us-la/manual/ldh/medicaid

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us-la/manual/ldh/medicaid — Axiom

(a-200)Louisiana Medicaid Eligibility Manual (LDH): A - 200 Definitions#

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Louisiana Medicaid Eligibility Manual Abbreviations/Acronyms/Definitions

Issued November 13, 2025 Page 1 of A-200 Replaces January 27, 2025

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A-200 DEFINITIONS

Absent Parent – A child's parent who does not live in the same home as the child.

Act 421 Children’s Medicaid Option (TEFRA) – An eligibility group for individuals under the age of 19 who have disabilities and meet institutional level-of-care requirements, regardless of parental income and resources.

Adequate Notice – 1. A written notice mailed to the beneficiary no later than the time action is taken upon a case. 2. A written notice of adverse action mailed to the beneficiary no later than the date the action is to be taken. No opportunity to rebut the decision.

Administrative renewal – Automatic recertification of SNAP-eligible children.

Adult Day Health Care Facility – A facility that treats the health and support needs of elderly or disabled adults in a home-like setting during scheduled daytime hours.

Adult Day Health Care Waiver – A non-residential program that can be an alternative to nursing home care for people who do not need care 24 hours a day, 7 days a week.

Adult Group – An eligibility group for individuals age 19 through 64 established by the Affordable Care Act (ACA) of 2010.

Advance Notice (Timely Notice) – A written notice of adverse action mailed to the beneficiary prior to taking the action and giving the beneficiary an opportunity to rebut the decision or to appeal the proposed action.

Adverse Action – Agency action that results in a denial, reduction, or termination of benefits.

Agency Representative – An individual employed or designated by the Louisiana Medicaid program to initiate the application process and/or determine eligibility.

Allocated Resource – The amount of countable couple resources that may be transferred to the community spouse or to another person for the benefit of the community spouse. These resources are not counted in the determination of continuing eligibility of the institutionalized spouse.

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Medicaid Eligibility Manual Abbreviations/Acronyms/Definitions

Issued November 13, 2025 Page 2 of A-200 Replaces January 27, 2025

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Allocation of Income – A process by which income is designated for individuals not included in the income unit.

Appeal – 1. A request for a fair hearing concerning a proposed agency action, a completed agency action, or failure of the agency to make a timely determination. 2. A legal proceeding in which the applicant/beneficiary and the Medicaid agency representative presents the case being appealed in front of an impartial hearing officer. (see Fair Hearing.)

Applicant – An individual who is requesting assistance from the agency.

Application – A formal request for benefits made to the agency in writing and signed by the applicant or someone acting on behalf of the applicant. The application may be received by mail, phone, fax, in person, or electronically.

Application Center – A place that provides outreach to individuals and families by assisting in completing an initial application for Medicaid.

Application Date – The date a signed application is received by telephone, mail, fax, in person, or electronically in the local Medicaid office or agency representative’s office. A local Medicaid office or agency representative’s office is defined as a local or regional Medicaid office, the LaCHIP Processing Office, the Medicaid Director’s office, family planning eligibility office, or a certified Medicaid application center. A long-term care nursing facility is not considered a certified Medicaid application center.

Assets – All of the income and resources belonging to the individual and the individual’s spouse.

Assistance Unit – Beneficiaries included in a medical assistance certification who are receiving Medicaid.

Authorized Representative – One or more individuals designated by an applicant/beneficiary (verbally or by use of a designation form) to act on his/her behalf with respect to a specific Medicaid application or renewal. (see Responsible Person.)

Auto Notices – The automated notice system that produces system generated forms or notices based on a transaction in LaMEDS.

Automated Renewal – Automated renewal process for programs that have a low chance of change in income and resources.

Available Resource – A resource to which the resource unit has legal access.

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Medicaid Eligibility Manual Abbreviations/Acronyms/Definitions

Issued November 13, 2025 Page 3 of A-200 Replaces January 27, 2025

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Basic Needs – Food, clothing, and shelter.

Basic Needs Allowance – Relating to beneficiaries of HCBS, an allowance equal to three times the SSI (FBR).

Beneficiary - Anyone for whom Medicaid eligibility has been established and for whom a case has been added to the LaMEDS eligibility file.

Blood Products Litigants – Former SSI beneficiaries who lost eligibility for cash assistance because of a payment made under the Susan Walker vs. Bayer Corporation et al. settlement.

Breast and Cervical Cancer Program – A program that provides full Medicaid benefits to uninsured women who are identified through the CDC National Breast and Cervical Cancer Early Detection Program, and diagnosed with either breast or cervical cancer or a pre-cancerous condition in need of treatment.

Budgeting – Performing specific steps and calculations to establish income eligibility for Medicaid.

Burial Insurance – Insurance that can be used to pay the burial expenses of the insured, that lists the covered services for the burial, and will have no cash surrender value if the policy was issued prior to 1978. If policy was issued after 1978, it may have a small cash surrender value of 3 percent.

Burial Space – A gravesite, crypt, mausoleum, urn, vault, casket, headstone, or other repository that is customarily and traditionally used for the remains of a deceased person.

Buy-In Program – A Medicaid program, known as “buy-in,” that pays Medicare Part A and Part B premiums for selected groups of Medicaid beneficiaries. The purpose of “buy-in” is to reduce Medicaid expenditures for certain beneficiaries by purchasing Medicare coverage, thus shifting Medicaid expenditures to Medicare.

Caretaker Relative – A relative of a dependent child by blood, adoption, or marriage with whom the child is living, who assumes primary responsibility for the child's care.

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Medicaid Eligibility Manual Abbreviations/Acronyms/Definitions

Issued November 13, 2025 Page 4 of A-200 Replaces January 27, 2025

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Cash Surrender Value – The amount of cash that a life insurance policy is worth upon surrender of the policy to the insurance company.

Category – Classification of applicants/beneficiaries based upon certain identifying requirements/categories: Aged (A), Blind (B), Parent and Caretaker Relative (C & M), Pregnant Women, Disabled (D), Medicare Beneficiaries (Q), Refugee (E), Tuberculosis Infected (TB), and Adults.

Certification – 1. The determination that the applicant's circumstances are within the standards for eligibility. 2. The identifying case and eligibility information maintained by the LaMEDS.

Certification Period – The length of time a beneficiary is certified for benefits.

Children's Choice Waiver – A waiver that offers supplemental support to individuals 0 to 20 years of age with intellectual and/or developmental disabilities (defined as disabled according to SSI criteria), who currently live at home with their families, or who will leave an institutional setting to return home.

Collateral Contact – A third party (related or unrelated) who verifies an applicant/beneficiary’s circumstances.

Combined Countable Couple Resources – The total assets/resources (separate and jointly owned community property) owned by a couple included in the resource unit for a determination of eligibility.

Community Choices Waiver – Provides services in the home/community to seniors or adults with onset disabilities as an alternative to nursing facility care.

Community Property – Property acquired with community funds during a marriage that may be held in the name of one or both members of the couple.

Community Spouse – The legal husband or wife of an institutionalized individual who is not in a medical institution, nursing home or receiving Home and Community-Based Services and were living together in the same household with the institutionalized spouse.

Compensation – All money, real or personal property, food, shelter or services received at or after the time of transfer in exchange for an asset if the compensation was provided pursuant to a binding (legally enforceable) agreement in effect at the time of the transfer.

Constructively Received – Counting income or resources which could be received but have been refused.

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Medicaid Eligibility Manual Abbreviations/Acronyms/Definitions

Issued November 13, 2025 Page 5 of A-200 Replaces January 27, 2025

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Continued Medicaid – The temporary continuation of Medicaid benefits for former PCR beneficairies through Transitional Medicaid.

Contractor – An individual or business entity that has entered into a legally binding contract with Medicaid.

Converted – Beneficiaries certified in the Aged, Blind and Disabled categories who retained Medicaid benefits and began receiving SSI benefits effective January 1, 1974. These are type cases 01/001, 02/001, and 04/001.

Cost Effectiveness – In the Recovery and Premium Assistance unit, the process whereby Medicaid balances and weighs that which it may reasonably expect to recover, against the time and expense of recovery. Application of the provision will be deemed cost effective when the amount reasonably expected to be recovered exceeds the costs of recovery and is greater than $1,000.

Countable Income – Income remaining after all allowable deductions and exclusions specific to the program have been applied.

Countable Resource – A resource that is countable when determining resource eligibility.

Countable Value – The amount of a resource counted toward the resource limit.

Couple – Two individuals who are legally married or living together and holding out as a married couple or who presents to the community as a husband or wife in a non-legal relationship.

Curator – Any person acting under legal authority for an applicant/beneficiary who is an interdict.

Current Market Value – The amount for which a resource can be expected to sell on the open market in the particular geographic area involved.

Date of Entry – The date a non-citizen has entered the United States according to documentation from the USCIS (formerly known as the BCIS and also INS).

Decertification – The loss of eligibility to participate as a Medicaid provider, or for a license to operate a Medical facility licensed by LDH.

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Medicaid Eligibility Manual Abbreviations/Acronyms/Definitions

Issued November 13, 2025 Page 6 of A-200 Replaces January 27, 2025

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Deemed Eligible – A child born to a woman eligible for Medicaid benefits on the date the child is born.

Deemed Income – In SSI-related cases, income from an ineligible individual such as a parent or spouse which is presumed to be available to an applicant/beneficiary whether or not the income is actually made available. This income is considered in determining income eligibility.

Deemed Resource – In SSI-related cases, a resource from an ineligible individual such as a parent or spouse which is presumed to be available to an applicant/beneficiary whether or not the resource is actually made available. This resource is considered in determining resource eligibility.

Dependent – An individual who is the financial responsibility of a member of the income unit and could be counted as a tax dependent if income tax is filed.

Discharge – Release from the care of a medical facility such as a nursing facility or hospital.

Domestic Partnership – Two people of the same or opposite sex who live together and share a domestic life, but are not married or joined by a civil union.

Earned Income – Income in cash or in-kind received in the form of wages, salary, commissions, or profit from activities in which an individual is actively engaged as an employee or from self-employment.

Earned Income Credit – Payments from the IRS to persons with tax dependents whose gross monthly earnings are at or below levels established by the IRS.

Equity – The fair market value of a resource, less any amount owed.

Estate – The gross (total value) estate of the deceased as determined by Louisiana succession law and any interest in any property, whether moveable or immovable, corporeal or incorporeal.

Estate Recovery – The process by which the state seeks recovery of Medicaid payments from the applicant/beneficiary’s estate for long-term care facility services, home and community based services, and related hospital and prescription drug services received by the beneficiary aged 55 and over.

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Medicaid Eligibility Manual Abbreviations/Acronyms/Definitions

Issued November 13, 2025 Page 7 of A-200 Replaces January 27, 2025

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Excluded Resource – A resource that is not counted in determining eligibility.

Exploitation – The illegal or improper use of funds, assets, or property, or the improper use of a power of attorney or guardianship.

Extended Medicaid – Medicaid coverage for those individuals who lose for SSI or Mandatory State Supplement (MSS) eligibility and meet all eligibility requirements for PICKLE, DAC, DW/W, EW/W, or DW/W with no SGA programs.

Extortion – Taking something of value from a person by force, intimidation, or abuse of legal or official authority.

Fair Hearing – A legal proceeding in which the applicant/beneficiary and Medicaid agency representative presents the case being appealed in front of an impartial hearing officer.

Fair Market Value – An estimate of the value of an asset, if sold at the prevailing price at the time it was actually transferred.

Family Opportunity Act – A buy-in program for children with disabilities whose family’s gross income is at or below 300% FPL.

Federal Benefit Rate – The maximum SSI payment.

Fiscal Intermediary – The contractor, managed by the MES section, which processes claims, issues payments to providers, handles provider inquiries and complaints, provides training for providers, and issues medical eligibility cards to a beneficiary.

For the Sole Benefit of – This phrase means to benefit one person only.

Former Foster Care Children – Individuals under 26 years of age, who were receiving Medicaid and were in foster care under the responsibility of the state at the time of their 18th birthday.

Fraud – The willful intent to obtain ineligible benefits or payments.

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Medicaid Eligibility Manual Abbreviations/Acronyms/Definitions

Issued November 13, 2025 Page 8 of A-200 Replaces January 27, 2025

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GAP Filing Rules – Applying the Marketplace’s Advance Premium Tax Credit (APTC) income rules when a individual is over income for Medicaid using Modified Adjusted Gross income methodology.

Good Cause – An acceptable reason to defer the requirement to cooperate for certain eligibility factors.

Grandfathered – Relating to MSS beneficiary, the process by which individuals were enrolled in the Aged, Blind, and Disabled categories. The Medicaid benefits and LTC vendor payments were continued (as of January 1, 1974) based on income and resource criteria established by the state, as opposed to SSI income and resource criteria.

Gross Income – Income before applying any deductions or exclusions.

Heir – A descendant in the first degree (parent, sibling, or child, biological or adopted).

Holding Out – Two individuals who are not legally married present themselves to the community in the same way as a married couple. Such individuals are considered married for Non-MAGI related programs.

Home – Property in which the individual has an ownership interest that serves as their principal place of residence.

Home and Community Based Services Waiver – Services provided by certain Medicaid programs to individuals living in the community rather than in a long-term care facility.

Homestead – One or more tracts of land, with a residence on one tract and a field, pasture or garden on the others, not exceeding 200 acres. Includes rural or urban buildings and improvements owned and occupied by the decedent, or a residence including a mobile home owned and occupied by the decedent, or a residence regardless of whether the homeowner owns the land upon which the home or mobile home is sited. This same homestead shall be the primary residence that served as a bona fide home and which was occupied by the individual immediately prior to the individual’s admission to a long-term care facility or when the beneficiary began receiving home and community based services.

Hospital Presumptive Eligibility – Designated hospitals are qualified to make presumptive Medicaid eligibility determinations based on preliminary, self-attested

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Medicaid Eligibility Manual Abbreviations/Acronyms/Definitions

Issued November 13, 2025 Page 9 of A-200 Replaces January 27, 2025

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information obtained from individuals seeking medical assistance.

Household Goods – Items of personal property customarily found in the home and used in connection with the maintenance, use, and occupancy of the home.

Illegal Non-citizen– A non-citizen who has not been lawfully admitted to the United States.

Income – A gain or recurrent benefit measured in money.

Income Unit – The individuals whose income, resources, and needs are considered in determining eligibility.

Incurred Medical Expense – A paid or unpaid bill incurred for medical care that is not covered by third party insurance or Medicaid, which are obligated to be paid by the applicant/beneficiary.

Individual – The individual applicant/beneficiary, the spouse acting on behalf of the applicant/beneficiary, or a court or administrative body with legal authority to act on behalf of the individual or at the direction or request of the individual or the individual’s spouse.

Ineligible Individual – A non-categorically eligible child, parent, or spouse who lives in the home with an SSI-related Medicaid applicant/beneficiary.

Ineligible Non-Citizen – A non-citizen admitted to the United States for a temporary or specified time who is eligible only for emergency medical services if eligibility requirements are met.

In-kind Income – Third party payments which do not result in an individual’s direct receipt of a basic need (food, clothing or shelter), but provides an in-kind item that an individual can apply to meet his/her basic needs by sale or conversion.

In-kind Support and Maintenance – Third party payments that result directly in an individual’s fulfillment of shelter.

Institution – A medical hospital or a long-term care facility (nursing facility, ICF/IID, or group home).

Institutionalized Individual – A person that is likely to reside in a medical institution

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Medicaid Eligibility Manual Abbreviations/Acronyms/Definitions

Issued November 13, 2025 Page 10 of A-200 Replaces January 27, 2025

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whereby payment is based on a level of care provided in a nursing facility; or who receives home and community based services for a continuous period of institutionalization.

Institutionalized Spouse – An individual who is legally married that meets the definition of an institutionalized individual.

Interdict – Any person determined by a court of law to be incompetent to take care of his/her own person or to administer his/her estate.

Interfaces - Electronic connections that share information between trusted data sources to verify an individual’s statement of details, helping streamline case processing and eligibility determinations.

Intranet – A private network, accessible only to an organization's staff and other authorized users.

Intrinsic Value – Something that has value in and of itself (i.e., property).

LaCHIP Affordable Plan – A cost-sharing program that provides assistance to uninsured children with family income in excess of regular LaCHIP limits.

LaCHIP Phase IV – An expansion of the SCHIP, designed to provide coverage to low income, uninsured mothers who are not otherwise eligible for other Medicaid programs. The program focuses on care for the prenatal child, from conception through birth, in an effort to reduce the occurrence of premature deliveries and costly emergency care for drop-in deliveries.

Legal Guardian – A person who has been granted custody of a minor by court order.

Local Governing Entity (LGE) – Regional districts and authorities that are collaborating with LDH to perform the level of care assessments.

Long-term Care (LTC) Facility – A nursing facility, ICF/IID, or psychiatric hospital.

Look-Back Date – The earliest date on which a penalty for transferring assets for less than fair market value can be assessed.

Louisiana Children's Health Insurance Program (LaCHIP) – A Medicaid program that provides health benefits for eligible uninsured children up to age 19.

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Medicaid Eligibility Manual Abbreviations/Acronyms/Definitions

Issued November 13, 2025 Page 11 of A-200 Replaces January 27, 2025

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Louisiana Health Insurance Premium Payment (LaHIPP) – A program which pays for employer sponsored group health insurance for Medicaid eligible persons when it is determined to be cost effective. “Cost effective”, as applicable to this program, means that it would cost less for Medicaid to pay the health insurance premium for the beneficiary than it would be to pay for the cost of the same person’s medical expenses if they didn’t have insurance.

Louisiana Medicaid Eligibility Determination System (LAMEDS) – The management information system for LDH that maintains records of individuals eligible for Medicaid. The system supports eligibility data for all current programs and transmits the eligibility information to the MES.

Louisiana State Health Insurance Information Program – Provides education and advocacy through local sponsoring organizations to both retired and pre-retirement age seniors as well as their families. The program offers free and confidential help with Medicare, private health insurance to supplement Medicare, and long-term care insurance options. Counselors have information on other resources, agencies and organizations that provide services to seniors.

Lump Sum – A non-recurring cash payment.

Modified Adjusted Gross Income (MAGI) – A methodology used to determine financial eligibility for Medicaid, Children’s Health Insurance Programs (CHIP), Cost sharing reductions, and Advanced premium tax credits (APTC) through the Federally Facilitated Marketplace (FFM).

Maintenance Needs Allowance – The maximum amount of income that can be allocated to a long-term care community spouse and/or legal dependents.

Mandatory State Supplement – A payment made to aged and disabled grandfathered beneficiaries who at the time did not have income for living expenses to allow them an amount equal to the SSI income standard.

Mass Change – Occurs when the federal or state government initiates a change in a program or a requirement that affects all cases with certain characteristics.

Medicaid Enterprise System – Fiscal Intermediary for the State of Louisiana.

Medicaid Purchase Plan – This program provides affordable health coverage to

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Medicaid Eligibility Manual Abbreviations/Acronyms/Definitions

Issued November 13, 2025 Page 12 of A-200 Replaces January 27, 2025

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working individuals, age 16 to 65, who meet the Social Security disability criteria. These individuals must also meet special income and resource limits.

Medically Needy Program – A federally funded program that provides full Medicaid coverage for up to six (6) months.

Medical Support –Payment of costs for medical care ordered by a court or by an administrative process established under state law.

Medicare Savings Program – A group of Medicaid programs (QMB, SLMB, QI and QDWI) administered by Louisiana Medicaid that may assist low income seniors and people with disabilities with the payment of their Medicare premiums, and in some cases, their deductibles and co-payments.

Minimal Essential Coverage – Any insurance that meets the Affordable Care Act requirement for having health coverage.

Need – Living at or below the income and resource eligibility standards for Medicaid.

New Admission – A first time admission to a medical facility or a readmission, after an absence of 30 days or more, when the absence was not due to hospitalization.

New Opportunities Waiver – A Medicaid program that allows qualifying individuals with developmental disabilities, age 3 and older, to have more choices and more flexibility when it comes to the services they receive through Louisiana Medicaid.

Non-Citizen – An individual who is not a U.S. citizen.

Non-Citizen Sponsor – An individual or organization that agreed to provide certain support to a non-citizen as a condition of the non-citizen's entry into the United States as a permanent resident.

Non-Excluded Resource – Any resource that is counted toward the resource limit or which would have counted, in whole or part, toward the resource limit, if the resource had been retained.

Non-Modified Adjusted Gross Income (Non-MAGI) – Medicaid eligibility categories for individuals whose eligibility is determined using traditional Medicaid income and resource tests (formerly known as SSI – Related) rather than MAGI.

Non-Qualified Non-Citizen – Non-citizens who do not meet qualified non-citizen

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Medicaid Eligibility Manual Abbreviations/Acronyms/Definitions

Issued November 13, 2025 Page 13 of A-200 Replaces January 27, 2025

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status, which also includes illegal/undocumented non-citizens.

Nursing Facility – A facility that provides intermediate or skilled nursing care.

Office of Aging and Adult Services – Oversees long-term care programs, e.g. nursing facility and waivers that serve senior citizens and individuals with adult-onset disabilities.

Office for Citizens with Developmental Disabilities – Serves as the Single Point of Entry into the developmental services system and oversees public and private residential service and other services for people with intellectual and/or developmental disabilities.

Parent and Caretaker Relatives – A relative of a dependent child by blood, adoption, or marriage with whom the child is living (formerly considered under LIFC program).

Patient Liability – The amount an individual residing in a facility is responsible for paying to the long-term care provider for LTC facility services.

Payee – The individual in whose name an application is opened and a case is certified.

Personal Care Needs – An amount allowed for a LTC beneficiary to cover the cost of personal items not covered by the facility fee.

Personal Effects – Items of personal property which are worn or carried by an individual or which have special significance to him/her. Personal effects are excluded resources.

Post-eligibility Treatment of Income (PETI) – Rules used to calculate a beneficiary’s PLI for nursing home, Home and Community Based Waiver or ICF/IID services.

Program of All Inclusive Care for the Elderly – A community-based alternative to placement in a nursing facility and includes a complete “managed care” type benefit that combines medical, social, and long-term care services. This program is designed for the elderly and frail or individuals with disabilities acquired as an adult.

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Medicaid Eligibility Manual Abbreviations/Acronyms/Definitions

Issued November 13, 2025 Page 14 of A-200 Replaces January 27, 2025

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Protected Income – The $90.00 VA improved pension benefit that is received by certain single VA individuals residing in long-term care facilities.

Provider – An individual or group that provides medical services.

Provisional Medicaid – Provides coverage to individuals with disabilities or age 65 or older whose income is below the FBR and resources that meet the SSI limits.

Prudent Person – An individual who uses good judgment or common sense in handling practical matters. The prudent person concept shall be used by eligibility staff in administering the Medicaid program to determine the reasonableness of an action or decision based upon his or her knowledge of an experience with the Medicaid program. Eligibility staff must be prudent when the circumstances of a particular case indicate the need for further inquiry. Additional verification or substantiation should be obtained whenever the information provided by the applicant or beneficiary is incomplete, unclear, or contradictory.

Qualified Medicare Beneficiary Only – An individual who is eligible for Medicaid payment only for Medicare Part A and/or B premiums, Medicare deductibles and Medicare co-insurance for Medicare covered services, not eligible for full Medicaid coverage. Formerly referred to as “pure QMB”.

Qualified Medicare Beneficiary Plus – An individual who is eligible for the same benefits as QMB Only and full benefit Medicaid in another program. Formerly referred to as “dual QMB.”

Qualified Non-Citizen – A non-citizen entering the U.S. on or after August 22, 1996, who is eligible only for emergency medical services until the residency requirement for consideration of full Medicaid coverage is met or unless they are not subject to the five (5) year bar.

Qualifying Individual – A Medicaid program whereby individuals are eligible for payment of Medicare Part B premiums.

Regular Renewal – A renewal by telephone, mail, or electronically submitted

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Medicaid Eligibility Manual Abbreviations/Acronyms/Definitions

Issued November 13, 2025 Page 15 of A-200 Replaces January 27, 2025

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application.

Renewal – A periodic evaluation of a certified Medicaid case to determine continued eligibility. This process was formerly referred to as “redetermination process.”

Residential Options Waiver – Assists in transitioning individuals with intellectual and developmental disabilities from Intermediate Care Facilities to their own home in the community.

Resource – Cash or other liquid asset, or any real or personal property that an individual (or spouse) owns and could be converted to cash.

Resource Unit – The individual(s) whose resources must be considered in determining eligibility.

Responsible Person – One or more individuals designated by an applicant/beneficiary (verbally or by use of a designation form) to act on his/her behalf with respect to a specific Medicaid application or renewal. See Authorized Representative.

Retroactive – 1. Determining eligibility up to three (3) months prior to month of application. 2. Period of eligibility up to three (3) months prior to the month of application.

Sanction – Denial of benefits for failure to comply with an eligibility requirement (e.g. cooperating with Support Enforcement.)

Separate Resource – A resource acquired by an individual outside of marriage, by either prior ownership or inheritance, and held separately and legally identifiable as owned solely by the individual.

Settlor – The person who creates a trust.

Shared Resources – Resources acquired during the marriage including community assets which may be held in the name of one or both members of the couple.

Siblings – Minor children living in the home who are brothers and sisters, including natural or biological, adopted, or half brothers and sisters.

Specified Low-Income Medicare Beneficiary Only – A Medicaid program that pays Medicare Part B premiums without, full Medicaid benefits.

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Medicaid Eligibility Manual Abbreviations/Acronyms/Definitions

Issued November 13, 2025 Page 16 of A-200 Replaces January 27, 2025

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Specified Low-Income Medicare Beneficiary Plus – An individual who is eligible for the same benefits as SLMB Only and full benefit Medicaid in another program.

Special Income Level – The LTC program income standard. The SIL is equal to three (3) times the SSI FBR. Previously referred to as “CAP.”

Spousal Impoverishment Income Allocation – The portion of the institutionalized spouse's income that may be given to the community spouse.

Spousal Impoverishment Resource Standard – The maximum allowable amount of a couple's combined countable resources allocated for the use and maintenance of the community spouse.

Spouse – An individual who is legally married to another individual.

Stepparent – An individual living in the home who is the legal spouse of the child's parent but is not the child's natural, legal, or adoptive parent.

Stepsibling – Minor children that have no parent in common who have been joined by marriage.

Streamlined Renewal – A review made by the Agency without the active involvement of the beneficiary. Streamlined renewals are not allowed for premium based programs.

Supplemental Security Income – A federal income supplement program designed to help aged, blind, and disabled individuals who have little or no income.

Support and Maintenance – Refer to In-Kind Support and Maintenance.

Swing Bed Services – Skilled nursing facility services provided in a hospital.

Take Charge Plus – A program with coverage limited to family planning-related services for men and women.

Third Party – An individual, institution, corporation, or agency that is responsible for all or part of the medical costs for Medicaid beneficiaries.

Third Party Query – A request to the SSA for verification of information from their records.

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Medicaid Eligibility Manual Abbreviations/Acronyms/Definitions

Issued November 13, 2025 Page 17 of A-200 Replaces January 27, 2025

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Title II – The portion of the Social Security Act that provides for entitlement to benefits based on earnings, known as RSDI.

Title IV-A – The portion of the Social Security Act that provided for the TANF program that, in Louisiana, is called FITAP.

Title IV-D – The portion of the Social Security Act that provides for Support Enforcement Services.

Title IV-E – The portion of the Social Security Act that provides for Foster Care and Adoption Assistance.

Title V – The portion of the Social Security Act that provides for the Maternal and Child Health Block Grant.

Title X – The portion of the Social Security Act that provides for family planning services.

Title XVI – The portion of the Social Security Act that provides for SSI.

Title XVIII – The portion of the Social Security Act that provides for Medicare.

Title XIX – The portion of the Social Security Act that provides for Medicaid.

Title XX – The portion of the Social Security Act that provides for social services.

Title XXI – The portion of the Social Security Act that provides for the Children’s Health Insurance Program.

Transitional Medicaid – Provides continued Medicaid coverage for a parent or caretakers who loses coverage in PCR because of an increase in MAGI from employment.

Tuberculosis Infected – Individuals who have been diagnosed with active Tuberculosis (TB) or suspected of being infected with TB.

Tutor – The legal guardian of a minor and of the minor's property.

Unavailable Resource – A resource that is not legally available to the resource unit.

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Medicaid Eligibility Manual Abbreviations/Acronyms/Definitions

Issued November 13, 2025 Page 18 of A-200 Replaces January 27, 2025

Revised/added text indicated by underscore Deleted text indicated by “**”

Uncompensated Value – The difference between the fair market value of an asset at the time of transfer (less any outstanding loans, mortgages, or other encumbrances on the asset), and the amount of compensation received by the individual or spouse in exchange for the asset.

Undue Hardship – Compelling circumstances that would result in placing an unreasonable burden on an heir.

Unearned Income – All income, cash or in-kind, that is not earned income.

Usufruct – The right to use property that is owned by another, and right to income that property produces.

Valid Loan/Valid Debt – A legally binding agreement made in good faith.

Valuable Consideration – When an individual receives in exchange for his or her right or interest in an asset some act, object, service, or other benefit which has a tangible or intrinsic value to the individual that is roughly equivalent to or greater than the value of the transferred asset.

Vehicle – Passenger car or other mode of transportation used to provide necessary transportation.

Vendor Payment – Payment made by a third party including Medicaid on behalf of an applicant/beneficiary.

Waiver Service – Home and community-based services offered as an alternative to institutional services.

Wire Third Party Query System (WTPY) - A federally mandated computer match with the Social Security Administration (SSA)

Youth Aging Out of Foster Care – An individual who is under 21 years of age and who, on the individual’s 18th birthday, was in foster care under the responsibility of the

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Medicaid Eligibility Manual Abbreviations/Acronyms/Definitions

Issued November 13, 2025 Page 19 of A-200 Replaces January 27, 2025

Revised/added text indicated by underscore Deleted text indicated by “**”

state.

(b-0000)Louisiana Medicaid Eligibility Manual (LDH): B - 0000 Introduction#

(b-0000)(page-1)Page 1#

Medicaid Eligibility Manual

Introduction

Reissued August 20, 2024 B-100 Replacing May 30, 2023 Medicaid Program “**” Text Deleted “Underlined” Text Revised

INTRODUCTION

B-100 MEDICAID PROGRAM

Title XIX of the Social Security Act, enacted by the Social Security Amendments of 1965, provided for grants to states to implement the Medicaid Program.

B-200 GOAL OF THE MEDICAID PROGRAM

The Medicaid Program was established to meet the following goals for all persons who qualify for Medicaid under the Title XIX State Plan Agreement with the federal government:

● Promote a healthy population.

● Prevent illness and premature death.

● Correct or limit disability.

● Treat illnesses.

● Provide maximum rehabilitation.

B-300 MEDICAID

Medicaid is a federal-state entitlement program that provides free or low- cost health coverage to low-income adults, children, pregnant women, the elderly, and people with disabilities.

Medicaid is financed jointly from federal and state funds.

B-400 100% STATE-FUNDED MEDICAL ASSISTANCE

The state provides payment from all state funds for medical assistance to certain beneficiaries who are ineligible for Medicaid. The same services are covered as those covered for Medicaid beneficiaries.

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Medicaid Eligibility Manual

Introduction

Reissued August 20, 2024 B-100 Replacing May 30, 2023 Medicaid Program “**” Text Deleted “Underlined” Text Revised

B-500 SINGLE STATE AGENCY

The Louisiana Department of Health (LDH) is the single state agency under the Louisiana State Plan for administration of medical benefits.

State laws governing the Medicaid Program are in Title 46 of the Louisiana Revised Statutes.

B-600 RESERVED

B-700 MEDICAL CARE ADVISORY COMMITTEE

LDH has a Medical Care Advisory Committee (MCAC), which is mandated by Title XIX regulations. The MCAC consists of 25 persons and includes state legislators, physicians and other representatives of the health professions, members of consumer groups, including Title XIX beneficiaries and consumer organizations, and the Secretary of LDH or a designee of the Secretary.

(c-0000)Louisiana Medicaid Eligibility Manual (LDH): C - 0000 Medical Services#

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Louisiana Medicaid Eligibility Manual Medical Services Reissued August 20, 2024 Replacing May 30, 2023

Page 1 of C-0000 Revised/added text indicated by underscore

Deleted text indicated by “**” C-0000 MEDICAL SERVICES

The following is a brief overview of medical services covered by Medicaid. Refer questions regarding specific medical services to the appropriate medical provider. Medical providers have access to Provider Manuals, the fiscal intermediary, and appropriate personnel within BHSF.

Managed care organizations are the way most of Louisiana’s Medicaid and LaCHIP beneficiaries receive health care services. Medicaid included populations are enrolled into a Healthy Louisiana plan. These plans all offer the same basic benefits but can differ by provider networks, referral policies, health management programs, extra services, and incentives. These plans are accountable to the Louisiana Department of Health (LDH).

C-100 GENERAL INFORMATION

Beneficiaries receive a Medical Eligibility Card (MEC) and are entitled to the services listed below, if the health services provider:

• is enrolled in the Medicaid Program, and

• agrees to bill Medicaid for services to the eligible person listed on the MEC.

Beneficiaries shall present the MEC when health care is requested.

Providers who accept Medicaid payment cannot bill beneficiaries.

Exceptions:

Medically Needy Spend-Down beneficiaries may be billed for partial payment of a medical bill on the Spend-Down date.

Long Term Care beneficiaries may be billed for a portion of the monthly facility fee.

Beneficiaries covered by third parties legally responsible for paying medical claims. Refer to P-0000, Third Party Liability.

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Louisiana Medicaid Eligibility Manual Medical Services Reissued August 20, 2024 Replacing May 30, 2023

Page 2 of C-0000 Revised/added text indicated by underscore

Deleted text indicated by “**” C-200 SERVICE LIMITS

Beneficiaries shall be advised of any limitations and/or prior authorization requirements prior to obtaining services, such as:

• Non-covered prescriptions

• Services only covered a specific number of times per calendar year

• Medical procedures or equipment that must be pre-approved

C-300 COVERED SERVICES

Behavioral Health

• A comprehensive package of behavioral health services for eligible beneficiaries provided through the Louisiana Behavioral Health Partnership (LBHP). Delivery of services is managed by a single Statewide Management Organization (SMO)

Case Management

• Individualized planning and service coordination for certain defined groups

Clinic Services

• Rural Health, Family Planning, Mental Health, Substance Abuse, Free-Standing End-Stage Renal Disease, Radiation Therapy, Prenatal, Ambulatory Surgical Centers, Sexually- Transmitted Disease, and Tuberculosis clinic services

Dental Services

• Limited to dentures and treatment for traumatic injury, malignancies or suspected malignancies for beneficiaries age 21 and over

• A full range of dental services for beneficiaries under age 21 as EPSDT services, in accordance with an approved treatment plan

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Louisiana Medicaid Eligibility Manual Medical Services Reissued August 20, 2024 Replacing May 30, 2023

Page 3 of C-0000 Revised/added text indicated by underscore

Deleted text indicated by “**”

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

• Medically necessary and preventive health care services provided to beneficiaries under age 21 including comprehensive assessments of physical and mental health, immunizations, lab tests, vision, hearing, and dental screenings, diagnostic and treatment services, and rehabilitation services

Eye Care Services

• Eye care for injury or disease for beneficiaries age 21 and over (Eyeglasses after cataract surgery are not covered except in QMB coinsurance)

• Routine eye exams and eyeglasses for beneficiaries under age 21 as EPSDT services

Home and Community Based Services

• Alternatives to institutional care such as, Personal Assistance Services (PAS), Long Term Personal Care Services ( LT-PCS), and Waiver services

Home Health Services

• Part-time skilled nursing services, home health aide services, medical supplies, equipment and appliances, and physical or occupational therapy, speech pathology, and audiology services provided in the beneficiary’s home

Hospital Services

• Inpatient, outpatient, and emergency room

• Inpatient psychiatric services in Free Standing Psychiatric Hospitals and Distinct Part Psychiatric Units of Acute Care General Hospitals

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Louisiana Medicaid Eligibility Manual Medical Services Reissued August 20, 2024 Replacing May 30, 2023

Page 4 of C-0000 Revised/added text indicated by underscore

Deleted text indicated by “**” Institution for Mental Diseases (IMD)

• Psychiatric services provided in an IMD for beneficiaries under age 21 or age 65 and older

Exception: Beneficiaries that are inpatient in an IMD on the day before their 21st birthday are eligible for benefits through the day before their 22nd birthday as long as they remain an inpatient and all other eligibility requirements are met.

Laboratory and X-Ray Services

• Medically necessary tests and x-rays that are not performed as routine procedures

Long Term Care (LTC) Services

• Residential care in a nursing facility

Medical Equipment, Appliances, & Supplies

• Medical equipment, appliances, and supplies provided with prior approval

Personal Care Services

• Services with an approved plan of care that provide assistance with distinct tasks, allowing the individual to remain at home instead of being an inpatient or a resident of a facility

Prescribed Medication

• Most prescriptions other than cosmetic drugs, cough and cold preparations, and minor tranquilizers

Professional Services

• Services provided by health care professionals in response to symptoms or diagnosed medical conditions indicating illness, injury, or trauma

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Louisiana Medicaid Eligibility Manual Medical Services Reissued August 20, 2024 Replacing May 30, 2023

Page 5 of C-0000 Revised/added text indicated by underscore

Deleted text indicated by “**”

Rehabilitation Services

• Prior-authorized speech, language, hearing, physical and/or occupational therapy provided by a rehabilitation center or outpatient hospital department. Does not include vocational or developmental evaluation, or voice evaluations or therapy.

Transportation

• Prior-authorized, non-emergency trips to obtain Medicaid- covered services.

Exception: Transportation for pharmacy services is not covered.

• Emergency transportation services (prior authorization is not required).

C-400 RESERVED

(e-0000)Louisiana Medicaid Eligibility Manual (LDH): E - 0000 Category#

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Louisiana Medicaid Eligibility Manual Category

Issued June 28, 2017

Page 1 of E-0000 Revised/added text indicated by underscore

Deleted text indicated by “**” E-0000 CATEGORY E-100 GENERAL INFORMATION

Eligibility for the Medicaid and Children’s Health Insurance Program (CHIP) is limited to certain groups of individuals authorized by Congress. When authorizing a group, Congress also establishes specific requirement(s) which must be met to qualify as a member of that group.

Each designated group is assigned a category of assistance. The requirement(s) which must be met to fit into that group or category is known as the categorical requirement(s).

E-200 CATEGORIES OF ASSISTANCE FOR WHICH BHSF DETERMINES MEDICAID ELIGIBILITY

The Patient Protection and Affordable Care Act, collectively referred to as the Affordable Care Act of 2010 (ACA), was enacted on March 23, 2010. Effective January 1, 2014, the ACA required states to adopt a new methodology for determining eligibility for Medicaid, which is based on Modified Adjusted Gross Income (MAGI).

As a result of ACA, programs are grouped by those that use MAGI methodology and those that do not (non-MAGI). **

MAGI Eligibility Groups  Adults ages 19 through 64  Pregnant Women  Infants and Children under age 19  Parent or other caretaker relative with a dependent child  Former foster care  Medically Needy  Transitional Medical Assistance  Tuberculosis Infected  Breast or Cervical Cancer  Family Planning Services

Non-MAGI Eligibility Groups  Aged, Blind and Disabled  Qualified Disabled and Working Individuals

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Louisiana Medicaid Eligibility Manual Category

Issued June 28, 2017

Page 2 of E-0000 Revised/added text indicated by underscore

Deleted text indicated by “**”  Medicare Beneficiaries entitled to Medicare Part A  Medically Needy  Institutionalized Individuals under a Special Income Level  Home and Community-Based Services  Program of All-Inclusive Care for the Elderly  Family Opportunity Act Children with Disabilities ** E-210 AGED (A)

Individuals aged 65 or older. An individual is categorically eligible beginning with the month s/he turns age 65.

Note: If age cannot be verified for the Aged category, eligibility shall be considered in the Blind or Disabled category.

E-220.1 Reserved

E-210.2 Reserved

E-220 BLIND (B)

By SSA standards, blindness is established when an Individual has a central visual acuity 20/200 or less in the better eye with the use of a correcting lens or a visual field limitation in the better eye of no greater than 20 degrees.

E-220.1 Reserved

E-220.2 Reserved

E-230 PARENTS AND CARETAKER RELATIVES (C and M)

This category includes families with minor or unborn children who meet all eligibility requirements based on the Aid to Families with Dependent Children (AFDC) State Plan in effect 7-16-96.

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Louisiana Medicaid Eligibility Manual Category

Issued June 28, 2017

Page 3 of E-0000 Revised/added text indicated by underscore

Deleted text indicated by “**”

The Personal Responsibility and Work Opportunity Act of 1996 (P.L. 104-193) eliminated the AFDC program and replaced it with a block grant program for temporary assistance for needy families (TANF). The law also established a new mandatory Medicaid eligibility group for low- income families with children (LIFC) using the AFDC State Plan in effect July 16, 1996 for eligibility criteria effective with the date the State implemented its TANF program (10-1-96 in Louisiana).

The Affordable Care Act of 2010 established a new Medicaid eligibility group called Parents and Caretaker Relatives (PCR). These adults were formerly considered for the Low Income Families with Children (LIFC) program as a parent or caretaker relative.

E-230.1 Reserved

E-230.2 Reserved

E-230.3 Pregnant Women

The individual must have been pregnant during the months which assistance is requested. The 60-day postpartum period is considered as part of the pregnancy. Therefore, assistance may be requested retroactively for the postpartum period.

E-231 RESERVED

E-240 DISABLED (D)

SSA defines disability as the inability to engage in any substantial gainful activity:

 By reason of any medically determinable physical impairment or mental impairment; and

 That can be expected to result in death or has lasted or can be expected to last for a period of not less than 12 consecutive months.

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Louisiana Medicaid Eligibility Manual Category

Issued June 28, 2017

Page 4 of E-0000 Revised/added text indicated by underscore

Deleted text indicated by “**”

Note: For a child under age 18 the determination of disability must include consideration of the child's functional capacity at each level of development.

A disability decision rendered by SSA/SSI takes precedence over disability determination made by the Medical Eligibility Determination Team (MEDT).

Blindness takes precedence over disability if the applicant/enrollee meets the categorical requirement of blindness.

E-240.1 Reserved

E-240.2 Reserved

E-250 MEDICARE BENEFICIARIES (Q)

Individuals ** must be entitled to or enrolled in Medicare Part A.

E-250.1 Reserved

E-250.2 Reserved

E-260 TUBERCULOSIS INFECTED (TB)

Individuals who have been diagnosed with active Tuberculosis (TB) or suspected of being infected with TB.

The applicant must be determined TB-infective by ** MEDT. Use the MEDT package to request a TB determination from MEDT. The agency representative shall provide all available medical and social information.

E-260.1 Reserved

E-260.2 Reserved

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Louisiana Medicaid Eligibility Manual Category

Issued June 28, 2017

Page 5 of E-0000 Revised/added text indicated by underscore

Deleted text indicated by “**” E-270 REFUGEES (E)

Individuals who have entered the United States as refugees. Eligibility must be determined for existing Medicaid programs first. If the refugee is not eligible for an existing program, then eligibility is determined for the time-limited Refugee Medical Assistance (RMA). Those refugees who receive cash benefits through the Refugee Resettlement Agency are automatically eligible for RMA.

E-280 ADULTS

The Affordable Care Act (ACA) of 2010 established a new Medicaid eligibility group for individuals age 19 through 64, hereafter referred to as the Adult Group.

E-300 CATEGORIES FOR WHICH BHSF DOES NOT DETERMINE ELIGIBILITY

BHSF ** does not have responsibility for eligibility determination for ** Categories F, I, O, and V. E-310 Reserved

E-320 CATEGORY F

The Department of Children and Family Services (DCFS) has responsibility for determining eligibility for children in state custody who are certified in these cases.

Category F refers to children directly served by DCFS. DCFS has responsibility for determining eligibility for these cases. Policy used to determine eligibility is contained in the Children, Youth, and Family Services (CYFS) Financial Assessment Manual.

This category includes minors under the age of 18 who are:

 Foster children whose income and resources are at or below the PCR standard, but are not Title IV-E eligible because of their inability to meet the criteria of the AFDC State Plan in effect 6/95.

 Foster children whose income and resources are at or

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Louisiana Medicaid Eligibility Manual Category

Issued June 28, 2017

Page 6 of E-0000 Revised/added text indicated by underscore

Deleted text indicated by “**” below the standards for Regular Medically Needy;

 State Adoption Subsidy children who were Medicaid eligible prior to being placed for adoption;

 Foster children who are SSI eligible; and

 Foster children who meet the standards for certification as CHAMP or CHAMP-PW.

E-330 CATEGORY I

Category I refers to children eligible under Title IV-E (DCFS and OJJ). DCFS has responsibility for determining eligibility for these cases. Policy used to determine eligibility is contained in the ** CYFS Financial Assessment Manual.

This category includes minors under the age of 18 who are:  Children of a Title IV-E eligible foster child;  Children in the custody of OCS who entered care from PCR eligible households or who would have been eligible for PCR had the family applied;  Title IV-E Adoption Subsidy children;  COBRA IV-E Adoption Subsidy children who were Title IV-E Adoption Assistance eligible in their state of origin;  COBRA IV-E Foster children who are Title IV-E Foster Care eligible in their state of origin; and  Children in the custody of OJJ who entered care from PCR eligible households or who would have been eligible for PCR had the family applied.

E-340 CATEGORY O

Category O refers to DCFS and OJJ children whose medical assistance benefits are state-funded. DCFS has responsibility for determining eligibility for these cases. These children are not Title XIX-Medicaid eligible. E-350 CATEGORY V Category V refers to OJJ children. DCFS has responsibility for

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Louisiana Medicaid Eligibility Manual Category

Issued June 28, 2017

Page 7 of E-0000 Revised/added text indicated by underscore

Deleted text indicated by “**” determining eligibility for these cases. Policy used to determine eligibility is contained in the CYFS Financial Assessment Manual. This category includes minors under the age of 21 who are:  Children in the custody of OJJ whose income and resources are at or below the PCR standard, but are not IV-E eligible because of their inability to meet the deprivation requirement;  Children in the custody of OJJ whose income and resources are at or below the standards for Regular Medically Needy;  Children in the custody of OJJ who are SSI eligible; and

**  Children in the custody of OJJ who meet the standards of CHAMP or CHAMP-PW.

(f-0000)Louisiana Medicaid Eligibility Manual (LDH): F - 0000 Medical Programs#

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Louisiana Medicaid Eligibility Manual Eligibility Determination Responsibility

Reissued July 27, 2023

Page 1 of F-0000 Replacing June 07, 2022

Revised/added text indicated by underscore

Deleted text indicated by “**” F-0000 MEDICAL PROGRAMS

F-100 ELIGIBILITY DETERMINATION RESPONSIBILITY

The following is a list of programs for which the Bureau of Health Services Financing (BHSF) determines eligibility:

• Act 421 Children’s Medicaid Option (TEFRA) • Acute Care/Rehabilitation • Adult Group • Infants and Children Under 19-CHAMP • Covid-19 Uninsured Eligibility • Continued Medicaid • Deemed Newborn Children • Extended Medicaid: o ** o Disabled Adult Children o Disabled Widows/Widowers o Disabled Widows/Widowers and Disabled Surviving Divorced Spouses Unable to Perform Substantial Gainful Activity (SGA Disabled W/W/DS) o Early Widows/Widowers o Pickle • Family Opportunity Act Buy-In • Former Foster Care Children • Home and Community-Based Services • Home and Community-Based Services Spend-Down Medically Needy • Individuals Eligible for Emergency Services: o Non-Citizens and o Qualified Non-citizens subject to the five-year bar

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Louisiana Medicaid Eligibility Manual Eligibility Determination Responsibility

Reissued July 27, 2023

Page 2 of F-0000 Replacing June 07, 2022

Revised/added text indicated by underscore

Deleted text indicated by “**” • LaCHIP • LaCHIP Affordable Plan • LaCHIP Phase IV - Prenatal Care • Long Term Care • Long Term Care Spend-Down • Medicaid Purchase Plan • Parents and Caretaker Relatives • Pregnant Women • Provisional Medicaid • Qualified Disabled Working Individuals • Qualified Individuals • Qualified Medicare Beneficiaries • Refugee Medical Assistance • Regular Medically Needy • Specified Low-Income Medicare Beneficiary • Spend-Down Medically Needy • Take Charge Plus • Tuberculosis Infected Individuals • Youth Aging Out of Foster Care

F-100.1 MANDATORY COVERAGE GROUPS

• Children with Adoption Assistance, Foster Care, or Guardianship Care Under Title IV-E • Continued Medicaid • Deemed Newborn Children • Disabled Adult Children (DAC) • Disabled Widows and Widowers (DW/W) • Disabled Widows/Widowers and Disabled Surviving Divorced Spouses Unable to Perform Substantial Gainful Activity (SGA

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Louisiana Medicaid Eligibility Manual Eligibility Determination Responsibility

Reissued July 27, 2023

Page 3 of F-0000 Replacing June 07, 2022

Revised/added text indicated by underscore

Deleted text indicated by “**” Disabled W/W/DS) • Early Widows/Widowers (EW/W) • Former Foster Care Children • Individuals Eligible for Emergency Medical Services • Individuals receiving SSI • Infants and Children Under 19-CHAMP • Mandatory State Supplement Individuals • Parents and Caretaker Relatives • PICKLE • Pregnant Women • Qualified Disabled Working Individuals • Qualified Medicare Beneficiaries • Qualifying Individuals • Specified Low-Income Medicare Beneficiary

F-200 LIMITED RESPONSIBILITY For the following programs, BHSF does not have responsibility for eligibility determination, but does have limited responsibility in the ongoing Medicaid certification. • Breast and Cervical Cancer • Children with Adoption Assistance, Foster Care, or Guardianship Care Under Title IV-E • Family Independence Temporary Assistance Program (FITAP) • Hospital Presumptive Eligibility • Mandatory State Supplementation (MSS) • Supplemental Security Income (SSI)

(g-0000)Louisiana Medicaid Eligibility Manual (LDH): G - 0000 Application Processing#

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Louisiana Medicaid Eligibility Manual Application Processing

Issued January 7, 2026 Replaced July 16, 2024 Page 1 of G-0000 Revised/added text indicated by underscore Deleted text indicated by “**”

G-0000 APPLICATION PROCESSING

G-100 INTRODUCTION This section contains information on processing applications for medical assistance.

Effective October 1, 2013, in accordance with the Patient Protection and Affordable Care Act of 2010 (ACA), the application must be the single streamlined application. The BHSF Form 1-A is used to apply for Modified Adjusted Gross Income (MAGI) Medicaid programs.

For individuals who may be eligible for certain non-MAGI programs, the agency has applications specifically designed for the following programs:  Long-term care (LTC);  Home and Community-Based Services (HCBS) Waivers;  Program of All-Inclusive Care for the Elderly (PACE); and  The Medicare Savings Programs (MSP).

For individuals applying for non-MAGI programs using the BHSF Form 1-A application, the agency uses supplemental forms to ask questions and collect information needed to determine eligibility on a basis other than MAGI. Individuals shall not be required to reapply.

MAGI methodology is used to determine income eligibility for the following groups:  Adult age 19-64;  Children;  Parents and Caretaker Relatives (PCR);  Pregnant Women (PW);  Child-related groups;  Other adult related groups:  Refugee Medical Assistance (RMA);  Regular and Spend-Down Medically Needy;  Take Charge Plus (TCP); And

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Louisiana Medicaid Eligibility Manual Application Processing

Issued January 7, 2026 Replaced July 16, 2024 Page 2 of G-0000 Revised/added text indicated by underscore Deleted text indicated by “**”

 Tuberculosis Infected (TB). See I-1550 MAGI Determinations for more information.

Note:

Although the term "applicant" is used in this section, this policy also applies to beneficiaries for whom a renewal of eligibility is being completed, as well as to responsible persons acting on behalf of an applicant/beneficiary.

G-200 GENERAL INFORMATION The local office is required to:  Provide adequate physical facilities to accommodate applicants and beneficiaries who come to the office, including privacy for interviews;  Courteously and promptly greet all persons who come to, or contact, the office and refer them to the appropriate staff without unnecessary delay;  Allow any individual the right to apply for any Medicaid benefit, regardless of circumstances;  Provide an application form to anyone who requests one and offer assistance completing the application to anyone who requires or requests assistance;  Provide, as appropriate, the applicant with the agency’s website and/or direct the applicant/beneficiary to the on-line application kiosk in the local office lobby;  Make referrals to agencies and resources that are designed to meet the applicant/beneficiary’s needs if those needs cannot be fulfilled by the agency;  Promptly and without undue delay (and consistent with established timelines) transfer the applicant/beneficiary’s electronic account via secure electronic interface to the Federally Facilitated Marketplace (FFM or Marketplace) when the applicant/beneficiary: o Is not found eligible for Medicaid using the MAGI methodology; or o Is pending a decision in the non-MAGI (formerly Aged, Blind, Disabled or Long-Term Care) categories; and

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Louisiana Medicaid Eligibility Manual Application Processing

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 Communicate information regarding services offered by the agency and through the Marketplace, in a clear and courteous manner. The criteria outlined below shall be used for communicating with individuals who are blind, deaf, have low literacy; or applicants/beneficiaries who are nonEnglish- speaking. o Applicant/Beneficiary who is blind  Explain the various services offered through the agency and answer any questions asked by the applicant/beneficiary. Read forms in their entirety and assist with completion of forms as needed or requested. o Applicant/Beneficiary who is deaf  Secure a person proficient in sign language or communicate in writing to explain the programs, answer any questions, and assist in the application process. o Applicant/Beneficiary with low literacy  Communicate the services offered through the agency in simple terms and phrases that the applicant/beneficiary may easily understand. Assist in the application process. o Applicant/Beneficiary with language barriers  Secure the assistance of an interpreter capable of speaking the applicant's language to communicate the services offered and assist in the application process by contacting Language Line Solutions. Expedite the application process upon receipt of the request for urgent medical care.

G-300 APPLICATION FORM The BHSF Form 1-A shall be used to review applicants for eligibility; however, if an older version of the application is received, a determination shall be made without requiring the applicant to reapply. Any additional information needed shall be obtained prior to a decision being made.

The applications and documentations required to establish eligibility may come via-

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 Online; o Applicants may complete an application using the LDH Self- Service Portal that allows the Agency to obtain an electronic signature.

 Telephone; o Applicants may complete the application by telephone with a CSU agent. A telephonic signature will be recorded and filed into the case record. o Under special circumstances, telephone applications completed by an Agency representative without CSU agent rights using a paper application require the applicant’s signature before benefits may be issued. The Agency representative shall mail the signature page to the applicant to sign.

 Mail; o Completed, signed applications are accepted by mail. An application is considered incomplete if it does not contain the applicant’s name, address, and signature. It is the Agency representative’s responsibility to obtain any necessary information on incomplete applications. Note: A typed name in the signature line of a paper application is not an acceptable signature.

 In person; or

 Through other commonly available electronic means.

It is an agency requirement that the applicant sign an initial application under the penalty of perjury. The agency must accept electronic, including telephonically recorded signatures and handwritten signatures submitted via any other electronic transmissions available.

The agency does not require a separate application for Medicaid from an individual automatically entitled to Medicaid following a determination of eligibility by another agency.

The Medicaid application form:

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 Is the official agency document used to collect information about the applicant(s) necessary to determine eligibility;  Is the applicant's formal declaration of financial and other circumstances at the time of application;  Is the applicant's formal declaration that all information provided is true and correct under the penalty of perjury;  Provides notice of the applicant’s rights and responsibilities  Shall not be altered after the applicant has signed the form; and  May be used in a court of law.

G-400 TIME LIMITS FOR DISPOSITION OF APPLICATIONS Time limits for disposition of applications cover the period from the date of application to the date the agency notifies the applicant of its decision.

Ninety (90) days are allowed for the disposition of applications requesting coverage on the basis of disability, which requires a determination, by the Medical Eligibility Determination Team (MEDT).

Fortyfive- (45) days are allowed for disposition of all other applications.

For individuals who have applied for LTC Prior to placement in a facility or HCBS and have not received a waiver offer, allow the application to remain pending up to forty-five (45) days. If the applicant is requesting LTC coverage, but has not entered the facility by the 45th day, deny eligibility for LTC and consider eligibility in other programs.

G-500 RESERVED

G-510 RESERVED

G-600 WHO MAY APPLY FOR ASSISTANCE An individual may apply for medical assistance without delay and may apply for any program they choose.

The following individuals may apply for assistance on behalf of someone

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Louisiana Medicaid Eligibility Manual Application Processing

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else:  The applicant,  An adult who is in an applicant's MAGI household (tax filer or non- tax filer),  An adult who is in the applicant’s family, [taxpayer and anyone claimed as tax dependent],  An Authorized Representative (R-0000): o Parent living with a minor child; o Legal Spouse; o Legal Guardian, curator, or tutor; o Power of attorney; o Representative for Minor SSI Recipient; or o A person designated by applicant to be an Authorized Representative.  Someone acting responsibly for the applicant who is deceased, a minor or incapacitated per court order. Age and letters from doctors are not evidence of incapacity; Note: A minor may apply for assistance without the consent of the parent or legal guardian with whom they reside.

 The appropriate Office of Juvenile Justice (OJJ) worker for a child in the custody of the state; or  Other authorized agencies.

G-700 APPLICATION DATE The application date is the date the signed application is received by the Agency, the Federally Funded Marketplace (FFM), an application assistor, or a certified Medicaid application center (AC). This applies to applications taken by telephone or received in-person, mail, fax, or electronically. Medicaid is responsible for processing all application requests and facilitating the completion of the application.

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G-800 ACCEPTING APPLICATIONS The agency shall require a written application, signed under penalty of perjury, on a form issued by the Agency. Electronic, including telephonically recorded, signatures and handwritten signatures transmitted via any other electronic transmission must be accepted. The Agency must accept an application and any documentation required from:  The applicant,  An adult who is an applicant's MAGI household (tax filer or non-tax filer),  An adult who is in the applicant’s family [taxpayer and anyone claimed as tax dependent],  An Authorized Representative (R-0000): o Parent living with a minor child, o Legal Spouse, o Legal Guardian, curator, or tutor, o Power of attorney, o Representative for Minor SSI Recipient; or o A person designated by applicant to be an Authorized Representative.  Someone acting responsibly for the applicant who is deceased, a minor or incapacitated per court order. Age and letters from doctors are not evidence of incapacity. An application will be accepted:  Via the LDH Self-Service portal;  By telephone;  By mail;  In-person;  Via the Federal Funded Marketplace (FFM);  From a certified application center; or  Through other commonly available electronic means (scanning, imaging, email and facsimile). Requirements to safeguard applicant

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information apply regardless of mode of submission. The applicant shall not have the right to remove him or herself from the eligibility process by the act of approving an authorized representative.

The applicant must sign the application unless:  Deceased, or  Physically or mentally incompetent or incapable as determined by court order even with an authorized representative.

Refer to G-810 Applicant Unable to participate in the Eligibility Determination Process and G-1500 Death of Applicant Before Certification for more information on these two situations.

If application is missing a valid signature, the Agency will need to obtain the required signature from the applicant.

Consider the application form properly signed if it contains:  The applicants name and address; and  The signature of the applicant/tax filer or the signature of a responsible person if the applicant was unable to sign; or  The signature of at least one of the parent(s) of the child who resides in the home. Note: The signature of a minor who chooses to apply, without the consent of the parent or legal guardian, with whom they reside, is acceptable. Remote Identity Proofing (RIDP) For a real-time eligibility decision to be processed on electronic applications (online or by telephone with a CSU agent), RIDP is processed by the applicant providing answers to personal computer-generated questions to verify identity. If electronic ID proofing is unable to be established or the applicant chooses to skip identity proofing, the Agency representative will have to establish identity of the applicant through electronic system clearances or by requesting verification from applicant. Note: Paper Applications received by mail or in person do not require electronic ID proofing of the applicant.

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G-810 APPLICANT UNABLE TO PARTICIPATE IN THE ELIGIBILITY DETERMINATION PROCESS If the applicant has been determined by court order to be physically incapable or mentally unable to complete the application form and has no one to act on their behalf, complete the form with information received from:  The parent, spouse, curator, or legal guardian (a person legally responsible for the care and management of the person or property of an individual considered by law to be incompetent to manage his own affairs); or  The responsible person (a person trusted or depended upon to assist in the care and management of the person or property of an individual, who has not been declared incompetent to manage his/her own affairs); Note: If the responsible person refuses or fails to cooperate, assist the applicant in designating another responsible person.  A different friend or relative;  Any other person with information about the applicant's situation who is designated to act as an authorized representative; or  By the agency representative's verification and documentation. Note: If the applicant is unable to participate in the eligibility process, or when the LTC responsible person fails to keep appointments or provide requested information, it becomes the agency representative's responsibility to assist the applicant in completing the application process. When the applicant is unable to participate, obtain and document supervisory approval when assuming this responsibility.

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G-900 APPLICATION INTERVIEWS G-910 GENERAL INFORMATION Interviews are official and confidential discussions of household circumstances. Whenever an interview is conducted, the agency representative must:  Inform applicants of their rights and responsibilities;  Provide information about program policies and procedures;  Review information on the application form;  Evaluate all available information, including the existing case record; and  Explore and resolve any unclear or incomplete information. In-person interviews shall not be required as part of the application process in determining eligibility.

Appropriate referrals should be made to other agencies based on the needs of the applicant; including referral to the FFM should the applicant not be eligible for Medicaid/LaCHIP.

G-911.2 SOURCES OF VERIFICATION Self-Attestation Medicaid eligibility shall not be determined solely on self-declarations except for the below barring any post eligibility conflicting information that may be found:  Residency;  Age;  Household Composition;  Pregnancy;  Caretaker Relative;  Medicare;  Application for other Benefits; or  Third party liability (TPL).

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Note on Residency: Homeless applicants must meet residency requirements but do not deny assistance solely because the assistance unit does not reside at a fixed address or in a permanent dwelling. Assist the homeless family to establish a mailing address that will ensure receipt of their medical eligibility card (MEC) or decision letters. This could be the agency office, a local non-profit agency, or local post office where the beneficiary can pick up the MEC or decision letters.

Self-attested income from the applicant is cleared though the Federal Data Hub and Reasonable Compatibility rules are run to determine if the self- attested income is acceptable or needs to be verified by the applicant. Any income from Self-Employment that is under program income limits must be verified by the applicant. Refer to S-0000 Verification And Documentation.

Self-attestation may not be accepted for the following eligibility factors prior to being cleared through the data services Hub and, as a backup, through electronic data sources used by the agency:  Social Security Number (SSN);  Citizenship; or  Immigration status. Note: If these methods do not verify the self-attestation then self- attestation is accepted for that individual to avoid delays in eligibility. The applicant/beneficiary is then given a reasonable opportunity period to obtain satisfactory evidence for the individual before taking adverse action on the individual’s eligibility.

See I-352 Reasonable Opportunity to Present Satisfactory Documentary Proof of Citizenship and I-600 Enumeration. Verify any questionable information that affects eligibility. Sources may include available data sources, collateral contacts, copies of paid or unpaid medical bills, contacts with former employers or absent parents, or any other source that can verify the applicant/beneficiary’s situation. Only require the applicant to provide information that cannot be obtained from other data sources and is necessary to make an eligibility determination. Give the applicant/beneficiary written notice of the specific

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verifications required and the date the information is due. Allow at least ten (10) calendar days for an applicant/beneficiary to provide the requested verifications. Exception: Allow at least thirty (30) calendar days for a beneficiary to provide the requested verifications needed for a renewal of eligibility based upon MAGI methodology.

G-911.3 CASE RECORD DOCUMENTATION REQUIREMENTS Document in the case record how any questionable information was verified.

G-911.4 CASE ACTION Do not deny benefits because applicant/beneficiary gives questionable or inconsistent information, unless defined as refusal to cooperate. Deny benefits or close the case when the applicant/beneficiary fails to provide verification or refuses to cooperate in providing verification. Refer to G-1100 Cooperation thru G-1140 Failure to Cooperate for exceptions.

G-920 INTERVIEWS A face-to-face interview is not required. A telephone interview is allowed. Refer to G-800 Who May Apply for Assistance. If a long-term care interview cannot be conducted, refer to G-810 Applicant Unable to Participate in the Eligibility Process.

G-930 INTERVIEW SITES If the applicant/beneficiary requests a face-to-face interview, conduct it at an LDH office or an application center, if possible.

If not possible, conduct the interview at a site that is adequate to preserve the privacy and confidentiality of the interview, and convenient to both the applicant and the agency representative.

Adequate sites may include a hospital or a LTC facility.

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G-940 REQUIRED INTERVIEW EXPLANATIONS The agency requires all initial applications to be signed by the applicant under penalty of perjury.

During the application interview, explain the following in terms that the applicant can understand:  The applicant's responsibility to provide information that is true and correct to the best of their knowledge;  The applicant's responsibility to cooperate in the eligibility determination process;  The applicant's responsibility to report all changes that may affect eligibility;  The legal penalties for withholding information or providing false information;  That the applicant's SSN will be matched against files of the Social Security Administration (SSA);  The agency's confidentiality policy;  The agency's nondiscrimination and equal delivery of services policy;  The applicant's right to an agency conference or a fair hearing;  Assignment of rights to medical support and third party resources, and  Estate Recovery. NOTE: The National Voter Registration Act of 1993 (NVRA) requires the Agency to offer the applicant/beneficiary the opportunity to register to vote when applying for benefits, renewing benefits, or changing their address and/or name. During the application interview, the following information must be furnished to all applicants and other individuals who request it:  The eligibility requirements;  Available Medicaid Services; and

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 The rights and responsibilities of applicants and beneficiaries.

G-1000 SECURING INFORMATION TO DETERMINE ELIGIBILITY Secure essential information for determining eligibility. Only require the applicant to provide information that cannot be obtained from other data sources, or the information obtained electronically is not reasonably compatible, and is necessary to make an eligibility determination or for purposes directly connected to the administration of the Medicaid State Plan.

The agency shall not request verification for information sent to the agency by the FFM that has been verified.

Consider the applicant as the primary source of information. The act of designating an authorized representative does not change or diminish the applicant/beneficiary’s responsibility to provide complete and correct information on the application form.

The applicant/beneficiary/responsible person or authorized representative is required to:  Make an effort to obtain all information needed to determine eligibility;  Authorize the obtaining of documents from third parties;  Answer all eligibility related questions to the best of their knowledge; and  Report any changes that may affect eligibility. If the applicant cannot furnish all of the required verifications at the time of application:  Send a request for information (RI) that contains a list of the items or actions needed with the deadline for submission specified. Allow at least ten (10) calendar days for an applicant/beneficiary to provide the requested verifications.

Exception: Allow at least thirty (30) calendar days for a beneficiary to provide the requested verifications for a renewal. If the applicant is unable to obtain the needed information, provide assistance by:

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 Review of the EDMS;  Checking electronic data sources;  Use of consent forms signed by the applicant to request verification directly from collateral sources; and  Requesting assistance from other Medicaid regions and State agencies in order to secure court records and other pertinent data. In situations involving a life-threatening health condition requiring urgent medical care, the Medicaid analyst shall expedite the application process, taking special steps to obtain any required verifications, including a field visit, if necessary.

G-1100 COOPERATION The agency representative has a responsibility to decide whether an applicant is capable of participating in the eligibility process. Refer to G-810 Applicant Unable to Participate in the Eligibility Determination Process.

For all applicants incapable of cooperation due to a physical, mental or intellectual condition, the application shall not be rejected for failure to cooperate.

G-1110 COOPERATION BY PHYSICALLY AND MENTALLY ABLE APPLICANTS The applicant must cooperate in the process of determining eligibility by completing an application form, being interviewed (when necessary), and providing required information. Refer to G-1130 LTC Refusal To Cooperate.

The agency representative shall:  Allow adequate time for the applicant/beneficiary to receive notice of the interview and make arrangements to attend;  Inform the applicant in writing of what is required and the consequences of not cooperating;  Allow at least ten (10) calendar days for the applicant to provide the information or advise the agency representative that the requested

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information cannot be secured; and  Assist the applicant in obtaining the needed information or identify and secure alternate information. The applicant/beneficiary shall not be asked to provide information that is clearly impossible for them to secure. Only require the applicant/beneficiary to provide information that cannot be obtained from other data sources and is necessary to make an eligibility determination.

G-1120 COOPERATION BY LTC AND OTHER APPLICANTS UNABLE TO PARTICIPATE For applicants unable to participate in the eligibility determination process, refer to G-810 Applicant Unable to Participate in the Eligibility Determination Process.

G-1130 LTC REFUSAL TO COOPERATE The application may be rejected only if the applicant, parent, or legal guardian:  Is physically, mentally, or intellectually able to apply and provide information;  Has been notified of the need to provide information;  Has been advised of the consequences of not cooperating; and  Has refused to do so. Do not reject an application for refusal to cooperate if the responsible person refuses to cooperate. In this case, assist the applicant in designating another responsible person. If none can be located, refer to G-810 Applicant Unable to Participate in the Eligibility Determination Process or G-1120 Cooperation by LTC and Other Applicants Unable to Participate.

G-1140 FAILURE TO COOPERATE It is the agency's responsibility to pursue the eligibility determination through the decision, unless the applicant/beneficiary refuses to

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cooperate. Refer to G-1130 LTC Refusal to Cooperate.

Before denying or closing eligibility for failure to cooperate, review the case record to determine the following:  That the applicant/beneficiary/responsible person is physically, mentally, or intellectually able to meet responsibilities;  That adequate time was given to provide the information or evidence;  That the applicant/beneficiary was given enough notice to make arrangements to provide the information requested or has made contact asking for a specified future date to provide;  That the request for information was clear, in writing, and dated;  That the applicant/beneficiary/responsible person was informed of the responsibility for providing and consequences of not providing information; and  That the applicant/beneficiary is not claiming good cause for failure to cooperate in pursuing a responsible third party. Refer to I-200 Assignment of Rights.

G-1150 SECOND CONTACT SITUATIONS Second contacts are required in the following situations:

A patient in an acute care hospital is given ten (10) calendar days to provide requested information. If the information is not provided, a final notice is sent to the applicant with an additional ten (10) calendar days given to supply the requested information.

If the agency representative is unable to judge the applicant's capability, contact the applicant or responsible person prior to rejecting the application for:  Failure to cooperate in supplying requested data;  Refusal to comply with agency regulations; or  Failure to keep an appointment without contacting to reschedule. After the second contact, if the applicant or responsible person fails to comply with the above, reject the application effective the day following the date of noncompliance, ** or 60 days from the application date,

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whichever occurs later.

G-1200 RESERVED

G-1300 OBVIOUS INELIGIBILITY Reject the application at any point during the eligibility determination when there is enough information obtained and recorded to establish ineligibility. See S-0000 Verification and Documentation.  If enough information is provided on the application form or in the interview that establishes that not all eligibility factors are met, explain that the application will be rejected without any further investigation.  If the information is received after the initial interview, contact the applicant to establish that the information is correct. If correct, explain that the application will be rejected and send the appropriate notice of rejection. NOTE: Advise the applicant that the case is being referred to the FFM for enrollment in an IAP.

G-1400 WITHDRAWALS

Withdrawals are initiated by the applicant/beneficiary. An applicant may voluntarily withdraw the application or request closure of their case at any point in the eligibility process. The applicant is allowed to request withdrawal verbally or in writing. Document the case record with the reason for withdrawal denial or closure and send the appropriate notice.

G-1500 DEATH OF APPLICANT BEFORE CERTIFICATION If an applicant dies before certification and eligibility is established, certify the case. Eligibility cannot extend beyond the date of death.

An eligibility determination may be made even if the applicant dies before

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signing the application form. Refer to MEM G-600 Who May Apply for Assistance. If there is no one to act for the deceased applicant, complete the application form with information received:  From a person who is knowledgeable of the decedent’s circumstances and can report the required information for eligibility determination accurately and under penalty of perjury; or  By agency representative verification and documentation. The agency representative shall obtain sufficient evidence to support the decision. Note: Long Term Care and medical providers shall not be allowed to sign the application form. A disability decision is required for deceased applicants for the period of assistance requested, if the application is in the disability-related non- MAGI category (Category D) and the applicant did not receive a Social Security (SSA) disability determination.

G-1600 SECURING DISABILITY DECISIONS FOR NON-MAGI (FORMERLY B AND D) CATEGORIES

Refer to E-220 Blind (B) and E-240 Disabled (D) and I-2100 Supplemental Security Income (SSI) Eligibility Status.

If the applicant has not already been determined disabled by SSA, submit the Medical Eligibility Determinations Team (MEDT) package.

G-1610 DISABILITY DECISIONS

Louisiana Medicaid’s MEDT determines categorical eligibility for disability/blindness based on medical criteria established by the SSA under Section 1634 of the Social Security Act. An SSA disability decision takes precedence over any contrary state disability determination. An MEDT decision should not be requested when the individual receives SSA disability, SSI benefits, or Medicare.

A disability decision shall not be requested from MEDT if the individual is otherwise ineligible. Send the appropriate denial notice and refer the applicant’s case to the FFM for review for enrollment in an IAP.

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All Medicaid applications or renewals based on disability, including those for nursing facilities or waiver services programs, require submission of a complete MEDT package, unless there is an existing MEDT approval that covers the certification period.

The Medicaid analyst is expected to assist to obtain any required medical documentation for the package. In situations involving life-threatening health conditions requiring urgent care, expedite the application process.

G-1610.1 MEDT PACKAGE The MEDT Package consists of:  The request for an MEDT decision from an MEDT consultant which contains the applicable program type, specific notes on case the consultant would need to know, and the period of coverage requested;  Completed Social information Interview form (Form MS), for all adult decisions, or a Minor Child’s Medical and Social information form (Form MS/C), if a minor;  Medical records obtained from providers;  All previous MEDT decisions and supporting documentation.

G-1610.2 MEDT DECISION REQUIRED An MEDT decision is required if:  A disability decision has not been rendered by SSA;  SSA has rendered an unfavorable disability decision and: o Medical documentation is available to demonstrate the deterioration of the applicant’s medical condition since the SSA denial; o A new medical condition can be documented; o The applicant is appealing the SSA determination; or o The applicant is employed and applying for Medicaid Purchase Plan coverage;  Retroactive eligibility is requested; or  The applicant has been diagnosed as, or is suspected of being,

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infected with tuberculosis and is not eligible in a non-MAGI category (formerly category A, B, or D).  A favorable MEDT (or SSA) disability review has expired.

G-1610.3 MEDT DECISION NOT REQUIRED An MEDT decision is not required if:  A favorable SSA decision (or MEDT decision) has been rendered for disability or Medicare which covers the requested period of Medicaid eligibility;  The applicant is otherwise ineligible; or  The applicant has lost RSDI/SSI for a reason other than cessation of disability, and a favorable SSA disability decision has been made within the twelve (12) months prior to application.

G-1610.4 MEDT APPROVAL If the applicant is otherwise eligible. Authorize the case.

If a case has closed and later recertified, the MEDT decision remains in effect, unless there has been improvement in the beneficiary’s condition. Submit a new MEDT packet prior to the MEDT due date if there has been improvement in the beneficiary’s condition.

A subsequent adverse disability decision made by SSA/SSI, that is not timely appealed, takes precedence over the MEDT consultant decision.

Exception: Submit a new MEDT packet for re-evaluation of the agency’s disability determination if a subsequent adverse disability decision by SSA is made for an MPP beneficiary.

G-1610.5 MEDT DENIAL Reject the application or close the case upon receipt of the MEDT denial decision. If applicable, issue an advance notice of closure.

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G-1610.6 RECONSIDERATION OF MEDT DENIAL A request for reconsideration of the MEDT decision should be completed if:  New medical or social information is obtained; or  At appeal, additional medical documentation is available which supports the deterioration of the applicant/beneficiary’s condition; or  A new medical condition can be documented.

G-1610.7 RESUBMIT TO MEDT Resubmit a complete MEDT package:  If the MEDT decision does not include the needed period of coverage, i.e., retroactive;  For a different categorical decision requiring MEDT approval;  At renewal;  At renewal for a beneficiary who lost RSDI/SSI for a reason other than cessation of disability;  At renewal for a case certified or continued based on a Division of Administrative Law decision;  If there are changes in the case which require approval by MEDT for continuance; or  If a subsequent adverse disability decision is made by SSA/SSI for an MPP beneficiary. Exception: Do not resubmit to MEDT if the SSA Denial code is N07, N08, N15, N16, N30, N35, N40, N41, N44, N46 or N51. Note: Verbal MEDT approval will not be provided.

G-1610.8 REAPPLICATION AFTER MEDT DENIAL If the applicant reapplies within ninety (90) days from the date of a previous MEDT denial, reject the Medicaid application unless there has been a significant deterioration of the applicant’s medical condition or a

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new medical condition is documented.

Include the applicant's statement regarding the change in their medical condition since the last MEDT denial on the Form MS or MS/C.

G-1610.9 REQUESTING AUTHORIZATION FOR MEDICAL EXAM The analyst should first determine if medical documentation is available from a licensed physician, clinic, hospital, Disability Determination Services (DDS), Louisiana Rehabilitation Services (LRS), or other sources. If medical documentation is not available for an MEDT decision, a request for authorization of a medical exam shall be included on the request sent to the MEDT consultant. Note: A completed Form MS is required with the submittal.

If authorization is approved, the analyst shall request a written report from the physician regarding the applicant's medical condition. In accordance with instructions, Form MR-A shall be used to authorize payment for the examination. The written report shall be included as part of the complete MEDT packet.

G-1610.10 SSA CERTIFIES APPLICANT FOR SSI Upon receipt of documentation that SSA has certified the applicant for SSI:  Certify for Medicaid (manually or through the State Data Exchange (SDX) process);  Certify for LTC retroactively to the date of SSI eligibility if the applicant was a resident of an LTC facility and met all of the other eligibility factors (Refer to H-800 Long Term Care); and  Make appropriate case changes, if the case was certified based on the MEDT Consultant approval.

G-1610.11 SSA DENIALS If SSA has denied the applicant's/beneficiary’s SSI application based on disability in the last twelve (12) months and the applicant is not appealing

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the SSA denial, reject the application or initiate closure action if the case was certified based on the MEDT Consultant approval. Refer to L-0000 Changes. Exception: Submit or re-submit a MEDT packet for MPP disability determination if the applicant/beneficiary is employed.

G-1610.12 SSI APPEALS Pending Application Disability-Related Medicaid Request an MEDT decision if SSA has denied the application based on disability in the last twelve (12) months and the applicant provides documentation that the SSA determination has been timely appealed. Submit or re-submit an MEDT packet for program type MPP disability determination if the applicant/beneficiary is employed. Certified Disability-Related Medicaid Case If an individual receiving Medicaid based upon disability is determined by SSA not to be disabled under the SSI standard and the individual provides documentation that the SSA determination has been timely appealed, continue Medicaid coverage when all other eligibility factors are met until the final determination of disability has been made by SSA. Review available interfaces or contact the local SSA office requesting notice of appeal decision.

Follow-up with SSA is required every ninety (90) days.

G-1610.13 SIGNIFICANT DETERIORATION IN MEDICAL CONDITION AFTER SSA DENIAL If the applicant has been denied based on disability within the twelve (12) months prior to the Medicaid application, reject the Medicaid application unless:  An SSI appeal is in progress and the applicant’s income is above the Federal Benefit Rate (FBR);  A significant deterioration in medical condition can be documented;  A new medical condition can be documented; or  The applicant is employed and is applying for MPP coverage.

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Include the applicant's statement regarding the change in medical condition since the denial on the Form MS or MS/C. Give the applicant ten (10) days to provide additional documentation verifying the change in medical condition before submitting the request to the MEDT consultant.

G-1615 RESERVED

G-1620 SIMPLIFIED DISABILITY DECISIONS FOR INFANTS Louisiana Medicaid allows a simplified determination of disability based on minimal evidence for premature or low birth weight infants and/or those infants with an allegation or diagnosis of Down syndrome, even if no other medical impairments exist.

A simplified disability decision for infants always begins on the date of birth and extends until the child reaches the age of one (1) year (date of birth through the 12th month).

Continuing eligibility for Medicaid must be explored whenever there are changes in the child’s circumstances that affect eligibility or once the simplified disability period ends. Another MEDT decision is required for an ongoing disability decision. A review of all current medical evidence must be completed.

G-1620.1 MEDT PACKAGE MEDT will make the simplified disability decision for infants. Submit a MEDT package consisting of a current request for MEDT decision from the MEDT Consultant requesting a simplified disability decision with a birth certificate or other evidence (e.g., the hospital admission summary, physician or other medical professional’s statement) that shows: 1. A weight below 1,200 grams (2 pounds, 10 ounces) at birth; or 2. A gestational age (age from conception to birth) at birth as specified in the bulleted list below with the corresponding birth weight indicated: - If the gestational age is 37- 40 weeks and the weight at birth is less than 2,000 grams (4 pounds, 6 ounces); - If the gestational age is 36 weeks and the weight at birth is less

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than 1,875 grams (4 pounds, 2 ounces); - If the gestational age is 35 weeks and the weight at birth is less than 1,700 grams (3 pounds, 12 ounces); - If the gestational age is 34 weeks and the weight at birth is less than 1,500 grams (3 pounds, 5 ounces); - If the gestational age is 33 weeks and the weight at birth is at least 1,200 grams, but no more than 1,325 grams (2 pounds, 15 ounces); or 3. An allegation or diagnosis of Down syndrome.

G-1700 RE-USING THE APPLICATION FORM An application form may be reused to open a new application only in the following situations:  To reopen an application rejected in error; or  To reopen an application that was denied for failure to return documentation, when needed documentation is returned within 30 days; or  To reopen a Spend-Down MNP case when there is no break in quarters of coverage. Applications Rejected in Error Use the previous application date as the date of application when reopening an application rejected in error, or upon reconsideration resulting from an appeal request. Contact the applicant if additional information is needed to determine eligibility. If additional information is required, allow the applicant time to return the information.

Applications That Were Denied Use the previous application date as the date of application when needed documentation is received within 30 days of the mail date of the decision notice.

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Louisiana Medicaid Eligibility Manual Application Processing

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Spend-Down Medically Needy Program (SD-MNP) The BHSF Form 1-A used in making a determination for SD-MNP is valid for up to twelve (12) months from the date of application as long as there is no break in quarters of coverage. Refer to H-1011 MNP Groups for more information on SD-MNP. Re-using the Renewal Form For individuals whose eligibility was terminated at renewal for failure to return the renewal form or needed documentation, the agency must reconsider eligibility without requiring a new application if the renewal form and/or requested information is returned within 90 calendar days after the date of termination.

The renewal form returned within the reconsideration period serves as an application, which means the agency must make a determination consistent with application timeliness standards.

The effective date of coverage for individuals found eligible for Medicaid will be the 1st day of the month the renewal was returned. Up to 3 months of retroactive coverage is available if the individual received Medicaid services following their termination and meet the Medicaid eligibility requirements when services were received.

G-1800 RESERVED

G–1900 REFERRALS TO SSI An application for SSI is not a requirement for eligibility in any Medicaid Program.

If the applicant/beneficiary applies for SSI, the Agency will be notified by SDX of SSI certification or denial. Scenarios for general Medicaid applications See Z-400 Federal Benefit Rate for FBR amounts

Individuals with/without spouse Income and resources below FBR. Referral for SSI is required.

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Individuals with/without spouse Income below FBR but resources above SSI resource limit. Ineligible for SSI and Medicaid. Do not refer to SSI.

Couple

If both members of a couple are applying and their countable couple income falls below couple FBR and couple resource limit. Referral for SSI is required. Scenarios for LTC Medicaid applications See Z-400 Federal Benefit Rate for FBR amounts LTC applicant w/o community spouse Applicant’s income and resources below FBR. Referral for SSI is required.

LTC applicant w/o community spouse Applicant’s income below individual FBR, but resources exceed individual limit. Do not refer to SSI.

LTC applicant w/community spouse Applicant’s income below individual FBR. Resources in applicant’s name exceed SSI individual limit and/or countable couple resources exceed the individual resource limit. Do not refer for SSI. Explain the spousal impoverishment resource provisions and the allowance under Medicaid LTC Program for transfers to the community spouse. Referral for SSI may be appropriate at renewal.

LTC applicant w/community spouse Applicant’s income below individual FBR and countable couple resources below individual SSI resource limit. Referral for SSI required.

LTC Couple If both members of a couple are applying, consider income eligibility separately as individuals. If either has income below individual FBR, refer only that member for SSI.

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Scenarios for HCBS Medicaid applications See Z-400 Federal Benefit Rate for FBR amounts

HCBS applicant, no spouse Income and resources below individual FBR. Referral for SSI required.

HCBS applicant, no spouse Income below individual FBR, but resources exceed limit. Do not refer for SSI.

HCBS applicant w/spouse Applicant’s income (including deemed income from ineligible spouse) and resources fall below individual FBR. Referral for SSI required.

HCBS applicant w/spouse Income is below FBR, but resources exceed individual limit. Do not refer for SSI. Explain the spousal impoverishment resource provision and the allowance under Medicaid LTC/HCBS programs for transfers to the community spouse.

G-2000 DECISION NOTICES Send the eligibility decision notice to the applicant upon disposition of the application.

For limited certifications (e.g., deceased applicant, complete retroactive certifications, and SD-MNP), the notice of certification may also serve as the closure notice.

The agency must provide individuals with the choice to receive notices and information in electronic format or by regular mail.

When an applicant/beneficiary is determined ineligible using the MAGI income methodology and the applicant/beneficiary is not aged, blind, or disabled, a notice shall be sent advising the applicant/beneficiary of the decision and advising them that their application is being referred to the Marketplace.

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LTC Only Send a notice of the eligibility decision to the applicant/authorized representative and the LTC facility.

HCBS Only Send a notice of eligibility decision to the applicant, the HCBS provider, and the LDH Office for Citizens with Developmental Disabilities (OCDD) or LDH Office of Aging and Adult Services (OAAS), as applicable.

G-2100 RETROACTIVE REIMBURSEMENT The agency reimburses the Medicaid beneficiary for part or all of any medical expenses paid by them from the effective date of eligibility through the date that they are expected to receive their MEC or the reactivation of the MEC.

Beneficiaries are eligible for reimbursement of medical expenses paid up to three (3) months prior to the month of application only if they request retroactive eligibility on their application and they are certified for the months requested. Refer to H-1800 Retroactive Medical Eligibility.

(h-100)Louisiana Medicaid Eligibility Manual (LDH): H - 100 General Information#

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

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Deleted text indicated by “**” H-0000 ELIGIBILITY DETERMINATIONS H-100 GENERAL INFORMATION

To determine eligibility, you must: • Have a complete application form; and • Verify all eligibility factors.

During the application review process: • Determine who is applying; • Determine what kind of assistance is being requested; and • Offer assistance to household members for whom assistance is not requested, if appropriate. H-100.1 Selecting A Program

In order to protect the rights of the applicant, review the applicant’s circumstances and potential eligibility in all programs for which the applicant may qualify. Refer to E-0000 Category, F-0000 Medical Programs, and I-0000 Eligibility Factors. The agency representative shall consider: • MAGI-related groups: o Adults; o Pregnant women; and/or o Children under age 19. See H-110 Roll-Down for MAGI-Related Assistance . • Non-MAGI-Related programs, such as: o Provisional Medicaid (PM), for applicants/enrollees who are aged (65 or older) or disabled and meet all eligibility requirements in the Supplemental Security Income (SSI) program. Refer to H-3300 Provisional Medicaid;

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Deleted text indicated by “**” o Family Opportunity Act Medicaid Buy-In Program (FOA), for children with disabilities and family gross income at or below 300 percent of the Federal Poverty Limit (FPL). Refer to H-2300 Family Opportunity Act Medicaid Buy-in Program; o Qualified Medicare Beneficiary (QMB), for all applicants or enrollees who are entitled to or enrolled in Medicare Part A. Consider QMB Plus eligibility before considering eligibility for QMB Only. Refer to H-1100 Qualified Medicare Beneficiary (QMB); o Specified Low-Income Medicare Beneficiary (SLMB), for all applicants/enrollees who are entitled to or enrolled in Medicare Part A. Consider SLMB Plus eligibility before considering eligibility for SLMB Only. Refer to H-1300 Specified Low-Income Medicare Beneficiary; o Qualified Individuals (QI), for all applicants/enrollees who are entitled to or enrolled in Medicare Part A. Refer to H- 2000 Qualified Individuals (QI); o Qualified Disabled and Working Individual (QDWI). Refer to H-1200 Qualified Disabled and Working Individuals (QDWI); and o Extended Medicaid (Disabled Adult Children (DAC), Disabled Widows/Widowers (DW/W), Early Widows/Widowers (EW/W), Pickle, and Disabled Widows/Widowers/Divorced Spouses with no Substantial Gainful Activity (SGA Disabled W/W/DS)), for every former SSI beneficiary who applies for Medicaid. Refer to H-600 Extended Medicaid. o Medicaid Purchase Plan, for people with disabilities who work. Refer to H-2100 Medicaid Purchase Plan (MPP). o Act 421 Children’s Medicaid Option (TEFRA) for children with disabilities who live in the community and who meet level of care provided in an institution. Refer to H-3800 Act 421 - Children's Medicaid Option (TEFRA). o Eligibility for long term care (LTC) for applicants in or who will enter a LTC facility (refer to H-800 Long Term Care), or who have been offered an opportunity for home and

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Deleted text indicated by “**” community based services (HCBS). Refer to H-900 Home and Community Based Services (HCBS). o Spend-Down Medically Needy Program (SD-MNP) eligibility for applicants denied Medicaid because of income. Refer to H-1000 Medically Needy Program – General Information. See also H-110 Roll-down for MAGI-related Assistance. o Acute Care Hospital (ACH) eligibility for individuals institutionalized in an Acute Care Hospital for at least 30 consecutive days. Refer to H-850 Long Term Care Note: An institutionalized individual with a community spouse and resources that exceed the allowable limits for another Medicaid program may be eligible using spousal impoverishment resource provisions. Refer to I-1660 Spousal Impoverishment Resource Provisions (LTC/HCBS).

An applicant has the right to apply for Medicaid in any program. If the applicant/enrollee insists on including persons in a program for which they are obviously ineligible, complete the eligibility process and certify only eligible individuals. Notify the applicant of the individuals found ineligible.

Once a program has been selected, determine eligibility in accordance with policy for that program. H-100.2 Evaluation of Eligibility in Other Programs

Eligibility in other assistance programs must be considered and the applicant/enrollee must be advised of other programs for which he may be eligible if: • At any point during the application process an applicant is determined ineligible; • At any point after certification an enrollee is determined ineligible; or • A new member enters the household. SD-MNP eligibility must be considered if the applicant/enrollee is income ineligible for all programs.

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Deleted text indicated by “**” Note: Eligibility for children under age 19 is continuous for twelve (12) months, unless: • The child moves out of state; • The child dies; • A written request for closure is received; or • The child reaches age 19.

Continuous eligibility begins in the month of application. Refer to H-1900 Continuous Eligibility for more information. H-100.3 Reserved H-110 ROLL-DOWN FOR MAGI-RELATED ASSISTANCE

There is a specific order for considering the kinds of assistance for which MAGI-related Medicaid eligibility must be examined.

The order is as follows: • Parent and Caretaker Relatives Group (PCR); • Former Foster Care (FFC); Note: If an individual is eligible for both the FFC program and the optional AG program, enroll the individual in FFC. • Pregnant Women Group (PW); • Adult Group (AG); • Children Under Age 19 Group; Note: If a child under age 19 is eligible for both CHAMP and the PW program, enroll the child in CHAMP. • Transitional Medical Assistance, Continued Medicaid; • Regular MNP;

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Deleted text indicated by “**” • MAGI-related SD-MNP; and, • Take Charge Plus (TCP). Note: Due to the conversion of net income standards to MAGI equivalent income standards, individuals who would have qualified for Regular MAGI-related MNP qualify under the Parent and Caretakers Relatives Group. H-110.1 MAGI-Related Eligibility Groups

An individual may be considered for MAGI-related MNP only when that individual has been: • Appropriately included in a MAGI-related eligibility group (PCR, Pregnant Women, a Children under age 19 group, or Continued Medicaid); and • Denied Medicaid because of income. Note: Individuals determined income ineligible for the AG are not considered for SD-MNP. An individual must be a parent, a caretaker relative, a pregnant woman, a child under age 19, or in a Continued Medicaid program for eligibility to be considered in MAGI-related SD-MNP.

Applicants can be certified in only one full-benefit MAGI-related eligibility group.

Medicaid enrollees who become ineligible shall be considered for eligibility in all other programs before being closed. H-110.2 Medically Needy

The Medically Needy Program (MNP) must, by regulation and interpretation, serve persons who are not eligible in a MAGI-related or Non-MAGI-related assistance group because of income. All persons must first be considered for assistance in a MAGI-related or Non- MAGI-related program. Only if the individual is ineligible for assistance because of income can MNP be considered Only if the applicant does not qualify for coverage because of income under any of the following MAGI-related eligibility groups can eligibility in SD-MNP be considered:

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Deleted text indicated by “**” • Parents and Caretaker Relatives Group; • Pregnant Women Group; and • Children Under Age 19 Group. Note: Individuals determined income ineligible for the AG program are not considered for SD-MNP. An individual must be a parent/caretaker relative, pregnant woman, or a child for eligibility to be considered in MAGI-related SD-MNP. Refer to H-1021.4 Establish Need, which specifies who is to be included in the medically needy income eligibility standard (MNIES). H-110.3 Documentation

Document that all full Medicaid coverage programs were considered prior to a SD-MNP Program determination.

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Deleted text indicated by “**” H-110.4 Roll-Down Flowchart For MAGI-Related Rejections, Closures, Or Removal Of Ineligible Enrollees

MAGI Groups (non-aged, blind, disabled) Non-disabled Adults Children under age 19 Pregnant women PCR Income to 24% FPL Former Foster Care (age 18 to 26; no income test; If eligible for both FFC and AG programs, enroll the individual in FFC.) Loses PCR/FITAP coverage due to increased income Transitional Medicaid (up to 1 year additional coverage) Adult Group Income to 138 % FPL (no Medicare coverage)

CHAMP Income to 147% FPL LaCHIP Income 148% to 255% FPL

CHAMP Income to 147% FPL Medicaid Citizens & Legal Immigrants Income to 138% FPL CHIP (Unborn Option) Citizens & Legal Immigrants Income 139% to 214% FPL Documented/Undocumented Non-immigrants Income to 214% FPL If over the income limit for above (except for AG), consider Regular MNP and SD-MNP. (Non-immigrant pregnant women who fall to MNP can only be covered for emergency medical services, which include labor and deliver)

TCP Income to 138% FPL (family planning coverage only)

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Deleted text indicated by “**” H-120 ROLL-DOWN FLOWCHARTS FOR NON-MAGI-RELATED REJECTIONS, CLOSURES, OR REMOVAL OF INELIGIBLE ENROLLEES

There is also a specific order for considering the kinds of assistance for which Non-MAGI Medicaid eligibility must be examined.

SD-MNP must, by regulation and interpretation, serve persons who are not eligible in another assistance group because of income. All persons must first be considered for assistance in a non-MAGI-related program. Only if the individual is ineligible for assistance because of income can SD-MNP be considered.

H-120.1 Roll-Down Flowchart For Non-MAGI-related (Formerly Aged, Blind, And Disabled Categories) Rejections, Closures, Or Removal Of Ineligible Beneficiaries

NON-MAGI Groups ABD Adults (over 18) Disabled Children under 18 LTC

Extended Medicaid Previously had SSI but lost it due to change in income.

DAC, D/W/W, E/W/W, Pickle and SGA Disabled W/W/DS

Provisional Medicaid

MPP Age 16-64, disabled and working (premium free or not)

Extended Medicaid Previously had SSI but lost it due to change in income.

Extended Medicaid Programs:

DAC (Age >18) OR Pickle

Act 421 – CMO

Provisional Medicaid

Individuals admitted to Nursing Facility or HCBS Waiver

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H-120.2 Roll-Down Flowchart for Other Rejections, Closures, Or Removal Of Ineligible Enrollees

MPP Age (16-64) Disabled and working (premium free or not)

FOA (premium free or not)

If over the income limit for the above, consider SD-MNP Other Programs Breast & Cervical Health (If not eligible for full benefits under another program) Emergency Medical Services Medicare Savings Programs

Tuberculosis

ACH Screened through CDC program and found to be in need of treatment for breast or cervical cancer (No income requirement for Medicaid but must be under 250% FPL to be screened through CDC) Individuals who otherwise meet criteria for a Medicaid program except for citizenship status. (coverage limited to services needed for treatment of certain emergency situations including labor and delivery)

QMB

SLMB

QDWI Diagnosed as, or suspected of, being infected with Tuberculosis 160% FPL MAGI-related

Individuals institutionalized in an acute care facility for 30 consecutive days or longer with income equal to or below 300% of the FBR

(h-600)Louisiana Medicaid Eligibility Manual (LDH): H - 600 Extended Medicaid#

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H-600 EXTENDED MEDICAID H-610 GENERAL INFORMATION

Medicaid coverage is protected for certain individuals who lose SSI/MSS eligibility.

To qualify for coverage in one of the Extended Medicaid programs, an applicant/beneficiary must have been eligible for both SSI (MSS) and RSDI in at least one month since April 1977 and:

● Received both a SSI or MSS payment and a RSDI payment, or

● Received SSI and was entitled to RSDI.

If a SSI recipient becomes entitled to RSDI benefits retroactively to a month in which he was receiving a SSI payment, the RSDI lump sum payment will be offset by the amount of the SSI payment. Even though the RSDI may offset the entire amount of SSI received, the individual still meets this requirement.

This requirement is met in situations where the individual is simultaneously entitled to RSDI and receiving a SSI or State supplemental payment for only one month, and that month is also the first month of entitlement to the RSDI benefit.

Example:

An individual who is already receiving SSI in June becomes entitled to RSDI effective that month as well. Entitlement to RSDI effective June 1 raises the individual's income to a point above the SSI income standard, and he/she loses SSI beginning July 1. The individual did not receive RSDI in June, because RSDI benefits are paid retrospectively; i.e. the benefit for June is not actually paid until July. However, the individual was entitled to RSDI as of June 1, the last

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month for which the individual was also eligible for and received a SSI benefit. Because entitlement to RSDI occurred in the same month as eligibility for and receipt of a SSI benefit (June), the individual can qualify for eligibility under the PICKLE amendment provided all other eligibility requirements are met.

Verify that the individual received benefits and was eligible for the benefits in at least one month since April 1977.

Verify in the following order:

● Case record documentation, if available, or

● SSA records, correspondence, or forms.

Note: It may be necessary to request a payment history from SSA for SSI and RSDI, if verification cannot be established through SSA on-line files.

H-610.1 Extended Medicaid Programs

Extended Medicaid is provided for applicants/beneficiaries who meet all eligibility requirements for coverage:

● As Disabled Adult Children,

● As Disabled Widow/Widowers,

● As Early Widow(er)s,

● Under the Pickle Amendment (result of the Lynch v. Rank decision), or

● As Disabled Widow(er)s/Divorced Spouses.

All SSI eligibility factors must continue to be met. SSI income standards are used in combination with budgeting rules, which allow the exclusion of certain benefits and COLAs.

If one member of a couple is applying he/she must be income eligible based on his/her income alone.

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If a member of a couple is applying in any of the Widows/Widowers programs, verify with SSA that the remarriage did not cause the applicant/beneficiary to lose the Extended Medicaid characteristics.

If both members of a couple meet the requirements for an Extended Medicaid program, determine their eligibility as a couple.

If they are ineligible as a couple they are both ineligible for Extended Medicaid. Do not determine eligibility as individuals.

H-610.2 Coverage

An Extended Medicaid beneficiary is eligible for the full range of Medicaid covered services.

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H-620 DISABLED ADULT CHILDREN (DAC) H-620.1 General Information Public Law 99-643 requires continuing Medicaid eligibility for individuals who are at least age 18 who:

 Became blind or disabled before age 22, and

 Lost SSI eligibility on or after July 1, 1987, as the result of entitlement to or increase in Child Insurance Benefits under Title II of the Social Security Act (RSDI).

Child Insurance Benefits are received by dependents based on a parent’s RSDI record. It is identified by the Beneficiary Identification Code (BIC) of “C” in the Social Security claim number. (Ex. 123-45- 6789-C1)

In the Extended Medicaid eligibility determination for Disabled Adult Children, disregard:

 The amount of RSDI (DAC) entitlement or increase which causes SSI ineligibility, and

 All RSDI COLAs received after SSI eligibility was lost.

Note: If the individual is receiving Child Insurance Benefits on more than one parent’s record, disregard all amounts regardless of which one actually causes SSI ineligibility.

H-621 ELIGIBILITY DETERMINATION PROCESS Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

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H-621.1 Determine Assistance/Benefit Unit The assistance/benefit unit consists of the applicant/beneficiary.

H-621.2 Establish Categorical Requirement SSA has determined that the applicant/beneficiary meets the blindness or disability requirement. H-621.3 Establish Non-Financial Eligibility Verify eligibility for the applicant/beneficiary with regard to the following factors:

● Assignment of Third Party Rights

I-200 ● Citizenship/Identity & Qualified Non-Citizen Status I-300 ● Enumeration

I-600 ● Residence

I-1900 ● SSI Requirement: Loss of SSI

H-610

H-621.4 Establish Need A. Determine Composition of the Income/Resource Unit

The income/resource unit consists of the:

● Applicant/beneficiary,

● Applicant/beneficiary and ineligible spouse living in the home, or

● Applicant/beneficiary who are a couple.

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B. Determine Need/Countable Resources

Determine total countable resources of the members of the resource unit. Refer to I-1630, Need - SSI-Related Resources.

Compare the countable resources to the SSI resource limit for the number in the resource unit. Refer to Z-900 Resource Limits By Program.

If resources are greater than the limit, the applicant/beneficiary is ineligible for Extended Medicaid as a Disabled Adult Child.

If resources are equal to or less than the limit, the applicant/beneficiary is resource eligible for Extended Medicaid as a Disabled Adult Child.

C. Determine Need/Countable Income

Individual

If the applicant/beneficiary is an individual with no spouse or with an ineligible spouse with no income, complete the following steps:

Step 1. Determine current RSDI.

Step 2. Subtract the amount of RSDI entitlement or increase which caused SSI ineligibility.

Step 3. Subtract all RSDI COLAs received subsequent to loss of SSI.

Step 4. The remainder is the countable RSDI.

Step 5. Add any other countable unearned income.

Step 6. Subtract $20 SSI disregard from unearned income.

Step 7. Determine total gross earned income.

Step 8. Subtract any remainder of $20 SSI disregard from gross earnings.

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Step 9. Subtract earned income deduction from remaining gross earnings. Earned income deduction is $65 and one-half of remainder of earnings.

Step 10. Combine remainders from Step 6 and Step 9.

Step 11. Compare to Income Standard for Individual. If income is

** greater than the individual Federal Benefit Rate (FBR) limit, the applicant/beneficiary is ineligible.

Ineligible Spouse Deeming

If there is an ineligible spouse with income, complete budget steps 1 through 11 above using only the applicant/beneficiary’s income. If the income is ** greater than the individual limit, the applicant/beneficiary is ineligible and there is no deeming. If the applicant/beneficiary’s income is equal to or less than the FBR for one, apply deeming policy, I-1424.2 Income Deeming Procedures.

Note: In the deeming process, subtract COLAs from the RSDI of the ineligible spouse for the same years used for the applicant/beneficiary.

Couple

If both members of a couple are potentially eligible, complete steps 1 through 4 separately for each individual and go to Step 5.

Step 1. Determine current RSDI.

Step 2. Subtract the amount of RSDI entitlement or increase which caused SSI ineligibility.

Step 3. Subtract all RSDI COLAs received subsequent to loss of SSI.

Step 4. The remainder is the countable RSDI.

Step 5. Add any other countable unearned income.

Step 6. Subtract one $20 SSI disregard per income unit, if applicable.

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Step 7. Determine total gross earnings.

Step 8. Subtract any remainder of the $20 SSI disregard from gross earnings.

Step 9. Subtract one earned income deduction from the remaining gross earnings of the income unit. The earned income deduction is $65 and one-half of the remainder of the earnings.

Step 10. Combine the remainders in Step 6 and Step 9.

Step 11. Compare total countable income to the current FBR for a couple.

If the income is ** greater than the current FBR for a couple, the applicants/beneficiaries are not eligible for Extended Medicaid as a Disabled Adult Child. Consider eligibility in MNP.

If the income is equal to or less than the current FBR for a couple, the applicants/beneficiaries are eligible for Extended Medicaid as a Disabled Adult Child.

H-621.5 Eligibility Decision Evaluate all eligibility requirements and verification received to make the eligibility decision.

Reminder: Explore Retroactive Medical Eligibility. Refer to H-1800.

H-621.6 Certification Period The certification period cannot exceed 12 months.

H-621.7 Notice of Decision Send the appropriate notice of decision to the applicant/beneficiary.

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H-630 DISABLED WIDOWS/WIDOWERS (DW/W) The COBRA Act of 1985 required that states restore Medicaid eligibility to disabled widows/widowers who would be eligible for SSI had there been no elimination of the reduction factor and no subsequent COLAs. These individuals must have applied for Medicaid by December 1, 1988. There are no longer any people who qualify in this group in Louisiana. Due to this, all further information on this program has been removed.

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H-640 EARLY WIDOW/WIDOWERS (EW/W) H-640.1 GENERAL INFORMATION OBRA of 1987 (P.L. 100-203) extended Medicaid coverage effective July 1, 1988, to individuals who receive SSI prior to age 60 and are required to file for RSDI early widow(er)s benefits at age 60 to 65 as long as:

• They were receiving SSI prior to the month they began receiving SSA RSDI Widow(er) benefits,

• They would continue to be eligible for SSI if the amount of the SSA RSDI benefit were not counted as income, and

• They are not entitled to Part A Medicare.

Medicaid coverage for this program continues to age 65 or until the beneficiary becomes entitled to Part A Medicare.

Note: Recipients of RSDI EW/W may become entitled to Part A Medicare prior to age 65 if:

• They qualify under renal dialysis or a kidney transplant provisions, or

• They may be concurrently drawing SSA disability benefits on his/her own SSN. Entitlement to Medicare based on this disability would begin with the 25th month of entitlement to such benefit.

H-641 ELIGIBILITY DETERMINATION PROCESS Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

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H-641.1 Determine Assistance/Benefit Unit The assistance/benefit unit consists of the applicant/beneficiary. H-641.2 Establish Categorical Requirement At the time of SSI loss due to income, SSA has determined that the applicant/beneficiary meets the blindness or disability requirement.

NOTE: EW/W SSA benefits are entitled based on age and not disability. After 12 months from SSI loss, disability needs to be determined for the beneficiary.

H-641.3 Establish Non-Financial Eligibility Verify eligibility for the applicant/beneficiary with regard to the following factors:

● Assignment of Third Party Rights

I-200 ● Citizenship/Identity & Qualified Non-Citizen Status I-300 ● Enumeration

I-600 ● Residence

I-1900 ● SSI Requirement: Loss of SSI

H-610

H-641.4 Establish Need A. Determine Composition of the Income/Resource Unit

The income/resource unit consists of the:

● Applicant/beneficiary,

● Applicant/beneficiary and ineligible spouse living in the home, or

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● Applicants/beneficiaries who are a couple.

B. Determine Need/Countable Resources

Determine total countable resources of the members of the resource unit. Refer to I-1630 Need - SSI-Related Resources.

Compare the countable resources to the SSI resource limit for the number in the resource unit. Refer to Z-900 Resource Limits By Program.

If resources are greater than the limit, the applicant/beneficiary is ineligible for Extended Medicaid as a Widow(er).

If resources are equal to or less than the limit, the applicant/beneficiary is resource eligible for Extended Medicaid as a Widow(er).

C. Determine Need/Countable Income

Individual

If the applicant/beneficiary is an individual with no spouse or with an ineligible spouse with no income, complete the following steps:

Step 1. Disregard the full amount of Widow(er)s RSDI benefits.

Step 2. Determine total unearned income.

Step 3. Subtract $20 SSI disregard from unearned income.

Step 4. Determine total gross earned income.

Step 5. Subtract any remainder of $20 SSI disregard from gross earnings.

Step 6. Subtract earned income deduction from remaining gross earnings. Earned income deduction is $65 and one-half of remainder of earnings.

Step 7. Combine remainders from Step 3 and Step 6.

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Step 8. Compare to Income Standard for Individual. If income is ** greater than the individual FBR limit, the applicant/beneficiary is ineligible.

Ineligible Spouse Deeming

If there is an ineligible spouse with income, complete steps 1 through 8 above using only the applicant/beneficiary’s income. If the income is ** greater than the individual limit, the applicant/beneficiary is ineligible and there is no deeming. Consider MNP. If the applicant/recipient's income is equal to or less than the FBR for one, apply deeming policy, I-1424.2 Income Deeming Procedures.

Couple

If both members of a couple are potentially eligible, complete the following steps:

Step 1. Disregard the full amount of Widow(er)s RSDI benefits.

Step 2. Combine all unearned income of the couple

Step 3. Subtract one $20 SSI disregard from unearned income.

Step 4. Combine all earned income of the couple.

Step 5. Subtract any remainder of the $20 SSI disregard from gross earnings.

Step 6. Subtract one earned income deduction from the remaining gross earnings. The earned income deduction is $65 and one-half of the remainder of the earnings.

Step 7. Combine the remainders in Step 3 and Step 6.

Step 8. Compare total countable income to the current FBR for a couple.

If the income is ** greater than the current FBR for a couple, the applicant/beneficiary is not eligible for Extended Medicaid as a Widow(er). Consider eligibility in MNP.

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If the income is equal to or less than the current FBR for a couple, the applicant/beneficiary is eligible for Extended Medicaid as a Widow(er).

H-641.5 Eligibility Decision Evaluate all eligibility requirements and verifications received to make the eligibility decision. Retro decision could not be made prior to January 1988.

Reminder: Explore Retroactive Medical Eligibility. Refer to H-1800.

H-641.6 Certification Period The certification period cannot exceed 12 months.

Eligibility must end when the beneficiary becomes entitled to Medicare.

H-641.7 Notice of Decision Send the appropriate notice of decision to the applicant/beneficiary.

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H-650 PICKLE H-650.1 GENERAL INFORMATION Public Law 94-566, Section 503, protects Medicaid coverage for two different groups of aged, blind, or disabled persons who become ineligible for SSI or MSS as the result of:

● A cost of living increase in RSDI benefits, or

● Any other income reason.

Group One consists of individuals who:

• Are currently receiving RSDI benefits under Title II,

● Were eligible to receive both SSI/MSS and RSDI in at least one month since April 1, 1977 (Refer to H-610 General Information on entitlement requirements), and

● Lost SSI/MSS as the direct result of a RSDI COLA.

In the Extended Medicaid eligibility determination for Group One, disregard:

● The RSDI COLA that resulted in the termination of SSI/MSS, and

● All subsequent RSDI COLAs for the applicant/beneficiary and spouse.

Group Two consists of individuals who:

• Are currently receiving RSDI benefits under Title II,

● Were eligible to receive both SSI/MSS and RSDI in at least one month since April 1, 1977 (Refer to H-610 General Information on entitlement requirements),

and

● Lost SSI/MSS eligibility for some income reason other than a RSDI COLA (increase in or receipt of Title II

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[RSDI] or other income), and

• Would again be eligible for SSI except for COLAs received since the loss of SSI.

In the Extended Medicaid eligibility determination for Group Two, disregard all RSDI COLAs received after SSI/MSS eligibility was lost for the applicant/beneficiary and spouse.

H-651 ELIGIBILITY DETERMINATION PROCESS Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

H-651.1 Determine Assistance/Benefit Unit The assistance/benefit unit consists of the applicant/beneficiary.

H-651.2 Establish Categorical Requirement SSA has determined that the applicant/beneficiary meets the age, blindness, or disability requirement.

H-651.3 Establish Non-Financial Eligibility Verify eligibility for the applicant/beneficiary with regard to the following factors:

● Assignment of Third Party Rights

I-200 ● Citizenship/Identity & Qualified Non-Citizen Status I-300 ● Enumeration

I-600 ● Residence

I-1900

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● SSI Requirement: Loss of SSI

H-610 H-651.4 Establish Need A. Determine Composition of the Income/Resource Unit The income/resource unit consists of the:

● Applicant/beneficiary,

● Applicant/beneficiary and ineligible spouse living in the home,

● A minor applicant/beneficiary and his parent(s) living in the home, or

● Applicant/beneficiary who are a couple. B. Determine Need/Countable Resources Determine total countable resources of the members of the resource unit including resources deemed from the parents of an applicant/beneficiary who is a minor. Refer to I-1630 Need - SSI-Related Resources, and to I-1400, Need - Deeming.

Compare the countable resources to the SSI resource limit for the number in the resource unit. Refer to Z-900 Resource Limits By Program..

If resources are greater than the limit, the applicant/beneficiary is ineligible for Extended Medicaid under the Pickle Amendment.

If resources are equal to or less than the limit, the applicant/beneficiary is resource eligible for Extended Medicaid under the Pickle Amendment. C-1. Determine Need/Countable Income for Group One Individual

If the applicant/beneficiary is an individual with no spouse or with an ineligible spouse with no income, complete the following steps:

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Step 1. Determine current RSDI.

Step 2. Subtract the amount of the RSDI COLA which caused SSI/MSS ineligibility.

Step 3. Subtract all RSDI COLAs received subsequent to the loss of SSI.

Step 4. The remainder is the countable RSDI.

Step 5. Add any other countable unearned income.

Step 6. Subtract $20 SSI disregard from unearned income.

Step 7. Determine total gross earned income.

Step 8. Subtract any balance of $20 SSI disregard from gross earnings.

Step 9. Subtract earned income deduction of $65 and one-half of the remainder from remaining gross earnings.

Step 10. Combine amounts from Steps 6 and 9.

Step 11. Compare total countable income to the current FBR for Individual. If income is greater than the individual limit, the applicant/beneficiary is income ineligible.

Note: An individual who loses SSI benefits because of receipt of a Title II (RSDI) COLA which increases their countable income to exactly the amount of the FBR (non-pay status EO1/NO1) is technically entitled to SSI and thus, Medicaid eligible under the Pickle Amendment (Group One).

Ineligible Spouse Deeming

If there is an ineligible spouse with income, complete steps 1 through 11 above using only the applicant’s/beneficiary’s income. If the income is greater than the individual limit, the applicant/beneficiary is ineligible and there is no need to deem. Consider MNP. If the applicant's/recipient's income is equal to or less than the individual limit, apply deeming policy, I-1424.2 Income Deeming Procedures.

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Note: In the deeming process, subtract COLAs from the RSDI of the ineligible spouse for the same years used for the applicant/beneficiary.

Parent(s) to Child Deeming

If the applicant/beneficiary is a minor child, apply deeming policy, I-1424.2 Income Deeming Procedures. Any income deemed from the parent(s) is considered unearned income of the applicant/beneficiary.

Couple

If both members of a couple are potentially eligible, complete Steps 1 through 4 separately for each individual and go to Step 5.

Step 1. Determine current RSDI.

Step 2. Subtract the amount of the RSDI COLA which caused SSI/MSS ineligibility.

Step 3. Subtract all RSDI COLAs received subsequent to the loss of SSI.

Step 4. The remainder is the countable RSDI.

Step 5. Add any other countable unearned income.

Step 6. Subtract one $20 SSI disregard from unearned income.

Step 7. Determine total gross earned income.

Step 8. Subtract any balance of the $20 SSI disregard from gross earnings.

Step 9. Subtract one earned income deduction of $65 and one-half of the remainder from the remaining gross earnings of the income unit.

Step 10. Combine the amounts from Steps 6 and 9.

Step 11. Compare total countable income to the current FBR for a couple. If the income is ** greater than the current FBR for a

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couple, the applicants/beneficiaries are income ineligible for Extended Medicaid under the Pickle Amendment. Consider eligibility in MNP.

If the income is equal to or less than the current FBR for a couple, the applicants/beneficiaries are eligible for Extended Medicaid under the Pickle Amendment.

C-2. Determine Need/Countable Income for Group Two Individual

If the applicant/beneficiary is an individual with no spouse or with an ineligible spouse with no income, complete the following steps:

Step 1. Determine current RSDI.

Step 2. Subtract all RSDI COLAs received subsequent to the loss of SSI/MSS.

Step 3. The remainder is the countable RSDI.

Step 4. Add any other countable unearned income.

Step 5. Subtract $20 SSI disregard from unearned income.

Step 6. Determine gross earned income.

Step 7. Subtract any balance of $20 SSI disregard from gross earnings.

Step 8. Subtract earned income deduction of $65 and one-half of remainder from remaining gross earnings.

Step 9. Combine amounts from Steps 6 and 8.

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Step 10. Compare total countable income to the current FBR for Individual. If income is ** greater than the individual limit, the applicant/beneficiary is income ineligible.

Ineligible Spouse Deeming

If there is an ineligible spouse with income, complete budget steps 1 through 10 above using only the applicant/beneficiary’s income. If the applicant/recipient's income is **greater than the current FBR for an individual, the applicant/beneficiary is ineligible and there is no need to deem. If the applicant/beneficiary’s income is less than the FBR for one, apply deeming policy, I-1424.2 Income Deeming Procedures.

Note: In the deeming process, subtract COLAs from the RSDI of the ineligible spouse for the same years used for the applicant/beneficiary.

Parent(s) to Child Deeming

Couple

Step 1. Determine current RSDI.

Step 2. Subtract all RSDI COLAs received subsequent to the loss of SSI/MSS.

Step 3. The remainder is the countable RSDI.

Step 4. Add any other countable unearned income.

Step 5. Combine countable RSDI and unearned income for both members of the couple.

Step 6. Subtract one $20 SSI disregard per income unit.

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Step 7. Determine total gross earned income.

Step 8. Subtract any balance of the $20 SSI disregard from gross earnings.

Step 9. Subtract one earned income deduction from the remaining gross earnings of the income unit.

Step 10. Compare total countable income to the current FBR for a couple.

If the income is ** greater than the current FBR for a couple, the applicants/beneficiaries are not eligible for Extended Medicaid as a Pickle 2. Consider eligibility in MNP.

If the income is equal to or less than the current FBR for a couple, the applicants/beneficiaries are eligible for Extended Medicaid under the Pickle Amendment.

** H-651.5 Eligibility Decision Evaluate all eligibility requirements and verifications received to make the eligibility decision.

Reminder: Explore Retroactive Medical Eligibility. Refer to H-1800. H-651.6 Certification Period The certification period cannot exceed 12 months.

H-651.7 Notice of Decision Send the appropriate notice of decision to the applicant/beneficiary.

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H-660 DISABLED WIDOW(ER)S AND DISABLED SURVIVING DIVORCED SPOUSES (DW/W/DS) H-660.1 GENERAL INFORMATION Under the OBRA Act of 1990 (Public Law 101-508, Section 5103), Congress permanently revised the special, more restrictive disability standard for disabled widow(er)s to the disability standard that applies to all title II and SSI adult disability applicants.

These public laws protect Medicaid coverage for Widow(er)s who become ineligible for SSI due to receipt of SSA Disabled Widow(er)’s Benefits age 50-59 as long as:

• They were receiving SSI for the month prior to the month they began receiving RSDI payments, and

• They would continue to be eligible for SSI if the amount of the Widow(er) RSDI benefit were not counted as income,

• They are not entitled to Part A Medicare.

The beneficiary loses eligibility for DW/WS at entitlement to Part A Medicare. Since DW/W/DS SSA benefits are based on disability, each month of SSI eligibility, including non-pay status month, is counted toward the individuals five month disability waiting period and twenty four month Medicare waiting period which will reduce (or eliminate) the normal wait for entitlement to disability benefits and/or Medicare twenty-four month waiting.

H-661 ELIGIBILITY DETERMINATION PROCESS Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

H-661.1 Determine Assistance/Benefit Unit The assistance/benefit unit consists of the applicant/beneficiary.

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H-661.2 Establish Categorical Requirement SSA has determined that the applicant/beneficiary meets the blindness or disability requirement.

H-661.3 Establish Non-Financial Eligibility Verify eligibility for the applicant/beneficiary with regard to the following factors:

• Assignment of Third Party Rights

I-200

• Citizenship/Identity & Qualified Non-Citizen Status I-300

• Enumeration

I-600

• Medicare Ineligibility

I-1100

• Residence

I-1900

• SSI Requirement: Loss of SSI

H-610

H-661.4 Establish Need A. Determine Composition of the Income/Resource Unit

The income/resource unit consists of the:

● applicant/beneficiary,

● applicant/beneficiary and ineligible spouse living in the home, or

● applicant/beneficiary who are a couple.

B. Determine Need/Countable Resources

Determine total countable resources of the members of the resource unit. Refer to I-1630 Need - SSI-Related Resources.

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Compare the countable resources to the SSI resource limit for the number in the resource unit. Refer to Z-900 Resource Limits By Programs.

If resources are greater than the limit, the applicant/enrollee is ineligible for Extended Medicaid as a Disabled W/W/DS.

If resources are equal to or less than the limit, the applicant/enrollee is resource eligible for Extended Medicaid as a Disabled W/W/DS.

C. Determine Need/Countable Income

Individual

If the applicant/beneficiary is an individual with no spouse or with an ineligible spouse with no income, complete the following steps:

Step 1. Determine current RSDI.

Step 2. Subtract the full amount of Disabled W/W/DS RSDI benefits received.

Step 3. ** Add any other countable unearned income.

Step 4. Subtract $20 SSI disregard from unearned income.

Step 5. Determine total gross earned income.

Step 6. Subtract any remainder of $20 SSI disregard from gross earnings.

Step 7. Subtract earned income deduction from remaining gross earnings. Earned income deduction is $65 and one-half of remainder of earnings.

Step 8. Combine remainders from Step 5 and Step 8.

Step 9. Compare to Income Standard for Individual. Refer to Z-400 Federal Benefit Rate. If income is ** greater than the individual limit, the applicant/beneficiary is ineligible.

Ineligible Spouse Deeming

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If there is an ineligible spouse with income, complete budget steps 1 through 10 above using only the applicant/beneficiary income. If the income is greater than the individual limit, the applicant/beneficiary is ineligible and there is no deeming. If the applicant/recipient's income is equal to or less than the FBR for one, apply deeming policy, I-1424.2 Income Deeming Procedures.

Couple

If both members of a couple are potentially eligible complete Steps 1 through 3 separately for each individual and go to Step 4.

Step 1. Determine current RSDI.

Step 2. Subtract the full amount of Disabled W/W/DS RSDI benefits received.

Step 3. ** Add any other countable unearned income.

Step 4. Subtract one $20 SSI disregard per income unit.

Step 5. Determine total gross earned income of the couple.

Step 6. Subtract any remainder of the $20 SSI disregard from gross earnings.

Step 7. Subtract one earned income deduction from the remaining gross earnings of the income unit. The earned income deduction is $65 and one-half of the remainder of the earnings.

Step 8. Combine the remainders in Step 5 and Step 8.

Step 9. Compare total countable income to the FBR for a couple.

If the income is ** greater than the current FBR for a couple, the applicants/beneficiary are not eligible for Extended Medicaid as a Disabled W/W/DS. Consider eligibility in MNP.

If the income is equal to or less than the current FBR for a couple, the applicants/beneficiary are eligible for Extended Medicaid as a

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Disabled W/W/DS.

H-661.5 Eligibility Decision Evaluate all eligibility requirements and verification received to make the eligibility decision.

Reminder: Explore Retroactive Medical Eligibility. Refer to H-1800.

H-661.6 Certification Period The certification period cannot exceed 12 months.

H-661.7 Notice of Decision Send the appropriate Notice of Decision to the applicant/beneficiary.

(h-700)Louisiana Medicaid Eligibility Manual (LDH): H - 700 SSI Retroactive Medicaid#

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H-700 SSI RETROACTIVE MEDICAID

H-710 GENERAL INFORMATION Applicants for Supplemental Security Income (SSI) are asked by Social Security Administration (SSA) at the time of the application interview if they have unpaid medical bills incurred during the three months prior to the month of application. The response to this is indicated on the SSA interface information for both SSI certifications and rejections by "Y" (yes) and "N" (no).

Explore SSI Retroactive Medicaid for those applicants who indicate unpaid medical bills ("Y" indicator), whether the SSI application is approved or denied.

This program will provide retroactive Medicaid coverage to applicants/beneficiaries with income below the Federal Benefit Rate (FBR) and resources that meet SSI limits. ** If the applicant/beneficiary is not eligible for SSI in the retroactive period, explore current eligibility in all other Medicaid programs. A disability determination may be made by Medicaid’s Medical Eligibility Determination Team (MEDT) without having an SSI determination made by the SSA.

Refer to Retroactive Medical Eligibility (RME) MEM H-1800 for more information.

H-711 NOTIFICATION OF APPLICANTS/BENEFICIARIES FOR SSI

** Upon the SSI approval or denial interface indicating that retroactive coverage was requested, the applicant/beneficiary is notified of their right to request Medicaid coverage for the three months prior to SSI application.

H-712 REQUEST ** FOR RETROACTIVE COVERAGE

The individual has ** 90 days from the date of the notice to request this retroactive coverage period.

The SSI Retroactive Medicaid Eligibility determination is separate from the determination for current and on-going eligibility, but the same application form is used.

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Deleted text indicated by “**” Revised/added text indicated by underscore Verify any questionable information that affects eligibility. Document in the case record how any questionable information was verified.

H-713 RETROACTIVE CERTIFICATION

** Individual(s) requesting retroactive medical benefits shall have had a medical service during at least one of the months for which RME is considered. (It is permissible to accept the applicant's verbal statement.)

The retroactive period may consist of any or all of the three months immediately prior to the month of SSI application. The months of retroactive eligibility do not have to be consecutive.

Example: The beneficiary applied for SSI in June and is certified for SSI and Medicaid effective that month. The worker learns that the beneficiary had unpaid medical bills incurred in April. The beneficiary met all eligibility requirements for March and April, but ** was not income eligible for May. Certify the beneficiary for RME for March and April. Consider eligibility in Medically Needy Program (MNP) for May.

Note: Continuous eligibility begins in the month of application rather than the first month of eligibility. See H-1900 Twelve Months Continuous Eligibility for more information.

H-714 DENIAL FOR SSI BECAUSE OF DISABILITY

If SSA denied an application because SSI disability was not met, explore the possibility that disability existed for the year immediately preceding the SSI application date.

If the applicant states that disability was continuous throughout the 12 months prior to SSI application, submit ** an MEDT package for a disability decision for the three month period of potential retroactive eligibility.

If the applicant states there was no disability during this one-year period, explore Magi-Related programs. If not eligible for any Medicaid program, deny the application for retroactive coverage.

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Deleted text indicated by “**” Revised/added text indicated by underscore H-715 INCOME REJECTIONS Explore retroactive eligibility in MNP for an individual who was not eligible for SSI Retroactive Medicaid because of income. H-716 RESERVED H-721 ELIGIBILITY DETERMINATION PROCESS Determine eligibility for each month in the retroactive period by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

H-721.1 Determine Assistance/Benefit Unit The assistance unit includes the applicant/beneficiary or both members of a couple (legal or non-legal spouse) if they both meet the SSI Medicaid criteria.

H-721.2 Establish Categorical Requirement Verify that the applicant/beneficiary was:

● Aged,

● Blind, or

● Disabled.

Refer to E-0000, Category.

H-721.3 Establish Non-Financial Eligibility Verify eligibility for the applicant/beneficiary with regard to the following factors:

• Assignment of Third Party Rights I-200

• Citizenship/Identity and Qualified Non-Citizen Status

I-300

• Enumeration I-600

• Residence I-1900

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A. Determine Composition of the Income/Resource Unit

The income/resource unit consists of the:

• Applicant/beneficiary,

• Applicant/beneficiary and ineligible spouse (spouse is not disabled nor aged) living in the home,

• Applicant/beneficiary who is a minor and their parent(s) living in the home, or

• Applicants/beneficiaries who are a couple (both are disabled or aged).

B. Determine Need/Countable Resources

Determine total countable resources of the members of the resource unit, including resources deemed from the parents of an applicant/beneficiary who is a minor. Refer to I-1420, Need- Deeming, and to I-1630 Need-SSI Related Resources.

Note: The cash surrender value (CSV) of life insurance is counted if the face value of all policies that can accumulate CSV is greater than $1,500.

The maximum burial fund exclusion for SSI Retroactive Medicaid is $1,500.

For more information, see I-1634 Type of Resources (SSI-Related).

Compare the countable resources to the SSI resource limit for the number of persons in the resource unit. Refer to Z-900 Resource Limits by Program.

If resources are greater than the limit, the applicant/beneficiary is resource ineligible for SSI Retroactive Medicaid.

If resources are equal to or less than the limit, the applicant/beneficiary is resource eligible for SSI Retroactive Medicaid.

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Deleted text indicated by “**” Revised/added text indicated by underscore C. Determine Need/Countable Income

Individual

If the applicant/beneficiary is an individual with no spouse or with an ineligible spouse with no income, go to Step 1.

Parent(s) to Child Deeming

If the applicant/beneficiary is a minor child, apply deeming policy I- 1424.2, Need – Deeming. Any income deemed from the parent(s) is considered unearned income of the applicant/beneficiary in the individual steps. Go to Step 1.

Note: If there is more than one eligible child in the household, divide the income deemed from the parent(s) equally among them.

Exception: Deeming of income or resources is not applicable to newborns who have never been discharged from the hospital and are expected to remain in the hospital for more than 30 days. Deeming is only applicable the month after the newborn is discharged. Refer to I-1422, When Deeming is Not Applicable and G-1620, Simplified Disability Decisions for Infants.

Note: Consider eligibility for children under age 19 in a MAGI Child group before SSI Retroactive Medicaid.

Complete the following budget steps:

Step 1. Determine total countable unearned income.

Note: In-kind support and maintenance (ISM) is counted for the SSI Retroactive Medicaid program. (For more information on ISM, see I-1534 Types of Income - SSI Related).

Step 2. Subtract $20 SSI disregard from unearned income.

Step 3. The remainder is the countable unearned income.

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued April 18, 2022

Page 6 of H-700 Replacing November 1, 2000

Deleted text indicated by “**” Revised/added text indicated by underscore

Step 4. Determine total gross earned income.

Step 5. Subtract any remainder of $20 SSI disregard from gross earnings.

Step 6. Subtract earned income deduction from remaining gross earnings. Earned income deduction is $65 and one-half of remainder of earnings.

Step 7. The remainder is the countable earned income.

Step 8. Combine remainders from Step 3 and Step 7.

Step 9. Compare to Federal Benefit Rate (FBR) Income Standard for Individual. If income is greater than the individual limit, the applicant/beneficiary is ineligible. Refer to Z-400 Federal Benefit Rate (FBR).

Consider the individual for eligibility in H-1030 Spend- Down Medically Needy - SSI related (MNP).

Note: Do not count ISM in determining eligibility for MNP (See I-1534 Types of Income (SSI Related) ).

Compare to FBR Income Standard for Individual. If income is equal to or less than the individual limit, the applicant/beneficiary is eligible. Refer to Z-400 Federal Benefit Rate (FBR).

Ineligible Spouse Deeming

If there is an ineligible spouse with income, complete steps 1 through 9 listed above using only the applicant/beneficiary’s income. If the income is greater than the individual limit (Refer to Z-400 Federal Benefit Rate (FBR)), the applicant/beneficiary is ineligible and there is no deeming – consider MNP. If the applicant/beneficiary’s income is less than the individual income standard, apply I-1424.2 Income Deeming Procedures

Couple

If both members of a couple are potentially eligible, complete the following steps:

(h-700)(page-7)Page 7#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued April 18, 2022

Page 7 of H-700 Replacing November 1, 2000

Deleted text indicated by “**” Revised/added text indicated by underscore

Step 1. Determine total unearned income of the couple.

Step 2. Subtract one $20 SSI disregard from the total unearned income.

Step 3. The remainder is the countable unearned income.

Step 4. Determine total gross earned income of the couple.

Step 5. Subtract any remainder of the $20 SSI disregard from gross earnings.

Step 6. Subtract one earned income deduction from the remaining gross earnings of the income unit. The earned income deduction is $65 and one-half of the remainder of the earnings.

Step 7. The remainder is the countable earned income.

Step 8. Combine the remainders in Step 3 and Step 7.

Step 9. Compare total countable income to the current FBR for a couple. Refer to Z-400 Federal Benefit Rate (FBR).

If the income is greater than the current FBR for a couple, the applicants/beneficiaries are not eligible for SSI Retroactive Medicaid.

Consider eligibility in H-1030 Spend-Down Medically Needy - SSI related.

If the income is equal to or less than the current FBR for a couple, the applicants/beneficiaries are income eligible for SSI Retroactive Medicaid.

H-721.5 Eligibility Determination Process

Evaluate all categorical and eligibility requirements and verification received to make the eligibility decision for each month.

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued April 18, 2022

Page 8 of H-700 Replacing November 1, 2000

Deleted text indicated by “**” Revised/added text indicated by underscore H-721.6 Certification Period

The certification period is one, two, or three months, depending on the month(s) of eligibility.

H-721.7 Notice of Decision

Send the appropriate notice of decision to the applicant/beneficiary.

(h-800)Louisiana Medicaid Eligibility Manual (LDH): H - 800 Long Term Care#

(h-800)(page-1)Page 1#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 1 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” H-800 INDIVIDUALS IN INSTITUTIONS - SPECIAL INCOME LEVEL

H-800.1 General Information

Medicaid coverage is available to individuals in institutions whose income is less than or equal to the special income level (SIL). This includes individuals in a:  Nursing facility; or  Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID). The special income level is also used to determine income eligibility for:  Home and community-based services (HCBS) waiver; or  Program of All-Inclusive Care for the Elderly (PACE).

Determine income eligibility by comparing the individual’s gross earned and unearned income, before deductions, to the SIL standard. The SIL standard is equal to three times the SSI Federal Benefit Rate (FBR) for an individual.

Note: For individuals applying for nursing facility care or HCBS waiver (Adult Day Health Care (ADHC), Community Choice Waiver (CCW), New Opportunities Waiver (NOW), Supports Waiver (SW) and Residential Options Waiver (ROW)) whose income exceeds the SIL, continue reviewing eligibility under the Spend-Down Medically Needy program.

Eligibility under the SIL is applicable to a period of institutionalization likely to be at least 30 consecutive days. Refer to I-400 Continuity of Stay.

H-810 LONG TERM CARE (LTC) PROGRAM

An applicant/beneficiary may be eligible for Medicaid services in the LTC program if he/she is a resident of:

● A Medicaid certified nursing facility (NF);

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 2 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” ● A Medicare certified skilled nursing facility (SNF); or

● A Medicaid certified ICF/IID facility. H-810.1 Coverage Medicaid will pay all or part of the facility fee, in addition to a full range of Medicaid services, for eligible applicants/beneficiaries. The Medicaid facility fee payment is referred to as the vendor payment.

Medicare Part A

Medicare Part A covers Medicare skilled nursing care facility (SNF) services. Refer to H-840. H-810.2 Medical Certification The medical certification determination is not a disability determination. Refer to I-1000 Medical Certification.

Care is given and vendor payment is made to the nursing or ICF/IID facility according to the medical needs of the resident. ICF/IID facilities are certified to provide ICF/IID services only.

Before LTC vendor payment can be authorized for any applicant/beneficiary an evaluation of the individual's medical needs is completed by the facility and the applicant’s/beneficiary’s physician in order to recommend a level of care (LOC).

An evaluation of the recommended level is made by Office of Aging and Adult Services (OAAS), Office for Citizens with Developmental Disabilities (OCDD) or its designee to determine the need for facility care and the level of care required. The decision may be for a different LOC than the recommended level or that nursing care is not the appropriate placement for the applicant/beneficiary.

All individuals seeking admission to a nursing facility require a medical certification from the OAAS and/or the appropriate Level II authority prior to admission. If the individual meets nursing facility LOC, OAAS issues the Form 142 Notice of Medical Certification. Once the approved Form 142 has been obtained, the individual must be admitted to the facility within 30 calendar days of the date of the approval.

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 3 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” If the Form 142 expires before admission to the nursing home, a new Form 142 is required. Medicaid vendor payment shall not begin prior to the date that medical and financial eligibility is established, and shall only begin once the individual is actually admitted to the facility.

An approved Form 142 is required each time there is a change in LOC or when there is a change in ICF/IID facility.

The Form 142 is issued by the OAAS, OCDD or its designee.

The Form 142 documents the:

● Approval or disapproval of the level of care;

● Effective date of the level of care approval; and

● Expiration date, if applicable.

NOTE: For nursing facility residents needing services beyond the expiration date on the Form 142, the nursing facility must submit a continued stay request to the OAAS NFA Unit in accordance with the timelines set by OAAS. H-810.3 Patient Liability

After determining the applicant/beneficiary is financially eligible for payment of nursing home or ICF/IID services, the applicant/beneficiary becomes subject to the post-eligibility treatment of income (PETI) calculation rules.

Patient liability (PLI) is a post-eligibility calculation used to determine the amount the applicant/beneficiary must pay the LTC facility towards their monthly cost of care. It is based on the amount of monthly income remaining after allowable deductions. Refer I-1536 Deductions and to I-1538 Patient Liability-Post Eligibility Treatment of Income (PETI).

H-810.4 Optional State Supplement The Optional State Supplement (OSS) is a state funded payment**, which is made to certain LTC beneficiaries to help meet their personal care needs. Refer to J-300 Optional State Supplement (OSS) Payments and MEM Table Z-700.

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 4 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” H-810.5 Categories F (06), V (22), I (08), and O (15) The Department of Children and Family Services (DCFS) is responsible for determining eligibility for LTC and patient liability for children in state custody who are certified in Categories F, V, I, and O. H-810.6 Incurred Medical Expense Deduction

A deduction for incurred medical expenses (IME) may be allowed in the LTC post-eligibility PLI determination. Refer to I-1536 Deductions. H-820 MAGI-BASED LONG-TERM CARE H-820.1 General Information

Applicants/beneficiaries residing in a long-term care (LTC) facility may be certified for MAGI-based LTC.

Individuals eligible for MAGI-based LTC fall into these groups:

● Individuals whose Medicaid eligibility has already been determined using MAGI-based rules and are certified for Parent and Caretaker Relatives Group, Children Under Age 19 Group, or Pregnant Women Group or Regular Medically Needy (MNP) at the time of admission to the facility.

Note: Individuals whose eligibility has or has not been established in the Adult Group cannot be considered for MAGI-based LTC. Eligibility must be considered for Non-MAGI LTC.

Note: Temporary absence policy allows for a temporary absence from the household for up to 90 days with continued Medicaid eligibility.

● Individuals whose Medicaid eligibility has not been determined using MAGI-based rules, but would be eligible in Parent and Caretaker Relatives Group, Children Under Age 19 Group, or Pregnant Women Group or Regular Medically Needy (MNP) had they applied prior to admission to the facility.

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 5 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” Income eligibility is based on the MAGI income and household composition prior to admission to the facility. The countable income is compared to the applicable MAGI-based program. Refer to Z-200 Federal Poverty Income Guidelines. If eligible, the individual may remain in the MAGI-based eligibility determination for the month of admission and three additional months before determining eligibility for MAGI-based LTC or Non-MAGI LTC.

Individuals who are not eligible for MAGI-based LTC must be evaluated for Non-MAGI LTC (e.g. adult group, aged, blind or disabled). Refer to H-830 Non-MAGI Long Term Care.

H-821 ELIGIBILITY DETERMINATION PROCESS Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

Cases in categories F, V, O, I are the responsibility of DCFS. Refer a case certified in one of these categories to DCFS for the LTC determination of eligibility. H-821.1 Determine Assistance/Benefit Unit Refer to the MAGI-based assistance/benefit unit that the institutionalized applicant/beneficiary was or could be included in.

Note: Individuals whose eligibility has or has not been established in the Adult Group cannot be considered for MAGI-based LTC. Eligibility must be considered for Non-MAGI LTC.

H-821.2 Establish Categorical Requirements

Verify the institutionalized applicant is certified for a MAGI-based program or Regular MNP.

If the institutionalized applicant is not included in an active certification, verify the individual meets all the eligibility criteria for a MAGI-based program or Regular MNP if he/she had applied.

H-821.3 Establish NonFinancial- Eligibility Verify eligibility for the applicant/beneficiary with regard to the following factors:

 Age – MAGI-based I-100

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 6 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**”  Assignment of Third Party Rights I-200  Citizenship/Identity and Qualified Non-Citizen Status I-300  Enumeration I-600  Medical Certification I-1000  Residence I-1900  Support Enforcement Services (SES) I-2000  Creditable Health Insurance I-2200

H-821.4 Establish Need Household composition continues to include those of the existing case for the month of admission and three (3) additional months.

Institutionalized Children under age 19 and Pregnant Women

Beginning with the fourth month through the sixth month, for institutionalized children under age 19 and pregnant women, determine eligibility for MAGI-based LTC. The income unit consists of only the institutionalized individual.

Remove the institutionalized individual from the existing MAGI-based certification and certify the individual in MAGI-based LTC. If the individual remains institutionalized more than six months, determine eligibility in Non-MAGI LTC. Institutionalized Parents/Caretaker Relatives

Beginning the fourth month for parents/caretaker relatives who remain institutionalized, remove the institutionalized individual from the existing MAGI-based certification and determine their eligibility in Non- MAGI LTC (e.g. aged, blind, or disabled). Refer to H-830 Non-MAGI Long Term Care.

H-821.5 Eligibility Decision

Evaluate all categorical and eligibility requirements and verification received to make the eligibility decision to reject or certify.

H-821.6 Determine Patient Liability There is no patient liability for an individual who is eligible for MAGI- based LTC.

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 7 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” H-821.7 Certification Period The certification period cannot exceed six (6) months for children under age 19 and pregnant women. If the applicant/beneficiary remains institutionalized for more than six (6) months determine their eligibility in Non-MAGI LTC.

The certification cannot exceed three (3) months for Parent Caretaker Relative (PCR).

H-821.8 Notice of Decision Send the notice of decision to the applicant/beneficiary and a copy to the facility.

H-821.9 Post Certification The applicant/beneficiary is required to apply for other benefits they are potentially eligible to receive. The applicant/beneficiary is not required to apply for SSI but should be encouraged to do so.

H-830 NON- MAGI LONG TERM CARE H-830.1 General Information

Applicants/beneficiaries residing in an LTC nursing facility may be certified for Non-MAGI LTC.

Persons eligible in the Non-MAGI LTC program fall into these groups:

● Those who are eligible for SSI at the time of admission;

● Those who are not certified for SSI but meet all eligibility criteria;

● Those who are not income eligible for SSI in the community, but have income equal to or below the SIL; or

● Those whose income is above the SIL, but have enough incurred medical expenses to spend-down their excess income. A vendor payment will be made if the post-eligibility process results in a PLI below the facility fee.

● Those who are expected to be continuously institutionalized in an Acute Care Hospital (ACH) for at least thirty (30) Days (e.g., a Hospital or Rehabilitation Center) with income equal to or

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 8 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” below the SIL. H-830.2 Special Income Level Income eligibility is based on the applicant/beneficiary's gross income, excluding Veterans Administration (VA) aid and attendance.

The applicant/beneficiary’s gross earned and unearned income is compared to the SIL rate. The SIL is three (3) times the monthly SSI Federal Benefit Rate (FBR) for an individual. The couple SIL is double the individual SIL. Refer to Z-700 LTC/HCBS SIL Rate, Resource Limits and Personal Care Needs Allowance.

For applicants/beneficiaries whose income exceeds the SIL, continue reviewing eligibility under the Spend-Down MNP. Refer to H-1030 Spend-Down Medically Needy - SSI Related or H-1040 Spend-Down Medically Needy - Long Term Care - SSI Related.

Exception:

There is no eligibility for LTC Spend-Down MNP in ACH.

H-830.3 Personal Care Needs Applicants/beneficiaries are allowed to keep a protected amount of money from their monthly income to spend on personal care needs items not covered by the facility fee. Refer to Z-700 LTC/HCBS SIL Rate, Resource Limits and Personal Care Needs Allowance.

H-830.4 SSI Recipients SSI recipients who enter a LTC facility remain eligible for Medicaid if they continue to receive an SSI payment while in the facility and may be eligible for nursing facility vendor payment.

There are three (3) circumstances under which vendor payment to an LTC facility may be denied for an individual who receives SSI and has been medically certified to receive nursing facility services. They are:  A Medicaid Qualifying Trust (MQT) exists;  An OBRA ’93 trust exists; or  There has been a transfer of resources for less than fair market value (FMV). Note: Refer to I-1700 Trust to determine if the Trust is a

(h-800)(page-9)Page 9#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 9 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” countable resource to the SSI recipient or if it will be treated as a transfer of resources. Transfer of resources for less than FMV made by the SSI recipient must be explored before determining eligibility for vendor payment. Refer to I-1670 Transfer of Resources For Less Than Fair Market Value.

H-830.5 Continued SSI Benefits For Recipients Expected To Be Temporarily Institutionalized

Refer to I-1534 Supplemental Security Income (SSI).

H-831 ELIGIBILITY DETERMINATION PROCESS Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

Consider possible eligibility under policy for grandfathered beneficiaries if the case was grandfathered and/or converted. Refer to Z-1000 Maximum Resource Limits as of 12-73 for Grandfathered/Converted SSI Recipients.

H-831.1 Determine Assistance/Benefit Unit The assistance/benefit unit consists of the applicant/beneficiary.

H-831.2 Establish Categorical Requirement Verify that the applicant/beneficiary is:

● Aged;

● Blind; or

● Disabled.

Refer to E-0000 Category.

H-831.3 Establish NonFinancial- Eligibility Verify eligibility for the applicant/beneficiary with regard to the following factors:

(h-800)(page-10)Page 10#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 10 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**”  Assignment of Third Party Rights

I-200  Citizenship/Identity/Qualified Non-Citizen Status

I-300  Continuity of Stay

I-400  Enumeration

I-600  Medical Certification

I-1000  Residence

I-1900

H-831.4 Establish Need Verify that the applicant/beneficiary is medically certified and receiving LTC services from a Medicaid enrolled provider.

A. Determine Composition of the Income Unit

The income unit consists of:

● The applicant/beneficiary;

● Applicants/beneficiaries who are a couple (legally married) residing in the same facility; or

● For the month of admission, the applicant/beneficiary who is a minor child and the parent(s) with whom they lived during the month. Refer to I-1420 Need - Deeming. After the first month of eligibility, the income/resource unit consists of the applicant/beneficiary.

Note: Never consider the income of the community spouse/legal dependent(s) at home in determining eligibility for an institutionalized applicant/beneficiary. Refer to I-1537 Spousal Impoverishment Income Provisions.

B. Determine Need/Income

Determine the gross income of the applicant/beneficiary including any income deemed from the parent(s). Refer to I-1530 Need - SSI-Related Income.

The applicant/beneficiary must be income eligible based on gross income. If the gross income before any deductions or allowances is greater than the SIL consider eligibility for Spend-down MNP. Refer to H-1030 Spend-Down Medically Needy - SSI-Related or H-

(h-800)(page-11)Page 11#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 11 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” 1040 Spend-Down Medically Needy - Long Term Care – SSI-Related.

Note: Exclude any income received from VA Pension for Aid and Attendance from the gross income computation.

Add the gross earned and the gross unearned income, including any income deemed from the parent(s), and compare the total to the SIL. If the applicant/beneficiary is an individual, including a minor child who has income deemed from the parent(s), use the individual SIL.

If the total gross income of the applicant/beneficiary is greater than the SIL, the applicant/beneficiary is income ineligible. Consider eligibility for Spend-down MNP. Refer to H-1030 Spend-Down Medically Needy - SSI-Related or H-1040 Spend-Down Medically Needy - Long Term Care - SSI Related.

If the total gross income is equal to or less than the SIL, the applicant/beneficiary is income eligible. Continue the determination of need.

Reminder: Consider QMB or SLMB eligibility for all LTC applicants. Refer to H-1100 Qualified Medicare Beneficiary (QMB) or H-1300 Specified Low-income Medicare Beneficiary (SLMB).

Couples in the Same Facility

Beginning with the month that both the applicant/beneficiary and legal spouse reside in the same facility, determine whether it is to their advantage to have need considered: ● As a couple; or ● As individuals. First, consider eligibility for each member of the couple as an individual.

If one member of the couple has gross countable income greater than the SIL, consider eligibility as a couple.

If need is considered for the applicants/beneficiaries as a couple, use the couple SIL.

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 12 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” If the combined total gross income of the couple is equal to or less than the couple SIL, the applicants/beneficiaries are income eligible. Continue the determination of need using the couple resource limit.

If need is considered for the applicant/beneficiary as a couple, eligibility for Qualified Medicare Beneficiary (QMB) and/or Specified Low-Income Medicare Beneficiary (SLMB) should be reviewed using the couple QMB/SLMB standard.

If the combined gross income of the couple exceeds the couple SIL, the couple is income ineligible. Re-evaluate the eligibility of each member as an individual using the individual’s income and comparing it to the individual SIL. If the individual’s total gross income is equal to or less than the SIL, the individual is income eligible.

If one or both members of the couple remain income ineligible when considered as an individual, determine individual eligibility in Spend-down MNP. Refer to H-1030 Spend-Down Medically Needy - SSI-Related or H-1040 Spend-Down Medically Needy - Long Term Care - SSI Related.

C. Determine Composition of the Resource Unit

The resource unit consists of:

 The applicant/beneficiary;

 The applicant/beneficiary and the community spouse;

 Applicants/beneficiaries who are a couple (legally married) residing in the same facility; or

 For the month of admission, only the applicant/beneficiary who is a minor child and the parent(s) with whom he lived during the month. Refer to I-1420 Need - Deeming. After the first month of eligibility, the resource unit consists of the applicant/beneficiary.

D. Determine Countable Resources

Determine eligibility with regard to resources.

(h-800)(page-13)Page 13#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 13 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” Determine the total countable resources of the applicant/beneficiary. Refer to I-1630 Need - SSI-Related Resources.

If resources were disposed of or a trust was established within 60 months prior to application, refer to I-1670 Transfer of Resources for Less Than Fair Market Value. If the applicant/beneficiary is ineligible for vendor payment because of a transfer of resources for less than the fair market value (FMV), consider eligibility for Medicaid benefits without vendor payment.

If the applicant/beneficiary’s equity interest exceeds the allowable home equity limit, consider eligibility for Medicaid benefits without vendor payment. Refer to I-1634 Types of Resources (SSI- Related), Individuals with Substantial Home Equity.

For an applicant/beneficiary who entered the facility on or after September 30, 1989, and has a spouse in the community, refer to I-1660 Spousal Impoverishment Resource Provisions (LTC/HCBS).

Compare the total countable resources to the resource limit for an individual (or couple). Refer to Z-900 Resource Limits by Program .

If the countable resources are greater than the resource limit, the applicant/beneficiary is resource ineligible for LTC.

If the countable resources are equal to or less than the resource limit, the applicant/beneficiary is resource eligible for LTC.

If the resources of a couple are greater than the couple resource limit, consider eligibility for each member of the couple as an individual.

Note: If considered as an individual for resource purposes, the applicant/beneficiary shall also be considered as an individual for income purposes.

H-831.5 Eligibility Determination

Evaluate all eligibility requirements and verification received to make the eligibility determination.

Consider QMB or SLMB eligibility for all LTC applicants. Refer to H-1100 Qualified Medicare Beneficiary (QMB) or H-1300 Specified Low-income Medicare Beneficiary (SLMB).

(h-800)(page-14)Page 14#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 14 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**”

If ineligible based on income, consider for Spend-down MNP. Refer to H-1030 Spend-Down Medically Needy - SSI-Related or H-1040 Spend- Down Medically Needy - Long Term Care - SSI Related.

If the applicant/beneficiary is LTC eligible, determine the OSS payment and patient liability.

If the applicant/beneficiary is not eligible for vendor payment because of transfer of resources or equity interest in the home exceeds the established limit, the applicant/beneficiary is responsible for the entire LTC payment and he is not eligible to receive an OSS payment. H-831.6 Post Eligibility Determination

Determine OSS Payment

The OSS payment is for an applicant/beneficiary residing in a nursing or ICF/IID facility who has gross income of less than $38.00.

Refer to J-300, Optional State Supplement (OSS) Payments.

Determine Patient Liability

Post-eligibility treatment of income (PETI) rules are used to calculate an applicant/beneficiary’s contribution to their cost of care for nursing home, Home and Community Based Waiver or ICF/IID services. Also called patient liability (PLI). PLI is the amount the applicant/beneficiary must pay towards their monthly cost of care. It is based on the amount of monthly income remaining after allowable deductions.

Refer to I-1538 Patient Liability-Post Eligibility Treatment of Income (PETI) for the Patient Liability Calculation Process.

If the applicant/beneficiary has a community spouse, refer to I-1537 Spousal Impoverishment Income Provisions.

Note: After eligibility for a couple has been established using the couple SIL, income may be divided to the advantage of the couple but not to the disadvantage of the agency in determining the PLI for each applicant/beneficiary.

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 15 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” H-831.7 Certification Period

The certification period cannot exceed 12 months beginning with the first month of eligibility.

H-831.8 Notice of Decision

Send the notice of decision to the applicant/beneficiary/authorized representative.

Send a copy of the decision notice to the facility.

H-831.9 Post Certification

Applicant/beneficiaries are required to apply for any annuity, pension, retirement, and disability benefits for which they are entitled. They should be encouraged, but not required to apply for SSI cash benefits.

H-840 MEDICAID COINSURANCE—MEDICARE SNF H-840.1 General Information

Original Medicare Part A covers skilled nursing facility (SNF) care provided to an applicant/beneficiary on a short-term basis if the following conditions are met. The applicant/beneficiary:

● Has Medicare Part A;

● Has a 3-day qualifying hospital stay; and

 Receives skilled nursing facility (SNF) services.

Original Medicare Part A covers SNF care for up to a total of 100 days per Medicare benefit period:

● Days 1 – 20: Medicare pays the full cost. Medicaid has no responsibility for payment.

● Days 21 – 100: Medicare pays all but the daily coinsurance. Medicaid may assist with payment of the daily coinsurance.

Medicare is a third party payor and is billed first in this situation. Medicaid is the payor of last resort.

When the reimbursement from Medicare exceeds the maximum

(h-800)(page-16)Page 16#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 16 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” allowable by Medicaid, Medicaid will make an approved payment of $0.00. This claim is considered payment in full and the provider may not seek payment from the applicant/beneficiary.

Applicant/beneficiary income shall not be considered in determining vendor payments for a period of up to 100 days provided he/she remains eligible for Medicare. This also includes the period for which coinsurance is being paid by the Medicaid Program. Refer to LAC 50:II.10147(B).

H-841 ELIGIBILITY DETERMINATION PROCESS Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

H-841.1 Determine Assistance/Benefit Unit The assistance/benefit unit consists of the applicant/beneficiary.

H-841.2 Establish Categorical Requirement

Verify that the applicant/beneficiary is:

● Aged;

● Blind; or

● Disabled.

Refer to E-0000 Category.

H-841.3 Establish NonFinancial- Eligibility Verify eligibility for the applicant/beneficiary with regard to the following factors:

 Assignment of Third Party Rights I-200  Citizenship/Identity and Qualified Non-Citizen Status I-300  Continuity of Stay

I-400  Enumeration

I-600  Medical Certification

I-1000

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 17 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**”  Residence

I-1900 H-841.4 Establish Need

A. Determine Composition of the Income Unit

The income/resource unit consists of:

● The applicant/beneficiary;

● Applicants/beneficiaries who are a couple (legally married) residing in the same SNF; or

● For the month of admission only, the applicant/beneficiary who is a minor and the parent(s) with whom he lived during the month. Refer to I-1420 Need - Deeming.

B. Determine Need/Income

Determine the gross income of the applicant/beneficiary including any parental deemed income. Refer to I-1530 Need - SSI-Related Income.

The applicant/beneficiary must have gross income which is equal to or below the SIL to be eligible for Medicaid coinsurance. If his/her income before any deductions or allowances is greater than the SIL, consider for Spend-down MNP. Refer to H-1030 Spend-Down Medically Needy - SSI-Related.

Note: Exclude any income received from VA Pension for Aid and Attendance from the gross income computation.

Add the gross earned and the gross unearned income, including any income deemed from the parent(s), and compare the total to the SIL. If the applicant/beneficiary is an individual, including a minor child, who has income deemed from the parent(s), use the individual SIL.

If the total gross income is greater than the SIL, the applicant/beneficiary is income ineligible. Consider eligibility in Spend-down MNP.

If the total gross income is equal to or less than the SIL, the applicant/beneficiary is income eligible. Continue the determination

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 18 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” of need.

Couples in the Same Facility

Beginning with the month that both the applicant and legal spouse reside in the same facility, determine whether it is to their advantage to have need considered:

● As a couple; or

● As individuals.

If the applicants/beneficiaries are a couple, use the couple SIL.

If the total gross income of the couple is equal to or less than the couple SIL, the applicants/beneficiaries are income eligible. Continue the determination of need.

If the combined gross income of the couple exceeds the couple SIL, the couple is income ineligible. Re-evaluate the eligibility of each individual using the individual’s income and comparing it to the individual SIL. If the individual’s total gross income is equal to or less than the SIL, the individual is income eligible.

If one or both members of the couple have income above the individual SIL, determine eligibility in the Spend down MNP. Refer to H-1030 Spend-Down Medically Needy - SSI-Related.

If need is considered for the applicants/beneficiaries as a couple, consider eligibility for QMB/SLMB using couple QMB/SLMB limit.

C. Determine Composition of the Resource Unit The resource unit consists of:

 The applicant/beneficiary;

 The applicant/beneficiary and the community spouse;

 Applicants/beneficiaries who are a couple (legally married) residing in the same facility; or

 For the month of admission (the month of eligibility listed on

(h-800)(page-19)Page 19#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 19 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” the BHSF Form 142), only the applicant/beneficiary who is a minor and the parent(s) with whom he lived during the month. Refer to I-1420 Need - Deeming. After the first month of eligibility, the resource unit consists of the institutionalized individual.

D. Determine Need/Countable Resources Determine total countable resources of the applicant/beneficiary. Refer to I-1630 Need - SSI-Related Resources.

Transfer of resources or substantial home equity only applies to LTC vendor payment and does not apply to Medicaid coinsurance eligibility determination.

If the applicant/recipient entered the facility on or after September 30, 1989, and has a spouse living in the community, refer to I-1660 Spousal Impoverishment Resource Provisions (LTC/HCBS).

Compare the total countable resources to the resource limit for an individual (or couple). Refer to Z-900 Resource Limits by Program.

If the countable resources are greater than the resource limit, the applicant/beneficiary is resource ineligible for Medicaid coinsurance.

If the countable resources are equal to or less than the resource limit, the applicant/beneficiary is resource eligible for Medicaid coinsurance.

If the resources of a couple are greater than the couple resource limit, consider eligibility for each as an individual.

Note: If considered as an individual for resource purposes the applicant/beneficiary shall also be considered as an individual for income purposes.

H-841.5 Eligibility Decision Evaluate all eligibility requirements and verification received to make the eligibility decision.

Note: Consider income eligibility in QMB or SLMB. Refer to H-1100

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 20 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” Qualified Medicare Beneficiary (QMB) or H-1300 Specified Low- income Medicare Beneficiary (SLMB).

H-841.6 Certification Period The certification period cannot exceed three (3) months beginning with the first month of eligibility for Medicaid coinsurance because coinsurance is limited to up to 80 days.

The facility is responsible for notifying Medicaid of the first day of the coinsurance.

Eligibility for coinsurance cannot extend beyond the month in which the Medicare payment ends. The facility is responsible for notifying Medicaid of the last day of Medicare payment.

Note: Because the beneficiary has no PLI while on Medicare/Medicaid coinsurance, he may retain all or most of his income, which may cause an increase in resources. At certification, notify the applicant/responsible person that:

● Resource eligibility is a factor for continued eligibility in coinsurance, and for LTC vendor payment after the coinsurance period ends; and

● It is their responsibility to report if resources exceed the resource limit as of the 1st moment of the month.

 It is the responsibility of the analyst to verify resources prior to the start of vendor payment.

H-841.7 Notice of Decision

Send the notice of decision to the applicant/beneficiary.

Send a copy to the facility.

Note: If the Medicare skilled determination originally made by the Facility Utilization Committee is later denied by Medicare, change the type case on MEDS and issue notification of Medicaid eligibility.

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 21 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” H-850 ACUTE CARE HOSPITAL (ACH)

H-850.1 General Information

Medicaid coverage is available to Individuals institutionalized in an Acute Care Hospital for at least 30 consecutive days, whose income is equal to or below the Special Income Level (SIL) and whose resources are equal to or below the SSI limit.

Eligibility under the SIL is applicable to a period of institutionalization likely to continue at least 30 consecutive days. Refer to I-400 Continuity of Stay.

H-850.2 Special Income Level Income eligibility is based on the applicant/beneficiary's gross income, excluding Veterans Administration (VA) aid and attendance.

The applicant/beneficiary’s gross earned and unearned income is compared to the SIL rate. The SIL is three (3) times the monthly SSI Federal Benefit Rate (FBR) for an individual. The couple SIL is double the individual SIL. Refer to Z-700 LTC/HCBS/ACH SIL Rate, Resource Limits and Personal Care Needs Allowance.

H-850.3 Patient Liability

There is no patient liability (PLI) for an individual who is eligible for ACH.

H-851 ELIGIBILITY DETERMINATION PROCESS

Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

H-851.1 Determine Assistance/Benefit Unit The assistance/benefit unit consists of the applicant/beneficiary.

H-851.2 Establish Categorical Requirement

Verify that the applicant/beneficiary is:

(h-800)(page-22)Page 22#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 22 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**”  Aged;

 Blind; or

 Disabled.

Refer to E-0000 Category.

H-851.3 Establish NonFinancial- Eligibility

Verify eligibility for the applicant/beneficiary with regard to the following factors:

 Assignment of Third Party Rights I-200  Citizenship/Identity and Qualified Non-Citizen Status I-300  Continuity of Stay

I-400  Enumeration

I-600  Residence

I-1900

H-851.4 Establish Need

A. Determine Composition of the Income Unit

The income unit consists of:

 The applicant/beneficiary

B. Determine Need/Income

The applicant/beneficiary must have gross income which is equal to or below the SIL to be eligible for ACH Medicaid.

Note: Exclude any income received from VA Pension for Aid and Attendance from the gross income computation.

Add the gross earned and the gross unearned income and compare the total to the individual SIL.

(h-800)(page-23)Page 23#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 23 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” If the total gross income is greater than the SIL, the applicant/beneficiary is income ineligible.

If the total gross income is equal to or less than the SIL, the applicant/beneficiary is income eligible. Continue the determination of need.

C. Determine Composition of the Resource Unit The resource unit consists of:

 The applicant/beneficiary; or

 The applicant/beneficiary and the community spouse;

D. Determine Need/Countable Resources Determine total countable resources of the applicant/beneficiary. Refer to I-1630 Need - SSI-Related Resources.

Transfer of resources or substantial home equity only applies to LTC vendor payment and does not apply to ACH eligibility determinations.

If the applicant/recipient entered the facility on or after September 30, 1989, and has a spouse living in the community, refer to I-1660 Spousal Impoverishment Resource Provisions (LTC/HCBS/ACH).

Compare the total countable resources to the resource limit for an individual (or couple). Refer to Z-900 Resource Limits by Program.

If the countable resources are greater than the resource limit, the applicant/beneficiary is resource ineligible for Medicaid coinsurance.

If the countable resources are equal to or less than the resource limit, the applicant/beneficiary is resource eligible for Acute Care Hospital coverage.

H-851.5 Eligibility Decision Evaluate all eligibility requirements and verification received to make the eligibility decision.

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Note: Consider income eligibility in QMB or SLMB. Refer to H-1100 Qualified Medicare Beneficiary (QMB) or H-1300 Specified Low- income Medicare Beneficiary (SLMB).

H-851.6 Certification Period The certification period cannot exceed twelve (12) months beginning with the first month of eligibility for Medicaid.

H-851.7 Notice of Decision

Send the notice of decision to the applicant/beneficiary.

H-860 UNDUE HARDSHIP AND UNDUE HARDSHIP EXCEPTION H-860.1 General Information An undue hardship may exist when a penalty is determined due to a transfer of assets or equity in home property being over the limit. The penalty would be the denial of vendor payment for nursing facility or home and community-based waiver services. An exception to the penalty may be requested if it is determined that imposing the penalty would cause undue hardship. The exception is for the applicant/beneficiary, not the community spouse. An applicant/beneficiary shall be informed in writing of the opportunity to apply for an undue hardship exception.

H-865 UNDUE HARDSHIP An undue hardship exists when the applicant/beneficiary's denial of eligibility for vendor payment results in:

● Denial of necessary medical care such that the individual's health or life would be endangered; or

● Loss of food, clothing, permanent residence and other necessities of life.

Undue hardship does not exist when application of the transfer of assets or excess equity in home property merely causes the individual inconvenience or restricts his or her lifestyle but would not put him/her

(h-800)(page-25)Page 25#

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Reissued January 6, 2026 Page 25 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” at risk of serious deprivation as described above.

Undue hardship does not exist in the following instances:

1. When transfers are made to the following persons:

● Blood relatives to a third degree cousin;

● Mother-in-law;

● Father-in-law;

● Brother-in-law; or

● Sister-in-law.

2. Undue hardship does not exist if the individual who transferred the assets, or on whose behalf the assets were transferred, has not exhausted all lawful means to recover the assets or the value of the transferred assets.

3. Undue hardship does not exist if the applicant/beneficiary’s health or age indicated a need for LTC services was predictable at the time of the transfer. H-870 UNDUE HARDSHIP EXCEPTION

An undue hardship exception is the dismissal of the penalty, either in whole or in part, which otherwise would have been imposed against an applicant/beneficiary after finding that an undue hardship exists.

H-870.1 Request for Undue Hardship Exception

Prior to imposition of a penalty the applicant/beneficiary must be sent a notice (Notice of the Right to Apply for a Hardship, BHSF Form 2- Hardship) that explains the penalty, their right to apply for an exception and how to apply for the exception. The notice must clearly state:

 That the request for consideration of the exception must be postmarked within seven (7) business days following receipt of the notice;

 That documentation supporting the request for the exception must be provided; and

 The address for the Medicaid office to which the request must be sent.

The Department of Health (LDH) may extend the request period if it

(h-800)(page-26)Page 26#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 26 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” determines that extenuating circumstances require additional time.

The request for the exception may be made by the applicant/beneficiary, his representative, or the facility in which he resides.

The individual must provide to the department sufficient documentation to support, by a preponderance of the evidence, the claim that application of the penalty will result in an undue hardship to the applicant/beneficiary; not to the community spouse.

Note: The community spouse is not protected by the hardship exception. The exception is for the applicant/beneficiary not to be deprived.

An undue hardship exception may be requested at any time during the penalty period if new circumstances leading to undue hardship arise during the duration of the penalty period. If granted, the undue hardship request shall be prospective from the date of the request. All requests for exceptions shall be referred to the Eligibility Policy Section with detailed documentation. If additional information is needed to make the exception determination, a notice shall be sent to the person making the request specifying the type of additional information needed and the time within which to provide the additional information.

Once LDH determines that it has received complete documentation, it shall inform the individual within ten (10) business days of the undue hardship decision.

If a request for undue hardship is not received within seven (7) days after notification of transfer penalty, or if the request is denied, LDH shall issue an eligibility determination specifying the applicable penalty period. If the individual is a beneficiary, the notice shall include the date of the Medicaid LTC termination. The notice shall include the right to request a fair hearing and continuing benefits while their appeal is pending.

LDH shall have no obligation to pay for long-term care services during the penalty period unless it grants an undue hardship exception or the applicant/beneficiary prevails in a fair hearing.

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued January 6, 2026 Page 27 of H-800 Replacing August 11, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” H-880 RESULTS OF FINDINGS If undue hardship is determined to exist and an exception granted, the transferred assets or equity value in the home shall not be considered in the eligibility process.

If a request for an undue hardship exception is denied, the applicant is notified of the decision in writing. The applicant has the right to appeal the denial decision.

If the individual is a beneficiary, the notice shall include the date of the Medicaid LTC termination. The notice shall include the right to request a fair hearing and continuing benefits. H-885 ENDING UNDUE HARDSHIP EXCEPTION

The undue hardship exception shall end if the individual, the spouse of the individual, or anyone with authority on behalf of the individual, makes any uncompensated transfer of assets after the undue hardship exception is granted.

Deny any requests for an undue hardship exception when it is to reconsider a previous hardship denial, or is a request to reconsider termination of a hardship exception.

(h-900)Louisiana Medicaid Eligibility Manual (LDH): H - 900 Home and Community Based Services (HCBS)#

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued June 1, 2026

Page 1 of H-900 Replacing June 08, 2021 Revised/added text indicated by underscore

Deleted text indicated by “” H-900 HOME AND COMMUNITY-BASED SERVICES (HCBS)

H-910 GENERAL INFORMATION

Home and community-based services offered under a waiver program are provided: • To individuals who would otherwise require long-term care services in an institutional setting; and • The total cost of waiver services is no more than the average cost of institutional care services the individual would otherwise require.

Eligibility for HCBS differs from other Medicaid eligibility in the following ways: • Persons covered under a waiver must meet specific medical criteria; • The number of beneficiaries that can be served may be limited; and • The geographical area where services are provided may be limited.

Medicaid HCBS Waivers

In Louisiana, there are seven (7) HCBS waivers offered that are administered through waiver and state plan programs and overseen by various State agencies.

The Office of Aging and Adult Services (OAAS) serves seniors and individuals with onset disabilities in home and community based services as an alternative to nursing facility care through the: (1) Adult Day Health Care (ADHC); and (2) Community Choices Waiver (OAAS-CCW);

The Office for Citizen’s with Developmental Disabilities (OCDD) coordinates statewide services to individual and families who require specialized support and services through the: (3) Children’s Choice waiver (OCDD-CC); (4) New Opportunities Waiver (NOW);

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Deleted text indicated by “” (5) Residential Options Waiver (ROW); and (6) Supports Waiver (SW).

The Department of Health (Office of Behavioral Health (OBH) and Medicaid) the Department of Children & Family Services (DCFS), the Department of Education (DOE), the Office of Juvenile Justice (OJJ), the Governor’s Office, family, youth, and advocate representatives establish a service delivery system to improve outcomes through the:

(7) Coordinated System of Care – Severely Emotionally Disturbed Waiver (CSoC-SED).

Note: An individual cannot be enrolled in two HCBS waiver programs at the same time.

Adult Day Health Care (ADHC) The ADHC waiver covers direct care provided in a licensed and Medicaid enrolled ADHC center for individuals age 65 and older or age 22 to 64 with a disability who would otherwise require nursing facility services.

Other services covered under the waiver include: • Support coordination; • Transition intensive support coordination; and • Transition services.

Community Choices Waiver (OAAS-CCW)

The OAAS-CCW provides one or more of the following services to individuals age 65 and older or physically disabled adults age 21 to 64 with disabilities who would otherwise require nursing facility services.

The OAAS-CCW provides the following services:

• Adult day health care service; • Caregiver temporary support service; • Assistive devices and medical supplies; • Environmental accessibility adaptations (home modification);

(h-900)(page-3)Page 3#

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Issued June 1, 2026

Page 3 of H-900 Replacing June 08, 2021 Revised/added text indicated by underscore

Deleted text indicated by “” • Home delivered meals; • Support coordination; • Nursing services; • Personal assistance services (PAS); • Skilled maintenance therapy; • Transition intensive support coordination; • Transition services; • Housing stabilization services; • Monitored in-home caregiving; and • Housing transition or crisis intervention services

Children’s Choice Waiver (OCDD-CC)

The OCDD-CC waiver provides supplemental support services to children who have intellectual and/or developmental disabilities, which meet the Louisiana definition for developmental disability, and who currently live at home with their families or who will leave a residential facility to return home. The OCDD-CC waiver is an option offered to children who meet the level of care requirements for ICF/IID. The age requirement is birth through age 20. Participants who reach age 18 and remain enrolled in school may continue to receive waiver services until their 21st birthday at which time they will transfer into an appropriate adult waiver as long as they remain eligible for waiver services. Participants currently receiving waiver services who reach age 18 and choose to no longer attend school may transition to a Supports Waiver anytime until their 21st birthday based on a person-center planning process. NOTE: Verification of school enrollment for beneficiaries aged 18 or older is not required. A beneficiary must choose to transition to a supports waiver and may do so at age 18 and when no longer attending school.

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Deleted text indicated by “” OCDD-CC waiver covers one or more of the following services: • Center-based respite; • Environmental accessibility adaptations; • Family training; • Family support; • Support coordination; • Specialized medical equipment and supplies; • Professional services: ° Aquatic therapy; ° Art therapy; ° Music therapy; ° Sensory integration ° Hippotherapy/therapeutic horseback riding; • Housing stabilization service; and • Housing stabilization transition service.

New Opportunities Waiver (NOW)

The NOW is intended to provide specific, activity focused services rather than continuous custodial care.

The NOW is offered to individuals who are age three or older and have an intellectual and/or developmental disability that meets the Louisiana definition for developmental disability.

Individuals requesting NOW services must meet the Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) level of care.

The following are services provided under the NOW: • Center-based respite care; • Community integration development (CID); • Day habilitation and transportation; • Prevocational services; • Environmental accessibility adaptations;

(h-900)(page-5)Page 5#

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Deleted text indicated by “” • Individual and family support (IFS) services; • One-time transitional expenses; • Personal emergency response system (PERS); • Professional services; • Skilled nursing services; • Specialized medical equipment and supplies; • Substitute family care (SFC); • Supported employment and transportation; • Supported independent living (SIL); • Adult companion care; • Housing stabilization service; and • Housing stabilization transition service.

Residential Options Waiver (ROW)

The ROW offers an alternative to institutional care that utilizes an array of services, supports, and residential options to individuals who would otherwise require ICF/IID facility services. There is no age-specific requirement for the ROW.

The ROW provides the following services: • Professional services: ° Psychology; ° Physical therapy; ° Occupational therapy; ° Nutrition/Dietary; ° Social Work; and ° Speech therapy. • Nursing services; • Dental services; • Community living supports; • Day habilitation; • Prevocational services;

(h-900)(page-6)Page 6#

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Deleted text indicated by “” • Supported employment; • Respite care out of home; • Shared living services; • Support coordination; • Companion care; • Host home; • Transportation - community access; • Assistive technology/specialized medical equipment and supplies; • Personal emergency response system; • Environmental accessibility adaptations; • One-time transition services; • Adult Day Health Care services (ADHC); • Housing stabilization services; and • Housing stabilization transition services.

Supports Waiver (SW)

The SW is intended to provide specific, activity focused services rather than continuous custodial care to support individuals living in the community who would otherwise require ICF/IID facility services.

Individuals requesting the SW must be 18 years of age or older with an intellectual and/or a developmental disability which manifested prior to age 22.

The SW covers one or more of the following services to individuals: • Supported employment services; • Day habilitation; • Prevocational services; • Respite; • Habilitation; • Personal emergency response system (PERS); • Support coordination;

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Deleted text indicated by “” • Housing stabilization service; and • Housing stabilization transition service.

Coordinated System of Care (CSoC) Severely Emotionally Disturbed (SED) Waiver

The CSoC-SED waiver provides intensive home and community-based psychosocial supportive services for youth from the age of 5 and individuals under the age of 21 who: • Have a qualifying mental health diagnosis; • Are identified as seriously emotionally disturbed (SED), which applies to youth ages 5 through 17, or seriously mentally ill (SMI) which applies to youth ages 18 through 20; • Would otherwise require nursing facility or hospital placement; and • Meet all other eligibility factors.

Note: Individuals between the ages of 0 to 5 and 20 to 21, who were enrolled in CSoC waiver prior to March 1, 2017, may continue to receive services as long as they continue to meet the level of care criteria and all other eligibility factors.

The CSoC-SED waiver provides four specialized services that are not available to other Medicaid youth: • Independent living/skills building; • Short term respite; • Youth support and training; and • Parent support and training.

Note: An individual cannot be enrolled in CSoC-SED and another HCBS waiver program at the same time.

H-910.1 Coverage

Medicaid provides vendor payment for eligible waiver beneficiaries for services that are not available to other beneficiaries. The specific services covered are described in the waiver document.

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Waiver services are covered in addition to regular non-institutional Medicaid services.

H-910.2 Medical Certification

Medical certification requires that the applicant meet the level of care requirements for the waiver program for which he/she is applying.

Therefore, before HCBS vendor payments can be authorized for any applicant, a comprehensive report and evaluation of the individual's medical needs must be completed.

For all waivers, except CSoC-SED

The waiver applicant's physician completes a report and evaluation and recommends a specific classification of care. The report and recommendation are submitted with the plan of care to the Office of Aging and Adult Services (OAAS) or its designee for ADHC and Community Choices, and to the Office for Citizens with Developmental Disabilities (OCDD) for NOW, Children’s Choice, Supports and ROW regional office staff for approval.

The plan of care is prepared by the following entities for each respective waiver:

ADHC – the potential ADHC provider; Community Choices – the support coordinator; Children’s Choice – the support coordinator; NOW – the support coordinator or OCDD if applicant is not already Medicaid eligible; ROW – the support coordinator; and Supports Waiver – the support coordinator.

For cases with a Level II assessment, the first day of eligibility for HCBS is no earlier than the effective date indicated by the Office of Behavioral Health (OBH) or OCDD regional office on BHSF Form 142, or the date financially eligibility is established, whichever is later.

Medical certification must be obtained any time the beneficiary's medical needs indicate a change in level of care or the beneficiary

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Deleted text indicated by “” is eligible for participation in a new waiver program.

Documentation of Medical Certification

OAAS or OCDD regional waiver office (or their designee) issues the BHSF Form 142 (Notice of Medical Certification).

The BHSF Form 142 documents the following:

• Approval or disapproval of the level of care; • The effective date of medical certification approval; and • All approved waiver services. Federal financial participation (FFP) is available only to services specified in the approved plan of care.

Note: A change in a support coordination agency does not require a BHSF Form 142.

For CSoC-SED Waiver only

A child/youth must have a mental health diagnosis determined by a physician or licensed mental health professional and qualifying scores on the Child and Adolescent Needs and Strengths (CANS) Comprehensive Multisystem to be clinically eligible for the enrollment in the HCBS CSoC-SED waiver.

Documentation of Medical Certification

The CSoC Contractor Clinical criteria must be met to be eligible for enrollment in the HCBS CSoC-SED waiver. The CSoC contractor is responsible for adding the CSoC-SED segment information to MES.

A medical certification is needed every six (6) months for CSoC-SED.

If a new medical certification is not received for the next six (6) month period, continuous eligibility is applicable to those children under age 19 for coverage of regular Medicaid services. The child can remain in the CSoC-SED waiver case but no segment is added.

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Deleted text indicated by “”

H-910.3 Special Income Level (SIL)

Income eligibility is based on the applicant/beneficiary gross income (excluding VA Aid and Attendance).

Gross income is compared to the SIL rate. The SIL rate for HCBS is three times the Supplemental Security Income (SSI) Federal Benefit Rate (FBR) for an individual. Refer to Z-700 LTC/HCBS SIL Rate, Resource Limits and Personal Care Needs Allowance.

Review eligibility under the HCBS Spend-Down Medically Needy program for an applicant/beneficiary eligible to participate in the Community Choices, ADHC, Supports, NOW, or ROW waivers, but who has countable gross monthly income over the SIL. Refer to H- 1050 Spend-Down Medically Needy - Home and Community Based Services – SSI-Related. Review eligible under the Regular and Spend-down Medically Needy program for an applicant/beneficiary eligible to participate in CSOC- SED (only), but who has income over the SIL. Refer to H-1020 Regular and Spend-Down Medically Needy - MAGI-Related. Refer to H-1030 Spend-Down Medically Needy - SSI related.

H-910.4 SSI Recipients

SSI recipients who admit to an HCBS waiver remain eligible for Medicaid and may be eligible for HCBS vendor payment.

There are three (3) circumstances under which vendor payment to an HBCS provider may be denied for an individual who receives SSI and has been medically certified to receive Home and Community Based Services. They are: • A Medicaid Qualifying Trust (MQT) exists; • An OBRA ’93 trust exists; or • There has been a transfer of resources for less than fair market value (FMV).

Note: Refer to I-1700 Trusts to determine if the Trust is a countable resource to the SSI recipient or if it will be treated as a transfer of resources.

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Deleted text indicated by “” Transfer of resources for less than FMV made by the SSI recipient must be explored before determining eligibility for vendor payment. Refer to I-1670 Transfer of Assets For Less Than Fair Market Value.

H-910.5 Patient Liability

There is no patient liability for an HCBS applicant/beneficiary who has countable gross income below the SIL. Refer to H-910.5, Maintenance Needs Allowance and Z-700 LTC/HCBS SIL Rate, Resource Limits and Personal Care Needs Allowance .

An applicant/beneficiary eligible to participate in the Community Choices, ADHC, Supports, ROW, or NOW under the HCBS Spend- Down Medically Needy program may have a patient liability. The patient liability is based on the amount of income remaining after the allowable deductions. Refer to H-1050 Spend-Down Medically Needy - Home and Community Based Services - SSI Related.

H-910.6 Maintenance Needs Allowance

HCBS beneficiaries are allowed maintenance needs allowance up to three (3) times the FBR.

H-910.7 Categories F, V, I, and O

The Louisiana Department of Children and Family Services (DCFS) Child Welfare office is responsible for determining HCBS eligibility and patient liability for children in state custody who are certified in categories F, V, I, and O.

H-920 ELIGIBILITY DETERMINATION PROCESS

Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

H-921.1 Determine Assistance Unit

The assistance unit consists of the applicant/beneficiary.

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H-921.2 Establish Categorical Requirements

Verify that the applicant/beneficiary is: • Aged; • Blind; or • Disabled.

Refer to E-0000 Category.

Exception: For the CSoC-SED, the only categorical requirement is that an applicant/beneficiary meets the CSoC 1915(c) level of care.

H-921.3 Establish Non-financial Eligibility

Verify eligibility for the applicant/beneficiary with regard to the following factors:

• Assignment of Third Party Rights

I-200 • Citizenship/Identity/Qualified Non-Citizen Status I-300 • Continuity of Stay

I-400 • Enumeration

I-600 • Medical Certification

I-1000 • Residence

I-1900

H-921.4 Establish Need

Verify that the applicant/beneficiary has been offered an opportunity (slot) for HCBS.

A. Determine Composition of the Income Unit

The income unit consists of: • The applicant/beneficiary; • Applicants/beneficiaries who are a couple and both receive HCBS waiver services; or

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Deleted text indicated by “” • For the month of admission (the month of eligibility listed on the BHSF Form 142) only the applicant/beneficiary who is a minor and the parent(s) with whom he lived during the month. Refer to I-1420 Need - Deeming. Exception: o Do not deem income from a spouse or from parents to a child who has been discharged from a facility to his home to receive HCBS. o Do not deem income from parents to a child in the CSoC-SED waiver. o Do not deem income from a parent to a child in HCBS after the first calendar month of admission.

B. Determine Need/ Countable Income

Determine countable gross income of the applicant/beneficiary including any parental deemed income. Refer to I-1530 Need – SSI-Related Income and Z-700 LTC/HCBS SIL Rate, Resource Limits and Personal Care Needs Allowance.

The applicant/beneficiary must be income eligible based on his/her gross income to be eligible for HCBS. If his/her income is greater than the SIL, consider for Spend-down MNP. Refer to H-1030 Spend-Down Medically Needy - SSI Related.

Note: Exclude any income received from VA Aid and Attendance.

Add the gross earned and gross unearned income including any income deemed from the parent(s) and compare the total to the SIL. If the applicant/beneficiary is an individual, including a minor child, use the individual SIL.

If the total gross income of the applicant/beneficiary is over the SIL, the applicant/beneficiary is income ineligible. For an applicant eligible to participate in the Community Choices, ADHC, Supports, NOW or ROW program, consider eligibility under HCBS Spend- down MNP Refer to H-1050 Spend-Down Medically Needy - HCBS - SSI-Related.

For an applicant/beneficiary eligible to participate in CSoC-SED, consider eligibility under Spend-Down MNP. Refer to H-1020

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Deleted text indicated by “” Regular and Spend-Down Medically Needy - MAGI-Based. Refer to H-1030 Spend-Down Medically Needy - SSI Related. If the total gross income is equal to or less than the SIL, the applicant/beneficiary is income eligible. Continue the determination of need.

Note: Consider QMB or SLMB eligibility for all HCBS applicants. Refer to H-1100 Qualified Medicare Beneficiary (QMB) or H-1300 Specified Low-income Medicare Beneficiary (SLMB).

Couples Receiving HCBS

Beginning with the month each member of a married couple is offered a waiver opportunity, determine whether it is to the couple’s advantage to have eligibility reviewed: • As a couple; or • As individuals.

First, consider eligibility for each applicant as an individual using the individual SIL.

If one member of the couple has gross income which is greater than the individual SIL, consider eligibility as a couple using the couple SIL.

If the total combined gross income of the couple is equal to or less than the couple SIL, the couple is income eligible. Continue the determination of need.

If eligibility for HCBS is established using the couple SIL, consider eligibility for QMB or SLMB using the couple QMB or SLMB standard.

If the total combined gross income of the couple is greater than the couple SIL rate, the couple is income ineligible. Eligibility for each applicant must be reviewed using the individual SIL.

If the total gross income of the individual is over the SIL, the applicant is income ineligible. Applicants/beneficiaries eligible to participate in the Community Choices, ADHC, Supports, NOW, or ROW waivers, should be considered for eligibility under the HCBS Spend-Down Medically Needy Program. Refer to H-1050 Spend-

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C. Determine Composition of the Resource Unit

The resource unit consists of: • The applicant/beneficiary; • Applicant/beneficiary and community spouse; or • For the month of admission (the month of eligibility listed on the BHSF Form 142) only the applicant/beneficiary who is a minor and the parent(s) with whom he/she lived during the month. Refer to I-1420 Need - Deeming. After the first month of eligibility, the income/resource unit only consists of the HCBS individual.

Exception: Do not deem resources from parents to a child who has been discharged from a facility to his/her home to receive HCBS.

D. Determine Need/Countable Resources

Determine eligibility with regard to resources:

Determine total countable resources of the applicant/beneficiary or couple. Refer to I-1630 Need - SSI-Related Resources.

If the applicant/beneficiary has a community spouse, refer to I-1660 Spousal Impoverishment Resource Provisions (LTC/HCBS) . Resources transferred for less than FMV with the 60 month look- back period, make the applicant/beneficiary ineligible for the waiver program for the duration of the penalty period.

Equity interest in home property that exceeds the allowable limit, makes the applicant/beneficiary resource ineligible for the waiver program.

Eligibility should be considered in other non-waiver programs. Refer to I-1670 Transfer of Assets For Less Than Fair Market Value.

• Compare total countable resources to the SSI resource limit for an individual (or couple). Refer to Z-900 Resource Limits

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Note: If eligibility for HCBS is established for a couple using the couple SIL, but the couple’s resources exceeds the $3,000 couple resource limit, eligibility as a couple is not met. Re-evaluate the eligibility as an individual for each member using the individual SIL and resource limit.

If resources are greater than the resource limit, the applicant/beneficiary is resource ineligible for HCBS. If resources are equal to or less than the resource limit, the applicant/beneficiary is resource eligible for HCBS.

H-921.5 Eligibility Decision

Evaluate all eligibility requirements and verification received to make the eligibility decision.

H-921.6 Reserved

H-921.7 Certification Period

The certification period cannot exceed twelve (12) months.

Children certified for the CSoC-SED waiver are eligible for twelve (12) months continuous eligibility for regular Medicaid services.

H-921.8 Notice of Decision

Send notice of decision to the applicant/beneficiary.

Send a copy of the decision notice to OAAS or OCDD regional office and the specified support coordinator for: • ADHC; • OAAS-CCW; • OCDD-CC; • NOW; • ROW; or • SW.

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Refer potentially eligible beneficiaries for SSI.

(h-1000)Louisiana Medicaid Eligibility Manual (LDH): H - 1000 Medically Needy Program - General Information#

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Deleted text indicated by “**” H-1000 MEDICALLY NEEDY PROGRAM (MNP) H-1010 GENERAL INFORMATION

The Medically Needy Program (MNP) provides Medicaid coverage to individuals or families who have income that is at or below the Medically Needy Income Eligibility Standard (MNIES) or have income which exceeds the MNIES but have enough medical expenses to reduce (spend-down) their excess income.

Note:

Resources are not considered for Modified Adjusted Gross Income (MAGI)-related eligibility groups.

Resources are considered for Non-MAGI-related eligibility groups Refer to Z-900 Resource Limits by Program. Resource eligibility should be explored using the Spousal Impoverishment Resource Provisions for individuals who are legally married and who have been, or are expected to be institutionalized for thirty (30) consecutive days. Refer to I-1660 Spousal Impoverishment Resource Provisions (LTC/HCBS).

Spend-Down MNP eligibility must be considered if the applicant/beneficiary is income ineligible for all programs.

H-1010.1 Categorical Relatedness

MNP eligibility cannot be considered prior to establishing income ineligibility in a MAGI-related or Non-MAGI related eligibility group.

Spend-down MNP has no upper income limit. Income eligibility is based on allowable medical expenses exceeding countable income.

H-1010.2 MNIES

The income standard used in MNP is the MNIES. Refer to Z-300 Medically Needy Income Eligibility Standards (MNIES).

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Deleted text indicated by “**” H-1011 MNP GROUPS

There are three (3) MNP groups.

1) MAGI-related Regular Medically Needy

Individuals or families who have income which is at or below the MNIES. Regular Medically Needy is only applicable to MAGI-related eligibility groups.

2) Spend-down Medically Needy

Spend-Down MNP is considered after establishing income ineligibility in Regular MNP or a Non-MAGI related eligibility group and excess income remains.

The following individuals may be considered for Spend-down MNP:

• Individuals or families who meet the requirements in a MAGI-related eligibility group. Refer to H-1020;

• Non-institutionalized individuals or couples who meet the requirements in a Non-MAGI related eligibility group. Refer to H-1030;

• Institutionalized individuals who have been, or are expected to be in a medical institution for a continuous period of thirty (30) days, and have income which exceeds the individual Federal Benefit Rate (FBR). Refer to H-1030; or

• Institutionalized individuals residing in a long-term care facility with Medicare coinsurance who have income which exceeds the special income level (SIL). The SIL is three (3) times the current FBR. Refer to H-1030.

3) LTC/HCBS Spend-down Medically Needy

Individuals residing in a Medicaid long term care (LTC) facility who are not on Medicare coinsurance or individuals offered a waiver opportunity for home and community-based services (HCBS) who have income which exceeds the SIL.

Refer to H-1040 and H-1050 for instructions.

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Note: HCBS Spend-down Medically Needy is limited to the Adult Day Health Care (ADHC), Community Choices (CC), New Opportunities (NOW), and Residential Options (ROW) waivers.

H-1011.1 Regular MNP

Individuals or families who meet the MAGI-related categorical requirements and have income at or below the monthly MNIES are certified for Regular MNP. Refer to H-1020, C-related MNP.

Note: The Parents/Caretaker Relative Program has a higher income limit than Regular MNP.

H-1011.2 Spend-down MNP

After completing the MAGI-related MNP or Non-MAGI related budget and excess income remains, deduct the allowable medical bills (refer to H-1011.5) incurred by the income unit to spend-down (reduce) the excess income to zero. Medical bills are deducted in chronological order (date order) based on the date of service).

Verify the applicant/beneficiary is liable for payment of the allowable bills used in the spend-down. If the allowable medical bills reduce the excess income to zero in the eligibility/budget period and all other eligibility factors are met, income eligibility is established. Eligibility for Medicaid begins on the date the excess income is spent down. If there is no Medicaid liability in the month the excess income is spent down, eligibility will begin on the first day of the month following the spend-down date in which there is a Medicaid liability or the first day of the month of the requested period of coverage whichever is earlier.

Note: The applicant cannot choose to exclude a month of eligibility coverage in which there is a Medicaid payable expense.

H-1011.3 Eligibility/Budget Period

Non-institutionalized The eligibility/budget period for non-institutionalized individuals is based on quarters (three (3) consecutive calendar months equal one

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Deleted text indicated by “**” (1) quarter) and is based upon the month of application.

Institutionalized The eligibility/budget period for institutionalized individuals is based on a one (1) month budget period.

The month of application must be one of the eligibility/budget months, unless the applicant requests retroactive eligibility to cover medical bills incurred three (3) months prior to the month of application.

An application form may be used for up to twelve (12) months unless there is a break in coverage.

Note: A break in coverage for MNP is defined as the beneficiary not being eligible for an entire month. One day of eligibility in the month is considered as being eligible for the entire month with no break in coverage.

The months of coverage shall not include previous Medicaid covered months, excluding Take Charge Plus, ** pure Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB) or Qualified Individual (QI) certifications.

Example:

Spend-Down Eligibility Period The date of application is April. The applicant incurred medical expenses for services received in January, February, March and April. The medical expenses from January, February and March were used in the eligibility/budget. The excess income was reduced to zero with a March expense with a remaining liability on the expense. The eligibility period would be March, April and May.

Consecutive eligibility/budget periods If an individual requests further coverage and has bills for medical services which are not covered by Medicaid and the bills were not used in a previous eligibility determination, the medical bills may be carried forward and used in the subsequent eligibility/budget period.

Note: An individual who attained Medicaid eligibility through a spend- down while pregnant is eligible for the extended postpartum coverage even if the individual does not have sufficient incurred

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Deleted text indicated by “**” medical or remedial care expenses to meet their spenddown in any subsequent budget period during the pregnancy or extended postpartum period.

H-1011.4 Limited Certifications for Non-Institutionalized Individuals

It is necessary in some instances to consider less than a full quarter of coverage. When considering less than a full quarter, multiply the monthly MNIES times the number of eligible months.

Income above the MNIES is not a reason for limiting the certification.

Any of the following conditions are reasons to limit the eligibility period to less than three months:

• Death of an applicant;

• The applicant/beneficiary does not meet a non-financial eligibility or categorical requirement in one or two months of the quarter;

• Full Medicaid coverage under another program for part of the quarter;

• Excess resources (Non-MAGI-related group); or

• In an Emergency Medical Services (EMS) certification.

H-1011.5 Medical Expenses Allowed in the Spend-down Process

• Allow all bills for medical services for which the applicant is legally liable and are recognized as medically necessary under state law (e.g., psychiatric, dental, physical therapy services, medical equipment, and medical supplies).

Note: Medical services not covered or limited by Medicaid are allowed in the spend-down calculation. For example, dental care for individuals age 21 or older.

For purposes of the Medicaid Program, "medically necessary under state law" refers to any medical service required by an applicant as prescribed by a physician. The physician must

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Deleted text indicated by “**” have the service included in the applicant/beneficiary’s treatment plan. If a copy of the treatment plan is not available, a letter from the physician indicating the need for the service may be used. An example of this service would be an attendant in the home who is not legally responsible for the care of the individual and who is providing personal care needs to an applicant/beneficiary.

• Allow bills for Medicaid covered medical services which are provided without charge (free care) to the applicant when services are delivered by a Medicaid-qualified provider and no third party will be charged for the medical services. (Federal financial participation (FFP) is available for Medicaid payments for care provided to individuals without charge.)

• Allow only the portion of the medical expense that is not covered or paid by a third party such as copays, coinsurance, or deductibles.

• Allow unpaid bills for medical services received not more than three (3) months prior to the month of application in chronological order from the oldest to the most recent.

If an applicant has been determined eligible for a budget period, any allowable bills that are not Medicaid payable (dental bills hearing aids, eyeglasses for a person 21 and over) and were not used in the spend-down for that budget period may be carried forward and used in the spend-down for the next budget period. As long as the applicant continues to be eligible in each subsequent budget period, allowable bills not previously used can be carried forward for use in the next budget period.

If the applicant becomes ineligible for a budget period and a break in coverage of at least one (1) month occurs, previous bills cannot be carried forward. The applicant will need to reapply and submit new bills.

• Allow current payments made on medical bills that were incurred prior to the spend-down period if the bills have not been used in a previous spend-down. A current payment is a payment made within the spend-down period.

Note: Treat unpaid loans and credit card charges which were used to pay

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Deleted text indicated by “**” the medical provider as unpaid medical bills if they were not used previously. Verify the applicant’s current liability. Verify that the loans and credit card charges were actually used to pay medical bills.

• Allow bills for all persons included in the MNIES.

• Allow bills incurred by a deceased person who would have been included in the MNIES if another person included in the MNIES is legally responsible for the bills.

• Allow Medicare or other private health insurance premiums when payment is due. For example, if the individual's policy is based on an annual premium, the premium deduction cannot be used again until the premium payment is due for an additional twelve (12) month policy period. If individuals are included in the policy but are not included in the MNIES, allow only the pro-rata share for the individuals included in the MNIES.

• Allow current state mileage reimbursement for medical transportation.

• Allow incurred Medicare coinsurance charges that are not payable by a third party while on skilled nursing care. Medicare coinsurance charges cannot be projected for individuals in a long term care facility.

Bills used to spend-down excess income are the responsibility of the applicant/beneficiary. Bills used in a spend-down budget that establishes eligibility can only be used once. All bills must be applied in chronological order. If bills occur on the same date, use the following designated order:

1) Bills for services not payable or covered by Medicaid, such as a dental bill for someone who is 21 and over;

2) Hospital bills;

3) All remaining bills.

To determine the chronological order of hospital bills (state and private) that cannot be itemized, use the per diem for the daily charges. The per diem is determined by dividing the total number of days, excluding the discharge date, into the total bill.

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Applicants receiving services in hospitals operated by the LSU Healthcare system have separate physician bills for each hospital day.

1011.6 Medical Expenses Not Allowed in the Spend-down Process

• Do not allow unpaid bills for services incurred more than three (3) months prior to the month of application.

• Do not allow bills marked "free care" incurred more than three (3) months prior to the month of application.

• Do not allow bills for individuals not included in the MNIES.

• Do not allow bills, portions of bills, or current payments on bills that have previously been allowed in a spend-down.

• Do not allow bills for services incurred during a prior period of Medicaid coverage except for:

- Bills for services not covered by Medicaid;

- Bills not paid because the provider did not accept Medicaid assignment; and

- Bills for services provided after the applicant/beneficiary has exhausted his annual limitation of services, such as an adult exceeding twelve (12) visits per year.

• Do not allow paid bills for services incurred more than three (3) months prior to the month of application.

• Do not allow paid or unpaid bills for services incurred after the eligibility/budget period being considered.

• Do not allow bills for which the applicant is no longer liable.

• Do not allow bills for anticipated services such as a package of services which are paid prior to the date the services are rendered.

Exception: If a pre-paid package is itemized, services incurred and paid in the spend-down period can be allowed according to the schedule of the itemized bill.

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• Bills or the portion of bills which have been paid or will be paid by insurance, legal settlement, family member who is not in the income unit or assistance unit or any other third party resource.

Take reasonable measures to determine the legal liability of third parties to pay for incurred expenses.

Do not forestall an eligibility determination simply because third party liability cannot be ascertained or payment by the third party has not been received.

Medicare Eligibles

If after exhausting every reasonable effort to determine the exact liability determine the liability as:

- the deductible for Medicare Part A (inpatient); and

- the deductible plus 20 percent of the balance of the actual charges for Medicare Part B (outpatient).

Note: For hospital inpatient stays, Medicare eligibles are allowed only the deductible for Part A. Do not allow the additional 20 percent for actual hospital charges.

Non-Medicare Eligibles

If every reasonable effort to determine the exact amount of the liability has been exhausted, obtain an estimated amount from the insurance company to be used in the spend-down process.

H-1012 MAGI-RELATED MNP CARETAKER RELATIVE

To be considered for Parents and Caretaker Relatives MNP, the individual must:

• Be a parent, grandparent, sibling or step-sibling, brother or sister-in-law, step-parent, aunt, uncle, first cousin, niece or nephew, the legal spouse of parents or caretaker relatives;

• Assume primary responsibility of a dependent child under age

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Deleted text indicated by “**” 18, or is age 18 and a full-time student in high school or vocational/technical training;

• Be included in the MAGI household with the dependent child,

Note: Non-legal parents (non-qualified aliens) of a dependent child may only be eligible for EMS or Louisiana Children’s Health Insurance Program (LaCHIP) Phase IV.

Individuals who are not considered to be a caretaker relative should be reviewed under the Non-MAGI related groups.

(h-1020)Louisiana Medicaid Eligibility Manual (LDH): H - 1020 Regular and Spend-Down Medically Needy - MAGI Related#

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H-1021 ELIGIBILITY DETERMINATION PROCESS

Determine eligibility by applying the following criteria. The elements are listed in the most logical order, but all steps should be performed simultaneously.

H-1021.1 Determine Assistance Unit

Include anyone who was not eligible in a MAGI-related group because of income. Refer to I-1550, MAGI Determinations.

Reminder: Do not include sanctioned individuals. Do not add anyone to the original MAGI-related household

H-1021.2 Establish Categorical Requirements

Categorical requirements must have been established in the Parents and Caretaker Relatives Group, Pregnant Women Group or Children Under Age 19 Group.

Exception: MNP eligibility cannot be considered for beneficiaries in the optional Adult Group.

H-1021.3 Establish Nonfinancial Eligibility

Non-financial eligibility requirements must have been established in Parents and Caretaker Relatives Group, Pregnant Women Group or Children Under Age 19 Group:

• Age – MAGI-Related I-100

• Assignment of Third Party Rights I-200

• Citizenship/Identity and Qualified Non-Citizen Status I-300

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Deleted text indicated by “**” • Enumeration I-600

• Residence I-1900

H-1021.4 Establish Need

Household composition for MAGI-related MNP shall only include those individuals that were in the original MAGI household. Refer to I-1550, MAGI Determinations.

Regular Medically Needy

Compare the total countable income to the monthly MNIES for the number of people in the MAGI household.

If income is equal to or less than the MNIES, the assistance unit is income eligible for Regular MNP.

If income is greater than the MNIES, the assistance unit is ineligible for Regular MNP. Consider for Spend-down MNP.

Spend-down Medically Needy

If the applicant has been determined income ineligible for Regular MNP, convert monthly MAGI income to quarterly MAGI income by multiplying by three, subtract quarterly MNIES for the number of people in the MAGI household, and subtract medical bills from the excess income in the following order:

Step 1. Subtract allowable bills for individuals other than the applicant who are included in the MAGI Household.

Step 2. Subtract unpaid bills for services received up to 3 months prior to the month of application in chronological order.

Step 3. Subtract allowable health insurance premiums. Refer to H-1011.5, Bills Allowed in the Spend-down process.

Note: Liability for health insurance premiums arises in the month payment is due, rather than in the month (or

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Deleted text indicated by “**” months) for which coverage is purchased.

Step 4. Subtract paid and unpaid bills including insurance co-payments and deductibles incurred for services received within the spend-down quarter in chronological order (per diem if necessary), oldest to most recent. Hospital bills shall be used before physician bills in the spend-down process.

On the date excess income is equal to the allowed medical expenses (“spent down”), the applicant is eligible for Spend-down MNP. This date is referred to as the spend-down date. Eligibility begins the date the excess income is spent down.

If there is no Medicaid liability in the month that the income is spent down, eligibility begins on the following date, whichever is earlier: • The first day of the month after the spend-down date, in which there is a Medicaid liability; or • The first day of the month of the requested period of coverage **.

Note: Refer to H-1011.4 Limited Certifications for Non- Institutionalized Individuals for limited one or two month certifications.

H-1021.5 Eligibility Decision

Regular MNP

Evaluate all eligibility requirements and verification received to make the eligibility decision.

Spend-down MNP

Evaluate all eligibility requirements and verification received to make the eligibility decision.

H-1021.6 Certification Period

Regular MNP

The certification period shall not exceed 6 months.

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Spend-down MNP

Certification begins no earlier than the spend-down date and shall not exceed three months. This certification will be automatically closed. Refer to H-1011.3 Eligibility/Budget Period.

Note:

An individual who attained Medicaid eligibility through a spend-down while pregnant is eligible for the extended postpartum coverage even if the individual does not have sufficient incurred medical or remedial care expenses to meet their spenddown in any subsequent budget period during the pregnancy or extended postpartum period.

H-1021.7 Notice of Decision

Send the appropriate notice of decision to the applicant/beneficiary.

H-1021.8 Form 110-MNP

BHSF Form 110-MNP must be completed listing each provider who rendered medical services on the spend-down date. **

(h-1030)Louisiana Medicaid Eligibility Manual (LDH): H - 1030 Spend-Down Medically Needy - SSI Related#

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H-1030 SPEND-DOWN MEDICALLY NEEDY—SSI-RELATED Non- Institutionalized and Institutionalized on Medicare Co- Insurance

H-1031 ELIGIBILITY DETERMINATION PROCESS

Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

H-1031.1 Determine Assistance Unit

The assistance unit consists of the applicant/beneficiary.

H-1031.2 Establish Categorical Requirement

Verify that the applicant is:

• aged,

• blind, or

• disabled.

Refer to E-0000 Category.

H-1031.3 Establish Non-Financial Eligibility

Verify eligibility for each member of the assistance/benefit unit with regard to the following factors:

• Assignment of Third Party Rights

I-100

• Citizenship/Identity and Qualified Non-Citizen Status I-300

• Enumeration

I-600

• Residence

I-1900

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H-1031.4 Establish Need

A. Determine Composition of the Income/Resource Unit

The SSI-MNP income/resource unit (MNIES) includes:

• Applicant,

• Applicant and ineligible spouse living in the home,

Note: Ineligible spouse is not categorically eligible and cannot be certified,

• Applicants who are a categorically eligible couple, or

• Applicant(s) who is a minor and his parent(s) living in the home.

Note: Alien sponsors are not included in the MNIES because their needs are considered in the deeming process.

B. Determine Need/Countable Resources

Determine total countable resources of the members of the income unit. Income received in any month of the budget period does not become a resource until a new budget period begins. Refer to I- 1630, Need - SSI-Related Resources.

Compare countable resources to the MNP resource limit for the number in the income/resource unit. Refer to Z-900 Resource Limits by Program **. Resources should be calculated as of the first day of the month being considered for eligibility.

If resources are greater than the limit, the applicant is ineligible for MNP.

If countable resources for an institutionalized individual with a legal spouse in the community are greater than the MNP SSI-Related resource limit, refer to I-1660 Spousal Impoverishment Resource Provisions and Z-800 Spousal Impoverishment Maintenance Needs and Resource Standards **.

If resources are equal to or less than the limit, the applicant is

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resource eligible for MNP. Continue the eligibility determination process.

C. Determine Need/Countable Income - Non Institutionalized Spend-down MNP

Individual

If the applicant is an individual with no spouse or with an ineligible spouse with no income, go to Step 1.

Ineligible Spouse Deeming

If there is an ineligible spouse with income, apply deeming policy, Refer to I-1420 Need - Deeming and I-1424.2 Income Deeming Procedures, then go to Step 1 below. Add the ineligible spouse's remaining unearned income to all of the eligible individual's unearned income. Add the ineligible spouse's remaining earned income to all of the eligible individual's earned income. Calculate all remaining budget steps and compare countable income to the couple MNIES.

Parent(s) to Child Deeming

If the applicant is a minor child, apply deeming policy, I-1420 Need - Deeming. Any income deemed from the parent(s) is considered unearned income of the child. Go to Step 1.

Couple

If both members of a couple are categorically eligible, go to Step 1.

Budget Steps

Step 1. Determine unearned income, including income deemed from the parent(s) or alien sponsor(s). For a couple combine all unearned income. (See MEM I-1424.2 Income Deeming Procedures when spouse to spouse deeming is applicable).

Step 2. Subtract one $20 SSI disregard per income unit, if applicable.

Step 3. The remainder is the countable unearned income.

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Step 4. Determine total gross earned income of the individual/couple.

Step 5. Subtract any remainder of the $20 SSI disregard from gross earnings. (See MEM I-1424.2 Income Deeming Procedures when spouse to spouse deeming is applicable).

Step 6. Subtract one earned income deduction from the remaining gross earnings of the income unit. The earned income deduction is $65 and one half of the remainder of the earnings.

Step 7. The remainder is the countable earned income.

Step 8. Combine the remainders in Step 3 and Step 7 to get to the total monthy income.

Step 9. Convert this total monthly income amount to a quarterly amount.

Step 10. Subtract the MNIES for the number in the income/resource unit to determine the excess income to spend down.

Step 11. Subtract allowable bills for individuals, other than the applicant, who are included in the MNIES.

Step 12. Subtract allowable health insurance premiums. Refer to H-1011.5 Bills Allowed in the Spend Down Process.

Note: Liability for health insurance premiums arises in the month payment is due, rather than in the month (or months) for which coverage is purchased.

Step 13. Subtract paid and unpaid bills including insurance co- payments and deductibles incurred for services received within the spend-down period, in chronological order (per diem if necessary), oldest to most recent.

Note: If multiple services are received on the same date, services verified as not covered by Medicaid or non- payable by Medicaid (because the provider does not

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accept Medicaid) should be used first and then hospital bills.

On the date excess income is “spent down” (income equal to allowed medical expenses) the applicant is eligible for Spend-down MNP. This date is referred to as the spend-down date. Eligibility begins the date the excess income is spent down. If there is no Medicaid liability in the month that the income is spent down, eligibility begins the first day of the month after the spend-down date in which there is a Medicaid liability or the first day of the month of the requested period of coverage, whichever is earlier.

D. Determine Need/Countable Income - Institutionalized on Medicare Co insurance - Spend-down MNP

Individual

If the applicant is an individual with no spouse or with an ineligible spouse with or without income, go to Step 1. There is no deeming from a spouse or to a child.

Couple

If both members of a couple are in a facility on Medicare co insurance, and each member’s income is over the SIL, go to Step 1 and review each member as an individual.

Note: When one member of the couple is income ineligible, consider as a couple using the couple SIL before reviewing for Spend- down MNP. If the combined income of the couple exceeds the couple SIL, re-evaluate eligibility as individuals. (Refer to ** MEM H-831.4 B Long Term Care - Couples in the Same Facility)

Budget Steps

Step 1. Determine unearned income of applicant(s).

Step 2. Subtract one $20 SSI disregard per income unit, if applicable.

Step 3. The remainder is the countable unearned income.

Step 4. Determine total gross earnings of applicant(s).

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Step 5. Subtract any remainder of the $20 SSI disregard from gross earnings.

Step 6. Subtract earned income deduction from the remaining gross earnings of the income unit. The earned income deduction is $65 and one half of the remainder of the earnings.

Step 7. The remainder is the countable earned income.

Step 8. Combine the remainders in Step 3 and Step 7 for the total countable income.

Step 9. Subtract the MNIES for 1 to determine the excess income to spend down.

Step 10. Subtract allowable health insurance premiums. Refer to H-1011.5, Bills Allowed in the Spend-Down Process and I- 1536 Deductions.

Note: Liability for health insurance premiums arises in the month payment is due, rather than in the month (or months) for which coverage is purchased.

Step 11. Subtract paid and unpaid bills including insurance co- payments and deductibles incurred for services received within the spend-down period, in chronological order (per diem if necessary), oldest to most recent.

Note: If multiple services are received on the same date, services verified as not covered by Medicaid or non- payable by Medicaid (because the provider does not accept Medicaid) should be used first and then hospital bills.

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month of the requested period of coverage whichever is earlier.

H-1031.5 Eligibility Decision

Evaluate all eligibility requirements and verification received to make an eligibility decision to either reject or certify the application. Review eligibility after each month the applicant is on Long Term Care Co- Insurance Spend-down for the previous month, and the first month after Co-Insurance ends for Long Term Care Spend-down eligibility.

H-1031.6 Certification Period

A Spend-down MNP certification is automatically closed at the end of each quarter of eligibility. For institutionalized persons, eligibility is to be reviewed for each month they are on co-insurance as a one month certification.

H-1031.7 Notice of Decision

Send the appropriate notice of decision to the applicant.

H-1031.8 Form 110-MNP

BHSF Form 110-MNP shall be completed on every Spend-down MNP certification. Each provider who rendered medical services on the spend down date is sent a copy of the Form 110-MNP.

(h-1040)Louisiana Medicaid Eligibility Manual (LDH): H - 1040 Spend-Down Medically Needy - Long Term Care - SSI Related#

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H-1040 LONG TERM CARE SPEND-DOWN MEDICALLY NEEDY PROGRAM (LTC SD MNP) – SSI-RELATED

H-1041 ELIGIBILITY DETERMINATION PROCESS

A person who resides in a long-term care (LTC) facility who meets all other eligibility requirements, but has income over the Special Income Limit (SIL) may be eligible for LTC SD MNP. The person must incur medical expenses in an amount which is equal to or greater than their monthly excess income to meet spend-down. LTC SD MNP uses a one-month budget period.

Consider the projected cost for facility care as an incurred medical expense to meet spend-down. The projected monthly cost of care is determined by multiplying the daily Medicaid facility rate for the specific nursing home or ICF/IID in which the individual resides by 365 days and then dividing by 12 months. The projected Medicaid facility rate should be prorated if the individual was not in the facility for the entire month.

Other allowable incurred medical expenses, including Medicare and private health insurance premiums, deductibles, skilled nursing facility (SNF) coinsurance, copays, and medical/remedial care expenses that are not subject to payment by a third party, can be used to spend- down excess income. Verify the applicant’s liability for payment of the incurred medical expenses used in the LTC SD MNP budget. Refer to H-1011.5 Medical Expenses Allowed in the Spend-down Process.

Note: Eligibility for LTC SD MNP cannot be established for individuals receiving Medicare skilled nursing facility (SNF) services incurred during the current month. Determine eligibility after charges are incurred for the previous month(s). Eligibility is evaluated on a monthly basis.

When the individual’s excess income is spent down using the projected Medicaid facility rate and the other allowable incurred medical expenses (Medicare co insurance, hospital bills, etc.), Medicaid eligibility begins the first day of the budget month. Vendor payment begins the date of admission or the first day of the month the individual is determined eligible, if later.

When the projected Medicaid facility rate and the other allowable

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incurred medical expenses (Medicare co insurance, hospital bills, etc.) are not sufficient to spend-down the individual’s excess income, continue the eligibility process to determine if individual could meet spend-down later in the month using LTC SD MNP/Income over Facility Fee.

For an LTC SD MNP/Income over Facility Fee budget use a combination of expenses actually incurred at the private payment facility rate and remaining expenses projected at the Medicaid facility rate to spend down excess income. Verify the nursing facility private pay rate and Medicaid facility rate used in the determination.

If eligibility is established, Medicaid eligibility begins the date the individual meets spend-down. Spend-down is met on the day that the remaining excess income is less than or equal to the projected Medicaid facility rate prorated for the remaining days of the month.

If eligibility is not established for the month of admission, the eligibility process should be continued to determine if individual could meet LTC SD MNP the next month using a full month of expenses. Incurred private payment charges incurred in the previous month may be used in spend-down if the bill remains unpaid.

Example: Individual entered the nursing facility on the 15th of a month. The prorated Projected Medicaid Facility rate does not spend-down the excess income for the month of entry. If using the actual private rate and Medicaid facility rate still does not spend-down the individual for the month of entry, the application should be held for the next full month to determine if the individual can spend down using a full month’s expenses.

Individuals certified under LTC SD MNP type cases may be eligible for vendor payment to the LTC Facility.

Note: No vendor payment is authorized to the LTC facility if the post- eligibility determination results in Patient Liability (PLI) that exceeds the Medicaid facility rate.

Exception: LTC SD MNP/Income over Facility Fee certifications are not eligible for vendor payment.

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Private payment charges incurred within the three months preceding the eligibility month may be used as medical deductions during the post-eligibility determination, provided they have not been previously allocated in a Spend-down MNP budget for an eligible month, and the individual is responsible for the payment.

Determine eligibility by applying the following criteria. The elements are listed in the most logical order, but work on all steps simultaneously.

H-1041.1 Determination of the Assistance/Benefit Unit

The assistance/benefit unit consists of the applicant/beneficiary.

H-1041.2 Establish Categorical Requirement

Verify that the applicant/beneficiary is:

• Aged,

• Blind, or

• Disabled.

Refer to E-0000 Category.

H-1041.3 Establish Non-Financial Eligibility

Verify eligibility for each member of the assistance/benefit unit with regard to the following factors:

• Assignment of Third Party Rights

I-200

• Citizenship/Identity and Qualified Non-Citizen Status I-300

• Continuity of Stay (LTC Only, Except HCBS)

I-400

• Enumeration

I-600

• Medical Certification

I-1000

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• Residence

I-1900

H-1041.4 Establish Need

A. Determination of the Composition of the Income Unit

The income unit consists of:

• The applicant/beneficiary; or

• The applicant/beneficiary who is a child and the parent(s) with whom the child lived for the month of admission only. After the first month of admission, parent deeming is no longer applicable. Refer to I-1420 Need - Deeming.

Note: The income of the community spouse and legal dependent(s) living in the community is not counted in determining eligibility for the institutionalized individual. Refer to I-1537 Spousal Income Provisions.

B. Determination of Countable Income

The LTC SD MNP applicant's countable income, after certain deductions, must be equal to or less than the MNIES for a household of one. Refer to Z-300 Medically Needy Income Eligibility Standards (MINES).

Budget Steps

Step 1. Determine gross unearned income for the individual excluding VA Aid and attendance.

Step 2. Subtract $20 SSI disregard.

Step 3. The remainder is the countable unearned income.

Step 4. Determine the total gross earned income for the individual.

Step 5. Subtract any unused remainder of the $20 SSI disregard

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from the gross earnings.

Step 6. Subtract $65 and one-half of the remainder of the earnings.

Step 7. The remainder is the countable earned income.

Step 8. Combine the countable earned and unearned income found in Step 3 and Step 7.

Step 9. Subtract the monthly MNIES for one (1) person.

Step 10. Subtract allowable health insurance premiums. Refer to I- 1536 Deductions.

Note: Liability for health insurance premiums arises in the month payment is due, not the month (or months) for which coverage is purchased. Premiums must be paid by the applicant/beneficiary.

Example: Wife enters a nursing facility and her supplemental medical insurance premium is deducted from her husband’s payroll or retirement check. The premium is not an allowable deduction.

Step 11. Determine the allowable incurred medical expense. Refer to H-1011.5 Medical Expenses Allowed in the Spend- down Process and H-1011.6 Medical Expenses Not Allowed in the Spend-down Process.

Note: MNP regulations allow the State to project the LTC Medicaid facility rate for SD MNP-LTC purposes. SNF coinsurance charges cannot be projected. However, SNF coinsurance charges are allowable medical expenses and can be used in spend-down once the charges are incurred.

Example: The individual is receiving Medicare SNF services. The

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individual is not eligible for LTC SD MNP. Determine eligibility for Spend-Down Medically Needy after coinsurance charges are incurred.

For the month the individual converts from Medicare coinsurance to Medicaid only, review eligibility for LTC SD MNP. Incurred coinsurance charges and the prorated projected Medicaid facility rate for the remainder of the month should be used to spend-down excess income.

Step 12. Subtract allowable paid and unpaid bills in chronological order oldest to most recent.

Step 13. Subtract the current monthly Medicaid facility rate. To determine the monthly Medicaid facility rate, multiply the daily rate for the facility by 365 days and divide by 12 months. This amount is used for a full month.

Note: For month of admission the facility rate must be prorated using the number of days an individual is in the facility in the month of entry, if the applicant is not admitted on the first day of the month.

Example #1: Individual admitted on the 28th of the month. The prorated expense for the partial month is determined by multiplying the daily Medicaid facility rate by the number of days remaining in month including the date of admission.

Example #2: The individual was in a facility on Medicare coinsurance. His coinsurance ended January 17th. The gross monthly income was $4,349.10. After deducting the $20.00 standard deduction and the MNIES ($92.00 rural parish), the individual’s excess income or spend- down amount is $4,237.10. The Medicare premium is $171.10. The incurred coinsurance charges for 17 days is $2,337.50 ($137.50/day x 17 days). The projected prorated Medicaid facility rate for 14 days is $1,797.88 ($128.42/day x 14 days). The incurred medical

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expenses and the prorated projected Medicaid facility rate are sufficient to meet spend-down.

$4,349.10 Gross monthly income - 20.00 Standard Deduction $4,329.10 - 92.00 Rural MNIES for 1 person $4,237.10 Spend-down amount (excess Income)

$4,237.10 -171.10 Medicare premium $4,066.00 -2,337.50 Coinsurance charges for 17 days $1,728.50 -1,797.88 Prorated Medicaid rate for 14 days .00 Spend-down met

If the remaining income is $0.00, the individual has spent down and is eligible for LTC SD MNP. Use LTC SD MNP when income is over the SIL and under the Medicaid Facility Rate. Proceed with the PLI determination. Refer to H-1041.5 Determine Patient Liability.

If excess income remains continue with section C below.

If there is no remaining excess income, proceed to Section D below.

C. Determination of Countable Income for Individuals with Income over the SIL and over the Medicaid Facility Rate.

Follow steps 1 through 11 above, then ** proceed to step 14 below.

Step 14. ** Subtract the current daily private payment rate and incurred medical expenses on a daily basis, in chronological order. The daily private payment rate continues to be deducted until the remaining excess income falls below the prorated balance of the Medicaid facility rate.

Note:

LTC SD MNP/Income over Facility Fee coverage begins on the day that the remaining excess income is less than or equal to the prorated balance of the

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Medicaid facility rate.

Example #1 The individual is in the facility as of May 1. The gross monthly income was $4,283.10. After deducting the $20.00 standard deduction and the MNIES ($92.00 rural parish), the individual’s excess income or spend-down amount is $4,171.10. The Medicare premium is $171.10. The projected monthly Medicaid facility rate is $3,906.11 ($128.42/day x 365 ÷ 12).

The projected monthly Medicaid facility rate and Medicare premium are not sufficient to spend-down the excess income. Eligibility is not established for LTC SD MNP However –

The daily private rate is $135.00. After remaining in the institution for three (3) days the individual has actually incurred charges of $405.00 at the private rate ($135.00 X 3). The projected Medicaid facility rate for the remaining 28 days in the month is $3,595.76 ($128.42 x 28 days). Thus as of the 4th day of the month the private payment charges of $405.00 and the projected Medicaid facility rate of $3,595.76 are sufficient to spend-down the excess income. Eligibility is established for LTC SD MNP/Income over Facility Fee effective the 4th day of the month through the end of the month (open/close certification).

$4,283.10 Gross monthly income - 20.00 Standard deduction $4,263.10 - 92.00 Rural MNIES for 1 person $4,171.10 Spend-down amount (excess income)

$4,171.10 - 171.10 Medicare premium $4,000.00

- 3,906.11 Projected Medicaid facility rate $ 93.89 Spend-down not met for LTC SD MNP

Continue eligibility review for LTC SD MNP/Income over Facility Fee

$4,283.10 Gross monthly income

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- 20.00 Standard deduction $4,263.10 - 92.00 Rural MNIES for 1 person $4,171.10 Spend-down amount

$4,171.10 - 171.10 Medicare premium $4,000.00 - 135.00 Daily private pay rate for Day 1 $3,865.00

- 135.00 Daily private pay rate for Day 2 $3,730.00 - 135.00 Daily private pay rate for Day 3 $3,595.00

- 3,595.76 Projected Medicaid facility rate for 28 days .00 Spend-down met on the 4th day of the

month in LTC SD MNP/Income over Facility

Fee.

Example #2: The individual entered the facility January 17th. The gross monthly income is $4,283.10. After deducting the $20.00 standard deduction and the MNIES ($92.00 rural parish), the individual’s excess income or spend-down amount is $4,171.10. The monthly Medicare premium is $171.10. The prorated Medicaid facility rate for 15 days is $1,926.30 ($128.42 X 15). The prorated Medicaid facility rate and Medicare premium are not sufficient to spend- down the excess income. Eligibility is not established for January in LTC SD MNP.

The prorated private payment rate for 15 days is $2,025.00 ($135.00 X 15). The private payment rate and Medicare premium are not sufficient to meet the spend- down. Eligibility is not established for January in LTC SD MNP/Income over Facility Fee:

$4,283.10 Gross monthly income - 20.00 Standard Deduction $4,263.10 - 92.00 MNIES for 1 person $4,171.10 Spend-down amount (excess income)

$4,171.10 Excess income - 171.10 Medicare premium

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$4,000.00 -1,926.30 Prorated Medicaid facility rate for 15 days $2,073.70 Spend-down not met in LTC SD MNP

Continue eligibility review for LTC SD MNP/Income over Facility Fee

$4,171.10 Excess income - 171.10 Medicare premium $4,000.00 -2,025.00 Private payment charges for 15 days $1,975.00 Spend-down not met in LTC SD MNP/Income over Facility Fee

Example #3: The individual is in a facility on Medicare coinsurance and has income over the SIL. Coinsurance ends January 3rd and the individual converts to Medicaid only. The gross monthly income is $4,600.40. After the deducting the $20.00 standard deduction and the MNIES ($92.00 rural parish), the individual’s excess income or spend- down amount is $4,488.40.

The monthly Medicare premium is $171.10. The bill for Medicare coinsurance incurred for 2 days is $389.00 ($194.50/day x 2). The prorated projected Medicaid facility rate for January is $3,724.18 ($128.42/day X 29). The incurred coinsurance charges, the Medicare premium, and the projected Medicaid facility rate are not sufficient to meet spend-down in LTC SD MNP.

The prorated private payment rate for January is $3,780.00 ($135.00/day X 28). The incurred coinsurance charges, Medicare premium and the prorated private rate are not sufficient to meet the spend-down in LTC SD MNP/Income over Facility Fee.

$4,600.40 Gross monthly income - 20.00 Standard Deduction $4,580.40 - 92.00 MNIES for 1 person $4,488.40 Spend-down amount (excess income)

$4,488.40 - 171.10 Medicare premium

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$4,317.30 - 389.00 Medicare coinsurance charges for 2 days $3,928.30 - 3,724.18 Prorated Medicaid facility rate for 29 days $ 204.12 Spend-down not met in LTC SD MNP

Continue eligibility review for LTC SD MNP/Income over Facility Fee

$4,488.40 Spend-down amount (excess income) - 171.10 Medicare premium $4,317.30 Excess Income

- 389.00 Incurred coinsurance charges $3,928.30 -3,915.00 Prorated private pay rate for 29 days $ 13.30 Spend-down not met in LTC SD

MNP/Income over Facility Fee

Example #4: The individual entered the facility January 17th. The gross monthly income is $4,283.10. After deducting the $20.00 standard deduction and the MNIES ($92.00 rural parish), the individual’s excess income or spend-down amount is $4,171.10. The monthly Medicare premium is $171.10. They also have incurred a dental bill on January 13th. The prorated Medicaid facility rate for 15 days is $1,926.30 ($128.42 X 15). The prorated Medicaid facility rate and Medicare premium are not sufficient to spend-down the excess income. Eligibility is not established for January in LTC SD MNP.

The prorated private payment rate for 15 days is $2,025.00 ($135.00 X 15). The private payment rate and Medicare premium are not sufficient to meet the spend- down. Eligibility is established for January in LTC SD MNP/Income over Facility Fee:

$4,283.10 Gross monthly income - 20.00 Standard Deduction $4,263.10 - 92.00 MNIES for 1 person $4,171.10 Spend-down amount (excess income)

$4,171.10 Excess income - 171.10 Medicare premium

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$4,000.00 -$1980.00 Incurred Medical Expense – Dental – Date of Service January 13th. $2,020.00 -$1926.30 Prorated Medicaid facility rate for 15 days $93.70 Spend-down not met in LTC SD MNP

Continue eligibility review for LTC SD MNP/Income over Facility Fee

$4,171.10 Excess income - 171.10 Medicare premium $4,000.00 -$1980.00 Incurred Medical Expense – Dental – Date of Service January 13th. $2,020.00 -$2025.00 Private payment charges for 15 days $0.00 Spend-down met in LTC SD MNP/Income over Facility Fee for January.

If the remaining income is $0.00, the individual has spent down and is eligible for LTC SD MNP/Income over Facility Fee. ** There is no vendor payment for LTC SD MNP/Income over Facility Fee certifications.

** Complete a Form 110-MNP when there is an incurred medical expense on the effective date of the coverage for LTC SD MNP/Income over Facility Fee certifications. Refer to MEM H- 1041.8 Form 110-MNP.

If there is remaining income after allowable incurred medical expenses have been considered in the budget process, the applicant/beneficiary is not eligible for Medicaid.

D. Determination of Countable Resources

Determine eligibility with regard to resources:

Determine total countable resources of the applicant/beneficiary. Refer to I-1630 SSI-Related Resources

If the applicant/beneficiary has a community spouse, refer to I-1660 Spousal Impoverishment Resource Provisions.

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If resources were transferred for less than FMV within the 60 month look back-period, and the transfer does not qualify for exception, a penalty period will be assessed. During the penalty period the applicant/beneficiary is ineligible for vendor payment. Consider eligibility for Medicaid benefits without vendor payment. Refer to I- 1670 Transfer of Assets for Less than Fair Market Value.

If the applicant/beneficiary’s equity interest exceeds the allowable home equity limit, consider eligibility for Medicaid benefits without vendor payment.

Compare total countable resources to the applicable resource limit. Refer to Z-900 Resource Limits by Program and Refer to Z-800 Spousal Impoverishment Resource Standard.

If resources are equal to or less than the applicable resource limit, the applicant/beneficiary is resource eligible. Continue the determination of need.

If resources are greater than the applicable resource limit, the applicant/beneficiary is resource ineligible.

H-1041.5 Determine Patient Liability – PLI **

Refer to I-1538 Patient Liability (PLI) ** for the Patient Liability Calculation Process.

Exception: LTC SD MNP/Income over Facility Fee certifications have neither a Patient Liability (PLI) nor a segment.

H-1041.6 Certification Period

Certification for LTC SD MNP may not exceed twelve (12) months.

Note: Although the instructions allow a twelve (12) month certification

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period, a review of the budget must be completed at six (6) month intervals to determine if the beneficiary remains eligible.

Certification for LTC SD MNP/Income over Facility Fee is limited to one (1) month. This is an open/closed certification. The case should again be reviewed in LTC SD MNP/Income over Facility Fee or LTC SD MNP for the subsequent month after each certification for up to 12 months from the application date. If ineligible for LTC SD MNP/Income over Facility Fee, consider eligibility in all other programs, a new application will be required the month following an ineligible month.

H-1041.7 Notice of Decision

Send the appropriate notice of decision to the applicant/beneficiary **.

H-1041.8 Form 110-MNP

** Form 110-MNP is only required for LTC SD MNP/Income over Facility Fee certifications when there is an incurred medical expense (IME) on the effective date of the coverage. Form 110 MNP is sent to the IME provider only.

(h-1050)Louisiana Medicaid Eligibility Manual (LDH): H - 1050 Spend-Down Medically Needy - Home and Community Based Services - SSI Related#

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

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Deleted text indicated by “**” H-1050 SPEND-DOWN MEDICALLY NEEDY - HOME AND COMMUNITY-BASED SERVICES (HCBS) - SSI-RELATED H-1051 ELIGIBILITY DETERMINATION PROCESS

Eligibility in SD MNP HCBS cannot be considered prior to establishing income ineligibility for the HCBS program. Refer to H-900 Home and Community-Based Services (HCBS).

Individuals who meet the eligibility requirements for the Community Choices, Adult Day Health Care, Residential Options Waiver, Supports, or New Opportunities Waiver Programs, but have countable monthly income that is over the special income limit (SIL), may be eligible for Medicaid healthcare coverage and payment of waiver services under the Spend-down Medically Needy HCBS Program. The applicant/beneficiary must incur monthly medical expenses in an amount greater than or equal to their excess income to be eligible for Medicaid.

The Medicaid Program considers the anticipated or projected cost for home and community-based waiver services as an incurred medical expense deduction. The projected waiver rate is based on the average monthly waiver costs associated with the waiver and is used to reduce the excess monthly income. Refer to Z-2400 Average Projected Rates for MNP By Program.

Other allowable incurred medical expenses include Medicare and private health insurance premiums, deductibles, coinsurance or copayment charges, and medical/remedial care expenses incurred by an individual that are not subject to payment by a third party. Verification of the applicant/beneficiary’s responsibility for payment of the incurred expense is required.

The projected waiver rate must be prorated when the applicant/beneficiary was not medically certified for the entire month. (Refer to the effective date recorded on the BHSF 142, Notice of Medical Certification.) When the projected waiver rate and the incurred medical expenses are equal to or greater than the applicant/beneficiary’s excess income, income eligibility is established for the budget period. Medicaid eligibility begins the first day of the budget period. Vendor payment eligibility will begin the later of the effective date recorded on the BHSF 142 or the date financial eligibility is established.

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When the projected waiver rate and incurred medical expenses are not sufficient to spend-down the applicant/beneficiary’s excess income to zero, eligibility is not established for the budget period. Continue the income eligibility process to determine if the applicant/beneficiary meets spend-down in the following budget period.

Example: The applicant is medically approved for the Community Choices Waiver Program on July 15th. The applicant’s gross monthly income is $3,062.00. After deducting the $20 SSI disregard and the $92 monthly MNIES, the applicant’s excess income is $2,950.00. The individual’s monthly Medicare premium is $109.00. The prorated projected waiver rate for July 15th to the end of the month is $2,794.46 ($5,000.00 average projected monthly rate x 12 months ÷ 365 days = $164.38 projected daily rate x 17 days = $2,794.46). The applicant has no other incurred medical expense deductions. After deducting the allowable incurred expenses, the applicant’s excess income does not spend-down to zero and is income ineligible for the budget period. **

$3,062.00 Gross monthly income

- 20.00 SSI standard deduction

$3,042.00

- 92.00 Rural monthly MNIES for 1

$2,950.00 Excess Income to spend-down

$2,950.00

- 109.00 Medicare premium

$2,841.00

- 2,794.46 Prorated waiver rate 46.54 Remaining Income

The application should be held for the next month to determine if the applicant will spend-down using for a full month of incurred expenses.

Individuals certified under the Spend-down MNP HCBS Program may be eligible for payment of HCBS waiver services (vendor payment). No payment is authorized to the waiver provider if the post eligibility determination results in a patient liability that exceeds the projected waiver rate.

Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps

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Deleted text indicated by “**” simultaneously. H-1051.1 Determine Assistance Unit

The assistance unit consists of the applicant/beneficiary.

H-1051.2 Establish Categorical Requirements

Verify that the applicant/beneficiary is:

• Aged; • Blind; or • Disabled.

Refer to E-0000 Category.

H-1051.3 Establish Non-Financial Eligibility

Verify eligibility for the applicant/beneficiary with regard to the following factors:

• Assignment of Third Party Rights

I-200 • Citizenship/Identity/Qualified Non-Citizen Status I-300 • Continuity of Stay

I-400 • Enumeration

I-600 • Medical Certification

I-1000 • Residence

I-1900

H-1051.4 Establish Need

Verify the applicant has been offered an opportunity (slot) for HCBS. A. Determine Composition of the Income Unit

The income unit consists of: • The applicant/beneficiary; or • The applicant/beneficiary who is a minor child and the parent(s) with whom the child lived for the month of admission (the month of eligibility listed on the BHSF

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Deleted text indicated by “**” Form 142) only. Refer to I-1420 Need - Deeming. After the first month of eligibility, the income unit consists of the HCBS participant.

Note: Never consider the income of the community spouse/legal dependent(s) at home in determining eligibility for an institutionalized/HCBS individual. Refer to I-1537, Spousal Income Provisions.

B. Determine Countable Income Determine the total countable monthly income of the applicant/beneficiary including any parental deemed income.

The applicant's countable income, after allowable deductions, must be equal to or less than the MNIES or equal to or less than the excess income.

Budget Steps

Step 1. Determine gross unearned income for the individual excluding VA Aid and attendance.

Step 2. Subtract $20 SSI standard deduction

Step 3. Remainder is countable unearned income.

Step 4. Determine gross earned income for the individual. Subtract any remainder of the $20 SSI standard deduction from gross earnings.

Step 5. Subtract $65 and one half of the remainder of the earnings.

Step 6. Remainder is countable earned income.

Step 7. Add the remaining countable unearned and earned income from in Step 3 and Step 6.

Step 8. Subtract the monthly MNIES for one (1)

Step 9. If the income remaining is greater than $0.00, deduct allowable incurred medical expenses. Determine allowable incurred medical expenses.

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Deleted text indicated by “**” Refer to H-1011.5 Medical Expenses Allowed in the Spend-down Process and H-1011.6 Medical Expenses Not Allowed in the Spend-down Process.

Step 10. Subtract allowable incurred medical expenses.

Note: Only unpaid medical bills for services incurred within three (3) months prior to the application month may be used in the spend-down process. Refer to H-1011.5, Bills Allowed in the Spend-down Process.

Step 11. Subtract the projected waiver rate. Refer to Z- 2400.

Note: The projected waiver rate must be prorated when the applicant/beneficiary was not medically certified for the entire month.

Example: The applicant is medically certified for the Community Choices Waiver Program on April 15th. The applicant’s gross monthly income is $2,830.00. After subtracting the $20 standard deduction and $92 monthly MNIES from the gross monthly income, the applicant’s excess income is $2,718.00. The applicant’s Medicare premium is $109.00. The prorated projected waiver rate from April 15th to the end of the month is $2,630.08 ($5,000 average projected monthly rate x 12 months ÷ 365 days = $164.38 projected daily rate x 16 days). The applicant has no other incurred medical expenses deductions. The allowable incurred medical expenses are sufficient to meet spend-down.

$ 2,830.00 Gross monthly income

- 20.00 SSI standard deduction

$ 2,810.00

- 92.00 Rural monthly MNIES for 1

$ 2,718.00 Excess Income to spend-

down

$ 2,718.00

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- 109.00 Medicare premium

$ 2,609.00

- 2,630.08 Prorated waiver rate

0.00

Step 12. If the remaining income is greater than $0.00, spend-down is not met and the applicant is income ineligible.

If the projected waiver rate is prorated for the budget month, review eligibility for the following month using the monthly projected waiver rate. If the remaining income is greater than $0.00, spend-down is not met and the applicant is income ineligible. Review the applicant for all other Medicaid programs.

C. Determine Composition of the Resource Unit

The resource unit consists of: • The applicant/beneficiary; • The applicant/beneficiary and the community spouse; or • For the month of admission only (the month of eligibility listed on the BHSF Form 142), the applicant/beneficiary who is a minor child and the parent(s) with whom they lived during the month. Refer to I-1420 Need - Deeming. After the first month of eligibility, the resource unit consists of the applicant/beneficiary.

Exception: Do not deem resources from parent(s) to a child who has been discharged from a facility to his home to receive HCBS.

D. Determine Countable Resources

Determine eligibility with regard to resources:

• Determine total countable resources of the applicant/beneficiary. Refer to I-1630 SSI-Related Resources.

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Deleted text indicated by “**” If the applicant/beneficiary has a community spouse, refer to I-1660 Spousal Impoverishment Resource Provisions.

Resources transferred for less than FMV within the 60 month look back-period make the applicant/beneficiary ineligible for the waiver program for the duration of the penalty period. Refer to I-1670 Transfer for Less than FMV.

Equity interest in home property that exceeds the allowable home equity limit makes the applicant/beneficiary resource ineligible for the waiver program.

Eligibility should be considered in other non-waiver programs.

• Compare total countable resources to the LTC resource limit for an individual. Refer to Z-900 Resource Limits by Program.

If resources are equal to or less than the individual resource limit, the applicant/beneficiary is resource eligible for HCBS. Continue the determination of need.

If resources are greater than the individual resource limit, the applicant/beneficiary is resource ineligible for HCBS.

H-1051.5 Determine the Patient Liability

Refer to I-1538 Patient Liability-Post Eligibility Treatment of Income (PETI) for the Patient Liability calculation process.

** The monthly patient liability will be paid directly to the waiver services

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Deleted text indicated by “**” provider by the applicant/beneficiary or responsible party and shall be used to reduce the Medicaid payment to the provider. The waiver services provider will be responsible for collecting the patient liability.

The agency is responsible for informing the applicant/beneficiary of the monthly patient liability requirement for participation in the waiver before Medicaid is approved. The applicant/beneficiary must agree to pay the required PLI amount prior to certification.

If the applicant/beneficiary agrees to pay the required PLI amount, the certification is completed.

If the applicant/beneficiary does not agree to pay the patient liability amount, the application for HCBS will be rejected. Eligibility must be considered in all other non-waiver Medicaid programs.

H-1051.6 Certification Period

Certification for Spend-down MNP HCBS may not exceed 12 months.

Note: Although the instructions allow a 12-month certification period, a review of the budget must be completed at six (6) month intervals to determine if the client remains eligible. Enterprise Document Management System (EDMS) case record entries will document the case review.

Six (6) month review: Actual projected waiver expenses must be verified prior to establishing a new spend-down period. The projected waiver expenses must be reconciled with actual incurred expenses. The waiver expenses can be reconciled using the Medicaid Enterprise System (MES) files reflecting the amount billed by the provider(s).

H-1051.7 Notice of Decision

Send the appropriate Notice of Decision to the applicant/beneficiary, the provider and OAAS/OCDD.

(h-1100)Louisiana Medicaid Eligibility Manual (LDH): H - 1100 Qualified Medicare Beneficiary (QMB)#

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued December 9, 2024

Page 1 of H-1100 Replacing February 6, 2023

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H-1100 QUALIFIED MEDICARE BENEFICIARY (QMB)

H-1110 GENERAL INFORMATION

Effective January 1, 1988, the Medicare Catastrophic Coverage Act of 1988 required expansion of Medicaid coverage for a mandatory eligibility group of low-income Medicare beneficiaries called Qualified Medicare Beneficiaries (QMB). The applicant/beneficiary must meet all of the following QMB requirements. A QMB must:

• Be entitled to or enrolled in hospital insurance benefits under Medicare Part A, but is not required to be enrolled in Medicare Part B. **

• Have income that is less than or equal to 100 percent of the Federal Poverty Income Guidelines (FPIG). Refer to Z-200 Federal Poverty Income Guidelines. Note: In January of each year, disregard the Social Security Administration (SSA) cost-of-living adjustment (COLA) through the month following the release of the annual FPIG update. For example, the annual FPIG is released in January, disregard COLA through February. Thereafter, determine eligibility using all income including the COLA for that year. • Meet all non-financial eligibility requirements for Medicaid.

H-1110.1 Coverage

QMB eligibles are divided into two categories:

QMB Only

Eligible for Medicaid payments for: • Medicare Part A (when applicable) and B premiums; • Medicare deductibles for Medicare covered services; and

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• Medicare coinsurance for Medicare covered services.

QMB Plus

Eligible for Medicaid payments for: • The same benefits listed for QMB Only; plus • The full range of Medicaid services.

Individuals who qualify for one of the Medicare Saving Programs (QMB, SLMB, or QI) are automatically enrolled in the SSA low- income subsidy (LIS) program (also called Extra Help). This subsidy helps pay for the Medicare Part D prescription drug plan premiums, co- payments, and the annual deductible. For more information on LIS/Extra Help, please visit the Social Security Administration Extra Help website.

Note: Although the BHSF Form 1-MB, Application for Medicare Savings Program, is commonly used to apply for QMB, it is acceptable to use BHSF Form 1-A, Application for Health Coverage.

SSI beneficiaries do not have to apply for QMB. Most Medicare- enrolled SSI recipients eligible for QMB must be automatically enrolled into QMB. If the SSI recipient who is entitled to enroll in Part A is not automatically enrolled, enter the QMB certification.

SSI recipients are deemed eligible for QMB the first month they are: • Eligible for Medicaid, and • Entitled to premium-free Part A and/or enrolled in Part B. The SSI recipients QMB eligibility coverage starts the first day of the month following the first month they are entitled to premium-free Part A and/or Part B. A beneficiary who is no longer eligible for full Medicaid may continue to be eligible as a QMB Only.

SSI/QMB Plus beneficiaries remain eligible for QMB after entering a long-term care (LTC) facility.

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Page 3 of H-1100 Replacing February 6, 2023

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Deleted text indicated by “”

H-1121 ELIGIBILITY DETERMINATION PROCESS

Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

H-1121.1 Determine Assistance Unit

The assistance unit includes the applicant(s)/beneficiary(s).

H-1121.2 Establish Categorical Requirement

Verify entitlement/enrollment in Medicare Part A for the applicant/beneficiary. Medicare Part A eligibility, the start date for Medicare Part A, and the Medicare claim number may be verified through the interfaces available in LaMEDS. H-1121.3 Establish Non-Financial Eligibility

Verify eligibility for each member of the assistance unit with regard to the following factors: • Assignment of Third Party Rights I-200 • Citizenship/Identity and Qualified Non-Citizen Status I-300 • Enumeration

I-600 • Residence

I-1900

H-1121.4 Establish Need

A. Determine Composition of the Income Unit

The income unit includes the: • Applicant/beneficiary; • Applicant/beneficiary and ineligible spouse living in the same home; or • Applicants/beneficiaries who are a couple living in the same home (eligible couple). Note: If SSA considers the applicant/beneficiary and their spouse as a couple for SSI, they are considered as an eligible couple for the purposes of budgeting in the Medicare

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Savings Programs (QMB, SLMB, QI). An eligible spouse is one who is aged, blind, or disabled and lives in the same household as the applicant/beneficiary. The eligible spouse does not have to be entitled to Medicare for the couple to be considered an eligible couple.

B. Determine Need/Countable Income

Individual

If the applicant/beneficiary is an individual with no spouse or with an ineligible spouse with no income, complete the following budget steps:

Step 1. Determine the total gross unearned income.

Step 2. Subtract the $20 SSI general income disregard from unearned income.

Step 3. The remainder is the countable unearned income.

Step 4. Determine the total gross earned income.

Step 5. Subtract any remainder of $20 SSI disregard from gross earnings.

Step 6. Subtract earned income deduction from remaining gross earnings. Earned income deduction is $65 and one-half of remainder of earnings.

Step 7. The remainder is the countable earned income.

Step 8. Add remainders from Step 3 and Step 7.

Step 9. Compare the total to 100 percent FPL for one person. Refer to Z-200 Federal Poverty Income Guidelines.

If the remaining income is greater than the QMB income limit for one person, the applicant/beneficiary is not income eligible.

If the remaining income is equal to or less than the QMB income limit for one person, the applicant/beneficiary is income eligible for QMB.

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Ineligible Spouse Deeming

If there is an ineligible spouse with income, complete budget Steps 1 through 9 above using only the applicant/beneficiary income. If the income of the applicant/beneficiary is greater than the QMB limit for one person, the applicant/beneficiary is ineligible and there is no deeming. Consider for the Medically Needy Program (MNP).

If the income of applicant/beneficiary is equal to or less than the QMB limit for one person, apply deeming policy. Refer to I-1420 Need - Deeming. Go to Step 1 of the couple budget.

Couple If both members of a couple are potentially eligible, or if there is income remaining in the deeming process, complete the following budget steps:

Step 1. Determine the total gross unearned income by combining the couple’s unearned income.

Note: When deeming income from an ineligible spouse, the income of the ineligible spouse remaining after allocation for ineligible children is combined with the income of the eligible spouse. The couple is then treated the same as an eligible couple for budgeting purposes.

Step 2. Subtract the $20 SSI general income disregard.

Step 3. The remainder is the couple’s countable unearned income.

Step 4. Determine the total gross earned income by combining the couple’s gross earned income.

Step 5. Subtract any remainder of the $20 SSI disregard from gross earnings.

Step 6. Subtract one earned income deduction from the remaining gross earnings of the income unit. The earned income deduction is $65 and one-half of the remainder of the earnings.

Step 7. The remainder is the couple’s countable earned income.

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Step 8. Combine the remainders in Step 3 and Step 7.

Step 9. Compare the total countable income to 100 percent FPL for two persons. Refer to Z-200 Federal Poverty Income Guidelines.

If the income is greater than the QMB income limit for two persons, the applicant/beneficiary is not eligible.

If the income is equal to or less than the QMB income limit for two persons, the applicant/beneficiary is income eligible.

Exception: Couples in a nursing facility or receiving waiver services who are being considered as individuals, are considered individuals for QMB need/countable income determinations. Refer to MEM 831.4.

If one spouse is in a nursing facility or receiving waiver services and his community spouse is not receiving waiver services, determine eligibility for each spouse as an individual. Consider income of each individual for separate QMB decisions. Note: Count as unearned income to the community spouse any income allocated from an institutionalized spouse.

H-1121.5 Eligibility Decision

Evaluate all eligibility requirements and verifications received to make eligibility decision.

H-1121.6 Certification Period

Eligibility for QMB shall not be retroactive from the application date.

The certification period shall not exceed 12 months.

QMB certifications are effective the month following the month the individual is determined to be QMB-eligible. The “month the individual is determined to be QMB-eligible” is the month that the individual is determined to meet all the requirements for QMB eligibility.

Example:

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If an individual applies for Medicaid on January 1 and is determined to meet all of the requirements of eligibility at that time, even if the state makes this determination on March 10th, the individual’s QMB coverage would begin on February 1.

H-1121.7 Notice of Decision

Send the appropriate notice of decision to the applicant(s)/beneficiary(s).

Note: Applicants enrolled in Medicare Part A are not referred to the Federally Facilitated Marketplace (FFM).

(h-1200)Louisiana Medicaid Eligibility Manual (LDH): H - 1200 Qualified Disabled and Working Individuals (QDWI)#

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Page 1 of H-1200 Replacing May 22, 2020

Deleted text indicated by “**” Revised/added text indicated by underscore

H-1200 QUALIFIED DISABLED AND WORKING INDIVIDUALS (QDWI)

H-1210 GENERAL INFORMATION

The OBRA law of 1989 established the Qualified Disabled Working Individual (QDWI) program to help certain individuals who lost entitlement to Social Security disability benefits and premium-free Medicare Part A coverage because their earnings exceeded the amount allowed under Social Security regulations pertaining to Substantial Gainful Activity (SGA).

SGA describes a level of work activity and earnings. Work is substantial if it involves significant physical or mental activities or a combination of both. Work is gainful if generally performed for pay or profit, or intended for profit, whether or not a profit is realized.

The applicant/enrollee must meet all of the following requirements for the QDWI buy-in program. A QDWI must:

● Be enrolled, or conditionally enrolled, in hospital insurance benefits (Medicare Part A) and must pay a premium for part A;

● Be under age 65;

● Have monthly income less than or equal to 200 percent of the Federal Poverty Income Guidelines (FPIG).

Refer to Z-200 Federal Poverty Income Guidelines;

Note: In January of each year, disregard the Social Security Administration (SSA) cost-of-living adjustment (COLA) through the month following the release of the annual FPIG update. For example, the annual FPIG is released in January, disregard COLA through February. Thereafter, determine eligibility using all income including the COLA for that year. ● Have resources equal to or less than twice the SSI limit. Refer to Z-900 Resource Limits by Program;

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Deleted text indicated by “**” Revised/added text indicated by underscore

● Continue to have a disabling physical or mental impairment;

● Have lost premium-free Medicare part A due to Substantial Gainful Activity (SGA); and

● Not otherwise be eligible for Medicaid.

Individuals that have at least 30 quarters of coverage are eligible for a reduction in the Medicare part A premium and meet all of the above requirements are eligible for QDWI.

H-1210.1 Coverage

Coverage is limited to the payment of the Medicare Part A premium.

Note: Although the BHSF Form 1-MB Application for Medicare Savings Program is commonly used to apply for MSP, it is acceptable to use BHSF Form 1-A, Application for Health Coverage.

H-1221 ELIGIBILITY DETERMINATION PROCESS

Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

H-1221.1 Determine Assistance/Benefit Unit

The assistance unit consists of the applicant(s)/enrollee(s).

H-1221.2 Establish Categorical Requirement

Verify that the applicant is enrolled, or conditionally enrolled, in Medicare Part A and is considered a QDWI. Medicare part A eligibility, the start date for Medicare Part A, and the Medicare claim number may be verified through the interfaces available in LaMEDS.

(h-1200)(page-3)Page 3#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued July 22, 2020

Page 3 of H-1200 Replacing May 22, 2020

Deleted text indicated by “**” Revised/added text indicated by underscore

H-1221.3 Establish Non-Financial Eligibility

Verify eligibility for the applicant/enrollee with regard to the following factors:

 Assignment of Third Party Rights I-200

 Citizenship/Alien Status

I-300

 Enumeration

I-600

 Residence

I-1900

H-1221.4 Establish Need

A. Determine Composition of the Income/Resource Unit

The income/resource unit consists of:

● Applicant/enrollee; or

● Applicant/enrollee and ineligible spouse living in the home; or

● Applicants/enrollees who are a couple living in the same home (eligible couple).

Note: If SSA considers the applicants/enrollees as a couple for SSI, they are considered an eligible couple for the purposes of budgeting in the Medicare Savings Programs. A categorically eligible spouse is one who is aged, blind, or disabled and lives in the same household of the eligible individual. The eligible spouse does not have to be entitled to Medicare for the couple to be considered an eligible couple.

B. Determine Need/Countable Resources

Determine the total countable resources of the members of the income/resource unit. Refer to I-1630 SSI-Related Resources.

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued July 22, 2020

Page 4 of H-1200 Replacing May 22, 2020

Deleted text indicated by “**” Revised/added text indicated by underscore

Compare the countable resources to the QDWI resource limits:

● For an individual, if there is no spouse living in the home; or

● For a couple, if there is a spouse (eligible or ineligible) living in the home.

Refer to Z-900 Resource Limits by Program.

If the countable resources are greater than the QDWI resource limit, the applicant/enrollee is resource ineligible.

If the countable resources are equal to or less than the QDWI resource limit, continue determination of need.

C. Determine Need/Countable Income

Individual

If the applicant/enrollee is an individual with no spouse or with an ineligible spouse with no income, complete the following budget steps:

Step 1. Determine the total gross unearned income.

Step 2. Subtract the $20 SSI general income disregard from unearned income.

Step 3. The remainder is the countable unearned income.

Step 4. Determine the total gross earned income.

Step 5. Subtract any remainder of the $20 SSI disregard from gross earnings.

Step 6. Subtract earned income deduction from remaining gross earnings. Earned income deduction is $65 and one-half of remainder of earnings.

Step 7. The remainder is the countable earned income.

Step 8. Combine remainders from Step 3 and Step 7.

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued July 22, 2020

Page 5 of H-1200 Replacing May 22, 2020

Deleted text indicated by “**” Revised/added text indicated by underscore

Step 9. Compare the total to 200 percent FPL for one person. Refer to Z-200 Federal Poverty Income Guidelines.

If the remaining income is greater than the QDWI income limit for one person, the applicant/enrollee is not income eligible.

If the remaining income is equal to or less than the QDWI income limit for one person, the applicant/enrollee is income eligible for QDWI.

Ineligible Spouse Deeming

If the applicant/enrollee has an ineligible spouse with income, complete budget steps 1 through 9 above using only the applicant/enrollee income.

If the income of the applicant/enrollee is greater than the QDWI limit for one person, the applicant/enrollee is income ineligible and there is no deeming. Consider for the Medically Needy Program (MNP).

If the income of the applicant/enrollee is less than or equal to the QDWI limit for one, apply deeming policy. Refer to I-1420 Need - Deeming. Go to Step 1 of the couple budget.

Couple

If both members of a couple are potentially eligible, or if there is income remaining in the deeming process, complete the following budget steps:

Step 1. Determine the total gross unearned income by combining the couple’s gross unearned income.

Step 2. Subtract one $20 SSI general income disregard.

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Issued July 22, 2020

Page 6 of H-1200 Replacing May 22, 2020

Deleted text indicated by “**” Revised/added text indicated by underscore

Step 3. The remainder is the couple's countable unearned income.

Step 4. Determine the total gross earned income by combining the couple’s gross earned income.

Step 5. Subtract any remainder of the $20 disregard from gross earnings.

Step 6. Subtract one earned income deduction from the remaining gross earnings of the income unit. The earned deduction is $65 and one-half of the remainder of the earnings.

Step 7. The remainder is the couple’s countable earned income.

Step 8. Combine the remainders in Step 3 and Step 7.

Step 9. Compare the total countable income to 200 percent FPL for two persons. Refer to Z-200 Federal Poverty Income Guidelines.

If the income is greater than the QDWI income limit for two persons, the applicant/enrollee is income ineligible.

If the income is equal to or less than the QDWI income limit for two persons, the applicant/enrollee is income eligible.

Note: Count as unearned income to the community spouse any income allocated from an institutionalized spouse.

H-1221.5 Eligibility Decision

Evaluate all eligibility requirements and verification received to make the eligibility decision.

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued July 22, 2020

Page 7 of H-1200 Replacing May 22, 2020

Deleted text indicated by “**” Revised/added text indicated by underscore

H-1221.6 Certification Period

The certification period may be effective no earlier than three (3) months prior to the application date provided the individual is otherwise eligible and is enrolled in Medicare part A during the retroactive period.

The months of retroactive coverage are not included in the twelve (12) month certification period. The certification shall not exceed twelve (12) months and begins with the month of application.

H-1221.7 Notice of Decision

Send the appropriate notice of decision to the applicant(s)/enrollee(s).

Note: Applicants enrolled in Medicare Part A are not referred to the Federally Facilitated Marketplace. (FFM).

(h-1300)Louisiana Medicaid Eligibility Manual (LDH): H - 1300 Specified Low-Income Medicare Beneficiary (SLMB)#

(h-1300)(page-1)Page 1#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued Feburary 06, 2023 Page 1 of H-1300 Replacing March 13, 2020 Revised/added text indicated by underscore Deleted text indicated by “**” H-1300 SPECIFIED LOW-INCOME MEDICARE BENEFICIARY (SLMB) H-1310 GENERAL INFORMATION

Effective January 1, 1993, the Omnibus Reconciliation Act (OBRA) of 1990 required payment of Medicare Part B premiums for a mandatory eligibility group of low income Medicare beneficiaries called Specified Low Income Medicare Beneficiaries (SLMB).

The applicant/beneficiary must meet all of the following SLMB requirements.

A SLMB must:

• Be enrolled in hospital insurance benefits under Medicare Part A, but does not have to be currently enrolled in Medicare Part B;

• Have income that is greater than 100 percent but less than 120 percent of the Federal Poverty Income Guidelines (FPIG). Refer to Z-200 Federal Poverty Income Guidelines; and

NOTE: In January of each year, disregard the Social Security Administration (SSA) cost of living adjustment (COLA) through the month following the release of the annual FPIG update. Thereafter, determine eligibility using all income including the COLA for the current year.

• Meet all non-financial eligibility requirements for Medicaid.

H-1310.1 COVERAGE

SLMB Only

• Eligible for Medicaid payment for the Medicare Part B premium only.

SLMB Plus

• Eligible for Medicaid payment for the Medicare Part B premium; and

(h-1300)(page-2)Page 2#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued Feburary 06, 2023 Page 2 of H-1300 Replacing March 13, 2020 Revised/added text indicated by underscore Deleted text indicated by “**” • Eligible for the full range of Medicaid services under any other category of assistance. Individuals who qualify for one of the Medicare Savings Programs (QMB, SLMB, or QI) are automatically enrolled in SSA low-income subsidy (LIS program, also called Extra Help). This subsidy helps pay for the Medicare Part D prescription drug plan. For more information on the LIS/Extra Help, please visit the Social Security Administration Extra Help website.

Note: Although the BHSF Form 1-MB, Application for Medicare Savings Program is commonly used to apply for SLMB, it is acceptable to use BHSF Form 1-A, Application for Health Care Coverage.

The eligibility determination is the same for both the SLMB Only and SLMB Plus.

A SLMB Plus beneficiary may continue to be eligible as a SLMB Only, when the full Medicaid case closes.

H-1321 ELIGIBILITY DETERMINATION PROCESS

Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

H-1321.1 DETERMINE ASSISTANCE UNIT

The assistance unit includes the applicant(s)/beneficiary(s).

H-1321.2 ESTABLISH CATEGORICAL REQUIREMENT

Verify enrollment in Medicare Part A for the applicant/beneficiary. Medicare Part A eligibility, the start date for Medicare Part A, and the Medicare claim number may be verified through the interfaces available in LaMEDS.

H-1321.3 ESTABLISH NON-FINANCIAL ELIGIBILITY

Verify eligibility for each member of the assistance unit with regard to

(h-1300)(page-3)Page 3#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued Feburary 06, 2023 Page 3 of H-1300 Replacing March 13, 2020 Revised/added text indicated by underscore Deleted text indicated by “**” the following factors:

• Assignment of Third Party Rights I-200

• Citizenship/Identity and Qualified Non-Citizen Status I-300

• Enumeration

I-600

• Residence

I-1900

H-1321.4 ESTABLISH NEED

A. Determine Composition of the Income Unit

The income unit includes the:

• Applicant/beneficiary,

• Applicant/beneficiary and ineligible spouse living in the Home, or

• Applicant/beneficiary and eligible spouse who are living in the same home (eligible couple).

Note: If the SSA considers the applicant/beneficiary and their spouse as a couple for SSI purposes, they are considered as an eligible couple for purposes of budgeting in the Medicare Savings Programs (QMB, SLMB, or QI). An eligible spouse is one who is aged, blind, or disabled and lives in the same household as the applicant/beneficiary. The eligible spouse does not have to be entitled to Medicare for the couple to be considered an eligible couple.

B. Determine Need/Countable Income Individual

If the applicant/beneficiary is an individual with no spouse or with an ineligible spouse with no income, complete the following budget steps:

Step 1. Determine total gross unearned income.

Step 2. Subtract the $20 SSI general income disregard from unearned income.

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued Feburary 06, 2023 Page 4 of H-1300 Replacing March 13, 2020 Revised/added text indicated by underscore Deleted text indicated by “**”

Step 3. The remainder is the countable unearned income.

Step 4. Determine the total gross earned income.

Step 5. Subtract any remainder of $20 SSI disregard from gross earnings.

Step 6. Subtract earned income deduction from remaining gross earnings. Earned income deduction is $65 and one half of remainder of earnings.

Step 7. The remainder is the countable earned income.

Step 8. Combine the remainders from Step 3 and Step 7.

Step 9. Compare the total to 120 percent FPL for one person. Refer to Z-200 Federal Poverty Income Guidelines.

If the remaining income is equal to or greater than the SLMB income limit for one person, the applicant/beneficiary is ineligible.

If the remaining income is less than the SLMB income limit for one person, the applicant/beneficiary is income eligible for SLMB.

Ineligible Spouse Deeming

If there is an ineligible spouse with income, complete budget Steps 1 through 9 above using only the applicant/beneficiary income. If the income is equal to or greater than the SLMB limit for one person, the applicant/beneficiary is ineligible and there is no deeming. Consider for the Medically Needy Program (MNP).

If the income of the applicant/beneficiary is less than the SLMB limit for one person, apply deeming policy. Refer to I-1420 Need - Deeming. Go to Step 1 of the couple budget.

Couple

For an eligible couple, or if there is income remaining in the deeming process, complete the following steps:

Step 1. Determine the total gross unearned income by combining the couple’s unearned income.

(h-1300)(page-5)Page 5#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued Feburary 06, 2023 Page 5 of H-1300 Replacing March 13, 2020 Revised/added text indicated by underscore Deleted text indicated by “**”

Step 2. Subtract the $20 SSI general income disregard.

Step 3. The remainder is the couple’s countable unearned income.

Step 4. Determine the total gross earned income by combining the couple’s gross earned income.

Step 5. Subtract any remainder of $20 SSI disregard from gross earnings.

Step 6. Subtract one earned income deduction from the remaining gross earnings of the income unit. The earned income deduction is $65 and one half of the remainder of the earnings.

Step 7. The remainder is the couple’s countable earned income.

Step 8. Combine the remainders in Step 3 and Step 7.

Step 9. Compare the total to 120 percent FPL for one person. Refer to Z-200 Federal Poverty Income Guidelines.

If the income is equal to or greater than the SLMB standard for two persons, the applicant/beneficiary is not eligible.

If the income is less than the SLMB limit for two persons, the applicant/beneficiary is income eligible. Refer to Z-200 Federal Poverty Income Guidelines.

Exception: Couples in a nursing facility or receiving waiver services who are being considered as individuals, are considered individuals for SLMB need/countable income determinations. Refer to MEM 831.4 If one spouse is in a nursing facility or receiving waiver services and the community spouse is not receiving waiver services, determine eligibility for each spouse as an individual. Consider income of each

(h-1300)(page-6)Page 6#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued Feburary 06, 2023 Page 6 of H-1300 Replacing March 13, 2020 Revised/added text indicated by underscore Deleted text indicated by “**” individual for separate SLMB decisions.

Note: Count as unearned income to the community spouse any income allocated from an institutionalized spouse.

H-1321.5 ELIGIBILITY DECISION

Evaluate all eligibility requirements and verification received to make the eligibility decision.

H-1321.6 CERTIFICATION PERIOD

The certification period may be effective no earlier than three (3) months prior to the application date provided the individual is otherwise eligible and is enrolled in Medicare Part A.

The months of retroactive coverage are not included in the twelve (12) month certification period. The certification period begins with the month of application.

H-1321.7 NOTICE OF DECISION

Send the appropriate Notice of Decision to the applicant(s)/beneficiary(s).

Note: Medicare beneficiaries are not referred to the Federally Facilitated Marketplace (FFM).

(h-1400)Louisiana Medicaid Eligibility Manual (LDH): H - 1400 Breast and Cervical Cancer Program#

(h-1400)(page-1)Page 1#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued Feburary 13, 2025

Page 1 of H-1400 Replacing November 22, 2022

Revised/added text indicated by underscore

Deleted text indicated by “**”

H-1400 BREAST AND CERVICAL CANCER (BCC) PROGRAM H-1410 GENERAL INFORMATION

The Breast and Cervical Cancer (BCC) Program provides full Medicaid benefits to uninsured women under age 65 who are identified through the Centers for Disease Control and Prevention’s (CDC) National Breast and Cervical Cancer Early Detection Program and are in need of treatment for breast and/or cervical cancer, including pre-cancerous conditions and early stage cancer.

An applicant/beneficiary may be eligible for Medicaid services under the BCC program if she: • Is under the age of 65; • Has been screened for breast and/or cervical cancer under the Louisiana Breast and Cervical Health Program (LBCHP) and found to “need treatment” for breast and/or cervical cancer (including a precancerous condition). A list of LBCHP partner providers can be found here: LBCHP providers.; Note: For purposes of the BCC program, “need treatment” means in the opinion of the applicant’s/beneficiary’s treating physician, the diagnostic test(s) following a breast and/or cervical cancer screen indicates she is in need of cancer treatment services. Cancer treatment services include diagnostic procedures necessary to determine the extent and proper course of treatment, as well as definitive cancer treatment itself. Based on the physician’s plan-of-care, women who require only routine monitoring services for a precancerous breast or cervical condition (e.g., breast examinations and mammograms) are not considered to “need treatment.” • Is not enrolled in Medicaid under any other mandatory eligibility group; and • Does not have creditable health insurance (Refer to I-2200 Creditable Health Insurance). If the applicant/beneficiary has health insurance coverage, she may be considered uninsured if: - The treatment of breast and/or cervical cancer is not covered by the plan,

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued Feburary 13, 2025

Page 2 of H-1400 Replacing November 22, 2022

Revised/added text indicated by underscore

Deleted text indicated by “**”

- Her lifetime limit on all benefits under the plan has been exhausted, - She is in a period of exclusion (such as a pre-existing condition exclusion) for treatment of breast and/or cervical cancer, or - She is an American Indian or Alaska Native woman eligible for health care services provided under a medical care program of the Indian Health Service or of a tribal organization.

H- 1410.1 COVERAGE

Beneficiaries are eligible for full Medicaid coverage. Coverage is not limited to the treatment of breast and/or cervical cancer.

H-1420 ELIGIBILITY DETERMINATION PROCESS

Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously:

H-1420.1 DETERMINE ASSISTANCE UNIT

The assistance unit includes the applicant/beneficiary.

H-1420.2 ESTABLISH CATEGORICAL REQUIREMENT

Verification must be provided that applicant is under age 65 and has been screened for breast and/or cervical cancer under the LBCHP and found to need treatment for breast and/or cervical cancer (including a pre-cancerous condition).

H-1420.3 ESTABLISH NON-FINANCIAL ELIGIBILITY

Verify eligibility for each member of the assistance unit with regard to the following factors:

• Assignment of Third Party Rights I-200

• Citizenship/Alien Status

I-300

(h-1400)(page-3)Page 3#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued Feburary 13, 2025

Page 3 of H-1400 Replacing November 22, 2022

Revised/added text indicated by underscore

Deleted text indicated by “**”

• Enumeration

I-600

• Residence

I-1900

• Creditable Health Insurance

I-2200

H-1420.4 ESTABLISH NEED

All income and resources are exempt for BCC Medicaid.

Note: To be eligible for a LBCHP screening, household income must be below 250 percent of the poverty level and is determined by LBCHP.

H-1420.5 ELIGIBILITY DECISION

Evaluate all eligibility requirements and verifications received, to make an eligibility decision.

H-1420.6 ELIGIBILITY PERIOD

Eligibility may begin up to three (3) months prior to the date of application if program requirements are met. Eligibility for coverage ends when the beneficiary’s course of treatment is complete or the state has determined the enrollee no longer meets the eligibility criteria for the program.

A beneficiary is not limited in the number of eligibility periods for which they may receive coverage under the BCC program. A new period of eligibility may begin each time an applicant/beneficiary has been screened under the LBCHP, found to need treatment for breast and/or cervical cancer, and meets all other eligibility criteria.

H-1420.7 CERTIFICATION PERIOD

The initial certification period shall not exceed six (6) months, including any retroactive coverage.

Retroactive medicaid eligibility shall be explored for the three (3) months prior to the month of application. Refer to H-1800 Retroactive Medical Eligibility (RME).

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued Feburary 13, 2025

Page 4 of H-1400 Replacing November 22, 2022

Revised/added text indicated by underscore

Deleted text indicated by “**”

Renewal

Renewals may be extended up to 12 months and is determined by the physician’s statement regarding the projected length of remaining treatment.

Consider the following when determining continued eligibility:

• ** • Continuous need for treatment of breast and/or cervical cancer based on the treating physician’s statement regarding the projected length of remaining treatment,

• Creditable insurance coverage, and

Note: Insurance that is paid by Medicaid through the LaHIPP program is not considered creditable insurance and therefore, does not affect eligibility for BCC.

• Age (under 65).

H-1420.8 NOTICE OF DECISION

Send the appropriate notice of decision to the applicant/enrollee.

Note: Applicants/beneficiaries that do not meet the eligibility requirements shall be referred to the FFM for enrollment in a qualified health plan (QHP).

(h-1500)Louisiana Medicaid Eligibility Manual (LDH): H - 1500 Continued Medicaid#

(h-1500)(page-1)Page 1#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued October 1, 2024 Page 1 of H-1500 Issued May 16, 2022 Revised/added text indicated by underscore Deleted text indicated by “**” H-1500 CONTINUED MEDICAID FOR THE PARENTS AND CARETAKER RELATIVES GROUP

H-1510 GENERAL INFORMATION

Medicaid coverage may be continued for parents or caretakers relatives who lose Parent and Caretaker Relatives Group (PCR) coverage because of an increase in Modified Adjusted Gross Income (MAGI) from employment. Medicaid coverage may be continued for parents or caretakers relatives, their legal spouses who are in the home, and the dependent child. **

H-1510.1 Coverage

TM beneficiaries are eligible for the full range of Medicaid covered services. **

H-1520 Reserved

H-1530 TRANSITIONAL MEDICAID

Transitional Medicaid (TM) may provide continued Medicaid coverage for a parent or caretaker relative, that individual’s spouse (if living together) and dependent children who lose eligibility in PCR because of an increase in MAGI.

Note: The designation as primary caretaker is not based on the parent or caretaker relative’s being a tax filer, tax dependent, or non-filer. Refer to MEM H-2082.1 if determining who is the parent or caretaker relative is questionable.

** If a parent or caretaker relative’s spouse returns to the home after an absence, the returning individual is eligible for the remainder of the extended eligibility period.

If a child is born, adopted, loses eligibility in another Medicaid program, or returns to the home after an absence, this child may also qualify for the remainder of the extended eligibility period.

(h-1500)(page-2)Page 2#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued October 1, 2024 Page 2 of H-1500 Issued May 16, 2022 Revised/added text indicated by underscore Deleted text indicated by “**” The parent/caretaker or child(ren) must be included for all purposes (e.g. eligibility, determination of income) if the parent or caretaker relative or child(ren) would have been considered a member of the MAGI household at the time benefits were terminated.

H-1531 ELIGIBILITY CRITERIA

Parents and other caretaker relatives qualify for TM if they:

• Were eligible for and received PCR coverage in at least three (3) of the six (6) months immediately preceding the month in which the parent/caretaker became ineligible for PCR due to new or increased MAGI earnings from employment.

• Lost eligibility under PCR due to earnings over the income standard for PCR, and

• Continue to live with a dependent child.

Child(ren) may be added if they:

• Live with the TM-eligible parent/caretaker relative,

• Are ineligible for the Champ/LaCHIP Medicaid program, and

• Meet age requirements. Refer to MEM I-100.

Note: A parent/caretaker from another state who received PCR in that state must receive PCR in Louisiana for at least (one) 1 month to qualify for TM. The months PCR was received in another state are counted in determining if the parent/caretaker meets the criteria of having received PCR in three (3) of the prior six (6) months.

There is no income test during the first six (6) month eligibility period.

The parents or caretaker relatives and dependent child(ren) continues to be eligible for TM unless the beneficiaries become ineligible based on one or more of the factors listed in H-1534 Reasons For Ineligibility.

(h-1500)(page-3)Page 3#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued October 1, 2024 Page 3 of H-1500 Issued May 16, 2022 Revised/added text indicated by underscore Deleted text indicated by “**” H-1532 PERIOD OF ELIGIBILITY

A new application is not required for TM. Eligibility begins with the first month of PCR ineligibility. If earnings were not reported timely, the parent/caretaker is still entitled to the first six (6) months of TM, but may receive Medicaid under an incorrect type case (for example, PCR rather than TM).

TM is not available to a parent/caretaker if it is determined that, at any time in the last six (6) months of receipt of PCR, the parent/caretaker was ineligible because of fraud.

TM may continue for up to twelve (12) months if certain eligibility requirements are met.

If a parent/caretaker again becomes PCR eligible during the twelve (12) months of TM, the family may choose between TM and PCR.

If the parent/caretaker chooses PCR and subsequently becomes ineligible for that program, the parent/caretaker may be eligible for:

1) A new period of continued benefits. To be eligible for a new period, the parent/caretaker would have to again meet the requirements to establish initial eligibility (such as the requirement for PCR eligibility in three (3) of the preceding six (6) months); or

2) The remainder of the original period of continued benefits. To qualify for the remainder of the original period of continued eligibility, the parent/caretaker would have to lose eligibility for a reason related to employment. The parent/caretaker would not have to meet the requirement for PCR eligibility in three (3) of the preceding six (6) months.

H-1533 REPORTING REQUIREMENTS FOR TRANSITIONAL MEDICAID

Once in TM, the beneficiary must continue to report any changes in household composition and gross earnings as they occur.

Evaluate changes reported by the beneficiary for continuing eligibility. Refer to H-1532 Period of Eligibility and H-1534 Reasons For

(h-1500)(page-4)Page 4#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued October 1, 2024 Page 4 of H-1500 Issued May 16, 2022 Revised/added text indicated by underscore Deleted text indicated by “**” Ineligibility. Not all changes reported in the initial six (6) month period will require action; some changes may need to be reviewed again in the 7th month to determine effect on eligibility.

Example: Mrs. Apple was certified for TM beginning June because she started a part-time job and her earnings exceeded the income limit for PCR. In September (the 4th month of TM), she reported that she is now working full time. While the increase in earnings does not affect eligibility in the initial six (6) month period, a review in December must be conducted to determine if Mrs. Apple is still working full time and if so, if her income is less than 185 percent of the Federal Poverty Level (FPL) to remain eligible in the second six (6) month period.

H-1533.1 RESERVED

H-1533.2 RESERVED

H-1534 REASONS FOR INELIGIBILITY

TM beneficiaries continue to be eligible unless one of the factors below applies. Take action as indicated.

Reasons for ineligibility during the first six (6) month period:

● A child is no longer in the home or the child no longer meets the age requirement. Refer to MEM I-100 AGE- MAGI Related.

● The parent/caretaker is no longer in the home.

● The residency requirement is not met.

Reasons for ineligibility during the second six (6) month period:

• A child is no longer in the home or the child no longer meets the age requirement. Refer to MEM I-100 AGE- MAGI Related.

● The former parent/caretaker is no longer in the home or

(h-1500)(page-5)Page 5#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued October 1, 2024 Page 5 of H-1500 Issued May 16, 2022 Revised/added text indicated by underscore Deleted text indicated by “**” no longer remains TM eligible.

● MAGI income exceeds 190 percent FPIG (185% plus 5% disregard). Refer to Z-200 Federal Poverty Income Guidelines. Termination is not retroactive.

• The residency requirement is not met.

● The parent/caretaker had no earnings in one or more of the previous three (3) months.

Exception: If lack of earnings was due to involuntary loss of employment, illness, or if the beneficiary can establish satisfactory other good cause for failure to earn, the parent/caretaker continues to be TM eligible.

H-1535 NOTICES

At the time eligibility is determined for TM, a notice of decision is sent.

Consideration for coverage under all other Medicaid programs is required for parents/caretakers who lose TM eligibility.

Advance notice of decision is sent to the beneficiary at any time case closure is proposed. This includes closures for failure to respond to the renewal process or when TM eligibility is exhausted and other eligibility is not established.

(h-1600)Louisiana Medicaid Eligibility Manual (LDH): H - 1600 Tuberculosis Infected (TB)#

(h-1600)(page-1)Page 1#

Louisiana Medicaid Eligibility Manual Tuberculosis (TB) Infected

Issued May 16, 2022 Page 1 of H-1600 Replacing August 12, 2021

Revised/added text indicated by underscore Deleted text indicated by “**”

H-1600 TUBERCULOSIS (TB) INFECTED

H-1610 GENERAL INFORMATION

Section 13603 of the Omnibus Budget Reconciliation Act (OBRA) of 1993 allows States the option to provide Medicaid benefits to eligible **beneficiaries diagnosed as, or suspected of, being infected with Tuberculosis (TB). The effective date of the optional TB provisions program is August 1, 1995.

These beneficiaries are only eligible for TB-related services, not the full range of Medicaid covered services. Coverage is restricted to outpatient medical services directly related to the diagnosis, confirmation and treatment of TB, including physician, pharmacy, laboratory, X-ray, Rural Health Clinic, and Federally Qualified Health Center services. TB-infected beneficiaries are eligible for directly observed therapy services for TB treatment from the Office of Public Health (OPH). They are not eligible for coverage of inpatient hospital services, nursing facility services, or room and board.

An applicant/beneficiary diagnosed as, or suspected of, being infected with TB, may be eligible for Medicaid services under the TB-infected program if not otherwise eligible for Medicaid.

Eligibility for individuals with TB will be determined using Modified Adjusted Gross Income (MAGI)-based income standards. This group included individuals with income less than or equal to 160 percent of the Federal Poverty Level (FPL) (155 percent plus 5 percent disregard).

H-1620 ELIGIBILITY DETERMINATION PROCESS

Determine eligibility by applying the following criteria. The elements are listed in the most logical order, but all steps should be performed simultaneously.

H-1620.1 DETERMINE ASSISTANCE UNIT

The assistance unit consists of the applicant/beneficiary.

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Louisiana Medicaid Eligibility Manual Tuberculosis (TB) Infected

Issued May 16, 2022 Page 2 of H-1600 Replacing August 12, 2021

Revised/added text indicated by underscore Deleted text indicated by “**”

H-1620.2 ESTABLISH CATEGORICAL REQUIREMENT

Verification must be provided that the applicant/beneficiary has been diagnosed as, or is suspected of, being infected with Tuberculosis, as determined by the Medical Eligibility Determination Team (MEDT). Request an MEDT disability decision with supporting medical documentation of the primary diagnosis. If a TB-infected diagnosis has not been rendered by the treating medical provider, the MEDT package must include a signed and dated statement from the medical provider indicating that the beneficiary is suspected to have active TB, while awaiting TB cultures results.

Request for a determination of TB-infected shall be clearly indicated on the MEDT request by checking the box labeled “TB-infected”.

H-1620.3 ESTABLISH NON-FINANCIAL ELIGIBILITY

Verify eligibility for each member of the assistance unit with regard to the following factors:

• Assignment of Third Party Rights

I-200 • Citizenship/Identity and Qualified Non-Citizen Status I-300 • Enumeration

I-600 • Residence

I-1900

H-1620.4 ESTABLISH NEED

Need/Countable Income is based on MAGI methodology and shall be determined by applying criteria found in I-1550 MAGI Determinations.

If income is equal to or greater than the individual 160% FPL limit (155% plus 5% disregard), the applicant/beneficiary is ineligible. Qualified Medicare Beneficiary (QMB) and Spend-Down Medically Needy (MNP) provisions do not apply to the TB-infected category.

H-1620.5 ELIGIBILITY DECISION

Evaluate all eligibility requirements and verification received to make the eligibility decision.

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Louisiana Medicaid Eligibility Manual Tuberculosis (TB) Infected

Issued May 16, 2022 Page 3 of H-1600 Replacing August 12, 2021

Revised/added text indicated by underscore Deleted text indicated by “**”

H-1620.6 CERTIFICATION PERIOD

The twelve (12) month certification period begins with the month of application. Retroactive medical eligibility (RME) may be explored for the three (3) months prior to the month of application. Refer to H-1800 Retroactive Medical Eligibility (RME). The months of retroactive coverage are not included in the twelve (12) month certification period.

H-1620.7 NOTICE OF DECISION

Send the appropriate notice of decision to the applicant/beneficiary.

(h-1800)Louisiana Medicaid Eligibility Manual (LDH): H - 1800 Retroactive Medical Eligibility (RME)#

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued April 29, 2024 Page 1 of H-1800 Replacing July 07, 2022

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H-1800 RETROACTIVE MEDICAL ELIGIBILITY (RME)

H-1810 GENERAL INFORMATION

Applicants for ** Medicaid assistance can be considered for Retroactive Medical Eligibility (RME) in each of the three months prior to application as a part of the initial eligibility determination process. The applicant has up to one year from the application date to request RME.

Note: RME in a particular program cannot cover a period prior to the date the program was enacted.

The RME determination is separate from the determination for current and on-going eligibility, but the same application form is used.

RME is considered first in the same program for which the current and on-going eligibility determination is being processed. Consider eligibility in other programs if the applicant is not eligible retroactively in the same program.

Applicants for retroactive medical benefits shall:

● Have had a medical service during at least one of the months for which RME is considered. (It is permissible to accept the applicant's verbal statement.), and

● Meet all eligibility factors for the program in which RME is considered.

The retroactive period may consist of any or all of the three months immediately prior to the month of application. The months of retroactive eligibility do not have to be consecutive.

Example:

The beneficiary applied for Medicaid in June and is certified effective that month. The worker learns that the beneficiary had unpaid medical bills incurred in April. The beneficiary met all eligibility requirements for March and April, but was not income eligible for May. Certify the beneficiary for RME for March and April.

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued April 29, 2024 Page 2 of H-1800 Replacing July 07, 2022

Revised/added text indicated by underscore Deleted text indicated by “**” Consider eligibility in Medically Needy Program (MNP) if the applicant is income or resource ineligible for retroactive medical coverage in all categorical programs.

Note: Continuous eligibility begins in the month of application rather than the first month of eligibility. See H-1900 Twelve Months Continuous Eligibility for more information.

H-1810.1 Coverage

Beneficiaries of RME receive the full range of Medicaid services covered by the program in which the applicant is certified.

H-1821 ELIGIBILITY DETERMINATION PROCESS

Follow the appropriate Eligibility Determination Process for the program in which retroactive eligibility is being considered.

Note: For all retroactive eligibility determinations, regardless of the program, use actual income received in the requested retroactive eligibility period.

Refer to H-700 SSI Retroactive Medicaid for Supplemental Security Income (SSI) applicants/beneficiaries who declared they had unpaid medical services incurred within the three months prior to SSI application.

H-1821.1 Certification Period

The certification period is one, two, or three months, depending on the month(s) of eligibility.

(h-1900)Louisiana Medicaid Eligibility Manual (LDH): H - 1900 Twelve (12) Months Continuous Eligibility#

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Medicaid Eligibility Manual Eligibility Determinations

Issued March 01, 2024 Page 1 of H-1900 Replacing February 27, 2024 Revised/added text indicated by underscore Deleted text indicated by “**”

H-1900 TWELVE (12) MONTHS CONTINUOUS ELIGIBILITY

H-1910 TWELVE (12) MONTHS CONTINUOUS ELIGIBILTY FOR CHILDREN

Effective November 1, 1998, children under age 19 became eligible for continuous eligibility for 12 months from the point of the latest certification or renewal, regardless of changes in circumstances.

12 months continuous eligibility is applicable to all children under age 19 enrolled in Medicaid or LaCHIP with the following exceptions:

● Children who are eligible for the Spend-down Medically Needy Program;

● **

● Children whose parent/guardian fails to provide verification of citizenship or immigration status after a reasonable opportunity has been allowed.

The continuous eligibility period begins on the effective date of the child's most recent determination or redetermination of eligibility, and ends the last day of the 12 months.

A continuous eligibility period will end effective the earliest possible month if any of the following changes occur:

● The child reaches age 19.

● The child reaches the end of the 12 month continuous eligibility period.

● A written request for disenrollment from the child or child’s representative;

● The child no longer resides in the state;

● It is determined that eligibility was erroneously granted at the most recent determination of eligibility because of agency error or fraud, abuse, or perjury attributed to the child or the child's representative.

● The child dies

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Medicaid Eligibility Manual Eligibility Determinations

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• **

Note: Continuous eligibility begins in the month of application rather than the first month of eligibility. Refer to H-1810 Retroactive Medical Eligibility for more information.

H-1920 TWELVE (12) MONTHS CONTINUOUS ELIGIBILITY FOR EXTENDED POSTPARTUM

At a minimum, Medicaid beneficiaries who are eligible and enrolled on the date their pregnancy ends must be provided coverage through the calendar month in which the sixty (60) day postpartum period ends. Continuous eligibility applies through the end of the 60-day postpartum period regardless of the eligibility group in which the beneficiary is enrolled and is not affected by changes in income that would otherwise result in a loss of eligibility.

Effective April 1, 2022, in accordance with Sections 9812 and 9822 of the American Rescue Plan Act of 2021 (ARP), the postpartum period is being extended to 12 months. Individuals who are eligible for and enrolled in Medicaid or CHIP while pregnant (including during a period of retroactive eligibility) are eligible for extended coverage through the month in which their extended postpartum period ends. The extended postpartum period begins on the last day of the beneficiary’s pregnancy regardless of how the pregnancy ends and extends through the end of the month in which the 12-month postpartum period ends.

Individuals eligible for extended postpartum are provided continuous eligibility through the last day of the month in which the 12-month postpartum period ends. Beneficiary’s receiving extended postpartum coverage remain eligible regardless of changes in circumstances that may affect eligibility such as income, household composition or categorical eligibility (loss of SSI, reaching an age milestone).

The extended postpartum continuous eligibility will end effective the earliest possible month if any of the following changes occur:

• The individual or representative requests voluntary disenrollment

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Medicaid Eligibility Manual Eligibility Determinations

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• The individual is no longer a resident of the state

● It is determined that eligibility was erroneously granted at the most recent determination of eligibility because of agency error or fraud, abuse, or perjury attributed to the individual

• The individual dies

Populations eligible for extended postpartum on April 1, 2022:

• Current beneficiaries who are pregnant as of April 1, 2022 or who enroll based on pregnancy or become pregnant after April 1, 2022.

• Current beneficiaries who enrolled in Medicaid or CHIP while pregnant and who are no longer pregnant but who are still within a 12-month postpartum period as of April 1, 2022.

• Individuals who were pregnant during a period of retroactive eligibility on or after April 1, 2022.

Example: Ava was pregnant and her pregnancy ended on May 15, 2022. Ava submits a Medicaid application and is determined eligible on June 15, 2022. Since Ava would have been eligible had she applied during her retroactive period she will receive continuous coverage through the end of the month in which her 12-month postpartum period ends, which is May 31, 2023.

Spend-Down Medically Needy

An individual who attained Medicaid eligibility through a Spenddown while pregnant is eligible for the extended postpartum coverage even if the individual does not have sufficient incurred medical or remedial care expenses to meet their spenddown in any subsequent budget period during the pregnancy or extended postpartum period.

Pregnant Non-Citizens Eligible for Emergency Services Only

Pregnant Qualified non-citizens and non-qualified non-citizens are eligible for extended postpartum coverage. Services during the

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Medicaid Eligibility Manual Eligibility Determinations

Issued March 01, 2024 Page 4 of H-1900 Replacing February 27, 2024 Revised/added text indicated by underscore Deleted text indicated by “**” extended postpartum period for non-qualified non-citizens are limited to services for the treatment of an emergency medical condition.

Populations not eligible for extended postpartum:

• Individuals who fail to provide verification of citizenship or immigration status after a reasonable opportunity has been allowed.

• Individuals enrolled in:

o LaCHIP Phase IV (Unborn Child Option) o Hospital Presumptive Eligibility o Refugee Medical Assistance, or o State funded programs (Category 15)

Individuals eligible for extended postpartum continuous eligibility who reach max age and are not otherwise eligible must remain enrolled in current type of assistance through the end of their postpartum period. A reduction in benefits or closure is not allowed during the 12-month postpartum period (except for those reasons listed).

Renewals are completed at the end of the extended postpartum period for individuals receiving extended postpartum coverage because the individual is continuously eligible.

Example:

Sydney applies for and enrolls in the Medicaid eligibility group for pregnant individuals on June 1, 2022. Sydney’s pregnancy ends on December 15, 2022. She is eligible for extended postpartum continuous eligibility until December 31, 2023. Her renewal will be completed at the end of the extended postpartum period; she has continuous eligibility during pregnancy through the end of the extended postpartum period.

Refer to H-1810 Retroactive Medical Eligibility for more information.

(h-2000)Louisiana Medicaid Eligibility Manual (LDH): H - 2000 Qualifying Individuals Program (QI)#

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

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H-2000 QUALIFYING INDIVIDUALS PROGRAM

H-2010 GENERAL INFORMATION

Effective January 1, 1998, Section 4732 of the Balanced Budget Act of 1997 required states to pay the Medicare Part B premiums for a new mandatory eligibility group of low-income Medicare beneficiaries, called Qualifying Individuals (QI).

The applicant/beneficiary must meet all of the following QI requirements. A QI must:

• Be enrolled in hospital insurance benefits under Medicare Part A, but does not have to be currently enrolled in part B;

• Have income equal to or greater than 120 percent, but less than 135 percent of the Federal Poverty Income Guidelines (FPIG). Refer to Z-200 Federal Poverty Income Guidelines; and

Note: In January of each year, disregard the Social Security Administration (SSA) cost of living adjustment (COLA) through the month following the release of the FPIG update. Thereafter determine eligibility using all income including the COLA for the current year.

• Meet all non-financial eligibility requirements for Medicaid.

The months of coverage for Medically Needy Program (MNP) shall not include previous Medicaid-covered months, excluding pure Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), or QI certifications. The only instance in which a person can be certified for both MNP and QI is for retroactive MNP coverage. Due to system limitations, overlaps in eligibility cannot be avoided and previous eligibility cannot be removed. Since federal regulations stipulate that a QI cannot be otherwise Medicaid eligible, any prospective overlaps in MNP/QI eligibility must be avoided.

An applicant/beneficiary who is eligible for QI can be certified in both the QI and Take Charge Plus (TCP) programs.

H-2010.1 Coverage

Eligible for Medicaid payment for the Medicare Part B premium.

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Deleted text indicated by “**”

Note: Although the online Self Service Portal (SSP) and BHSF Form 1-MB, Application for Medicare Savings Program, are commonly used to apply for initial or continued QI benefits, it is also acceptable to use BHSF Form 1-A, Application for Health Coverage.

H-2020 ELIGIBILITY DETERMINATION PROCESS

Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

H-2020.1 Determine Assistance/Benefit Unit

The assistance/benefit unit consists of the applicant(s)/beneficiary(ies).

H-2020.2 Establish Categorical Requirement

Verify ** enrollment in Medicare Part A for the applicant/beneficiary. Medicare Part A eligibility, the start date for Medicare Part A, and the Medicare claim number can be verified through the interfaces available in LaMEDS.

H-2020.3 Establish Non-Financial Eligibility

Verify eligibility for each member of the assistance unit with regard to the following factors:

• Assignment of Third Party Rights

I-200 • Citizenship/Identity and Qualified Non-Citizen Status I-300 • Enumeration

I-600 • Residence

I-1900

H-2020.4 Establish Need

A. Determine Composition of the Income Unit

The income unit includes the: • Applicant/beneficiary;

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• Applicant/beneficiary and ineligible spouse living in the home; or • Applicant/beneficiary and eligible spouse who are living in the same home (eligible couple). Note: If the SSA considers the applicant/beneficiary and their spouse as a couple for SSI purposes, they are considered as an eligible couple for the purposes of budgeting in the Medicare Savings Programs (QMB, SLMB, QI). An eligible spouse is one who is aged, blind, or disabled and lives in the same household as the applicant/beneficiary. The eligible spouse does not have to be entitled to Medicare for the couple to be considered an eligible couple.

B. Determine Need/Countable Income

Individual

If the applicant/beneficiary is an individual with no spouse or with an ineligible spouse with no income, complete the following budget steps:

Step 1. Determine total gross unearned income.

Step 2. Subtract the $20 SSI general disregard from unearned income.

Step 3. The remainder is the countable unearned income.

Step 4. Determine the total gross earned income.

Step 5. Subtract any remainder of the $20 SSI disregard from gross earnings.

Step 6. Subtract the earned income deduction from remaining gross earnings. Earned income deduction is $65 and one half of remainder of earnings.

Step 7. The remainder is the countable earned income.

Step 8. Add the remainders from Step 3 and Step 7.

Step 9. Compare the total to 135 percent FPL for one person. Refer to Z-200 Federal Poverty Income Guidelines.

If the remaining income is equal to or greater than the QI income limit for one person, the applicant/beneficiary is income ineligible.

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If the remaining income is less than the QI limit for one person, the applicant/beneficiary is income eligible.

Ineligible Spouse Deeming

If the applicant/beneficiary has an ineligible spouse with income, complete budget Steps 1 through 9 above using only the applicant/beneficiary income. If the income of the applicant/beneficiary is equal to or greater than the QI income limit for one person, the applicant/beneficiary is ineligible and there is no deeming. Consider for Medically Needy Program (MNP).

If the income of the applicant/beneficiary is less than the QI limit for one person, apply deeming policy (See I-1420 Need - Deeming). Go to Step 1 of the couple budget.

Couple

If both members of a couple are potentially eligible, or if there is income remaining in the deeming process, complete the following budget steps:

Step 1. Determine the total gross unearned income by combining the couple’s unearned income.

Step 2. Subtract the $20 SSI general income disregard. Step 3. The remainder is the couple’s countable unearned income.

Step 4. Determine the total gross earned income of the couple by combining the couple’s gross earned income.

Step 5. Subtract any remainder of the $20 SSI disregard from gross

earnings.

Step 6. Subtract one earned income deduction from the remaining

gross earnings of the income unit. The earned income

deduction is $65 and one-half of the remainder of the

earnings.

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Step 7. The remainder is the couple’s countable earned income.

Step 8. Combine the remainders in Step 3 and Step 7.

Step 9. Compare the total countable income to the 135 percent FPL for two persons. Refer to Z-200 Federal Poverty Income Guidelines.

If the income is equal to or greater than the QI income limit for two (2) persons, the applicant/beneficiary is not eligible.

If the income is less than the QI income limit for two (2) persons, the applicant/beneficiary is income eligible.

H-2020.5 Eligibility Decision

Evaluate all eligibility requirements and verification received to

make the eligibility decision.

H-2020.6 Certification Period

The certification period can be effective no earlier than three (3) months prior to the application date provided the individual is otherwise eligible and is enrolled in Medicare Part A.

Coverage of QI is mandatory. However, federal funds are limited. Therefore, the state is authorized to limit participation so that the total assistance provided is (on an estimated basis) equal to, but not greater than the funding allocated to the state for participation.

Individuals who are eligible for QI shall be certified on a first come, first served basis. Individuals who were receiving assistance either under QI, in December of the previous year and remain eligible, or in the case of QMB or SLMB, become eligible under the QI program, must be given preference. Once an individual is determined eligible, he/she is entitled to receive assistance for a twelve (12) month certification period as long as he/she remains eligible and funding for the program is available.

H-2020.7 Notice of Decision

Send the appropriate notice of decision to the applicant/beneficiary.

Note: Applicants enrolled in Medicare Part A are not referred to the

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Federally Facilitated Marketplace. (FFM).

(h-2100)Louisiana Medicaid Eligibility Manual (LDH): H - 2100 Medicaid Purchase Plan (MPP)#

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued July 10, 2025 Issued October 17, 2022

Page 1 of H-2100 Revised/added text indicated by underscore

Deleted text indicated by “**” H-2100 MEDICAID PURCHASE PLAN (MPP)

H-2110 GENERAL INFORMATION

The Ticket to Work and Work Incentives Improvement Act of 1999 (Public Law 106-170, also known as TWWIIA) became law on December 17, 1999. This legislation allowed states to adopt the option of allowing individuals with disabilities to purchase Medicaid coverage that is necessary to enable such individuals to work.

Act 207 of the First Extraordinary Session of 2003 of the Louisiana Legislature directed the Louisiana Department of Health (LDH) to implement a buy-in program for working persons with disabilities using the provisions of the TWWIIA effective January 1, 2004.

Effective January 1, 2014, LDH eliminated buy-in premiums from the Medicaid Purchase Plan (MPP).

Effective July 1, 2025, LDH implemented the following changes to MPP:

• Increased the countable income from less than or equal to 100% to less than or equal to 200% of the Federal Poverty Level (FPL),

• Raised the resource limit from less than $10,000 to less than $25,000, and

• Added buy-in premiums for individuals with income over 150% and up to 200% FPL.

To qualify for MPP coverage, an individual must:

• Have a medically determinable physical or mental impairment which meets or equals the Social Security Administration’s definition of disability. Substantial gainful activity is not a factor;

• Be employed;

• Be at least age 16 but not yet age 65;

• Have countable income equal to or less than 200 percent Federal Poverty Limit (FPL);

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• Have countable assets less than $25,000; and

• Take no-cost health insurance, if available.

Beneficiaries are eligible for full Medicaid coverage.

Note: Eligibility for this program terminates the month the beneficiary turns age 65. H-2120 ELIGIBILITY DETERMINATION PROCESS

Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

H-2120.1 Determine Assistance Unit

The assistance unit consists of the applicant/beneficiary.

H-2120.2 Establish Categorical Requirement

Verify that the applicant/beneficiary:

• Is at least age 16, but not yet 65;

• Has a medically determinable physical or mental impairment which meets the Social Security Administration’s definition of disability. Substantial gainful activity is not a factor; and

• Is employed or self-employed.

There is no minimum work or earnings requirement. Employment is defined as a reasonable work effort for which a person receives financial compensation and pays all applicable federal, state, and payroll taxes.

H-2120.3 Establish Non-Financial Eligibility

Verify eligibility for the applicant/beneficiary with regard to the following factors:

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

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Page 3 of H-2100 Revised/added text indicated by underscore

Deleted text indicated by “**” • Assignment of Third Party Rights I-200

• Citizenship/Alien Status

I-300

• Enumeration

I-600

• Residence

I-1900

• Health insurance coverage – verify eligibility and coverage for no-cost health insurance such as Medicare Part A and certain employer sponsored group health plans.

H-2120.4 Establish Need

A. Determine Composition of the Income/Resource Unit

The income/resource unit consists of the:

• Applicant/beneficiary;

• Applicant/beneficiary and the ineligible spouse (is not aged, blind, or disabled) living in the home;

• Applicant/beneficiary who is a minor and his parent(s) living in the home. Refer to I-1420 Need - Deeming; or

• Applicants/beneficiaries who are a couple.

B. Determine Need/Countable Resources

Determine the total countable resources of the resource unit including resources deemed from the parent(s). Refer to I-1630 Need - SSI-Related Resources.

Compare the total countable resources to the MPP resource limit of $25,000. Refer to Z-900 Resource Limits by Program.

If the countable resources are greater than the resource limit, the applicant/beneficiary is resource ineligible for MPP.

If the countable resources are equal to or less than the resource limit, the applicant/beneficiary is resource eligible for MPP. Continue the eligibility determination process.

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C. Determine Need/Countable Income

Determine the total countable income of the income unit. Refer to I-1530 through I-1536 – SSI Related Income.

Individual

If the applicant/beneficiary is an individual with no spouse or with an ineligible spouse with no income, go to Step 1. Parent(s) to Child Deeming

If the applicant is a minor child, apply deeming policy I-1424.2, Need – Deeming. Any income deemed from the parent(s) is considered unearned income of the applicant /beneficiary in the individual steps. Go to Step 1.

Complete the following budget steps:

Step 1. Determine the total gross unearned income.

Step 2. Subtract the $20 Supplemental Security Income (SSI) general income disregard.

Step 3. The remainder is the countable unearned income.

Step 4. Determine the total gross earned income.

Step 5. Subtract any remainder of the $20 SSI general income disregard from the gross earnings.

Step 6. Subtract the SSI earned income deduction from the remaining gross earnings. The earned income deduction is $65 and one-half of the remainder of the earnings.

Step 7. Add the remainders from Step 3 and Step 6.

Step 8. The remainder is the total countable income.

Step 9. Compare the total countable income to 200% FPL for one (1) person. Refer to MEM Z-200 Federal Poverty Income Guidelines.

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Deleted text indicated by “**” If the remainder is greater than the allowable income limit, the applicant/beneficiary is income ineligible for MPP.

If the remainder is equal to or less than the allowable income limit, the applicant/beneficiary is income eligible for MPP.

Continue with the eligibility determination process.

Ineligible Spouse Deeming

If there is an ineligible spouse with income, complete budget steps 1 through 9 above using only the applicant/beneficiary income. If the income is greater than the MPP limit for one (1) person, the applicant/beneficiary is income ineligible and there is no deeming. Consider for MNP.

If the applicant/beneficiary’s income is less than or equal to the MPP limit for one (1) person, apply deeming policy in I-1420 Need - Deeming. Go to Step 1 of the couple budget.

Couple

If both members of a couple are categorically eligible, complete the following steps:

Step 1. Determine the total unearned income by combining the couple’s unearned income.

Step 2. Subtract the $20 SSI general income disregard.

Step 3. The remainder is the couple’s countable unearned income.

Step 4. Determine the total gross earned income by combining the couple’s gross earned income.

Step 5. Subtract any remainder of the $20 SSI disregard from gross earnings.

Step 6. Subtract one earned income deduction from remaining gross earnings of the income unit. The earned income deduction is $65 and one-half of the remainder of the earnings.

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Deleted text indicated by “**” Step 7. The remainder is the couple’s countable earned income

Step 8. Add the remainders in Step 3 and Step 7.

Step 9. The remainder is the total countable income.

Step 10. Compare total countable income to 200% FPL for two (2) persons. Refer to MEM Z-200 Federal Poverty Income Guidelines.

If the remainder is greater than the allowable income limit, the applicant(s)/beneficiary(s) is/are income ineligible for MPP.

If the remainder is less than or equal to the allowable income limit, the applicant(s)/beneficiary(s) is/are income eligible for MPP. Continue with the eligibility determination process.

Exception: If one spouse is in a nursing facility or receiving Waiver services and the other spouse is at home and not receiving Waiver services, consider income of each individual separately.

D. Determine MPP Program Premium Amount

The monthly premium amount is determined by comparing the total countable income to the monthly premium scale. Refer to MEM Z- 2500 Premium Program Income Limits.

Income Range(% FPIG) Monthly Premium ≤ 150% $0.00 > 150% - ≤ 200% $131.00

The initial MPP premium begins the month after the beneficiary is determined eligible for MPP and is due by the 10th of that month. Premiums for all following months are also due by the 10th of each month.

The premiums will not be applied for the month of determination and any months before the decision month (including retroactive Medicaid eligibility). See H-1800 Retroactive Medical Eligibility (RME).

A premium is owed for each employed individual enrolled.

(h-2100)(page-7)Page 7#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued July 10, 2025 Issued October 17, 2022

Page 7 of H-2100 Revised/added text indicated by underscore

Deleted text indicated by “**”

Federally recognized American Indians or Alaskan Natives do not pay a premium.

Upon notification that the premium is 60 days past due, an advance notice to close should be generated. Beneficiaries may pay outstanding payments prior to the effective date of closure to remain open to avoid gaps in coverage.

Once the closure becomes effective, the beneficiary is not required to pay any outstanding payments, and these will not be a factor when reapplying for benefits.

H-2120.5 Eligibility Decision

Evaluate all eligibility requirements and verification received to make the eligibility decision to either reject, close, certify, or extend eligibility.

H-2120.6 Certification Period

A MPP certification period shall not exceed twelve (12) months.

H-2120.7 Retroactive Eligibility

Coverage can start as early as three (3) months before application as long as all eligibility requirements are met.

H-2120.8 Notice of Decision

Send the appropriate notice of decision to the applicant/beneficiary.

(h-2300)Louisiana Medicaid Eligibility Manual (LDH): H - 2300 Family Opportunity Act Medicaid Program#

(h-2300)(page-1)Page 1#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued October 24, 2025 Page 1 of H-2300 Replacing April 21, 2025 Revised/added text indicated by underscore Deleted text indicated by “*” H-2300 FAMILY OPPORTUNITY ACT MEDICAID BUY- IN PROGRAM

H-2310 GENERAL INFORMATION

On October 1, 2007, the Family Opportunity Act Buy-In Program (FOA) was implemented to cover children with disabilities up to age 13, and family gross income at or below 300 percent of the Federal Poverty Income Guidelines (FPIG).

Effective October 1, 2008, the program expanded to include children with disabilities up to age 19. When applicable deductions are applied this makes the family gross income limit effectively at or below 300 percent of the FPIG.

Families wishing to enroll their child(ren) with disabilities in the program are required to take employer-offered insurance when it is available, and when the following conditions apply: • The coverage is under a group health plan; and • The employer contributes at least 50 percent of the total annual premium.

Applicants/beneficiaries are eligible for the full range of Medicaid covered services.

In FOA, a person is only required to obtain/maintain creditable coverage. For instance, if a person has coverage and it is no longer creditable, the coverage may be dropped.

H-2320 ELIGIBILITY DETERMINATION PROCESS

Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

Explore eligibility for programs that offer full Medicaid benefits without a premium before considering FOA.

Note: Individuals with disabilities no longer have income deemed from their parents upon reaching age 18. Eligibility in other Medicaid programs, such as Provisional Medicaid, should be explored to ensure certification in the most beneficial program and that premiums are not being charged to these individuals unnecessarily.

(h-2300)(page-2)Page 2#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued October 24, 2025 Page 2 of H-2300 Replacing April 21, 2025 Revised/added text indicated by underscore Deleted text indicated by “*” Refer to I-1425, Changes in Deeming Status.

H-2320.1 Determine Assistance/Benefit Unit

The assistance/benefit unit consists of the applicant/beneficiary.

H-2320.2 Establish Categorical Requirement

Establish that the applicant/beneficiary: • Is a child under age 19; and • Has a physical or mental impairment that is disabling under the Social Security Administration’s listing of impairments; and • Has gross family income that is equal to or less than 300 percent of the FPL.

Note: Disability determinations must be made by the Medical Eligibility Determination Team (MEDT) unless disability has been established by SSA. Refer to G-1600, Securing Disability Decisions for B and D Categories.

H-2320.3 Establish Non-Financial Eligibility

Verify eligibility for each member of the assistance/benefit unit with

regard to the following factors:

• Assignment of Third Party Rights I-200 • Citizenship/Identity and Qualified Non-Citizen Status I-300 • Enumeration I-600 • Residence I-1900

H-2320.4 Establish Need A. There is no resource test in determining eligibility. B. Determine Composition of the Income Unit The income unit consists of the following persons living in the home: • Applicant/beneficiary under age 19 who is unmarried, • His/her legal/natural parent(s), and • Any legal siblings under age 19.

Do not include step parents or step siblings.

(h-2300)(page-3)Page 3#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued October 24, 2025 Page 3 of H-2300 Replacing April 21, 2025 Revised/added text indicated by underscore Deleted text indicated by “*”

C. Determine Countable Income

Complete the following steps:

Step 1. Determine total gross earned and unearned income of the income unit.

Step 2. Subtract the FOA deduction of $85. This yields the countable income for premium determination. If eligible, at the end of all budget steps, this amount will be used to determine monthly premium amount due. (See H-2320.5 Determine Monthly Family Opportunity Act (FOA) Medicaid Buy-In Program Premium Amount)

Step 3. Subtract one-half of the remainder from Step 2.

Step 4. Compare the remaining monthly income to the comparable household size at 150 percent of the FPIG. If income is greater than the limit, the applicant/beneficiary is ineligible. If income is equal to or less than the limit, the applicant/beneficiary is eligible. H-2320.5 Determine Monthly Family Opportunity Act Medicaid Buy-In Program Premium Amount

Premiums for FOA are charged per family or income unit.

Subtract the $85 FOA deduction from the total gross earned and unearned income.

Compare the remainder to the MEM Z-2500 FPIG for Premium Programs.

Income units with income less than or equal to 200 percent FPIG will not have a premium.

A premium payment is required for income units with income above 200 percent and less than or equal to 250% FPIG according to the following:

Income Range (% FPIG) Legal/Natural Parents in Home have Creditable Health Insurance Monthly Premium Above 200% – <= 250% Yes $12.00 Above 200% – <= 250% No $30.00

(h-2300)(page-4)Page 4#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued October 24, 2025 Page 4 of H-2300 Replacing April 21, 2025 Revised/added text indicated by underscore Deleted text indicated by “*” Above 250% – <= 300 Yes $15.00 Above 250% – <= 300% No $35.00

Federally recognized American Indians or Alaskan Natives do not pay a premium.

The premium is waived where requiring a payment would create an undue hardship. Undue hardship exists when a family: • Is homeless or displaced due to a flood, fire, or natural disaster, • Resides in an area where there is a Presidentially Declared Disaster in effect, • Has a current notice of eviction or foreclosure, or • Has a circumstance the Medicaid Director’s office determines meets the criteria.

The first month a premium applies is the month after the eligibility decision is made. Premiums will not be applied for coverage in any months prior to the month the eligibility decision is made (including retroactive Medicaid eligibility). See H-1800 Retroactive Medical Eligibility (RME).

H-2320.6 Eligibility Decision

Evaluate all eligibility requirements and verification received to make the eligibility decision to either reject, close, certify, or extend eligibility.

H-2320.7 Certification Period

Certification period shall not exceed 12 months from the month of

application.

H-2320.8 Notice of Decision

An eligibility notice of decision shall be sent to the applicant.

(h-2400)Louisiana Medicaid Eligibility Manual (LDH): H - 2400 Refugee Medical Assistance#

(h-2400)(page-1)Page 1#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued October 21, 2025 Page 1 of H-2400 Replacing March 14, 2023 Revised/added text indicated by underscore Deleted text indicated by “**” H-2400 REFUGEE MEDICAL ASSISTANCE

H-2400 GENERAL INFORMATION Refugee Medical Assistance (RMA) is a short-term, federally funded program designed to ensure that refugees receive the medical care they need while they make the transition to life in the United States. Eligibility must be reviewed for all other Medicaid programs prior to being certified. The Refugee Resettlement Agency (RRA) will refer all applicants/beneficiaries and must provide verification of acceptable refugee status.

All recipients of Refugee Cash Assistance (RCA) that are ineligible for a Medicaid program shall be certified in RMA. It is not a requirement that applicants/beneficiaries receive or apply for RCA to be eligible for RMA.

A refugee who loses eligibility for Medicaid because of increased earnings from employment and is within the eligibility time period shall be transferred to RMA.

The Affordable Care Act (ACA) changed the methodology for determining financial eligibility for Medicaid for most individuals to the Modified Adjusted Gross Income (MAGI) methodology. The Office of Refugee Resettlement (ORR) granted authority to states to apply MAGI methodologies to the RMA program. Applicants/beneficiaries in RMA are considered a MAGI group for the duration of this authority.

Effective March 28, 2022 in accordance with ORR regulations the RMA eligibility period has been extended from eight (8) months to twelve (12) months if the individual’s date of eligibility for ORR benefits is on or after October 1, 2021. Additionally, for individuals enrolled on or after May 5, 2025, the eligibility period is limited to a maximum of four (4) months.

H-2410 COVERAGE Applicants/beneficiaries are eligible for the full range of Medicaid covered services.

H-2415 ELIGIBILITY DETERMINATION PROCESS Explore eligibility for other Medicaid programs that offer full Medicaid benefits before considering the RMA program.

All recipients of RCA that are ineligible for a Medicaid program shall be

(h-2400)(page-2)Page 2#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued October 21, 2025 Page 2 of H-2400 Replacing March 14, 2023 Revised/added text indicated by underscore Deleted text indicated by “**” certified in RMA.

If not eligible for RCA, determine eligibility by applying the following criteria beginning with H-2415.1 Determine Assistance/Benefit Unit. The elements have been listed in the most logical order, but work on all steps simultaneously.

H-2415.1 DETERMINE ASSISTANCE/BENEFIT UNIT The assistance/benefit unit consists of the applicant, spouse, and/or any minor children living in the home. Each member of the unit must meet all eligibility requirements.

H-2415.2 ESTABLISH CATEGORICAL REQUIREMENT Establish that the applicant/beneficiary:

• Is a Refugee or Asylee; Cuban or Haitian entrant; Iraqi or Afghan Special Immigrant; severe trafficking victim (Refer to I-312 Qualified Alien); and

• Is not eligible for Medicaid or the Louisiana Children’s Health Insurance Program (LaCHIP); and

• Falls into the established time limit of twelve (12) months from the date of arrival in the United States (for refugees), or from the date asylum is granted (for asylees); and

• Is not enrolled as a full-time student in an institution of higher education, unless it is a one (1) year re-certification program that is part of the refugee’s Comprehensive Resettlement Plan (CSR); and

• Provides the name of the sponsoring RRA (Asylees are exempt from this requirement.); or

• A child may receive RMA coverage if both parents meet the RMA requirements or the mother is receiving RMA when the child is born. These newborns can receive RMA until the end of the mother’s period of eligibility.

H-2415.3 Establish Non-Financial Eligibility

Verify eligibility for each member of the assistance/benefit unit with regard to the following factors:

(h-2400)(page-3)Page 3#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued October 21, 2025 Page 3 of H-2400 Replacing March 14, 2023 Revised/added text indicated by underscore Deleted text indicated by “**” • Assignment of Third Party Rights I-200 • Citizenship/Identity and Alienage I-300 • Enumeration I-600 • Residence

I-1900

H-2415.4 Establish Need

Household composition and countable income for RMA are based on MAGI. Refer to I-1550, MAGI Determinations.

There is no asset or resource test for the MAGI groups.

Compare the total countable income to the monthly Medically Needy Income Eligibility Standards (MNIES) for the number of individuals in the MAGI household.

If the income is equal to or less than the MNIES, the assistance unit is income eligible for RMA.

If the income is greater than the MNIES, the assistance unit is ineligible for RMA. Consider for the Spend Down Medically Needy Program - RMA.

Spend Down Medically Needy Program - RMA If the applicant has been determined income ineligible for Regular RMA, convert the monthly MAGI income to quarterly MAGI income by multiplying by three (3), subtract the quarterly MNIES for the number of individuals in the MAGI household, and subtract the medical bills from the excess income in the following order:

Step 1. Subtract allowable medical bills for individuals, other than the applicant, who are included in the MAGI household.

Step 2. Subtract unpaid medical bills for services received up to three (3) months prior to the month of application, in chronological order.

Step 3. Subtract allowable health insurance premiums. Refer to H-1011.5 Medical Expenses Allowed in the Spend-down Process.

(h-2400)(page-4)Page 4#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued October 21, 2025 Page 4 of H-2400 Replacing March 14, 2023 Revised/added text indicated by underscore Deleted text indicated by “**” Note: Liability for health insurance premiums arises in the month payment is due, rather than in the month(s) for which coverage is purchased.

Step 4. Subtract paid and unpaid bills incurred for services received within the spend-down quarter, from oldest to most recent (per diem if necessary). Include insurance co-payments and deductibles. Hospital bills shall be used before physician bills in the spend-down process.

The applicant is eligible for the Spend-Down Medically Needy Program - RMA on the date the excess income is equal to the allowed medical expenses (or “spent-down”).

Reminder: When determining eligibility:

• Do not consider in-kind services and shelter provided by an applicant’s sponsor or local resettlement agency;

• Do not consider any cash assistance payments provided to an applicant; and

• Do not average income over the application processing period. Use the applicant’s income on the date of application.

H-2415.5 Eligibility Decision Evaluate all eligibility requirements and verification received to make the eligibility decision to either reject, close, certify, or extend eligibility.

H-2415.6 Eligibility Period For individuals enrolled on or after October 1, 2021, the certification period shall not exceed twelve (12) months. For individuals enrolled on or after May 5, 2025, the certification period is limited to a maximum of four (4) months. For persons granted asylum, the entry date is the date the individual is granted asylum. Once certified, increased earnings from employment shall not affect the applicant/beneficiary’s eligibility for RMA.

Note: The initial date of eligibility for Ukrainian Humanitarian Parolees (UHP) is

(h-2400)(page-5)Page 5#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued October 21, 2025 Page 5 of H-2400 Replacing March 14, 2023 Revised/added text indicated by underscore Deleted text indicated by “**” May 21, 2022, or the individual’s date of humanitarian parole, whichever is later. The initial date of eligibility for Afghan Humanitarian Parolees (AHP) is July 31, 2021 through September 30, 2023, or the individual’s date of humanitarian parole, whichever is later.

Retroactive Eligibility for Refugee Medical Assistance

RMA eligible individuals are eligible for up to three months of retroactive eligibility to the same extent as are MAGI beneficiaries provided that:

• The individual applies within their RMA eligibility period.

• The individual meets all RMA eligibility requirements during any retroactive months.

• The three (or fewer) months of retroactive eligibility are within their RMA eligibility period.

Example:

An individual is granted asylum on January 1, 2022 and applies for RMA on April 1, 2022. The individual requests retroactive coverage. The individual could be eligible for RMA from January 1, 2022 as long as they meet all RMA eligibility requirements during any retroactive months and coverage would continue through December 2022.

H-2415.7 Notice of Decision A notice of decision shall be sent to the applicant.

(h-2500)Louisiana Medicaid Eligibility Manual (LDH): H - 2500 Youth Aging Out of Foster Care#

(h-2500)(page-1)Page 1#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued October 11, 2022

Page 1 of H-2500 Replacing June 14, 2016 Revised/added text indicated by underscore

Deleted text indicated by “**”

H-2500 YOUTH AGING OUT OF FOSTER CARE H-2510 GENERAL INFORMATION

The Chafee Foster Care Independence Act allows Louisiana to offer Medicaid to youth aging out of foster care and leaving state custody. This includes individuals who have aged out of foster care in other states and now reside in Louisiana. For the purposes of this program, the term “youth” means an individual who is under 21 years of age and who, on the individual’s 18th birthday, was in foster care under the responsibility of the state. This program covers youth who reach age 18 on or after March 1, 2009 and coverage continues up to their 21st birthday.

Note: Effective January 1, 2014, youth who age out of foster care that were enrolled in Medicaid at the time of their 18th birthday are to be certified in the Former Foster Care Children group (refer to H-3100 Former Foster Care Children). Eligibility in this group shall be considered prior to the Youth Aging Out of Foster Care (YAOFC) program.

If eligibility is lost due to moving out of state, a youth may be recertified in the YAOFC program if Louisiana residency is re-established prior to turning age 21.

H-2510.1 COVERAGE

Youths certified in this program are eligible for the full range of Medicaid covered services.

H-2520 ELIGIBILITY DETERMINATION PROCESS

Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

H-2520.1 DETERMINE ASSISTANCE UNIT

(h-2500)(page-2)Page 2#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued October 11, 2022

Page 2 of H-2500 Replacing June 14, 2016 Revised/added text indicated by underscore

Deleted text indicated by “**”

The assistance unit consists of the youth that has aged out of foster care and is no longer in state custody.

H-2520.2 ESTABLISH CATEGORICAL REQUIREMENT

Establish that the applicant/beneficiary:

• Is at least age 18, but under age 21;

• Currently lives in Louisiana;

• Was a child in foster care in any state’s custody upon obtaining age 18 on or after March 1, 2009 (enrollment in Medicaid upon obtaining age 18 is not a requirement of eligibility for the program); and

• Is not eligible or enrolled for mandatory coverage in another Medicaid program.

H-2520.3 ESTABLISH NON-FINANCIAL ELIGIBILITY

Verify eligibility for the youth with regard to the following factors:

• Age - MAGI-Related

I-100

• Assignment of Third Party Rights I-200

• Citizenship / Identity and Qualified Non-Citizen Status I-300

• Enumeration

I-600

• Residence

I-1900

H-2520.4 ESTABLISH NEED

A. There is no resource test in determining eligibility.

B. There is no income test in determining eligibility.

(h-2500)(page-3)Page 3#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued October 11, 2022

Page 3 of H-2500 Replacing June 14, 2016 Revised/added text indicated by underscore

Deleted text indicated by “**”

** H-2520.5 ELIGIBILITY DECISION

Evaluate all eligibility requirements to determine if the youth is eligible.

H-2520.6 CERTIFICATION PERIOD

The certification period may be effective no earlier than three (3) months prior to the application date provided the individual is otherwise eligible. The months of retroactive coverage are not included in the twelve (12) month certification period. The twelve (12) month certification period begins with the month of application.

Retroactive medical eligibility shall be explored for the three months prior to the month of application. Refer to H-1800 Retroactive Medical Eligibility (RME).

Note: Prior to closure of the Youth Aging Out of Foster Care, eligibility in other programs must be explored.

H-2520.7 NOTICE OF DECISION

Send the appropriate notice of decision to the applicant/beneficiary.

(h-2800)Louisiana Medicaid Eligibility Manual (LDH): H - 2800 Parents and Caretaker Relatives#

(h-2800)(page-1)Page 1#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued November 06, 2023 Page 1 of H-2800 Replacing July 20, 2016 Revised/added text indicated by underscore Deleted text indicated by “**” H-2800 PARENTS AND CARETAKER RELATIVES GROUP H-2801 GENERAL INFORMATION The Affordable Care Act of 2010 established a new Medicaid eligibility group called Parents and Caretaker Relatives (PCR). These adults were formerly considered for the Low Income Families with Children (LIFC) program as a parent or caretaker relative. Effective January 1, 2014, this ** group included individuals with income less than or equal to 24 percent of the Federal Poverty Level (19 percent FPL plus the 5 percent disregard).

Note:

Effective July 1, 2016, only apply the 5 percent disregard to those parents or caretaker relatives whose income is over 19 percent FPL and who cannot be considered under the Adult Group (i.e. parent or caretaker over age 64 or entitled to Medicare). For all others, apply the 5 percent disregard only when being considered under the Adult Group

Eligibility will be determined using Modified Adjusted Gross Income (MAGI) based income standards. H-2802 ELIGIBILITY DETERMINATION PROCESS Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously. H-2802.1 Assistance Unit A caretaker relative is a relative of a dependent child by blood, adoption, or marriage with whom the child is living, and who assumes primary responsibility for the child’s care. As may, but is not required to, be indicated by claiming the child as a tax dependent for federal income tax purposes. A caretaker relative is one of the following: • Parent; • Grandparent; • Sibling (brother or sister); • Brother-in-law; • Sister-in-law; • Step-parent;

(h-2800)(page-2)Page 2#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued November 06, 2023 Page 2 of H-2800 Replacing July 20, 2016 Revised/added text indicated by underscore Deleted text indicated by “**” • Step-sibling; • Aunt; • Uncle; • First cousin; • Niece; or • Nephew.

The spouse of such parents or caretaker relatives may be considered a caretaker relative even after the marriage is terminated by death or divorce.

The assistance unit consists of the parent and/or caretaker relative and the spouse of the parent and/or caretaker relative, if living together, of a child(ren) under age 18, or is age 18 and a full-time student in high school or vocational/technical training, and is expected to complete the course of study before or during the month of their 19th birthday.

If more than one unmarried parent or caretaker relative lives in the home with the child, only the parent or caretaker relative who has primary responsibility (i.e., considered the primary caretaker) for the child can be considered for eligibility under the Parent and Caretaker Relatives group.

The designation as primary caretaker is not based on the parent or caretaker relatives being a tax filer, tax dependent or non-filer.

Note: A child does not have to be Medicaid eligible or be included in the request for Medicaid in order for the parent/caretaker to be certified for the Parent and Caretaker Relative Group. Consider eligibility for children included in the request for Medicaid in the appropriate children’s group.

H-2802.2 Establish Categorical Requirement Verify that there is a child under age 18, or is age 18 and a full-time student in high school or vocational/technical training, and is expected to complete the course of study before or during the month of their 19th birthday.

School attendance requirements are met if: • A child is out of school because of vacation, temporary illness,

(h-2800)(page-3)Page 3#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued November 06, 2023 Page 3 of H-2800 Replacing July 20, 2016 Revised/added text indicated by underscore Deleted text indicated by “**” or family emergency; • An incapacitated child attends fewer hours or receives instruction from a visiting teacher at home; • A child is enrolled in a Job Corps program; or • A child is enrolled in the National Guard Youth Challenge Program.

H-2802.3 Establish Non-Financial Eligibility Establish non-financial eligibility requirements in the Parents and Caretaker Relatives program. Verify eligibility for each member of the assistance unit with regard to the following factors:

• Age – MAGI Related

I-100

• Assignment of Third Party Rights I-200

• Citizenship/Alien Status

I-300

• Enumeration

I-600

• Residence

I-1900

• SES Referral

I-2000

Evaluate the need for Support Enforcement Services (SES) referral. Refer to I-2000 Support Enforcement Services.

H-2802.4 Establish Need Household composition for the Parents and Caretaker Relatives Group is based on MAGI. Refer to I-1550 MAGI Determinations. Countable Income for the Parents and Caretaker Relatives Group is based on MAGI. Refer to I-1550 MAGI Determinations. Compare to Income Standard for Parents and Caretaker Relatives Group. Refer to Z-200 Federal Poverty Income Guidelines.

H-2802.5 Eligibility Decision Evaluate all eligibility requirements and verifications received to make the eligibility decision.

(h-2800)(page-4)Page 4#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued November 06, 2023 Page 4 of H-2800 Replacing July 20, 2016 Revised/added text indicated by underscore Deleted text indicated by “**” H-2802.6 Certification Period The certification period may be effective no earlier than three (3) months prior to the application date provided the individual is otherwise eligible. The months of retroactive coverage are not included in the twelve (12) month certification period. The twelve (12) month certification period begins with the month of application. Retroactive medical eligibility shall be explored for the three months prior to the month of application. Refer to H-1800, Retroactive Medical Eligibility.

H-2802.7 Notice of Decision Send the appropriate notice of decision to the applicant/beneficiary

(h-2900)Louisiana Medicaid Eligibility Manual (LDH): H - 2900 MAGI Pregnant Women#

(h-2900)(page-1)Page 1#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued October 11, 2022

Page 1 of H-2900 Replacing May 09, 2022 Revised/added text indicated by underscore

Deleted text indicated by “**” H-2900 PREGNANT WOMEN GROUP

H-2901 GENERAL INFORMATION

In accordance with the requirements of the Patient Protection and Affordable Care Act of 2010, referred to as the Affordable Care Act (ACA), pregnant applicants/beneficiaries shall be screened and eligibility in the Pregnant Women (PW) group determined using the Modified Adjusted Gross Income (MAGI) methodology.

Eligibility in this group for individuals whose MAGI-based income is at or below 138 percent of the Federal Poverty Level (133 percent of the FPL, plus a 5 percent disregard) may begin: • At any time during a pregnancy; and • As early as three (3) months prior to the month of application. Eligibility cannot begin before the first month of pregnancy.

Note: The PW group certification may extend through the calendar month in which the 12-month postpartum period of continuous eligibility ends.

An applicant/beneficiary whose pregnancy terminated in the month of application or in one of the three (3) months prior, without a surviving child, shall be considered a pregnant woman for the purposes of determining eligibility in the PW group.

Certification shall be from the earliest possible month of eligibility (up to three (3) months prior to application) through the month in which the 12 months of continous eligibility for extended postpartum ends. Retroactive eligibility shall be explored regardless of current eligibility status.

If the applicant/beneficiary is eligible for any of the three (3) prior months, she remains eligible throughout the pregnancy and until the 12 months of continous eligibility for extended postpartum ends. When determining retroactive eligibility, actual income received in the month of determination shall be used.

Example: Mary Smith applies in June, which is her fifth month of pregnancy. Her income in June exceeds the allowable income, however, in

(h-2900)(page-2)Page 2#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued October 11, 2022

Page 2 of H-2900 Replacing May 09, 2022 Revised/added text indicated by underscore

Deleted text indicated by “**” March she had no income. Certification is effective March through the month in which the 12 months of continous eligibility for extended postpartum ends.

If application is made after the month the postpartum period ends, the period of eligibility will be retroactive but shall not start more than three (3) months prior to the month of application.

The start date of retroactive eligibility is determined by counting back three (3) months prior to the date of application. The start date will be the first day of that month.

Example: Jane Doe applies on June 16th, but delivered her baby in May. The start date would be March 1, if all eligibility requirements are met.

Eligibility may not extend past the month in which the 12 months of continous eligibility for extended postpartum ends.

The applicant/beneficiary must be income eligible during the initial month of eligibility only. Changes in income after the initial month will not affect eligibility.

Coverage

Beneficiaries in this group receive full Medicaid coverage. Coverage includes: • Prenatal care; • Delivery; • Postpartum care for twelve (12) months; and • Any conditions that may affect the health of the pregnant woman, and subsequently the outcome of the pregnancy, as determined by the provider. H-2902 ELIGIBILITY DETERMINATION PROCESS Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

(h-2900)(page-3)Page 3#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued October 11, 2022

Page 3 of H-2900 Replacing May 09, 2022 Revised/added text indicated by underscore

Deleted text indicated by “**” H-2902.1 Determine Assistance Unit The assistance unit consists of the pregnant woman.

H-2902.2 Establish Categorical Requirement An applicant/beneficiary must be pregnant for each month of eligibility, except the 12 months of continous eligibility for extended postpartum.

Note: If a child under age 19 is eligible for both CHAMP and the PW program, enroll the child in CHAMP.

H-2902.3 Establish Non-Financial Eligibility Eligibility shall be verified with regard to the following factors: • Assignment of Third Party Rights

I-200 • Citizenship / Identity and Qualified Non-Citizen Status I-300 • Enumeration

I-600 • Residence

I-1900

Evaluate the need for Support Enforcement Services (SES). Refer to I-2000.

H-2902.4 Establish Need Household composition and need/countable income for the PW group are based on MAGI methodology. Refer to I-1550 MAGI Determinations.

Exception: When determining Medicaid eligibility for pregnant women under age 19, all income is disregarded. Compare MAGI-based income to PW group income standard. Refer to Z-200, Federal Poverty Income Guidelines.

Note: The pregnant woman’s household composition and income unit shall always include the unborn child(ren).

(h-2900)(page-4)Page 4#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued October 11, 2022

Page 4 of H-2900 Replacing May 09, 2022 Revised/added text indicated by underscore

Deleted text indicated by “**” H-2902.5 Eligibility Decision All eligibility requirements and verification received shall be evaluated to make the eligibility decision.

H-2902.6 Certification Period The certification period begins the first day of the month of eligibility and continues, without interruption, through the calendar month in which the 12 months of continous eligibility for extended postpartum ends.

H-2902.7 Notice of Decision Send the appropriate notice of decision to the applicant/beneficiary.

(h-3010)Louisiana Medicaid Eligibility Manual (LDH): H - 3010 Children Under Age 19 Group - Deemed Newborn Children#

(h-3010)(page-1)Page 1#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued June 11, 2021

Page 1 of H-3010 Replacing May 22, 2014 Revised/added text indicated by underscore

Deleted text indicated by “**” H-3010 CHILDREN UNDER AGE 19 GROUP - DEEMED NEWBORN CHILDREN

H-3011 GENERAL INFORMATION

A child born to a woman determined eligible for Medicaid benefits in any category on the date the child is born shall be deemed Medicaid eligible for up to one year.

This includes a child ** born to a woman who is determined retroactively eligible for the date the child was born or to a non-citizen mother eligible for emergency services only.

Exceptions: • Do not deem the newborn if the mother is certified for Qualified Medicare Beneficiary (QMB)-only, Specified Low- Income Medicare Beneficiary (SLMB)-only, Qualified Disabled and Working Individuals (QDWI) or Qualifying Individuals Program (QI). • Do not deem the newborn if the mother is certified for a state-funded program only. (Refer to ** E-330 Category I.) Consider eligibility in another program.

An application for assistance or financial eligibility determination is not required for the deemed newborn.

Under the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), the deemed newborn’s eligibility is no longer dependent on: • The newborn coming home from the hospital to live with the mother, • The newborn remaining in the mother’s household, or • The mother remaining Medicaid eligible (or would be eligible if still pregnant).

The Patient Protection and Affordable Care Act of 2010 ** (ACA) combines all mandatory and optional eligibility groups for individuals under age 19 into one coverage group. The Children Under Age 19 Group includes those newborns covered under Deemed Newborn Children.

(h-3010)(page-2)Page 2#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued June 11, 2021

Page 2 of H-3010 Replacing May 22, 2014 Revised/added text indicated by underscore

Deleted text indicated by “**” H-3012 Coverage

A deemed newborn is eligible for the full range of Medicaid covered services for the first year of life.

Prior to closure of the deemed newborn’s coverage, eligibility in other programs must be explored.

H-3013 ELIGIBILITY DETERMINATION PROCESS

Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

H-3013.1 Reserved

H-3013.2 Establish Categorical Requirement

Verify that the newborn has not reached their first birthday and that the mother was eligible on the date of birth.

H-3013.3 Establish Non-Financial Eligibility

The mother must be Medicaid eligible at the time of the newborn’s birth. This includes a mother who is determined retroactively eligible for the date of the newborn’s birth. See I-1200 Mother's Medicaid Eligibility.

Enumeration for deemed newborns ** is accomplished by filing for a birth certificate.

Note: Support Enforcement Services (SES) referral is not an eligibility factor for deemed newborns.

H-3013.4 Reserved

(h-3010)(page-3)Page 3#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued June 11, 2021

Page 3 of H-3010 Replacing May 22, 2014 Revised/added text indicated by underscore

Deleted text indicated by “**” H-3013.5 Eligibility Decision

Evaluate all eligibility requirements and verifications received to determine if the newborn is eligible to be deemed.

** H-3013.6 Certification Period

The certification period cannot extend past the month of the newborn's first birthday.

H-3013.7 Notice of Decision

Send appropriate notice of decision to the applicant/enrollee.

Medical Providers are notified through the Provider Portal on the Louisiana Medicaid Eligibility Determination System (LaMEDS).

(h-3020)Louisiana Medicaid Eligibility Manual (LDH): H - 3020 CHAMP#

(h-3020)(page-1)Page 1#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued September 30, 2024

Page 1 of H-3020 Replacing August 11, 2023 Revised/added text indicated by underscore

Deleted text indicated by “**” H-3020 Children Under Age 19 Group-CHAMP

H-3021 GENERAL INFORMATION

As a result of the Sixth Omnibus Budget Reconciliation Act of 1986 (SOBRA), Louisiana implemented the Child Health and Maternity Program (CHAMP) in January 1989, to provide Medicaid benefits to pregnant women and children under age 19 who meet income and non-financial eligibility criteria.

The Patient Protection and Affordable Care Act of 2010, referred to as the Affordable Care Act (ACA), combined all mandatory and optional eligibility groups for individuals under age 19 into one coverage group. This group includes those children covered under CHAMP.

Eligibility for applicants/beneficiaries in the children’s group is determined by using Modified Adjusted Gross Income (MAGI) methodology.

ACA expanded mandatory coverage to all children under age 19 with household MAGI-based income at or below 147 percent of the Federal Poverty Level (142 percent FPL, plus 5 percent disregard). Such children are considered CHAMP children.

There is no resource eligibility requirement for CHAMP children.

Note: CHAMP children include those previously ineligible children, ages 6-18 years old, with other health insurance. CHAMP children in this age group, with income between 108 percent and 147 percent FPL, who do not have other health insurance, should be certified in LaCHIP Category/Type Case 03-07. The state is allowed to collect enhanced funding for this group.

H-3022 ELIGIBILITY DETERMINATION PROCESS

Determine eligibility by applying the following criteria as outlined. The elements have been listed in the most logical order, but work on all steps simultaneously.

H-3022.1 Determine Assistance Unit

The assistance unit consists of the child(ren) under age 19 for whom assistance is requested.

(h-3020)(page-2)Page 2#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued September 30, 2024

Page 2 of H-3020 Replacing August 11, 2023 Revised/added text indicated by underscore

Deleted text indicated by “**” H-3022.2 Establish Categorical Requirement

Each child must be under age 19.

Note: If a child under age 19 is eligible for both CHAMP and the PW program, enroll the child in CHAMP.

H-3022.3 Establish Non-Financial Eligibility

Verify eligibility for each member of the assistance/benefit unit with regard to the following factors:

• Assignment of Third Party Rights I-200

• Citizenship/Alien Status

I-300

• Enumeration

I-600

• Residence

I-1900

Evaluate the need for Support Enforcement Services (SES) referral. Refer to I-2000 Support Enforcement Services.

H-3022.4 Establish Need

Household composition and countable income for CHAMP children is based on MAGI income standards. Refer to I-1550 MAGI Determinations.

Exception: When determining Medicaid eligibility for pregnant women under age 19, all income is disregarded.

Compare MAGI-based income to the CHAMP child income standard. Refer to Z-200 Federal Poverty Income Guidelines.

Note: In determining family size for the eligibility determination of a pregnant woman, she is counted as herself, plus each of the children she is expected to deliver. Do not include the unborn(s) in the family size for eligibility determinations of other household members.

(h-3020)(page-3)Page 3#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued September 30, 2024

Page 3 of H-3020 Replacing August 11, 2023 Revised/added text indicated by underscore

Deleted text indicated by “**” H-3022.5 Eligibility Decision

Evaluate all eligibility requirements and verifications received to make the eligibility decision.

H-3022.6 Certification Period

The certification period may be effective no earlier than three (3) months prior to the application date, provided the individual is otherwise eligible. The months of retroactive coverage are not included in the twelve (12) month certification period. The twelve (12) month certification period begins with the month of application.

Retroactive medical eligibility shall be explored for the three (3) months prior to the month of application. Refer to H-1800 Retroactive Medical Eligibility.

H-3022.7 Notice of Decision

Send the appropriate notice of decision to the applicant/recipient.

Reminder: BHSF Flyer WIC shall be provided to recipients who did not receive information about the special supplemental nutrition program for Women, Infants, and Children (WIC) at application.

(h-3030)Louisiana Medicaid Eligibility Manual (LDH): H - 3030 LaCHIP#

(h-3030)(page-1)Page 1#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued August 11, 2023

Page 1 of H-3030 Replacing March 3, 2021 Revised/added text indicated by underscore

Deleted text indicated by “**” H-3030 CHILDREN UNDER AGE 19 GROUP-LaCHIP

H-3031 GENERAL INFORMATION

The Balanced Budget Act of 1997, enacted on August 5, 1997, established a children's health insurance program under Title XXI of the Social Security Act. The purpose of this program is to enable States to initiate and expand the provision of child health assistance to uninsured, low-income children.

The law allows Louisiana to expand coverage to "targeted low-income children" under an expansion of Medicaid (for children who would not qualify for Medicaid under State rules in effect as of April 15, 1997), a separate state child health insurance program, or through a combination of these programs.

Senate Bill No. 78 of the First Extraordinary Session of the 1998 Louisiana Legislature authorized implementation of the State Children's Health Insurance Program (LaCHIP) as a combination of an expanded Medicaid program and a separate child health insurance program and placed administrative authority with the Department of Health and Hospitals. Initial implementation involved only an expansion of Medicaid.

A "targeted low-income child" is one:

• Who is under age 19;

• Whose MAGI-based income meets the specified cut-off level;

• Who does not have other insurance; and

• Who has been determined eligible for child health assistance under the state plan.

By opting to expand health insurance coverage to targeted low-income children through a Medicaid expansion, a State may cover the same groups of children which they would be permitted to cover under a separate state child health insurance program. For Medicaid purposes, these children are referred to as "optional targeted low- income children".

The Patient Protection and Affordable Care Act of 2010, referred to as the Affordable Care Act (ACA), combines all mandatory and optional

(h-3030)(page-2)Page 2#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued August 11, 2023

Page 2 of H-3030 Replacing March 3, 2021 Revised/added text indicated by underscore

Deleted text indicated by “**” eligibility groups for individuals under age 19 into one coverage group. The Children Under Age 19 Group includes those children covered under LaCHIP. Eligibility for applicants/beneficiaries in the Children Under Age 19 Group is determined by using Modified Adjusted Gross Income (MAGI) methodology

A LaCHIP child is a child who:

• Is under the age of 19;

• Is not eligible for Medicaid under any other optional or mandatory eligibility group or eligible as medically needy (without spend-down liability).

• Does not have health insurance;

• Has MAGI-based income at or below 217 percent of the Federal Poverty Level (212 percent FPL plus 5 percent disregard).

Note:

Children certified in Category/Type Case 03-07:

• Ages 6-18 years old, and • MAGI income between 108 percent and 147 percent FPL, and • Do not have other health insurance

The state is allowed to collect enhanced funding for this group.

H-3032 ELIGIBILITY DETERMINATION PROCESS

Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

H-3032.1 Determine Assistance Unit

The assistance unit consists of the child(ren) under age 19.

H-3032.2 Establish Categorical Requirement

Verification must be provided that each child is under age 19.

(h-3030)(page-3)Page 3#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued August 11, 2023

Page 3 of H-3030 Replacing March 3, 2021 Revised/added text indicated by underscore

Deleted text indicated by “**” H-3032.3 Establish Non-financial Eligibility

Verify eligibility for each member of the assistance/benefit unit with regard to the following factors: • Assignment of Third Party Rights I-200 • Citizenship/Identity and Qualified Non-Citizen Status I-300 • Enumeration I-600 • Residence I-1900 • Lack of Creditable Health Coverage I-2200

Evaluate the need for Support Enforcement Services (SES) referral. Refer to I-2000 Support Enforcement Services (SES).

H-3032.4 Establish Need

Household composition and countable income for LaCHIP Children is based on MAGI. Refer to I-1550, MAGI Determinations.

Compare MAGI-based income to LaCHIP Children Income Standard. Refer to Z-200, Federal Poverty Income Guidelines.

H-3032.5 Eligibility Decision

Evaluate all eligibility requirements and verifications received to make the eligibility decision to either reject/close, certify, or extend eligibility.

H-3032.6 Certification Period

The certification period may be effective no earlier than three months prior to the application date provided the individual is otherwise eligible. The 12-month certification period begins with the month of application.

Retroactive medical eligibility shall be explored for the three months prior to the month of application. Refer to H-1800, Retroactive Medical Eligibility.

(h-3030)(page-4)Page 4#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued August 11, 2023

Page 4 of H-3030 Replacing March 3, 2021 Revised/added text indicated by underscore

Deleted text indicated by “**” H-3032.7 Notice of Decision

Send the appropriate notice of decision to the applicant/beneficiary.

(h-3040)Louisiana Medicaid Eligibility Manual (LDH): H - 3040 LaCHIP Affordable Plan#

(h-3040)(page-1)Page 1#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

March 24, 2025

Page 1 of H-3040 Replacing March 01, 2024 Revised/added text indicated by underscore

Deleted text indicated by “**” H-3040 CHILDREN UNDER AGE 19-LACHIP AFFORDABLE PLAN H-3041 GENERAL INFORMATION

Effective June 1, 2008, Louisiana expanded the State Child Health Insurance Program (SCHIP) to provide health assistance to uninsured children with family income in excess of the limits for the regular Louisiana Children’s Health Insurance Program (LaCHIP), but equal to or less than 255 percent (250 percent, plus a 5 percent disregard) of the Federal Poverty Level (FPL).

The LaCHIP Affordable Plan (LAP) is a separate state SCHIP program. LAP is a cost-sharing program with a monthly premium of $50 per household, regardless of the number of certifications per household due to multiple income units. A household that has at least one (1) eligible child verified as a member of a federally-recognized American Indian or Alaskan native tribe will pay no premium.

Eligibility for applicants/beneficiaries for LAP is determined by using the Modified Adjusted Gross Income (MAGI) methodology.

A LAP child is one: • Who is under age 19; • Who is income ineligible for regular LaCHIP; • Who has MAGI-based income that does not exceed 255 percent of the FPL; • Who does not have other insurance or access to the State Employees Health Plan (SEHP); • Who has been determined eligible for child health assistance under the SCHIP; • **

H-3042 ELIGIBILITY DETERMINATION PROCESS

Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously. H-3042.1 Determine Assistance Unit

(h-3040)(page-2)Page 2#

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March 24, 2025

Page 2 of H-3040 Replacing March 01, 2024 Revised/added text indicated by underscore

Deleted text indicated by “**” The assistance unit consists of the child(ren) under age 19.

H-3042.2 Establish Categorical Requirement

Each eligible child must be under age 19.

H-3042.3 Establish Non-financial Eligibility

Verify eligibility for each member of the assistance/benefit unit with regard to the following factors:

• Assignment of Third Party Rights I-200 • Citizenship/Identity and Qualified Non-Citizen Status I-300 • Enumeration I-600 • Residence I-1900 • Creditable Health Coverage I-2200 • Access to a SEHP • Employer sponsored insurance not voluntarily cancelled during the prior three (3) months.

H-3042.4 Establish Need

Household composition and countable income for LaCHIP Affordable Plan children are based on the MAGI methodology. Refer to I-1550 MAGI Determinations.

Compare MAGI-based income to the LAP income standard. Refer to Z-200, Federal Poverty Income Guidelines.

H-3042.5 Eligibility Decision

Evaluate all eligibility requirements and verifications received to make the eligibility decision.

H-3042.6 Certification Period

(h-3040)(page-3)Page 3#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

March 24, 2025

Page 3 of H-3040 Replacing March 01, 2024 Revised/added text indicated by underscore

Deleted text indicated by “**” The certification period shall not exceed twelve (12) months. Eligibility will always begin on the first of the month after the eligibility determination has been completed.

Retroactive coverage is not available.

** H-3042.7 Notice of Decision

Send the appropriate notice of decision to the applicant/beneficiary.

H-3042.8 Premiums

LAP is a cost-sharing program with a monthly premium of $50 due by the 10th of each month. LAP benefits begin after the first premium payment is received. Applicants are allowed 60 days to pay the first premium. **

(h-3050)Louisiana Medicaid Eligibility Manual (LDH): H - 3050 LaCHIP Phase IV#

(h-3050)(page-1)Page 1#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued May 1, 2023

Page 1 of H-3050 Replacing July 7, 2016 Revised/added text indicated by underscore

Deleted text indicated by “**” H-3050 CHILDREN UNDER AGE 19 - LaCHIP PHASE IV (SCHIP) H-3051 GENERAL INFORMATION

Effective May 1, 2007, the Louisiana Department of Health and Hospitals (DHH) implemented an expansion of the State Children’s Health Insurance Program (SCHIP) to provide prenatal care services, from conception to birth, for low income uninsured mothers who were not otherwise eligible for Medicaid. This Louisiana Children’s Health Insurance Program (LaCHIP), called LaCHIP Phase IV, also covers non-citizen women who are not qualified for other Medicaid programs due to citizenship status only.

The Patient Protection and Affordable Care Act of 2010, referred to as the Affordable Care Act (ACA), combines all mandatory and optional eligibility groups for individuals under age 19 into one coverage group. LaCHIP Phase IV is considered under the Children Under Age 19 Group as the program benefits the unborn child from conception to birth. Eligibility for LaCHIP Phase IV is determined by using Modified Adjusted Gross Income (MAGI) methodology.

MAGI based income for LaCHIP Phase IV beneficiaries must not exceed 214 percent of the Federal Poverty Level (209 percent FPL, plus a 5 percent disregard).

H-3052 ELIGIBILITY DETERMINATION PROCESS

Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

H-3052.1 Determine Assistance/Benefit Unit

The assistance/benefit unit consists of the pregnant woman.

H-3052.2 Establish Categorical Requirement

A LaCHIP Phase IV pregnant woman must be pregnant for each month of eligibility.

H-3052.3 Establish Non-Financial Eligibility

Verify eligibility for each member of the assistance/benefit unit with regard

(h-3050)(page-2)Page 2#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued May 1, 2023

Page 2 of H-3050 Replacing July 7, 2016 Revised/added text indicated by underscore

Deleted text indicated by “**” to the following factors:

• Assignment of Third Party Rights I-200

• Citizenship/Alien Status

I-300

• Enumeration

I-600

• Residence

I-1900

• Creditable Health Coverage

I-2200

For LaCHIP Phase IV, citizenship/non-citizen status and enumeration are not eligibility requirements. Attempt to obtain and document any information the applicant can offer for herself and income unit members.

Applicants must be uninsured at the time of application. Applicants are considered to be uninsured if they do not have creditable health insurance that provides coverage of prenatal care services.

For LaCHIP Phase IV, an applicant cannot have access to a state employee health benefits plan (SEHBP) that covers prenatal services. A SEHBP is defined as a plan that is offered or organized by the state government, or on behalf of state employees, or other public agency for employees within the state.

H-3052.4 Establish Need

Household composition and countable Income for LaCHIP Phase IV Children is based on MAGI. Refer to I-1550 MAGI Determinations.

Compare MAGI-based income to the LaCHIP Phase IV income standard. Refer to Z-200 Federal Poverty Income Guidelines. H-3052.5 Eligibility Decision

Evaluate all eligibility requirements and verifications received to make the eligibility decision to either reject or certify the case.

(h-3050)(page-3)Page 3#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued May 1, 2023

Page 3 of H-3050 Replacing July 7, 2016 Revised/added text indicated by underscore

Deleted text indicated by “**”

H-3052.6 Certification Period

The certification period shall not exceed nine (9) months, beginning with the first month of eligibility, and continuing without interruption, until the pregnancy ends. Labor and delivery are covered. There is no 12-month post-partum continuous eligibility period for this program.

Retroactive medical eligibility shall be explored for the three (3) months prior to the month of application if the applicant was pregnant in the months requested. Refer to H-1800 Retroactive Medical Eligibility (RME). H-3052.7 Notice of Decision

Send the notice of decision to the applicant/beneficiary. H-3052.8 Deem Newborn

The newborn is deemed eligible at birth if the mother is determined eligible, initially or retroactively, for the month of birth. Refer to H-3010 Deemed Newborn Children.

(h-3100)Louisiana Medicaid Eligibility Manual (LDH): H - 3100 Former Foster Care Children#

(h-3100)(page-1)Page 1#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued May 1, 2023

Page 1 of H-3100 Replacing January 23, 2023 Revised/added text indicated by underscore

Deleted text indicated by “**”

H-3100 FORMER FOSTER CARE CHILDREN H-3110 GENERAL INFORMATION

In accordance with §1902(a)(10)(A)(i)(IX) of the Patient Protection and Affordable Care Act (ACA) of 2010, Medicaid coverage must be extended to all individuals under age 26 who were formerly children in foster care.

These individuals are applicants/beneficiaries, under 26 years of age, who were receiving Medicaid and were in foster care under the responsibility of the state at the time of their 18th birthday.

The Patient Protection and Affordable Care Act (ACA) has been amended to grant eligibility and enrollment to former foster care youth who were enrolled in Medicaid and who aged out of foster care in another state on or after January 1, 2023.

There is no income or asset test required and beneficiaries may have other insurance and remain eligible.

Former Foster Care Children (FFC) may also be applicants or beneficiaries who lost eligibility due to moving out of state, but re- established residency prior to reaching age 26.

H-3110.1 COVERAGE

Individuals enrolled in FFC are eligible for the full range of Medicaid covered services.

H-3120 ELIGIBILITY DETERMINATION PROCESS

Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

H-3120.1 DETERMINE ASSISTANCE UNIT

The assistance unit consists of the applicant/beneficiary that was formerly a child in foster care and is no longer in state custody.

(h-3100)(page-2)Page 2#

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Reissued May 1, 2023

Page 2 of H-3100 Replacing January 23, 2023 Revised/added text indicated by underscore

Deleted text indicated by “**”

H-3120.2 ESTABLISH CATEGORICAL REQUIREMENT

Establish that the applicant/beneficiary:

• Is at least age 18, but under age 26;

• Currently lives in Louisiana;

• Was a child in foster care in Louisiana’s custody upon reaching age 18 prior to January 1, 2023; or

• Was a child in foster care in any state’s custody upon reaching age 18 on or after January 1, 2023.

• Was enrolled in *** Medicaid upon reaching age 18.

• Is not enrolled in another mandatory eligibility group. Refer to F-100.1 Mandatory Coverage Groups.

Verification of Foster Care Status

***

The process to verify foster care status is coordinated between Child Welfare which administers the foster care program and State Independent Living and Education and Training Voucher (ETV) Coordinators. The individual will contact the ETV coordinator assigned to their state to obtain a verification letter. If the individual needs assistance in obtaining the required verification the agency is to contact the ETV Coordinator assigned to the individual’s state. A list of ETV Coordinators can be found here.

If the individual was in Foster Care in Louisiana, Child Welfare will electronically update the system with the updated foster care status. If the information has not been electronically updated in the system a request for information will be sent to the individual to provide verification. *** Types of Verification:

• Proof of aging out of foster care and being enrolled in Medicaid upon reaching age 18. • Proof of FFC eligibility in another state. • Refer to S-0000 Verification and Documentation

(h-3100)(page-3)Page 3#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued May 1, 2023

Page 3 of H-3100 Replacing January 23, 2023 Revised/added text indicated by underscore

Deleted text indicated by “**”

H-3120.3 ESTABLISH NON-FINANCIAL ELIGIBILITY

Verify eligibility with regard to the following factors:

• Age - MAGI-Related

I-100

• Assignment of Third Party Rights I-200

• Citizenship / Identity and Qualified Non-Citizen Status I-300

• Enumeration

I-600

• Residence

I-1900

H-3120.4 ESTABLISH NEED

There are no income or resource tests in determining eligibility.

H-3120.5 ELIGIBILITY DECISION

Evaluate all requirements to determine eligibility.

H-3120.6 CERTIFICATION PERIOD

Retroactive medical eligibility shall be explored for the three months prior to the month of application. Refer to H-1800 Retroactive Medical Eligibility (RME).

Note: Prior to closure of Former Foster Care Children, eligibility in other programs must be explored. H-3120.7 NOTICE OF DECISION

Send the appropriate notice of decision to the applicant/beneficiary.

(h-3200)Louisiana Medicaid Eligibility Manual (LDH): H - 3200 Hospital Presumptive Eligibility (HPE)#

(h-3200)(page-1)Page 1#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued June 20, 2023

Page 1 of H-3200 Replacing September 6, 2016 Revised/added text indicated by underscore Deleted text indicated by “**”

H-3200 HOSPITAL PRESUMPTIVE ELIGIBILITY

H-3210 GENERAL INFORMATION

The Patient Protection and Affordable Care Act of 2010 and the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the Affordable Care Act, or ACA) include provisions enabling states to improve and expand access to health insurance coverage for the Medicaid and CHIP populations. One such provision is the option for qualified hospitals to be designated as entities qualified to make presumptive Medicaid eligibility determinations based on preliminary, self-attested information obtained from individuals seeking medical assistance.

Effective January 1, 2014, any hospital designated by Louisiana Medicaid as a Hospital Presumptive Eligibility Qualified Entity (HPEQE) may obtain information and determine Hospital Presumptive Eligibility (HPE) for individuals who are not currently enrolled in Medicaid and who are in need of medical services covered under the State Plan.

Household composition and countable income for HPE coverage groups are determined using a simplified Modified Adjusted Gross Income (MAGI) methodology. Refer to I-1550 MAGI Determinations. There is no resource test for these groups.

H-3220 COVERAGE GROUPS

HPE coverage groups include the following individuals: • Adults; • Certain individuals needing treatment for breast and/or cervical cancer (BCC); • Children under age 19; • Former foster care children; • Parents and caretaker relatives; • Pregnant women; and • Take Charge Plus.

Note: Individuals must meet all of the requirements of the Medicaid program for which they are determined presumptively eligible. For example, a pregnant woman must be a citizen or a qualified alien to qualify for HPE.

(h-3200)(page-2)Page 2#

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Issued June 20, 2023

Page 2 of H-3200 Replacing September 6, 2016 Revised/added text indicated by underscore Deleted text indicated by “**”

H-3230 COVERED SERVICES

HPE beneficiaries receive the same benefits as those provided under the Medicaid group for which they are determined presumptively eligible. For example, an individual who is found presumptively eligible for Take Charge Plus will receive services limited to Take Charge Plus services and supplies.

Exception: HPE coverage for pregnant women is limited to ambulatory (outpatient) prenatal services including medically necessary transportation. Pregnant women are limited to one HPE period per pregnancy.

H-3240 HPE DETERMINATION PROCESS

HPE shall only be determined by a HPEQE by completing and submitting the BHSF Form 1-HPE. Louisiana Medicaid shall not make HPE determinations; however, program staff shall enter the HPE certification in the Louisiana Medicaid Eligibility Determination System (LaMEDS).

The agency shall not change an HPE determination made by a HPEQE, even if the determination was incorrect.

Exception: If the beneficiary has received HPE in the past twelve (12) months, or in the case of pregnant women, if the beneficiary has received HPE for the current pregnancy, the HPE certification shall be denied.

H-3240.1 HPE CERTIFICATION LIMITS

HPE certifications shall be limited to no more than one per twelve (12) month period for all coverage groups, with the exception of pregnant women, who are limited to one period of coverage per pregnancy.

H-3240.2 HPE CERTIFICATION PERIOD

The HPE certification period: • Begins on the date that the HPEQE determines eligibility; • Is never retroactive;

(h-3200)(page-3)Page 3#

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Issued June 20, 2023

Page 3 of H-3200 Replacing September 6, 2016 Revised/added text indicated by underscore Deleted text indicated by “**”

• Ends the last day of the month following the month in which the HPE determination is made if the beneficiary has not filed an application for regular Medicaid; • Continues until the eligibility determination is made if an application for regular Medicaid is received prior to the end of the HPE certification period; and • Is limited to no more than one HPE certification period every twelve (12) months for all eligibility groups, with the exception of pregnant women, who are limited to one certification period per pregnancy.

H-3240.3 HPE DECISION

If the HPE potential beneficiary is determined to be presumptively eligible the HPEQE is responsible for: • Advising the beneficiary, in writing, of their presumptive eligibility at the time the determination is made by providing a copy of the approved BHSF Form 1-HPE, Assessment Tool for Hospital Presumptive Eligibility Only; • Educating the beneficiary regarding HPE requirements and conveying the importance of submitting BHSF Form 1-A, Application for Health Coverage to Louisiana Medicaid prior to the end of the HPE certification period in order for benefits to continue; • Assisting in the completion and filing of the BHSF Form 1-A; and • Forwarding the completed HPE assessment within five (5) working days of the HPE determination, via fax, to (225) 389-2741 or (877) 747-0985. • The HPEQE is prohibited from requiring individuals to provide verification of any of the eligibility factors used in a Medicaid determination. The HPEQE must accept client attestation for all factors of eligibility.

If the individual is determined not to be presumptively eligible, the HPEQE is responsible for: • Assisting the individual with completing the BHSF Form 1-A; or • Advising the individual that they may apply for a formal determination of Medicaid eligibility by:  Seeking assistance from the in-hospital financial department;

(h-3200)(page-4)Page 4#

Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued June 20, 2023

Page 4 of H-3200 Replacing September 6, 2016 Revised/added text indicated by underscore Deleted text indicated by “**”

 Speaking with an on-site certified application counselor, if there is a certified application center on-site;  Referral to the nearest certified application center if there is not one on-site;  Applying on-line;  Applying via the customer service hotline at (888) 342- 6207; or  Visiting the nearest Medicaid office.

H-3240.4 HPE NOTICES

BHSF Form 1-HPE, issued at the time of HPE certification by the HPEQE, shall also serve as the termination notice. No advance notice or appeal rights are granted when terminating HPE coverage.

H-3240.5 MEDICAID RESPONSIBILITY UPON RECEIPT OF HPE DETERMINATION

Review of HPE Assessment

The HPE assessment is complete if it contains basic beneficiary information, HPE representative signatures, and dates. . If the assessment contains enough information for certification, enter the HPE certification immediately on LaMEDS. If the assessment does not contain enough information for certification, contact the beneficiary to secure the information and make a notation in the case notes.

Note: Medicaid payments made as a result of an erroneous Presumptive Eligibility (PE) determination by the HPEQE are not considered overpayments.

HPE eligibility decisions are not subject to Quality Control review.

(h-3300)Louisiana Medicaid Eligibility Manual (LDH): H - 3300 Provisional Medicaid#

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

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Deleted text indicated by “**”

H-3300 PROVISIONAL MEDICAID

H-3310 GENERAL INFORMATION

Effective February 9, 2014, for dates of service beginning February 1, 2014, Louisiana Medicaid implemented the Provisional Medicaid (PM) program for individuals with disabilities or age 65 and older. Coverage may not begin prior to February 1, 2014.

This program will provide Medicaid coverage to applicants/beneficiaries with income below the Federal Benefit Rate (FBR) and resources that meet SSI limits. A disability determination may be made by Medicaid’s Medical Eligibility Determination Team (MEDT) without first having an SSI determination made by the SSA.

Note: A decision by the MEDT is also required for applicants alleging blindness or a disability based on visual impairment. These applicants must be certified in the Disability “D” category and not in the Blind “B” category.

H-3320 DISABILITY DETERMINATIONS

An applicant who alleges a disabling condition shall have a disability determination made by MEDT when any of the following circumstances exist:

1. The applicant has applied for Medicaid and has not applied to SSA for SSI cash benefits.

2. The applicant has applied for Medicaid and SSI benefits and is found ineligible for SSI for a reason that does not apply to Medicaid (i.e. lawful permanent resident without 40 quarters of work history and other alien status, incarceration, resident of a state mental hospital/IMD, or transfer of assets).

3. The applicant has applied both for Medicaid and to SSA for SSI, and SSA has not made an SSI disability determination.

4. The applicant has applied for Medicaid and:

• claims a disabling condition different from, or in addition to,

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Deleted text indicated by “**” that considered by SSA in making its determination, or

• claims that his or her condition has deteriorated and it has been more than 12 months since the most recent SSA disability denial

• SSA has denied the application based on disability in the last twelve (12) months and the applicant provides documentation that the SSA decision has been timely appealed. H-3330 COVERAGE

Provisional Medicaid beneficiaries receive the full range of Medicaid covered services.

H-3340 ELIGIBILITY DETERMINATION PROCESS

Determine eligibility by applying the following criteria. Elements have been listed in the most logical order, but work on all steps simultaneously.

H-3340.1 Determine Assistance Unit

The assistance unit includes the applicant/beneficiary or both members of a couple (legal or non-legal) if they meet the Provisional Medicaid criteria.

H-3340.2 Establish Categorical Requirement

Verify that the applicant/beneficiary is:

• Aged;

• Blind; or

• Disabled.

Refer to E-0000 Category.

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Deleted text indicated by “**” H-3340.3 Establish Non-Financial Eligibility

Verify eligibility with regard to the following factors:

• Assignment of Third Party Rights I-200

• Citizenship/Identity and Qualified Non-Citizen Status I-300

• Enumeration I-600

• Residence I-1900

H-3340.4 Establish Need

A. Determine Composition of the Income/Resource Unit

The income/resource unit consists of the:

• Applicant/beneficiary,

• Applicant/beneficiary and ineligible spouse (is not disabled nor aged) living in the home,

• Applicant/beneficiary who is a minor and his parent(s) living in the home, or

• Applicants/beneficiaries who are a couple (both are disabled or aged)

B. Determine Need/Countable Resources

Note: The cash surrender value (CSV) of life insurance is counted if the face value of all policies that can accumulate CSV is greater than $1,500.

The maximum burial fund exclusion for Provisional Medicaid is $1,500.

For more information, see I-1634 Type of Resources (SSI-Related).

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Compare the countable resources to the SSI resource limit for the number of persons in the resource unit. Refer to Z-900 Resource Limits by Program .

If resources are greater than the limit, the applicant/beneficiary is resource ineligible for Provisional Medicaid.

If resources are equal to or less than the limit, the applicant/beneficiary is resource eligible for Provisional Medicaid.

C. Determine Need/Countable Income

Individual

If the applicant/beneficiary is an individual with no spouse or with an ineligible spouse with no income, go to Step 1.

Parent(s) to Child Deeming

If the applicant beneficiary is a minor child, apply deeming policy I- 1424.2, Need – Deeming. Any income deemed from the parent(s) is considered unearned income of the applicant/beneficiary in the individual steps. Go to Step 1.

Note: If there is more than one eligible child in the household, divide the income deemed from the parent’s equally among them.

Exception: Deeming of income or resources is not applicable to newborns who have never been discharged from the hospital and are expected to remain in the hospital for more than 30 days. Deeming is only applicable the month after the newborn is discharged. Refer to I- 1422, When Deeming is Not Applicable and G-1620, Simplified Disability Decisions for Infants.

Note: Consider eligibility for children under age 19 in a MAGI Child group before Provisional Medicaid.

** Complete the following budget steps:

Step 1. Determine total countable unearned income.

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Deleted text indicated by “**” NOTE: In-kind support and maintenance (ISM) is counted for the Provisional Medicaid program. (For more information on ISM, see I-1534 Types of Income - SSI Related).

Step 2. Subtract $20 SSI disregard from unearned income.

Step 3. The remainder is the countable unearned income.

Step 4. Determine total gross earned income.

Step 5. Subtract any remainder of $20 SSI disregard from gross earnings.

Step 6. Subtract earned income deduction from remaining gross earnings. Earned income deduction is $65 and one-half of remainder of earnings.

Step 7. The remainder is the countable earned income.

Step 8. Combine remainders from Step 3 and Step 7.

Consider the individual for eligibility in H-1030 Spend- Down Medically Needy - SSI related (MNP).

Note: Do not count ISM in determining eligibility for MNP (See I-1534 Types of Income (SSI Related) ).

Compare to FBR Income Standard for Individual. If income is equal to or less than the individual limit, the applicant/beneficiary is eligible. Refer to Z-400 Federal Benefit Rate (FBR).

Ineligible Spouse Deeming

If there is an ineligible spouse with income, complete steps 1 through 7 listed above using only the applicant’s/beneficiary’s income. If the income is equal to or greater than the individual limit (Refer to Z-400 Federal Benefit Rate (FBR)), the

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Deleted text indicated by “**” applicant/beneficiary is ineligible and there is no deeming – consider MNP. If the applicant’s/beneficiary’s income is less than the individual income standard, apply I-1424.2 Income Deeming Procedures

Couple

If both members of a couple are potentially eligible, complete the following steps:

Step 1. Determine total unearned income of the couple.

Step 2. Subtract one $20 SSI disregard from the unearned income.

Step 3. The remainder is the countable unearned income.

Step 4. Determine total gross earned income of the couple.

Step 5. Subtract any remainder of the $20 SSI disregard from gross earnings.

Step 6. Subtract one earned income deduction from the remaining gross earnings of the income unit. The earned income deduction is $65 and one-half of the remainder of the earnings.

Step 7 The remainder is the countable earned income.

Step 8. Combine the remainders in Step 3 and Step 7.

Step 9. Compare total countable income to the current FBR for a couple. Refer to Z-400 Federal Benefit Rate (FBR).

If the income is greater than the current FBR for a couple, the applicants/beneficiaries are not eligible for Provisional Medicaid.

Consider eligibility in H-1030 Spend-Down Medically Needy - SSI related.

If the income is equal to or less than the current FBR for a couple, the applicants/beneficiaries are income

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Deleted text indicated by “**” eligible for Provisional Medicaid.

H-3340.5 Eligibility Decision

Evaluate all eligibility requirements and verifications received to make the eligibility decision to either reject/close, certify, or extend eligibility.

H-3340.6 Certification Period

The certification period shall not exceed twelve months, not including any retroactive coverage. Retroactive medical eligibility shall be explored for the three months prior to the month of application. Refer to H-1800 Retroactive Medicaid Eligibility (RME).

NOTE: Applicants will be required to apply for any annuity, pension, retirement, and disability benefits (not including SSI) for which they are entitled to. A review is to be conducted every six months to determine the status of the beneficiary’s application for other benefits, if any. Confirmed receipt of other benefits must be evaluated to determine effect on eligibility.

H-3340.7 Notice of Decision

Send the notice of decision to the applicant/beneficiary.

H-3350 SOCIAL SECURITY ADMINSTRATION (SSA) DETERMINATIONS

SSI determinations take precedence over the MEDT determination. An SSI denial decision will require action to determine if it applies to Medicaid and if so, a review for eligibility in any other Medicaid program prior to taking action to close the Provisional Medicaid certification. Refer to G-1610.12 SSI Appeals, when the SSA decision has been appealed.

(h-3400)Louisiana Medicaid Eligibility Manual (LDH): H - 3400 Take Charge Plus#

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Eligibility Determinations

Issued July 20, 2020

Page 1 of H-3400 Replacing June 14, 2016

Deleted text indicated by “**” Revised/added text indicated by underscore

H-3400 TAKE CHARGE PLUS

H-3410 GENERAL INFORMATION

Section 2303 of the Affordable Care Act of 2010 established a new optional Medicaid eligibility group called Take Charge Plus (TCP). On July 1, 2014, Louisiana began offering services to this new eligibility group, with coverage limited to the following family planning-related services:  Family planning education and counseling;  Laboratory tests for family planning;  Medications and supplies, such as: birth control pills, condoms, implants or patches, injections and intrauterine devices (IUDs) **;  Voluntary sterilization procedures, such as tubal ligation or vasectomy;  Seven (7) visits to any approved medical professional in a calendar year. This includes four (4) yearly physical examinations and revisits. Monthly birth control medications are not counted as a visit unless seen by a medical professional;  Drugs for the treatment of sexually transmitted infections/sexually transmitted diseases (STIs/STDs);  Drugs for the treatment of certain lower genital tract and genital skin infections as it relates to family planning;  Vaccine to prevent human papillomavirus (HPV), the virus that causes cervical cancer;  Treatment of major complications resulting from certain family planning procedures;  Non-emergency medical transportation (NEMT); and  Yearly physical examinations and revisits (up to four (4) covered service visits in a calendar year by an approved medical professional). Eligibility requirements:  Women or men of any age; and  Family income at or below 138 percent of the Federal Poverty Level (FPL); and

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 Has not previously had a medical procedure that would prevent pregnancy, such as tubal ligation, hysterectomy or vasectomy.

H-3420 ELIGIBILITY DETERMINATION PROCESS Determine eligibility by applying the following criteria (beginning at H-3420.1). Elements have been listed in the most logical order, but work on all steps simultaneously.

H-3420.1 DETERMINE ASSISTANCE UNIT The assistance/benefit unit consists of the applicant/enrollee. H-3420.2 ESTABLISH NON-FINANCIAL ELIGIBILITY

Verify eligibility with regard to the following factors:  Assignment of Third Party Rights I-200  Citizenship/Alien Status I-300  Enumeration I-600  Residence I-1900  SES Referral I-2000

H-3420.3 ESTABLISH NEED Household composition and countable income for TCP is based on the Modified Adjusted Gross Income (MAGI) methodology. Refer to I-1550 MAGI Determinations.

Compare MAGI-based income to the TCP income standard. Refer to Z-200 Federal Poverty Income Guidelines.

H-3420.4 ELIGIBILITY DECISION Evaluate all eligibility requirements and verifications received to make the eligibility decision to either reject/close, certify, or extend eligibility.

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H-3420.5 CERTIFICATION PERIOD The certification period may be effective no earlier than three (3) months prior to the application date, provided the individual is otherwise eligible. The twelve (12) month certification period begins with the month of application. The months of retroactive coverage are not included in the twelve (12) month certification period.

** Note: If otherwise eligible, an individual may be enrolled in TCP and a limited benefit program such as the Medicare Savings programs (QMB, SLMB, or QI). Retroactive medical eligibility (RME) shall be explored for the three (3) months prior to the month of application. Refer to H-1800, Retroactive Medical Eligibility (RME).

H-3420.6 NOTICE OF DECISION Send the notice of decision to the applicant/enrollee.

H-3420.7 RENEWALS TCP eligibility is reviewed every twelve (12) months. **

Renewal Eligibility Decision If eligibility is extended, a notice of decision is sent to the enrollee. If eligibility is not extended, an advance notice of decision is sent, advising the enrollee of the proposed action.

(h-3500)Louisiana Medicaid Eligibility Manual (LDH): H - 3500 Adult Group#

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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Issued June 4, 2021

Page 1 of H-3500 Replacing November 6, 2020 Revised/added text indicated by underscore

Deleted text indicated by “**” H-3500 ADULT GROUP H-3501 GENERAL INFORMATION

The Affordable Care Act (ACA) of 2010 established a new optional Medicaid eligibility group for individuals age 19 through 64, hereafter referred to as the Adult Group (AG). Beginning July 1, 2016, this new group includes individuals with income less than or equal to 138 percent of the Federal Poverty Level (133 percent FPL, plus 5 percent disregard). Eligibility will be determined using Modified Adjusted Gross Income (MAGI) based income standards. H-3502 ELIGIBILITY DETERMINATION PROCESS Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously. H-3502.1 Assistance Unit The assistance unit consists of the adult individual. H-3502.2 Establish Categorical Requirement Verify that the individual meets the following requirements: • Is age 19 or older, but under age 65; • Is not pregnant; Note: Enrollees who later become pregnant may remain in the Adult Group. • Is not entitled to or enrolled in Medicare Part A or Part B; Note: Applicants/enrollees with Medicare are not eligible for coverage, however, private insurance coverage is allowed.

• Is not otherwise eligible for Medicaid; and Reminder: If an individual is eligible for both the Former Foster Care (FFC) program and the optional AG program, enroll the individual in FFC.

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• If a parent or other caretaker relative living with a dependent child under age 19, the child must have health coverage (Medicaid or private health coverage). H-3502.3 Establish Non-Financial Eligibility

Establish non-financial eligibility requirements in the Adult program. Verify eligibility with regard to the following factors: • Age – MAGI-Related I-100 • Assignment of Third Party Rights I-200 • Citizenship/Identity and Qualified Non-Citizen Status I-300 • Enumeration I-600 • Residence I-1900 If an applicant is applying for coverage for themselves and there is a child in the home, verify eligibility with regard to the following factor: • Support Enforcement Services (SES) I-2000

H-3502.4 Establish Need Household composition for the Adult Group is based on the MAGI methodology. Refer to I-1550 MAGI Determinations. Countable income for the Adult Group is based on the MAGI methodology. Refer to I-1550 MAGI Determinations. Compare to the income standard for the Adult Group. Refer to Z-200 Federal Poverty Guidelines. H-3502.5 Eligibility Decision Evaluate all eligibility requirements and verifications received to make the eligibility decision. H-3502.6 Certification Period The certification period may be effective no earlier than three (3)

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Page 3 of H-3500 Replacing November 6, 2020 Revised/added text indicated by underscore

Deleted text indicated by “**” months prior to the application date, provided the individual is otherwise eligible. The months of retroactive coverage are not included in the twelve (12) month certification period. The twelve (12) month certification period begins with the month of application. Twelve months continuous eligibility does not apply to AG. Retroactive medical eligibility (RME) shall be explored for the three (3) months prior to the month of application. Refer to H-1800, Retroactive Medical Eligibility. ** H-3502.7 Notice of Decision Send the appropriate notice of decision to the applicant/enrollee.

(h-3600)Louisiana Medicaid Eligibility Manual (LDH): H - 3600 Program of All Inclusive Care for the Elderly (PACE)#

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Issued September 23, 2024 Page 1 of H-3600 Replacing October 17, 2022 Revised/added text indicated by underscore Deleted text indicated by “**” H-3600 PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY

H-3610 GENERAL INFORMATION

The Program of All-inclusive Care for the Elderly (PACE) organization must provide preventative, primary health, acute and long-term care services to people age 55 or older who are certified to require nursing home care. The program enables frail, older adults to live in their homes while enhancing their quality of life.

The PACE organization must provide all Medicaid and Medicare services. The PACE organization provides primary care, adult day health care and therapy services. They must have a provider network for all other services (physicians, therapists of all kinds, pharmacies, hospitals, hospice, nursing homes, home health agencies, medical supplies, and personal care services, etc.).

Emergency services may be provided outside the PACE network, but non-emergency services must be authorized and paid by the PACE provider. Medicare and Medicaid will not reimburse any other provider for covered services when the beneficiary is linked to a PACE organization.

A participant’s enrollment in PACE is effective on the first day of the calendar month following the date the PACE organization receives the signed enrollment agreement.

To be eligible to enroll in PACE, an individual must:

• Be 55 years of age or older;

• Reside in the PACE organization’s service area;

• Meet nursing home level of care requirements; and

• Be able to live safely in the community at the time of enrollment.

Note: PACE organizations are located in the Greater New Orleans, East and West Baton Rouge, and Lafayette areas.

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H-3610.1 Coverage

Medicaid eligible PACE participants shall be eligible for payment of the monthly PACE premium. The PACE premium is paid directly to the PACE organization. No retroactive capitated payments shall be made.

The participant, while enrolled in a PACE program, must receive Medicare and Medicaid benefits solely through the PACE organization.

H-3610.2 Medical Certification

Medical approval requires that the PACE applicant meet the medical criteria for placement in a nursing facility. An assessment of the individual is completed by the PACE provider and forwarded to the Office of Aging and Adult Services (OAAS) for review. OAAS determines whether s/he needs the level of care required for coverage of nursing facility services.

OAAS will issue the medical certification form (BHSF Form 142).

The BHSF Form 142 documents the:

• Approval or disapproval for enrollment in PACE; and

• Effective date of medical certification approval.

H-3610.3 Special Income Limit (SIL)

Countable income must be equal to or below the SIL.

Income eligibility is based on the individual’s gross income (excluding VA Aid and Attendance).

The individual’s gross income is compared to the the special income limit used for individuals receiving home and community-based services. The SIL is three times the SSI Federal Benefit Rate (FBR) for an individual. The SIL for a couple is double the individual SIL. Refer to Z-700, LTC/HCBS SIL Rate, Resource Limits and Personal Care Needs Allowance.

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H-3610.4 Post-Eligibility Determination

Post-eligibility treatment of income rules do not apply.

PACE participants do not owe a patient liability while being cared for in the community.

When a PACE participant can no longer be cared for in the community, they may be placed in a nursing facility. As long as the participant resides in a nursing facility and remains enrolled in PACE, the PACE provider will continue to pay for all of their care.

H-3610.5 SSI Beneficiaries

SSI beneficiaries who enter PACE remain eligible for Medicaid if they continue to receive SSI payments while enrolled in PACE.

There are two circumstances under which payment to the PACE organization may be denied due to resource ineligibility for an individual who receives SSI and has been medically certified for PACE. They are:

• A Medicaid Qualifying Trust exists; or • An OBRA ’93 Trust exists.

Refer to I-1700 Trust to determine if the Trust is a countable resource to the SSI beneficiary.

Note:

Transfer of resources for less than FMV does not apply when

determining eligibility for PACE.

H-3620 ELIGIBILITY DETERMINATION PROCESS

Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

H-3621.1 Determine Assistance/Benefit Unit

The assistance/benefit unit consists of the applicant/beneficiary.

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H-3621.2 Establish Categorical Requirement

Verify that the applicant/beneficiary is:

• Aged;

• Blind; or

• Disabled.

Refer to E-0000 Category.

H-3621.3 Establish Non-Financial Eligibility

Verify eligibility for the applicant/beneficiary with regard to the following factors:

• Assignment of Third Party Rights

I-200

• Citizenship/Identity and Qualified Non-Citizen Status I-300

• Continuity of Stay (LTC Only, Except HCBS) I-400

• Enumeration

I-600

• Medical Certification (LTC and HCBS Only) I-1000

• Residence

I-1900

H-3621.4 Establish Need

Verify that the applicant/beneficiary is receiving or plans to receive PACE services from a Medicaid-enrolled PACE provider.

A. Determine Composition of the Income Unit

The income unit consists of:

• The applicant/beneficiary; or

• Applicants/beneficiaries who are a couple (legally married)

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Note: Never consider the income of the legal spouse and/or dependent(s) living in the home when determining eligibility for the PACE participant.

B. Determine Need/Income

Individual

Determine the gross income of the applicant. Refer to I-1530 Need - SSI-Related Income.

The applicant/beneficiary must be income eligible based on gross income.

Note: Exclude any income received from VA Aid and Attendance from the gross income computation.

Add the gross earned and unearned income. Compare the total income to the SIL. If the applicant/beneficiary is an individual, use the individual SIL. Refer to Z-700 LTC/HCBS SIL Rate, Resource Limits & Personal Care Needs Allowance.

If the total gross income of the applicant/beneficiary is greater than the SIL, the applicant/beneficiary is income ineligible.

If the total gross income is equal to or less than the SIL, the applicant/beneficiary is income eligible. Continue the determination of need.

Couples enrolled in PACE

Beginning with the month that both the applicant and legal spouse enroll in PACE, determine whether it is to their advantage to have need considered:

● As a couple; or ● As individuals. First, consider eligibility for each member of the couple as an individual. If one member of the couple has gross countable

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Issued September 23, 2024 Page 6 of H-3600 Replacing October 17, 2022 Revised/added text indicated by underscore Deleted text indicated by “**” income greater than the SIL, consider eligibility as a couple.

If need is considered for the applicants/beneficiaries as a couple, use the couple SIL.

If the combined total gross income of the couple is equal to or less than the couple SIL, the applicants/beneficiaries are income eligible. Continue the determination of need using the couple resource limit.

If need is considered for the applicants/beneficiaries as a couple, consider eligibility for Qualified Medicare Beneficiary (QMB) or Specified Low-Income Medicare Beneficiary (SLMB) using the couple QMB or SLMB standard.

C. Determine Composition of the Resource Unit

The resource unit consists of:

• The applicant/beneficiary;

• The applicant/beneficiary and the legal spouse living in the home; or

• Applicants/beneficiaries who are a couple (legally married) and both enrolled in PACE.

D. Determine Countable Resources

Determine total countable resources of the applicant/beneficiary. Refer to I-1630, Need - SSI-Related Resources.

If the individual’s home equity exceeds the limit, the individual will be totally ineligible for PACE. However, eligibility should be considered in other non-waiver programs.

If the applicant/beneficiary enrolled in PACE has a legal spouse living in the home, refer to I-1660 Spousal Impoverishment Resource Provisions (LTC/HCBS).

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Compare total countable resources to the SSI resource limit for an individual (or couple). Refer to Z-900 Resource Limits by Program.

If resources are greater than the resource limit, the applicant/beneficiary is resource ineligible for PACE.

If resources are equal to or less than the resource limit, the applicant/beneficiary is resource eligible for PACE.

If the resources of a couple are greater than the couple resource limit, consider eligibility for each spouse as an individual.

H-3621.5 Eligibility Decision

Evaluate all eligibility requirements and verification received to make the eligibility decision.

Medicaid eligibility may begin on the first day of the calendar month following the date the PACE organization receives the signed enrollment agreement.

Consider QMB or SLMB eligibility for all PACE applicants. Refer to H-1121, QMB Eligibility Determination Process or H-1321, SLMB Eligibility Determination Process.

H-3621.6 Certification Period

The certification period cannot exceed twelve months beginning with the first day of the first month of eligibility for the PACE program.

H-3621.7 Notice of Decision

Send the notice of decision to the applicant/beneficiary.

Send a copy of the decision notice to the PACE organization.

H-3621.8 Post Certification

Refer potentially eligible beneficiaries for SSI.

(h-3800)Louisiana Medicaid Eligibility Manual (LDH): H - 3800 Act 421 Children's Medicaid Option (TEFRA)#

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Issued March 14, 2023 Replacing August 29, 2022 Page 1 of H-3800 Revised/added text indicated by underscore Deleted text indicated by “” H-3800 ACT 421 CHILDREN’S MEDICAID OPTION (TEFRA)

H-3810 GENERAL INFORMATION

The Act 421 Children’s Medicaid Option (Act 421-CMO), implemented January 1, 2022, will cover individuals under age 19 who qualify with a disability who are living in the community and who meet the level of care provided in a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities.

Only the income and resources of the Act 421-CMO child are counted in the eligibility determination process. This allows children with complex medical needs to qualify based on their own income and resources to receive medical services in a less-costly home setting, instead of an institution when such care can be provided safely at home.

Note: Parental income and resources can be used to explore eligibility for Medicaid and CHIP programs that offer full benefits before ACT 421 –CMO with the exception of LAP and FOA. Consider eligibility for ACT 421- CMO before LAP and FOA **.

H-3810.1 Coverage

Act 421-CMO beneficiaries receive the full range of Medicaid covered services.

H-3810.2 Medical Certification

BHSF Form 142 – Notice of Medical Certification indicates if the applicant/beneficiary meets the level of care requirements for hospital, skilled nursing facility, or intermediate care facility for individuals with intellectual disabilities (ICF/IID).

The Office for Citizens with Developmental Disabilities (OCDD) Local Governing Entity (LGE) issues the BHSF Form 142.

The BHSF Form 142 documents the following: • Approval or disapproval of the level of care; and

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Issued March 14, 2023 Replacing August 29, 2022 Page 2 of H-3800 Revised/added text indicated by underscore Deleted text indicated by “” • The effective date of medical certification.

The LGE assesses the Act 421-CMO beneficiary annually to determine that the level of care requirement continues to be met.

H-3810.3 Special Income Level (SIL)

Income eligibility is based on the applicant/beneficiary's gross income. Gross income is compared to the SIL rate. The SIL rate is three times the Supplemental Security Income (SSI) Federal Benefit Rate (FBR) for an individual. Refer to Z-700 SIL Rate, Resource Limits & Personal Care Needs Allowance.

H-3820 ELIGIBILITY DETERMINATION PROCESS

Determine eligibility by applying the following criteria. The elements have been listed in the most logical order, but work on all steps simultaneously.

H-3820.1 Determine Assistance/Benefit Unit

The assistance/benefit unit consists of the applicant/beneficiary. Each applicant/beneficiary must meet all eligibility requirements.

H-3820.2 Establish Categorical Requirement

Establish that the applicant/beneficiary:

• Is under the age of 19; • Meets the level of care provided in a hospital, skilled nursing facility or intermediate care facility, but lives at home; and • Has a physical or mental impairment, or a combination of conditions, that is disabling under the Social Security Administration listing of impairments; Note: Disability determinations must be made by the Medicaid Eligibility Determination team (MEDT) unless disability has been established by SSA. Refer to G-1600 Securing

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Issued March 14, 2023 Replacing August 29, 2022 Page 3 of H-3800 Revised/added text indicated by underscore Deleted text indicated by “” Disability Decisions for Non-Magi (Formerly B and D) Categories

H-3820.3 Establish Non-Financial Eligibility

Verify eligibility for the applicant/beneficiary with regard to the following factors:

• Assignment of Third Party Rights

I-200 • Citizenship/Identity/Qualified Non-Citizen Status I-300 • Enumeration

I-600 • Medical Certification

I-1000 • Residence

I-1900

H-3820.4 Establish Need

A. Determine Composition of the Income Unit

The income unit consists of the applicant/beneficiary.

B. Determine Composition of the Resource Limit

The resource unit consists of the applicant/beneficiary.

** C. Determine Need/Countable Income

Determine the gross income of the applicant/beneficiary. Parent-to- child income deeming is not applicable. Refer to I-1530 Need - SSI-Related Income and Z-700 SIL Rate, Resource Limits & Personal Care Needs Allowance.

The applicant/beneficiary must be income eligible based on their own income to be eligible for Act 421-CMO. If the total gross income of the applicant/beneficiary is over the SIL, the applicant/beneficiary is ineligible for Act 421-CMO.

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D. Determine Need/Countable Resources

Determine countable resources of the applicant/beneficiary. Parent-to-child resource deeming is not applicable. Refer to I-1630, Need – Non-MAGI Related Resources.

Compare countable resources to the SSI resource limit for an individual. Refer to Z-900 Resource Limits by Program. If countable resources are equal to or less than the SSI resource limit for an individual, the applicant/beneficiary is resource eligible for the Act 421-CMO program.

If countable resources are greater than the SSI resource limit for an individual, the applicant/beneficiary is resource ineligible.

H-3820.5 Eligibility Decision

Evaluate all eligibility requirements and verifications received to make the eligibility decision to either reject, close, certify or continue eligibility.

H-3820.6 Certification Period

The certification period for Act 421-CMO shall not exceed 12 months.

Eligibility cannot begin prior to the first of the month of the medical certification and no earlier than three months prior to the application date.

H-3820.7 Notice of Decision

Send the notice of decision to the applicant/beneficiary. A copy of the notice will be issued to the LGE.

(h-3900)Louisiana Medicaid Eligibility Manual (LDH): H - 3900 Louisiana Health Insurance Premium Payment Program (LaHIPP)#

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H-3900 Louisiana Health Insurance Premium Payment Program (LaHIPP) H-3901 General Information

The Louisiana Health Insurance Premium Payment (LaHIPP) program is a Medicaid benefit that helps individuals and families pay for employer- sponsored insurance (ESI) or Individual Health Insurance (IHI) when it is cost-effective for Medicaid. The program enables eligible individuals and their families to maintain private health coverage while reducing Medicaid program costs.

LaHIPP may reimburse premiums for the policyholder and Medicaid eligible family members who are enrolled or have access to employer-sponsored health insurance or Individual Health Insurance (IHI) when it is determined that the cost of premiums is less than the projected Medicaid expenditures.

LaHIPP enrollment requires a determination that pays the employer- sponsored insurance premium or individual health insurance (IHI) is cost- effective.

An applicant/beneficiary may qualify for LaHIPP if:

• The employee is Medicaid eligible or have a family member who is Medicaid eligible; and • The individual must be enrolled or have access to employer- sponsored or individual health insurance coverage; and • The coverage must be determined cost-effective by the Louisiana Department of Health (LDH).

The following individuals do not qualify for LaHIPP:

• Individuals enrolled in spenddown; • Medicaid beneficiaries entitled to Medicare Part B, but refuse to enroll; • Long-Term Care (excluding TEFRA), Waiver, Chisolm and CSoC beneficiaries; • Persons with only Hospital Indemnity Insurance; • Persons with single scope of coverage insurance, such as dental or vision insurance under a separate premium; • A self-employed individual, unless this individual offers insurance to employees in his company or • A child receiving court ordered medical support

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H-3902 Coverage

The LaHIPP Program is a premium assistance program, not a separate Medicaid coverage group. Participation in LaHIPP does not establish Medicaid, affect eligibility, or provide independent Medicaid coverage and is not considered creditable coverage. Eligible individuals remain enrolled in their existing coverage group.

A LaCHIP or BCC applicant/beneficiary may have insurance coverage if purchased through the LaHIPP program. If Medicaid is reimbursing the premium through LaHIPP, this coverage is not considered creditable health insurance and does not impact LaCHIP or BCC eligibility.

LaHIPP reimburses the cost of employer-sponsored or individual health insurance premiums for the policyholder and Medicaid-eligible dependents when coverage is determined to be cost-effective.

Medicaid covers insurance co-payments and deductible if the beneficiary’s provider is in the health insurance plan's network and accepts Medicaid as a secondary payer, and the beneficiary follows all plan guidelines. If an individual covered on the health insurance policy is not a Medicaid beneficiary, they are responsible for their own copays, coinsurance and deductibles.

H-3903 Eligibility Determination Process

LaHIPP Eligibility Advisors are responsible for making the eligibility determination.

H-3904 Cost-Effectiveness

Cost-effectiveness means the total amount the state pays for premiums and required cost-sharing is less than what it would cost Medicaid to provide the same services directly. The Louisiana Department of Health (LDH) determines cost-effectiveness using established methodology and projected Medicaid expenditures.

Cost-Effective Methodology

1. To determine the total cost of ESI/IHI participation, add the following:

• Annual Premium Cost • Deductible o If enrolled 12 months or more, use actual deduction o If enrolled less than 12 months, calculate 60%

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• Copay Wrap Costs • Administrative Costs • Benefits Wrap Costs 2. The Medicaid amount is either: • The Per Month Per Member (PMPM) rate if the member is in an Managed Care Organization (MCO) or • The FFS claims cost if the member is in Fee-for-Service (FFS) (excluding waiver services) 3. The case is cost-effective when the Medicaid amount is higher than the total cost of ESI/IHI participation.

H-3905 Renewals

Renewal is the process of verifying that the beneficiary continues to meet all eligibility factors of the program. Periodical reviews are conducted to ensure cost-effectiveness to ensure continued eligibility and fiscal benefit to the Medicaid program.

Renewal packets are sent 30 Calendar days prior to the first Calendar Day of the policyholder’s Open Enrollment and process renewals prior to the end of the policyholder’s Open Enrollment.

H-3906 Changes

Participants are required to report the following changes within 10 days: • Changes in employment status or access to insurance; • Changes in premium amount or policy coverage; and • Termination of employer-sponsored insurance.

Failure to report changes may result in termination of LaHIPP participation or overpayment recovery.

A cost-effectiveness review is required when any of the following occur during the eligibility period.

• Change in employment or access to employer-sponsored coverage. • Change in premium amount, cost-sharing, or insurance plan benefits. • Change in household composition or Medicaid eligibility status. • Change in projected Medicaid expenditures that affects the cost- effectiveness calculation.

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H-3907 Eligibility Period

LaHIPP eligibility follows the individual’s insurance enrollment period.

LaHIPP participation will be terminated when: • The coverage is no longer cost-effective; • The Medicaid eligibility of the covered individual ends; • The employer-sponsored insurance ends or becomes unavailable; • The participant fails to submit the documentation needed to meet program requirements; • The primary holder moves out of state or • The primary holder dies.

H-3908 Securing Information to Determine Eligibility

Secure essential information for determining eligibility. Only require the applicant to provide information that cannot be obtained from other data sources and is necessary to make an eligibility determination or for purposes directly connected to the administration of the Medicaid State Plan.

If the applicant cannot furnish all of the required verifications at the time of application, send a missing information request that contains a list of the items or actions needed, with the deadline for submission specified. Allow at least ten (10) calendar days for an applicant/beneficiary to provide the requested verifications for applications and changes.

Allow at least thirty (30) calendar days for a beneficiary to provide the requested verifications for a renewal and change.

H-3909 Notice of Decision

LaHIPP Eligibility Advisors will issue a decision notice.

H-3910 Fair Hearing

Refer to T-100 GENERAL INFORMATION

(i-100)Louisiana Medicaid Eligibility Manual (LDH): I - 100 Age - MAGI Related#

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Page 1 of I-100 Replacing November 6, 2023 Revised/added text indicated by underscore

Deleted text indicated by “**” I-100 AGE - MAGI RELATED I-110 REQUIREMENT

Parents and Caretaker Relatives, Transitional Medicaid, and MAGI-Based Medically Needy Program (MNP)

In order to be considered in the Parents and Caretaker Relatives Group (PCR) and Transitional Medicaid, the parents or caretaker relatives must be living with and assuming primary responsibility for the care of a dependent child who is under age 18. If the child is age 18 and a full-time student, continue Medicaid through the month the child completes their course of study if both the following conditions are met:

• The child is a full time student in high school or in vocational or technical training at a level equivalent to high school, and • The child is expected to complete the course of study before or during the month of their 19th birthday.

Refer to I-140 School Attendance.

Children Under Age 19 Group A child must be under age 19 to be considered in CHAMP, LaCHIP, and LaCHIP Affordable Plan.

I-120 VERIFICATION Self-attestation of Age shall be accepted unless a discrepancy is found through available electronic data sources used by Agency. Refer to MEM S-0000 Verification and Documentation.

If any discrepancies are found for the age of a child, give the individual reasonable opportunity to provide documentary evidence such as an official birth record, hospital birth record, or baptismal certificate from a church with valid records.

If the applicant/beneficiary is unable to obtain the above documents the following, which include the child’s name and birthday, may be used: • Medical records other than the hospital birth record, • Licensed midwife records, • Immunization or other Health Unit records,

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Page 2 of I-100 Replacing November 6, 2023 Revised/added text indicated by underscore

Deleted text indicated by “**” • School records, • Adoption records, • Indian census records, • Insurance policies over three (3) years old, • Church records, • Family Bible records, • U.S. Census records, • Passports, • Naturalization papers, • United States Immigration and Naturalization Service (INS) documentation, or • Information provided in correspondence from a national VOLAG (Voluntary Resettlement Agency).

I-130 DOCUMENTATION Document and file a copy of the verification of age of each beneficiary.

I-140 SCHOOL ATTENDANCE School attendance is applicable only in Parents and Caretaker Relatives Group, Transitional Medicaid, and MAGI–Based MNP.

A parent or caretaker relative may be eligible for Medicaid if the child is: • Age 18, • Living in the same home under their care, and; • Attending a secondary, vocational or technical school full-time and is expected to graduate or complete the course of study before or during the month of their 19th birthday.

School attendance requirements are met if: • A child is out of school because of vacation, temporary illness, or family emergency, • An incapacitated child attends fewer hours or receives instruction from a visiting teacher at home, or • A child is enrolled in a Job Corps program.

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Deleted text indicated by “**” Verify school attendance and completion date for the course of study for each child who is age 18 at application or who will be age 18 before the next renewal.

School attendance may be verified by school records, current report cards, or any other documentary evidence.

Document and file verification of school attendance.

(i-1000)Louisiana Medicaid Eligibility Manual (LDH): I - 1000 Medical Certification#

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I-1000 MEDICAL CERTIFICATION

I-1010 REQUIREMENT

I-1010.1 Long-term Care and Home and Community Based Services Only

An individual must meet Long-term Care (LTC) medical certification criteria to be eligible for nursing facility (NF) or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) vendor payment or Home and Community Based Services (HCBS). To meet this criteria the individual must meet the level of care for institutionalization in a nursing facility or ICF/IID.

The level of care determination is made by the Office of Aging and Adult Services (OAAS), the Office for Citizens with Developmental Disabilities (OCDD) or the designees of each agency for the respective programs.

OAAS

• Nursing Facility Admission • Home and Community Based Waivers – Community Choices Waiver (CCW) – Adult Day Health Care (ADHC)

OCDD

• ICF/IID Admission • Home and Community Based Services – New Opportunities Waiver (NOW) – Children’s Choice Waiver (CC) – Supports Waiver (SW) – Residential Options Waiver (ROW)

The medical certification is separate from and unrelated to any determination of disability made by MEDT or SSA/SSI.

Nursing Facility Admission

Eligibility will be the later of the medical certification approval date, the date of admission, or the date that financial eligibility is established.

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For individuals seeking admission to a Medicaid-certified nursing facility, regardless of the source of payment for the nursing facility services, the medical certification shall be obtained from the Office of Aging and Adult Services (OAAS) and/or the appropriate Level II authority prior to admission.

The individual must be admitted to the facility within 30 days of the date of the medical certification. If the individual is not admitted within 30 days of the certification approval date, a new medical decision is needed. If a time limited (temporary) medical certification is issued, it is the responsibility of the nursing facility to submit a continued stay request to OAAS timely to avoid a lapse in Medicaid vendor payment.

The pre-admission process is applicable for nursing facility admission and is not applicable to ICF/IID and HCBS Waivers.

ICF/IID Admissions

Eligibility will be the later of the medical certification approval date, the date of admission, or the date that financial eligibility is established.

Home and Community Based Services

Eligibility will be the later of the medical certification approval date, or the date that financial eligibility is established.

I-1010.2 Louisiana Coordinated System of Care only

The Coordinated System of Care (CSoC) was developed for Louisiana’s children and youth with significant behavioral health challenges that are in or at risk of out of home placement. To receive services through the Louisiana Behavioral Health Partnership (LBHP) or Coordinated System of Care (CSoC), individuals must meet a level of need and in some instances a level of care for nursing facility or hospital placement.

Individual assessments are made by the CSoC Contractor’s Care Manager and submitted to the CSoC Contractor. The CSoC Contractor submits approvals for eligible individuals.

A new determination will be made every 6 months for CSoC children.

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I-1010.3 Program for All-Inclusive Care for the Elderly (PACE) only

The PACE organization provides services to frail elderly qualifying individuals who require the level of care provided in a nursing facility. PACE programs provide services primarily in an adult day health center and are supplemented by in-home and referral services in accordance with the enrollee’s needs.

The PACE provider completes an individual assessment of the enrollee for OAAS to review. OAAS determines whether the enrollee meets the level of care required to receive services through the PACE program.

Eligibility will be the first day of the calendar month following the date the signed enrollment agreement is received by the PACE organization if the individual meets Medicaid financial eligibility and medical certification approval.

I-1010.4 ACT 421 Children’s Medicaid Option (TEFRA)

The Act 421-CMO program provides healthcare services to children with complex medical needs living at home that are under the age of 19, regardless of parental income and resources.

The Office for Citizens with Developmental Disabilities (OCDD) Local Governing Entity (LGE) completes the assessment for children needing services and determines if the level of care requirement is met.

Eligibility will be the later of the medical certification approval date, or the date that financial eligibility is established.

I-1011 LEVEL TWO SCREENING FOR ADMISSION TO LTC INSTITUTIONS/FACILITIES

Level Two Screening is an additional assessment of the appropriate placement for all new admissions with a diagnosis of mental illness (MI) or intellectual disability (ID). The medical certification may be delayed pending completion of the Level Two Screening.

A Medicaid-certified nursing facility shall not admit an individual with a diagnosis of a serious MI or ID without a preadmission screening and a decision from the Level II authority.

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OCDD is responsible for the Level II screening and level of care determination for persons with intellectual disabilities (ID).

Office of Behavioral Health (OBH) is responsible for the Level II screening and level of care determination for persons with the diagnosis mental illness (MI).

I-1020 VERIFICATION

I-1020.1 LTC

The medical certification approval or denial is documented on BHSF Form 142 indicating the effective date and level of care.

The medical certification approval remains valid unless the individual:

• Does not admit to a nursing facility within 30 days of the approval date (the approval date counts as day one),

• Breaks institutional care,

• Has a temporary medical approval, or

• Changes the level of care.

I-1020.2 HCBS

The medical certification approval or denial is documented on the BHSF Form 142, which will indicate the effective date and type of waiver program. The medical certification approval remains valid unless the individual is permanently discharged from waiver.

I-1020.3 CSoC

The medical certification approval process is handled by the CSoC contractor with the CSoC Care Manager conducting the initial screening. After eligibility is established, the Contractor submits which services the child is eligible for, the date span for the waiver and the child’s living setting directly to provider enrollment to add eligibility to the enrollee’s file.

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I-1020.4 PACE

The medical certification approval or disapproval for enrollment is documented on the BHSF Form 142. Once enrolled, the medical certification remains valid unless the participant is disenrolled from the PACE program.

I-1020.5 ACT 421 Children’s Medicaid Option (TEFRA)

The medical certification for enrollment is documented on the BHSF Form 142, which will indicate the approval or disapproval of the level of care and the effective date of medical certification. After eligibility is established, OCDD LGE assesses the Act 421-CMO beneficiary annually to determine that the level of care requirement continues to be met. **

I-1030 DOCUMENTATION

A copy of the Medical Certification Form 142 is filed in the Enterprise Document Management System (EDMS).

(i-1400)Louisiana Medicaid Eligibility Manual (LDH): I - 1400 Need - General Information#

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Eligibility Factors Issued March 31, 2026

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An applicant/beneficiary shall be considered in need if their income and resources meet certain program standards.

All of the current and available income and resources of the applicant/beneficiary are considered in determining need for non- Modified Adjusted Gross Income (MAGI)-related (formerly D-related) programs.

I-1411 RESERVED

I-1415 PROHIBITED SSI PROVISIONS

If an agency provides Medicaid to aged, blind or disabled individuals receiving Supplemental Security Income (SSI), it must provide Medicaid to individuals who would be eligible for SSI, except for an eligibility requirement in SSI that is specifically prohibited under Medicaid.

Apply prohibited SSI provisions (PSP) at the conclusion of the SSI-related Medicaid eligibility determination if any of the following factors cause ineligibility. The individual must meet all other SSI eligibility factors, except for the prohibited eligibility requirement.

Deeming of Income and Resources

Medicaid regulations prohibit counting certain income and resources available in determining Medicaid eligibility for the following individuals:

Do not consider the income and resources of a step-parent or grandparent as available to a child.

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Deleted text indicated by “” I-1416 OTHER PROHIBITED PROVISIONS I-1416.1 Treatment of payments made under the Susan Walker v. Bayer Corporation et al. settlement and the Ricky Ray Hemophilia Relief Fund Act of 1998 (Referred to collectively as Blood Products Litigation, or BPL)

Section 4735 of the Balanced Budget Act of 1997 (Public Law 105-33) and the Ricky Ray Act of 1998 (Public Law 105-369) provided for the continuation of Medicaid eligibility for individuals receiving payments under the Susan Walker v. Bayer Corporation et al. settlement or the Ricky Ray Act relief fund.

Payments made to individuals under the settlement or relief fund are not counted as income or resources in determining either eligibility for, or the amount of, benefits under the Medicaid Program, notwithstanding any other provisions of law.

Important: Income derived from these settlement payments is not exempt.

If any payments are placed in interest-bearing accounts or some other investment medium, the income generated will be counted as unearned income.

If the payments are used to purchase an item that would not normally be excluded as a resource, the value of that item may be counted as a resource in determining eligibility.

Do not assess a transfer of resources penalty if the individual transfers the settlement or relief funds for less than fair market value. Do not count settlement or relief funds placed in a trust.

I-1420 NEED - DEEMING

Deeming is the process of considering income and resources of another individual or individuals to be available for meeting an applicant/beneficiary’s basic needs of food, clothing, and shelter whether or not the income and resources are actually made available.

Deeming of income and resources is appropriate in the following non-MAGI-related programs: • Qualified Medicare Beneficiary (QMB);

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Deleted text indicated by “” • Specified Low-Income Medicare Beneficiary (SLMB); • Qualified Disabled and Working Individuals (QDWI); and • SSI-related cases. Deem income for these individuals: • Ineligible spouse-to-eligible spouse, when living together in a legal or non-legal union (e.g.: Holding out); • Ineligible parents-to-eligible child, when living in the same household; and Note: Deem income from natural and/or legal parents in the home only. Do not deem step-parent income to a child. • Non-citizen sponsor-to-non-citizen, whether or not living in the same household.

It is not equitable to deem the entire amount of income and resources from the ineligible spouse, parent or non-citizen sponsor to the Medicaid applicant/beneficiary. The ineligible person is allowed to allocate income and resources to meet their own needs and those of ineligible children, as well as legal tax dependents of non-citizen sponsors, prior to deeming.

When deeming income from an ineligible parent or non-citizen sponsor, count deemed income as unearned income.

When deeming income from an ineligible spouse, the remaining income of the ineligible spouse, after allocation for ineligible children, is combined with the income of the eligible spouse. The couple is then treated the same as an eligible couple for budgeting purposes. I-1421 DEFINITIONS FOR DEEMING PURPOSES Non-citizen Sponsor A person or agency who signed an affidavit or statement agreeing to support a non-citizen as a condition of the non-citizen's entry into the U.S. as a permanent resident.

Allocation A deduction from income, which is subject to deeming, that is set aside

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Child An individual who is neither married nor the head of a household and: • Under age 18; or • A student under age 22. An eligible child is: • Related by blood or legal adoption to a parent in the household; • Under age 18; and • Blind or disabled, as defined by the Social Security Administration (SSA). An ineligible child is: • Related by blood or legal adoption to a parent in the household; and  Under age 18; or  A student under age 21; and • Is not blind or disabled as defined by SSA.

Holding Out Two individuals who presenting themselves as a married couple to the community are considered married for Supplemental Security Income (SSI) related programs.

Household Two or more persons living in common quarters and sharing facilities under such domestic arrangements and circumstances as to create a single family unit. A household does not exist if a person or group or persons does not have a residence.

When an applicant is age 18 or over and does not meet the deeming definition of a child, the household is comprised of: • The applicant/beneficiary; • His spouse; and

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Deleted text indicated by “” • Any children of the couple.

When an applicant is under age 18, the household is comprised of: • The applicant/beneficiary; • The parents; and • Any other children of the parents. An individual remains a household member when he is temporarily away from home for reasons of: • Employment; • Hospitalization; or • School or vocational training. Note: These individuals remain household members if the intent is to return to the home. This intent may be evidenced by visits home on occasional weekends, holidays, or summer vacations.

An individual is not considered a member of the household when they are away from home for a prolonged period for reasons of: • Military service; or • Long-term medical treatment and/or rehabilitation; or Note: If the individual leaves the household for medical treatment and returns in the same month or the following month, the absence is temporary and deeming continues to apply.

• Hospitalization of premature or ill newborns which is expected to last more than thirty (30) days.

Parent An individual living in the same household as the eligible child and who is the: • Natural, adoptive or legal parent; or • The spouse of the natural, adoptive or legal parent.

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Deleted text indicated by “” Spouse The legal or non-legal husband or wife of: • An eligible individual; or • The parent of an eligible child. An eligible spouse is a spouse who is aged, blind or disabled. An ineligible spouse is a spouse who is not aged, blind or disabled.

I-1422 WHEN DEEMING IS NOT APPLICABLE

In the non-MAGI-related eligibility groups, deeming does not apply in situations where a family does not have a residence. For example, if a family lives in a car because they cannot afford shelter, neither spouse-to-spouse nor parent-to-child deeming would apply.

Deeming of income or resources is not applicable: • From a child to a parent or siblings; • To newborns that have never been discharged from the hospital and are expected to remain in the hospital for more than thirty (30) days; • To children that receive long-term care (LTC) or home and community-based services (HCBS) after the first calendar month of admission; • To children that are discharged from a facility to his home to receive HCBS in the month of admission; • To children with severe emotional disturbance that receive services in the Coordinated System of Care-Severely Emotionally Disturbed (CSoC-SED) waiver; and • From sponsor to non-citizen when: o The disability or illness of the non-citizen begins after the date of entry into the U.S.; o The non-citizen is residing in the U.S. under the Permanent Residence Under Color of Law (PRUCOL) legal category; o The sponsor is an organization; or o The non-citizen's sponsor is also the non-citizen's spouse and is eligible for SSI.

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Eligibility Factors Issued March 31, 2026

Page 7 of I-1400 Replacing October 16, 2025 Revised/added text indicated by underscore

Deleted text indicated by “” • Domestic partners who are not holding out.

Do not deem resources to ineligible children.

Do not deem income to or from a spouse when one or both live in LTC facilities or receive HCBS. Refer to I-1660 Spousal Impoverishment Resource Provisions (LTC/HCBS).

Do not deem income or resources when both members of a couple are categorically eligible and are applying for assistance. In these cases: • Combine their income; • Do not include an allowance for ineligible children; • Apply the appropriate income exclusions to the combined income; Note: Allow only a single: • Standard deduction; • $65 deduction; and • One-half disregard to the combined incomes. • Use the appropriate income limit for two (2) persons for each case; • If MNP, combine their medical bills; and • Combine their resources and compare to the appropriate resource limit for two (2) persons. I-1423 DEEMING OF RESOURCES Deeming of resources is applicable from the: • Ineligible spouse to the applicant; • Ineligible parents (or parent's spouse) to the child; • Sponsor (or sponsor's spouse) to the non-citizen. Deeming is applicable beginning with the month that U.S. Citizenship and Immigration Services (USCIS) grants permanent resident status to the non-citizen, up to three (3) years.

Combine the resources of an applicant and the spouse living in the

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Louisiana Medicaid Eligibility Manual

Eligibility Factors Issued March 31, 2026

Page 8 of I-1400 Replacing October 16, 2025 Revised/added text indicated by underscore

Deleted text indicated by “” home. Compare the countable value to the appropriate resource limit for two (2) persons.

I-1423.1 Resources Excluded from Deeming

Resources which would be excluded for an applicant are excluded from deeming if they are owned by: • A parent, or the spouse of a parent, when deeming from parent to child; or • The non-citizen sponsor who is also the spouse or parent of the non-citizen. A pension fund is not counted as a resource in the deeming process if it is owned by: • An ineligible spouse; • An ineligible parent; or • The spouse of an ineligible parent.

Note: Amounts distributed from a pension fund are considered income. Refer to I-1424 Deeming of Income.

I-1423.2 Parent-to-Child Resource Deeming Procedure

Total the non-excluded resources of the ineligible parents.

Deduct the resource limit for: • One (1), if one parent is in the home; or • Two (2), if both parents are in the home.

The remaining resources are deemed to the potentially eligible child. If more than one child is applying, divide the deemed resources equally among the potentially eligible children.

Add the deemed resources to the child's countable resources.

I-1423.3 Sponsor-to-Non-citizen Resource Deeming Procedure

Consider the non-excluded resources of the sponsor and the sponsor's

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Eligibility Factors Issued March 31, 2026

Page 9 of I-1400 Replacing October 16, 2025 Revised/added text indicated by underscore

Deleted text indicated by “” spouse, whether or not living in the home with the non-citizen.

Compare the value of the resources belonging to the sponsor (or sponsor and spouse) to the SSI resource limit for one (or a couple). Any amount over the resource limit is deemed to the non-citizen.

If the sponsor lives with a spouse and the spouse is also a sponsor of the non-citizen, allow twice the SSI resource limit for one and deem any resources over this amount to the non-citizen.

Add the deemed resources to the other countable resources of the non-citizen.

I-1424 DEEMING OF INCOME When determining eligibility for non-MAGI-related groups, deeming of income is applicable to an: • Eligible individual residing in the same household with an ineligible spouse; • Eligible child residing in the same household with the parents or a parent and the spouse of a parent; Exception: If the natural or adoptive parent is deceased/divorced and the eligible child lives with a stepparent only, the stepparent's income is no longer deemed to the eligible child. • Non-citizen, whether or not living in the same household with the sponsor. Deeming is applicable beginning with the month that USCIS grants permanent resident status to the non-citizen, up to three (3) years.

I-1424.1 Income Not Included in Deeming

Do not deem the following income from an ineligible spouse or ineligible parent: • Income excluded by federal law from consideration in SSI-related cases (Refer to I-1534 Types of Income (SSI- Related)); • Income based on need which is furnished by any local, state or federal agency , and any income which was taken into account in determining eligibility and which affected the amount of such

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Eligibility Factors Issued March 31, 2026

Page 10 of I-1400 Replacing October 16, 2025 Revised/added text indicated by underscore

Deleted text indicated by “” assistance or payment; Examples: • SSI; • Family Independence Temporary Assistance Program (FITAP) cash assistance; • Veteran’s Administration (VA) pensions; or • In-kind support and maintenance. • Grants, scholarships or fellowships for tuition and fees or other expenses necessary to the securing of an education at educational or vocational institutions; • Tax refunds; • Income paid by a household member to comply with court-ordered support payments or payments enforced under Title IV-D; • Foster care payments received for providing care to an ineligible child; • Up to the maximum allowable limit per-month total earned income of a child who is a student. When the child makes the income available to the household, the excluded income cannot exceed the per-calendar-year limit. Refer to Z-100 Maximum SSI Student Child Earned Income Exclusion Amounts for limits; • Disaster assistance; • Work expenses of the blind; and • Income necessary and used for an SSA-approved plan for achieving self-support.

All income from a non-citizen sponsor is countable, except: • Housing assistance, when the non-citizen is living in the house for which the sponsor receives housing assistance; • Disaster assistance; and • Energy assistance

I-1424.2 Income Deeming Procedures

Refer to Z-1500 Deeming Allowance.

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Deleted text indicated by “” Spouse-to-Spouse Deeming

Step 1. Determine eligibility of the applicant/beneficiary based on their own income before determining whether deeming is applicable.

For deeming to apply in programs other than the Spend-Down Medically Needy Program (SD-MNP), the applicant/beneficiary must be eligible based on their own income. • Subtract the $20 disregard from unearned income, if applicable. • Subtract any remainder of the $20 disregard, and $65 and one-half of the remainder from gross earned income. • Compare the countable income to the appropriate current individual income limit. • For programs which use the Federal Poverty Income Guidelines (FPIG), compare to FPIG, not the Federal Benefit Rate (FBR). If the income is equal to or greater than the individual income limit, the applicant/beneficiary is ineligible. Consider eligibility in SD- MNP.

If the income is less than the individual income limit or if considering eligibility in SD-MNP, determine whether there is income to deem from the ineligible spouse.

Step 2. Determine whether any of the income of the ineligible spouse can be allocated to ineligible children. Do not include any child who receives FITAP or SSI. To calculate the unmet living allowance for each ineligible child, follow these steps: • The allocation for each ineligible child is the FBR for an eligible couple minus the FBR for an eligible individual. • Subtract the ineligible child's own income from the initial allocation. • The remaining amount is the child’s unmet living allowance. If there is no remainder, the child’s needs are met and no income is allocated to them.

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Page 12 of I-1400 Replacing October 16, 2025 Revised/added text indicated by underscore

Deleted text indicated by “” The sum of the unmet living allowances for all ineligible children is the total unmet living allowance to be used in Step 3. Step 3. These are the three (3) sub-steps necessary to determine whether the ineligible spouse's remaining income exceeds the individual living allowance (the difference in FBR for an individual and FBR for a couple): • Calculate the ineligible spouse's earned and unearned income, applying only the appropriate exclusions listed in MEM I-1424.1 Income Not Included in Deeming. Do not subtract the $20 or $65 plus one-half deductions. • Subtract any unmet living allowance, for the children, from the ineligible spouse's unearned income. If the ineligible spouse has insufficient unearned income to cover the allocations, the balance is deducted from the ineligible spouse's earned income. • Compare the remaining income of the ineligible spouse to the living allowance (the difference in FBR for an individual and FBR for a couple). See Z-1500 Deeming Allowance.

If the remaining income is equal to or less than the living allowance (the difference in FBR for an individual and FBR for a couple), there is no income to deem to the applicant/beneficiary. Compare the income of the applicant/beneficiary to the individual income standard for the appropriate program.

If the remaining income is greater than the living allowance (the difference in the individual FBR and couple FBR), deeming is applicable. The applicant/beneficiary and ineligible spouse are treated as an eligible couple for budgeting purposes. • Add the remaining unearned income of the ineligible spouse to all of the unearned income of the eligible individual. Add the remaining earned income of the ineligible spouse to the earned income the eligible individual. • Subtract one $20 disregard from the total unearned income determined in Step 6. If there is earned income, subtract any remainder of the $20 disregard, and $65 and one-half of the remainder from the total earned income determined in Step 6.

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Page 13 of I-1400 Replacing October 16, 2025 Revised/added text indicated by underscore

Deleted text indicated by “” • Add the remaining earned and unearned income together to determine total countable income. Compare countable income to the couple income standard for the appropriate program.

Parent-to-Child Deeming

Step 1. Calculate the earned and unearned income of the parents of the applicant/beneficiary, allowing only the appropriate exclusions listed in I-1424.1 Income Not Included in Deeming. Do not subtract the $20 or $65 plus one-half deduction. Step 2. Determine the amount that can be allocated to ineligible children: • The allocation for each ineligible child is the difference between the Federal Benefit Rate (FBR) for an eligible couple and the FBR for an eligible individual. See Z- 1500 Deeming Allowance). Do not include in the count children who receive SSI or FITAP. • Each ineligible child's allocation is reduced by the amount of their own income. • Total each child’s remaining allocation. • Total the unearned income of the parents. • Subtract any remaining ineligible child’s allocation for each ineligible child. • Total the earned income of the parents. Subtract any remaining living allowance for ineligible children. If there is no remainder, there is no income to deem.

If there is income remaining, deeming is applicable.

Step 3. Determine the amount of parental income to be deemed to eligible child. • Subtract $20 (the SSI standard deduction) from any remaining (Step 3) parental unearned income. • Subtract $65, plus any of the remainder of the SSI standard deduction, and one-half of the remainder from remaining (Step 4) earned income. • Add the remaining unearned and earned income.

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Page 14 of I-1400 Replacing October 16, 2025 Revised/added text indicated by underscore

Deleted text indicated by “” • From this total, subtract the individual FBR (for a one (1)-parent household) or the couple FBR (for a two (2)-parent household). The remaining income is deemed to be unearned income to the child. Note: If more than one child is applying, divide deemed income equally.

Sponsor-to-Non-citizen Deeming Deeming Pretest Before deeming from the sponsor, determine the eligibility of the non-citizen based on their own income.

Sponsor-to-non-citizen deeming is applicable for three years (36 months) or five years (60 months), depending on and beginning with the month that the USCIS grants the non-citizen permanent resident status. Refer to Deeming Period, below.

A non-citizen may be subject to more than one period of sponsor to non-citizen deeming if USCIS revokes their status as permanent resident and later re-admits them as a permanent resident. Refer to Multiple Deeming Periods, below.

Sponsor-to-non-citizen deeming applies whether or not the non- citizen and sponsor live together.

If the spouse of the non-citizen is their sponsor, apply spouse-to- spouse deeming rather than sponsor-to-non-citizen deeming.

Do not apply sponsor-to-non-citizen deeming when: • The disability or illness of the client begins after date of entry into the U.S.; • The non-citizen is a permanent resident under PRUCOL; • The sponsor is an organization; or, • The sponsor of the non-citizen is their spouse and the sponsor/spouse is eligible for SSI.

Deeming Period

Effective October 1, 1996, the sponsor-to-non-citizen deeming

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Page 15 of I-1400 Replacing October 16, 2025 Revised/added text indicated by underscore

Deleted text indicated by “” period became three (3) years following the date of lawful admission to the U.S., in all cases.

Multiple Deeming Periods A non-citizen may be subject to more than one (1) period of sponsor-to-non-citizen deeming.

If USCIS revokes the status of a non-citizen as a lawful permanent resident, but the non-citizen is later readmitted as a permanent resident, sponsor-to-non-citizen deeming is applicable again.

The new date of admission as a permanent resident, as assigned by USCIS, begins a new deeming period.

A Form I-551 (issued by USCIS upon the non-citizen's readmission into the U.S. and displaying a new date of admission) is sufficient documentation to establish the previous revocation of permanent resident status.

An absence from the U.S. (even one that results in the suspension of SSI eligibility and payments) does not affect the calculation of the deeming period unless USCIS revokes permanent resident status.

Deeming Procedures

Step 1. Total the gross earned and unearned income of the non- citizen. Step 2. Subtract the $20 disregard, and the $65 and one-half of the remaining earned income deduction, to determine countable income. Step 3. Compare the countable income of the non-citizen to the FBR for one (1) person.

If the countable income of the non-citizen is equal to or greater than the FBR for one (1) person, they are ineligible. Consider eligibility in SD-MNP.

If the countable income of the non-citizen is less than the FBR for one (1) person, or if considering for SD-MNP, determine whether there is income to deem from the ineligible sponsor.

Sponsor's Living Allowance

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Page 16 of I-1400 Replacing October 16, 2025 Revised/added text indicated by underscore

Deleted text indicated by “” Step 4. Total the earned and unearned income of the sponsor of the non-citizen and their spouse living in the home, if any. Step 5. Subtract from the total income: • The FBR for one (1) person, as the allowance for the sponsor; • The essential person allowance for the spouse of the sponsor if any; and • The ineligible child allowance for each legal dependent of the sponsor other than the non-citizen and spouse of the non-citizen. Note: Do not subtract the income of an ineligible child from the allowance.

If the husband and wife are both sponsors of the non-citizen, subtract the FBR for each and deduct the ineligible child allowance only once for each legal dependent.

The remaining income of the sponsor and spouse is deemed to the non-citizen. Do not count the needs of the sponsor (or spouse of the sponsor) in the Medically Needy Income Eligibility Standard (MNIES) because their needs were considered in Step 5 above of the deeming process.

I-1425 CHANGES IN DEEMING STATUS

Certain changes in the household can affect deeming status. Such changes are effective the month after the change occurs, except as noted: • Ineligible spouse becomes eligible: o Treat as an eligible couple effective the month of the change in status; • Domestic Partner’s claim they are holding out as a married couple; • Spouses separate or divorce; • Eligible individual begins living with an ineligible spouse; • Death of ineligible spouse or parent; or • Child reaches age 18 or 21.

(i-1500)Louisiana Medicaid Eligibility Manual (LDH): I - 1500 Need - Income#

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 13, 2023 Replacing April 1, 2016 Page 1 of I-1500 Revised/added text indicated by underscore Deleted text indicated by “**” I-1500 NEED ― INCOME I-1510 GENERAL INFORMATION

Count gross income in the month in which it is received, unless otherwise stated in I-1534 Types of Income (SSI -Related) and/or I- 1553 MAGI-Related Types of Income.

Exceptions: A regular periodic payment received in a month other than the month of normal receipt will be counted in the normal month of receipt unless there is an intent to interrupt the regular payment schedule. Such funds are considered resources in the month following the month of normal receipt.

Most common examples: • Advanced Dated Checks because the regular payment date falls on a weekend or holiday • An Electronic Funds Transfer (EFT) direct deposits that are posted before or after the date payable.

All reported income shall be considered in accordance with policies established in this manual.

Do not count as income the cash received from the sale of an allowable resource, as the resource is being converted from one form to another. The cash received is a countable resource.

Receipt of income is reported or discovered by:

• The applicant/beneficiary is the primary source of information and is responsible for accurate and complete reporting of the situation. Inconsistent or incomplete information from the applicant/beneficiary (regarding income, and/or expenses,) can indicate the need for documentation, and • Electronic services. **

Refer to S-0000 Verification and Documentation for further information on how the self-attested information is used with electronic services in determining eligibility.

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Reissued June 13, 2023 Replacing April 1, 2016 Page 2 of I-1500 Revised/added text indicated by underscore Deleted text indicated by “**” I-1510.1 Income Standards

Income standards are used to determine need in relation to income. The income standard used depends on the program considered. The income standards are the: • Supplemental Security Income (SSI) Federal Benefit Rate (FBR); • Federal Poverty Income Guidelines (FPIG); • Medically Needy Income Eligibility Standard (MNIES); and • Special Income Level (SIL) rate for long term care (LTC) and home and community-based services (HCBS).

The standard for the number of persons in the income unit is compared to the countable income. Refer to Z-0000 Charts.

I-1510.2 Ownership of Income

For Medicaid purposes, cash income belongs to the individual(s) for whom it is intended. If the income is received in the form of a check or money order, the income belongs to the person(s) named on the check. Exceptions: Child support and FITAP payments are income to the person(s) for whom they are intended. Retirement, Survivors and Disability Insurance (RSDI) checks may be made payable to "Jane Doe for Johnny Doe". The payment is countable income for Johnny Doe. ** To determine ownership for Veteran’s Administration (VA) income for SSI related programs, Refer to I-1534 Types of Income (SSI- Related): VA Benefits.

I-1511 VERIFICATION and DOCUMENTATION

**Verify and document the amount and receipt of income following S- 0000 Verification and Documentation policy.

I-1512 ** RESERVED

(i-1530)Louisiana Medicaid Eligibility Manual (LDH): I - 1530 Need - SSI-Related Income#

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Page 1 of I-1530 Replacing February 17, 2025

Deleted text indicated by “” Revised/added text indicated by underscore

I-1530 NEED – SSI-RELATED INCOME

I-1531 INCOME UNIT

The income unit is the individual or group of individuals whose income must be considered in determining eligibility.

The income unit must include the:

• Applicant/beneficiary,

• Spouse living in the home, except in LTC and HCBS programs, and

• Parent(s) living in the home, when the applicant is a minor.

Exception: If a child is an intellectually or developmentally disabled applicant coming from a non-institutionalized setting, include the parent(s) living in the home in the income unit the first calendar month of Medicaid approved participation only. Refer to H-900 Home and Community Based Services.

If the applicant lives with a spouse who is an SSI beneficiary, include the SSI beneficiary in the income unit but do not count the beneficiary's SSI income.

I-1532 POTENTIAL INCOME (Applying for Other Benefits)

If the applicant/beneficiary is eligible for other benefits, s/he must apply for and accept those benefits.

Count as though received any benefits for which the applicant/beneficiary may be entitled but refuses to apply for or receive, except when the individual presents evidence of good cause.

Consider each request for a good cause exception. Good cause is present when:

• The applicant/beneficiary is mentally or physically incapable of filing for benefits and does not have an authorized representative to act on their behalf,

• Death or serious illness in the applicant/beneficiary’s family,

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Deleted text indicated by “” Revised/added text indicated by underscore

• Transportation problems,

• The applicant/beneficiary had previously filed and was denied benefits for reasons that have not changed, or

• There is a delay in payment for reasons, which are beyond the applicant/beneficiary’s control.

If the applicant/beneficiary is eligible for a benefit but chooses not to receive the benefit:

• Verify the amount of the benefit available, and

• Budget that amount as though actually received when determining eligibility and, if LTC, patient liability.

Exception: If an individual has a life insurance policy which allows him/her to receive their death benefit while living, and the individual meets the insurance company's requirements for receiving such proceeds, s/he is not required to file for such proceeds.

If unable to determine the amount of benefits available because of the applicant/beneficiary inability or refusal to cooperate, refer to G-1100 Cooperation.

Referrals

Refer applicants/beneficiaries for the following benefits and follow up after referral as appropriate:

• Retirement Survival Disability Income (RSDI)

Refer applicants/beneficiaries who are potentially eligible to SSA.

• Veterans Administration (VA) Aid and Attendance Benefits

Refer all veterans, veterans' widows, and eligible parents of veterans to the Parish Office of Veterans Affairs for possible benefits when HCBS services begin or upon entry into an LTC facility.

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• VA Pension Assistance

Refer veterans potentially eligible for a pension to the Parish Office of Veterans Affairs. The VA Office will also explore eligibility for improved VA pension assistance.

Note: SSI is not considered potential income. An applicant/beneficiary is not required to apply for SSI benefits.

I-1533 RESERVED

I-1534 TYPES OF INCOME (SSI-Related)

Begin with gross income when determining eligibility.

Income exclusions are listed when exclusion is allowable for that type of income. The programs for which the exclusion is allowed are also noted. If no exclusion is listed, none shall be given.

For LTC cases, all income counted is used in determining eligibility and patient liability unless otherwise indicated.

ADOPTION SUBSIDY

State General Funds

Do not count as income to the child.

State-funded subsidies are counted as unearned income to the adoptive parent(s).

Title IV-E

Do not count as income to the adoptive parent(s).

Count as unearned income to the adopted child.

Note: Adoption subsidy payments made to the adoptive parents are based on the social, emotional, and medical needs of the child, and are not based on the financial need of adopting parents.

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AGENT ORANGE SETTLEMENT PAYMENTS

Do not count any payments made from the Agent Orange Settlement Fund or any other fund established as a result of a settlement in the Agent Orange Product Liability Litigation.

Do not count any interest earned on these payments as income in the month of receipt, but as a resource the following month.

AGRICULTURE AND STABILIZATION/CONSERVATION PAYMENTS

Count as unearned income.

NON-CITIZEN SPONSOR'S INCOME

Count income deemed from the Non-citizen Sponsor as unearned income. Refer to I-1424.2 Sponsor to Non-Citizen Deeming.

Consider the income of the sponsor and of their legal or non-legal spouse living with them.

Sponsor to Non-citizen deeming is applicable for three years, beginning with the month that the Bureau of Citizenship and Immigration Services (BCIS) grants permanent resident status.

Do not apply sponsor-to- Non-citizen deeming in the following situations:

• The applicant/beneficiary becomes ill or disabled after the date of entry into the United States. This situation applies to an applicant/beneficiary in the A category, as well as in D category and B category.

• The Non-citizen is a permanent resident under color of law.

• The sponsor is an organization.

• The Non-citizen's sponsor is his/her spouse and the sponsor/spouse is eligible for SSI. Treat as an eligible couple.

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ALIMONY

Count any court-ordered alimony received as unearned income.

Voluntary alimony or support received is considered a contribution.

ANNUITY

Count as unearned income.

ASSISTANCE BASED ON NEED

Do not count assistance based on need.

Assistance based on need is assistance:

• Provided under a program which uses income as a factor of eligibility, and

• Funded completely by a state, a political subdivision of a state, or a combination of such jurisdictions.

Note: If a program uses income to determine payment amount but not eligibility, it is not assistance based on need.

Refer to Income Based on Need.

BLACK LUNG DISEASE BENEFITS

Count as unearned income.

CAPITAL GAINS DISTRIBUTIONS

Count as unearned income.

CASH AND IN-KIND REPLACEMENT ITEMS

Do not count cash and in-kind items that are received from any sources for the replacement or repair of lost, damaged, or stolen

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excluded resources.

Note: Do not count the interest earned on this cash during the period it is excluded as a resource. Refer to I-1630, Need – SSI-Related Resources.

CENSUS BUREAU EARNINGS

Do not count earnings from the temporary employment of individuals by the Census Bureau in conducting Census activities.

CHILD CARE FOOD PROGRAM PAYMENTS

Count as earned income from self-employment payments received for providing meals to children in day care.

The costs of purchasing, preparing, and serving the meals are considered deductible business expenses.

CHILD SUPPORT

Count as unearned income to the child any court-ordered or voluntary child support.

Exclude one third of court-ordered child support payments in a child’s SSI-related MNP case.

Note: When deeming income, the one-third child support disregard is not applicable when calculating income of an ineligible child.

In LTC, do not exclude the one-third child support disregard in eligibility determination or PLI determination.

COMMISSIONS

Refer to Wages, Salaries and Commissions.

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COMMUNITY SPOUSE'S ALLOCATED INCOME

Count as unearned income to the community spouse any income allocated from an institutionalized spouse, in addition to their own earned and unearned income.

CONTRACTUAL INCOME

Count as earned income in the month of receipt money received under an implied, oral, or written contract for services or goods.

CONTRIBUTIONS

Count as unearned income.

A contribution may be:

• In cash, or

• In-kind for the purpose of meeting basic needs.

CONTRIBUTIONS FROM TAX-EXEMPT ORGANIZATIONS

Do not count the following gifts, made on or after October 28, 1996, from tax-exempt organizations, such as the Make-A-Wish Foundation, to children under age 18 who have a life-threatening condition.

• Any in-kind gift, not converted to cash; and

• A cash gift to the extent that the total cash excluded under this provision does not exceed $2,000 in any calendar year. Cash in excess of $2,000 received in a calendar year is subject to regular income counting rules.

If an in-kind gift is converted to cash, the cash is counted as income in the month converted.

Count interest paid on unspent portion as unearned income in the month of receipt and as a resource the following month.

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DEATH BENEFITS

Count as unearned income that portion of the benefit that exceeds expenses.

A death benefit is a benefit other than life insurance received as the result of another individual's death.

Examples of death benefits include:

• Death benefits from labor unions,

• Death benefits from SSA or Railroad Retirement paid to the:

– legal or non-legal spouse who was living with the individual, or

– the spouse or child receiving RSDI or Railroad Retirement benefits from the individual's record.

• Veterans Administration burial benefits, and

• Cash given by relatives, friends, or a community group (e.g., benevolent society) to assist with expenses related to the death.

Exclude that portion of death benefits which is used to pay expenses for the deceased person's last illness and burial.

Note: Recurring survivor benefits (e.g., those received under RSDI or private pension programs) are not death benefits. Therefore, expenses of last illness and burial cannot be deducted from these benefits.

Last illness and burial expenses include:

• Related hospital and medical expenses,

• Funeral, burial plot, and interment expenses, and

• Other related expenses.

Verify all last illness and burial expenses. If an expense has been incurred but not paid, assume that the applicant/beneficiary will pay the

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expense from the death benefits.

Note: Count as a resource any part of the death benefit that the applicant/beneficiary has not spent by the first day of the second month after the month of receipt.

Verify the amount of death benefits received by a statement from the payor of the benefit.

Accept the applicant/beneficiary's statement as to the amount of cash given by relatives, friends, or community groups.

DISABILITY PAYMENTS

Count as unearned income.

Exception: Do not count credit disability insurance payments made directly to a loan or mortgage company.

Refer to Sick Pay.

DISASTER ASSISTANCE

Do not count federal assistance received as a result of a federally declared natural disaster.

Exclude as income and resources interest paid on unspent portion.

Assistance from ‘The Road Home Program’ is considered disaster assistance, as it is 100% federally funded and a result of a presidentially declared disaster.

Many types of Pandemic-related assistance under the Coronavirus Aid, Relief, and Economic Security Act (CARES ACT), the Consolidated Appropriations Act (CAA), and the American Rescue Plan Act (ARPA) are considered disaster assistance and will be permanently disregarded for SSI-related income and resources for all individuals involved in computation of benefits. The Pandemic-related assistance meeting criteria for disaster assistance exclusions are:

• Economic Impact Payments

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• All Unemployment Benefits (regular and pandemic) during the pandemic period,

• Paycheck Protection Program

• Economic Injury Disaster Loan Program

• Tribal Payments from the Coronavirus State and Local Fiscal Recovery fund

• State Stimulus Payments

• Covid-19 Funeral Assistance

• Emergency Rental Assistance

• Emergency Assistance for Rural Housing Assistance

• Homeowner Assistance Fund

• Housing Assistance and Supportive Services Programs for Native Americans

• Higher Education Emergency Relief Fund

• Supporting Foster Youth and Families during the Pandemic

• COVID-19 Veteran Rapid Restraining Assistance Program

• Emergency Assistance to Children and Families through the Pandemic Emergency Assistance Fund

• Coronavirus Food Assistance Program-Direct Payments to Farmers and Ranchers

• Farm Loan Assistance for Socially Disadvantaged Farmers and Ranchers

• USDA Assistance and Support for Socially Disadvantaged Farmers, Ranchers, Forest Land Owners and Operators, and Groups.

• Chicago Resilient Communities Cash Assistance Pilot

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DIVIDENDS

Do not count as income in the month of receipt. Count as a resource the month following the month of receipt. This applies to all dividends.

Note: Dividends paid on a life insurance policy that are left in the custody of the insurer to accumulate interest are considered a resource.

Do not count interest paid on dividends as income in the month of receipt, but as a resource the following month.

DOMESTIC VOLUNTEER SERVICE ACT

Do not count.

Examples of these types of payments are reimbursements to individual volunteers serving:

• As foster grandparents,

• As senior health aides,

• As senior health companions,

• In SCORE, ACE, VISTA, or

• In any other program under Titles I, II, and III of P.L.93-113.

DONATIONS OR GIFTS

Count as unearned income to the individual a donation of cash or real property.

To be a donation, an item must:

• Be given irrevocably,

• Not be compensation or return for services, and

• Be given without legal obligation on the part of the donor.

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A donation may be:

• In cash, or

• In-kind for the purpose of meeting basic needs.

A donation or gift received as the result of a death is considered a death benefit. Refer to Death Benefits.

EARNED INCOME CREDITS (EIC)

Do not count EIC tax payments received either as advances or as refunds.

Count interest paid on unspent portion as unearned income in the month of receipt and as a resource the following month.

ECONOMIC IMPACT PAYMENT

Refer to Disaster Assistance.

EDUCATIONAL ASSISTANCE (GRANTS, SCHOLARSHIPS, FELLOWSHIPS, GIFTS)

Effective June 1, 2004, any portion of a grant, scholarship, fellowship, or gift used for paying tuition, fees, or other necessary educational expenses at any educational institution, including vocational or technical, is excluded from income. Any portion of such assistance not used to pay for education but will be used for an educational expense at a future date is excluded from income in the month of receipt. This exclusion does not apply to any portion set aside or actually used for food, clothing, or shelter. See Z-100 Maximum SSI Student Child Earned Income Exclusion Amounts.

Educational expenses include laboratory fees, student activity fees, transportation, stationery supplies, books, technology fees, and impairment-related expenses necessary to attend school or perform schoolwork.

Any portion of assistance not used or not set aside for paying tuition, fees, or other necessary educational expenses is income in the month received and a resource the month after the month of receipt. See

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I-1634 Earned Income Tax Credits (EITC) and Child Tax Credits (CTC) for treatment as a resource.

If a portion of the funds that have been set aside to pay for future expenses is used for some other purpose, the funds are income at the earliest of the following points: in the month that it is spent, or the month the individual no longer intends to use the funds for education.

Exception: Do not count any student financial assistance provided under Title IV of the Higher Education Act of 1965 or Bureau of Indian Affairs regardless of use. There is no time limit on the exclusion.

Do not count as income any interest or dividends paid on unspent educational assistance. However, any interest or dividends paid on unspent funds not intended to be used for education is counted as unearned income in month of receipt.

ENERGY ASSISTANCE

Do not count utility supplement payments made from Department of Housing and Urban Development (HUD), local housing authorities, or governmental housing programs, whether they are in the form of cash, in kind, or vendor payment.

Count as unearned income any other payments made directly to the beneficiary.

FELLOWSHIPS

Refer to Educational Assistance.

FOSTER CARE PAYMENTS

Count the part of the payment provided to meet the needs of the foster child as unearned income to the foster child.

Do not allow the $20 disregard because foster care payments are based on the need of the child.

Count any part of the payment meant for the foster care provider's own personal use (such as service or incentive pay) as unearned income to

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the foster care provider.

Note: Contact the payor of the benefit to obtain the breakdown of the payment into the child's portion and the provider's portion.

GRANTS

Refer to Educational Assistance.

HOME PRODUCE FOR PERSONAL CONSUMPTION

Do not count.

HOUSING ASSISTANCE PAYMENTS

If the applicant/beneficiary is the renter, do not count:

• HUD Community Development Block Grant Funds,

• HUD payments or subsidies, or

• Government housing subsidies.

Count as unearned income housing assistance payments to the applicant/beneficiary if s/he is the property owner.

INCOME BASED ON NEED

Count income based on need as unearned income unless it is totally excluded by statute. Do not apply the $20 general income exclusion.

Income based on need is assistance:

• Provided under a program which uses income as a factor of eligibility, and

Funded completely or partially by the federal government or by a non-government agency for the purpose of meeting basic needs. Refer to Assistance Based on Need.

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INCOME TAX REFUNDS AND CREDITS

Do not count Federal or State tax refunds or advance tax credits as income.

Note: All Federal tax refunds and advance tax credits are excluded from being counted toward resources for 12 months after receipt.

INDEMNITY MEDICAL INSURANCE BENEFITS (INCOME REPLACEMENT POLICIES)

Count benefit payments from these policies as unearned income.

Types of policies:

• Cash replacement policies, and

• Indemnity insurance policies.

These policies:

• May pay to the insured specified benefits for each day of confinement, and

• Are not a medical insurance (third party liability resource).

INDIAN FISHING RIGHTS INCOME

Income derived by a member of an Indian tribe from the exercise of recognized fishing rights (i.e., secured as of March 17, 1988, by a treaty, Executive Order, or an Act of Congress) is counted as unearned income in the month of receipt.

INDIAN RELATED PAYMENTS

Count per capita distribution of gaming operations/casino revenue as unearned income.

To determine whether certain Indian related payments are excludable, the applicant shall provide documentation of the purpose of the

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payment, including reference to the applicable federal statute that provides for the payment or the alleged SSI income/resource exclusion.

INDIVIDUAL AND FAMILY GRANT ASSISTANCE

Do not count.

INHERITANCE

Inheritance is cash, a right, or a non-cash item(s) received as the result of someone's death.

Consider an inheritance as income in the month received. Receipt is deemed to be the day of death in the case of a direct descendant, or when there is an uncontested will designating the individual as the beneficiary.

Refer to Death Benefit.

IN-KIND INCOME

In-kind income is third party noncash payments that are not a basic need (food and/or shelter), but can be sold or converted by an individual to meet their basic needs. See In-Kind Support and Maintenance for payments that are food or shelter.

Count payments made directly to an individual for meeting basic needs as unearned income.

Count in-kind payments made in lieu of cash wages as earned income, except when made to agricultural or domestic employees, which are not counted. Count maintenance obligation on rent-free shelter as self-employment income in-kind.

Exceptions: Do not count in-kind contributions used to supplement the personal care needs of an LTC beneficiary.

Do not count in-kind income to individuals receiving Long Term Care throughout a month:

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Example: When an individual has contracted to purchase an automobile or a home and his/her son is making the payments on their behalf, the payment is not considered in-kind income.

Refer to In-Kind Support and Maintenance when there is any question whether a third party payment is in-kind income or in-kind support and maintenance.

The value of in-kind income is determined by the fair market value at the time of receipt.

IN-KIND SUPPORT AND MAINTENANCE (ISM)

In-kind Support and Maintenance (ISM) are third party payments that result directly in an individual's fulfillment of a basic need for only shelter expenses (Rent, mortgage payments, and utility expenses).

Apply when the applicant/beneficiary lives throughout a month in another person’s household and receives shelter from others living in the same household or when someone outside the home pays for the individual’s shelter costs.

Count as unearned income up to the Presumed Maximum Value.

Exception: Do not count ISM in determining eligibility for Act-421 CMO, MNP, MPP, QMB, SLMB, QI, and TB individuals.

Presumed Maximum Value

When determining the value of in-kind support and maintenance, presume that the value is not more than an amount equal to one- third of the appropriate SSI standard payment plus $20. Refer to MEM Z-400.

The individual should be advised of their right to rebut the presumed maximum value and establish actual value. The amount of in-kind support and maintenance to be counted is the lesser of:

• The presumed maximum value, or

• The established actual value.

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INSURANCE PAYMENTS

Refer to Cash and In-Kind Replacement Items.

INTEREST

Do not count. Unless otherwise noted, interest retained after the month of receipt is a countable resource.

Exception: Count as unearned income in the month of receipt interest paid on unspent portions of the following:

• Advance Earned Income Tax Credit

• Child Tax Credits

• Earned Income Tax Credits

• Contributions from Tax-exempt Organizations

• Relocation Assistance

• Title II and Title XVI Retroactive Payments

• Victim’s Compensation

• Educational Assistance not used for education

Also, count interest:

• Paid on non-excluded burial funds,

• Paid on excluded burial funds when the interest is not left to accumulate, and

• Paid on mortgages and promissory notes

Month of Receipt

The month of receipt is the month in which the interest is:

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• Actually received,

• Credited to the applicant/beneficiary’s account and available for use, or

• Set aside for the applicant/beneficiary’s use.

IRREGULAR OR INFREQUENT INCOME

Count irregular or infrequent income in the month of receipt according to the particular type of income.

Examples of irregular or infrequent income are lease arrangements for mineral and surface rights, mineral rights, and royalties.

Irregular or Infrequent Income Exclusion

Income that is received either infrequently or irregularly may be excluded from any type case, provided the total of such income does not exceed $30 per quarter for earned income and/or $60 per quarter for unearned income.

In order for this exclusion to apply, income need only be one or the other of:

• Infrequent - income received no more than once in a calendar quarter from a single source; or

• Irregular - income not reasonably expected

Winnings from Gambling, Lottery and Other Prizes

Count as unearned income in the month of receipt.

Note: Gambling losses are not subtracted from gambling winnings when determining an applicant/beneficiary's countable income. If an individual claims gambling as a profession and files tax returns to that effect, consider as self-employment.

If an individual is offered a choice between an in-kind item and cash, the amount of cash offered is counted regardless of which one the individual chooses or the value of the in-kind item.

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JOB TRAINING PARTNERSHIP ACT (JTPA)

Count earnings from JTPA as earned income.

LEASE ARRANGEMENTS FOR MINERAL AND SURFACE RIGHTS

Count as unearned income in the month of receipt.

Lease arrangements include gas, oil, timber, gravel, and land use leases.

Note: Use net income when the difference between gross and net in oil royalties is for payment of severance tax.

LIFE INSURANCE

Count money received by the beneficiary at the death of the insured.

Exception: For spouses and parents of the deceased, the expenses of last illness and burial are deducted from the lump sum.

Do not count money received from cashing in a life insurance policy as it is considered conversion of a resource.

Count accelerated life insurance payments made for certain ill policy holders as income in the month of receipt. The receipt of accelerated payments is not treated as a conversion of a resource because the policy holder is receiving the proceeds from the policy and not the policy's cash surrender value.

Do not count as potential income if accelerated payments are available to an applicant/beneficiary and he chooses not to apply for them.

LOANS

Do not count income received as the result of valid loan agreements.

A loan is a transaction:

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• This is not an in-kind payment,

• For which a valid loan agreement exists, and

• In which:

– one party advances money or services to another party,

– the other party (borrower) at the time of the loan or the beginning of the services promises to repay the debt in full within a specified period of time which must be within his /her lifetime, and

– neither party to the agreement is a minor or has been declared legally incompetent.

A valid loan agreement can be written or oral. Oral loans that meet the above criteria are legally binding under Louisiana law.

A written loan agreement must meet the following conditions:

• The borrower's acknowledgment of an obligation to repay (with or without interest),

• A timetable for repayment, and

• A realistic plan for repayment (e.g., borrower plans to repay the loan when he receives anticipated income).

Verification of an oral agreement must include:

• Signed statements from both parties giving a description of the loan agreement. Compare the statements to see if they have agreed as to:

– the amount of the loan,

– the timetable for repayment, and

– the amount of the payments.

• The signed statement of the borrower acknowledging their current intent to comply with the loan agreement described above.

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An oral agreement cannot include a minor or a person who has been declared legally incompetent.

LONG-TERM CARE (LTC) INSURANCE POLICY PAYMENTS

Count as unearned income in month of receipt any policy benefits paid directly to the beneficiary while a beneficiary is receiving Medicaid payment of LTC services.

LUMP SUM PAYMENTS

SSI

Do not count.

RSDI

Count as unearned income in the month of receipt.

VA Aid and/Attendance

Do not count.

Exception: Count as unearned income in the month of receipt when determining:

• LTC/HCBS patient liability, and

• MNP spend-down.

Workers’ Compensation

Count as unearned income in the month of receipt less any portion of the Workers’ Compensation award or payment that the authorizing or paying agency designates for medical expenses, legal expenses, or other expenses attributable to obtaining the WC award. The expenses may be past, current, or future. The WC payments designated for such expenses may be received in a lump sum or as a continuing payment.

Note: There is no resource exclusion that applies specifically to WC payments that have been deducted from income. Resource rules apply to WC payments retained after the month of receipt.

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Other Types

Count as unearned income in the month of receipt.

Note: Refer to I-1630 Need - SSI-Related Resources, Lump Sum Payments, for lump sums retained after the month of receipt.

MIGRANT WORKER INCOME

Count as earned income.

MILITARY PAY AND ALLOWANCES

Count as earned income:

• Military pay,

• Allowances for quarters, housing, and food,

• Base pay, and

• Flight pay.

Count allotments for dependents as unearned income.

MINERAL RIGHTS

Count income from mineral rights as unearned income in the month of receipt.

Refer to I-1630 Need - SSI-Related Resources, Property.

MORTGAGES AND PROMISSORY NOTES

Count as unearned income interest payments received on mortgages and promissory notes.

The portion of the payment received which represents repayment of the principal is not counted as income. It is counted as a resource that

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is converted from one form to another. Refer to I-1630 Need – SSI- Related Resources, Mortgages and Promissory Notes.

See also Reverse Mortgages and Reverse Annuity Mortgages.

PENSIONS AND ANNUITIES

Count the total pension or annuity as unearned income in the month of receipt.

RADIATION EXPOSURE COMPENSATION PAYMENTS

Do not count payments made to persons through the Radiation Exposure Compensation Act enacted October 15, 1990, or the Radiation Exposure Compensation Amendments of 2000, which was enacted on July 10, 2000.

RAILROAD RETIREMENT BENEFITS

Count as unearned income the gross benefits amount of entitlement.

Retirement benefits are payable only to the railroad employee and the spouse of the employee, not to children. Benefits may be increased because of dependent children. The increase is income to the employee, not the child.

RECOUPMENTS

Count as unearned income any portion of a benefit that is being recouped to repay prior overpayments (e.g., RSDI, Railroad Retirement.)

REIMBURSEMENTS

Do not count.

Exception: For determining patient liability in LTC cases, count as unearned income reimbursements for previously budgeted deductions (e.g.,

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medical insurance premiums).

RELOCATION ASSISTANCE

Do not count any assistance received under Title II of the Uniform Relocation Assistance and Real Property Acquisitions Policies Act of 1970.

Do not count any funds received from May 1, 1991 through May 1, 1994 as state or local government relocation assistance.

RENTAL PROPERTY INCOME

Count as unearned income if the applicant/beneficiary does not perform any work activity related to the property such as maintenance and yard work.

Count as earned income if the owner of the income is in the business of renting property. Refer to Self-Employment. Note: In LTC cases, count rental income as unearned income.

Budget gross rental income minus allowable costs of production that are paid during the budget month. Allowable costs of production include but are not limited to:

• Property taxes,

• Insurance,

• Interest payments on mortgages,

• Incidental repairs that are minor repairs to an existing structure, such as replacing a leaky faucet,

• Maintenance, such as lawn mowing or housekeeping,

• Curator fees, and

• Management (realtor) fees.

Do not deduct capital expenditures that are expenses for an addition or increase in the value of property, which is subject to depreciation for

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income tax purposes.

Do not consider rent received or expenses paid in months prior to Medicaid eligibility.

Determine gross rent received and deductible expenses month-by-month.

Subtract deductible expenses paid in a month from gross rent received in the same month.

If deductible expenses paid in a month exceed the gross rent, subtract the excess expenses from the next month's gross rent and continue doing this as long as necessary until the end of the tax year in which the expense was paid.

Note: Do not carry excess expenses over to other tax years or use them to offset other income.

When only a portion of the property is rented, prorate the allowable costs of production for that portion which is rented.

If the applicant/beneficiary as Landlord pays for utilities, average the cost for a year and deduct the pro rata share from the monthly rent as an allowable expense.

REPARATION PAYMENTS

Do not count as income reparation payments received from the Republic of Germany, the Austrian General Social Insurance Act, the Nazi Persecution Victims Eligibility Act, or Netherlands WUV payments.

Do not count any interest earned from the unspent portion of these payments as income in the month of receipt, but as a resource the following month.

Accept the applicant/beneficiary statement of the amount and date received.

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RESTITUTION PAYMENTS

Do not count restitution payments made by the U.S. government to individual Japanese-Americans (or their survivors) or to Aleuts who were interned or relocated during World War II.

Do not count any interest earned from these payments as income in the month of receipt, but as a resource the following month.

RETIREMENT BENEFITS

Count the total gross amount of retirement benefits as unearned income.

REVERSE ANNUITY MORTGAGES

A reverse mortgage arrangement involving the purchase of an annuity is a Reverse Annuity Mortgage (RAM). Count payments from a reverse annuity mortgage as unearned income.

REVERSE MORTGAGES (AKA HOME EQUITY CONVERSION MORTGAGES)

Reverse mortgages are plans which allow homeowners to borrow, via a mortgage contract, some percentage of the appraised value of their home as long as it is occupied as their primary residence. Homeowners retain ownership of the home and receive periodic payments (or a line of credit) up to the specified amount. Reverse mortgages are due and repaid when the last surviving borrower dies, sells the home or permanently moves out.

Permanently moves out generally means the homeowner has not lived in the home for twelve consecutive months. There may be other “conditions of default” written into the agreement by the lender which also cause the loan to become due.

Do not count payments received from a Reverse Mortgage. These payments are considered loan proceeds. Unspent portions of the payments become a resource the month following receipt.

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ROYALTIES

Refer to Lease Arrangements for Mineral and Surface Rights for royalties paid to the owner of a mine, oil well, timber tract, or other resource.

Count as earned income any royalties earned in connection with the publication of a person's work and any honorarium received for services rendered.

S-CORPORATIONS

An S-Corporation is a legal small business corporation in which the shareholders may elect to be an employee of the corporation and be paid wages. They may also receive dividend payments on their investments.

Employees of an S-Corporation are not considered self-employed. Their monthly income received is budgeted as earned income. Dividends paid on capital investments are not considered earnings.

SALARIES

Refer to Wages, Salaries, and Commissions.

SCHOLARSHIPS

Refer to Educational Assistance.

SEASONAL EARNINGS

Count as earned income in the month received.

If contractual, such as a bus driver or teacher, prorate the earned income over the period it is intended to cover.

If earnings are self-employment seasonal income, refer to Self- Employment Earnings.

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SELF-EMPLOYMENT EARNINGS

Count net earnings as earned income.

To determine net earnings, first determine gross earnings.

If personal and business funds are commingled in an account, withdrawals from the account for personal use are counted as net earned income. Any income withdrawn that cannot be documented specifically for business expenses shall be considered for personal use.

Count the distributive share (whether or not distributed or received) as net earned income, if the business is a partnership.

Acceptable verification of gross earnings and deductions in order of preference are:

• Applicant's income tax return for the previous calendar year (including all schedule attachments such as Schedule C, Profit or Loss from Business, necessary to determine gross earnings and allowable business expenses),

• Business records, and

• Applicant's signed statement of income and deductions, only if no other verification is available and only for the initial eligibility determination.

Yearly income and deductions (even if seasonal) from a tax return are divided equally among the months in the tax year to determine monthly income.

When the applicant's statement is used, advise the applicant that business records for income tax purposes must be maintained and presented for future determinations (renewals or reapplications).

Deduct the following business expenses allowable by the Internal Revenue Service to obtain net earned income:

• The applicant's statement concerning the amount of the following expenses may be accepted:

– advertising,

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– car and truck expenses,

– commissions,

– freight,

– laundry and cleaning,

– office expenses,

– repairs, and

– supplies.

• The applicant's statement is not acceptable for the following expenses because these expenses can be documented by the business or institution to which it was paid:

– bad debts from sales or services,

– bank services,

– depletion,

– depreciation,

– dues and publications,

– employee benefit programs,

– insurance,

– interest on mortgages,

– legal and professional services,

– pension and profit-sharing plans,

– rent on business property,

– taxes,

– travel, meals, and entertainment,

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– utilities and telephone, and

– wages.

Exclude from income the following work expenses of the blind:

• FICA,

• Federal income taxes,

• State income taxes,

• Transportation,

• Lunches, and

• Seeing-eye dog.

Note: Persons meeting LTC medical certification requirements generally will not be able to engage in any self-employment activity. In some cases, however, employment is recommended as a therapeutic or rehabilitative measure.

SENIOR COMMUNITY SERVICE EMPLOYMENT PROGRAM (SCSEP)

A wage or salary paid under Chapter 35 of Title 42 of the U.S. Code, Programs for Older Americans, is earned income.

Anything provided under Chapter 35 of Title 42 of the U.S. Code, Program for Older Americans, other than a wage or salary is excluded from income.

SHELTERED WORKSHOP EARNINGS

Refer to Wages, Salaries, and Commissions.

SICK PAY

Sick pay is a payment made to or on behalf of an employee by an employer or a private third party for sickness or accident disability.

Sick pay is counted as either earned or unearned income, depending

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on when the pay is received and whether or not it is attributable to the employee's own contribution as follows.

Note: Sick pay paid to an LTC beneficiary can only be considered as wages if the employment is part of the approved plan of care. Refer to I-1536.

Attributable to

Employee's Own When Received Contribution? Type of Income

More than 6 months

N/A

Unearned Income after stopping work

Within 6 months after No

Wages stopping work

Yes

Unearned Income

To determine the 6-month period after stopping work:

• Begin with the first day of non-work.

• Include the remainder of the calendar month in which work stops.

• Include the next 6 full calendar months.

SOCIAL SECURITY RETIREMENT, SURVIVORS AND DISABILITY INSURANCE BENEFITS (RSDI)

Count as unearned income the gross amount of the entitlement, regardless of recoupments for a prior overpayment or deductions for Medicare Parts A or B.

Count the net amount of the benefit received plus the Medicare Part B and Part D premiums withheld when the monthly benefit payment has been reduced due to a Workers’ Compensation offset.

SPOUSAL IMPOVERISHMENT ALLOCATED INCOME

Count as unearned income to a community spouse/dependent, money allocated by an LTC/HCBS beneficiary as defined in I-1537, Spousal Impoverishment Income Provisions.

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STUDENT EARNINGS

Count as earned income for a child who is subject to the SSI Child Earned Income Exclusion:

• A student regularly attending school,

• Blind or disabled, and

• Under age 22,

Refer to Z-100 Maximum SSI Student Child Earned Income Exclusion Amounts for maximum exclusion amounts.

Apply exclusion consecutively to months in which there is earned income until yearly exclusion is exhausted.

Do not count earnings received prior to the month of eligibility toward the yearly limit.

This is in addition to the SSI Standard Deduction and Earned Income Exemption.

SUPPLEMENTAL SECURITY INCOME (SSI)

Do not count.

Patient Liability Determination

Refer to I-1538 Patient Liability (PLI)

TRUST INCOME AND TUTORSHIP FUNDS

Inaccessible Trusts

Count as unearned income trust distributions, which are or could be made to the applicant/beneficiary or on their behalf by the trustee.

Do not count as income interest or dividend payments.

Count food, clothing, or shelter received as a result of disbursements from the trust as in-kind support and maintenance and valued under

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the presumed maximum (PMV) rule as unearned income.

Do not count trust funds paid to a provider of medical services for care rendered to the individual.

Accessible Trusts

Do not count as income trust dividends or interest, which are received or are constructively received according to the terms of the trust.

Do not count withdrawals as income because the principal has been counted as a resource.

UNDIVIDED ESTATE INCOME

When property is part of an undivided estate, in which the applicant/beneficiary has an interest:

• Determine his/her share of the income from the property according to their pro rata share in the resource, and

• Apply the policy set forth in this section for the type of income.

Examine and verify the ownership of property to determine the applicant/beneficiary's share of the undivided estate and whether or not succession has been opened.

UNEMPLOYMENT COMPENSATION BENEFITS (UCB)

Count as unearned income in the month of receipt.

Note: During the pandemic period, do not count regular and Pandemic Unemployment Assistance (PUA) in the SSI income calculation. Refer to Disaster Assistance.

UNIFORM GIFTS TO MINORS AND UNIFORM TRANSFERS TO MINORS ACT (UGMA/ATMA)

UTMA and UGMA accounts are taxable investment accounts set up by a donor to benefit a minor, but controlled by an adult custodian until the minor reaches their age of majority.

Donor: Additions to the principal that occur before a transfer may be

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income to the donor. (Example: rental income received by donor then moved to the minor’s fund would be considered rental income for donor.)

Custodian: Additions to or income generated by the principal after a transfer are not income to the custodian who has no right to use the additions or income for his or her own support or maintenance.

Minor (under age 18)

• These accounts property, including additions or earnings, is not income to the minor;

• The custodian’s accounts disbursements to the minor are income to the minor in month of disbursement and a resource beginning the following month;

• The custodian’s account disbursements on behalf of the minor may be treated as ISM if used to make certain third party vendor payments for the minors support and maintenance.

Minor turns age 18:

• In the month the minor attains age 18, all the accounts property becomes available to the individual and is subject to income counting. The accounts property becomes subject to resource counting the following month.

VENDOR PAYMENTS

Vendor payments are third party payments made directly to a creditor or provider of a service.

Count vendor payments that are in-kind income or in-kind support and maintenance. Refer to In-Kind Income and In-Kind Support and Maintenance.

Do not count other vendor payments including Medicaid vendor payments made on behalf of a beneficiary to a Medicaid provider.

VETERAN'S ADMINISTRATION (VA) BENEFITS

Count VA benefits as unearned income.

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Exception: Do not count VA Aid and Attendance or housebound allowances in determining eligibility.

Count VA Aid and Attendance in determining LTC patient liability.

Exception: Do not count the protected VA Improved Pension Reduction in determining patient liability. It is protected as a part of the personal care needs allowance.

Do not allow the $20 disregard for VA pension.

Do not deem a VA pension because it is based on need or any income received which was used to determine amount of pension.

Do not count a dependent's portion as income to the veteran or widow(er) unless all the following conditions exist:

• The dependent lives apart from the veteran/surviving spouse; and

• The dependent has applied to the VA for apportionment; and

• The dependent has received the VA's written denial of the apportionment request, and

• The dependent has not received the augmentation directly from the veteran/surviving spouse.

Do not count reimbursements for medical expenses.

Under 10 U.S.C. 1408, the spouse’s portion of the total VA retirement benefit should not be counted as income to the Medicaid applicant if the following conditions are met:

• There is a court order with respect to division of property of the former spouses;

• The former spouses were married for at least 10 years; during which,

• The member performed at least 10 years of creditable service in the military,

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If there is no documentation to prove the three requirements of counting the spousal portion as separate property, the following verifications should be acquired:

• Marriage license

• Judgment of Divorce

• Judgment of Partition of Community property specifically expressing the division of property in a dollar amount or as a percentage of the disposable retirement pay belonging to the former spouse pursuant to 10 USC 1408.

• Enrollment date in service

• Certificate of honorable discharge.

VA benefits include the following types of payments:

• VA compensation:

– is a payment based on a service-connected disability or death, and

– may be paid to a veteran or survivor of the veteran.

• VA pension is a payment based on need.

• VA Improved Pension Assistance is a re-computation of pension benefits that may result in a higher benefit amount.

• VA Aid and Attendance is an allowance to veterans, spouses of disabled veterans, and surviving spouses who are in regular need of the aid and attendance of another person or who are housebound.

VA Aid and Attendance and housebound allowances are combined with the individual's pension or compensation payment. Verify all VA payments with VA to determine if Aid and Attendance or housebound allowances are involved.

Note:

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Failure of the beneficiary of VA benefits to return VA income statements will result in VA termination.

If notified that VA benefits have terminated, contact VA to verify the reason(s) for termination to determine whether to continue budgeting the income as stated in Potential Income. If the termination was caused by the failure of the applicant/beneficiary to comply with VA correspondence requirements, determine whether he was unable to comply because of his physical or mental condition. If so, assist the applicant/beneficiary in reinstating VA benefits. Do not report an overpayment or underpayment. No patient liability adjustment is necessary.

VICTIM'S COMPENSATION

Do not count payments received from a state-administered victim's compensation fund.

Note: A victim is not required to accept victim's compensation.

Count interest paid on unspent portion as unearned income in the month of receipt and as a resource the following month.

WAGES, SALARIES, AND COMMISSIONS

Count gross wages, salaries, and commissions including paid sick and vacation leave as earned income.

Persons meeting LTC medical certification requirements generally will not be able to engage in any wage earning activity. In some cases, however, employment is recommended as a therapeutic or rehabilitative measure. When a question concerning medical certification for such a case arises, send a summary of the situation to the Health Standards Regional Office.

If earned income is reported for a SNF beneficiary, submit current medical data and employment information to the Health Standards Regional Office for a review of level of care.

WORKER'S COMPENSATION

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Count the gross amount as unearned income.

Refer to Lump Sum Payments

WORKERS’ COMPENSATION MEDICARE SET-ASIDE ARRANGEMENT (WCMSA)

Count any interest earned on unspent portions as unearned income in the month of receipt and as a resource the following month.

I-1535 NEED – SSI-RELATED - TREATMENT OF INCOME

I-1536 DEDUCTIONS

Medicaid deductions are determined:

• By the program,

• By the type of income, and

• According to whether the budget is the eligibility determination or the LTC patient liability determination.

The specific order that must be used in allowing these deductions is indicated below, followed by an alphabetical list of deductions and an explanation of each.

Extended Medicaid, Retroactive Medicaid for SSI Applicants, and Medicare Savings

1. Standard SSI Deduction 2. Earned Income Deduction 3. Remainder, if any, of the Standard SSI Deduction

MNP Spend-down

1. Standard SSI Deduction 2. Earned Income Deduction 3. Remainder, if any, of the Standard SSI Deduction 4. Health Insurance Premiums 5. Allowable Medical Bills

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LTC Eligibility Determination

No deductions allowed

LTC Patient Liability

1. Earned Income Deduction

2. Personal Needs Allowance

3. Maintenance Needs of Community Spouse 4. Maintenance Needs of Family a. Legal Dependents Living with a Community Spouse b. Legal Dependents with no Community Spouse 5. Allowable Health Insurance Premiums, Deductibles, Co- Insurance Charges and Copayments 6. Allowable Medical Bills

LTC Spend-down MNP Eligibility Determination

1. Standard SSI Deduction 2. Earned Income Deduction 3. Remainder, if any, of the standard deduction 4. MNIES 5. Allowable Medical Bills

LTC Spend-down MNP Patient Liability

1. Earned Income Deduction

2. Personal Needs Allowance

HCBS Eligibility Determination

No deductions allowed

HCBS Patient Liability

There is no PLI determination for HCBS beneficiaries with income below the Special Income Level (SIL).

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HCBS Spend-down MNP Eligibility Determination (Community Choices, Adult Day Health Care, Supports, ROW and NOW only)

1. Standard SSI Deduction 2. Earned Income Deduction 3. Remainder, if any, of the standard deduction 4. MNIES 5. Allowable Medical Bills

HCBS Spend-down MNP Patient Liability (Community Choices, Adult Day Health Care, Supports, ROW and NOW)

1. Earned Income Deduction

2. Basic Needs Allowance

Allowable Medical Bills

This deduction applies to MNP Spend-down, LTC SD MNP, Community Choices SD MNP, Adult Day Health Care SD MNP, Row SD MNP, Supports SD MNP and NOW SD MNP eligibility determinations.

Deductions for medical expenses may be allowed in LTC, LTC SD MNP, Community Choices SD MNP, Adult Day Health Care SD MNP, Row SD MNP, Supports SD MNP and NOW SD MNP post eligibility patient liability determinations.

• Incurred expenses have to be dated no earlier than three months preceding the month of application.

• For any changes, only account for expenses in the last three (3) months prior to report date, with carryover if necessary.

Basic Needs Allowance

See H-910.4 Beneficiary Liability (needs allowance is 3 x Federal

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Benefit Rate (FBR) for all waivers).

For HCBS beneficiary liability determinations, deduct an allowance equal to three times the SSI FBR.

Refer to Z-700 LTC/HCBS SIL Rate, Resource Limits and Personal Care Needs Allowance.

Earned Income Exemption (EIE)

Deduct $65 and one-half of the remainder from gross earned income for each individual or couple.

This deduction applies to:

• All programs except LTC in the eligibility determination, and

• LTC patient liability determinations, if the employment is part of the approved plan of care. Refer to Sick Pay.

Note: Many ICF/IID beneficiaries engage in wage earning activity as a part of their plan of care and are eligible for the SSI earned income deductions ($65 and one half of the remainder) in the patient liability determination only.

Beneficiaries of ICF I and II services whose physician plan of care prescribes a wage earning activity as a therapeutic or rehabilitative measure shall be eligible for the SSI earned income deductions ($65 and one half of the remainder) in the patient liability determination only.

Garnishments

Unearned income includes amounts withheld from unearned income because of a garnishment or to make certain other payments (such as payment of Medicare premiums).

Health Insurance Premiums, Deductibles, Co-insurance Charges and Copayments

This deduction applies to:

• MNP eligibility determinations, and

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• LTC and LTC/HCBS Spend-down MNP patient liability determinations.

Deduct the verified monthly premium amount paid by the applicant/beneficiary:

Note: The premium must be paid by the applicant/beneficiary. It may NOT be paid by the community spouse (i.e. deducted from spouse’s earned/unearned income) or other third party.

• Medicare (shall be deducted first),

• Medical insurance, and

• Medical transportation insurance.

• LTC Partnership Insurance

Note: In patient liability determinations, medical insurance premiums that are paid quarterly, annually, etc. may be prorated monthly. For Medically Needy LTC, refer to H-1011.5 Bills Allowed in the Spend- Down Process.

Allowable medical insurance policies are those that relate payment to the amount of expense incurred by paying either actual charges or actual charges less a percentage.

Verify the monthly amount of medical transportation and medical insurance premiums at application and renewal.

If the applicant/beneficiary does not provide adequate verification, attempt to verify the premium by contacting the insurance company or agent.

Do not allow a deduction if the premium amount cannot be verified or the time period the premium covers cannot be determined.

A canceled check is not adequate verification.

Do not allow deductions for premiums for:

• Income replacement policies,

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• Accidental death and dismemberment policies, or

• Sick and accident policies.

Evaluate policies with combined coverage (i.e., those that provide medical insurance and income replacement) to determine whether the premium for the income replacement provision can be determined separately.

If the premiums can be determined separately, deduct the medical insurance portion of the premium.

If the premiums cannot be determined separately but the majority (over 50%) of policy provisions is allowable, deduct the total premium.

Maintenance Needs Allowance for Legal Dependents

For long term care facility patient liability determinations involving Spousal Impoverishment Provisions only deduct the allowance for legal dependents of a long term facility care applicant/beneficiary living with a long term facility care community spouse. Refer to I-1537.3, Maintenance Needs

For long term care facility patient liability determinations involving an individual with legal dependents and no community spouse, deduct the MNIES for the number of dependents. Refer to I-1537.3, Maintenance Needs

For HCBS Spend-down MNP patient liability determinations involving an individual with legal dependents with or without a community spouse, deduct the monthly MNIES for the number of dependents.

Maintenance Needs Allowance for Community Spouse

For long term care facility patient liability determinations involving Spousal Impoverishment Provisions only deduct the allowance for a long term care facility community spouse. Refer to I-1537.3, Maintenance Needs

For HCBS Spend-down MNP patient liability determinations involving Spousal Impoverishment Provisions deduct the allowance for a long term care community spouse.

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Personal Care Needs

For long term care facility patient liability determinations only, deduct a standard allowance to help cover the cost of personal care items not covered by the facility fee.

Note: The $90.00 VA Improved Pension may not be used to reduce the Medicaid payment to the facility and does not replace the PCN.

Refer to Z-700 LTC/HCBS SIL Rate, Resource Limits and Personal Care Needs Allowance.

SSI Standard Deduction

Do not apply this deduction to:

LTC categorically needy eligibility or patient liability determinations, or income based on need (e.g., AFDC payments, VA pensions).

For all other programs, including LTC/HCBS Spend-down MNP, deduct $20 from monthly income not based on need for each:

• Individual, or

• Couple.

Deduct the $20 from unearned income first. Then deduct any unused portion of the $20 from earned income.

I-1537 SPOUSAL IMPOVERISHMENT INCOME PROVISIONS

I-1537.1 General Information

Apply these provisions only in the LTC patient liability determination for an LTC/HCBS/ACH applicant/beneficiary who has a legal community spouse. The community spouse is the legal spouse of an institutionalized individual, who lives in a non-institutionalized setting. Spousal Impoverishment applies if the spouses are not residing in the same home due to medical reasons or due to circumstances beyond their control. A person receiving home and community based services is considered institutionalized for Medicaid purposes.

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There is no residence requirement for spousal impoverishment. The legal spouse can live in another state or country and the LTC applicant/beneficiary can have spousal impoverishment apply as long as all other eligibility requirements are met.

Note: Verify that the marriage is legal.

A legal dependent is a person who may be claimed as a dependent by either member of the couple for income tax purposes under the Internal Revenue Code. Legal dependents may be:

• A couple's minor or dependent child(ren),

• Parents, or

• Siblings.

Note: For dependents not living with a community spouse, refer to I-1536, Deductions, Maintenance Needs Allowance for Legal Dependents.

The gross income of the applicant/beneficiary must be below the individual SIL or the individual must be eligible under LTC/HCBS Spend-down MNP guidelines before these provisions can be applied. Refer to H-0000, Eligibility Determinations.

Note: Never consider the income of the community spouse/legal dependents at home in determining eligibility for an institutionalized individual.

Allow income to meet the needs of the legal spouse/dependents at home only if:

• The applicant/beneficiary agrees to make the income available to the spouse/dependent, and

• The spouse/dependent is willing to accept the income.

I-1537.2 Ownership of Income

Determine ownership of income for each spouse without regard to

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community property laws. A spouse has:

• Full ownership of income paid in his/her name,

• Half ownership of income paid in the names of both spouses, and

• Pro rata ownership of income paid in the names of either one or both spouses and another individual.

I-1537.3 Maintenance Needs

Spouse’s Maintenance Needs

Determine the Spousal/Child/Family Member Needs amount for an applicant/beneficiary with a community spouse as follows:

• Total gross income (including VA Aid and Attendance) of the applicant/beneficiary less earned income deductions, if applicable.

• Total spouse's gross income including any countable interest earned from allowable resources.

- Subtract spouse's income from the Spouse's Maintenance Needs Standard. Refer to Z-800 Spousal Impoverishment Maintenance Needs and Resource Standards. The remainder, if any, is the spouse's maintenance needs allowance limit.

Do not allocate more than the Maintenance Needs Allowance limit. Refer to Table Z-800 Spousal Impoverishment Maintenance Needs and Resource Standards

Dependent’s Maintenance Needs

• For each legal dependent living with a community spouse:

- Total the dependent’s gross income including any countable interest paid on allowable resources.

- Subtract this income from the dependent's Maintenance

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Needs Standard. Refer to Z-800 Spousal Impoverishment Maintenance Needs and Resource Standards.

- Divide the remainder by three. The remaining amount, if any, is the dependent’s maintenance needs allowance. Do not allocate more than one-third of the Dependent’s Need Standard for each dependent.

• For each legal dependent not living with a Community spouse:

- Total all dependent’s income, including any countable interest paid on allowable resources.

- Subtract this income from the MNIES for the number of dependents. Refer to Z-300 Medically Needy Income Eligibility Standards (MNIES). The remainder, if any, is the maintenance needs.

I-1537.4 Verification

Obtain verification that:

• The couple is legally married,

• The dependents who are allowed the Maintenance Needs Allowance are legal dependents, • The applicant/beneficiary agrees to make the income available to the spouse/dependent, and

• The spouse/dependent is willing to accept the income.

I-1537.5 Documentation

Document and file copies of the verification.

I-1538 Patient Liability (PLI)

PLI is the amount the applicant/beneficiary must pay towards their monthly cost of care. It is based on the amount of monthly income

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remaining after allowable deductions. PLI is projected for a three month period, beginning with the first month of Medicaid eligibility. Post-eligibility treatment of income (PETI) rules are used to calculate an applicant/beneficiary’s PLI for nursing home, Home and Community Based Waiver or ICF/IID services.

Allow deductions in the following order:

Deductions

1. Earned Income Deduction

2. Personal Care Maintenance Needs Allowance

PLI Steps for LTC, LTC SD MNP and HCBS SD MNP

Step 1. Determine the total unearned income.

For the month of entry to an institution or the month the individual converts from Medicare to Medicaid pay status include the entire SSI payment.

** Include all VA Pension including Aid and Attendance payments.

Step 2. Determine the total gross earned income. All earned income is counted.

Step 3. Add the countable earned and countable unearned income.

Step 4. Deduct the personal care maintenance needs allowance. Refer to Z-700 LTC/HCBS SIL Rate, Resource Limits and Personal Care Needs Allowance.

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Note: The reduction of the VA Improved Pension to a maximum of $90 is protected as the personal care needs allowance. Allow the $90 PCN when the VA actually reduces the pension to $90.

Step 5. Deduct maintenance needs of the community spouse

Step 6. Deduct maintenance needs of dependents living in the home prior to admission. Refer to I-1536 Deductions.

Step 7. Subtract all allowable medical insurance premiums and other allowable medical bills. Refer to I-1536 Deductions.

Step 8. The remainder is the patient liability owed by the applicant/beneficiary for their cost of care. This is the projected PLI.

PLI Steps for ICF (Group Homes)

Step 1. Determine the total unearned income.

Include all VA Pension including Aid and Attendance payments.

Step 2. Determine the total gross earned income.

a) Subtract $65 earned income disregard, and b) Subtract one-half of the remainder.

The remaining amount is the countable earned income.

Step 3. Add the countable earned and countable unearned income.

Step 4. Deduct the personal care maintenance needs allowance. Refer to Z-700 LTC/HCBS SIL Rate, Resource Limits and Personal Care Needs Allowance.

Note: The reduction of the VA Improved Pension to a maximum of $90 is protected as the personal care needs allowance. Allow the $90 PCN when the VA actually reduces the pension to $90.

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Step 5. Subtract all allowable medical insurance premiums and other allowable medical bills. Refer to I-1536 Deductions.

Step 6. The remainder is the patient liability owed by the applicant/beneficiary for their cost of care. This is the projected PLI.

Reconciliation

PLI is reconciled at the end of the projection period or when a change in income or deductions occurs. • Limit changes in income to the three months prior to the reported on date. • Deductions are required to be reported within 3 months of the date of service. The projected PLI will be reconciled against the actual PLI for the three months prior to the date the change was reported. Any differences will be carried forward to the first month in which PLI is allowed to be adjusted per Advance Notice rules. Refer to MEM L-700 Advance Notice.

During reconciliation verify the actual income and deductions for each of the prior three months and determine the actual PLI for each month. Any difference between the projected PLI and the actual PLI will be reflected as a cumulative positive or negative amount called a carryforward for each month. • Any carryforward remaining after the first adjustable month is combined with the projected PLI for subsequent months until completely absorbed. • One-time, non-recurring deductions should also be combined with the new projected PLI in addition to the carryforward if there is one.

I-1538.1 Patient Liability Notice

Send the Quarterly Patient Liability Summary Notice to the applicant/beneficiary/authorized representative and the provider every three months from the certification/renewal month with the next

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three projected months’ patient liability.

Send the Patient Liability Change Summary Notice to the applicant/beneficiary/authorized representative and the provider any time a change is reported.

I-1538.2 Reasonable Limits for Allowable Medical Bills

1. For medically necessary care, services, and items not paid under the Medicaid State Plan or, if covered under the Medicaid State Plan, denied due to service limitations. The medical or remedial care must be:

• Recognized under state law;

• Medically necessary as verified by an independent licensed physician or medical director; and

• Incurred no earlier than three months preceding the month in which it is reported to the state.

2. The medical or remedial care cannot be for:

• Cosmetic or elective purposes, except when medically necessary as verified by an independent licensed physician or medical director; and/or

• Payment of a medical or dental service plan that has not been approved by the Louisiana Department of Insurance in accordance with the Louisiana Insurance Code or is sold by an entity not licensed by the Louisiana Department of Insurance to engage in the business of making contracts of insurance in the state of Louisiana.

3. The deduction for medical and remedial care expenses that were incurred as a result of imposition of transfer of assets penalty period is limited to $0.

4. The deduction for medical and remedial care expenses that were incurred as a result of the individual’s equity interest in the home is limited to $0. Refer to I-1634 Individuals with Substantial Home Equity.

(i-1550)Louisiana Medicaid Eligibility Manual (LDH): I - 1550 MAGI Determinations#

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 1 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**” I-1550 MAGI DETERMINATIONS

I-1551 MODIFIED ADJUSTED GROSS INCOME (MAGI)

Effective January 1, 2014, the Modified Adjusted Gross Income (MAGI) methodology is used to determine financial eligibility for:  Medicaid,  Children’s Health Insurance Programs (CHIP),  Cost sharing reductions, and  Advanced premium tax credits (APTC) through the Federally Facilitated Marketplace (FFM).

This change was made in accordance with Section 1004(a)(2) of the Patient Protection and Affordable Care Act of 2010, and codified at Section 36B(d)(2)(B) of the Internal Revenue Code.

MAGI is a methodology, based on federal tax rules, for determining income and household composition. It is not a number on a tax return, but it is based on federal rules for determining adjusted gross income.

MAGI-based rules are used to determine eligibility for the following groups of applicants/beneficiaries:  Adults age 19-64;  Parents and Caretaker Relatives (PCR);  Pregnant Women (PW);  Child-related groups; and  Other adult-related groups:  Breast and Cervical Cancer (BCC);  Refugee Medical Assistance (RMA);  Regular and Spend-Down Medically Needy;  Take Charge Plus (TCP); and  Tuberculosis (TB).

Note: The MAGI methodology is not used to determine financial eligibility for the Medicare Savings Program (MSP) or non- MAGI-related program groups (i.e. the aged, blind, or disabled categories).

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 2 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**” I-1552 MAGI HOUSEHOLD Construct a MAGI household for each individual for whom coverage is being requested. An individual’s household may or may not include everyone listed on the application/renewal form.

The MAGI household depends upon whether an individual is:  A tax filer;  Married living with a spouse;  A tax dependent; or  A non-filer (neither a tax filer nor a tax dependent).

MAGI HOUSEHOLD—TAX FILER RULES Tax filer rules are applied when the individual expects to:  File taxes; or  Be claimed as a tax dependent.

Note: Spouses who are separated and not living together are not included in each other’s MAGI households, even when expected to file jointly.

MAGI HOUSEHOLD FOR TAX FILERS For the tax filer, the MAGI household consists of the following:  The tax filer  The spouse of the tax filer; and  All claimed tax dependents. Including tax dependents not living with the tax filer. See Example E.

When determining the MAGI household for a pregnant woman, include the child(ren) she is expected to deliver.

Example: Sally is pregnant and applies for Medicaid coverage for herself, her unborn, and her two child-tax dependents, Amy and Arnold:  Sally’s MAGI household is composed of Sally, the unborn, Amy, and Arnold.

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 3 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**”  Amy’s MAGI household is composed of Amy, Arnold, and Sally.  Arnold’s MAGI household is composed of Arnold, Amy, and Sally. Note: When determining Medicaid eligibility for pregnant women under age 19, all income is disregarded.

MAGI HOUSEHOLD FOR TAX DEPENDENTS For the tax dependent, who does not meet a tax dependent exception, the MAGI household is the same as the household of the tax filer claiming the individual, including:  The tax dependent;  The tax dependent’s legal spouse, if living together, whether claimed by the tax filer or not;  The tax filer;  The spouse of the tax filer; and  All other tax dependents claimed by the tax filer.

If an adult is a tax dependent, include the individual in the MAGI household regardless of whether they reside in household. A child who expects to file taxes but is claimed as a tax dependent by a parent is considered a tax dependent when constructing the child’s MAGI household.

MAGI HOUSEHOLD FOR JOINT CUSTODY Using information available on the application, it is reasonable to treat the parent applying for health coverage for the child as the custodial parent, when there is no other information to indicate that the parent is non-custodial.

In cases where there is a discrepancy (both parents are applying separately for health coverage for the same child in the same year), the custodial parent is the parent with whom the child spends most nights.

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 4 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**” In joint custody situations where both parents have applied for the child and the child spends equal time with both parents, the custodial parent is the parent who claims the child as a tax dependent.

MAGI HOUSEHOLD—NON-FILER RULES

Non-filer rules are applied when the individual:  Does not expect to file taxes;  Does not expect to be claimed as a tax dependent; or  Meets a tax dependent exception: 1. Being claimed as a tax dependent by a tax filer other than a parent or spouse. See Examples B and C. 2. Children under age 19, who expect to be claimed by one parent as a tax dependent and are living with both parents but whose parents do not expect to file a joint tax return; See Example D. 3. Children under age 19 claimed as a tax dependent by a non-custodial parent. See Example E.

MAGI HOUSEHOLD FOR NON-FILER - ADULTS

The MAGI household for an adult non-filer consists of:  The individual;  The individual’s spouse (if living in the home);  The individual’s children (natural, adopted, or step-children) under age 19 who live in the home.

See Examples A and F.

MAGI HOUSEHOLD FOR NON FILER RULES - MINORS (UNDER AGE 19)

The MAGI household for a minor non-filer consists of:  The individual’s parents (natural, adoptive, or step-parents) who live in the home;  The individual’s siblings under age 19 (natural, adopted, and

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Issued January 7, 2026 Page 5 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**” step-siblings) who live in the home;  The individual’s legal spouse who lives in the home; and  The individual’s children under age 19 (natural, adopted, and step-children) who live in the home.

See Examples A and F.

Example A: Mimi lives with her child, Mikey, and her boyfriend, Dan, who is the father of Mikey. Dan works and claims Mimi and Mikey on his tax return. Mikey already receives Medicaid. Mimi is the only person applying for coverage since Dan is not requesting coverage for himself.

Mimi meets the MAGI household exception of being claimed as a tax dependent by a tax filer other than a parent or spouse since she will be claimed by Dan (someone other than a married spouse) on his tax return.

The MAGI household for Mimi is determined by using non-filer rules, and consists of herself and Mikey.

Example B: Mary is the tax filer and the grandparent of Joey, age 11, who she claims as a tax dependent.

Since Mary is a tax filer, Mary’s MAGI household consists of herself and her grandson, Joey.

Joey is a tax dependent and meets an exception because he is being claimed as a tax dependent by a tax filer other than a parent or spouse. His MAGI household is determined using non-filer rules, and consists of himself only.

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 6 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**” Example C:

Rebecca and John are in a non-legal union. Rebecca has a 12- year-old child from a previous union, Samantha. John claims Rebecca and Samantha as tax dependents.

Although Samantha is a tax dependent for John, she meets an exception because she is being claimed as a tax dependent by a tax filer other than a parent or spouse. John is not her natural, adoptive, or legal parent; therefore, her MAGI household is determined using non-filer rules, and consists of herself and her mother Rebecca.

Example D: Bob is married to Jane. They live together and file separately. Bob has one child from a previous union, Alice, who is 20 years old, that he claims on his taxes. He and Jane have two (2) children together: Stephanie and Lynne. Jane claims herself and their two (2) children on her taxes. Each individual is applying for coverage.

Since Bob is a tax filer, Bob’s MAGI household consists of himself, Alice, and his wife, Jane.

Since Jane is also a tax filer, Jane’s MAGI household consists of herself, her husband, Bob, and their two (2) children together.

Bob and Jane’s two (2) children in common meet an exception because they are children living with two parents who do not expect to file a joint tax return. They are claimed as tax dependents by their mother, Jane, but reside with both of their parents.

The MAGI household of Stephanie or Lynne is determined using non-filer rules. In this case, each of their MAGI households consist of Stephanie, Lynne, Bob and Jane.

Note: Although Alice is a tax dependent of Bob and a half sibling of the other children, according to non-filer rules she is not part of this MAGI household because she is not under age 19.

The MAGI household for Alice consists of Alice, her father Bob, and Bob’s legal spouse, Jane (same household as Bob).

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 7 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**” Example E:

Susan and John are divorced and living apart. Their children, Harry and Jordan, live with their custodial parent, Susan. John pays child support throughout the year and claims Harry and Jordan on his taxes as dependents.

Although Harry and Jordan are claimed as tax dependents by their father, an exception is met since they live with their mother, Susan, who is the custodial parent.

The MAGI household of Harry or Jordan is determined using non-filer rules. In this case, each child has the same household of Harry, Jordan, and Susan.

The MAGI household of John is determined by tax filer rules. In this case, John claims Harry and Jordan as his tax dependents therefore his MAGI household would include John, Harry and Jordan.

Example F: David and Terri are not married and do not file or expect to file taxes. They live together with their three (3) children: Edmond, age 12; Trent, age 9; Joseph, age 6; and David’s daughter Wendy, age 17, from a previous union.

The MAGI household for David is David and his four (4) children Wendy, Edmond, Trent, and Joseph.

The MAGI household for Terri is Terri and her three (3) children, Edmond, Trent, and Joseph.

The MAGI household for Wendy is Wendy, her father David, and her half siblings, Edmond, Trent, and Joseph.

The MAGI household for Edmond, Trent, and Joseph is Edmond, Trent, Joseph, their half sibling Wendy, and both of their natural parents, David and Terri.

Note: If David and Terri were married, this would bring the whole family together such that the MAGI household would then be David, Terri, Wendy, Edmond, Trent, and Joseph.

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 8 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**” I-1553 MAGI-RELATED TYPES OF INCOME

Consider the following types of taxable income in MAGI budgeting:

 ALIMONY Count as unearned income, only those payments ordered by a judgment dated prior to January 1, 2019 made directly to the household from non-household members. Do not count payments ordered by a judgement dated on or after January 1, 2019.

 ALIEN SPONSOR'S INCOME Count as unearned income.

 ANNUITY INCOME Count as unearned income any taxable portion of annuity income.

 BUSINESS INCOME (OR LOSS) Count net profit or loss from partnerships, corporations, etc. as earned income.

 CAPITAL GAIN (OR LOSS) Allow for a capital gain or loss when budgeting.

 CONTRACTUAL INCOME Count as earned income. Annual income received under an implied, verbal, or written contract in less than twelve (12) months shall be averaged over the twelve (12) month period it is intended to cover unless the income is received on an hourly or piecework basis.

Example: Income received by teachers, teacher's aides, and school bus drivers.

 DISABILITY INSURANCE BENEFITS Count as unearned income.

Exception:

Count as earned income if federal and/or state taxes are being deducted.

 DIVIDENDS Count as unearned income. Income from dividends should be averaged over the period they are intended to cover.

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 9 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**”

 INTEREST Count as unearned income (this includes tax-exempt interest). Average interest income for the period it is intended to cover. Sources could include financial accounts, US treasury bills, bonds, state or municipal bonds or mutual funds.

 IRREGULAR AND UNPREDICTABLE INCOME Count as earned income in the month of receipt.

 JOB TRAINING PARTNERSHIP ACT OF 1982 (JTPA) Income received from employment through the JTPA program is counted as earned income. Note:

Income received for training through the JTPA program is counted as unearned income.

 LUMP SUM PAYMENTS Count as unearned income a non-recurring cash payment only in the calendar month of receipt. Do not count if payment is not taxable. Note: This includes insurance settlements, back pay, state tax refunds, inheritance, IRA or other retirement distributions, and retroactive benefit payments.

Count as unearned income qualified lottery winnings or qualified lump sum income received on or after January 1, 2018. Qualified lottery winnings are defined as winnings from a sweepstakes, lottery, or pool operated by a multistate or multijurisdictional lottery association, including amounts awarded as a lump sum payment. Qualified lump sum income is defined as income that is received as a lump sum from monetary winnings from gambling. Based on the amount of the income received, it is counted according to the following criteria: o If less than $80,000, count in the month in which it is received.

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 10 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**” o If greater than or equal to $80,000 but less than $90,000, count in equal installments in the month in which it is received, and in the following month. o If greater than or equal to $90,000 but less than $100,000, count in equal installments in the month in which it is received, and in the following two (2) months. If greater than or equal to $100,000, count in equal installments in the month in which it is received, and in the following two (2) months. Add an additional month for each increment of $10,000, not to exceed 120 months for amounts of $1,260,000 or more,

Note: The requirement to count qualified lottery and gambling winnings in household income over multiple months applies only to the individual who receives the winnings. After the month of receipt, do not count these winnings as income for the other household members.

Example: In May, Steve wins $85,000 while gambling at the casino.

Steve’s MAGI household consists of Mike (tax filer), Cindy, his spouse (joint tax filer), and their tax dependents Mikey and Joey. Based on the rules above, divide the total winnings over two months and count $42,500 as income for May for the entire household, and count $42,500 as income for June for Steve only.

Lottery/Gambling Winnings - Hardship Exception An individual in receipt of lottery or gambling winnings in excess of the applicable income limits shall continue to be eligible if it is determined that the denial of eligibility of the individual would cause an undue medical or financial hardship.

Results Of Findings

If undue hardship is determined to exist and an exception granted, the lottery/gamblings winnings shall not be considered in the eligibility process.

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 11 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**” If a request for an undue hardship exception is denied, the applicant is notified of the decision in writing. The applicant has the right to appeal the denial decision.

 OIL AND LAND LEASES Count as unearned income. Prorate regular recurring income from leases over the period it is intended to cover and count as unearned income.

Payments received in the first year of an oil lease, which are above the regular recurring rental and payments received when an oil lease is written for a single year, are treated as non-recurring lump sum payments.

 PENSIONS Count as unearned income.

 POTENTIAL INCOME Count income that is potentially available when the applicant/beneficiary has a legal interest in a liquidated sum and has the legal ability to make this sum available for the support and maintenance of the MAGI household.

Count income that is available but the applicant/beneficiary chooses not to receive it. Note: If the agency representative is unable to determine the amount of benefits available because of the applicant/beneficiary’s inability or refusal to cooperate, reject the case for failure to cooperate. Refer to G-1100 Cooperation.

 RAILROAD RETIREMENT Count the amount of the entitlement as unearned income. Note: Include the amounts deducted from the check for the Medicare premiums, less any amount being recouped for a prior overpayment.

 RENTAL PROPERTY INCOME Ownership of rental property is considered a self-employment enterprise. Count profit after allowable deductions. Income received from rental property may be earned or unearned. To be

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 12 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**” counted as earned income, the applicant/beneficiary must perform some work-related activity. If the applicant/beneficiary does not perform work-related activity, the money received is unearned income. Deduct only allowable expenses associated with producing the income. If the income is earned, also allow other earned income deductions. See also Self-Employment Income.

 RETIREMENT Count the gross amount of retirement benefits as unearned income, including military retirements.

Note: The CARES Act of 2020 allows qualified individuals distribution options and rollover rules for up to $100,000 of coronavirus-related distributions from eligible retirement plans. Count this income monthly over the time period of the IRS-approved option chosen by the individual.

 ROYALTIES Count as unearned income. Prorate royalties for the period they are intended to cover.

 SCHOLARSHIPS, AWARDS, OR FELLOWSHIP GRANTS Count as unearned income if used for living expenses, such as room and board and not for education purposes.

Count as unearned income any academic scholarships, awards, or fellowship grants that are used for room and board, travel, research, clerical help or equipment and are not required for enrollment at the educational institution.

Count as unearned income the part of any scholarship or fellowship grant that represents payment for teaching, research or other services required as a condition for receiving the scholarship.

Exception: Do not count income received under the National Health Service Corps Scholarship (NHSCS) program or the Armed Forces Health Professionals Scholarship and Financial Assistance Program (AFHPSFAP).

 SEASONAL EARNINGS Count as earned income in the month received.

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 13 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**”

If contractual, prorate the earned income over the period it is intended to cover.

Example: The earnings of a farm hand or a crab picker.

If earnings are from seasonal self-employment, refer to Self-Employment Income.

 SELF-EMPLOYMENT INCOME This is income received from an applicant/beneficiary’s own business, trade, or profession if no federal, state withholding tax, or Social Security tax is deducted. This may include earnings as a result of participation in Delta Service Corps and farm income.

Expenses Allow the same expenses as those allowed when filing taxes on an Internal Revenue Service (IRS) Schedule C, or Farm Income Schedule F.

Net Operating Loss (NOL) A Net Operating Loss occurs when an individual’s annual business loss is greater than the annual business income. An NOL year is the year in which the NOL occurs. The NOL may be deducted from income in another year or years. **

Note: Self-attestation of self-employment income is not allowed, unless the self-attested amount indicates obvious ineligibility. If verification is needed, see the Self-Attestation of Self-Employment Income section under S-0000 Verification And Documentation and I-1530 Need - SSI Related Income for more details.

 SOCIAL SECURITY RETIREMENT, SURVIVORS AND DISABILITY INSURANCE BENEFITS (RSDI) Count the amount of the entitlement as unearned income, including the amount deducted from the check for the Medicare premium, less any amount that is being recouped for a prior overpayment.

Note: Supplemental Security Income (SSI) is excluded. If an

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 14 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**” individual receives RSDI and SSI, count only the RSDI portion and none of the SSI income.

Exclude Social Security benefits when a child or tax dependent does not meet the tax filing threshold. (See I-1554.4 Income of Children and Tax Dependents.)

 TAXABLE REFUNDS Count as unearned income taxable refunds, credits, or offsets of state and local income taxes if claimed on IRS Form 1040.

 TRUST FUNDS Count as unearned income withdrawals, dividends, or interest that are or could be received from a trust by the applicant/beneficiary.

 TUTORSHIP FUNDS Count as unearned income any money released by the court to the applicant/beneficiary.

 UNEMPLOYMENT COMPENSATION BENEFITS (UCB) Count payments as unearned income in the month of receipt.

 WAGES, SALARIES, TIPS, AND COMMISSIONS Count taxable gross wages, salaries, tips, and commissions, including paid sick and vacation leave, as earned income.

Include as earned income vendor payments made by the employer instead of all or part of the salary.

Include the cash value of an in-kind item received from an employer instead of all or part of the salary.

Include foreign earnings.

Exception: Under CARES Act 2020 provisions, exclude from an employee's income payments for educational assistance that are provided by an employer.

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Louisiana Medicaid Eligibility Manual Eligibility Factors

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Revised/added text indicated by underscore Deleted text indicated by “**”

 WORK STUDY PROGRAM Count payments as unearned income in the month of receipt.

Do not consider the following types of income for MAGI budgeting:

 ADOPTION ASSISTANCE Disregard amounts paid or expenses incurred by the employer.

 AGENT ORANGE SETTLEMENT PAYMENTS

 ALIMONY Do not count payments ordered by a judgement dated on or after January 1, 2019.

 AMERICAN INDIAN AND NATIVE AMERICAN CLAIMS AND LANDS This includes: o Distributions from Alaska Native Corporations and Settlement Trusts; o Distributions from any property held in trust, subject to Federal restrictions, located within the most recent boundaries of a prior Federal reservation, or otherwise under the supervision of the Secretary of the Interior; o Distributions and payments from rents, leases, rights of way, royalties, usage rights, or natural resource extraction and harvest from:  Rights of ownership or possession in any lands held in trust, subject to Federal restrictions, located within the most recent boundaries of a prior Federal reservation, or otherwise under the supervision of the Secretary of the Interior; or  Federally protected rights regarding off-reservation hunting, fishing, gathering, or usage of natural resources; o Distributions resulting from real property ownership interests related to natural resources and improvements:  Located on or near a reservation or within the most recent boundaries of a prior federal reservation; or

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Revised/added text indicated by underscore Deleted text indicated by “**”  Resulting from the exercise of federally-protected rights relating to such real property ownership interests;  Payments resulting from ownership interests in or usage rights to items that have unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or a traditional lifestyle according to applicable tribal law or custom;  Student financial assistance provided under the Bureau of Indian Affairs education programs.

 CASH CONTRIBUTIONS

 CENSUS BUREAU EARNINGS

 CHILD SUPPORT PAYMENTS Disregard payments received for anyone in the home.

 CONTRIBUTIONS FROM TAX-EXEMPT ORGANIZATIONS

 DISASTER PAYMENTS

 DOMESTIC VOLUNTEER SERVICE ACT

 EARNED INCOME CREDITS

 EDUCATIONAL LOANS

 ENERGY ASSISTANCE

 FEDERAL INCOME TAX REFUNDS

 FEDERAL TAX CREDITS

 FOSTER CARE PAYMENTS

 HOUSING AND URBAN DEVELOPMENT (HUD) BLOCK GRANT FUNDS, PAYMENTS OR SUBSIDIES

 IN-KIND SUPPORT AND MAINTENANCE

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 17 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**”  KINSHIP CARE SUBSIDY PROGRAM (KCSP)

 LOANS

 NUTRITIONAL PROGRAMS

 RADIATION EXPOSURE

 RELOCATION ASSISTANCE

 SCHOLARSHIPS, AWARDS, OR FELLOWSHIP GRANTS Income used for education purposes and not for living expenses is excluded, provided that: o The student is a candidate for a degree at an eligible educational institution, as described in section 170(b)(1)(A)(ii) of the Internal Revenue Code; and o The amount is for qualified educational expenses required by the institution for courses of instruction.

Note: Tuition and fees required for enrollment or attendance at the educational institution for books, supplies, and equipment, are considered countable income and are no longer exempted.

 SUPPLEMENTAL SECURITY INCOME Note: SSI income is excluded. If an individual receives RSDI and SSI, count only the RSDI portion and none of the SSI income.

 TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF)

 VENDOR PAYMENTS

 VETERANS BENEFITS

 WOMEN, INFANTS AND CHILDREN (WIC) PROGRAM

 WORKERS COMPENSATION

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Louisiana Medicaid Eligibility Manual Eligibility Factors

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Revised/added text indicated by underscore Deleted text indicated by “**”

I-1554 MAGI INCOME BUDGETING

Self-Attestation of Income

Self-attested income is unverified income information provided by the applicant/beneficiary. Accept the self-attested income amount when the reasonable compatibility standard is met.

 Attestation is above data sources: o If the individual's self-attested income is above the data sources, the self-attested income is used.  Attestation is below data sources: o Prior to September 7, 2025: If the individual’s self- attested income is below data sources, consider it reasonably compatible and use it if the difference is less than 10 percent; if the difference is 10 percent or more, request a reasonable explanation from the individual. o Effective September 7, 2025: If the individual’s self- attested income is below data sources, accept it as reasonably compatible and use it if the difference is less than 4 percent; if the difference is 4 percent or more, request a reasonable explanation from the individual. • If the reasonable explanation is accepted, the self-attested income is used. The case must be documented with a note that includes the details that weighed on the decision.  Attestation cannot be confirmed through electronic data sources, such as in the cases of new employment: o Use self-attested income.  If a parent applying for their child refuses to provide their SSN so that we can confirm attestation through electronic data sources, we must request income verification from the parent.

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 19 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**” Note:

Verify:  All self-employment income, unless the self-attested amount indicates obvious ineligibility.  Income of a non-applicant who refuses to provide their SSN, unless the non-applicant is not in the MAGI household of the applicant.

See S-0000 Verification and Documentation for more information.

I-1554.1 Income Budgeting

Use current monthly household income received based on the latest information available to the agency. Include all amounts that the applicant/beneficiary will be expected to receive in the current month. Account for future decreases in monthly household income. (e.g., termination, interruption, change in number of hours worked, changes in hourly wage, changing from full-time to part-time, etc.).

Note: A change for purposes of this section does not include normal fluctuations in the number of hours worked, amount paid or short term temporary changes such as covering for another employee who was ill.

To determine gross monthly income, use the following conversion factors:  Divide yearly income by 12;  Multiply weekly income by four (4);  Add amounts received twice a month; or  Multiply amounts received every other week by two (2).

Certain pre-tax deductions allowed by the IRS are not included when determining taxable income for MAGI budgeting. Pre-tax deductions must be clearly designated on the employee’s paystub or W-2 forms showing both the total gross earnings and the adjusted taxable gross earnings. The deductions listed below are only allowable when they belong to someone in the tax filing unit or in the household (for non-filers). Pre- tax deductions may include but are not limited to:  Dependent care expenses

(i-1550)(page-20)Page 20#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 20 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**”  Health Flexible Spending Account (FSA–employer sponsored)  Health insurance premiums  Retirement contributions

I-1554.2 Actual Income Budgeting Actual income budgeting involves looking at income received within a specific month to determine income eligibility for that month. Actual income should be used for all retroactive coverage.

Refer to I-1554.7 Projecting Income for additional details.

I-1554.3 Rounding Procedures

Round only when calculating gross monthly income.

Round to the nearest dollar after the computation of the monthly earnings, using the conversion factor. Do not round until after the conversion in this situation.

Round down in each calculation that equals 49 cents or less. Round up in each calculation that equals 50 cents or more.

Example: Weekly gross income: $ 543.21

x 4

$2,172.84

Round to $2,173

I-1554.4 Income of Children and Tax Dependents

When the income meets the tax filing threshold that requires the filing of a tax return, count the income of:  A child of any age who is included in the MAGI-based household of a natural, adopted or step-parent;  A tax dependent of any age in the MAGI-based household of the tax filer; Note: Do not use Social Security benefits or other non-taxable income to determine if a child or tax dependent meets the tax filing threshold.

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 21 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**”

Exclude the income when the child’s or tax dependent’s income is below the tax filing threshold. Refer to Z-500 Filing Requirements for Children and Tax Dependents for more information about the tax filing threshold.

When determining the total household income of a child who is not living with a parent (i.e., a grandchild living with a grandparent), the child’s MAGI-based income is always counted in determining the child’s eligibility, even if the child’s income is below the tax filing threshold.

When determining the total household income of a tax dependent who is claimed by someone other than a parent, the tax dependent’s MAGI- based income is always counted in determining the tax dependent’s own eligibility even if the income is below the tax filing threshold.

Example: Marty expects to claim his adult son, Mark (age 22), who is a full- time student, as a tax dependent. Marty makes $1,500 a month. Mark makes $400 a month working as a waiter. Marty and Mark will be included in each other’s MAGI-based households. Mark’s income does not meet the tax filing threshold and is excluded from the total household income.

Example: Mary expects to claim her father, Matthew (age 61), as a tax dependent. Mary earns $2,500 a month in wages. Matthew earns $450 a month from his part-time job. Mary’s MAGI-based household will include herself and Matthew. Matthew’s income does not meet the tax filing threshold and is excluded from the total household income.

Matthew’s MAGI-based household will include only himself since he meets an exception to the tax dependent rules for being claimed as a tax dependent by someone other than his spouse or his parent. Matthew’s income is included regardless of whether it meets the tax filing threshold.

I-1554.5 Allowable Tax Deductions for MAGI

MAGI budgeting rules require the use of current monthly income in the

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 22 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**” Medicaid determination. Different methodologies are used for the different types of deductions in order to determing monthly MAGI-based income. The different types of deductions are consistent monthly, lump sum and annualized deductions. Consistent Monthly Deductions The monthly expense is deducted from the current monthly income.

Lump Sum Deductions Divide the total lump sum expense by 12 and deduct one twelfth from current monthly income.

Annualized Deductions Divide the total expense by 12 and deduct one twelfth from current monthly income.

I-1554.6 Methods to Budgeting Deductions

DEDUCTION TYPE METHODOLOGY Alimony payments ordered by a judgment dated prior to January 1, 2019. Consistent Monthly Deduction Deduct Monthly Certain business expenses of reservists, performing artists and fee basis government offices. Annualized Deduction Deduct 1/12 Monthly Deductible part of self-employment tax Annualized Deduction Deduct 1/12 Monthly Domestic production activities deductions Annualized Deduction Deduct 1/12 Monthly Educator expenses Lump Sum Deduction Deduct 1/12 Monthly Health savings account deduction (employee owned) Annualized Deduction Deduct 1/12 Monthly Hobby income expenses, or expenses from an activity from Annualized Deduction Deduct 1/12 Monthly

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 23 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**” which a profit was not expected Individuals who elect not to itemize tax deductions, contributions of money or made to the following qualified charities:  Churches, synagogues, temples, mosques, and other religious organizations;  Federal, state, and local governments, if solely for public purposes; Nonprofit schools and hospitals;  Nonprofit schools and hospitals; The Salvation Army, American Red Cross, CARE, Goodwill Industries, United Way, Boy Scouts of America, Girl Scouts of America, or Boys and Girls Clubs of America;  War veterans' groups Annualized Deduction Up to $300 for individuals. Up to $600 for people who file Married Filing Jointly Deduct 1/12 Monthly IRA deductions Annualized Deduction Deduct 1/12 Monthly Moving expenses: Only if active duty military and moved due to permanent change of station. Annualized Deduction Deduct 1/12 Monthly Penalties on early withdrawal of savings Annualized Deduction Deduct 1/12 Monthly Self-employed health insurance deductions Annualized Deduction Deduct 1/12 Monthly The deductible part of self- employment tax Annualized Deduction Deduct 1/12 Monthly Self-employed pension (SEP), Simple, and qualified plans Annualized Deduction Deduct 1/12 Monthly Student loan interest deductions Annualized Deduction Deduct 1/12 Monthly

A deduction is not allowed for money or property given to: o Civic leagues, social and sports clubs, labor unions, and chambers of Commerce;

(i-1550)(page-24)Page 24#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 24 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**” o Foreign organizations (except certain Canadian, Israeli, and Mexican charities); o Groups that are run for personal profit; o Groups whose purpose is to lobby for law changes; o Homeowners' associations; o Individuals; or 54 o Political groups or candidates for public office.

Obtain verification of any and all applicable deductions at application and redetermination.

Note: Do not allow the following credits or deductions:  The standard deduction.  Itemized deductions detailed in IRS Form Schedule A (home mortgage interest, medical and dental expenses, gifts to charity).  Child tax credits.  Child support payments.

I-1554.7 Projecting Income

Projecting income is the process of estimating the amount of income an individual is expected to receive during a specific period. This estimate uses available information, including recent pay, employer statements, year-to-date (YTD) earnings or averages to ensure eligibility is based on an accurate projection of the individual’s income.

When projecting income, the most accurate and verifiable information available must be used to estimate the amount the individual is likely to receive during the eligibility period. Projections must be reasonable, reflect expected ongoing earnings, and account for patterns such as fluctuating or seasonal pay. The method and data used to support the projection must be documented in the case record.

 Representative Pay – Use representative pay when available. Do not use pay that includes unusual overtime, bonuses, corrections, or other one-time payments to project or average ongoing income. When recent pay is non-representative,

(i-1550)(page-25)Page 25#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 25 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**” alternate methods such as YTD amounts or averaging may be used.  Non-Fluctuating Income – Base projections on the current rate of pay and regular schedule.  Fluctuating Income – Use YTD information or averaging to determine the most reasonable estimate of ongoing earnings.  YTD Income – YTD income may be used for missing pay periods when it provides a more accurate reflection of ongoing earnings, especially for fluctuating or seasonal income. Identify the time period represented to ensure a reliable average.  Average Income – Average income may be used when income fluctuates. Averages may be based on available pay periods, employer statements, or YTD information.

I-1555 MAGI - FINANCIAL ELIGIBILITY

I-1555.1 Resources

There is no asset or resource test for the MAGI groups.

I-1555.2 MAGI Budget Steps

To determine income eligibility: 1. Determine MAGI household composition for each individual requesting coverage. o Include the number of children expected to be delivered in the income unit when determining eligibility for a pregnant woman. Note: When determining Medicaid eligibility for pregnant women under age 19, all income is disregarded. 2. Determine countable income for each MAGI household. o Combine all countable MAGI-related types of income of each member of the household. Reduce income by MAGI-related taxable deductions for each member of the household.

Note: For a tax filer, the income of a tax dependent is not counted

(i-1550)(page-26)Page 26#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 26 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**” when less than the tax filing threshold. 3. Allow the five (5) percent disregard on MAGI budgets. 4. Compare the combined net countable income for the individual’s household to the applicable income standard for the household size. Refer to Z-200 Federal Poverty Income Guidelines. o If the countable income is at or below the income standard for the applicable MAGI group, the individual is income eligible. o If the countable income is above the income standard for the applicable MAGI group, the individual is income ineligible.

I-1556 GAP-FILLING RULE - FINANCIAL ELIGIBILITY

Gap filling is a component of the MAGI-based financial methodology for Medicaid/CHIP. The gap filling rule only applies to the individual’s finaincial eligibility determination. The individual must meet all other eligibility factors, including the requirements for an eligibility group.

Due to differences in eligibility rules, an individual may be financially ineligible for both Medicaid under the MAGI (Modified Adjusted Gross Income) rules used for Medicaid/CHIP and for the Advance Premium Tax Credit (APTC) under the MAGI rules used by the Marketplace for determining APTC. This results in a coverage gap where the individual may be determined to have monthly household income too high for Medicaid/CHIP and have annual household income too low for APTC.

Under the gap filling rule, financial eligibility for Medicaid/CHIP is determined using the household income as calculated for APTC purposes. Medicaid/CHIP-specific rules shall not be applied for the purposes of gap filling. This includes tax dependent exceptions, treatment of lump sum payments, and budgeting of current monthly income.

The Federally Facilitated Marketplace (FFM) bases APTC eligibility on annualized income. The household income used for APTC eligibility includes projected annual income for the entire calendar year. The household’s projected annual income must be at least 100% FPL but not exceed 400% FPL to qualify for APTC.

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 27 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**” I-1556.1 Application of the Gap-filling Rule

Determine financial eligibility for Medicaid/CHIP using gap-filling when the following conditions apply:

 The current monthly household income is over the applicable income standard; and,

 Projected annual income is below 100% FPL.

Household Composition

The household consists of:  The tax filer;  The tax filer’s spouse if filing jointly; and  All other tax dependents.

Note: Non-filer households and applicants who file federal income tax return married filing separately (with limited exceptions such as for domestic violence) cannot be determined eligible for Medicaid using gap-filling rule.

Household Income Household income includes:  The gross income of every household member required to file a federal income tax return;  Income counted is based on projected annual income for the current calendar year; Example Susan and her husband, Jon, are both enrolled in Medicaid. Jon has been working the full year and earns $1083 per month. Susan did not have income from January through July. On August 5, Susan reports that she started a new job on August 1, earning $1,500 per month. Monthly income test (August): • $1,500 (Susan) + $1083 (Jon) = $2583 monthly household income.

(i-1550)(page-28)Page 28#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued January 7, 2026 Page 28 of I-1550 Replacing November 13, 2025

Revised/added text indicated by underscore Deleted text indicated by “**” • The monthly income exceeds the Adult Group (AG) income limit of $2,433 (138% FPL). Annualized income test (January -December): • $1500 x 5 months = $7,500 (Susan) + $1083 x 12 months = $12,996 (Jon) = $20,496 total annual household income. Susan and John are over the income limit when evaluated on a monthly basis but their annualized income of $20,496 falls below 100% FPL annual income limit of for a household size of two ($21,150). Applying the gap-filling rule shows they remain eligible for Adult Group (138% FPL). Note: If an individual is ineligible due to income, evaluate for Spend- Down Medically Needy – MAGI-Based. See H-1020 Regular and Spend Down Medically Needy – MAGI-Based. Gap-filling methodology may also be used to determine retroactive eligibility, provided the individual's projected annual income is below 100% FPL and all other requirements are met. Retroactive coverage is limited to the standard three-month period prior to the application month, unless otherwise specified by policy. See H-1800 Retroactive Medical Eligibility (RME). I-1556.2 GAP-FILLING RENEWALS

A redetermination of financial eligibility of each individual determined eligible using gap-filling rule must be completed by January of the following calendar year.

Note: Redetermine eligibility for children under age 19 with 12 months continuous eligibility and indiviudals eligible for 12 months postpartum eligible when the continuous eligibility period ends.

(i-1600)Louisiana Medicaid Eligibility Manual (LDH): I - 1600 Need - Resources - General Information#

(i-1600)(page-1)Page 1#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued June 2, 2023

Page 1 of I-1600 Replacing February 28, 2020 Revised/added text indicated by underscore

Deleted text indicated by “**” I-1600 NEED – RESOURCES

I-1610 GENERAL INFORMATION

Resources are cash assets or those assets which can be converted to cash to meet basic needs.

I-1610.1 Resource Standards

Resource standards are used to determine need in relation to resources. The resource standard used depends on the type of program considered. The resource standards are the:

● Non-MAGI Related (SSI-Related) resource limits;

● QDWI resource limits; and

● Medicaid Purchase Plan resource limits.

Exception:

There is no resource test for:

• MAGI-Related programs;

• Family Opportunity Act Medicaid Program; or

• Medicare Savings Programs (QMB, SLMB, QI).

The standard for the number of persons in the resource unit is compared to the countable resources. Refer to Z-900 Resource Limits by Program.

I-1610.2 Determining Countable Value

Refer to I-1630 Need—SSI-Related Resources to determine the countable value for each type of resource.

I-1610.3 Conversion of a Resource

Receipts from the sale, exchange, or replacement of a resource are not income but are resources which have been converted from one form to another form (e.g., sale of a piece of property for cash). The

(i-1600)(page-2)Page 2#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued June 2, 2023

Page 2 of I-1600 Replacing February 28, 2020 Revised/added text indicated by underscore

Deleted text indicated by “**” value of the resource continues to be countable or becomes countable (e.g. sale of excluded home property for cash).

I-1611 VERIFICATION and DOCUMENTATION

Verify and document in the record, the value of resources at:

● application;

● renewal; and

● when a change is reported.

Refer to S-120 Documentary Evidence to find electronic sources available to verify and document resources and to I-1634 Types of Resources (SSI-Related) to determine acceptable hard copy documentation.

I-1612 RESERVED **

(i-1620)Louisiana Medicaid Eligibility Manual (LDH): I - 1620 Long-Term Care Partnership (LTCP) Program#

(i-1620)(page-1)Page 1#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued May 16, 2022

Page 1 of H-1620 Revised/added text indicated by underscore

Deleted text indicated by “**”

I-1620 LONG-TERM CARE PARTNERSHIP (LTCP) PROGRAM

I-1621 GENERAL INFORMATION

Effective October 1, 2009, Louisiana Medicaid implemented the Long-Term Care Partnership (LTCP) Program. The LTCP Program encourages Louisiana residents to plan for their future Long-Term Care (LTC) needs by offering individuals a way to protect their assets if they need to apply for LTC services. This program allows the policy beneficiary of a qualified LTCP policy to have certain resources disregarded in determining LTC Medicaid eligibility and to have those same resources protected from Medicaid estate recovery.

The resource disregard is applied in the form of a deduction when: • Determining the applicant/beneficiary’s resource eligibility for LTC Medicaid, and • Determining the amount of resources protected at Estate Recovery from the applicant/beneficiary’s estate. The purchase of a LTCP policy does not automatically qualify the applicant/beneficiary for Medicaid. An applicant/beneficiary who owns a LTCP policy can apply for Medicaid before the exhaustion of policy benefits.

I-1622 REQUIREMENT

For an applicant/beneficiary to be considered under the LTCP program, the applicant/beneficiary: • Must be the policyholder and beneficiary of the qualified LTC insurance policy, • Must have received some or all of the LTC benefits paid out under a qualified LTC policy prior to the month of application for LTC, and • Must meet the categorical, non-financial, financial, and medical eligibility requirements to qualify for Medicaid under nursing facility, Home and Community Based Services (HCBS), and/or PACE programs.

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued May 16, 2022

Page 2 of H-1620 Revised/added text indicated by underscore

Deleted text indicated by “**”

I-1623 DETERMINING IF A LTCP POLICY IS QUALIFIED

In order for a LTCP policy to be “qualified”, the policy must satisfy all relevant requirements of federal and state laws. The Louisiana Commissioner of Insurance is responsible for certifying that these policies are qualified. A listing of approved companies who can sell these policies can be found on the Louisiana Department of Insurance website.

Individuals who were a resident in another participating state who purchased qualifying policies are allowed to participate in the LTCP program if the policy was purchased when coverage first became effective under that State’s policy. A list of these participating states and start dates can be found at Reciprocating States.

A policy issued under a group insurance contract may be considered qualified if the certificate meets the requirements.

Policies issued prior to the LTCP program's effective date of October 1, 2009 are not considered a qualified policy. The policyholder may be entitled to exchange the existing non-qualified policy for a qualified policy. A policy received in an exchange on or after October 1, 2009, is treated as newly issued and is eligible for LTCP program status.

The applicant/beneficiary who owns an insurance policy that are not qualified as LTCP policies are not eligible to participate in the LTCP program and their resources cannot be disregarded in the Medicaid eligibility determination or protected from Estate Recovery.

I-1624 VERIFICATION NEEDED

Request a copy of the policy from the applicant/beneficiary. Verify with the Louisiana Department of Insurance that the insurance company is approved to sell these policies in Louisiana.

The applicant will be responsible for providing policy status changes (i.e. termination of coverage, change in ownership, termination of premiums).

(i-1620)(page-3)Page 3#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued May 16, 2022

Page 3 of H-1620 Revised/added text indicated by underscore

Deleted text indicated by “**”

I-1625 VERIFICATION OF PAID INSURANCE BENEFITS

Written verification from the insurance carrier of benefits is required.

The insurance carrier must verify the following policy information before the resource disregard can be applied for Medicaid eligibility or estate recovery purposes: • LTCP policy status, • Amount of insurance benefit payments made by the policy prior to application or renewal, and • The amount of benefits remaining. The Explanation of Benefits (EOB) statement is an acceptable form of paid benefits verification. Note: Insurance benefit payments, for purposes of resource disregarded when applying for Medicaid, are payments made for LTC benefits and services and do not include benefits such as cash surrender values, return of premiums, premium waiver, or death benefits.

I-1626 RESOURCES IN THE ELIGIBILITY PROCESS

The disregarded resource is determined on a 1:1 ratio. The amount of the disregard is equal to the amount of the insurance benefit payments made to or on behalf of the individual.

The resource rules used to determine eligibility for the LTC programs apply to this program with the exception of the resource disregarded.

The resource disregard can only apply to the resources owned by the policyholder/beneficiary. Once it is determined the policyholder is entitled to a resource disregard, the verified amount of benefits paid will be applied in the form of a deduction and will reduce the value of policyholder’s countable resources. These disregarded resources are protected from estate recovery.

(i-1620)(page-4)Page 4#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued May 16, 2022

Page 4 of H-1620 Revised/added text indicated by underscore

Deleted text indicated by “**”

Example 1: Ruth is a resident of a medical care facility. She has no spouse . Her qualified $90,000 LTCP policy has been paying for her care. When Ruth applies for LTC Medicaid, she verifies that her LTCP policy has paid out $80,000 in policy benefits. Ruth's total resources equal $81,000. You will deduct the $80,000 disregard leaving her with $1000 in countable resources. If Ruth were to pass away at this point, $80,000 of her resources would be protected from estate recovery.

A year later, Ruth’s eligibility for Medicaid is reviewed. Ruth verifies that she has exhausted her LTCP policy benefits, which has paid out the full $90,000. The worker determines that Ruth's total resources equal $91,000. Since $90,000 has been paid out by Ruth’s policy, an additional $90,000 in resources is disregarded. Ruth continues to qualify for Medicaid since she is still below the resource limit. If Ruth were to pass away, $90,000 of her resources would be protected from estate recovery.

Example 2: Emma had been residing in a nursing home and had been eligible for Medicaid for the past 2 years. Her $90,000 LTCP policy had been paying for a portion of her care. As of her last Medicaid review, the policy had paid out $70,000, an amount disregarded in determining her continued Medicaid eligibility. Ten months after her last review, Emma died. Emma’s representatives verify that her policy paid out an additional $10,000. Emma’s estate can protect a total of $80,000 from estate recovery.

The resource disregard can be applied to reduce or eliminate a transfer penalty on resources that the policyholder transferred without compensation. Any uncompensated transfer, or a portion thereof, not offset by the amount of the disregard, will result in a transfer penalty period.

The transferred resource does not affect an applicant/beneficiary’s eligibility for Medicaid vendor payment if the value does not exceed the value of the resource disregarded. The value of the transfer will result in a reduction or elimination of the resource disregard for Medicaid eligibility and estate recovery protection under LTCP.

(i-1620)(page-5)Page 5#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued May 16, 2022

Page 5 of H-1620 Revised/added text indicated by underscore

Deleted text indicated by “**”

Example: Joe applies for Medicaid and his LTCP policy has paid out $100,000. Joe is found eligible using his disregard of resources. A few months later, Joe reports he has given $100,000 to his son. Because he has given away no more than the $100,000 protected asset amount, there is no transfer penalty. However, because he has divested the entire payout amount, he can no longer take advantage of the LTCP protections with regard to his Medicaid eligibility. That means he must have assets below $2,000 to remain eligible (instead of $102,000). Since he already gave away the entire protected amount during his lifetime, that amount will not be protected from estate recovery.

I-1627 TREATMENT OF SUBSTANTIAL HOME EQUITY

The LTCP resource disregard cannot be applied to excess home equity value. If an applicant/beneficiary’s equity value in their home property exceeds limit in effect at time of application (Refer to MEM Z-2300), and the exceptions or undue hardship does not apply, the applicant/beneficiary is not eligible for LTC services of vendor payment to the nursing facility, HCBS, or PACE.

I-1628 TREATMENT OF RESOURCES - SPOUSAL RESOURCE ELIGIBILITY DETERMINATION

The resource disregard can only apply to the resources owned by the applicant/beneficiary receiving LTC services who is the policyholder/beneficiary and not to resources owned separately by the community spouse. Jointly owned resources are considered as belonging to the applicant.

The following steps will be used when resource eligibility is being reviewed under the Spousal Impoverishment Resource Provision for allocating resources: Step 1 Determine the applicant’s total countable resources

for the most recent continuous period of LTC services, Step 2 Deduct the dollar amount of paid insurance benefits the applicant/beneficiary receiving LTC services received from the qualifying policy, Step 3 This remainder is the applicant’s remaining resources,

(i-1620)(page-6)Page 6#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued May 16, 2022

Page 6 of H-1620 Revised/added text indicated by underscore

Deleted text indicated by “**”

Step 4 Add these remaining resources to the Community Spouses separate resources, Step 5 This sum is the Adjusted Countable Couple Resources, Step 6 Deduct the Spousal Impoverishment Resource

Standard (based on the first continuous period of LTC

services), Step 7 Compare the amount to the SSI Individual Resource

Limit ($2,000) to determine if the applicant/beneficiary

receiving LTC services is resource eligible.

I-1629 RESOURCES TRANSFERRED TO COMMUNITY SPOUSE

The following steps should be used when determining the amount of resources that may be allocated to the community spouse under the Spousal Impoverishment Resource Provision above for allocating resources. Step 1 Determine the Adjusted Countable Couple Resources Step 2 Deduct the Community Spouses Separate Resources Step 3 Deduct the SSI Individual Resource Limit Step 4 The remaining resources have to be transferred to the

community spouse prior to the first renewal. If the community spouse, who is not a LTCP policyholder, applies for LTC or HCBS, Medicaid eligibility for the spouse shall be determined using the standard Medicaid rules. Consequently, only the LTCP policyholder’s portion of resources will be disregarded and protected. The remaining unprotected resources will be considered available to the non-Partnership spouse for purposes of determining Medicaid eligibility.

Example: Mr. Jones is married and has a community spouse. Mr. Jones entered a nursing facility and is applying for Medicaid. The Jones’ have the combined total of countable resources of $250,000. Mr. Jones’ LTCP policy has paid $200,000 of benefits on his behalf. The adjusted countable resources of $50,000 is less than the spousal resource standard so the countable resources are $0, which is less than the $2,000 resource limit. For Mr. Jones to remain eligible for Medicaid, $50,000 adjusted countable couple resources minus

(i-1620)(page-7)Page 7#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued May 16, 2022

Page 7 of H-1620 Revised/added text indicated by underscore

Deleted text indicated by “**”

the $2,000 SSI Individual resource limit leaves $48,000 that must be transferred to Mrs. Jones prior to the first renewal.

I-1630 TREATMENT OF RESOURCES AT RENEWAL

If the policy benefits were not exhausted at application, the applicant/beneficiary may continue to receive LTCP benefits and would be entitled to an additional resource disregard and protection equal to the amount of benefits paid out since the last eligibility determination.

The difference between the total value of all verified resources minus the verified benefit amount paid out to date (the available disregard) by the LTCP policy is the beneficiary’s countable resources.

A Special Needs Trust or an annuity which names the State of Louisiana, Louisiana Department of Health as the residual beneficiary of funds remaining, cannot be protected under the LTCP Program due to federal law and must be available after death of the applicant to reimburse Medicaid for the benefits paid on behalf of the applicant.

I-1632 CASE RECORD DOCUMENTATION

Document all information verified and any documentation received in the case record.

I-1632 TREATMENT OF ONGOING INSURANCE PAYMENTS Income

LTCP policy benefits paid directly to the beneficiary while a beneficiary is receiving Medicaid payment of LTC services under this policy will be considered unearned income and will be budgeted in the month of receipt.

Third Party Liability

(i-1620)(page-8)Page 8#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Issued May 16, 2022

Page 8 of H-1620 Revised/added text indicated by underscore

Deleted text indicated by “**”

LTCP policy benefits paid directly to the provider under this policy that are available while a beneficiary is receiving Medicaid payment of LTC services are treated as third party liability. Medical Deduction

A post-eligibility deduction may be given for a LTCP policy premium if the policyholder continues to pay the premium while receiving benefits.

(i-1630)Louisiana Medicaid Eligibility Manual (LDH): I - 1630 Need - SSI-Related Resources#

(i-1630)(page-1)Page 1#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 1 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” I-1630 NEED - SSI-RELATED RESOURCES

I-1631 REQUIREMENT

Countable resources shall not exceed the allowable limits of:

• $2,000 per individual, or

• $3,000 per couple.

Exception: Grandfathered and/or converted beneficiaries shall have their resources compared to the limits established on or prior to December 31, 1973.

Effective October 1, 2019, all resources shall be disregarded in eligibility determinations for Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB) and Qualifying Individual (QI) Programs.

Refer to Z-900 Resource Limits by Program.

I-1632 RESOURCE UNIT

The resource unit is the individual or group of individuals whose resources must be considered in determining eligibility.

I-1633 GENERAL INFORMATION

Count resources as of the first moment of the first day of the month.

Changes in resources during the month do not affect resource eligibility for the month. If resources are acquired during the current month, re-evaluate resource eligibility as of the first day of the following month.

Since money shall not be considered as income and a resource in the same month, do not count as a resource any money considered as income.

(i-1630)(page-2)Page 2#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 2 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” Occasionally, a regular periodic payment (e.g., wages, title II, or VA benefits) is received in a month other than the month of normal receipt. Such funds are first subject to evaluation as resources in the month following the month of normal receipt. Refer to I-1500 Need – Income for how the income should be counted.

 Income remaining the first day of the month after the month of receipt becomes a resource.

Exception: SSI and RSDI lump sum payments received prior to March 2, 2004 are excluded as resources for six months. Payments received after March 2, 2004 are excluded for nine months. Refer to Lump Sum Payments.

Money received to enable the beneficiary to pay outstanding debts for medical or social services (e.g., payment received from Medicare for an outstanding debt) is excluded as a resource for one full calendar month following the month of receipt. Any funds retained as of the first moment of the second month following receipt are included as a countable resource at that time.

Refer to I-1660, Spousal Impoverishment Resource Provisions, for additional information regarding resources of LTC, HCBS, ACH or PACE applicants/beneficiary(s) with community spouses.

Refer to I-1670, Transfer of Resources for Less Than Fair Market Value, for policy concerning transferred resources.

If the applicant/beneficiary is a child or a qualified non-citizen, refer to I-1420, Need - Deeming.

Resources are available if:

• The resource unit has legal means to access,

Note: "Legal means to access" includes property settlement and succession. If there is any way the person can legally obtain the resource, then it is considered available.

• The cash value is available to the resource unit, or

• Held by a representative payee, legal guardian, or curator on

(i-1630)(page-3)Page 3#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 3 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” behalf of an applicant/beneficiary. These resources are treated as though the applicant/beneficiary were controlling and managing them.

Consider the resource available to the applicant/beneficiary regardless of:

• Power of attorney,

• Interdiction,

• Need for interdiction, or

• The fact that a succession has not been opened or settled.

Equity value is the amount for which the resource can be expected to sell on the open market in the particular geographic area (fair market value) less legal encumbrances to the resource.

To establish equity, the encumbrance must be recognized as legally binding on the holder of the resources.

The inability to find a buyer for the resource does not affect the determination of countable value.

An encumbrance may also exist when the applicant/beneficiary has written a check and legally obligated funds from a bank account. Refer to Bank Accounts.

I-1634 TYPES OF RESOURCES (SSI-Related)

 Louisiana Achieving a Better Life Experience (ABLE) Account

Achieving a Better Life Experience (ABLE) account is a tax- advantaged savings account that enables individuals with disabilities to save money which can later be used to pay for qualified disability expenses (QDE).

Do not count funds in an ABLE account as a resource.

Note: SSI counts as a resource the amount of an ABLE account that is over $100,000. If the countable amount of the ABLE account causes the individual to have resources that exceed the SSI

(i-1630)(page-4)Page 4#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 4 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” resource limit, SSI benefits are suspended until the resources are reduced below the SSI limit. Medicaid eligibility continues during the suspension.

 Accumulated Resources due to the COVID-19 Public Health Emergency

Disregard resources accumulated from March 18, 2020 through March 31, 2023 that would have otherwise been part of an individual’s liability for his or her institutional or home and community-based waiver services based on application of the post-eligibility treatment of income (PETI) rules. Such resources will continue to be disregarded through the twelfth month following the first full redetermination of the beneficiary’s eligibility conducted after March 31, 2023.

Note: If accumulated resources are commingled with countable funds, assume countable funds are spent first.  Agent Orange Settlement Payments

Do not count unspent portions of Agent Orange Settlement payments.

Note: Do not count as income any interest earned on the unspent portion. Any interest retained after the month of receipt becomes a resource.

 Annuities

For employment related annuities, refer to Retirement Funds.

For Medicaid eligibility purposes an annuity is considered a legal instrument or device similar to a trust (Refer to I-1730, Trusts Established After August 11, 1993). An annuity is defined as a contract or agreement by which one receives fixed non variable payments on an investment for a lifetime or a specified number of years.

Treatment of Annuities created January 1, 2003 thru February 7, 2006

An annuity containing a balloon payment will be considered an available resource. An annuity purchased by or for an individual using that individual’s assets will be considered an available

(i-1630)(page-5)Page 5#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 5 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” resource unless all of the following criteria are met. The annuity:

1. Is irrevocable;

2. Pays out principal and interest in equal monthly installments (no balloon payment) to the individual in sufficient amounts that the principal is paid out within the actuarial life expectancy of the institutionalized individual,

3. Names the State of Louisiana, Louisiana Department of Health (LDH) or its successor agency as the primary and permanent residual beneficiary of funds remaining in the annuity, not to exceed any Medicaid funds expended on the individual during their lifetime, and

4. Is issued by an insurer or other body licensed and approved to do business in the jurisdiction in which the annuity is established.

Annuities which do not meet all of the above criteria must be amended to comply with these requirements. Annuities which do not provide for pay out of principal and interest in equal monthly installments and for which documentation is received from the issuing company that the “pay out” arrangements cannot be changed, will be considered to meet the new requirements once amended to name the State of Louisiana, Department of Health and Hospitals or its successor agency as the primary and permanent residual beneficiary of funds remaining in the annuity, not to exceed any Medicaid funds expended on the individual during their lifetime.

Note: The Department of Insurance web site can be used to determine if a company is licensed and approved to do business in LA. The site is www.ldi.state.la.us. Use the Industry Search feature, at Search Forms use Company Search Form. The name of the company is entered for the search.

Use Z-1200 Life Expectancy Tables to determine actuarial life expectancy of the annuitant when necessary.

Treatment of Annuities created on or after February 8, 2006

Effective February 8, 2006, all long term care applicants, including SSI beneficiaries, were required to disclose on their application

(i-1630)(page-6)Page 6#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 6 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” and renewals for Medicaid assistance, a description of any interest the applicant or community spouse may have in an annuity. The disclosure is a condition for Medicaid coverage of long term care services, including nursing facility services and home and community based waiver services.

This disclosure requirement applies regardless of whether or not an annuity is irrevocable or is treated as an asset.

Note: Application and renewal forms for long term care are required to include a statement that names the State as a remainder beneficiary on any annuity purchased on or after February 8, 2006 by virtue of the provision of medical assistance for institutional care.

Requirement to Name the State as Beneficiary

The requirement to name the state as a remainder beneficiary is not restricted to annuities purchased by or on behalf of an institutionalized individual who has applied for medical assistance for nursing facility or other long term care services. It applies to annuities purchased by an applicant or by a spouse, and to transactions made by the applicant or spouse.

An annuity must name the State as the remainder beneficiary in the first position for the total amount of Medicaid assistance paid on behalf of the institutionalized individual unless there is a community spouse and/or a minor or disabled child. If there is a community spouse and/or a minor or disabled child, the State may be named in the next position after those individuals.

If the state has been named beneficiary after a community spouse and or a minor or disabled child, and any of those individuals or their representatives dispose of any of the remainder of the annuity for less than fair market value, the State may then be named in the first position.

If the state is not named as a remainder beneficiary in the correct position, the purchase of the annuity will be considered a transfer for less than fair market value if it was obtained within the 60 month lookback period. The full purchase value of the annuity will be considered the amount transferred. If the annuity was purchased outside of the lookback period, the full Fair Market Value should be

(i-1630)(page-7)Page 7#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 7 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” counted as a resource.

For any annuity disclosed, Medicaid must also notify the issuer of the State’s right as a preferred remainder beneficiary.

Medicaid may also require the issuer to notify it regarding any changes in disbursement of income or principal from the annuity.

The issuer of an annuity may disclose information about the State’s position as remainder beneficiary to others who have a remainder interest in the annuity.

Refusal to disclose sufficient information related to any annuity will result in denial or termination of Medicaid entirely, based on the applicant’s failure to cooperate in accordance with existing Medicaid policies.

When an unreported annuity is discovered after eligibility has been established and after payment for long-term care services has been made, appropriate steps to terminate payment for long term care services will be taken, including appropriate notice to the individual of the adverse action.

In addition to purchases of annuities, certain related transactions which occur to annuities on or after February 8, 2006 make an annuity, including one purchased before that date, subject to all of the annuity provisions that went into effect on February 8, 2006.

Any action taken on or after February 8, 2006 by the individual that changes the course of payment to be made by the annuity or the treatment of the income or principal of the annuity, including:

• Additions of principal,

• Elective withdrawals,

• Requests to change the distribution of the annuity,

• Election to annuitize the contract and similar actions taken by the individual.

Routine changes and automatic events that do not require any action or decision after the effective date of the enactment are not considered transactions that would subject the annuity to treatment under these provisions that went into effect on February 8, 2006.

(i-1630)(page-8)Page 8#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 8 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**”

Treatment of Annuities in Determining Eligibility

The following types of annuities are not treated as a transfer of assets if the annuity meets the following conditions (these conditions do not apply to an annuity owned or purchased by the community spouse):

a) The annuity is considered either :

(1) An individual retirement annuity (according to Section 408(b) of the Internal Revenue Code of 1986 (IRC)), or

(2) A deemed Individual Retirement Account (IRA) under a qualified employer plan (according to Section 408(q) of the (IRC)); or

b) The annuity is purchased with proceeds from one of the following:

(1) A traditional IRA (IRC Sec. 408a); or

(2) Certain accounts or trusts which are treated as IRAs (IRC Section 408 §(c)); or

(3) A simplified retirement account (IRC Sec. 408 §(p)); or

(4) A simplified employee pension (IRC Sec. 408 §(k)); or

c) The annuity meets all of the following requirements:

(1) The annuity is irrevocable and non-assignable; and

(2) The annuity is actuarially sound; and

(3) The annuity provides payments in approximately equal amounts, with no deferred or balloon payments.

Applicants or their responsible or authorized representative will be responsible for providing documentation from the financial institution for verifying qualifying IRS annuities. Absent such documentation, the purchase of the annuity will be considered a transfer for less than fair market value which is subject to penalty. The full purchase value of the annuity will be considered the

(i-1630)(page-9)Page 9#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 9 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” amount transferred.

Even if the purchase of an annuity is not treated as a transfer, if the annuity or income stream from the annuity is transferred, it may be subject to a penalty except when transferred;

• To or for the spouse’s sole benefit,

• To their child who is under age 21 or blind or disabled,

• Or to a trust established solely for the benefit of an individual under 65 years of age who is disabled,

Consideration of Income and Resources from an Annuity

Even when an annuity is not penalized as a transfer of resources, it must still be considered in determining eligibility, including spousal income and resources, and in the post eligibility calculation.

Count Income or resources derived from an annuity in determining eligibility.

The state is required to notify the issuer of any annuity disclosed under these provisions of the state’s rights as a preferred beneficiary. The state may require the issuer to notify it regarding any changes in disbursement of income or principal from the annuity.

 Bank Accounts

Count the balance shown by the bank for the first moment of the first day of each month for which eligibility is considered.

Advise the applicant/beneficiary and/or the authorized representative:

• Of their responsibility to furnish information on all bank accounts, and

• That a computer match to the IRS 1099 file will be done.

Investigate all accounts declared by the applicant/*beneficiary/ authorized representative or reported by any other source.

(i-1630)(page-10)Page 10#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 10 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” Do not count income received in a month and deposited in a bank account in determining resource eligibility for that month.

An encumbrance is defined as a legal obligation to pay a debt. An encumbrance may exist when a check has been written from a bank account, and it has not cleared by the first moment of the first day of the month in which eligibility is considered. To establish the equity value of a bank account, an encumbrance may be deducted from the bank account balance.

When the applicant/beneficiary and/or the authorized representative allege that a check was written that legally obligated funds in an account, determine that:

• The check was written prior to the month for which eligibility is considered (copy of check and/or check registry),

• The amount of the check was deducted from the bank account the month which eligibility is considered, and

• The check was not written with the purpose to reduce resources in order to qualify for Medicaid (establish historical patterns).

Example: The applicant’s bank statement shows an account balance of $2,050 as of May 1. The applicant alleges the statement balance includes a rent check of $500 which was written and given to the landlord on April 25, but the landlord has not yet cashed the check.

Review of the applicant’s bank statement shows a $500 check was written on April 25, and the check cleared the bank and has been deducted from the applicant’s account. Further review of the applicant’s bank statements shows a history s/he has written a $500 check to their landlord for rent on the 25th of each month for the last six months.

Since there is evidence that the applicant has written the check and has legally obligated those funds in the account, and their records provide a complete and consistent picture of the account, deduct the $500 check from the May 1 account balance of $2,050 as of May 1. The new balance of $1,550 is considered in determining resource eligibility.

Count direct deposits made at the end of a month for the following

(i-1630)(page-11)Page 11#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 11 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” month as income in the month for which it is intended. The balance is considered a resource the first day of the following month (e.g., SSA income).

Bank accounts can be set up in a variety of ways including individual accounts, joint accounts, funds held in the account of another, or charitable funds accounts. ** Individual Accounts

Count the value of funds maintained in a checking or a savings account on which the applicant/beneficiary's name appears.

Joint Accounts

Restricted Access ("and") Accounts

Count the value of the applicant/beneficiary's ownership interest in the account less encumbrances if:

• The funds are held jointly with an ineligible individual(s), and

• The applicant/beneficiary has restricted access.

Ownership interest is presumed to be the applicant/beneficiary's equal share, unless the applicant/beneficiary rebuts this presumption.

Rebuttal for Restricted Access Accounts

The applicant/beneficiary may rebut the presumption(s) if:

• Access is denied by the other owners, or

• The applicant/beneficiary does not consider themselves owner of at least an equal share of the account.

The following documentation is required to rebut the presumption:

(i-1630)(page-12)Page 12#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 12 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” • A written statement from the applicant/beneficiary or authorized representative giving their statement regarding:

- Ownership of the funds,

- The reason the joint account was established,

- Who made deposits to or withdrawals from the account,

- How the withdrawals were spent, and

• Corroborating statements from the other account holder(s).

The applicant/beneficiary must:

• Change the account designation to remove their name, or

• Establish a new account in his/her name which contains only their funds.

The applicant/beneficiary must submit the original new or revised account records to document the change.

If the rebuttal is successful, consider the change in the "and" account effective the date of application.

Presumption of equal share is upheld if the applicant/beneficiary:

• Chooses not to rebut the presumption, or

• Does not provide all documents necessary to rebut the presumption.

If the presumption is upheld, count an equal share of the joint account(s).

Unrestricted Access ("or") Accounts

The applicant/beneficiary is presumed to be the owner of all

(i-1630)(page-13)Page 13#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 13 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” of the funds held in an unrestricted access account.

Count the total value of the account less encumbrances regardless of the source of the funds if:

• The funds are held jointly with an ineligible individual(s), and

• The applicant/beneficiary has unrestricted access.

Count an equal share of the account regardless of the source of the funds if:

• Two or more eligible applicants/beneficiaries are holders of the same joint account with or without ineligible individuals, and

• Each has unrestricted access to the funds in the account.

Rebuttal for Unrestricted Access Accounts

The applicant/beneficiary may rebut the presumption(s) if:

• There is unrestricted access, and

• The applicant/beneficiary does not consider themselves owner of all or part of the funds.

The following documentation is required to rebut the presumption of full or partial ownership:

• A written statement from the applicant/beneficiary or responsible party giving their statement regarding:

- Ownership of the funds,

- The reason the joint account was established,

- Who made deposits to or withdrawals from the account, and

- How the withdrawals were spent,

(i-1630)(page-14)Page 14#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 14 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” • Corroborating statements from the other account holder(s),

• A change in the name of the account(s) to correctly reflect ownership, or establishment of a new account in the applicant/beneficiary’s name which contains only their funds if they claim partial ownership, and

• Submittal of the original new or revised account records to document the change.

If the rebuttal is successful, consider the change in the "or" account effective the date of application.

Presumption of ownership is upheld if the applicant/beneficiary:

• Chooses not to rebut the presumption,

• Does not provide all documents necessary to rebut the presumption, or

• Does not change the account and submit documentation as required after a successful rebuttal.

If the presumption is upheld:

• Count the full value of the joint account(s) if held with an ineligible person(s), or

• Count an equal share of total funds if held with one or more eligible person(s).

Funds Held In The Account of Another

Count the value of funds held for an applicant/beneficiary in the account of another if:

• The holder of the account agrees that the funds belong to the applicant/beneficiary, and

• The funds are available to the applicant/beneficiary.

Encourage the applicant/beneficiary to:

(i-1630)(page-15)Page 15#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 15 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**”

• Correctly name the account at the financial institution, or

• Convert their share to a correctly named account.

Do not count the value of the funds if the holder(s) of the account:

• Will not acknowledge the applicant/beneficiary's ownership of the funds, or

• Denies the applicant/beneficiary access to the funds.

Verification of value of the funds shall include written statements from the applicant/beneficiary and the holder of the account.

Charitable Funds Bank Accounts

Count the value of funds in an account set up to receive and hold charitable contributions if:

• The name of the applicant/beneficiary is on the account, and

• The funds are available to the applicant/beneficiary.

Dedicated Accounts

Do not count as a resource. Account set up for a person under 18 years of age with a representative payee, who is eligible for a lump sum for past-due SSI benefits. If the lump sum is 6 times the FBR, SSA requires the representative payee to establish a dedicated account in a financial institution for the money to be deposited. Subsequent past due benefits may be but are not required to be deposited in the account. The money is to be kept separate from other money and used for certain expenses. Do not count interest earned on the accounts as income or resources.

Direct Express Card Account

The Direct Express Card allows individuals receiving Social Security or Supplemental Security Income payments to have

(i-1630)(page-16)Page 16#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 16 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” their benefit directly deposited in their card account. Count direct deposits as income in the month for which it is intended. The balance is considered a resource the first day of the following month.

 Bonds

A bond is:

• A written obligation to pay a sum of money on a future, specified date,

• Not cash but a promise to pay cash,

• A negotiable instrument, and

• Transferable.

Municipal, Corporate, and Government Bonds

A municipal bond is an obligation of a:

• State,

• Locality (county, parish, city, town, village), or

• Special-purpose authority (e.g., a school district).

Corporate bonds include bonds and debentures of private corporations.

U.S. government bonds are distinct from U.S. Savings Bonds as they are transferable obligations issued or backed by an agency of the federal government.

Count the current bond market value.

A municipal or corporate bond must be held until the specified date of maturity for it to be redeemed for the stated value. The current cash value of a bond before maturity is determined by the bond market.

(i-1630)(page-17)Page 17#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 17 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” It is the applicant/beneficiary's responsibility to provide a written statement from a securities dealer verifying the value.

U. S. Savings Bonds

A U.S. Savings Bond:

• Is an obligation of the federal government,

• Is not transferable,

• Can only be sold back to the government,

Savings bonds are issued as traditional paper bonds or as book- entry securities. Book-entry securities (also called savings security instruments or electronic savings bonds) are sold online by the U.S. Treasury Department.

The individual in whose name a U.S. Savings Bond is registered is the owner. The owner may name a beneficiary of the bond but retains sole ownership rights throughout their lifetime. Upon death of the owner the beneficiary then becomes the new owner.

Paper bonds may have co-owners. Each individual owns equal shares of the redemption value of the bond.

Some electronic bonds called “with” bonds may have the owner listed with one additional person. The additional person listed has authority to cash the bond but has no ownership rights.

Ownership of paper bonds is noted on the front of the bond and can be verified by viewing the bond itself. Ownership of electronic bonds is maintained by the Treasury Department and verification is obtained by the owner downloading a record of the holdings from the Treasury Department.

Physical possession of a paper bond is a requirement for redeeming it. If a person other than the applicant/beneficiary will not relinquish possession of the bond, it is not a resource. This applies to sole and co-ownership bonds. Obtain a statement from this other person verifying that s/he:

• Has physical possession of the bond,

(i-1630)(page-18)Page 18#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 18 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” • Will not allow the bond to be cashed, and

• In the case of a co-owner, will not cash the bond and give the individual their share of its value.

Physical possession does not apply to electronic bonds.

U.S. Savings Bonds are subject to a mandatory retention period before they can be redeemed and therefore are excluded from resources as following:

• Series E, EE, and I bonds issued prior February 1, 2003 for the first 6 months,

• Series EE and I bonds issued on or after February 1, 2003 for the first 12 months, and

• Series H and HH bonds for first 6 months regardless of the issue date.

Count the current cash value as a resource the month following the last month of the exclusion period.

To determine the value of E, EE and I Paper Bonds:

• Use the tools at TreasuryDirect.gov such as theSavings Bond Calculator;

• Use a current copy of the Table of Redemption Values for U.S. Savings Bonds; or

• As a last alternative, obtain the value from a local bank.

To determine the value of E, EE, or I Electronic Bonds ask the applicant/beneficiary to obtain the “Current Holdings” list from the Treasury Direct web site, http://www.savingsbonds.gov/. Electronic bonds have no set denominations (can be purchased in any amount between $25 and $30,000) so the value cannot be determined the same as paper bonds.

If the individual alleges that the Current Holdings list cannot be obtained because the password or account number has been lost, the individual must contact the Treasury Department to retrieve them.

(i-1630)(page-19)Page 19#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 19 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**”

Series E, EE and I bonds accrue interest which is added to the redemption value of the bonds. Owners do not receive interest payments.

Series H and HH are only issued as paper bonds. They are issued at their face value and do not increase in value. Interest is paid to the owner every six months. Do not count the interest as income in the month of receipt. The cash value is the bond’s face value and is obtained from the bond itself.

 Bond for Deed

A Bond for Deed is a contract for the sale of property in which the transfer of ownership is delayed until the property is paid for in full or paid down to an agreed upon level. The seller no longer has legal rights to sell the property or convert it to cash, therefore, it is no longer available to them and NOT a countable resource. A Bond for Deed contract may be cancelled if the buyer fails to make the scheduled payments. If the Bond for Deed is cancelled, the property becomes a countable resource to the seller.

Count interest and principal portion of payments received on a Bond for Deed as unearned income in month of receipt.

 Burial Contracts

A burial contract is a resource if it is revocable or salable, and conditions for its liquidations do not present a significant hardship.

However –

• Any portion of the contract that clearly represents the purchase of burial space, may be excludable, and

• Some or all of the remaining value may be excludable as burial funds.

A burial contract is not a resource if it cannot be revoked and cannot be sold without significant hardship.

Note:

(i-1630)(page-20)Page 20#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 20 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” The $1,500 ($10,000 for Non-MAGI Related Medically Needy program, MPP and the special income level group [LTC, individual in a medical institution for at least 30 days or receiving waiver services for 30 consecutive days]) burial fund exclusion is reduced by the value of the irrevocable contract.

Significant hardship means an unrealistic demand on the buyer, e.g., having to move out of state. If conditions creating hardship are not evident on the face of the contract, count the contract as a resource unless the applicant/beneficiary provides evidence to the contrary.

Use the value of the amount payable upon revocation or use its current market value if the contract is not revocable but is salable as the countable resource value.

A life insurance funded burial contract involves an individual purchasing a life insurance policy on their own life and then assigning, revocably or irrevocably, either the proceeds or ownership of the policy to a third party, generally a funeral provider to fund the contract. The value of the burial arrangement is the value of the life insurance policy.

Example #1: Mrs. Jones files an application for LTC. Her resources consist of two life insurance policies with a total face value of $14,500 and CSV of $2,850 and an irrevocable burial contract of $12,000. Since the total face value exceeds $10,000, count the CSV of the policies. Since the maximum excludable amount of funds for burial is met by the irrevocable burial contract, no further burial exclusion is allowable and Mrs. Jones is ineligible for medical assistance because her countable resources of $2,850 are above the allowable limit.

Example #2: Mr. White is a resident of a Medicaid facility. He applies for Medicaid. His resources consist of two life insurance policies with a total face value of $1,000 and a savings account with a balance of $10,000, which he intends to use for burial. The face value of the life insurance policies meets $1,000 of the $10,000 allowable exclusion. The additional $9,000 that may be excluded for burial reduces the savings account balance to $1,000 ($10,000 - 9,000). This is within the resource limit. Mr. White is eligible because the entire fund is designated for burial.

Example #3:

(i-1630)(page-21)Page 21#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 21 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” Mrs. Green applies for Extended Medicaid. Her countable resources consist of three whole life insurance policies with a total face value of $2,500 and total CSV of $1,950 and a checking account with a balance of $525. Mrs. Green designates the countable CSV of her life insurance policy for her burial. The total CSV of $1,950 minus the limit of $1,500 for burial leaves $450 in non-excluded CSV of life insurance policies. Mrs. Green's countable resources have a total value of $975, $450 plus $525 (checking account). This is within the resource limit, and Mrs. Green is eligible.

Irrevocable Arrangements

A pre-need funeral contract may be excluded as a countable resource if it is an irrevocable contract and includes an itemized list of services with a total value equal to the pre-paid amount.

A burial fund contract funded by life insurance may be excluded as a countable resource if:

• The ownership of the life insurance is irrevocably assigned to a funeral home; or

• The owner has signed an amendment irrevocably waiving their rights under the policy to surrender the policy for cash, to obtain a loan against the policy or to change the ownership.

Obtain a copy of any irrevocable burial contracts, trusts, or arrangements.

Irrevocable arrangements including placing funds in a burial trust are considered a purchase and not a transfer regardless of the date of the transaction.

 Burial Funds

Funds set aside for the burial expenses of the applicant/beneficiary and/or their spouse may be excluded if certain criteria regarding use and total value of the burial funds are met.

Burial funds are:

(i-1630)(page-22)Page 22#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 22 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**”

• All or part of the CSV of all life insurance policies which were used to determine total countable resources because the total face value was over $1,500 ($10,000 for Non-MAGI Related Medically Needy program, MPP, and the special income level group [LTC, individual in a medical institution for at least 30 days or receiving waiver services for 30 consecutive days]).

• Revocable burial contracts;

• Revocable burial trusts;

• Other revocable burial arrangements (including the value of certain installment sales contracts for burial spaces);

• Cash;

• Savings or checking accounts; or

• Other financial instruments with a definite cash value (stocks, bonds, certificate of deposit, etc.).

Funds must be clearly designated for the individual's or spouse's burial expenses. Property other than listed above will not be considered as burial funds.

A maximum exclusion of up to $1,500 ($10,000 for Non-MAGI Related Medically Needy program, MPP, and the special income level group [LTC, individual in a medical institution for at least 30 days or receiving waiver services for 30 consecutive days]) each in funds set aside is allowed for:

• The burial expenses of the individual; and

• The burial expenses of the individual's spouse.

The burial fund exclusion is separate from and in addition to the burial space exclusion. Burial funds may include payments made on installment contracts for burial spaces which do not qualify for the burial space exclusion.

The maximum $1,500 ($10,000 for Non-MAGI Related Medically Needy program, MPP, and the special income level group [LTC, individual in a medical institution for at least 30 days or receiving

(i-1630)(page-23)Page 23#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 23 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” waiver services for 30 consecutive days]) burial fund exclusion is reduced by the following:

• The face value of burial insurance which has no cash surrender value. Refer to Life Insurance.

• The full face of any life insurance policies which were disregarded as resources because the total face value was $1,500 ($10,000 for Non-MAGI Related Medically Needy program, MPP, and the special income level group [LTC, individual in a medical institution for at least 30 days or receiving waiver services for 30 consecutive days]) or less and any accumulated dividends. Refer to Life Insurance.

• The value of a prepaid burial contract excluding the value of burial spaces if their value can be identified in the contract. Any unidentified portion of a contract that implies it covers burial space items but does not identify them is considered burial funds. Refer to Burial Contracts.

A subsequent purchase of a disregarded life insurance policy or an irrevocable burial contract reduces the amount of exclusion effective the month after the month in which the life insurance or the irrevocable burial contract was purchased.

Determine the excludability of funds set aside for burial. In order to be excluded, the funds must be:

• Kept separate from non-burial related resources,

• Separately identifiable for each spouse, and

• Designated for burial.

Written verification that the resource is separately held and not co- mingled with non-burial assets is required.

Funds which are not co-mingled can be designated for burial by a written statement signed by the applicant/beneficiary and/or their spouse.

The statement shall contain:

• The specific resource which is designated for burial (e.g.,

(i-1630)(page-24)Page 24#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 24 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” countable life insurance CSV, burial contract, bank account),

• The amount of funds set aside for burial,

• For whose burial the funds are set aside,

• The date the funds were set aside, and

• The individual's acknowledgement that any money withdrawn from funds set aside for burial will be counted as income in the month of withdrawal.

Separately held funeral funds may be excluded to the later of the following dates:

• The first day of the month following the month in which funds are separately held and not commingled,

• November 1, 1982, or

• Month of application.

Exclude from resources (and from income) any increase in the value of excluded funds because of accumulated interest or appreciation of the funds. This includes interest earned by burial funds, provided the interest is left to accumulate as part of the funds.

Once a fund is designated for burial purposes, it remains a burial fund until:

• Eligibility terminates,

• Part or all of the fund can no longer be excluded as a burial fund because the individual purchased excluded life insurance or an irrevocable burial contract which partially or totally offsets the available burial fund exclusion, or,

• The individual uses the funds for another purpose.

Note: Transferring excluded burial funds from one form of burial exclusion to another is not considered "use for another purpose".

If excluded burial funds are used at any time for a purpose other than

(i-1630)(page-25)Page 25#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 25 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” burial-related expenses, the amount used will be considered as income in the month of withdrawal. Reconsider the burial fund as an excludable resource. Immediately count all interest or other assets that have accumulated in the burial fund account.

Exception: No penalty applies if on the first day of the month in which the excluded funds were used for another purpose the individual's resources would not have exceeded the limits even if the burial funds were counted.

Only actions taken by the individual who designated the excluded burial fund or by someone acting as that individual's agent are construed as "use for another purpose".

Actions by a joint owner of a designated burial fund who withdraws funds for their own use are not construed as "use for another purpose" by the owner of the burial exclusion.  Burial Spaces

A fully paid burial space or agreement which represents the purchase of a burial space held for the burial of the individual, their spouse, or immediate family is an excluded resource regardless of value.

Note: The burial space exclusion is in addition to, and has no effect on, the burial fund exclusion.

A burial space is a(n):

• Burial plot;

• Gravesite;

• Crypt;

• Mausoleum;

• Casket;

• Urn;

• Niche; or

(i-1630)(page-26)Page 26#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 26 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” • Other repository customarily and traditionally used for the deceased's bodily remains.

The term burial space also includes:

• Vaults;

• Headstones, markers, or plaques;

• Burial containers; and

• Arrangements for opening and closing the gravesite.

An agreement which represents the purchase of a burial space is a contract with a burial provider for a burial space held for the eligible individual or a member of their immediate family.

If the agreement does not entitle the person to the burial space items until the full purchase price has been paid, the burial space is not "held for". Consider any amount paid on the installment burial contact as burial funds until such time the installment payments are completed. Refer to Burial Funds.

 Cash

Count the value of cash on hand including cash in a safety deposit box.

Do not count cash from any source for the replacement or repair of a lost, damaged, or stolen excluded resource. This cash is an excluded resource for nine (9) months from the date of receipt. The exclusion can be extended for up to an additional nine (9) months if circumstances beyond the control of the applicant/beneficiary:

• Prevent repair or replacement of the lost, damaged, or stolen resource, and

• Keep the applicant/beneficiary from contracting for such repair or replacement.

The exclusion of cash received for replacement or repair of an excluded resource due to the result of a catastrophe which is declared to be a major disaster by the President of the United States can be

(i-1630)(page-27)Page 27#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 27 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” extended for an additional twelve (12) months. The exclusion period of eighteen (18) months, plus an additional twelve (12) months for a maximum non-resource counting period of thirty (30) months if:

• The excluded resource is geographically within the disaster area as defined by the presidential order,

• The individual intends to repair or replace the excluded resource and,

• The individual presents evidence of good cause. (Good cause is present when circumstances beyond the individual’s control prevent repair or replacement of the lost, damaged, or stolen property; or keep the individual from contracting for such repair or replacement.)

If such cash is commingled with other funds assume that non-excluded funds are withdrawn first.

Note: Exclude as income the proportionate share of interest paid on a commingled account.

 Certificates of Deposit

Refer to Time Deposits.

 Contributions from Tax-exempt Organizations

Do not count as resources the following gifts, made on or after October 28, 1996, from tax-exempt organizations, such as the Make-A-Wish Foundation, to children under age 18 who have a life-threatening condition;

• Any in-kind gift, not converted to cash; and

• A cash gift to the extent that the cash excluded does not exceed $2,000 in any calendar year. Retained cash in excess of $2,000 received in a calendar year is subject to regular resource counting rules.

(i-1630)(page-28)Page 28#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 28 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” Count any interest earned on unspent portion as unearned income in the month of receipt and as a resource the following month.

 Crops in Storage

Count the equity value that is not excluded as a business asset (refer to Business Assets).

Legal debts may include storage costs, liens, and chattel mortgages.

**  Death Benefits

If expenses of last illness and burial have been verified but the applicant/beneficiary has not yet paid the expenses:

• Assume that s/he will pay them, and

• Disregard any death benefits (e.g., SSA or VA death benefits) that are less than or equal to the verified expenses.

In the month following the month of receipt, count as a resource only that portion of death benefits that exceeds the verified costs of the last illness and burial.

 Disaster Assistance

Permanently exclude any assistance received because of a catastrophe which is declared to be a major disaster by the President of the United States. Funds should be identifiable as disaster funds. ‘The Road Home’ program money is considered disaster assistance.

Note: Exclude as income and resources any interest earned.

(i-1630)(page-29)Page 29#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 29 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” • Economic Impact Payments

• All Unemployment Benefits (regular and pandemic) during the pandemic period,

• Paycheck Protection Program

• Economic Injury Disaster Loan Program

• Tribal Payments from the Coronavirus State and Local Fiscal Recovery fund

• State Stimulus Payments

• COVID-19 Funeral Assistance

• Emergency Rental Assistance

• Emergency Assistance for Rural Housing Assistance

• Homeowner Assistance Fund

• Housing Assistance and Supportive Services Programs for Native Americans

• Higher Education Emergency Relief Fund

• Supporting Foster Youth and Families during the Pandemic

• COVID-19 Veteran Rapid Retraining Assistance Program

• Emergency Assistance to Children and Families through the Pandemic Emergency Assistance Fund

• Coronavirus Food Assistance Program-Direct Payments to Farmers and Ranchers

• Farm Loan Assistance for Socially Disadvantaged Farmers and Ranchers

• USDA Assistance and Support for Socially Disadvantaged Farmers, Ranchers, Forest Land Owners and Operators, and Groups.

(i-1630)(page-30)Page 30#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 30 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” • Chicago Resilient Communities Cash Assistance Pilot

 Dividend Accumulations from Life Insurance

Dividend accumulations are dividends that the policy owner has received but left in the custody of the insurer to accumulate interest (similar to money in a bank account). They are not a value of the policy as the owner can obtain them at any time without affecting the policy’s face value or cash surrender value.

Dividend accumulations cannot be excluded under the life insurance exclusion, even if the policy itself is excluded as a resource.

Count as a resource unless they can be excluded under another provision (e.g., designated for burial).

Do not count interest as income in the month of receipt.

 Earned Income Tax Credits (EITC) and Child Tax Credits (CTC)

Exclude from countable resources any EITC or CTC payment received prior to March 2, 2004 either as an advance or refund for one month following the month of receipt. For those payments received on or after March 2, 2004, exclude for nine months following the month of receipt. For those payments received on or after January 2, 2013, exclude for twelve months following the month of receipt. Any funds retained as of the first moment of the month following the exclusion period are a countable resource.

Count interest paid on unspent portion as unearned income in the month of receipt and as a resource the following month.

 Economic Impact Payments

Refer to Disaster Assistance

 Escrow Accounts

An escrow account is a deed, bond, money, or piece of property delivered to a third party. The third party in turn delivers it to the granter only upon the fulfillment of a condition.

(i-1630)(page-31)Page 31#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 31 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” Count any portion that is accessible.

Example: A homeowner pays a certain amount to the mortgage company to be held in escrow for payment of insurance. The insurance company then bills the mortgage company who pays the premium from the escrow account. Any amount in excess of the insurance premium is countable if accessible to the homeowner.

 Estate

An estate is the assets and liabilities left by an individual at death.

Count the applicant/beneficiary's share of an undivided estate as a resource the first day of the month following receipt. Receipt is deemed to be the day of death in the case of a direct descendant or when there is an uncontested will designating the individual as beneficiary.

Refer to the specific type of SSI-related resource.

 Home Property

Refer to Property.

 Inheritances

Consider an inheritance as a resource the month following the month in which it meets the definition of income.

Refer to the appropriate kind of resource.

 Jointly Owned Resources

Refer to the appropriate kind of resource to determine what to count.

Refer to Bank Accounts, Joint Accounts, Rebuttal if a disagreement concerning ownership of funds occurs.

(i-1630)(page-32)Page 32#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 32 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**”  Life Insurance

Life insurance is a contract under the terms of which the insured pays premiums to the insurer for the period specified in the policy (contract) and the insurer agrees to make a cash payment of a specified amount at the death of the insured.

The face value is the amount of basic death benefit contracted for at the time the policy is purchased.

A policy's cash surrender value (CSV) is a form of equity value that it acquires over time. A life insurance policy is a resource if it generates a CSV.

Types of Life Insurance

Burial

A policy is considered burial insurance if:

• It accumulates no cash surrender value, and

• It can be used only to pay for burial expenses.

If a "burial" policy has a cash surrender value to which the owner has access, the policy is not burial insurance. Refer to Ordinary Life.

Ordinary Life

Ordinary life insurance:

• Is also called whole life and straight life,

• Is a contract under the terms of which the insured pays premiums:

- For their lifetime,

- To age 100,

- By single premium, or

(i-1630)(page-33)Page 33#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 33 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**”

- By letting the dividends accumulate, and

• Usually has a cash surrender value after the second year.

Term Life

Term life insurance:

• Provides protection only for the months or years that the premium is paid, and

• Accumulates no countable cash surrender value.

Determining Countable Value

Do not count life insurance which has no potential cash surrender value in determining total countable resources.

For policies owned by the applicant/beneficiary, total the face values of all policies with cash surrender value for each insured:

• If the total face value of all life insurance policies on an insured person does not exceed $1,500 ($10,000 for Non- MAGI Related Medically Needy program, MPP, and the special income level group [LTC, individual in a medical institution for at least 30 days or receiving waiver services for 30 consecutive days]), then no part of the CSV of any such policy or policies shall be counted as a resource.

• If the total face value of all life insurance policies on an insured person exceeds $1,500 ($10,000 for Non-MAGI Related Medically Needy program, MPP, and the special income level group [LTC, individual in a medical institution for at least 30 days or receiving waiver services for 30 consecutive days]), then the cash surrender value of all such policies must be counted as resources.

Examples: Owner has three policies on herself Mrs. Lambert, an aged individual, owns three life insurance

(i-1630)(page-34)Page 34#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 34 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” policies on herself with the following values: • $400 FV with $700 CSV, • $500 FV with $1000 CSV, and • $200 FV with $400 CSV

The total FV of her policies is $1100 ($400 + $500 + $200 = $1100) and the total CSV of the policies is $2100 ($700 + $1000 + $400 = $2100). Even though the total CSV is more than the resource limit of $2000, the life insurance policies are entirely disregarded because they are for the same insured person and the total FV is less than $1500 ($10,000 for Non-MAGI Related Medically Needy program, MPP, and the special income level group [LTC, individual in a medical institution for at least 30 days or receiving waiver services for 30 consecutive days]). Owner has policies on herself and others Mrs. Lambert, from above, also owns three additional life insurance policies on other insured people. In this case, calculate the total FV for each insured individual. If the total FV of the policies on each insured individual is less than $1500 ($10,000 for Non-MAGI Related Medically Needy program, MPP, and the special income level group [LTC, individual in a medical institution for at least 30 days or receiving waiver services for 30 consecutive days]), those policies are disregarded.

Transfer of a disregarded life insurance policy for less than FMV may result in a penalty period. Refer to MEM I-1670 Transfer of Assets for Less Than Fair Market Value

If counting the CSV results in ineligibility, the CSV may be excluded if the life insurance policy, subject to the $1,500 burial fund limit ($10,000 for Non-MAGI Related Medically Needy program, MPP, and the special income level group [LTC, individual in a medical institution for at least 30 days or receiving waiver services for 30 consecutive days]), is intended for the applicant/beneficiaries burial.

The CSV of an insurance policy can only be designated for the burial of the named insured. Refer to Burial Funds.

Note: Do not include the face value of dividend additions in determining whether a policy is a countable or excludable

(i-1630)(page-35)Page 35#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 35 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” resource. If the policy is a countable resource, include the CSV of dividends in determining the resource value of the policy.

Verification

Verify face value of an insurance policy by:

• Viewing the policy, or

• Direct contact (letter or telephone) with the insurance company.

Verify cash surrender value of insurance policies at application and each renewal, if face value exceeds limit, by direct contact with the insurance company.

Use cash surrender value tables attached to the policies only if no other verification is available.

 Livestock

Count the value of livestock that:

• Is not used for home consumption, or

• Is not excluded as a business asset (refer to Business Assets).

 Loans

A loan is a transaction whereby one party advances money to, or on behalf of another party, who is obligated to repay the lender in full, with or without interest. The loan agreement may be written or oral, and is enforceable under State law.

The loan agreement must be in effect at the time that the lender provides the cash to the borrower. Money or property given to an individual with no obligation to repay is not considered a loan and such a transaction cannot be altered to become a loan at a later date.

If the applicant/beneficiary is the borrower, count any portion of the proceeds retained after the month of receipt.

(i-1630)(page-36)Page 36#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 36 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**”

When the applicant/beneficiary is the lender, count the outstanding principal balance as a resource. The loan must meet the following criteria:

• The repayment term must be actuarially sound;

• Payments must be made in equal amounts and no balloon payments; and

• The loan must prohibit the cancellation of the balance upon the death of the lender.

If the criteria is not met treat the loan as a transfer of resources for less than fair market value.

Refer to Mortgages and Promissory Notes.

Refer to I-1534 Types of Income (SSI-Related), Loans

 Lump Sum Payments

Lump sum payments are non-recurring cash payments countable as income in the month of receipt and as a resource beginning the month after receipt. Refer to I-1534 Types of Income (SSI-Related), Lump Sum Payments.

Exclude from countable resources any cash paid to a beneficiary that is intended to cover medical or social service expenses for one full calendar month after the month of receipt (for example, a Medicare payment for an outstanding debt). Cash that reimburses the beneficiary for medical or social service expenses the beneficiary has already paid is countable as a resource. Any funds remaining at the beginning of the second month after the month of receipt must be counted as a resource at that time.

Count interest paid on the unspent portion of a lump sum payment that is a non-excludable resource as unearned income in the month of receipt, and as a resource the following month.

SSI and RSDI Retroactive Payments

Exclude SSI and RSDI retroactive lump sum payments for the nine

(i-1630)(page-37)Page 37#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 37 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” months following the month of receipt. The exclusion applies only to the lump sum payments. The exclusion does not apply to items purchased with the payments unless those items are otherwise excludable. This is true even if the exclusion period has not expired. Any portion of the SSI or RSDI lump sum retained as of the first day of the month following the exclusion period is included as a countable resource. See Bank Accounts and Dedicated Accounts at Section I-1634.3.

Note: SSI and RSDI lump sum payments deposited in Medicaid Qualifying Trusts are considered available immediately. Refer to I-1700 Trusts.

The money from SSI and RSDI lump sum payments must be identifiable in order to be excluded. Being Identifiable does not require that the excluded funds be kept physically apart from other funds. Any withdrawals made from an account with commingled funds, presume that the non-excluded funds are withdrawn first, leaving as much of the excluded funds as possible in the account.

Interest earned on excluded lump sum payments from SSI and RSDI is exempt income in the month of receipt and a resource thereafter.

VA Aid and Attendance and Other Types of Lump Sum Payments

Count as a resource any portion remaining as of the first day of the month following receipt.

Property Insurance

Do not count as resources the lump sum payments received due to claims resulting from natural disasters as long as the funds are used for replacement and repair of property. The funds should be identifiable as disaster funds. When funds are withdrawn from an account with commingled funds always assume that non-excluded funds are withdrawn first, leaving as much of the excluded funds in the account as possible.

Victims Compensation Payments

Effective May 1, 1991, exclude Victims Compensation payments

(i-1630)(page-38)Page 38#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 38 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” from countable resources for a period of nine months after the month of receipt.

Bob Dean Unspent Settlement Funds

Disregard from resources unspent funds received as a class member of the settlements from Nancy Anderson, et al. v Bob Dean Jr., et al.,34th Judicial District Court, Parish of Jefferson, No. 820-839.

NOTE: If Bob Dean Settlement funds are commingled with countable funds, assume countable funds are spent first.

 Mortgages and Promissory Notes

A mortgage is a pledge of a particular property:

• For the payment of a debt, or

• For the performance of some other obligation within a prescribed time period.

Mortgages may be held on real estate or personal property other than real estate. Mortgages on real estate deal with land and buildings. Mortgages on personal property other than real estate (e.g., crops, fixtures, and inventory) are called chattel mortgages.

A promissory note is a written unconditional promise signed by the person who promises to pay a specified sum of money:

• At a specified time, or

• On demand to the person, company, corporation or institution named on the note.

The mortgage or promissory note must meet the following criteria:

• The repayment term must be actuarially sound;

• Payments must be made in equal amounts during the term of the loan with no deferral of payments and no balloon payments; and

(i-1630)(page-39)Page 39#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 39 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**”

• The loan must prohibit the cancellation of the balance upon the death of the lender.

If the criteria is not met treat the promissory note or mortgage as a transfer of resources for less than fair market value.

Value

Consider the value of the outstanding principal balance as the countable resource. Also the portion of the payment received which represents repayment of the principal is counted as a resource, and must be excluded as income because it is conversion of a resource from one form to another.

Verification

Copy the mortgage or promissory note. **

 Mutual Fund Shares

A mutual fund is a pool of shared investment assets managed by a fund manager. The manager is authorized to buy and sell securities and other property for the purpose of producing earnings and increasing the value of the assets. For this service, the mutual fund is allowed to charge the investor for the purchase, exchange, and liquidation of shares in the mutual fund. In return for this investment, the owner of a mutual fund shares in the earnings/losses of the fund in proportion to the number of shares owned.

Count the equity value of mutual fund shares. The value of mutual fund shares is expressed on a "bid" and "asked" or "buy" and "sell" basis. To determine the value of a mutual fund share, use the closing price (bid or buy) on the last business day of the month prior to application or renewal.

 Now Accounts

Refer to Bank Accounts.

 Over the Counter Cards (OTC)

(i-1630)(page-40)Page 40#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 40 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” OTC cards (e.g., PACE and Medicare Advantage) are not counted as income and are not resources until the Second (2nd) Month after they are received.

 Patient Fund Accounts

Count the amount of cash in the patient fund account at a LTC facility.

 Pension Funds

Refer to Retirement Funds.

 Promissory Notes

Refer to Mortgages and Promissory Notes.

 Property

Ownership of Property

Property can generally be divided into two categories:

• Movable property, and

• Real property (immovable property).

Movable property is governed by the laws of the state in which the owner resides. Real property is governed by the laws of the state in which the property is located. These laws vary widely from state to state.

When dealing with real property located in another state, accept verification only from a knowledgeable source familiar with property laws in that state. Knowledgeable sources include but are not limited to:

• Real estate brokers,

• The local office of the Farmer’s Home Administration (for rural land),

• The local office of the Agricultural Stabilization and

(i-1630)(page-41)Page 41#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 41 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” Conservation Service (for rural land),

• Banks, savings and loans and loan associations, mortgage companies and similar lending institutions,

• An official of the local property tax jurisdiction (i.e., parish assessor).

Note: Be sure to obtain the individual’s market estimate rather than the office’s assessment.

• The County/Parish Agricultural Extension Service.

The file date of ownership and/or transfer of property indicated in courthouse records is recognized as the date that ownership and/or transfer of property officially occurred.

Significance of Ownership

Ownership interests in property, whether real or personal, can occur in various types and forms. Since the type and form of ownership may affect the value of property and even its status as a resource, they are significant in determining resource eligibility.

Types of Ownership

• Sole vs. Shared Ownership

An individual may have sole ownership of a property or share its ownership with others.

Sole ownership of (real or personal) property means that only one person may sell, transfer or otherwise dispose of the property. Sole ownership may be subject to conditions imposed by others, for example, sole ownership of a remainder interest in property.

Shared ownership of (real or personal) property means that two or more people own it concurrently.

• Fee Simple Ownership

Fee simple ownership, which relates only to real property, is

(i-1630)(page-42)Page 42#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 42 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” completely free of conditions imposed by others.

• Less Than Fee Simple Ownership

- Usufruct interest conveys ownership of a limited duration. A usufruct is a form of legal ownership and usually created through a deed or will or by operation of law.

- Equitable ownership can occur when an individual does not have legal title to property. For example, an individual who is making mortgage payment on a piece of property or an individual who has ownership interest in an un- probated estate have an equitable ownership in the property.

• Property Rights without Ownership

An individual may have certain rights with respect to property without also having the right to dispose of the property. The individual may have the right to sell their right but not the property.

Verification of Value of Real Property Verify the value in at least one of the following ways: • By current assessment if the assessed value makes the applicant/beneficiary ineligible. ** • By the current tax assessment, when it reflects the fair market value or identifies the total value upon which the assessment is based.

Note: Dividing the total value by the percentage of ownership may overstate what the person could sell their undivided interest for on the open market. The market value is what the market will pay. The value of the undivided interest shall be obtained from a knowledgeable source.

• By obtaining copies of the most recent act of the sale in the conveyance records, offer of sale, mortgage, judgement, or other documentary evidence.

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• By an appraisal that is less than one year old.

• Obtain a FMV estimate from a knowledgeable third party if the real property did not sell on the open market (e.g., to a relative or act of donation). Note: If the property was sold on the open market, this difference between the asking price and the sale price is not uncompensated value.

Community Property

Louisiana is a community property state. Community property is:

• Acquired during the marriage with community funds, and

• Not divided during the lives of both members of the couple. Neither spouse can sell their interest unless both sell the entire property.

Note: Disregard pre-nuptial agreements, matrimonial agreements, and legal separation of community property during the marriage. Ownership of property for Medicaid eligibility shall be determined in accordance with policy regarding community and separate property as detailed in this section.

Separate property is:

• Property brought into the marriage by either spouse,

• Property inherited by either spouse during the marriage, or

• Property purchased by either spouse with separate funds during the marriage, unless the spouse has made it community property.

When one spouse dies, the survivor:

• Retains one-half ownership interest in the community

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Louisiana Medicaid Eligibility Manual Eligibility Factors

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• Has usufruct of the deceased spouse's half of the community property, unless the decedent's will provides otherwise.

The right to usufruct of community property terminates if the surviving spouse remarries, unless the decedent's will provides otherwise.

Note: The one-half ownership interest is an undivided interest. The value may be less than one-half the value of the complete piece of property. Dividing the total value by the percentage of ownership may overstate what the person could sell their undivided interest for on the open market. The market value is what the market will pay. The value of the undivided interest shall be obtained from a knowledgeable source.

No Will

If the decedent dies without a will (intestate), the laws of intestate succession determine who receives the decedent's property and how much of it they receive.

Inheritance of the decedent's separate property and of their one-half share of community property occurs as follows:

• Descendants

The first heirs of property are the descendants (children) of the decedent and the descendants of any child who is also deceased. Current Louisiana law of forced heirship does not distinguish between:

- Legitimate and illegitimate children;

- Children of the present marriage and children of a prior marriage; or

- Natural children and adopted children.

Each of these children are entitled to a share of their parent's estates. An adopted child is entitled to a share of their natural parents' estates and to a share of their adoptive parents' estates.

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Note: The entire property is inherited by the decedent's child(ren), if there are any, in equal proportions. An only child is entitled to the entire estate of the decedent (both the decedent's community half and all the decedent's separate property). If there are two or more children, each is entitled to an equal share of the decedent's entire estate (both the decedent's community half and all the decedent's separate property).

A descendant may accept or reject an inheritance:

- If s/he accepts, s/he is deemed to have accepted from the moment of the decedent's death,

- If s/he rejects, refer to I-1670 Transfer of Resources for Less than Fair Market Value.

• No Descendants

- Decedent's one-half share of community property - If the decedent leaves no descendants, the surviving spouse succeeds to the decedent's share of community property.

- Decedent's separate property - If the decedent is survived by parent(s) and sibling(s) or descendants of deceased siblings, then the siblings (or their descendants) succeed to the remainder interest (naked ownership) of the separate property subject to a usufruct (life estate) in favor of the surviving parent(s). If the decedent is not survived by parent(s) and sibling(s), relatives are first heirs to separate property in the following order:

- Spouse,

- Aunts and/or uncles,

- Cousins.

If the decedent leaves no blood relatives, the state inherits the separate property.

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Deleted text indicated by “**” Real Property Rights

Count as a resource the value of real property rights. These rights are separate resources for which values can be determined.

** When an individual owns the land associated with property rights, the value of those rights is presumed to be included in the fair market value (FMV) of the land and should not be separately counted. When an individual owns mineral rights independent of the land and the rights are not producing income, the agency may accept the individual’s self-attestation of value. When mineral rights generate income, the FMV must be verified. A current tax assessment may be used to verify the FMV of the mineral rights, if available.

Note: Pursuant to Title 31 of the Louisiana Civil Code, mineral rights revert to the landowner after ten (10) years of nonproduction. Real property rights include:

• Surface rights, including timber rights and easements,

• Water rights,

• Mineral rights to oil, natural gas, gravel, sand, coal, and salt,

• Usufruct, and

• Remainder interest.

Note: The terms usufruct and naked ownership are used in Louisiana law. Other states use a variety of different terms (e.g., life estate, remainder interest). For purposes of this policy, the terms "usufruct" and "remainder interest" are used.

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Usufruct conveys upon an individual or individuals the following rights to property:

• The right of possession,

• The right to use of the property,

• The right to obtain profits from the property, and

• The right to sell the usufruct interest.

The contract establishing usufruct:

• May restrain any one or more of these rights,

• May measure the duration of the usufruct by:

- The lifetime of the owner of usufruct or of another person, or

- The occurrence of some specific event, such as the remarriage of the owner of the usufruct.

The owner of the usufruct does not have title to the property or portion of the property for which he has been granted usufruct.

Note: The right to sell the property is the right of the remainder man.

Valuation of Usufruct

Consumables: If there is usufruct over consumables such as money, Certificates of Deposit, promissory notes, bank accounts, stocks of merchandise, etc. count the entire amount (100%) of the asset’s value as available to the person gaining usufruct. Under Louisiana law, a usufruct over a consumable actually transfers ownership at creation of the usufruct.

Non-consumables: If there is usufruct over items such as

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Louisiana Medicaid Eligibility Manual Eligibility Factors

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Revised/added text indicated by underscore

Deleted text indicated by “**” land, houses, shares of stock, vehicles, furniture, animals, etc. determine usufruct value as follows:

Determine the value of usufruct held by the applicant/beneficiary using the following steps:

• Determine the equity value of the proportionate share of the property to which the applicant/beneficiary has separate usufruct rights.

• Refer to Z-1300 Usufruct and Remainder Interest Tables.

• Select the line for the age at the last birthday of the owner of usufruct on the chart.

• Multiply the figure in the usufruct column for the age by the equity value of the proportionate share of the property.

• The result is the usufruct value.

Unless the instrument (will or deed) establishing the usufruct places restrictions on the rights of the usufruct owner, the owner has the right to possess, use, and obtain profits from property and to sell their usufruct interest. The market value of usufruct interest is likely to be reduced since such a sale is subject to the remainder interest.

Remainder Interest

An individual may convey usufruct to one person for that person's life and convey ownership to a second person. The person to whom ownership is conveyed is referred to as the remainder man.

Unless restricted by the instrument establishing the remainder interest, the remainder man is generally free to sell their interest in the physical property even before the life estate interest expires. In such cases, the market value of the remainder interest is likely to be reduced since such a sale is subject to the life estate interest.

At the death of the usufruct owner, the remainder man will hold full title. If there are two or more remainder men, the remainder interest will be shared among the remainder men.

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Valuation of Remainder Interest

Determine the value of the remainder interest held by the applicant/beneficiary by using the following steps:

• Determine the equity value of the proportionate share of the property to which the applicant/beneficiary has remainder man rights.

Note: If the remainder interest is in undivided real property, the market value is further reduced. Therefore, the value of a remainder interest in undivided real property should be obtained from a knowledgeable source.

• Refer to Z-1300 Usufruct and Remainder Interest Tables.

• Select the line for the age at the last birthday of the holder of the usufruct on the chart, and

• Multiply the figure in the remainder column by the equity value of the proportionate share of the property.

• The result is the remainder value.

Types of Property

For Medicaid purposes, property includes:

• Business assets,

• Home property,

• Household goods and personal effects, and

• Other real property.

Business Assets (Property Essential For Self-Support)

Effective May 1, 1990, exclude from resources all property used

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Deleted text indicated by “**” in a trade or business and all property used by an employee in connection with employment when the assets are necessary to the individual in maintaining their basic needs.

Property essential to self-support includes the necessary capital and operating assets of a business, such as:

• Real property,

• Buildings,

• Inventory,

• Equipment,

• Machinery,

• Livestock,

• Motor vehicles, and

• Tools, safety equipment, uniforms, etc., used in self-employment.

Property, including property used by an individual as an employee, must be in current use in the type of activity that qualifies it as essential to self-support. Exclude property that is not in current use only if:

• It has been in use, and

• There is a reasonable expectation that the use will resume.

Resumption of use must be expected within twelve months of last use. MEDT may grant an extension of any additional twelve-month period if the applicant/beneficiary's illness or disability prevents current use.

If the applicant/beneficiary is blind or disabled and has an SSA approved plan for self-support which permits retention of business assets for future use, request the additional extension if use will not resume within twelve months.

Note:

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Deleted text indicated by “**” If an individual does not expect the property to be put back into use, the property becomes a countable resource the month following the month of last use.

If the business has existed for one year or less, or if there is a question that a business exists, determine and document that a valid business exists.

Disregard the cash and bank accounts of a trade or business which are required for the business to function. Accept the applicant/beneficiary's written statement as to the amount of cash or money on deposit needed for the operation of the business. For this provision to apply, the individual or spouse must be actively involved in the operation of the business.

If personal funds are commingled with business funds in one bank account, disregard the amount required for the business. Count the personal funds. Accept the applicant/beneficiary's statement regarding the amount of business funds in the account.

Seasonal Business

If a business is seasonal or there are seasonal fluctuations in the amount of business expenditures, the reasonable amount limit may be significantly higher during the peak seasonal periods. Obtain the applicant/beneficiary's written statement as to the amount of operating cash needed during peak periods, as well as during non-peak periods. Use business records from the previous year to establish peak seasonal periods.

Home Property

Definition of Home Property: property in which s/he has an ownership interest and that serves as their principal place of residence.

Home property includes:

• The house or lot which is the usual residence,

• All contiguous property, and

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Deleted text indicated by “**” • Any other buildings on the home property.

Property is contiguous to the residence if it is touching the residential property (even corner to corner) and is not separated by property owned by others. Property separated by a public right of way, such as a road, is considered contiguous.

Note: Do not rely on Homestead Exemption status for determining home property.

Do not count home property or the value of any ownership interest the applicant/beneficiary may have in the property, including usufruct, if the applicant/beneficiary is living:

• In the home,

• Away from home temporarily because of natural disaster, such as a flood,

• Away from home because of their medical condition, and

- Is keeping their home available, and

- Intends to use it as his/her home when their condition permits, or

• Away from home, and

- The spouse and/or dependent relative lives there, or

- An SSI eligible individual has joint ownership of the home;

- It is income-producing and meets the $6,000/6% return rule. Refer to Other Real Property.

- Its sale would cause undue hardship, due to loss of housing for a co-owner of the property, or

- Left the home due to domestic abuse and has not established a new principal place of residence.

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Home Property in Trust

** If an individual’s excluded home property is placed into a trust that is a countable resource, such as a revocable trust, then the home maintains the home property exclusion since the beneficiary still has an equitable ownership interest in it.

If an individual’s home property is placed into a trust that is not a countable resource, such as an irrevocable trust, then it is also not considered a resource, since the individual no longer has an ownership interest in the home, however, it should be evaluated for a transfer of resources. Refer to I-1700 Trusts.

Individuals with Substantial Home Equity

An individual who is applying for Long Term Care on or after November 1, 2007 may not be eligible for payment of nursing home cost (vendor payment) if the individual’s equity interest in the home property less encumbrance exceeds the allowable home equity limit (Refer to Z-2300 Home Equity Limits by Year). This is not a change in the general rule that excludes a home of any value for purposes of determining eligibility for Medicaid. It applies only to the payment for nursing facility services, or other long-term care services

Exception: The limitations on home equity do not apply if the spouse of the individual, the individual's child under 21, or the individual's blind or disabled child is residing in the home.

An individual who is applying for home and community- based waiver services cannot be eligible for waiver services if their equity interest in the home property less encumbrance exceeds the allowable limit and no exception is allowed.

The individual must be given the opportunity to apply for an undue hardship exception. Refer to H-860 Undue Hardship and Undue Hardship Exception.

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If the home property includes property used in a trade or business, consider the current use of the property to determine if the property can be excluded. Refer to Business Assets (Property Essential For Self Support).

Sale of Excluded Home Property

If the home property is offered for sale, it is no longer excludable based on intent to return. “Intent to return” applies only to the continued exclusion of property which met the definition of the individual’s home property prior to the time the individual left the property.

Note: A Nursing Facility resident cannot establish a new home property while residing in a facility as they would have never lived there and the new residence would not meet the definition of home property.

It may still be excludable if:

• The spouse and/or dependent relative lives there.

• An SSI eligible has joint ownership of the home.

• The proceeds of the sale are used to purchase another excluded home within three full calendar months from the receipt of the proceeds.

• The proceeds are received under an installment contract, the proceeds are the down payment and that portion of subsequent payments that is not interest. The contract is excludable if the individual:

- Plans to use the entire down payment and entire principal portion of each installment payment to buy another excluded home, and

- Does so within three full calendar months of receipt of the down payment or installment payment.

Note: "Within three full months" means by the end

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Revised/added text indicated by underscore

Deleted text indicated by “**” of the third month following the month of receipt of the payment.

• If the proceeds are received in a lump sum, the proceeds are the net amount the seller receives at settlement.

Example: An installment contract has a principal balance of $5,000 as of July 1. On July 10, the buyer makes a payment of $200. As of October 31, the beneficiary has used only $150 of the July payment in connection with the purchase of a new home. The exclusion of the unused $50, and of the installment contract itself, is revoked back to July 10. As a result, the $50 and the value of the contract as of August 1 ($4,800) are included in a revised determination of resources for August.

Proceeds may be used to pay any costs associated with the purchase of another excludable home. These costs include but are not limited to:

• Down payment,

• Settlement costs,

• Loan processing fees and points,

• Moving expenses,

• Necessary repairs or replacement to the new home that are identified and documented prior to occupancy ( e.g., roof, plumbing, appliances), and

• Mortgage payments.

Obtain from the beneficiary a statement of intent regarding the use of the proceeds in purchasing another excludable home within three full calendar months from the receipt of a lump sum payment or installment payments.

Out of State Home Property

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Count the value of home property in another state, unless:

• The spouse and/or dependent relative lives there,

• An SSI eligible has joint ownership of the home, or

• It is income-producing and meets the $6,000/6% return rule. Refer to Other Real Property.

Grandfathered/Converted Individuals

Apply policy in effect in December, 1973 for home property whether it was acquired before or after January 1, 1974 for:

• Beneficiaries converted to SSI effective January 1, 1974,

• Grandfathered beneficiaries who entered LTC facilities after January 1, 1974 and continued to meet grandfather provisions, and

• Individuals who were receiving only Medicaid nursing home vendor payments in December, 1973.

Policy as of December, 1973 provides that property shall continue to be considered home property, not excess property, if:

• The beneficiary is forced to live away from home and s/he is keeping the property available and intends to use it as his/her home when their condition permits, or

• The beneficiary is forced to live elsewhere because of the need for nursing care or medical care or had to leave their home temporarily because of a natural disaster.

Household Goods and Personal Effects

Exclude household goods and personal effects from resources, regardless of value.

Household Goods

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Household goods are items of personal property customarily found in the home and used in connection with the maintenance, use, and occupancy of the premises as a home. They include, but are not limited to:

• Furniture,

• Household appliances,

• Televisions,

• Carpets,

• Cooking and eating utensils, and

• Dishes.

Personal Effects

Personal effects are items of personal property that are worn or carried by an individual or that have an intimate relation to them. They include, but are not limited to:

• Clothing,

• Jewelry,

• Personal care items,

• Educational/recreational items such as books, musical instruments, hobby materials.

Other personal property

Property that an individual acquires or holds because of its value or as an investment is a countable resource (unless excluded under a different provision) and is not considered a household good or personal effect for the purposes of this exclusion.

Examples of other personal property:

• Gems;

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• Jewelry that one does not wear or does not hold for family significance;

• Animals for investment purposes, such as a horse or dog for breeding, for resale, or investment; and

• Collectibles

Other Real Property

Count the total equity value of other real property that:

• Is not income producing, or

• Is income-producing and does not earn at least a 6% annual net rate of return.

Count the equity value over $6,000 if the property is income-producing and earns at least a 6% annual net rate of return.

Note: For income-producing property, refer to $6,000/6% Rule and Business Assets.

Count as an available resource the applicant/beneficiary's ownership interest in an undivided estate that has not been settled whether or not a succession has been opened, if the applicant/beneficiary is an heir of the deceased.

Count as an available resource the applicant/beneficiary's undivided ownership interest in real property when succession has been completed but the property has not been divided.

Note: The value of an individual's ownership interest in jointly owned real property is excluded for as long as sale of the property would cause undue hardship, due to loss of housing, to a co-owner.

Do not count the equity value of property which has been sold at public auction for non-payment of taxes. Verify accessibility of

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Deleted text indicated by “**” the property at each renewal for three years after the date of the auction.

$6,000/6% Rule

If property not excluded as trade or business property produces income at an annual net rate of return of 6% or more of the equity value, up to $6,000 of the equity value may be excluded.

Determine the number of separate pieces of property. Property is separate if it is not contiguous, that is, separated by property owned by others at all points.

Exception: Property separated by a public road or right of way is still contiguous.

Apply the following to each separate piece of income producing property:

• Determine the equity value.

• Determine the annual net income (gross income less allowable deductions).

• Determine the annual net rate of return:

Annual net income ÷ Equity value = Annual net rate of return

If the annual net rate of return is at least 6% of the equity value:

• Exclude up to $6,000, and

• Count the amount over $6,000 towards the resource limit.

If the annual net rate of return is less than 6% of the equity value, count the full equity value.

Exception: Less than 6% annual return may be used to exclude the

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Deleted text indicated by “**” equity value if the reduced return is caused by circumstances beyond the applicant/beneficiary's control, such as a fire or flood, and there is a reasonable expectation of a future 6% annual return.

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EXAMPLES OF $6000/6% RULE

Equity Value

Annual Rate of Return

Countable Value

$6,000 or less

6% or more

None

$6,000 or less

Less than 6%

Count the entire

equity value.

Greater than $6,000

6% or more

Count the equity

value over $6,000.

Greater than $6,000

Less than 6%

Count the entire

equity value.

$6,000 or less on

6% or more on the

Exclude the total the total of more

equity value of each

equity values of than one income

property

the properties. producing property

$6,000 or less on Less than 6% on one

Count the entire the total of more

or more of several

value of any than one income

properties

property not producing property

meeting the 6% annual rate of return requirement.

Greater than $6,000

6% or more on the

Total the equity on the total equity

equity value of each

values and count values of more than

property

the amount in one income-producing

excess of property

$6,000.

Greater than $6,000

Less than 6% on the

Count the entire on the total equity

equity value of one

equity value of values of more than

or more of the several

any property not one income-producing

properties

meeting the 6% property

annual rate of

return requirement,

as well as any

excess over $6,000.

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Deleted text indicated by “**”  Recreational Vehicles (Boats, Motors, and Campers)

Count the equity value unless the resource has been excluded as necessary for self-support.

Note: The current J.D. Power Values Online trade-in value may be used. ** Use average trade-in value when obtaining values from the online service.

Refer to Vehicles.

 Relocation Assistance

Exclude from resources unspent relocation assistance payments from the federal government.

Exclude only for nine months unspent relocation assistance payments from a state or local government which are received after May 1991. The last month this exclusion may apply is April 1994.

Note: Count as unearned income in the month of receipt any interest paid on unspent federal, state or local government payments and as a resource the following month.

 Reparation Payments

Exclude from resources reparation payments received from the Republic of Germany or from the Austrian General Social Insurance Act, the Nazi Persecution Victims Eligibility Act or Netherlands WUV payments.

Note: Do not count as unearned income any interest paid on unspent reparation payments as income in the month of receipt, but as a resource the following month.

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Deleted text indicated by “**”  Restitution Payments

Exclude from resources restitution payments made by the U.S. government to individual Japanese-Americans (or their survivors) or to Aleuts who were interned or relocated during World War II.

Note: Do not count as income in the month of receipt any interest earned on these payments, but as a resource the following month.

 Retirement Funds

Retirement plans include:

• Plans administered by an employer or union:

- Pensions,

- Disability plans, and

- Retirement plans, and

• Funds put into an individual retirement accounts:

- 401(K), and

- KEOGH plans.

Employment related retirement funds

Individuals who have retirement funds through a plan at their place of employment will not have access to these funds until employment ends. When employment has terminated, the retirement fund generally becomes available.

If the individual is eligible for periodic (usually monthly) retirement benefits, he is required to apply for the benefits. The application for monthly benefits makes the funds no longer available. Count the fund balance as a resource through the month of application for periodic/monthly benefits is filed. Count the monthly retirement fund payment as unearned income effective the month following the month the application for periodic payment is filed.

(i-1630)(page-64)Page 64#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 64 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**”

If an applicant/beneficiary is not eligible for periodic payments but has the option of withdrawing the funds, count the retirement fund as a resource.

Note: If application for periodic payments is denied, count the value of the retirement funds as a resource effective the month following the month of the denial notice.

If an employed applicant/beneficiary must terminate employment in order to file for a retirement fund, do not count the fund as a resource.

IRAs

Money put into an IRA can usually be withdrawn regardless of whether or not the individual is working. Count funds in an IRA as a countable resource.

When retirement funds are an available/countable resource, use the following information to determine the countable value of the retirement fund:

• If there is a penalty assessed for early withdrawal, count the amount available after the penalty is deducted.

• If there are taxes owed on the funds, count the amount before taxes are deducted.

• If the actual withdrawal is delayed for reasons beyond the control of the applicant/beneficiary, count the value as a resource effective the first month the funds were actually available, even though the funds are not actually received until a later month.

Exclude retirement funds held separately by an ineligible spouse in determining total countable assets for a couple in the SSI related deeming process only.

Count retirement funds owned separately by the community spouse in the LTC determination of combined countable couple assets or spousal income assignment, depending on availability of fund balance.

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 65 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**”

 Safe Deposit Boxes

Count the value of any countable resource contained in a safety deposit box. Advise the applicant/beneficiary not to open the box until the contents can be verified.

Contents of a safety deposit box may be verified by:

• Written verification from the financial institution, or

• Sworn statements from third parties who view the contents.

Note: The applicant/beneficiary's statement of the contents is not acceptable verification/documentation.

If the applicant/beneficiary is unable to provide verification, at the request of the applicant/beneficiary the agency representative may accompany them to the financial institution and view the contents of the safety deposit box.

 Saving Bonds

Refer to Bonds.

 Savings Certificates

Refer to Time Deposits.

 Stocks

Shares of stock represent ownership in a corporation.

Most stocks, for incorporation purposes, are assigned a certain value known as "par value". Par value has no relation to the actual market value of a stock. The value of a stock is normally determined by the demand for it when it is bought and sold. As a result of trading, the value of stocks varies from day to day.

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 66 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” Stocks may be traded:

• On the New York Stock Exchange,

• On the American Stock Exchange, or

• NASDAQ (over-the-counter exchange).

To establish the value of a stock, use the closing price on the last business day of the month prior to application or renewal. This determination of value applies to stocks (common and preferred) as well as to warrants, rights, and options to purchase common stocks.

To establish the value of stock in a privately-owned or closed corporation (not publicly traded), have the applicant/beneficiary provide the value from a knowledgeable source.

Verification

Verify by consulting a newspaper for the closing price on the last business day of the month prior to the month of application or renewal.

If the closing price of a stock is not shown in the next day's newspaper, have the applicant/beneficiary contact a local securities firm to determine its value.

The applicant's statement that a stock is worthless should be supported by a local securities dealer's statement that there is no market for the stock.

 Tax Refunds and Advanced Tax Credits

Exclude all Federal tax refunds and advance tax credits from resource counting for a period of 12 months after the month of receipt. Any funds retained as of the first moment of the month following the exclusion period are a countable resource.

 Time Deposits

A time deposit is a contract between an individual and a financial

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 67 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” institution whereby the individual agrees to leave funds on deposit for a specified period and the financial institution agrees to pay interest at a specified rate for that period. Certificates of Deposit (CDs) and savings certificates are common forms of time deposits.

Withdrawal of a time deposit before the specified period expires incurs a penalty, which usually is imposed against the principal. This penalty does not prevent the time deposit from being a resource, but does reduce its value as a resource.

Occasionally, the terms of a time deposit will prohibit early withdrawal.

If the owner of a time deposit cannot under any circumstances withdraw it before it matures, it is not a resource. It becomes a resource, not income, on the date it matures and may affect countable resources for the following month.

Note: If the owner has no access to the interest before the deposit matures, accrued interest is not a resource. Do not count the interest as income in the month the deposit matures but as a resource the month after maturity.

The resource value of a time deposit at any given time is the amount the owner would receive upon withdrawing it at that time, excluding interest paid that month. Generally, this is:

• The amount originally deposited,

• Plus accrued interest for all but the current month,

• Minus any penalty specified on the certificate for early withdrawal.

Examination of a time deposit certificate should reveal:

• The date of maturity,

• The date the funds can be withdrawn without penalties, and

• Any penalties for early withdrawal.

Contact the financial institution that issued the certificate to resolve any questions.

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 68 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**”

 Trusts

A trust is a legal arrangement involving property and ownership interests. Property held in trust may or may not be considered a resource.

A trust or similar legal device established prior to August 11, 1993 which is not a resource for SSI purposes may affect Medicaid eligibility. Refer to I-1720 Medicaid Qualifying Trusts.

Trusts created on or after August 11, 1993 must first be evaluated under the rules established by the Omnibus Budget Reconciliation Act of 1993 (OBRA 1993) to determine impact on Medicaid eligibility. Refer to I-1730.

Trusts that meet the exception requirements of policy I-1720 are to be evaluated under the following rules of the SSI cash assistance program to determine if they are countable resources for Medicaid eligibility purposes.

Definitions

Trust - a trust is a property interest whereby property is held by an individual (trustee) subject to a fiduciary duty to use the property for the benefit of another (the beneficiary).

Grantor - (also called a settlor or trustor) is a person who creates a trust. An individual may be a grantor if an agent, or other individual legally empowered to act on their behalf (e.g., a legal guardian, person acting under power of attorney or conservator), establishes the trust with funds or property that belong to the individual.

Trustee - a trustee is a person or entity who holds legal title to property for the use or benefit of another.

Trust Beneficiary - a trust beneficiary is a person for whose benefit a trust exists.

Trust Principal - the trust principal is the property placed in trust by the grantor which the trustee holds, subject to the rights of the beneficiary plus any trust earnings paid into the trust and left to accumulate.

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 69 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” Whether a trust is counted as a resource depends on the applicant/beneficiary's role as trust beneficiary, trustee, or settlor, and the specific terms of the trust.

If the trustee has no access to the funds for their personal use, the trust is not a resource to the trustee. However, there are some trusts which allow the trustee access to the funds for their personal use and these trusts are counted as resources to the trustee.

Even though the trust beneficiary does not hold legal title to the trust, under certain circumstances the trust is counted as a resource to them.

When the trust is considered a resource:

• Count the total value of the trust, and

• Count any interest or distributions the month following the month of receipt. Distributions are counted as income in the month of receipt while interest is excluded as income.

Note: Do not count as income any withdrawals made from a trust which is a countable resource, because the funds have already been counted as a resource.

Applicant/Beneficiary as Trustee

Count the trust as a resource, regardless of whose funds were originally deposited into the trust, if the applicant/beneficiary:

• Is the trustee, and

• Has the legal right to:

- Revoke the trust, and

- Use the money for their own benefit.

Applicant/Beneficiary as Trust Beneficiary

Count the trust as a resource if the applicant/beneficiary is trust beneficiary and has unrestricted access to the trust.

Note: The authority for trustee discretion in the use of trust funds

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Page 70 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” assumes that the trustee has the best interests of the beneficiary in mind.

Unless the trust specifically states the amounts and time frames for disbursement, the amounts and time frames for distribution decided by the trustee shall not be questioned.

Trustee discretion in the use of trust funds should not be misconstrued to mean that the principal is available or unavailable to the applicant/beneficiary.

Do not count the trust as a resource if the trust beneficiary's access is restricted (i.e., only the trustee or court can invade the principal), even if:

• It can be revoked by someone other than the trust beneficiary, or

• It provides a regular specified payment from the principal to the beneficiary for their use, or

• It designates a representative payee or legal guardian as trustee.

Note: Count as income all payments made to the trust beneficiary from a restricted trust.

Applicant/Beneficiary as Settlor

Count the trust as a resource if the applicant/beneficiary is the settlor (created the trust) and:

• Has the right to revoke it, and

• Can use the funds for their own benefit.

Consider penalties under the transfer of resource policy (refer to I-1670 Transfer of Resources For Less Than Fair Market Value) if the applicant/beneficiary:

• Created the trust,

• Does not have the right to revoke it, and

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Page 71 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**”

• Cannot use the principal for their own benefit.

Verification

Verify the following information for all trusts:

• Applicant/beneficiary's role as trustee, trust beneficiary, and/or settlor,

• The applicant/beneficiary's access to the principal, and

• If access to principal is restricted, whether the applicant/beneficiary created the trust and imposed the restrictions.

If the trust document does not clearly provide the above information, refer the document to the Medicaid Eligibility Policy Unit at Medicaid.EligibilityPolicyUnit@la.gov.

**  Uniform Gifts to Minors Act and Uniform Transfers to Minors Act (UGMA/UTMA)

UTMA and UGMA accounts are taxable investment accounts set up to benefit a minor, but controlled by an adult custodian until the minor reaches their age of majority. UGMA accounts allows donors to make gifts to minors that are free of tax burdens but were limited to only gifts of cash or securities. UTMA accounts allow any kind of property (real or personal, tangible or intangible) to be transferred from a donor to a custodian for the benefit of a minor.

Donor: Money and assets transferred are no longer resources of the donor beginning the month after the month of the transfer. The transfer of resources provision may apply if the donor is an eligible individual or individual’s spouse.

Custodian: The accounts assets are not the custodian’s resources because they may not legally use any of the funds for their own support.

Minor is under age 18:

These accounts property, including additions or earnings, is neither

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Louisiana Medicaid Eligibility Manual Eligibility Factors

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Page 72 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” income nor a resource to the minor unless it can be considered a device similar to a trust. If funds belonging to the minor are placed in one of these type accounts, the account may be considered a device similar to a trust and you would evaluate the account under the trust rules;

The custodian’s accounts disbursements to the minor are income to the minor in month of disbursement and a resource beginning the following month.

Minor turns age 18:

In the month the minor attains age 18, all the account property becomes available to the individual and is subject to income counting. The accounts property becomes subject to resource counting the following month.

 Vehicles

Consider as vehicles passenger cars and other conveyances, whether registered or not registered, used as transportation.

Exclude only one vehicle per household, regardless of its value if anyone in the applicant/beneficiary's household uses it for transportation.

Note: Donating or giving away an “excluded” vehicle does not result in a transfer of resources for less than fair market value since the value of the vehicle is not counted towards the resource limit.

Assume the vehicle is used for transportation unless there is evidence to the contrary.

Apply exclusion in a manner most advantageous to the individual.

The exclusion applies to temporarily inoperable vehicles which are expected to be repaired and used for transportation within the next 12 months.

If the applicant/beneficiary owns more than one vehicle the exclusion applies to the car with the greater equity value, regardless of which car is actually used.

(i-1630)(page-73)Page 73#

Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued June 9, 2026

Page 73 of I-1630 Replacing September 23, 2024

Revised/added text indicated by underscore

Deleted text indicated by “**” Count the equity value of all other vehicles, including inoperable vehicles and vehicles used for show (e.g., antique cars).

The Average Trade-In Value provided by J.D. Power Values Online is the Current Market Value (CMV) used for resource determination. If the trade-in value is unavailable from this site, obtain the Trade-In Value from a third party knowledgeable source. If the value affects eligibility and the individual disagrees with it, give the individual the opportunity to rebut it.

 Victims' Compensation Payments

Effective May 1, 1991, do not count unspent portions of victims' compensation payments for nine months following the month of receipt.

Note: Count any interest earned on unspent portions as unearned income in the month of receipt and as a resource the following month.

 Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA)

A Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) is an allocation of funds from a workers’ compensation- related settlement, judgment, or award which are set aside to pay for future medical services and/or prescription drug expenses related to the workers’ compensation injury or disease.

Medicare does not pay for an individual's workers’ compensation (WC) related medical services and drug expenses when that individual received a WC settlement, judgment, or award that includes funds for future medical expenses, until all such funds are properly expended.

The funds set aside in the WCMSA are not available or countable as resource unless they are actually used for food or shelter (i.e., rent, mortgage payments, utilities, etc.). There may be cases in which funds in a Medicare set-aside arrangement are placed in trusts. Refer to MEM I-1700, Trust, to determine how the trust is counted for eligibility purposes.

(i-1660)Louisiana Medicaid Eligibility Manual (LDH): I - 1660 Spousal Impoverishment Resource Provisions (LTC/HCBS)#

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I-1660 SPOUSAL IMPOVERISHMENT RESOURCE PROVISIONS (LTC/HCBS/ACH)

I-1661 GENERAL INFORMATION & DEFINITIONS

This policy allows certain LTC/HCBS/ACH applicants/beneficiaries and individuals residing in medical institutions for a continuous period of institutionalization (at least 30 consecutive days), to allocate resources:

• To a community spouse who lives in a non-institutionalized living arrangement, and

• For the community spouse's own use and maintenance.

Exception: The spousal impoverishment provisions do not apply to individuals residing in a Group Home.

Verify that the marriage is legal.

Apply this policy to an LTC/HCBS/ACH institutionalized individual who has a community spouse and who:

• Meets all other eligibility requirements, and

• Entered LTC/HCBS/ACH on or after September 30, 1989.

The maximum amount of the couple's combined countable resources that may be allocated to the community spouse can be found at Table Z-800 Spousal Impoverishment Maintenance Needs and Resource Standards.

Exception:

An increase in the spouse’s resource allocation may be

granted to generate additional income if the available

income is below the spousal allowance.

Before a requested increase in the community spouse

resource allocation can be granted, all available income

of the institutionalized spouse must be allocated or

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attributed to the community spouse.

Example: Community spouse’s monthly income is $500 below the spousal maintenance needs. Before the community spouse would be allowed to allocate additional assets to income- producing assets, the institutionalized spouse would have to transfer as much of the $500 from their income as possible to the community spouse.

Referrals for increases in the community spouse’s resource allowance must be sent to State Office Eligibility Policy section for a decision.

When a court order of support exists which stipulates that an amount greater than the Spousal Resource Standard be allocated to the community spouse for his use and maintenance, the court-ordered amount shall be used as the Spousal Resource Standard.

Allocated Resources

The amount of resources that may be transferred from the combined countable couple resources to the community spouse or to another person for the benefit of the community spouse, in order to be disregarded in the determination of continuing eligibility for the institutionalized spouse.

Community Spouse

The LTC/HCBS/ACH institutionalized individual's legal spouse who lives in a non-institutionalized setting. A person receiving HCBS is considered institutionalized for Medicaid purposes.

New Admission

A first time admission or a readmission after an absence of 30 days or more from an LTC/HCBS/ACH institutionalized setting.

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Note:

Hospitalization is not considered an absence for purposes of this definition.

Separate Resources of Community Spouse

Resources acquired by the community spouse outside of marriage either by prior ownership or inheritance and which are held separately and are identifiable as owned solely by the community spouse.

Separate Resources of LTC/HCBS/ACH Institutionalized Individuals

Resources acquired by the LTC/HCBS/ACH institutionalized spouse outside of marriage either by prior ownership or inheritance and which are held separately and are identifiable as owned solely by the institutionalized spouse.

Shared Resources

Resources acquired during the marriage including community assets, which may be held in the name of one or both members of the couple.

Spousal Resource Standard

The maximum allowable amount of a couple's combined countable resources which may be allocated for the use and maintenance of the community spouse. Refer to Table Z-800 Spousal Impoverishment Maintenance Needs and Resource Standards.

I-1663 SPOUSAL RESOURCES ASSESSMENT

An assessment of the couple's resources, shall be completed for the beginning of each continuous period of institutionalization:

● At the request of an institutionalized individual, the community spouse, or the authorized representative of either spouse whether or not Medicaid application is made, or

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● At the time a Medicaid application is made ** for each New Admission to an institutionalized setting.

Note: If an application for Medicaid is not made at the time of admission to the institution and the assessment is not completed at the time of admission, the assessment at the time of the Medicaid application shall be based on resources at the beginning of the most recent continuous period of institutionalization.

When an assessment is done prior to application, compare the countable resources at application to the resources of the institutionalized spouse as determined in the resource assessment. Refer to I-1664, Resources Assessment. Evaluate any significant difference as a transfer of resources for less than Fair Market Value (FMV). Refer to I-1670, Transfer of Resources for Less than FMV.

Note: When a couple requests an assessment and no application, an application form is not required. Verify ownership interest and current value of resources. If necessary documentation and/or verification is not provided timely, notify the couple in writing that the assessment cannot be completed.

The couple who is not applying has no right to appeal a resource assessment decision. As a part of Patient Rights, nursing homes are required to advise all new admissions of their right to request an assessment of couple resources. Although it is not required that either spouse apply for assistance, they shall be encouraged to apply to protect the date of application and to provide appeal rights. Advise the couple that they will also be required to meet all other applicable eligibility factors.

I-1664 RESOURCE ASSESSMENT PROCEDURES

Complete a resource assessment for the couple as of the first day of the month of the most recent new admission to the LTC/HCBS/ACH facility as follows:

Determine the separate assets of the community spouse, separate assets of the institutionalized spouse and shared assets of the couple.

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Combined countable couple assets which are considered to be the total assets of the institutionalized spouse include separate resources of the community spouse, separate resources of the institutionalized spouse and shared assets of the couple. Refer to Section I of the LTC Spousal Resources Assessment/Worksheet (Form 4 LTC/SP-R)

Step 1. Determine the total countable separate resources of the community spouse. Do not count shared resources.

Step 2. Determine the total countable separate resources of the institutionalized spouse. Do not count shared resources.

Step 3. Determine the total countable shared resources of the couple. Do not include separate resources.

Step 4. Combine sums from Step 1, Step 2, and Step 3. The total is considered countable couple assets.

Step 5. Subtract the appropriate spousal impoverishment maximum protected resource amount from countable couple resources to determine the countable resources of the LTC/HCBS/ACH institutionalized spouse. Refer to Z-800 Spousal Impoverishment Maintenance Needs and Resource Standards.

Compare the institutionalized spouse's countable resources to the SSI individual resource limit.

When remaining resources are equal to or below the SSI individual resource limit, the institutionalized spouse is eligible. When remaining resources are above the SSI individual resource limit, the individual is not eligible.

If the institutionalized spouse is ineligible the couple shall be notified of the decision and the right to appeal.

If the institutionalized spouse is eligible based on the provisions for allocating resources to the community spouse, inform the couple that resources allocated to the community spouse must be transferred to the community spouse to remain eligible and that they will be allowed until the first renewal to effect the transfer.

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Obtain the signatures of both members of the couple acknowledging that they have been informed of their right to transfer allocated resources to the community spouse without penalty until the first renewal.

The institutionalized spouse may remain eligible under the allocation of resources provisions until the first renewal to allow reasonable time for the couple to complete the actual transfer of assets to the community spouse. Couples should be encouraged to effect such transfer at the earliest possible date. Documentation of the transfer of assets to the community spouse shall be maintained in the case record.

Allocated resources transferred to the community spouse are not subject to the Transfer of Assets provisions.

Amounts in excess of the allocated resource transferred to the community spouse by the institutionalized spouse or by the community spouse themselves shall be considered under the transfer provisions.

Prior to any actual transfer, inform the couple that resources transferred to the community spouse will make at least one spouse ineligible for Medicaid if the community spouse applies for assistance.

Note: If ineligibility is established based on income information on the application form:

● Complete the assessment, and

● Advise the couple that even if the resources are spent they are currently ineligible based on income. There are no provisions for disposing of income to become eligible.

Determine total countable resources within 45 days of the request for assessment. The determination shall be made within 10 days of receipt of the requested documentation or verification, if the assessment is delayed beyond 45 days because of:

● Non-receipt of documentation, or

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● Failure of the requesting couple to provide needed information.

Document in detail efforts to complete assessments timely.

Provide a copy of the assessment work sheet to the LTC/HCBS/ACH institutionalized individual and his spouse. The work sheet indicates:

● The couple's total countable resources,

● The amount that can be allocated to the community spouse, and

● The amount that will be counted for the LTC/HCBS/ACH institutionalized individual.

Note: Spousal impoverishment provisions do not apply beginning the first full calendar month following changes that result in an institutionalized spouse no longer being institutionalized or no longer having a community spouse.

Determine countable resources for each individual member of the couple. Refer to I-1630, Need - SSI-Related Resources.

I-1665 TRANSFER TO COMMUNITY SPOUSE

If resource eligibility depends on the transfer of allocated resources, and the couple intends to transfer resources:

 Complete Form 4 LTC/SP-R1 and obtain the signatures of both members of the couple acknowledging that they have been informed of their right to transfer the allocated resources to the community spouse, and

 Inform the couple:

- That allocated resources may be transferred to the community spouse without penalty, and

- That for ongoing certifications the couple will be allowed until the first renewal to effect the transfer of allocated resources.

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The institutionalized spouse is resource eligible if the couple signs acknowledgements of spousal transfer policy (Form 4 LTC/SP-R1).

Determine resource eligibility for the applicant/beneficiary at the first renewal of eligibility or subsequent application for assistance. Include all countable resources retained in the name of the institutionalized spouse. If allocated resources were not transferred, advance notice is required prior to any termination of coverage.

Additional resources acquired after certification by the institutionalized spouse may be transferred to the community spouse to the extent that the maximum has not already been transferred.

Example: Mrs. Jones entered a nursing facility 1-1-2005, Spousal Resource Standard $95,100.00 for institutionalized spouse. Mr. Jones had $20,000.00 in resources, Mrs. Jones had $20,000.00 in resources, and they had $10,000.00 joint resources. Mrs. Jones transferred her resources and her share of the joint resources to Mr. Jones which gave him a total of $50,000.00 in resources. Two years later, Mrs. Jones receives an inheritance of $20,000.00 which is over the resource allowance for an institutionalized individual. (The inheritance is counted as income in the month it is received.) In the same month she received the inheritance she transferred it to Mr. Jones. The transfer is allowed as long as the amount is below the maximum resource allowance at the time Mrs. Jones entered the facility. $50,000.00 + $20,000.00 = $70,000.00 which is below $95,100.00.

An increase in or additional resources acquired by the community spouse after certification has no effect on resource eligibility for the institutionalized spouse.

Example: Mrs. Jones enters a LTC facility. The spousal allocation of resources is done and the resources transferred to Mr. Jones before the first renewal. Mr. Jones retains the allocated resources and uses them appropriately to meet his needs. Three years later, Mr. Jones is involved in an accident and receives a very large settlement. Even though Mr. Jones might now have resources above the spousal resource

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amount, we would not recalculate the spousal assessment.

Request for Extension

If for any reason the applicant/beneficiary has not been able to complete the transfer by renewal or new application, email documentation of the situation, including the reason that the resources have not been transferred to the Medicaid Eligibility Policy Unit.

Requests for each extension must include:

 An itemization of resources to be transferred,

 The actions taken to effect the transfer, and

 The reasons for which the extension is needed.

If the request for an extension is not approved, advance notice is required prior to any termination of coverage.

I-1666 TRANSFER OF RESOURCES BY COMMUNITY SPOUSE

The community spouse must retain allocated resources or use them to meet his needs or the needs of the institutionalized spouse.

Transfer of allocated resources by the community spouse for less than FMV will be counted as though the institutionalized spouse had made the transfer.

Transfer by the community spouse of his/her separate resources for less than FMV will be counted as though the institutionalized spouse had made the transfer. Refer to I-1670, Transfer of Resources For Less Than FMV.

Consider transfer of resources if countable resources retained by the institutionalized spouse are transferred:

 By the institutionalized spouse to the community spouse in excess of their Spousal Impoverishment Resource limit, or

 By the community spouse.

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Refer to I-1670, Transfer of Resources for Less than FMV.

I-1667 REVISIONS TO ALLOCATED RESOURCES

Revise allocated resource amounts only if:

 An error was made in the initial determination, or

 Inaccurate information was provided at the initial determination.

I-1668 UNDUE HARDSHIP (Refer to Section H-860)

I-1669 NOTIFICATION

Notify the applicant/beneficiary, community spouse, and responsible party in writing:

 Of the value of resources allocated to the community spouse,

 That the allocated resources must be transferred to the community spouse by the first renewal for the LTC/HCBS/ACH institutionalized spouse to remain eligible, and

● That the allocated resources from a one month certification must be transferred to the community spouse prior to any subsequent certifications.

(i-1670)Louisiana Medicaid Eligibility Manual (LDH): I - 1670 Transfer of Assets For Less Than Fair Market Value#

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued October 21, 2025 Page 1 of I-1670 Replacing January 27, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” I-1670 TRANSFER OF ASSETS FOR LESS THAN FAIR MARKET VALUE (FMV)

I-1671 GENERAL INFORMATION

An institutionalized individual who is applying or approved for long-term care (LTC) or home and community-based services (HCBS) waiver, or the spouse of the individual, that disposes of assets for less than fair market value (FMV) during or after the look-back period may not be eligible for payment of services. The look-back period for an institutionalized individual is the 60 months prior to applying for Medicaid.

Any income or resources transferred during or after the 60-month look- back period must be evaluated to determine if FMV was received in exchange for the asset. If FMV was not received in exchange for the asset, a period of ineligibility, known as a penalty period, must be served by the institutionalized individual. During the penalty period, Medicaid will not pay for the services provided in a nursing facility or by an HCBS waiver program.

Note: Do not apply the transfer of assets rules to the Program of All- inclusive Care for the Elderly (PACE).

The transfer of an asset for less than FMV is presumed to be for the purpose of qualifying for Medicaid, unless the individual presents convincing evidence that the transfer was exclusively for some other purpose.

The individual shall be offered the opportunity to rebut the presumption that a transfer was made to reduce assets in order to qualify for Medicaid. Convincing evidence must be provided that proves that the transfer was done solely for a reason other than to qualify for Medicaid.

For every case in which a penalty period is determined, the individual shall be offered the opportunity to apply for an undue hardship exception. It is the responsibility of the individual to provide convincing evidence that imposing a penalty period would deprive the individual of medical care such that the individual’s health or life would be endangered or of food, clothing, shelter, or other necessities of life.

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued October 21, 2025 Page 10 of I-1670 Replacing January 27, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” bathing, dressing, grooming, transferring, toileting, and eating. The PCA shall be considered a transfer for less than FMV unless all of the following mandatory provisions are met:

• The agreement provides for the provision of reasonable and necessary medical care or assistance, which is not otherwise covered by Medicare, Medicaid, or private insurance.

• The agreement must be in writing and properly executed prior to the service or assistance being provided. The agreement cannot be applied retroactively to pay for services or assistance that was provided prior to the agreement.

• The agreement must specify the type of service to be provided, the frequency for providing the service, the time to be spent providing the service or assistance, and the amount of compensation to be paid for the service.

• The agreement must provide for payment upon rendering of the services or assistance, or within 30 days thereafter.

• The agreement must be supported by evidence that services and payments were made in accordance with the agreement.

• The caregiver cannot be the spouse or parent of the applicant/beneficiary.

• The applicant/beneficiary or his/her legally authorized representative has the power to modify, revoke, or terminate

the agreement.

A PCA that fails to contain all of the mandatory provisions is considered a transfer for less than FMV. Payments made under the written agreement that do not have the mandatory provisions will be considered as the amount transferred.

If a written agreement meets the mandatory requirements, it must be determined whether adequate compensation in the form of services or assistance was provided.

Adequate compensation shall be measured against the usual and customary charges for these services in the local area. If services or assistance require extraordinary skill, the provider or caregiver must possess the required skill, experience, or expertise. These services or assistance may be valued in accordance with similar services in the

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Louisiana Medicaid Eligibility Manual Eligibility Factors

Reissued October 21, 2025 Page 11 of I-1670 Replacing January 27, 2025 Revised/added text indicated by underscore Deleted text indicated by “**” community.

If payments are made for compensated services or assistance, but the payments exceed the usual and customary charges for the services or assistance, then the amount of the payment is a transfer without compensation.

The services and assistance must be provided within thirty days from the date of payment. Pre-payment for services or assistance not yet rendered, and that cannot be provided within 30 days, is a transfer without compensation.

The Personal Care Agreement ceases upon the death of the applicant/beneficiary or upon admission to a nursing facility.

Note: Relatives and family members can legitimately be paid for care they provide; however, it is presumed that services provided for free at the time were intended to be provided without compensation. Therefore, any payment to a relative for care provided for free in the past is a transfer of assets for less than fair market value.

I-1674 EXCEPTIONS TO APPLICATION OF TRANSFER OF ASSET PENALTIES

1. The transferred asset is the individual's home and the title to the home is transferred to the individual's: • Spouse,

• Child who is: o Under age 21, or o Meets the definition of Blindness or disability, as defined by SSI, at the time of the transfer. If there is no disability determination at the time of the transfer, obtain an MEDT decision. The age at onset of disability is not a factor. Refer to G-1600 Securing Disability Decisions for Non- MAGI Categories

• Sibling who has: o An equity interest in the home, and o Been residing in the home for a period of at least one

(a-100)Louisiana Medicaid Eligibility Manual (LDH): A - 100 Abbreviations and Acronyms#

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(a-100)Louisiana Medicaid Eligibility Manual (LDH): A - 100 Abbreviations and Acronyms#

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(a-200)Louisiana Medicaid Eligibility Manual (LDH): A - 200 Definitions#

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(b-0000)Louisiana Medicaid Eligibility Manual (LDH): B - 0000 Introduction#

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(c-0000)Louisiana Medicaid Eligibility Manual (LDH): C - 0000 Medical Services#

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(e-0000)Louisiana Medicaid Eligibility Manual (LDH): E - 0000 Category#

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(f-0000)Louisiana Medicaid Eligibility Manual (LDH): F - 0000 Medical Programs#

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(g-0000)Louisiana Medicaid Eligibility Manual (LDH): G - 0000 Application Processing#

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