The CAO will consider the total countable earned and unearned income of all applicant/recipient group members when determining eligibility for Non money Payment (NMP) and Medically Needy Only (MNO) Medical Assistance (MA).
For Modified Adjusted Gross Income (MAGI)-related MA the CAO will consider the total countable earned and unearned income of the MAGI household based on tax filer or non-filer rules. (See Section 312.4, Income.)
State and federal laws exclude certain types and sources of income. Excluded sources of income for TANF-related, GA-related, MAGI-related and SSI-related categories are listed in this chapter and are not counted in the eligibility decision.
The CAO must use the exact amount of income as it appears on the paystub or other verification source when entering income into the system. The CAO must not round up or down to the nearest dollar as it may affect eligibility.
When averaging income, the amount must be rounded up or down to the nearest cent.
NOTE: This does not apply to Unemployment Compensation, which is rounded to the nearest dollar on Exchange 2.
The individual, or an individual acting for them, must report all earned and unearned income used to determine MA eligibility.
Before requesting proof of reported income from the individual, the CAO must review all available electronic data sources in an attempt to verify reported income information.
If the CAO is able to verify the reported information via electronic data sources and the information is reasonably compatible with what the individual reported, the CAO must not request further information from the individual.
If the CAO is unable to verify reported information using electronic data sources, or the information available is not reasonably compatible with what the individual reported, the CAO must request proof from the applicant or recipient.
NOTE: The CAO can authorize CHP 04 when income verification is not provided and reported income exceeds the 314 percent Federal Poverty Level.
See Chapter 378 Verification, Section 378.12 Reasonable Compatibility for income for more information about reasonable compatibility.
An applicant or recipient may not be turned down for MA for not having proof, if they cooperate in trying to obtain the proof.
NOTE: If the individual has cooperated, the CAO will help the individual obtain the proof.
If proof is required, the CAO will clearly explain to the individual what proof is needed to determine their eligibility for MA. Approval of MA will not be delayed while waiting for proof for other programs.
Sources of proof include, but are not limited to, the following:
Bank statements showing deposits.
Court orders.
Pay stubs or pay envelopes.
NOTE: Individuals can provide one pay stub that is representative of their income and deductions. This representative pay can be received up to 60 days before the application date.
An employer's statement of past or expected earnings.
Internal Revenue Service (IRS) Form 4070 (used to report tips).
Tax returns.
Award letters.
Statements of earned or unearned income.
Business records.
Benefit checks or check stubs.
Reminder: Benefit checks and bank statements do not always show the gross amount of the income. Add in any deductions taken for medical insurance, support payments, etc.
The applicant/recipient must apply for or obtain any potential source of income available to them. If an individual is cooperating with pursuing potential sources of income, MA must not be rejected, closed or delayed. An individual who, without good cause, does not cooperate in obtaining potential benefits is ineligible for MA. MA should not be delayed or terminated for an individual whose responsible relative fails or refuses to apply for potential benefits for self or the individual. MA eligibility of the legally responsible relative who fails or refuses to apply for potential benefits for the individual is not affected by non-cooperation.
For TANF-related, MAGI-related and SSI-related categories, the individual is ineligible until they cooperate.
For GA-related categories, the individual is ineligible for a minimum of 60 calendar days. If the individual is still not cooperating after 60 days, the individual stays ineligible until they cooperate.
Potential benefits include, but are not limited to, the following:
Retirement, Survivors and Disability Insurance (RSDI).
NOTE: Individuals are eligible for early retirement at age 62. This is considered a potential benefit. The CAO will grant good cause to an individual from applying for early retirement if they are under their full retirement age and working an average of 30 hours or more per week. (See Section 350.121, Early Social Security Retirement-Good Cause)
Supplemental Security Income (SSI)
Unemployment compensation.
Workers compensation.
State or county retirement or disability benefits.
Pensions and annuities.
Veteran's Affairs (VA) benefits.
NOTE: The CAO will not make an individual apply for an increase in nonservice-related VA benefits that are available under the Veterans Pension Act of 1959.
NOTE: Support is not considered a potential benefit. (See Section 350.31, Support Payments.)
Reminder: Resources are excluded for all MAGI determinations and for any individual who has a child under age 21 (including unborn children) in the household if the individual is the parent of the child or the individual is taking care of and in charge of the child (except for MAWD and Buy-In programs). In these cases, if the potential benefit is a resource that would not make any income, the parent or caretaker would not have to apply.
When an individual age 62 or older is working an average of 30 hours or more per week and has not reached their full retirement age, the CAO will grant the individual good cause from applying for early Social Security retirement benefits. The CAO can determine full retirement age using https://www.ssa.gov/planners/retire/retirechart.html.
If the applicant/recipient ends their full-time employment or has work hours reduced to less than 30 per week, the individual will be required to apply for Social Security benefits at that time as a condition of eligibility. The CAO will inform the individual of the requirement at the time the change in employment is reported. An overpayment may occur if the individual does not report the change and the CAO later learns of the decrease in hours or end of employment.
When alert “AGE 013 – Age 62 – Review Potential Income” is received for an individual who has turned age 62, the CAO will complete an “ex-parte” review to verify average hours worked per week, if the individual is working. If the CAO is unable to verify work hours through the “ex-parte” review, they will send a PA 253 to request verification from the individual. If the individual is not working, they are required to apply for Social Security.
NOTE: The CAO must use the individual’s pay stubs or tax records if provided, to determine hours worked.
Good cause will not be granted to an individual who is not working an average of 30 hours or more per week but wants to delay applying for retirement benefits to avoid a penalty and receive a higher benefit at their full retirement age.
The CAO will calculate hours worked based on the verification source as follows:
Exchange 1 Department of Labor and Industry (DLI) Wage Information:
1. Determine the individual’s average gross monthly income by dividing the quarterly amount by three.
NOTE: If the CAO knows the individual is paid weekly or biweekly, divide the quarterly wage amount by thirteen and multiply the result by four.
NOTE: If the individual only worked part of the last quarter (i.e., new employment), the CAO must request verification of income and hours.
2. Divide the gross monthly income by the federal minimum wage (currently $7.25 per hour) to determine monthly hours worked.
NOTE: The CAO must use the individual’s actual pay rate if it is known to the worker (i.e., previous pay stub, case comment, etc.).
3. Divide the monthly hours worked by four weeks to determine weekly hours worked.
NOTE: The CAO must use the individual’s pay stubs or tax records if provided, to determine hours worked.
Self-Employment:
1. Determine the individual’s gross earned income.
2. Subtract the allowable business expenses.
3. Divide the net profit by the federal minimum wage (currently $7.25 per hour) to determine annual hours worked.
4. Divide the annual hours worked by 52 weeks to determine weekly hours worked.
NOTE: The CAO must use the individual’s pay stubs or tax records if provided, to determine hours worked.
Example: Jerry Smith is the owner and sole employee of a registered business. He provides verification of working an average over 36 hours/week year-round, but after deducting allowable business expenses, his net profit was only $380. The CAO will use his verified 36-hour average in lieu of a calculation.
Updated June 12, 2024, Replacing April 17, 2024