305.5 Modified Adjusted Gross Income (MAGI)-Related Categories

MAGI-related categories are assigned to:

• Children aged 18 and under

• Pregnant and postpartum women

• Families with income at or below 33 percent of the Federal Poverty Income Guideline (FPIG)

• Transitional Medical Assistance (TMA)

• Individuals aged 19-64

• Incarcerated individuals

• Family Planning Services

• Presumptive Eligibility

For more information about MAGI-related groups and eligibility criteria, see Chapter 312, Affordable Care Act/Modified Adjusted Gross Income.

NOTE: Individuals eligible for Home and Community Based Services (HCBS) should NOT be enrolled in MAGI-related categories.

Exception: Individuals eligible for the Adult Community Autism Program (ACAP) waiver can continue to be authorized in MAGI budgets as they were previously. They are currently the only waiver program allowed to use MAGI methodologies to determine eligibility. See the HCBS Procedural Desk Guide for details about authorizing the ACAP waiver.

305.51 Children Aged 18 and Under

Children aged 18 and under are assigned category MG with program status code (PSC) 00 if they have household income between 33% of the FPIG and the applicable limit for their age group:

• Under Age 1 (Target Type I): 215 percent FPIG

• Age 1-5 (Target Type C): 157 percent FPIG

• Age 6-18 (Target Type Y): 133 percent FPIG

Children aged 6-18 who have household income between 100 percent and 133 percent FPIG and who do not have other health insurance are assigned category MG with PSC 19 and a Target Type of “Y”.

If a child aged 18 and under becomes ineligible for MA during their 12-month  continuous eligibility (CE) period, category/PSCs are assigned to designate CE:

• Children under the age of 1 born to a parent receiving MA or CHIP at birth and who become income ineligible for MA are assigned category MG, PSC 18, and Target Type of “N”.

• Children aged 0-18 who become ineligible for MA are assigned category MG, PSC 18, and Target Type of “C”.

NOTE: CE budgets should only be closed prior to the renewal date in limited circumstances.  See Chapter 312.141, Continuous Eligibility for Children Under Age 19 for more information.

305.52 Pregnant and Postpartum Women

Pregnant women with income at or below 215 percent FPIG are assigned a category/PSC based on their MA status at the time pregnancy is reported:

• New applicant: Assigned to category MG, PSC 00, Target Type “P”.

• Recipient in MG 90: Assigned to category MG, PSC 90, Target Type “P”.

• Recipient in MG 91: Assigned to category MG, PSC 91, Target Type “P”.

Pregnant individuals will remain in their category/PSC/Target Type combination through the end of their 12-month postpartum period.

If an individual becomes income ineligible for any MA category during their pregnancy, they will be assigned to category MG, PSC 18, and Target Type “P”.

If an individual becomes income ineligible during their postpartum period, they will be assigned to category MG, PSC 00, and Target Type “E”.

NOTE: If a pregnant individual is receiving MA in another category other than MG 90 or MG 91 at the time a pregnancy is reported, they will remain in that category for the duration of their pregnancy and postpartum period.

If they become ineligible for their category during their pregnancy or postpartum period, MG 00 P, MG18 P, or MG 00 E will be assigned based on household income.

305.53 Families with Income At or Below 33 Percent FPIG

Families with household income at or below 33 percent FPIG will be assigned category MG with PSC 27. Target Type is assigned based on the recipient:

• Under Age 1: Target Type “I”

• Age 1-5: Target Type “C”

• Age 6-18: Target Type “Y”

NOTE: An 18-year-old can only be assigned MG 27 Y if they are a full-time secondary or vo-tech student. If they are not, they will be assigned MG 00 Y.

• Parents/Caretakers: Target Type “T”

NOTE: A caretaker does not have to have a blood relationship to the child.

305.54 Transitional Medical Assistance (TMA)

If an individual receiving MA in an MG 27 category loses eligibility, they may be eligible for Transitional Medical Assistance (TMA) if the following are true:

• Eligibility lost due to increased earned income or alimony/spousal support.

• Household contains a dependent child (under age 18 or 18 and full-time secondary/vo-tech student)

• Received MA in an MG 27 category for 3 of the last 6 months.

Individuals who are ineligible for MG 27 due to alimony/spousal support and who meet the other criteria above are assigned category MG and PSC 23. They receive 4 months of coverage in MG 23 after MG 27 closes.

Individuals who are ineligible for MG 27 due to earned income and who meet the other criteria above are assigned category MG and PSC 71. They receive up to 12 months of additional coverage in MG 71 after MG 27 closes.

See Chapter 339, Transitional Medical Assistance (TMA) for more information.

305.55 Individuals Aged 19-64

Individuals aged 19-64 who do not meet criteria for SSI-related or TANF-related MA are assigned category MG and PSC 91 if they meet any of the following criteria:

• Non-disabled Parent/Caretakers aged 21-64 with income between 33 percent and 133 percent of the FPIG.

• Non-disabled childless adults aged 21-64 with income at or below 133 percent of the FPIG.

• Permanently disabled adults aged 21-64 with a disability NOT verified by SSA or MRT, no Medicare, and income at or below 133 percent of the FPIG.

• Permanently disabled adults aged 21-64 with a disability verified by the SSA or MRT with no Medicare and income at or between 102 percent and 133 percent of the FPIG.

Some individuals aged 19-64 who would meet eligibility in SSI-related or TANF-related MA are assigned category MG and PSC 90:

• Permanently disabled with disability verified by the Social Security Administration (SSA) or the Medical Review Team (MRT) with income under 102 percent FPIG are assigned category MG, PSC 90, with Target Type “D”.

• Aged 19-20 with income under the Enhanced MNO limit are assigned category MG, PSC 90, with Target Type “N”.

NOTE: If a recipient of MG 91 or MG 90 reports a pregnancy, they remain in their category and PSC, but the target type is changed to “P” until the end of the post-partum period.

Example: Individual receiving in MG 90 N reports a pregnancy. They will change to MG 90 P until the end of the post-partum period.

When an individual turns 65, they must be reviewed for SSI-related MA and cannot be in a MAGI-related category. The CAO must review income, resources, and Medicare information and request required verification, if necessary.

• If all required verifications are already in the case or are provided by the individual, the CAO must run eligibility in the system to review for the correct category.

• If the individual fails to provide required verification, the CAO will close MA for failure to provide verification and issue a 15-day advance notice.

305.56Family Planning Services

Individuals of any age can request to be reviewed for Family Planning Services if they have income under 215 percent FPIG. They are assigned category PSF and PSC 15.

If an individual indicates they are requesting confidential review of Family Planning Services, they are assigned category PSF and PSC 14. In this category, income of other household members is not considered when determining eligibility.

305.57 Presumptive Eligibility (PE)

There are two types of presumptive eligibility:

• Pregnant Women

• Hospital-Based

For both types, a qualified medical or hospital provider determines eligibility based on MA criteria. The individual is authorized in MA for a limited period until an ongoing MA determination can be made.

See Section 312.8, Authorizing Presumptive Eligibility for more information.

Updated August 21, 2024, Replacing February 14, 2012