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TITLE 16 HEALTH AND SAFETY DELAWARE ADMINISTRATIVE CODE 7

When the application of the standard deduction results in a finding of ineligibility, the applicant or recipient will be given an opportunity to show that actual self-employment expenses exceed the standard deduction. If the actual expenses exceed the standard deduction, they will be used to determine net income from self-employment. 9 DE Reg. 564 (10/01/05) 10 DE Reg. 143 (07/01/06)

17300.3.2.5 Unearned Income

Unearned income is income that is paid because of a legal or moral obligation rather than for work activity performed. It is all income that is not earned income. This includes Social Security, Railroad Retirement, pensions, benefits, alimony, child support and other types of payments. Interest and dividend income is excluded.

Rental income is unearned unless the rental proceeds are ordinary income of a trade or business being carried on by a self-employed individual, such as a real estate broker.

See the Long Term Care Section for more information on determining net rental income and more types of unearned income.

17300.3.2.6 Income Computation

Since different exclusions apply to earned income than to unearned income, it is important to recognize the difference between them. In determining a QMB's countable income, deduct $20.00 from the gross income. This $20 exclusion is first applied to unearned income with the balance, if any, applied to the earned income. From earned income deduct the $20 if not already used, deduct $65 and 1/2 of the remainder. After the application of the deductions compare what is now the countable income to the income limits. There is only one $20.00 disregard from total combined income for a married couple. There is only one $65 and 1/2 remainder disregard from total combined earned income of the couple.

Verify the gross income of the ineligible spouse (the spouse who is not Medicare eligible). If that income is equal to or less than half the income limit for one QMB, then do not count any of the ineligible spouse's income toward the eligible spouse for the eligibility determination.

If none of the ineligible spouse's income is counted toward the Medicare spouse, the income limit for an individual is used to determine eligibility. If we must deem income from the ineligible spouse to the Medicare spouse, the income limit for a couple is used.

When determining the countable income of an applicant with children under age 18 and in the home, you can give a child's disregard which is 1/2 of the QMB's income limit for one. The child's disregard can only be applied to the ineligible spouse's income not the QMB's income and cannot be applied if the child has income that exceeds 1/2 of the QMB limit for one. Apply child's disregard before applying the $65 and 1/2 remainder disregard.

Please remember that we do not deem children's income to parents. We use a child's disregard to reduce the income we have to deem from the ineligible spouse to the eligible QMB.

17300.4 Effective Date of Coverage

QMB's coverage cannot be retroactive prior to 1/1/90. By Federal mandate QMB's are to become eligible the first day of the month after you determine them eligible. An individual may have dual eligibility as a QMB and as a Medicaid recipient. When authorizing coverage for an individual who is being terminated from Medicaid, you may begin coverage the month following the Medicaid termination.

Benefits are effective with the beginning of the month after the month in which you make a determination that an individual is a Qualified Medicare Beneficiary. For example, if you make a determination on August 15, benefits under this provision are effective beginning September 1. 17300.4.1 Retroactive Coverage Precluded Three month retroactive eligibility as provided for in 1902(a)(34) of the Social Security Act and in regulations at 42 CFR 435.914, is precluded under this provision. Thus, you may not make an individual eligible under this provision before the beginning of the month after the month in which the eligibility determination is made. 17300.5 Benefits Medicaid will pay the:

·Part A hospital premium if a QMB has to pay for the premium. Most Medicare beneficiaries receive this coverage for free.

·Part A or hospital deductible.

·Part B premium.

·The annual Part B deductible.

·Coinsurance requirement of 20%. Physicians, labs, etc., would bill Medicare for 80% of the service and then bill Medicaid for 20% coinsurance or the remainder.

We can only pay enrolled providers (those with a Medicaid contract). We cannot reimburse the recipients. 17300.6 Redetermination of Eligibility

A redetermination of eligibility must be completed at least every 12 months. We will promptly redetermine eligibility when information is received about changes in circumstances that may affect eligibility. 17300.7 Identification of Beneficiaries