in home, if not in tax household.

Only count income of tax dependents who expect to file a tax return.

Count income of tax filer(s)

Count income of the tax dependent applicant, and other tax dependents who expect to file a tax return. Count the income of the tax dependent’s spouse if not included in the tax household.

Counting Income Non Filer

 

Tax Dependent – not child of tax filer

(non-filer rules)

Adult – age 19 or older

Medicaid age child – under age 19

Non-filer rules

Count income for own household regardless of whether they expect to file taxes and count income of live-in spouse.

If the tax dependent has children under age 19 in the household, count income of children under age 19 if they expect to file return.

If the tax dependent is under age 19 ( see last column for Medicaid age child-under age 19)

Count income of applicant and spouse, if in home.

Count income of children in household under 19 only if expects to file return

If parent(s) is not in the household count income for own household regardless of whether they expect to file taxes and count income of live in spouse and live in siblings under age 19.

If the Medicaid age child has children under age 19, count income of children under age 19 if expects to file return.

If parent(s) is in the household, count the income of the parent(s). Do not count income of the child or siblings under age 19 unless the child/sibling expects to file a tax return.

VII. EXAMPLES

    Applicant

MAGI Household

Rose

Alice

Kitty

Family Size

Countable Income

Eligibility

Rose

    x

    x

 

    2

    $1560

    MAF-D

Alice

    x

    x

 

    2

    $1560

    MIC

Kitty

 

    x

    x

    2

    $0

    MIC

    Applicant

MAGI

Household

Mary

Bill

Ned

Nancy

Family Size

Countable

Income

Eligibility

Mary

    x

    x

    x

    x

    4

    $700

    MAF

Bill

    x

    x

    x

    x

    4

    $700

    MAF-D

Ned

   

    x

    x

    2

    $1000

    MIC

Nancy

   

    x

    x

    2

    $1000

    MIC

VIII. Provider instructions for approving eligibility

IX. Presumptive Eligibility Period

X. Appeal Rights

If you have any questions regarding this information, please contact a Medicaid Program Representative.

Sincerely,

 

 

Robin Gary Cummings, M.D.

Deputy Secretary for Health Services

Director, Division of Medical Assistance

RC/pc

(This material was researched and written by Pam Cooper and Christine Coffey, Policy Consultants, Medicaid Eligibility Unit).

MAGI MEDICAID INCOME LIMITS

***MAGI groups do not have Reserve Limits - Only MAF-M group***

Revised effective 1/1/2014

Family & Children’s MA

1

2

3

4

5

6

7

8

9

10

Add’l

196% MPW

1877

2534

3190

3847

4504

5160

5817

6473

7130

7787

657

195% MAF-D

1868

2521

3174

3827

4481

5134

5787

6440

7094

7747

654

194%-210% MIC-1<1

1858.01-2011

2508.01-2715

3158.01-3418

3808.01-4122

4458.01-4825

5108.01-5529

5757.01-6232

6407.01-6936

7057.01-7639

7707.01-8343

704

194% MIC-N <1

1858

2508

3158

3808

4458

5108

5757

6407

7057

7707

650

141%-210% MIC-1(Age 1-5)

1351.01-2011

1823.01-2715

2295.01-3418

2768.01-4122

3240.01-4825

3712.01-5529

4185.01-6232

4657.01-6936

5129.01-7639

5602.01-8343

704

141% MIC-N (Age 1-5)

1351

1823

2295

2768

3240

3712

4185

4657

5129

5602

473

107%-133% MIC-1(Age 6-18)

1025.01-1274

1383.01-1720

1742.01-2165

2100.01-2611

2459.01-3056

2817.01-3502

3176.01-3947

3534.01-4393

3893.01-4838

4251.01-5284

446

107% MIC-N (Age 6-18)

1025

1383

1742

2100

2459

2817

3176

3534

3893

4251

359

MAF-C/N

434

569

667

744

824

901

975

1036

1096

1169

78

MAF-M

242

317

367

400

433

467

500

525

542

575

MANUAl

Reserve: MAF-M

3000

3000

3000

3000

3000

3000

3000

3000

3000

3000

3000

NC Health Choice

1

2

3

4

5

6

7

8

9

10

 

133%-159% MIC-J (Age 6-18)

1274.01-1523

1720.01-2056

2165.01-2588

2611.01-3121

3056.01-3654

3502.01-4186

3947.01-4719

4393.01-5251

4838.01-5784

5284.01-6317

533

>159%-211% MIC-K (Age 6-18)

1523.01-2021

2056.01-2728

2588.01-3435

3121.01-4141

3654.01-4848

4186.01-5555

4719.01-6262

5251.01-6969

5784.01-7676

6317.01-8382

707

 

 

 

 

 

 

 

 

 

 

 

 

                       

MAGI disregard

1

2

3

4

5

6

7

8

9

10

Add’l

FPL 5% DISREGARD

47.88

64.63

81.38

98.13

114.88

131.63

148.38

165.13

181.88

198.63

16.75

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