AGED, BLIND AND DISABLED MEDICAID 009 Table of Standards: Medicare Savings Program-Income

Supersedes: ABD 009 (04/01/2025) Reference: ARM 37.83.201; 37.82.101; P.L. 100-360 (1988); P.L. 110-275 (MIPPA)

Overview: Use the following standards to determine financial eligibility for Medicare Savings Programs. Medicare Savings programs include Qualified Medicare Beneficiaries (QMB), Special Low Income Medicare Beneficiary (SLMB) and Qualified Individuals (QI).

INCOME: Effective April 1, 2026, use the following standards to determine income eligibility for Medicare Savings Programs (MSP):

QMB (100%) SLMB (120%) QI (135%) Individual $0 to $1,330 $1330.01 to $1,596 $1,596.01 to $1,796 Couple $0 to $1,804 $1,804.01 to $2,164 $2,164.01 to $2,435

NOTE: In years in which there is an SSA COLA increase, on-going MSP recipients’ SSA COLA increases are disregarded when received until the new MSP benefit standard is implemented for that year. These clients are entitled to receive continuous MSP benefits until the new MSP income limits are published. The system handles this disregard automatically.

APPLICATION: Effective January 1, 2010, applications for Social Security Extra Help are considered applications for Medicare Savings Programs. Medicare beneficiaries may also apply for

Medicare Savings Programs through the traditional application process at any Office of Public Assistance and can apply online at apply.mt.gov. The State will be notified electronically of applications received by Social Security for Extra Help. These applications will be processed after that notification. If the LIS information indicates eligibility, no further verification is needed. If the information is questionable or indicates they MAY be eligible, verifications should be requested.

Effective Date: 04/01/2026

Aged, Blind, And Disabled Medicaid 011 Table of Standards: Pickle Eligibility-Income

Supersedes: ABD 011 (01/01/2025) Reference: ARM 37.82.101, and .903; 42 CFR 435.135

Overview: If the applicant's countable income exceeds the amount found on the table, they are not "Pickle" eligible.

DATE SSI Ended Individual Living in Community Couple Living in Community Residential Care/Assisted Living Mentally Ill Group Home DD Community Home Foster Care DD Semi- Independent Living Jan-26 - $994 $1,491 $1088 $1,088 $1,088 $1,047 $1,020 Jan-25 - Dec-25 $1,022 $1,533 $1,118 $1,118 $1,118 $1,076 $1,049 Jan-24 - Dec-24 $1,048 $1,572 $1,147 $1,147 $1,147 $1,104 $1,075 Jan-23 - Dec-23 $1,081 $1,622 $1,184 $1,184 $1,184 $1,139 $1,110 Jan-22 - Dec-22 $1,176 $1,764 $1,287 $1,287 $1,287 $1,239 $1,207 Jan-21 - Dec-21 $1,245 $1,868 $1,363 $1,363 $1,363 $1,312 $1,278 Jan-20 - Dec-20 $1,261 $1,892 $1,381 $1,381 $1,381 $1,329 $1,294 Jan-19 - Dec-19 $1,281 $1,922 $1,402 $1,402 $1,402 $1,350 $1,315 Jan-18 - Dec-18 $1,317 $1,976 $1,442 $1,442 $1,442 $1,387 $1,352 Jan-17 - Dec-17 $1,344 $2,016 $1,471 $1,471 $1,471 $1,416 $1,379 Jan-15 - Dec-16 $1,348 $2,022 $1,475 $1,475 $1,475 $1,420 $1,383

Jan-14 - Dec-14 $1,371 $2,056 $1,500 $1,500 $1,500 $1,444 $1,407 DATE SSI Ended Individual Living in Community Couple Living in Community Residential Care/Assisted Living Mentally Ill Group Home DD Community Home Foster Care DD Semi- Independent Living Jan-13 - Dec-13 $1,392 $2,087 $1,523 $1,523 $1,523 $1,466 $1,428 Jan-12 - Dec-12 $1,415 $2,123 $1,549 $1,549 $1,549 $1,491 $1,452 Jan-09 - Dec-11 $1,466 $2,199 $1,605 $1,605 $1,605 $1,544 $1,505 Jan-08 - Dec-08 $1,552 $2,327 $1,698 $1,698 $1,698 $1,634 $1,592 Jan-07 - Dec-07 $1,587 $2,381 $1,738 $1,738 $1,738 $1,672 $1,629 Jan-06 - Dec-06 $1,640 $2,460 $1,795 $1,795 $1,795 $1,728 $1,683 Jan-05 - Dec-05 $1,708 $2,562 $1,869 $1,869 $1,869 $1,799 $1,752 Jan-04 - Dec-04 $1,753 $2,630 $1,919 $1,919 $1,919 $1,847 $1,799 Jan-03 - Dec-03 $1,790 $2,685 $1,959 $1,959 $1,959 $1,886 $1,837 Jan-02 - Dec-02 $1,815 $2,723 $1,987 $1,987 $1,987 $1,912 $1,863 Jan-01 - Dec-01 $1,862 $2,793 $2,038 $2,038 $2,038 $1,961 $1,910 Jan-00 - Dec-00 $1,927 $2,891 $2,110 $2,110 $2,110 $2,030 $1,978 Jan-99 - Dec-99 $1,974 $2,961 $2,161 $2,161 $2,161 $2,079 $2,026 Jan-98 - Dec-98 $2,000 $3,000 $2,189 $2,189 $2,189 $2,107 $2,052 Jan-97 - Dec-97 $2,042 $3,063 $2,235 $2,235 $2,235 $2,151 $2,095 Jan-96 - Dec-96 $2.101 $3,152 $2,300 $2,300 $2,300 $2,213 $2,156 Jan-95 - Dec-95 $2,156 $3,234 $2,360 $2,360 $2,360 $2,271 $2,212 Jan-94 - Dec-94 $2,217 $3,325 $2,426 $2,246 $2,426 $2,335 $2,275 Jan-93 - Dec-93 $2,274 $3,411 $2,489 $2,489 $2,489 $2,396 $2,334 Jan-92 - Dec-92 $2,343 $3,514 $2,564 $2,564 $2,564 $2,468 $2,404 Jan-91 - Dec-91 $2,429 $3,644 $2,659 $2,659 $2,659 $2,559 $2,493 Jan-90 - Dec-90 $2,561 $3,841 $2,803 $2,803 $2,803 $2,697 $2,628 Jan-89 - Dec-89 $2,681 $4,012 $2,934 $2,934 $2,934 $2,824 $2,751

Effective Date: January 1, 2026

AGED, BLIND, AND DISABLED MEDICAID 012 Table of Standards: Qualified Disabled Working Individual

Supersedes: ABD 012 (04/01/2025) Reference: ARM 37.83.401, .402, .406, 37.82.101

Overview: Effective April 1, 2026, use the following standards to determine income eligibility for Qualified Disabled Working Individuals (QDWI). Applicants with monthly countable income in excess of the QDWI income standard; 200 percent of the federal poverty level are not eligible for QDWI coverage. Individual: $2,660 Couple: $3,607 QDWI is not a Medicare Savings Program. A recipient cannot be open for QDWI and another Medicaid program at the same time. He or she must choose one program (for example, choose between QDWI and Medically Needy coverage).

BENEFITS: An eligible QDWI is entitled to have only monthly Medicare Part A (hospital insurance) premiums paid by Medicaid. "Regular" Medicaid benefits (e.g. physician visits, hospitalization, etc.) are not available to QDWIs. Effective Date: 04/01/2026

AGED, BLIND, AND DISABLED MEDICAID 013 Table of Standards: Nursing Home Residents-Income

Supersedes: ABD 013 (07/01/2025) Reference: ARM 37.82.101, .1313, .1320, .1330, .1331, .1336-.1338 Overview: Use the following standards to determine eligibility and category of coverage (categorically versus medically needy) for residential medical institution Medicaid benefits. Otherwise eligible institutionalized individuals and spouses are income- eligible for nursing home coverage so long as their monthly nursing home costs equal or exceed their monthly income. After a nursing home resident has been determined eligible for nursing home coverage as either categorically or medically needy, the amount the client is responsible to apply toward the cost of care must be calculated in STEP II of the eligibility process. CATEGORICALLY NEEDY INCOME STANDARD: The monthly categorically needy income standard for an institutionalized individual is $30. MEDICALLY NEEDY INCOME LEVEL: The monthly medically needy income level (MNIL) is $525. COMMUNITY SPOUSE INCOME MAINTENANCE ALLOWANCE: When computing the amount of monthly income the nursing home spouse must apply toward the cost of care (STEP II), the community spouse's income maintenance allowance is the lesser of: 1. $4067 (effective 01-01-2026) less the community spouse's own gross monthly income; or

2. A combination of: a. Shelter expenses for the community spouse’s principal residence which exceed the basic shelter allowance of $794 (effective 07-01- 2025); plus b. The basic needs standard of $2644 (effective 07-01-2025); less c. The community spouse's own gross income.

Effective Date: 01/01/2026

AGED, BLIND, AND DISABLED MEDICAID 014 Table of Standards: Poverty Guidelines

Supersedes: ABD014 (04/01/2025) Reference: 20 CFR 416.410 and ARM 37.82.101

Overview: Use the following table to determine eligibility for coverage groups that have income eligibility based on poverty guidelines.

2026 Monthly Poverty Guidelines

Household Size 100% 120% 135% 150% 200% 250% 1 person $1330 $1596 $1796 $1995 $2660 $3325 2 persons $1803 $2164 $2435 $2705 $3607 $4508

Effective Date: 04/01/2026

AGED, BLIND, AND DISABLED MEDICAID 017 Table of Standards: Life Estate Interest Table Supersedes: MA 009 (09/01/98) Reference: 26 CFR 20.2031-7 and 49 Federal Register Vol. 49 No 93/05-11-1984 Overview: Use the following table to determine life estate values. UNISEX LIFE ESTATE INTEREST TABLE

AGE LIFE ESTATE FACTOR

AGE LIFE ESTATE FACTOR

AGE LIFE ESTATE FACTOR 0 .97188 1 .98988 2 .99017 3 .99008 4 .98981 5 .98938 6 .98884 7 .98822 8 .98748 9 .98663 10 .98565 11 .98453 12 .98329 13 .98198 14 .98066 15 .97937 16 .97815 17 .97700 18 .97590 19 .97480 20 .97365 21 .97245 22 .97120 23 .96986 24 .96841 25 .96678 26 .96495 27 .96290 28 .96062 29 .95813 30 .95543 31 .95254 32 .94942 33 .94608 34 .94250 35 .93868 36 .93460 37 .93026 38 .92567 39 .92083 40 .91571 41 .91030 42 .90457 43 .89855 44 .89221 45 .88558 46 .8786. 47 87.137 48 .86374 49 .85578 50 .84743 51 .83674 52 .82969 53 .82028

UNISEX LIFE ESTATE INTEREST TABLE

AGE LIFE ESTATE FACTOR

AGE LIFE ESTATE FACTOR

AGE LIFE ESTATE FACTOR 54 .81054 55 .80046 56 .79006 57 .77931 58 .76822 59 .75675 60 .74491 61 .73267 62 .72002 63 .70696 64 .69352 65 .67970 66 .66551 67 .65098 68 .63610 69 .62086 70 .60522 71 .58914 72 .57261 73 .55571 74 .53862 75 .52149 76 .50441 77 .48742 78 .47049 79 .45357 80 .43659 81 .41967 82 .40295 83 .38642 84 .36998 85 .35359 86 .33764 87 .32262 88 .30859 89 .29526 90 .28221 91 .26955 92 .25771 93 .24692 94 .23728 95 .22887 96 .22181 97 .21550 98 .21000 99 .20486 100 .19975 101 .19532 102 .19054 103 .18437 104 .17856 105 .16962 106 .15488 107 .13409 108 .10068 109 .04545

Effective Date: July 01, 2017

AGED, BLIND, AND DISABLED MEDICAID 105-1 Disability Determination Supersedes: ABD 105-1 (07/01/06) Reference: 42 CFR 435.540, 541, .911; ARM 37.82.101, .204, ARM 46.12.3002 Overview: An individual applying for Medicaid based on disability must meet the Social Security Administration's (SSA) disability criteria, unless disability is based on death. Disability may be established through SSA and/or MEDS (Medicaid Eligibility Disability Services), using SSA criteria. A disability determination is not required prior to the client being evaluated for disability- related Medicaid. If the client is otherwise eligible, their disability determination is pursued through SSA and/or MEDS as outlined below. NOTE: Eligibility for (VA) Veterans Administration disability benefits does not automatically meet SSA disability criteria. Therefore, veterans must complete the SSA or MEDS disability determination process. DISABILITY DETERMINATION FOR DECEASED APPLICANT: A Medicaid application may be filed on behalf of a deceased person. Benefits are provided if the individual would have been eligible had an application been made prior to his/her death. An individual is considered to meet disability criteria in the month of their death. If the cause of death was a factor during any of the previous three retro months, the deceased is assumed to have been disabled for those months. A doctor’s statement is required to establish if the cause of death was a factor during the retro months. MEDS DISABILITY DETERMINATION: DPHHS is required to make a disability determination through MEDS when a Medicaid applicant: 1. Has not applied for SSI cash benefits; NOTE: Medicaid clients are not required to apply for SSI. 2. Has applied for SSI benefits and is found ineligible for benefits for a reason other than disability (e.g., excess income or resources); NOTE: When SSI benefits are denied because the client's income exceeds the SSI limits, the client may meet Medicaid eligibility criteria for other programs (e.g., medically needy). 3. Has applied for SSDI benefits and is found ineligible for a reason other than disability (e.g., insufficient creditable quarters of work);

4. Has applied for SSI and/or SSDI and separately to DPHHS for Medicaid and SSA has not made a disability determination as of Medicaid application date; NOTE: If SSA has not made a disability determination by the Medicaid application date, a MEDS disability determination is pursued. The application remains pended (not denied) while awaiting either a MEDS or SSA disability determination. NOTE: A SSA disability determination of “Hold Early Input” confirms no disability determination has been made by SSA. In these situations, the MEDS process should be used to establish a disability determination while a decision from SSA is pending. 5. Alleges a disabling condition different from, or in addition to that considered by SSA in making its determination; OR 6. It has been more than 12 months since the individual’s most recent SSA determination denying their disability and the following criteria are met: a. The individual alleges that his or her condition has changed or deteriorated since that SSA determination, AND b. Alleges a new period of disability which meets the durational requirements of the ACT, AND c. Has not applied to SSA for a determination with respect to these allegations. 7. It has been less than 12 months since the individual’s most recent SSA determination denying their disability and the following criteria are met: a. The individual alleges that his or her condition has changed or deteriorated since that SSA determination, AND b. Alleges a new period of disability which meets the durational requirements of the ACT, AND c. Has applied to SSA for reconsideration or reopening of its disability decision and SSA refused to consider the new allegations; AND/OR d. He or she no longer meets the non-disability requirements for SSI but may meet the State’s non-disability requirements for Medicaid eligibility. MEDS RE-EXAMINATION: When MEDS provides a disability approval determination that includes a future re-exam date, the disability determination is only valid through the re-exam date. A new MEDS disability determination is required to continue to use the MEDS determination to meet the Medicaid disability criteria past the re- exam date. SSA DISABILITY DETERMINATION: SSA determines disability for: 1. Social Security Disability Insurance (SSDI) benefits; and 2. Supplemental Security Income (SSI) benefits. An SSI application filed with SSA is also a Montana Medicaid application.

SSA DECISION ON APPLICANT: When SSA determines a Medicaid applicant is not disabled, but MEDS has determined the applicant is disabled, the SSA decision supersedes the MEDS determination, and the Medicaid request for coverage based on disability must be denied. Re-evaluate the client’s Medicaid request when the Medicaid denial is based solely on an SSA disability denial, when: 1. SSA reverses the disability denial; and 2. The client is later approved for SSDI or SSI Medicaid eligibility is re-evaluated as follows: 1. Approved for SSDI – back to original Medicaid application date; 2. Approved for SSI – back to the earlier of the SSI application date or the original Medicaid application date. SSA DECISION ON CLIENT: If SSA finds a Medicaid client is not disabled (whether favorable MEDS determination or when SSA finds that an individual who they previously considered disabled no longer meets that criteria), Medicaid is continued during the 60-day period within which an SSA appeal may be filed. The eligibility staff member sets a system alert for the first of the month of the 60th day after the SSA notice of decision date, if they are aware of the findings in advance. NOTE: Repayment of benefits is not required during the 60-day period the client has to file an appeal. This process does not apply to a termination of presumptive SSI eligibility. PRESUMPTIVE DISABILITY ENDS: If SSA determines that an individual who receives Medicaid due to receipt of presumptive SSI benefits is not disabled; SSI Medicaid is terminated as soon as possible, allowing for timely notice, rather than being continued for 60 days. Non-SSI Medicaid may be provided during the 60-day period within which an SSA appeal may be filed. In the month in which the 60-day appeal period expires, send timely notice of Medicaid closure to the client using the appropriate system notice. The notice informs the client that Medicaid benefits will be terminated at the end of the month unless they provide verification (within 15 days of the notice) that the disability decision has been appealed to the Social Security Administration. The notice also informs the client that if their appeal is unsuccessful they may have to repay the continued Medicaid benefits they requested. If the client brings in verification of the SSA appeal, and requests continued Medicaid benefits, those benefits continue through the appeal process until a decision is reached by the Appeals Council.

If the client does not appeal the decision (timely), or does not provide verification of a timely appeal to OPA within the required 15 days of OPA notice, request sufficient information to determine eligibility under other Medicaid programs (ex parte review). If the client is unsuccessful in the appeal to the Appeals Council and there is no eligibility under any other Medicaid program, close Medicaid and send timely notice of adverse action. TIMELY APPLICATION REQUIREMENTS: Eligibility must be determined with ninety (90) days for applications requiring a disability determination. See CMA 103-1 regarding the availability of extensions. REQUIREMENT TO APPLY FOR BENEFITS: SSDI Benefits: As a condition of eligibility, applicants who have at least 40 work quarters must apply for Social Security Disability Insurance (SSDI) no later than during the Medicaid application process OR within five months of the stated onset of disability, whichever comes later. SSI Benefits: Application for benefits which do not affect Medicaid eligibility is NOT a requirement. SSI income is excluded, so does not affect Medicaid eligibility. Effective Date: January 01, 2017

AGED, BLIND AND DISABLED MEDICAID 200 Groups Covered-Overview Supersedes: MA 200 (07/01/10), MA 200-1 (07/01/08) & ABD Bulletin 117 (04/08/15) Reference: 20 CFR 416.2101, .2111, .2116; 42 CFR 435.1, .120, .121, .122, .130, .131, .132, .133, .134, .135, .136, .137, .138, .404, .601-.602 and ARM 37.82.101, .901-.903, .911-.916 Overview: Medicaid for the aged, blind and disabled is provided to otherwise eligible individuals who meet ABD financial and non-financial eligibility requirements, and who fall into one of the groups listed below. CATEGORICALLY NEEDY GROUPS: 1. SSI-eligible clients as defined in ABD 201-1; 2. Recipients of optional state supplemental payments (ABD 201-1); NOTE: Individuals receiving optional state supplemental payments are treated as SSI recipients. 3. SSI-eligible clients eligible as 1619b; 4. Aged, blind and disabled individuals with countable income at or below the categorically needy income standard (ABD 007). 5. Certain Pickle-eligible clients (ABD 201-2); 6. Certain Early Widows and Widowers/Divorced Surviving Spouses (ABD 201-3); 7. Certain individuals who received both public assistance (OAA, AB, APTD or AABB) and Social Security benefits in July 1972 (ABD 201-4) 8. Certain DAC-eligible clients (ABD 201-5); 9. MWD-eligible clients who pay monthly cost share fees; (ABD 201-6); 10. QDWI-eligible individuals (ABD 201-7); NOTE: Medicaid benefits available under QDWI include payment of Medicare Part A premiums only. 11. Certain Medicare beneficiaries whose countable income is within the limits for Medicare Savings Programs (ABD 008) MEDICALLY NEEDY GROUPS: Clients who meet all ABD non-financial and resource requirements, but whose income exceeds the Categorically Needy Income standards at ABD 007. ELIGIBLE IN MORE THAN ONE CATEGORY:

QMB clients must be evaluated to determine if they qualify for medically needy coverage. QMB clients who need vision or dental coverage, waiver services or other non-Medicare covered services can receive assistance in meeting these needs when they qualify for medically needy Medicaid coverage. ASSISTANCE/ FILING UNIT: The income and resources of some filing unit members must be considered when determining Medicaid eligibility. See ABD 601-2, "Financial Responsibility of Relatives." An ABD assistance unit is never more than two people. If both parents, as well as a child, are disabled, two assistance units are created; parental income is deemed to the child. If both parents live with the child, both of their incomes are deemed. Under no circumstance can a child’s income be considered when determining their disabled parent’s eligibility. SAME SEX MARRIAGE: Same-sex couples who marry in a jurisdiction that recognizes same-sex marriage are considered spouses. Same-sex marriages are permissible under Montana law, and Montana recognizes same-sex marriages performed in other jurisdictions. NOTE: Civil unions and domestic partnerships do not impact marital status and therefore these couples are not considered spouses when determining Medicaid eligibility. Effective Date: July 01, 2016

AGED, BLIND, AND DISABLED MEDICAID 201-1 SSI Eligibles

Supersedes: ABD 201-1 (July 01, 2016) Reference: 20 CFR 416.2101, .2111 and .2116; 42 CFR 435.120; ARM 37.82.101 and .901-.903 Overview: A Supplemental Security Income (SSI) application filed with the Social Security Administration (SSA) is also a Medicaid application, and individuals eligible for SSI are categorically eligible for SSI-related Medicaid, provided they meet all non- financial requirements. Individuals eligible for State Supplemental Payments (SSP) or eligible under Section 1619 of the Social Security Act are also categorically eligible for SSI-related Medicaid, provided they meet all non-financial requirements. SSI-eligible clients must cooperate, both for themselves and for other household members, with all third-party liability requirements. Because the SSA determines their financial eligibility, income and resources are not evaluated for SSI-eligible clients before issuing SSI-related Medicaid. In addition, SSI-eligible clients applying for nursing home or Home and Community Based Waiver services coverage: 1. May be asked to provide additional information and/or verification necessary to determine the additional level of coverage; and 2. are evaluated for uncompensated asset transfers during the look-back period. DATE OF MEDICAID ELIGIBILITY: SSI-related Medicaid eligibility begins the month prior to the month in which the initial SSI cash payment is made. This is because SSA delays the initial payment for one month. Retroactive Medicaid may be available for the three months immediately

preceding the SSI application, provided the individual meets all necessary criteria, including disability in each month. If the SSI disability onset date does not cover the retroactive period, the MEDS process is pursued. SSI ENDS: SSI-related Medicaid ends the month after the client’s SSI payment or 1619b status ends. NOTE: An ex-parte review is completed when SSI-related Medicaid is closed. SEE BUSINESS PROCESS: SSI Eligible Individuals Process Effective Date: July 01, 2024

AGED, BLIND, AND DISABLED MEDICAID 201-3 Early Widows and Widowers/Divorced Surviving Spouse Supersedes: MA 201-5 (01/01/08) Reference: 42 CFR 435.138; ARM 37.82.101, .901 & .903; 42 U.S.C. 1383c (d)(1)(a) Overview: Certain widow(er)s or divorced surviving spouses may qualify for categorically needy Medicaid. Coverage is limited to individuals who: 1. Are widows/widowers or divorced surviving spouses and are eligible for and receiving Social Security Early Widow(er)’s/divorced surviving spouse’s benefits; 2. Are age 60 through 64 years old; 3. Are losing or have lost SSI or SSP benefits because they are receiving Early Widow(er)’s/ divorced surviving spouse’s benefits; 4. Are not entitled to Medicare Part A (hospital insurance); and 5. Have countable resources within the general resource limit (CMA 001). Effective Date: July 01, 2016

AGED, BLIND, AND DISABLED MEDICAID 201-4 Social Security Increase of July 1972 Supersedes: MA 201-7 (09/01/98) Reference: ARM 37.82.901, 903 and 42 CFR 435.134 Overview: Categorically needy Medicaid is provided to individuals who meet the following conditions: In August 1972, the individual was entitled to OASDI (Old Age, Survivors, and Disability Insurance Program) and: 1. Was receiving OAA (Old Age Assistance), AB (Aid to the Blind), APTD (Aid to the Permanently and Totally Disabled), or AABD (Aid to the Aged, Blind and Disabled); or 2. Would have been eligible for one of the above programs had they applied, and the State Medicaid Plan covered this optional group; or 3. Would have been eligible for one of the above program if they were not in a medical institution or intermediate care facility, and the State Medicaid Plan covered this optional group; AND 4. Would currently be eligible for SSI or SSP if the OASDI increase under P.L. 92-336 had not raised their income over the SSI limit. This includes individuals who: 1. Meet all current SSI requirements except for filing an application; or 2. Would meet all current SSI requirements if they were not in a medical institution or intermediate care facility, and the State Medicaid Plan covered this optional group. BUDGET PROCEDURE: 1. Budget: + Gross Income: - Social Security Increase Received in 1972 - Income disregards (as appropriate) = Countable Income 2. Compare countable income to the Categorically Needy Standard for one person (ABD 007). If the income is: a. Less than the standard, the individual qualifies for categorically needy Medicaid coverage; or

b. Greater than the standard, the individual does not qualify for Medicaid under this group. NOTE: Social Security increases received after July 1972 are not excluded from income when determining medical assistance eligibility for this coverage group. Effective Date: July 01, 2016

AGED, BLIND, AND DISABLED MEDICAID 201-5 Disabled Adult Children Supersedes: MA 201-8 (07/01/08) Reference: 42 U.S.C. 1383(c); 42 CFR 435.120; ARM 37.82.101 Overview: Certain disabled adult children (DAC) may qualify for categorically needy Medicaid (i.e., no spend down). DAC coverage is limited to individuals who: 1. Meet all non-financial eligibility criteria; 2. Are within resource limitations; 3. Lost SSI/SSP eligibility after July 1, 1987, due to entitlement to or an increase in Social Security DAC benefits. NOTE: An increase to a DAC benefit could include COLA. 4. Currently receive Social Security DAC Benefits; and 5. Do not reside in a residential medical facility. All criteria listed above (1-5) must be met to correctly determine DAC Medicaid Eligibility. Simply verifying current receipt of Social Security DAC benefits is not sufficient. DAC & WAIVER: DAC Medicaid clients may also receive services under a Medicaid waiver. For couples, both spouses must be covered under the same waiver program. Effective Date: July 01, 2016

AGED, BLIND, AND DISABLED MEDICAID 201-6 Montana Medicaid for Workers with Disabilities (MWD)

Supersedes: MA 201-6 (10/01/2018) Reference: 42 USC 1396a(a)(10)(A)(ii)(XIII); MCA 53-6-113(6), 53-6-131(13), 53-6-195; ARM 37.82.101, 37.82.1002-1007 Overview: Working disabled Medicaid clients may qualify for the Montana Medicaid for Workers with Disabilities (MWD) program by paying a cost share fee. Coverage is limited to individuals who: 1. Meet all Medicaid non-financial requirements, 2. Are currently considered disabled, or would be considered disabled under Social Security Act criteria if not for their current work activities, or for whom a disability determination under SSA criteria is not required due to being aged (65+); 3. Are age 16 or older, 4. Are employed or self-employed, as defined in this policy, 5. Are within the MWD program resource limits (CMA 001 General Resource Limits) (Asset transfer evaluations apply to MWD Waiver); NOTE: Retirement accounts the aged/disabled worker owns are excluded only for MWD eligibility, 6. Have countable income at or below 250% of federal poverty level, NOTE: Parental deeming and spousal impoverishment rules do not apply to MWD Waiver eligibility. 7. Are not residing in residential medical institutions, and 8. Pay a monthly cost share fee, which is based on only the aged/disabled worker’s income. For married individuals see cost share fee information below.

NOTE: MWD clients who attest to being enrolled in a tribe are exempt from cost share fees. (The client must answer Indian Enrollment questions.) WORK ACTIVITIES: To qualify for MWD, the aged/disabled worker must have performed paid work, or be expected to perform paid work in the benefit month. An individual is considered to be working in any month in which the individual works or is expected to work. An individual is not disqualified simply because they do not receive pay in a month; pay may be received the following month. If employment activities or work were performed in the benefit month, the individual may qualify for MWD. The individual is not considered employed in a month they did not perform work, even if they received pay for a prior month’s work. NOTE: For MWD purposes, employed is defined as engaging in work with the expectation of receiving pay, either as an employee or through self-employment. An individual is only considered employed if both Medicare and social security taxes are withheld from their pay. For self-employed individuals, they must pay both Medicare and social security taxes on their self- employment income. An employed individual must provide proof of legal employment by documenting: · FICA and other employment-related tax withholding from pay, · Worker’s compensation insurance coverage, and · They are paid, per State labor regulations, for work activities performed. Self-employment must be validated as a legitimate legal business through documentation of: · Material participation in the business, · Proof of regular and on-going business transactions, · Business is registered with the Secretary of State, · A current business license, · Filing self-employment tax documents, · Property and/or accounts in the business’s name, and · A profit motivation. Corporations, LLCs, partnerships, and passive business ownership are not self- employment (CMA 503-1 Self-Employment Income). Income paid to corporate shareholders, LLCs, etc. is unearned income. However, individuals who are corporate employees, and whom the corporation pays wages with appropriate withholding, may be considered employed.

COST SHARE FEES: Medicaid coverage is issued to an eligible MWD client for any benefit month the cost share fee is paid. Cost share fees are based on only the aged/disabled worker’s income. MWD eligible clients who are married, and whose spouse does not qualify for MWD, have their cost share determined based on only their net countable income (the spouse’s income is NOT included). If both spouses qualify for MWD, the cost share fee is based on their combined net countable income. A cost share fee is not the same as a spend down. A cost share fee cannot be reduced by applying medical expenses such as health insurance premiums, copays or other out- of-pocket medical costs. Effective Date: 05/01/2025

AGED, BLIND, AND DISABLED MEDICAID 201-7 Qualified Disabled Working Individuals (QDWI) Supersedes: MA 201-10 (09/01/98) Reference: ARM 46.12.3601 and .3603 Overview: An eligible Qualified Disabled Working Individual (QDWI) is a person: 1. who is entitled to re-enroll in Medicare Part A hospital insurance coverage because he/she lost premium-free Part A coverage due to engaging in a substantial gainful activity; 2. who meets all nonfinancial requirements which include: a. being categorically eligible (i.e., disabled); b. having or applying for a Social Security Number; c. being a U. S. citizen or legally admitted alien; and d. being a Montana resident; 3. whose income does not exceed 200% of the federal poverty guideline; and 4. whose resources do not exceed twice the Supplemental Security Income (SSI) general resource limit. RETROACTIVE: Up to three months retroactive coverage is available to eligible QDWIs. COVERAGE BENEFITS: A QDWI is only entitled to have monthly Medicare Part A (hospital insurance) premiums paid by Medicaid. Regular Medicaid benefits (e.g., prescriptions, physician visits, dental care, etc.) are not available to QDWIs. Effective Date: July 01, 2016

AGED, BLIND, AND DISABLED MEDICAID 201-8 Medicare Savings Programs

Supersedes: ABD 201-8 (7/1/2024) Reference: ARM 37.82.101, ARM 37.83.201, .202, P.L. 105-33, P.L. 110-275; P.L. 100- 360 (1988), P.L. 101-239 § 6411 (1989), and P.L. 101-508 § 4501 (1990); 42 U.S.C. 1396d (p) Overview: Qualifying Medicare beneficiaries may be eligible for additional coverage to help with Medicare-related expenses. There are three Medicare Savings Programs (MSP): 1. Qualified Medicare Beneficiaries (QMB); 2. Specified Low-Income Medicare Beneficiaries (SLMB); 3. Qualifying Individual (QI). Clients may be eligible for QMB or SLMB coverage in addition to categorically or medically needy (“regular”) Medicaid coverage. When the OPA is notified (via interface or client report) that a current Medicaid client is entitled to Medicare Part A or Part B, MSP eligibility must be evaluated. MEDICARE ENTITLEMENT: Unless refused, Medicare Part A and B enrollment is automatic for most Medicare beneficiaries. MSP coverage cannot be denied for an otherwise-eligible client simply because they are not enrolled in Medicare Part A and/or Part B. Medicare coverage (entitlement) always begins on the first day of the coverage month. MEDICARE ENROLLMENT PERIOD: There are two enrollment periods for Medicare A & B entitlement: 1. The initial enrollment period, which includes the: a. Three months prior to an individual’s 65th birthday or 25th month of disability benefits receipt; b. Month of the 65th birthday or 25th month of disability benefits receipt; and

c. Three months after the month of the 65th birthday or 25th month of disability benefits receipt. and 2. The general/open enrollment period: every January, February and March. NOTE: MSP clients can enroll in Medicare outside the open enrollment period. They are automatically enrolled in Medicare Part B when an MSP is approved. QMB clients are automatically enrolled in both Part A and Part B (if they do not qualify for free Part A). MEDICARE PART A BENEFITS: Medicare Part A coverage includes inpatient hospitalization, some follow- up care, and skilled level nursing home care. MEDICARE PART B BENEFITS: Medicare Part B coverage includes physician services, laboratory and x-ray services, medical supplies, outpatient hospital care, and other services. MSP PROGRAM BENEFITS: QMB benefits include payment of: 1. Medicare Part A premiums (for individuals who do not receive premium-free Part A coverage); 2. Medicare Part B premiums; 3. Medicare deductibles; and 4. Medicare coinsurance (the cost share amount the recipient is responsible to pay). SLMB and QI pay only Medicare Part B premiums. NOTE: Because SLMB and QI only pay Medicare Part B premiums, no Medicaid ID card is issued. HOUSEHOLD COMPOSITION: Evaluate each MSP applicant’s living situation to determine the correct household composition, assistance, and filing units. Treat the following as individuals: 1. Married individual living separately in the community. 2. Married living separately because one spouse is in Assisted Living. 3. Couple with both spouses residing in nursing homes, even if they share a room at the nursing home.

Treat the following as a couple: 1. Married living together in the community.

2. Married living together in Assisted Living even if one or both spouses receive Medicaid waiver coverage. (Spousal impoverishment does not apply to MSP eligibility). 3. Married living together: one in the community and one waiver spouse. NONFINANCIAL REQUIREMENTS: Medicaid standard nonfinancial requirements are listed in section CMA 300. In addition to the standard criteria that applies to all Medicaid programs, the following nonfinancial criteria are specific to all MSP programs: · Must be enrolled in Medicare Hospital Insurance (Part A)

Qualified Individual additional criteria · Other medical coverage (i.e., medically needy) cannot be issued with QI for more than one month NOTE: QI continues when a QI recipient requests and meets medically needy eligibility for only one month. FINANCIAL REQUIREMENTS: Countable income must be within the following guidelines for the appropriate household size: QMB: at or below 100% FPL SLMB: above 100% and at or below 120% FPL QI: above 120% and at or below 135% FPL Countable resources cannot exceed the MSP resource standards listed in CMA 001. COST OF LIVING ADJUSTMENT (COLA): Yearly COLA increases are disregarded for QMB clients who would lose eligibility due to the COLA. NOTE: The system automatically disregards these COLA increases. SSI RECIPIENTS: An individual in receipt of SSI, State Supplement payment, or 1916b is not required to have an independent evaluation of income and resources when the recipient requests additional coverage, such as MSP. COVERAGE EFFECTIVE DATE: QMB benefits begin the first of the month after application, provided all eligibility criteria are met. QMB coverage cannot be approved retroactively. SLMB and QI benefits begin the first of the application month and may be approved retroactively for up to three months prior to application/coverage request. ESTATE RECOVERY: Effective January 1, 2010, Medicare premiums paid for through an MSP benefit are not subject to estate recovery.

SEE BUSINESS PROCESSES: Acting on Changes Medicare and Qualified Individual and Medicare Auto Enrollment Process Effective Date: 5/1/2025

AGED, BLIND, AND DISABLED MEDICAID 201-9 Residents in Medical Institutions prior to October 01, 1989 Supersedes: MA 905-1 (02/01/02) Reference: 42 CFR 435.725; ARM 37.82.1306, .1311, .1313, and .1320 Overview: Medicaid is available to eligible individuals who entered a licensed medical facility/ intermediate care facility (nursing home) prior to October 1, 1989. NONFINANCIAL ELIGIBILITY CRITERIA: Medicaid standard nonfinancial requirements are listed in section CMA 300. In addition to the standard criteria that applies to all Medicaid programs, the following nonfinancial criteria are specific to residents institutionalized prior to October 1, 1989. • Preadmission screening FINANCIAL ELIGIBILITY CRITERIA: Countable resources include only the resources the institutionalized individual owns in whole or in part, and cannot exceed $2,000 for an individual. NOTE: Resource assessments are not required for individuals who have been continuously institutionalized since prior to October 1, 1989. Income eligibility is determined using the same process as any other institutionalized individual (see ABD 805-1). NOTE: The community spouse may be entitled to an income maintenance allowance, even though a resource assessment isn’t completed for individuals continuously institutionalized since prior to October 1, 1989. Effective Date: July 01, 2016

AGED, BLIND, AND DISABLED MEDICAID 402-4 Conditional Assistance Supersedes: MA 402-4 (07/01/06) Reference: 42 CFR 435.601, 20 CFR 416.1240-.1245; ARM 37.82.101, .423 Overview: Conditional assistance is a contractual agreement by the client to: 1. make a bona fide effort to sell excess non-liquid resources at current market value; and 2. repay Medicaid for benefits paid during the conditional assistance period. Conditional assistance may be available to clients who own non-liquid resources in excess of the allowable limit. NOTE: Conditional assistance cannot be used for property the client does not own (i.e., owned by a corporation or trust). Before conditional assistance can be used to reduce countable resources a client must: 1. Meet all non-financial eligibility criteria; 2. Own resources with a total countable value in excess of the ABD resource limit (see CMA 001). 3. Have countable liquid resources below the appropriate Medicaid resource limit when the item listed for sale is excluded by conditional assistance; and 4. Agree in writing (form HCS-97, "Agreement to Sell Property") to: a. Sell excess non-liquid resources within the conditional assistance period; and b. Use net sale proceeds to repay Medicaid for benefits paid during the conditional assistance period. LIQUID RESOURCES: Cash, as well as other non-cash resources are considered liquid and therefore are not eligible under conditional assistance. Absent proof to the contrary, the following are assumed to be liquid resources: 1. stocks, bonds and mutual fund shares; 2. checking accounts, savings accounts and time deposits; 3. U.S. savings bonds and Treasury bills, notes and bonds; 4. mortgages and promissory notes; and 5. life insurance. NON-LIQUID RESOURCES:

A non-liquid resource is property which: 1. is not cash; and 2. cannot be converted to cash within twenty (20) workdays. Absent proof to the contrary, the following are assumed to be non-liquid personal resources: 1. personal real property; 2. automobiles, trucks, tractors and other vehicles; 3. machinery and livestock; 4. buildings and land; 5. non-cash business property; and 6. household goods and personal effects of unusual value. JOINTLY-OWNED PROPERTY: Jointly-owned property that meets inaccessibility criteria does not need to go through the conditional assistance process. Review inaccessibility policy in CMA 401-1. If a jointly-owned property’s contract provides that an individual cannot sell their proportionate share without the consent of all joint owners and all joint owners provide a written statement indicating they refuse to agree, the property is considered inaccessible. Central office must evaluate the contract to establish inaccessibility. If a jointly-owned property’s contract provides that an individual can sell their individual proportionate share without the consent of all joint owners their proportionate interest is accessible. The client is required to provide verification of the FMV of only their proportionate interest of the property. NOTE: Joint owners outside the Medicaid household cannot be required to list their proportionate portion for sale. ELIGIBILITY PERIOD: Conditional Medicaid assistance may be provided to eligible individuals for a maximum of either 6 months (excess personal property) or 12 months (excess real property). Conditional assistance cannot be extended. No more than one conditional assistance period is allowed for the client’s ownership interest in any specific property. RETROACTIVE CONDITIONAL ASSISTANCE: Conditional assistance can be applied retroactively only when the excess non-liquid resource(s) were already listed for sale during the retroactive eligibility period. NOTE: Any retroactive months are included in the 6 or 12-month conditional assistance period. REASONABLE EFFORTS TO SELL: All steps necessary to sell the property at FMV in the geographic area it is located must be taken. The applicant must, within 30 days of signing the conditional assistance agreement:

1. List the property with an agent or other knowledgeable source in the business of selling the specific property type; or 2. All of the following: a. continuously advertise the property for sale at FMV in at least one appropriate local media; b. place a “For Sale” sign on the property in clear public view; c. begin showing the property to interested parties (this may be through ‘open houses’ or other appropriate methods); AND d. attempt any other appropriate method of sale. REPAYMENT: The conditional Medicaid assistance that must be repaid is the lesser of the: 1. client’s share of net proceeds balance after deducting the: a. amount necessary to raise the client’s countable resources to the applicable resource limit, based on program and filing unit size (individual or couple); and b. legal encumbrances on the property; or 2. the total amount of conditional medical assistance payments made on the individual's (and spouse's, if any) behalf. The client must repay Medicaid benefits received during the conditional assistance period when the property is sold. It does not matter if the property is sold during or after the conditional assistance period or after the client is no longer receiving Medicaid benefits; the repayment must be made. NOTE: If the client does not repay Medicaid with the sale proceeds as agreed, an overpayment is established. PROPERTY NOT SOLD DURING CONDITIONAL ASSISTANCE PERIOD: Property that is not sold during the conditional assistance period is considered inaccessible only if the client continues to make reasonable efforts to sell it. The property is a countable resource when the client is no longer making continuous reasonable efforts to sell. MEDICAID LIENS: When both conditional assistance and a Medicaid lien apply to the same property, the larger obligation is owed to Medicaid. Normally, the Medicaid lien will be the higher of the two obligations, and will include the conditional assistance period. TRACKING: OPA staff must track the property sale and pursue repayment when the property is sold, regardless of when it is sold. If a valid Medicaid lien exists, Lien and Estate Recovery will pursue repayment. OPA staff must verify that a valid Medicaid lien exists before they cease tracking the property sale. Effective Date: July 01, 2016

AGED, BLIND AND DISABLED MEDICAID 404-5 Pursuing Claims on Property and Estates Supersedes: MA 404-6 (07/01/08) Reference: 72-2-221, MCA; ARM 37.82.101 Overview: Medicaid clients who receive or request institutional or waiver coverage are required to pursue all legal claims to income or assets to which they are entitled. Failure or refusal to pursue these claims is evaluated as an uncompensated asset transfer. RESOURCES CONSIDERED AVAILABLE IMMEDIATELY: All resources the Medicaid client owned with the deceased spouse as “joint tenants with right of survivorship” or other joint tenancy are immediately considered available to the Medicaid client. Resources the community spouse owned solely at the time of their death are not automatically considered available to the Medicaid client. RESOURCES WILLED TO A MEDICAID CLIENT: If a deceased person willed all or part of their estate to a Medicaid client, the resources are not considered available/countable until the estate has been probated and otherwise settled. The Medicaid client/their authorized representative must take action to begin settling the estate within a reasonable time. This timeframe varies from case to case, but 60 days is normally considered reasonable to begin this process. RESOURCES WILLED TO PERSONS OTHER THAN AN INSTITUTIONALIZED SPOUSE: If a community spouse wills all or part of their estate to anyone other than their institutionalized spouse, the institutionalized spouse is entitled to an elective share. The elective share percentage will vary depending on how long the couple was married, but for those married 15 or more years, the elective share is 50%. If pursuit of their elective share causes a hardship to the institutionalized spouse, they are not required to pursue their elective share. However, if no hardship exists, the institutionalized spouse must pursue their elective share. After Medicaid eligibility is established, the community spouse can transfer assets without an asset transfer penalty being imposed against the institutionalized spouse. The community spouse can will up to 50% of their personal assets to someone other than their spouse and the spouse is not subject to

transfer penalty. There is also no requirement to pursue the elective share as the surviving spouse will have received at least 50% of the estate. NOTE: If the community spouse later requests institutional or waiver Medicaid, any assets they transferred must be evaluated for an uncompensated asset transfer/penalty. COMMUNITY SPOUSE DIES WITH NO WILL: When a community spouse dies and doesn’t leave a will, the institutionalized spouse is entitled to all or a large portion of the estate. FAMILY ALLOWANCES: A Medicaid client who is or may be entitled to a “family allowance” from a deceased family member’s estate, or any other inheritance/allowance, must pursue their claim. OTHER ENTITLEMENTS: If a Medicaid client is entitled to other assets over and above their family allowance or elective share, they must pursue those assets. Effective Date: July 01, 2016

AGED, BLIND, AND DISABLED MEDICAID 800 Residential Medical Institutions Overview

Supersedes: ABD 800 (July 1 2016) Reference: 42 U.S.C. 1396r-5; 42 CFR 435.301, .725, .832; .1008 and 1009; 42 CFR 435 Subpart E; ARM 37.82.101, 37.82.1301-.1306; .1310-.1313, .1320 and .1321 Overview: Aged, blind and disabled individuals who live in licensed medical institutions may be eligible for Medicaid provided they meet all ABD institutional coverage requirements. Individuals listed below are not considered residents of a medical institution but may qualify for a different Medicaid program. 1. Individuals temporarily placed in an institution pending other arrangements; or 2. Individuals receiving an education or vocational training while living in a public or vocational training institute (e.g., School for the Deaf and Blind, Job Corps, etc.) SSI CASH RECIPIENTS: An individual in receipt of SSI or State Supplement payment or 1916b is not required to have an independent evaluation of income and resources when the recipient requests additional coverage, including MSP, Waiver, and Nursing Home. COVERED MEDICAL INSTITUTIONS: Residents of licensed medical institutions or intermediate care facilities/nursing homes who meet all financial and nonfinancial eligibility criteria may receive Medicaid to help pay for their care. INSTITUTIONS FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES (IID): Institutions for the individual with intellectual disabilities are primarily for the diagnosis, treatment and rehabilitation of individuals with intellectual disabilities, cerebral palsy, epilepsy or other developmental diseases. The facility provides evaluation, 24-hour supervision, and coordination of health and rehabilitative services in a protected residential setting.

INSTITUTION FOR MENTAL DISEASES (IMD): These facilities generally provide diagnosis, treatment or care for individuals with mental diseases. Residents of these facilities must meet the following age requirements: 1. Must be age 65 or older, or under age 21; 2. Residents under 21 who are receiving inpatient psychiatric services are considered institutional residents until they are unconditionally released or reach age 21, whichever occurs first. 3. Individuals aged 21 and older are no longer considered institution residents when released or on convalescent leave. They may be eligible for non-institutionalized Medicaid coverage. INTERMEDIATE CARE FACILITY (ICF)/NURSING HOME: Nursing homes provides medical services at a level above room and board. Residents must be admitted by a physician and continuously remain under a physician's care. INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES: (ICF/IID): An ICF/IID provides intermediate care to individuals with intellectual disabilities or those who have cerebral palsy or other developmental diseases. ICF/IID residents may be eligible if they meet all eligibility requirements. SKILLED NURSING FACILITY (SNF)/NURSING HOME: A Skilled Nursing Facility provides skilled nursing care to individuals admitted by a physician and who remain in need of daily services that can only be provided on an in- patient basis. SWING BEDS: When a nursing home bed is not available within a 25-mile radius, approved hospitals may provide temporary long-term care services. The cost of swing bed care may be used to reduce the client’s spend down. NOTE: Medicaid requires a pre-admission screening before covering the cost of swing bed services. Effective Date: July 01, 2024

AGED, BLIND, AND DISABLED MEDICAID 804-1 Long Term Care Partnership Supersedes: MA 903-2 (07/01/09) Reference: 42 U.S.C. 1396p; ARM 37.82.101, 6.6.3101-.3115, .3117-.2120; P.L. 109-171 Overview: Resources equal to the Long Term Care (LTC) Partnership policy benefits may be protected when an institutionalized/waiver client or spouse purchases a Qualified LTC Partnership policy or converts an existing LTC policy to a Qualified LTC Partnership policy on or after July 1, 2009. Once the LTC Partnership policy lifetime limits have been fully exhausted, assets equal to the insurance benefits paid for the client or spouse are protected/ disregarded. An amount of resources equal to the total LTC Partnership insurance benefits paid are protected/disregarded when determining institutional/waiver Medicaid eligibility. These resources are also protected from Medicaid estate recovery. When both spouses are covered by a joint LTC Partnership policy, the couple receives full asset protection as well as estate recovery protection, regardless of which spouse actually received the insurance benefits. Uncompensated asset transfer provisions apply to protected assets, and it can’t be assumed that transfer of protected assets was done for a reason other than qualifying for Medicaid. For example, transferring a protected asset could result in loss of countable income, which directly affects Medicaid eligibility. APPLICATION OF OTHER MEDICAID PROVISIONS: All other financial and nonfinancial eligibility criteria and Medicaid policy applies when determining institutionalized/waiver eligibility for an individual/couple who have a Qualifying LTC Partnership policy. Qualifying LTC Partnership resource protections do not apply when determining Medicare Savings Program or non-institutional/waiver Medicaid eligibility. QUALIFIED LONG TERM CARE PARTNERSHIP POLICY: The Montana Insurance Commissioner must certify in writing that a LTC policy meets the Qualified LTC Partnership policy definition. The required certification is often attached to the policy. The certification verifies the policy meets the following: 1. The insured was a resident of a Partnership State when the policy first became effective; 2. Policy meets the IRS definition (IRS code of 1986) of ‘Qualified LTC Insurance Policy’; 3. The policy was issued no earlier than July 1, 2009 (date of Montana’s Long Term Care Partnership Medicaid State Plan Amendment); and

NOTE: Policies issued before July 1, 2009 are treated as newly issued only if reissued or exchanged on or after July 1, 2009. An additional rider, endorsement or change in the schedule page to policies issued before July 1, 2009 is treated as an exchange for purposes of meeting this provision. 4. The policy meets specific rules of the National Association of Insurance Commissioners (NAIC); and NOTE: When the policy doesn’t contain this information, the client must provide written proof from either the insurance company or the Montana Insurance Commission to verify the policy meets the criteria. 5. The policy includes inflation protection, which varies depending on the insured’s age when the policy was purchased: • For purchasers under 61 years old, compound annual inflation protection; • For purchasers 61-76 years old, some level of inflation protection; • For purchasers over 76 years old, inflation protection is optional. QUALIFIED LTC POLICY ISSUED IN ANOTHER STATE: If the other Partnership state offers reciprocity, a Qualified LTC Partnership policy issued in another Partnership state is recognized if the covered individual moves to Montana. If a LTC Partnership policy holder from another state moved to Montana, eligibility staff will contact the ABD Policy Specialist in Central Office (through the Service Desk). BOTH SPOUSES HAVE LTC PARTNERSHIP: When both spouses apply for LTC Partnership resource protection and they have a joint LTC Partnership policy or each has a separate policy, the protection is apportioned between them; each cannot receive full resource protection separately. The total protection benefit given to both spouses combined cannot exceed the total amount of insurance benefit. When one spouse applies for nursing home/waiver Medicaid, and transfers resources protected under the LTC Partnership policy to the community spouse, these resources retain their protected status, even when the community spouse is later institutionalized. If the protected resources are not transferred to the community spouse, the community spouse cannot receive resource protection for additional resources they own should they later be institutionalized. Total resource protection cannot exceed the full amount of all benefits paid from all exhausted LTC Partnership polices when both spouses enter the nursing home and apply for Medicaid in the same month. Because they are treated as individuals, they can opt to protect jointly held resources or allocate the protection between them either equally or proportionate to LTC benefits paid for each. Effective Date: July 01, 2016

AGED, BLIND, AND DISABLED MEDICAID 805-1 Nursing Home Budgeting Supersedes: MA 904-1 (007/01/09); 904-6 (01/01/08) Reference: ARM 37.82.101, 1312, .1313 & .1320; Public Law 108-422, Section 202 Overview: Eligibility staff must determine if clients applying for residential institutionalized care (e.g., nursing home) fall into categorically needy or medically needy. Once that is established, medical need is determined to see if the individual is eligible for Medicaid coverage of their institutional cost of care. If determined eligible, post-eligibility budgeting occurs to determine the client’s share of the cost of care. Only the applicant’s income is used to determine residential medical institution income eligibility. NOTE: Medicaid will not pay for institutional care for clients who fail the medical need determination. However, these clients may be eligible as medically needy and Medicaid may pay for other medical expenses. LONG TERM CARE (LTC) INSURANCE: Long term care insurance typically pays per day the individual is institutionalized. There are many types of LTC insurance, including Medicare Part A, QMB, private LTC insurance policies and Veteran’s Per Diem payments. VA PER DIEM PAYMENTS: Qualified veterans receive VA per diem payments, which are paid directly to the facility. VA per diem is not treated as income, but rather as a Third Party Liability benefit. VA per diem and VA Aid and Attendance (A&A) should not be confused as they are separate payments, and A&A is paid directly to the veteran. VA per diem payments are not included in any ABD Medicaid budget determinations for veterans living in a state veteran’s home. NOTE: Montana has two state veterans’ homes; Eastern Montana Veterans’ Home in Glendive, and Montana Veterans’ home in Columbia Falls. However, VA per diem payments are included when determining medical need for veterans living in private or county nursing homes. See the Step 1 business process. VA per diem payments are used to offset the Medicaid daily rate in Step 1 budgeting when paid to private or county nursing homes. Effective Date: July 01, 2016

AGED, BLIND AND DISABLED MEDICAID 805-2 Post Eligibility Treatment of Income (PETI)

Supersedes: ABD 805-2 (01/01/2026) Reference: 42 CFR 435.725 and .832; ARM 37.82.101, .1320; 42 U.S.C. 1396r-5 Overview: When Medicaid is contributing to the cost of institutional care, the institutionalized individual’s (whether married or unmarried) gross monthly income, less allowable deductions, must be applied to the cost of care. This is known as “Step 2” in the institutional budget process. The institutionalized individual’s (married or unmarried) spend down is calculated using a different method when Medicaid is not contributing to the cost of care. Total deductions cannot exceed the institutionalized individual’s (married or unmarried) gross income. NOTE: Blind/disabled work expenses are not used in PETI. When Medicaid is contributing to the cost of care, allowable deductions may include: 1. Up to $65 of gross earned income. 2. A $50 personal needs allowance (or the remaining income amount, if less than $50). NOTE: In addition to the $50 personal needs allowance, veterans receive an additional exclusion of up to $90 per month in VA pension income. The amount of VA pension income that exceeds $90 per month is countable. 3. A community spouse income maintenance allowance (allowed only when institutionalized individual is married). NOTE: Allow this deduction unless the institutionalized spouse specifically refuses it. The deduction is not allowed unless the funds are actually transferred to the community spouse. 4. Family maintenance allowance (allowed only when institutionalized individual is married). 5. The institutionalized individual’s (married or unmarried) incurred medical or remedial care expenses, including health insurance premiums. NOTE: Medicare Part B premiums must be entered as a medical expense for nursing home residents who receive Medicare, but not QMB or SLMB. 6. Court-ordered child support actually paid (CMA 601-1 Prospective Budgeting); 7. Court-ordered spousal support actually paid (CMA 601-1 Prospective Budgeting); and

8. Home maintenance allowance (only when institutionalized individual is not married). INCURRED MEDICAL EXPENSES: Some of the institutionalized individual’s medical expenses can be deducted from their income when determining their cost of care liability. Medical expenses incurred during an asset transfer penalty month are not allowed. Life insurance premiums are not medical expenses and are not deductible. Incurred medical expense deductions are limited to: 1. Medical expenses incurred in the three months immediately preceding the institutional care Medicaid application or coverage request; or 2. Current payments on expenses incurred more than three months prior to application/coverage request. 3. Incurred medical expenses must also meet ALL of the following to be allowed: a. Unpaid at time of institutional Medicaid application/coverage request; AND b. Medical services, supplies or equipment recognized and regulated by State law; AND c. Not payable by a third party; AND d. Not previously used to meet/reduce a spend down or offset the client’s cost of care liability in a previous month. Allowable medical expenses must be reported and verified within the application/request processing period, or within three months of coverage request date, whichever is later. See CMA 702-1 Medical Expense Option for more information. 1. Health insurance premiums (including Medicare); 2. Medical expenses incurred while institutionalized that are: a. prescribed by a physician; b. not Medicaid-covered services; c. not payable by a third party; and d. subject to the limitations outlined in CMA 702-1 Medical Expense Option Items included in the Medicaid payment to a nursing facility as part of Medicaid- covered services cannot be separately billed to the nursing home resident and cannot be deducted if the family purchases them elsewhere and brings them to the facility. These include, but are not limited to eye drops, wipes, procedure gloves, etc. Medicaid-covered services received from a non-participating provider are not allowable. Providers have up to a year to enroll in Medicaid and bill for the services. Medical expenses incurred after application must be reported timely (within 10 days of knowledge).

HOME MAINTENANCE (UNMARRIED INDIVIDUALS ONLY): Allow a home maintenance allowance equal to the MNIL for one (CMA 002 Table of Standards- Med Needy Income) in the following time periods: 1. Month of Entry: The individual entered the facility after the first day of the month (including when entering from a hospital stay if they entered the hospital from the community); or 2. Up to six months: The individual intends to return home/to the community within six months of entering the nursing home (even when housing expenses are not verified during stay); or NOTE: The home maintenance allowance is only allowed when a statement from the client’s doctor/physician confirms the possibility of the client returning to their home/the community within six months of entering the nursing home. 3. Month of Discharge: The client returns home/to the community before the last day of the month. SPOUSAL INCOME MAINTENANCE ALLOWANCE (MARRIED INDIVIDUALS): The community spouse income maintenance allowance is the lesser of: 1. $4067 (effective 01/01/2026) less the community spouse's own total gross monthly income (see "Income Attribution" in CMA 500 Income Overview); or a. NOTE: Total gross income includes all income (including gross SSI) the community spouse receives from all sources; income deductions, exclusions, exemptions or disregards do not apply, except in very few situations. Only those payments excluded from all public assistance determinations by other laws are not considered, these include Native American Income and tax stimulus payments. 2. A combination of: a. Community spouse’s shelter expenses (principal residence) that exceed the $811.50 basic shelter allowance (effective 07/01/2026); plus b. $2,705 (Effective 07/01/2026) basic needs standard; less c. Community spouse’s total gross income (see “NOTE” above) NOTE: The community spouse’s income and shelter expenses are used to establish the Community Spouse Income Maintenance Allowance. Changes in these values must be reported to the Department within ten (10) days of knowing of the change. NOTE: If the community spouse applies for Medicaid coverage (such as MSP or medically needy), the CSIMA is countable income in the eligibility determination. SHELTER EXPENSES: Allowable shelter expenses (see "Spousal Income Maintenance Allowance" above) include:

1. Rent or mortgage (including principal and interest) payments, 2. Property taxes and homeowner's insurance. NOTE: If property tax and homeowner’s insurance are prorated to a monthly amount, the notice must include this information, 3. Condo or Co-op maintenance charge or homeowners’ association fees, AND 4. Utilities (if paid separately). UTILITY EXPENSES: Allow the SNAP SUA (Standard Utility Allowance) as defined in SNAP 602-4 Shelter Deductions when the community spouse is responsible for major heating/cooling costs. Allow the SNAP standard telephone allowance as defined in SNAP 602-4 Shelter Deductions when the community spouse is not responsible for major heating/cooling but does have a telephone. Actual utility expenses are never used, whether or not the community spouse is responsible for major heating/cooling. For example, if the community spouse is responsible for electricity (not related to heating or cooling) and water, but not for heating, cooling or telephone, no utility expense is allowed. FAMILY ALLOWANCE (MARRIED INDIVIDUALS): Only children, parents, or siblings of either the institutionalized or community spouse are eligible to receive a family maintenance allowance; they must live with the community spouse and be eligible to be claimed as dependents for tax purposes. Family members who receive HCBS waiver services or are institutionalized are not eligible for a family maintenance allowance. Each additional dependent can receive a maximum maintenance needs allowance equal to 1/3 the difference between the $2,705 (effective 07/01/2026) basic needs standard and the family member’s gross income. FAMILY CONTRIBUTION TO FACILITY: An additional amount paid directly to the facility to upgrade the client to a private room (regardless of who pays) is not considered vendor/in-kind income for shelter. Expenses paid directly to the residential facility are medical expenses. NOTICE: When the institutionalized individual is married, both spouses must each receive a notice detailing the institutionalized spouse’s applicable deductions and each spouse can appeal the allowance determination. An unmarried individual and/or their authorized representative must receive the same notice. A notice must also be sent to the medical facility stating the client’s cost of care liability, even when it is zero. Effective Date: 07/01/2026

AGED, BLIND, AND DISABLED MEDICAID 806-1 Montana State Hospital Residents Supersedes: MA 907-1 (01/01/08); Bulletin MA 115 (11/01/14) Reference: 42 CFR 435.725, .832, and .1008-1009, & 441.151; ARM 37.82.101, .1301, .1305, .1306, .1312, .1313, .1321, .1330, .1331, .1336-.1338 Overview: Montana State Hospital at Warm Springs (MSH) residents who are over age 21 and under age 65 receive, are not eligible for Medicaid payment or ANY medical services, regardless of who provides or where the services are provided. However, Medicaid clients who are admitted to MSH for a continuous period beginning prior to their 21st birthday remain Medicaid eligible through the date of their 22nd birthday, unless they lose Medicaid eligibility for another reason (e.g., resources, disability, etc.) ADMISSION AND DISCHARGE: MSH contacts the Department and provides the patient’s admission date each time a Medicaid client is admitted. A part of the discharge plan, MSH contacts the Department to notify of the planned discharge date. CONVALESCENT LEAVE AND CONDITIONAL RELEASE: Because they are no longer considered MSH residents, individuals over age 21 who leave MSH on convalescent leave or conditional release may be Medicaid eligible for payment of services received during the leave/conditional release. A temporary release to obtain medical treatment is not considered conditional release. For individuals who turn 21 while residing at MSH, but are not yet 22, convalescent leave and conditional release are not considered the same as unconditional release from the facility and do not disrupt their status as continuously institutionalized. RESIDENTS UNDER AGE 21 AND AGE 65 OR OLDER: Medicaid coverage may be available to individuals under age 21 (or 22) and age 65 or older. Financial and nonfinancial criteria for nursing home residents apply to MSH residents, and may include: • Determination of liability toward cost of care; (ABD 805-2) • Home maintenance allowance

• Resource assessments when there is a community spouse (CMA 803-1) • Spousal income maintenance (ABD 805-2) • Family income maintenance (ABD 805-2) • Temporary absence from home (CMA 402-1 "Home and Surrounding Property") • Conditional Assistance (ABD 402-4) NOTICES: Medicaid clients residing in MSH, or any state-run facility, must receive timely eligibility notices, including initial determination, any changes to eligibility and notification of their patient liability toward cost of care (for clients under age 21 (or 22) or age 65 and older), even if patient liability is zero. Additionally, MSH billing staff must receive notification of the patient liability for clients under age 21 (or 22) or age 65 or older, even if patient liability is zero. DPHHS Fiscal is notified via a system notice to the following: DPHHS Facility Reimbursement – Dept. 30 111 N Sanders Helena, MT 59601 Effective Date: July 01, 2016

AGED, BLIND, AND DISABLED MEDICAID 900 HCBS/Waiver Overview

Supersedes: ABD 900 (07/01/2024) Reference: ARM 37.40.1401, .1408, .1421, and 37.82.101; 42 CFR 441 Subparts G and H; 42 USC 1396r-5 Overview: Home and Community Based Services (HCBS) waivers are designed to allow individuals to remain in the community, rather than being institutionalized to receive necessary care and services. Individuals living in the community may be eligible for HCBS/waiver if they: 1. Apply for Medicaid or request the additional level of coverage (if Medicaid is already open); 2. Would qualify for Medicaid if placed in a nursing home or intermediate care facility for individuals with Intellectual Disabilities (ICF/IID); 3. Would require nursing home or ICF/IID placement without Home and Community Based Services (HCBS); and 4. Have an HCBS waiver slot available to them. SSI RECIPIENTS: An individual in receipt of SSI or State Supplement payment or 1619b is not required to have an independent evaluation of income and resources when the recipient requests additional coverage, including MSP. FINANCIAL RESPONSIBILITY OF RELATIVES (PD, AGED & DD WAIVERS): If an HCBS/Waiver applicant or recipient (Physically Disabled Waiver, Aged Waiver or any Developmental Disability Waiver) meets all nonfinancial criteria, is approved for one of the above-mentioned waivers, and will be enrolled into an HCBS/Waiver opening (slot), treat their responsible relative’s income and resources as follows:

1. Ineligible parent to eligible child income and resource deeming are waived (Waiver Medicaid eligibility is based solely on the waiver recipient’s income and resources); 2. Spousal impoverishment rules apply if only one member of a married couple meets level of care unless the second spouse resides in a medical institution that could be Medicaid covered, such as a nursing facility or MSH; 3. When only one spouse requests waiver program services and meets level of care, the other spouse, unless residing in a nursing home, is referred to as the ‘non- waiver spouse’ or ‘community spouse’ and the eligible individual is the ‘waiver spouse’. NOTE: Spousal impoverishment rules apply to the waiver spouse. The couple cannot be treated as individuals or as a non-waiver couple, even if more beneficial to them. Additionally, the waiver spouse’s income, resources, and presence are not considered when determining the non-waiver spouse’s Medicaid eligibility. 4. When both spouses are requesting HCBS/Waiver program services and meet level of care, or the non-waiver spouse resides in a nursing home or other covered medical institution (ABD 800 Residential Medical Institutions Overview), each spouse is treated as an individual and spousal impoverishment rules (such as resource assessments and spousal income maintenance) do not apply. RESOURCE ASSESSMENTS: Resource assessments are required for married HCBS/Waiver clients requesting HCBS/Waiver program services and meet level of care. Only one resource assessment is required unless there are errors discovered. See CMA 803-1 Institution and Waiver Resource Assessments for resource assessment instructions. ASSET TRANSFERS: Asset transfer/look back provisions apply to assets either the client or their spouse transferred prior to HCBS/Waiver eligibility determination. An asset transfer evaluation is completed for SSI related recipients. See CMA 404-1 Asset Transfers. RESOURCES OWNED JOINTLY BY TWO WAIVER SPOUSES: Evaluate resources held jointly by two waiver spouses, or by a waiver spouse and a spouse in a residential medical facility, according to jointly owned resource policy in CMA 401-1 Ownership, Accessibility and Equity Value. PREADMISSION SCREENING: Addictive and Mental Disorders Division (AMDD) conducts independent screenings for:

• PRTF Waiver, • SDMI Waiver, and • DD Waivers. An SLTC/DD-55 completed by AMDD meets the required screening criteria for the above- listed programs. NOTE: A new Mountain Pacific-Quality Health Foundation (MPQHF) screening (SLTC-61) is required when a client moves from a DD or AMDD waiver slot to a nursing home. MPQHF completes required screenings (SLTC-61) for: • Physically Disabled Waiver • Aged Waiver, and • Nursing home services. NOTE: SLTC-61 screenings are valid for 90 days for both waiver and nursing home services. When a waiver client with a valid SLTC-61 screening enters a nursing home directly from the waiver program, a new SLTC-61 screening is not required; the existing SLTC-61 is used. Likewise, a nursing home client with a valid SLTC-61 screening may leave the nursing home and directly enter the waiver program without needing a new SLTC-61. The pre-admission screening must be completed within 90 days of enrollment into a Medicaid HCBS/Waiver program or entry into a nursing home. AGED WAIVER: HCBS/Waiver services are available to eligible physically disabled aged individuals under the Aged Waiver. Senior and Long-Term Care (SLTC), Community Services Bureau (CSB) administers the Aged Waiver. PHYSICALLY DISABLED WAIVER: Individuals under age 65 who have been determined disabled according to Social Security criteria may be eligible for HCBS/Waiver services under the Physically Disabled Waiver. The Physically Disabled Waiver is administered by the Senior and Long-Term Care Division, Community Services Bureau. If the individual is eligible for an ACA program, we will not require a disability determination. DEVELOPMENTAL DISABILITIES (DD) WAIVER: Specialized services are provided to waiver-eligible clients under HCBS Developmental Disabilities (DD) waivers. There are several DD waivers. Eligible DD individuals may receive HCBS services under the Waiver 208; Comprehensive Services waiver.

To qualify for coverage through the 208 waiver, individuals under age 65 must be determined disabled according to SSA criteria. NOTE: In addition to being categorized as DD by the Developmental Disabilities Program (DDP), clients must also be determined disabled by SSA or through the MEDS process. If the individual is eligible for an ACA program, we will not require a disability determination. Disability Service Division (DSD), Developmental Disabilities Program (DDP) administers the DD waivers. NOTE: DSD/DDP and the Disability Determination Services Bureau (DDS or DDB) are not one and the same. DDS/DDB makes disability determinations for the SSA. SEVERELY DISABLING MENTAL ILLNESS (SDMI) WAIVER: HCBS waiver services under the SDMI waiver are available to eligible individuals who are diagnosed with Severely Disabling Mental Illness (SDMI). Eligible clients can receive SDMI coverage under the SDMI Waiver program. Resource assessments, waiver of spousal deeming, and spousal/family income maintenance must be applied. Asset transfers must be evaluated. Under this program, a disability determination is not required. Under ACA program, clients are not required to have a resource assessment completed and waiver of spousal deeming, and spousal/family income maintenance rules will not apply. Asset transfers must be evaluated. If the individual is eligible for an ACA program, we will not require a disability determination. Under ABD Medicaid, resource assessments, waiver of spousal deeming, and spousal/family income maintenance must be applied. Asset transfers must be evaluated. In addition, if the client is requesting SDMI Waiver under an ABD program as a disabled individual, the client must meet SSA's disability criteria and have a disability determination established through SSA or MEDS PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) WAIVER: Children ages 6 through 17 diagnosed with serious emotional disturbance (SED), and who meet psychiatric residential treatment facility (PRTF) admission criteria, may receive HCBS services under the PRTF waiver. Waiver of parental deeming and spousal impoverishment rules do NOT apply to the PRTF waiver. Clients must fit into a coverage group (disabled, child, pregnancy, ACA PCR, etc.) to receive coverage under the PRTF waiver. However, children who aren’t eligible for HMK Plus or Family Medicaid must be determined disabled (according to SSA criteria) before they can receive these services. Disability must be determined through either SSA or the MEDS process.

LIVING ARRANGEMENTS: Services may be covered under the Aged and Physically Disabled Waivers while the enrolled client lives in a private residence, personal care home, retirement home, physically disabled or mental health group home, adult foster care, or adult residential placement. Services are not covered if the client is institutionalized or in the hospital. OVERLAPPING SPANS – WAIVER & INSTITUTION: Physically disabled, SDMI, or PRTF waiver spans and nursing home span may overlap by no more than 30 consecutive days. Revision Date: 02/01/2025

AGED, BLIND, AND DISABLED MEDICAID 901-1 HCBS/Waiver Income Budgeting

Supersedes: ABD 901-1 (07/01/2025) Reference: 42 CFR 435.217; ARM 37.40.1401, .1402 .1406 through.1408; 37.82.101 Overview: Home & Community Based Services (HCBS) Waiver clients can be either categorically needy or medically needy. Determination of categorically needy is outlined in the Categorically Needy Business Process. If the client is ineligible for Categorically Needy coverage, the following Waiver medically needy budgeting policies apply to individuals who meet Level of Care and request HCBS/Waiver coverage under the following programs: 1. Physically Disabled Waiver 2. Aged Waiver 3. SDMI Waiver 4. Developmental Disabilities Waiver A Waiver applicant’s income eligibility is determined using only the waiver applicant’s income. NOTE: Individuals in the Psychiatric Residential Treatment Facility (PRTF) waiver must qualify for Medicaid through non-waiver policies outlined in CMA 601-1 Prospective Budgeting a through CMA 603-1 Deeming. When determining the budget for a medically needy waiver applicant, allowable deductions may include: 1. $20 general disregard 2. Up to $65 of gross earned income 3. One-half remainder of earned income 4. A community spouse income maintenance allowance (allowed only when institutionalized individual is married)

5. Family maintenance allowance (allowed only when institutionalized individual is married) 6. The waiver applicant’s (married or unmarried) incurred medical or remedia care expenses, including health insurance premiums 7. Court-ordered child support actually paid (CMA 601-1 Prospective Budgeting) 8. Court-ordered spousal support actually paid (CMA 601-1 Prospective Budgeting) NOTE: It is possible for a waiver spouse to be medically needy without a spend down the spousal income maintenance allowance and/or family maintenance allowance(s) reduces the spend down to zero. Example: Waiver spouse's income is $1000 per month Social Security. $1000 - $20 general income disregard = $980 - $525 MNIL - $391 MN deduction = $64. If the spousal income maintenance is calculated to be $64 or more, this medically needy waiver spouse will have no spend down. Blind/disabled work expenses are not used in Post Eligibility Treatment of Income (PETI). ABD 805-2 Post Eligibility Treatment of Income (PETI)

l if SPOUSAL INCOME MAINTENANCE ALLOWANCE (MARRIED INDIVIDUALS): The community spouse income maintenance allowance is the lesser of: 1. $4067 (Effective 01/01/2026)less the community spouse’s own total gross monthly income (see Income Attribution in CMA 500 Income Overview) NOTE: Total gross income includes all income (including gross SSI) the community spouse receives from all sources; income deductions, exclusions, exemptions or disregards do not apply, except in very few situations. Only those payments excluded from all public assistance determinations by other laws are not considered, these include Native American Income and tax stimulus payments. OR 2. A combination of: a. Community spouse’s shelter expenses (principal residence) that exceed the $794 basic (effective 07/01/2025) shelter allowance; plus b. $2644 (effective 07/01/2025) basic needs standard; less c. Community spouse’s total gross income (See ‘NOTE’ above). s

The community spouse’s income and shelter expenses are used to establish the Community Spouse Income Maintenance Allowance. Changes in these values must be reported to the Department within ten (10) days of knowing of the change. · Allow this deduction unless the institutionalized spouse specifically refuses it. · The deduction is not allowed unless the funds are actually transferred to the community spouse. · If the applicant/recipient is determined to be categorically needy and has dependent family members, no community spouse income allowance will be calculated, because there is no remainder (Spend Down) from which to deduct the allowance.

If the community spouse applies for Medicaid coverage (such as MSP or medically needy), the CSIMA is countable income in the eligibility determination.

Shelter Expenses: Allowable shelter expenses (see Spousal Income Maintenance Allowance above) include: 1. Rent or mortgage (including principal and interest) payments; 2. Property taxes and homeowner’s insurance; 3. Condo or co-op maintenance charge or homeowner’s association fees; AND 4. Utilities (if paid separately). When the waiver spouse and non-waiver spouse reside together in the community, one- half of the shelter expenses will be allocated to each spouse for purposes of calculating shelter expenses for the Spousal Income Maintenance Allowance. When a waiver spouse and a non-waiver spouse reside together in an assisted living facility, the non-waiver spouse’s individual expenses (room, board, personal care, etc.) must be itemized by the assisted living facility and only the shelter (‘room’) charges are considered shelter expenses. Board (food), personal assistance, cable TV, etc., are not shelter expenses. Utility Expenses: Allow the SNAP SUA (standard utility allowance) as defined in SNAP 602-4 Shelter Deductions when the community spouse is responsible for major heating/cooling costs.

Allow the SNAP standard telephone allowance as defined in SNAP 602-4 Shelter Deductions when the community spouse is not responsible for the major heating/cooling but does have a telephone. Actual utility expenses are never used, whether or not the community spouse is responsible for major heating/cooling. For example, if the community spouse is responsible for electricity (not related to heating or cooling) and water, but not for heating, cooling or telephone, no utility expense is allowed. Family Allowance (Married Individuals): Only children, parents, or siblings of the institutionalized spouse are eligible to receive a family maintenance allowance; they must live with the community spouse and be eligible to be claimed as dependents for tax purposes. Family members who receive HCBS waiver services or are institutionalized are not eligible for a family maintenance allowance. Each additional dependent can receive a maximum maintenance needs allowance equal to 1/3 the difference between the $2644 (Effective 07/01/2025) basic needs standard and the family member’s gross income. NOTE: If the applicant/recipient is determined to be categorically needy and has dependent family members, no community spouse income allowance will be calculated, because there is no remainder (Spend Down) from which to deduct the allowance. Family Contribution to Facility (regardless of who pays): When an additional amount is paid directly to the assisted living facility to upgrade the client to a private room, a “nicer” room, or for additional food, the additional charge is considered vendor/in-kind income for shelter or food. NOTE: Room and board charges paid to residential medical facilities such as nursing homes are considered medical expenses. Additional payments paid to an assisted living facility are NOT medical expenses. Notices: When the waiver individual is married, both spouses must each receive a notice detailing the institutionalized spouse’s applicable deductions and each spouse can appeal the allowance determination. An unmarried individual and/or their authorized representative must receive the same notice. A notice must also be sent to the medical facility stating the client’s cost of care liability, even when it is zero.

Effective Date: 01/01/2026

AGED, BLIND, AND DISABLED MEDICAID 902-1 HCBS/Waiver Medically Needy Supersedes: MA 1003-1 (02/01/05) Reference: 42 CFR 435.217, ARM 37.40.1401, 1406-.1408, ARM 37.82.101 Overview: HCBS/Waiver clients who have income exceeding the categorically needy income standard for one (ABD 007) are eligible as medically needy, and must meet a monthly spend down. The spend down is the difference between the MNIL (Medically Needy Income Level – CMA 002) for one and the client’s countable monthly income, after CSIMA and/or family maintenance allowance deductions, if applicable. The spend down can be met by: 1. Making a cash payment to the Department equal to their spend down obligation; 2. Incurring medical expenses equal to their spend down obligation; 3. A combination of medical expenses and cash payment. The following expenses may be used to meet the spend down: 1. Paid and unpaid medical expenses incurred during the benefit month; 2. Paid and unpaid medical expenses incurred during the three months preceding the benefit month; and 3. Current payments on the unpaid balances of bills incurred more than three months prior to the benefit month. See CMA 700 for additional medically needy information. PROJECTING EXPENSES: Expenses cannot be projected. This option was eliminated July 1, 2003. WAIVER SERVICES: SLTC establishes waiver services, and services may include: 1. Case Management; 2. Homemaker; 3. Personal care (waiver-related); 4. Adult day care; 5. Respite;

6. Habilitation, which may include: a. independent living evaluation; b. habilitation aid; c. physical therapy - maintenance; d. occupational therapy - maintenance; e. speech therapy - maintenance; f. psychological consultation, g. other services as defined by Case Management. 7. Medical alert; 8. Nutritional/Dietitian; 9. Non-medical transportation; 10. Environmental modification/Adaptive equipment; 11. Respiratory therapy; 12. Nursing services; 13. Supported Living services; 14. Pre-vocational services; 15. Supported employment services; 16. Specially trained attendant services; 17. Cognitive rehabilitation services; 18. Behavioral programming services; 19. Chemical dependency counseling; 20. Comprehensive day treatment; 21. Community residential rehabilitation services; 22. Special child care for children with AIDS; 23. Adult residential care; 24. Specialized medical equipment and supplies; and 25. Consumer/family intensive support service. A billing statement is required before monthly waiver service expenses can be used to reduce/meet the spend down. SPECIAL PROCESSING FOR MEDICALLY NEEDY GROUP HOME RESIDENTS: The difference between the residential service rate at the group home and the MNIL is recognized as a medical expense used to meet the spend down for medically needy group home residents whose income exceeds the SSI State Supplement income standard, making them ineligible for SSI State Supplement payments. The medical expense is determined by subtracting the MNIL from the total residential service fee (group home rate). Effective Date: July 01, 2016

AGED, BLIND, AND DISABLED MEDICAID 015 Table of Standards: Standard Payment Amounts (SPA) Supersedes: ABD 015 (01/01/2020) Reference: 20 CFR 416.410 and .412; ARM 37.82.101 Overview: The Standard Payment Amount (SPA) is allotted to eligible Supplemental Security Income (SSI) clients to maintain a standard of living at the established federal minimum income level. The SPA is based on whether the individual is living independently, in the household of another or in a medical institution. INDEPENDENT LIVING ARRANGEMENT: A living arrangement where the person is self-sufficient and does not rely upon another or an institution to provide food and/or shelter. IN ANOTHER’S HOUSEHOLD: A living arrangement where both shelter and food are provided to an individual either directly by another person or entity or by virtue of payment for both shelter and food by another person or entity. STANDARD PAYMENT AMOUNT Effective: January 1, 2021 LIVING ARRANGEMENT INDIVIDUAL COUPLE Independent living arrangement $841.00 $1261.00 In the household of another $584.00 $845.00 In a medical institution $30.00 $30.00 each

Effective Date: January 1, 2022

AGED, BLIND, AND DISABLED MEDICAID 201-2 Pickle Eligibility Supersedes: MA 201-3 (01/01/08) Reference: ARM 37.82.101, .903 and 42 CFR 435.135 Overview: Pickle eligible individuals and couples receive Medicaid with no spend down. Pickle criteria or eligibility does not qualify an individual for an additional level of coverage such as nursing home, waiver or Medicare Savings Programs. To qualify for Pickle coverage, the client/couple must meet all of the following criteria: 1. Currently receiving Social Security benefits; and 2. Have countable resources within the categorically needy resource limit (CMA 001); and 3. Were concurrently eligible for both Social Security benefits and SSI or SSP at any time since April 1977; and 4. Lost SSI/SSP eligibility for any reason; and 5. Have countable income not exceeding the amount in the Pickle Table (ABD 011). COUPLES: Both members of an eligible couple must meet Pickle eligibility for either individual to qualify for Pickle coverage. NOTE: When determining Pickle When for a couple, the earliest SSI/SSP end date is used for both spouses’ eligibility. Effective Date: July 01, 2016

ACA/FMA MEDICAID 003 Table of Standards: ACA Parent Caretaker Relative Income

Supersedes: ACA/FMA 003 (04/01/2024) Reference: ARM 37.82.101; PL 104-193; 42 CFR 435.110, .601 Overview: Use the following Income Standards to determine income eligibility for an income standards after specified disregards. If countable monthly income exceeds the standard, these standards are not applied to determine medically needy eligibility for a parent/caretaker relative. (see CMA 002 Table of Standards-Medically Needy Income) COUNTABLE MONTHLY INCOME STANDARDS – Effective April 01, 2025 FAMILY SIZE INCOME PER MONTH 1 $313 2 $423 3 $533 4 $643 5 $753 6 $863 7 $973 8 $1,083 9 $1,193 10 $1,303 11 $1,413

12 $1,523 13 $1,633 14 $1,743 15 $1,853 16 $1,963

Effective Date: 04/01/2025

ACA/FAMILY MEDICAID 004 Table of Standards: ACA Pregnancy Income

Supersedes: ACA-FMA 004 (04/01/2025) Reference: ARM 37.82.101 & .701, 42 CFR 435.116, ACA 2010 Overview: Pregnant women may qualify for categorically needy Medicaid if: 1. They meet the nonfinancial criteria for ACA Pregnancy Medicaid, and 2. Household income does not exceed 157 percent of the federal poverty level standard. COMPUTATION: The following income standards are effective April 1, 2026 Income Standards for PREGNANCY Medicaid (157% FPL) Family Size Monthly Income Standard 1 $2,088 2 $2,831 3 $3,574 4 $4,318 5 $5,061 6 $5,804 7 $6,547 8 $7,290 9 $8,033 10 $8,776 11 $9,519 12 $10,263

13 $11,006 14 $11,749 15 $12,492 16 $13,235

Effective Date: 04/01/2026

ACA/FAMILY MEDICAID 005 Table of Standards: Healthy Montana Kids Program-Income (HMK and HMK Plus)

Supersedes: ACA-FMA 005 (04/01/2025) Reference: ARM 37.82.101 & .701; 42 CFR 435.118, Federal Register Vol. 89, No. 11 Overview: Children under age nineteen may qualify for ACA Healthy Montana Kids Plus (Medicaid) or ACA Healthy Montana Kids (Insurance) if: 1. They meet the nonfinancial criteria for the program (ACA HMK Plus or ACA HMK) 2. Household income does not exceed: a. 143 percent federal poverty level (FPL) for ACA HMK Plus, or b. 261 percent of the FPL for ACA HMK COMPUTATION: The following income standards are effective April 1, 2026. Income Standards for ACA Healthy Montana Kids Plus (Medicaid) (143 % FPL) Family Size Monthly Income Standard 1 $1,902 2 $2,579 3 $3,256 4 $3,933 5 $4,609 6 $5,286 7 $5,963 8 $6,640 9 $7,317 10 $7,994

Family Size Monthly Income Standard 11 $8,671 12 $,9,347 13 $,10,024 14 $10,701 15 $11,378 16 $12,055

Income Standards for ACA Healthy Montana Kids (Insurance) (261% FPL) Family Size Monthly Income Standard 1 $3,471 2 $4,707 3 $5,942 4 $7,178 5 $8,413 6 $9,648 7 $10,884 8 $12,119 9 $13,355 10 $14,590 11 $15,825 12 $17,061 13 $18,296 14 $19,532 15 $20,767 16 $22,002

Effective Date: 04/01/2026

ACA/FAMILY MEDICAID 006 Table of Standards: Breast & Cervical Cancer Treatment-Income Supersedes: ACA-FMA 006 (04/01/2025) Reference: ARM 37.82.101 & .701 Overview: To qualify for Medicaid coverage under the Montana Breast and Cervical Cancer Treatment Program (MBCCTP), the household’s countable gross earned, and unearned income cannot exceed 250 percent of the federal poverty level (FPL) standard. COMPUTATION: The following standards are effective April 1, 2026. Income Standards for MBCCTP Medicaid (250% FPL) Family Size Monthly Income Standard 1 $3,325 2 $4,508 3 $5,692 4 $6,875 5 $8,058 6 $9,242 7 $10,425 8 $11,608 9 $12,792 10 $13,975 11 $15,158 12 $16,342 13 $17,525 14 $18,708

Family Size Monthly Income Standard 15 $19,892 16 $21,075 Effective Date: 04/01/2026

ACA/FAMILY MEDICAID 007 Table of Standards: ACA Adult Medicaid/ACA Adult Income

Supersedes: ACA-FMA 007 (04/01/2025) Reference: ARM 37.82.101, .301; ARM 37.84.101-.115; 42 CFR 435.119 Overview: Individuals and parents/caretaker relatives ages 19-64 may qualify for health coverage if: 1. They meet the nonfinancial criteria for ACA Adult/ACA Adult Medicaid and 2. Household income does not exceed 133 percent of the federal poverty level. COMPUTATION: The following standards are effective April 1, 2026. Income Standards for ACA Adult and ACA Adult Medicaid (133% FPL) FAMILY SIZE INCOME PER MONTH 1 $1,769 2 $2,398 3 $3,028 4 $3,658 5 $4,287 6 $4,917 7 $5,546 8 $6,176 9 $6,805 10 $7,435 11 $8,064

12 $8,694 13 $9,323 14 $9,953 15 $10,582 16 $11,212

Effective Date: 04/01/2026

ACA/FAMILY MEDICAID 018 Table of Standards: Plan First Income

Supersedes: (04/01/2025) Reference: 42 CFR 435.214; ARM 37.82.101, .701, .702, .703 Overview: Females ages 19-44 may qualify for Plan First coverage if: 1. They meet the nonfinancial criteria for Plan First and 2. Household income does not exceed 211 percent of the federal poverty level. COMPUTATION: The following standards are effective April 1, 2026. Income Standards for Plan First Coverage (211% FPL) FAMILY SIZE INCOME PER MONTH 1 $2,806 2 $3,805 3 $4,804 4 $5,803 5 $6,801 6 $7,800 7 $8,799 8 $9.797 9 $10,796 10 $11,795 11 $12,794 12 $13,792 13 $14,791

14 $15,790 15 $16,789 16 $17,787

Effective Date: 04/01/2026

ACA/FAMILY MEDICAID 201-4 Healthy Montana Kids Plus (ACA HMK Plus)

Supersedes: ACA/Family Medicaid 07/01/2016 Reference: 42 CFR 435.118; 42 CFR 435.926; ARM 37.82.101, .701; MCA 53-6-131; 42 USC 1396b Overview: Children from birth through age 18 may be eligible for HMK Plus coverage through the end of the month they turn 19. Countable income must be at or below 143% FPL (ACA FMA 005 Table of Standards- Healthy Montana Kids Program-Income). NON-FINANCIAL CRITERIA: Medicaid standard nonfinancial requirements are listed in section CMA 300 Non- Financial Overview. In addition to the standard criteria that apply to all Medicaid programs, the following non-financial criteria are specific to ACA HMK Plus: • Child must be under age 19 CONTINUOUS ELIGIBILITY: Children eligible for HMK Plus have a 12-month continuous span in which they remain eligible, regardless of changes in household circumstances. The span begins the first day of the application month and continues through the last day of the 12th month. CONTINUOUS ELIGIBILITY ENDS IF: 1) The child is no longer a Montana resident, 2) The child or the child’s representative requests closure, 3) The child dies, 4) The child turns 19 yrs old, or 5) If the agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility due to: a) Agency error or b) Fraud, abuse or perjury attributed to the child or the child’s representative

NOTE: If a child is in HMK Plus continuous eligibility span and they become incarcerated, we do not close until their span has ended. CHILD MOVES BETWEEN HOUSEHOLDS: When a child’s parents both have an open health coverage case and the child moves between households, the child’s continuous span will follow into the new case. Effective Date: 01/01/2026

ACA/FAMILY MEDICAID 201-5 ACA Healthy Montana Kids (HMK)

Supersedes: FMA 201-5 (12/01/2022) Reference: 42 CFR 457.310; 42 CFR 457.342; ARM Chapter 37.79 Overview: Children from birth through age 18 may be eligible for HMK coverage, if their household’s countable income exceeds the HMK Plus standard, but is equal to or less than 261% FPL (ACA FMA 005 Table of Standards- Healthy Montana Kids Program- Income). Children born to women receiving HMK have coverage (through their mother’s policy) during the first 31 days after their birth. NON-FINANCIAL CRITERIA: Standard nonfinancial requirements are listed in section CMA 300 Non-Financial Overview. In addition to the standard criteria that apply to all Medicaid and HMK recipients, the following nonfinancial criteria are specific to ACA HMK, the child: 1. Must be under age 19, 2. Cannot reside in an institution for mental disease, 3. Cannot be an inmate of a public institution, and 4. Cannot have creditable health insurance CREDITABLE COVERAGE: The following are not considered creditable health insurance coverage: 1. Accident-only insurance policies, 2. Tribal or Indian Health Services (IHS), 3. Healthy Montana Kids Plus (HMK Plus) or Medicaid, 4. Mental Health Services Plan (MHSP), 5. School insurance purchased so a child can participate in school-related activities, 6. Children’s Special Health Services (CSHS), and 7. Specific illness (e.g., cancer) or body parts (e.g., dental or vision) insurance.

CONTINUOUS ELIGIBILITY: Children eligible for HMK have 12-months continuous eligibility in which they remain eligible regardless of changes in household circumstances. The span begins the first day of the application month and continues through the last day of the 12th month. A child can be enrolled (i.e., HMK coverage begins) the earlier of the first day of the month the application was received or first of the month after application. There is no retro coverage for HMK. CONTINUOUS ELIGIBILITY ENDS IF: 1. The child becomes Medicaid eligible, 2. The child is no longer a Montana resident, 3. The child or the child’s representative requests closure, 4. The child dies, 5. The child turns 19 yrs. old, or 6. The agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility due to: a. Agency error or b. Fraud, abuse or perjury attributed to the child or the child’s representative NOTE: If a child is in an HMK continuous span and they are discovered to be enrolled in a creditable health insurance or becomes incarcerated, we do not close until their span has ended. CHILD MOVES BETWEEN HOUSEHOLDS: When a child’s parents both have open health coverage cases and the child moves between households, the child’s continuous span will follow into the new case. Effective Date: 01/01/2026

ACA/FAMILY MEDICAID 201-7 ACA Adult Medicaid and ACA Adult Supersedes: 01/01/2023 ACA/FMA 201-8 (05/02/2024); 05/01/2025 Reference: 42 CFR 435.119; ARM 37.82.101-102, 301; ARM 37.84.102, 116-123; P.L. 119-21 Overview: The Montana Health and Economic Livelihood Partnership (HELP) program created two new coverage groups beginning January 1, 2016; ACA Adult and ACA Adult Medicaid. These are expanded Medicaid coverage to otherwise eligible adults. ACA Adult Medicaid and ACA Adult cover individuals aged 19 through 64. FINANCIAL CRITERIA: Income is determined under modified adjusted gross income (MAGI) rules. Each member’s MAGI is compared to the federal poverty level (FPL) to see if they qualify for coverage. ACA Adult Medicaid income must be 0% to 50% FPL (after a 5% disregard from their total countable income) and ACA Adult must be 51% to 133% FPL (after a 5% disregard from their total countable income). NON-FINANCIAL CRITERIA: Medicaid standard nonfinancial requirements are listed in section CMA 300 Non- Financial Overview. In addition to the standard criteria that apply to all Medicaid programs, the following non-financial criteria must be met: 1. Must be aged 19 through 64 years of age; 2. Not eligible for or enrolled in Medicare Parts A and/or B, 3. Not be pregnant at application, and 4. Meet Community Engagement requirements or have a temporary exemption in the look-back period; or qualify for an exclusion. See CMA 310-1 Community Engagement and Exclusion Policy

FILING UNIT: Required filing unit members are determined based on tax filing rules. See FMA 200-1 ACA Filing Unit for ACA filing unit requirements. ACA ADULT MEDICAID AND ACA ADULT COVERAGE ENDS: ACA Adult Medicaid and ACA Adult coverage closes when the client: 1. Requests closure, 2. Dies, 3. Moves out of Montana, 4. Is non-compliant PERM and/or Program Compliance, 5. Becomes eligible for Medicare or has Marketplace coverage, 6. Is unable to be located, 7. Reaches age 65 (eligibility ends the month before their 65th birthday), or 8. No longer meets Community Engagement requirements or a temporary exemption; or no longer qualifies for an exclusion.

If coverage is closing due to a reported/discovered change, an ex parte review will be completed. See CMA 1501-1 Reporting Changes.

Effective Date: 07/01/2026

ACA/FAMILY MEDICAID 805-1 Residential Chemical Dependency Treatment

Supersedes: FMA 1201-1 (01/01/06) Reference: ARM 37.82.101; 42 CFR 435.211, .725 Overview: Child and Family Services Division provides special funding for residential chemical dependency treatment for certain children who they determine to be “youth in need”. Effective Date: July 01, 2016

COMBINED MEDICAID 0-3 Introduction Supersedes: FMA 0-3, (01/01/06) and MA 0-3 (09/01/98) Reference: Overview: Title XIX of the Social Security Act is a federal-state matching entitlement program that pays for medical assistance for certain vulnerable and needy individuals and families with low incomes and resources. Medicaid became law in 1965 as a jointly funded cooperative venture between the federal and state governments to assist states furnishing medical assistance to eligible needy individuals. Medicaid is the largest program funding medical and health-related services for America’s poorest people. Within broad national guidelines established by federal statutes, regulations and policies, each state: 1. Establishes its own eligibility standards; 2. Determines the type, amount, duration and scope of services; 3. Sets the payment rate for services; and 4. Administers its own program. Medicaid policies for eligibility and services are complex, and vary considerably even among similar- sized and/or adjacent states. Thus, a person who is eligible for Medicaid in Montana may not be eligible in another state; and the services provided in Montana may differ considerably in amount, duration, or scope from services provided in neighboring states. In addition, Medicaid eligibility and/or services within a state can change during the year. RESPONSIBILITY FOR PROGRAM ADMINISTRATION: Medicaid is administered in joint cooperation by Federal and State governments. This is accomplished cooperatively with the Field Offices of Public Assistance and processing centers providing the day-to-day client contact under state policies. The Federal government provides guidelines for state operations. USING THIS MANUAL: The policies in this manual are intended as a guide for eligibility determination and are written within the Centers for Medicare and Medicaid Services (CMS) imposed limits. The policies are intended to be sufficiently flexible to allow eligibility staff to exercise reasonable judgment in processing Medicaid eligibility.

In this regard, the concept of the “prudent worker” is helpful. The term refers to the reasonableness of the judgments made by an individual eligibility staff member in a given situation. In a court case, a person charged with negligence will try to show that his actions were the actions that any reasonable or “prudent” person would take in the same circumstances. When finalizing an eligibility decision, eligibility staff should be conscientious about making a decision that is reasonable, based on his or her knowledge of and experience with the Medicaid programs. If the eligibility staff member encounters a problem in a specific case that is felt to be outside the ordinary policy and procedure, the problem should be referred first to their supervisor/field operations manager, and then to the Service Desk. If the problem applies to only a specific case or to a limited number of cases and is generally covered by existing policy, the eligibility staff member makes a judgment that is defined as reasonable and prudent. Case notes are documented with the actions taken. Effective Date: July 01, 2016

COMBINED MEDICAID 001 Table of Standards: General Resource Limits

Supersedes: CMA 001 (01/01/2025) Reference: ARM 37.82.101, .903,.1007, 1106, .1313, .1320, .1330, .1336-.1338; 37.79.201; 37.83.201, .401-.406, 501; 20 CFR 416.410 & .412; 42 CFR 435.601(b) & (d)(2); 435.811; 53-6-113(6), 53-6-131(11), 53-6-195, MCA; 42 USC 1396a (a)(10)(A)(ii)(XIII); PL 110-275 Overview: Resources in excess of the resource standard disqualify the individual or family for Medicaid. If the individual or family is resource eligible any day of the month, they are considered resource eligible for the full month (current or retroactive month). (See CMA 402-1 Countable and Excluded Resources) The household may reapply at any time, even within the same month. Use the following resource standards to determine resource eligibility: FAMILY-RELATED PROGRAMS: ACA: Effective January 1, 2014, there are no resource limits for any ACA Medicaid or ACA HMK program. ACA programs include ACA Parent/Caretaker Relative, ACA HMK Plus, ACA Pregnancy, ACA Former Foster Care and ACA HMK. BREAST & CERVICAL CANCER: There is no resource limit for the Montana Breast and Cervical Cancer program. MEDICALLY NEEDY: Family-Related medically needy programs include Qualified Pregnant Woman, Family Medically Needy and Child Medically Needy. Effective July 1, 2001: Filing Unit: . . . $3,000 (regardless of number of people included) AGED, BLIND and DISABLED (ABD) PROGRAMS: CATEGORICALLY NEEDY: Effective July 1, 2001

Individual . . . . . . . . . . . . . . $2,000 Couple . . . . . . . . . . . . . . . . $3,000 MEDICALLY NEEDY: Effective July 1, 2001 Individual . . . . . . . . . . . . . . $2,000 Couple . . . . . . . . . . . . . . . . $3,000 MEDICARE SAVINGS PROGRAMS: Medicare Savings programs include Qualified Medicare Beneficiary (QMB), Special Low Income Medicare Beneficiary (SLMB) and Qualified Individuals (QI). Effective January 1, 2026 Individual . . . . . . . . . . . . . . . $9,950 Couple . . . . . . . . . . . . . . . . . $14,910 PICKLE: Effective July 1, 2001 Individual . . . . . . . . . . . . . . . $2,000 Couple . . . . . . . . . . . . . . . . . $3,000 QDWI (QUALIFIED DISABLED WORKING INDIVIDUALS): Effective April 1, 2014 Individual . . . . . . . . . . . . . . . $4,000 Couple . . . . . . . . . . . . . . . . . $6,000 MWD (MONTANA MEDICAID FOR DISABLED WORKERS): Effective July 1, 2015 Individual . . . . . . . . . . . . . . $15,000 Couple . . . . . . . . . . . . . . . . $30,000 NURSING HOME RESIDENTS: The resource standard for an unmarried institutionalized individual is $2000. The general resource limit for an institutionalized spouse is also $2000. See CMA 803-1 Institution and Waiver Resource Assessments policy. COMMUNITY SPOUSE RESOURCE MAINTENANCE ALLOWANCE: Effective January 1, 2026, when completing a couple's resource assessment, the community spouse resource maintenance allowance (CSRMA) is the greater of: 1. One-half (not to exceed $162,660) the couple's combined countable resources; 2. The minimum resource maintenance allowance of $32,532 3. An amount designated by hearings officer (override); or 4. An amount which has been court ordered (override).

COMBINATION PROGRAMS (MAY BE FAMILY OR ABD): COBRA 75: Effective July 1, 2005 Individual . . . . . . . . . . . . . . . $4,000 Couple . . . . . . . . . . . . . . . . . $6,000

Effective Date: 01/01/2026

COMBINED MEDICAID 002 Table of Standards: Medically Needy Income

Supersedes: CMA 002 (01/01/2025)

Reference: 42 CFR 435.811; ARM 37.82.101, .1106; 42 U.S.C. 415

Overview: ACA/Family: An individual or family that meets all the nonfinancial criteria for non-medically needy Family Medicaid assistance, but fails to meet the income standards, may qualify for medically needy Medicaid. Eligibility for medically needy Medicaid (with or without a spend down) is based on income received or reasonably anticipated for the month. Use the appropriate income level from the table on page 3 of this section.

The needs of parents/specified caretaker relatives are not covered under the Family medically needy Medicaid program, whether or not there is a spend down.

MEDICALLY NEEDY INCOME DEDUCTION:

ABD: Effective January 1, 2026, an additional $391 is deducted from a medically needy filing unit’s total countable net income when calculating the spend down amount. See CMA 602-1 Income Disregards and Deductions for more information.

ABD Only: This deduction does not apply to institutional eligibility. Step 1 only determines if the applicant is categorically needy or medically needy. Step 2 budgeting of liability toward cost of care also does not include this deduction.

SPEND DOWN OBLIGATION: Medically needy clients can establish medically needy coverage by: 1. Using incurred medical expenses to meet their spend down obligation (CMA 702-1 Medical Expense Option); 2. Choosing the cash option and paying the spend down obligation amount to the Department (CMA 701-1 Cash Option); or 3. Using a combination of incurred medical expenses and the cash option.

MULTIPLE FILING UNITS IN A HOUSEHOLD (ACA/Family only): Regardless of the number of filing units in a household, test the income of each filing unit against the appropriate income standards based on household size and circumstances.

ABD MEDICALLY NEEDY INCOME LEVELS (MNIL): Effective July 1, 2001 Individual…$525 Couple…$525

ACA/FAMILY COMPUTATION: Use the table of income levels to determine: 1. Income eligibility for medically needy; or 2. The amount of spend down required before medically needy eligibility may be granted. When the individual or family income (after appropriate disregards -- see 602-1) is more than the countable monthly income standard (CMA 002) but equal to or less than the appropriate Medically Needy Income Level (MNIL), the child(ren) is eligible for medically needy without a spend down. When the individual or family income (after appropriate disregards) is more than the applicable MNIL, the child(ren) is eligible for medically needy with a spend down.

ACA/FAMILY MEDICALLY NEEDY INCOME LEVELS (MNIL):

Effective July 1, 2001 Family Size Net Income Level 1 $525 2 $525 3 $658 4 $792 5 $925 6 $1058 7 $1192 8 $1317 9 $1383 10 $1450 11 $1508 12 $1558 13 $1608 14 $1658 15 $1700 16 $1742

Effective Date: 01/01/2026

COMBINED MEDICAID 0-4 Acronyms and Glossary

Supersedes: CMA 0-4 (02/25/2025) A A & A—Veterans Administration Aid and Attendance ABD—Aged/Blind/Disabled ACA—Affordable Care Act ACE—Active Corps of Executives ACV—Action Cooperative Volunteer Program ADH – Administrative Disqualification Hearing ARM—Administrative Rules of Montana ACCESS—As it relates to joint checking/savings accounts: • Restricted—Limited access to money in an account. • Unrestricted—Unlimited access to money in an account by one or all of the account holders. ACTUARIALLY SOUND—For purposes of Medicaid resource eligibility, a situation where the amount expected to be paid to the holder of a payment contract within his or her lifetime (which could be a contract-for-deed, or an annuity, for example) meets or exceeds the original value of the contract. Actuarial soundness is determined by multiplying the periodic payment amount by the holder’s life expectancy and then comparing this to the value of the contract (for a contract-for-deed, the value of the contract is the original value of the contract; for an annuity, this is the purchase price of the annuity). If the total of expected payments to be received during the contract holder’s lifetime is less than the original value of the contract, then the contract is not actuarially sound. ADEQUATE NOTICE—Written notification to be received by the individual no later than the date of intended action or the date benefits would have been received. Notices must be mailed no later than two working days after CHIMES cutoff to meet adequate timeframes. ADMINISTRATIVE MONTH—The calendar month preceding the benefit month(s) for which eligibility determination is reviewed. ADULT—ABD: An individual age 18 or older. ACA/Family: An individual (age 19 or older) other than a dependent child (unless such a child is the minor custodial parent of another dependent child whose needs are being met). An emancipated child is considered an adult.

ADULT CHILD—An individual whose legal or biological relationship to another is child, but who has reached the legal age of majority (18). For purposes of determining exemption of a home, a “dependent adult child” is one who is dependent upon his/her parent(s) and is claimed on the parents’ income taxes (or if the parents did not file an income tax return but could claim the child if they did file one) as a dependent. ADVANCED PREMIUM TAX CREDIT (APTC)—The Affordable Care Act provides a new tax credit to help consumers afford health coverage purchased through the Marketplace. The consumer must purchase the health insurance through the Federally Facilitated Marketplace in order to receive the tax credit. ADVERSE ACTION—A decision to deny, decrease, suspend or terminate the benefits. AGED—Sixty-five (65) years of age or older. AGED/BLIND/DISABLED (ABD) MEDICAID—Term used to reference Medicaid programs serving aged, blind and disabled individuals. ABD Medicaid uses the financial and some non-financial criteria of the SSI cash assistance program administered by the Social Security Administration. ABD programs have also been known as SS-related Medicaid. ALERT—A system reminder to the worker to reevaluate case circumstances. ALIEN—A person residing in the United States of America who is not a citizen. ALIEN SPONSOR—A person or any public or private agency or organization that executed an affidavit of support (Form I-134) or similar agreement so that an alien could enter the United States. ALIMONY—Court ordered payment made by one spouse or former spouse to another after a legal separation or divorce. Spousal Support is income to the recipient and, if court-ordered, an income disregard to the payer. AMERICAN INDIAN OR ALASKA NATIVE (AI/AN)— a person who (A) is an Indian or an Urban Indian (as defined in paragraphs (13) and (28) of section 4 of the Indian Health Care Improvement Act), (B) is a California Indian (as described in section 809(a) of such Act), or (C) has otherwise been determined eligible as an Indian for the Indian Health Service under HHS regulations. ANCILLARY CHARGES—Fees for medical services (such as hospital, doctor, ambulance, prescriptions or therapy) that are not included in the cost of medical institutional care. ANNUITY—An agreement between two parties in which one party (annuitant) transfers an asset to another party (obligor) in return for unsecured payments for the remainder of the annuitant's life. Annuities may be purchased by an individual, an employer, or as part of a court ordered settlement. The annuity contract may be a resource, and the payments are countable income. • Commercial Annuity: A Commercial Annuity is an annuity, endowment, or life insurance contract issued by an insurance company licensed to do business under the laws of any State. • Private Annuity: For the agreement to be classified as a private annuity, neither party can be in the business of selling annuities - that is, neither party can be an insurance company. ANNUITY CONVERSION: Certain actions to change an annuity, such as annuitizing a previously un-annuitized annuity or change an annuity form one time to

another. Automatic events that are not voluntary, such as the start of pre-arranged payments or other actions the annuity company takes are NOT considered conversions. APPLICATION DATE—The date the completed and signed application form is received and date stamped in the County Office or central scanning, or date an electronic application arrives in the online application mailbox, or the date a client completes a telephonic application. ASIAN—A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. ASSISTANCE UNIT—Those filing unit members who are eligible to receive benefits. ABD: Includes an aged, blind or disabled individual and his/her aged, blind, or disabled spouse. ACA/Family: Includes eligible individuals who are tax filers, non-filers, and tax dependents. AUTHORIZED REPRESENTATIVE—A person acting for an applicant/recipient through the individual's written authorization. AVAILABLE resources: the condition of having direct or indirect access to property that can be used for the individual’s needs. Available income: the applicant/recipient has a legal interest in a liquidated sum with the legal ability to make such a sum available for support and maintenance. Includes income earned by the applicant, unearned income from any source, amounts deemed available from the applicant’s ineligible spouse or alien sponsor (or parents if applicant is under 18 and blind or disabled), and the value of any support or maintenance received “in kind.” B BCBS MT—Blue Cross Blue Shield of Montana BEOG–Basic Educational Opportunity Grant BIA—Bureau of Indian Affairs BENDEX–The Social Security Administration’s Beneficiary Data Exchange System, which provides the amount of Retirement, Survivors, Disability Insurance (RSDI) and Title II Social Security benefits paid to people entered on the system. BENDEX also provides data on pensions and wages. BENEFIT MONTH—Calendar month for which Medicaid benefits are issued. BLACK OR AFRICAN AMERICAN—A person having origins in any of the black racial groups of Africa. Terms such as “Haitian” or “Negro” can be used in addition to “Black or African American.” BLIND ACCORDING TO SSA CRITERIA—Meets SSA’s definition of blindness for qualifying for blindness-related SSA benefits. BOARDER—An individual who receives both food and lodging in either a commercial boarding house or in another household. BONA FIDE—Good faith; without fraud or deceit. BOND—A written obligation to pay a sum of money at a future specified time. A bond is a negotiable instrument.

BUDGET MONTH—The month that the financial and non-financial criteria of the unit are used to determine eligibility. Using prospective budgeting, the budget month is the same as the benefit month. BUDGETING—Calculating the assistance unit’s eligibility for the benefit month. BURIAL FUNDS—Burial contract, burial trust, life insurance or other burial agreements (whether irrevocable, revocable, rescindable or non-rescindable) or any other separately identifiable funds that are clearly designated for burial expenses. BURIAL SPACES—Conventional grave sites, crypts, mausoleums, urns, and other repositories which are customarily and traditionally used for the remains of deceased persons. BUSINESS EXPENSES—Costs directly related to the production of income. C CA—Conditional Assistance CD—Certificate of Deposit CE – Community Engagement Activity - A “Community engagement activity” is an activity listed in ARM 37.84.118 that counts toward the community engagement requirement in ARM 37.84.116. CFR—Code of Federal Regulations CFS-- Child and Family Services CHIMES EA—Combined Healthcare Information and Montana Eligibility System- Enterprise Architecture. CMS—Centers for Medicare and Medicaid Services. CMS is the federal agency responsible for the administration of the Medicaid and Medicare programs. CMV—Current Market Value COBRA—Consolidated Omnibus Budget Reconciliation Act COLA—Cost of Living Adjustment CS—Community Spouse CSE - Child Support Enforcement CSED--Child Support Enforcement Division CSC—Client Service Coordinator CSIMA—Community Spouse Income Maintenance Allowance CSRMA—Community Spouse Resource Maintenance Allowance CWS - Child Welfare Services CALENDAR YEAR—January 1 through December 31. CAPITAL GAINS—Increased in property value between the time purchased and the time sold; represents a financial gain to the owner. CAPITAL LOSS—Decreases in property value between the time purchased and the time sold. CARE AND CONTROL--The physical care, guidance or maintenance of a child or children provided by a responsible parent or caretaker relative. CAREGIVER - a parent, guardian, relative, or family caregiver (as defined in section 2 of the RAISE Family Caregivers Act, P.L. 115-119) of a dependent child who is 13 years of age and under or of a disabled individual

CARETAKER RELATIVE—For Family-Related Medicaid purposes, an adult, age 19 or older who meets the definition of a relative and is exercising the care and control of the child(ren). An emancipated child may also be a caretaker relative. CASE—Documents or computer data relating to a household. CASE MANAGEMENT—Steps completed by eligibility staff or others that are managing or reviewing the case. Includes gathering and entering into the eligibility system, information needed to establish eligibility, communicating eligibility to client through notices and contacts, updating case with changes, etc. CASE MANAGEMENT TEAM—The provider and the state representative responsible for developing a plan of care as well as locating, coordinating and monitoring the delivery of Home and Community Based Services (HCBS/Waiver) for the client. CASE NOTE—A clear, concise, complete, objective journal entry of significant facts which justify actions taken and supports eligibility decisions. CASH SURRENDER VALUE—The actual cash amount the insurer will pay upon cancellation of a life insurance policy. This value usually increases with the age of the policy but is decreased by any outstanding loans against the policy. CASH VALUE—For resources: the amount that would be received if the resource were sold or converted to cash. For income: the amount of the income or the value assigned to the service rendered for in-kind income. CATEGORICALLY NEEDY—An individual or couple who meet all non-financial eligibility criteria and whose income does not exceed the categorically needy income limit. CERTIFICATE OF DEPOSIT—See “Time Deposit”. CERTIFIED APPLICATION COUNSELOR (CAC) - Certified application counselors are available to provide information to consumers and to help facilitate consumer enrollment in Qualified Health Plans and insurance affordability programs. CHANGE IN CIRCUMSTANCE—A reversal or variation of the fact from what was previously known. CHILD—The legal (biological or adopted) son or daughter of a parent; this includes stepsons and stepdaughters. CHILD SUPPORT—Court ordered payment by a non-custodial parent for the purpose of meeting his or her child(ren)’s needs. COLLATERAL CONTACTS—Knowledgeable individuals or sources who serve to support or confirm information. COLLECTIBLES—Any item of value, which may or may not be part of a collection, such as paintings, coins, stamps, etc. COMMERCIAL BOARDING HOUSE—A house where paying guests are provided with meals and lodging. COMMINGLED FUNDS—Countable and exempt funds that are combined in a bank, IIM, or other account. COMMON LAW MARRIAGE—A legally binding marriage between two adults who are competent to enter into marriage and who, without the benefit of a marriage license or ceremony, mutually consent and agree to a common law marriage, who then cohabit and who are reputed in the community to be husband and wife. Common law marriage

is based on the couple living together for a “significant period of time,” holding themselves out as a married couple (may refer to one another as “my husband” and “my wife”, may file joint tax returns and may use the same last name), and who intend to be married. A common law marriage must be terminated by a formal legal divorce. Common law marriage is not recognized in all states, or on some Indian reservations. COMMUNITY ENGAGEMENT ACTIVITIES- Activities that count toward the community engagement requirement COMMUNITY SERVICE- means unpaid work, completed voluntarily or because of a mandate by court order, with a structured program that is completed for the direct benefit of the community under the auspices of public or nonprofit organizations (including embedded activities of the program that allow an individual to develop skills necessary to complete community service). The public or nonprofit organizations: (i) Include organizations described in section 501(c)(3) of the Internal Revenue Code of 1986 (26 U.S.C. 501(c)(3)) and other organizations. (ii) Must provide oversight of the activity, which must not serve a partisan purpose, and have a process in place to track the community service completed by individuals, including the type of community service activity, dates and hours the community service is completed, and a point of contact who can confirm the hours completed. COMMUNITY SPOUSE—A spouse who is not living in a residential medical institution or nursing facility or participating in the Medicaid HCBS waiver program. COMPENSATION—Money, real or personal property, food, shelter or services received by an individual in exchange for goods or services provided by that individual. COMPLETE THE PROGRAM--An individual enrolled in high school or an equivalency program is considered to have completed the program if the institution has awarded a diploma or certificate of completion. CONCILIATION--The informal process for resolving a recipient’s complaint, grievance, or dispute. CONFIDENTIAL INFORMATION—Applicant or recipient information that may only be shared for purposes of establishing eligibility, determining amount of assistance, and providing services, with related federally mandated and assisted programs and agencies under contract to the Department or operating with a Memorandum of Understanding. CONTRACT FOR DEED—A real estate transaction where the seller carries the buyer's obligation to pay the purchase price. The seller agrees to transfer the property deed to the buyer when all payments have been made. A contract for deed is a negotiable instrument. CONVALESCENT LEAVE—A temporary release from a residential medical facility such as Montana State Hospital, without final discharge. COST SHARE REDUCTION (CSR) - A discount that lowers the amount a consumer pays out-of-pocket for deductibles, coinsurance, and copayments. A person can get this reduction if they get health insurance through the Marketplace, their income is below a certain level, and they choose a health plan from the silver plan category.

COUNTABLE INCOME—The total of earned and unearned income (after allowable disregards) not excluded by policy that is expected to be received by the filing unit for the budget/benefit month. COUNTABLE INTEREST—Also known as “proportionate interest.” The fair market value of a property multiplied by an individual’s percentage of ownership. COVERAGE REQUEST DATE—The date an individual requests Medicaid coverage. This date may or may not be the same as the application date. For example, on March 12, Mary applies and is approved for Medicaid for herself but does not request coverage for her children. Mary’s application and coverage request date are both March 12. On May 9, Mary requests coverage for her children. The children’s coverage request date is May 9, but the application date is March 12 (as a new application cannot be required when other family members are receiving Medicaid). Any request for retro coverage is based on the coverage request date. In this scenario, Mary’s could request retro coverage for her children for February, March and April, as those are the three months immediately preceding their coverage request date. CREATOR—Used in terms of a trust, the person who creates a trust, also known as a "settlor" or "grantor". CREDITABLE COVERAGE—Coverage of the individual provided under any of the following: 1. a group health plan, 2. health insurance coverage, 3. Part A or Part B of Title XVIII of the Social Security Act (Medicare), 4. Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under section 1928, 5. chapter 55 of Title 10 USC (CHAMPUS), 6. a medical care program of the Indian health service or of a tribal organization, 7. a state health benefits risk pool, 8. a health plan offered under chapter 89 of Title 5 USC (Federal Employees Health Benefits Program), 9. a public health plan as defined in federal regulation, and 10. a health benefit plan under section 5(e) of the Peace Corps Act (22 USC 2504(e)). CURRENT MARKET VALUE (CMV) - See Fair Market Value. CURRENTLY AVAILABLE PROPERTY RESOURCES—Assets which an applicant or recipient has a legal right and reasonable practical ability to liquidate. Liquidation does not need to be possible immediately or within a given benefit month for an asset to be currently available. D DAC—Disabled Adult Child DD—Developmentally Disabled DDB—Disability Determination Services, a.k.a. Disability Determination Bureau DDP—Developmental Disabilities Program DDS—Disability Determination Services (see DDB) DMS—Document Management System (electronic case file) (Replaced with Perceptive) DOC—Department of Corrections

DLI—Department of Labor and Industry DOR—Department of Revenue DPHHS—Department of Public Health and Human Services DEBIT CARDS—Prepaid or electronic funds deposit account where the individual has access to available funds (including, but not limited to Direct Express, Walmart Debit cards, prepaid credit cards, etc.). The card owner can login to an online account or call the company to check their balance, view transactions and view record history. DEEMED HOUSEHOLD –For ACA/Family: The deemed person plus their dependents living in the home who are not included in the Medicaid filing unit. Dependents who are included in either the filing unit or assistance unit cannot be included in the deemed household. DEEMING—Considering a portion of income and resources of one person as the income and resources of a second person, whether actually available or contributed. DEPENDENT CHILD— child who is: 1. under age 19; and 2. living with an adult (age 19 or older) caretaker. The caretaker may or may not be a specified relative. 3. If a dependent child is under the age of 14, their parent or guardian may be exempt (excluded) from certain community engagement or work requirements. A minor child who is living independently, and not with a parent or stepparent adult caretaker, is not considered a dependent child. However, if the child is under age 19, they are still considered a minor child for Family-related Medicaid purposes. DISABILITY—The physical and/or mental impairment of an individual, based on criteria set out in Social Security Administration eligibility rules. The impairment may be either temporary or permanent. DISABLED—Permanently and totally disabled as determined by either Social Security Administration or MEDS, according to Social Security disability criteria. DISABLED STUDENT—A disabled individual who is under age 22, and who is in a college or university at least 8 hours per week, or in grades 7-12 for at least 12 hours per week, or in a training course preparing for a paying job for at least 12 hours per week (15 hours if shop practice is involved), or for less time than indicated for reasons beyond the student‘s control such as illness, the nature of his/her disability, or lack of transportation. DISREGARD—A dollar amount designated for a specific purpose which is deducted from the filing unit’s income. ABD: $65 and ½ of earned income, legally obligated child support payment. ACA: A 5% disregard that is deducted from the filing unit’s gross income. Family Medically Needy: $200 plus 25% of remaining earned income, dependent care and legally obligated child support. No disregards are allowed if GMI test is failed DIVIDEND A share of profits received by a stockholder or by a policyholder in a mutual insurance society.

DOCUMENT—Used as a noun, indicates a written record on system case notes of the circumstances of an event or fact. Used as a verb, indicates the act of entering in the case file actual proof or statement of proof that the contents of the record are accurate. E EA—Emergency Assistance EIC/EITC—Earned Income Credit/Earned Income Tax Credit EMHP—Extended Mental Health Plan for HMK benefits EARNED INCOME—Employee payments received in cash or in-kind for wages, tips, commissions, or net profit from activities in which the individual is engaged as self- employed, the gross income before deductions for personal or employment expenses or garnishments. EARNED INCOME TAX CREDIT (EITC) - An amount of money which has been either deducted from the taxes owed or paid as a refund resulting from filing a Form 1040 or 1040A Tax Return for a calendar year. EITC is disregarded as income and as a resource in the month following receipt. ELECTRONIC CASE FILE—Electronic images contained in the Document Management System (DMS). ELIGIBILITY FACTOR—A specific condition that a client must meet to qualify for or continue receiving benefits. ELIGIBILITY STAFF MEMBER—The staff person who provides case management in the Field Offices of Public Assistance and Processing Centers. ELIGIBLE—A person who meets a specific program’s eligibility requirements; considered qualified to receive the program’s benefits. ELIGIBLE CHILD—ACA/Family: A child, under age 19, who is eligible to be included in the filing and assistance units. ELIGIBLE JUVENILE - An individual who is under 21 years of age who was determined eligible for any Medicaid eligibility group; an individual determined eligible for the mandatory eligibility group for former foster care children, immediately before becoming an inmate of a public institution; or who is determined eligible for Medicaid while an inmate of a public institution. ELIGIBLE SPOUSE—ABD: Spouse of a Medicaid applicant/recipient where neither spouse is institutionalized or waiver. If one member of a couple is institutionalized or waiver (or waiver eligibility is being determined), the applicant/recipient’s spouse (whether ABD or not) is a community spouse. EMERGENCY ASSISTANCE FOR NEEDY FAMILIES—A short-term program to assist families in an emergency caused by an unforeseen circumstance. ENCUMBRANCE—A claim or legal debt(s) against a resource which is supported by a written document, and which must be paid when the resource is sold. ENGLISH AS A SECOND LANGUAGE (ESL)--Classroom training for those who are non- English speaking, but literate in their native tongue. It should provide them with sufficient command of the English language to compete and participate in the labor market, or to participate in training. ENUMERATION—The act of assigning a Social Security Number (SSN).

EPSDT—Early and Periodic Screening, Diagnosis and Treatment services for individuals under age twenty-one (21), who are covered by Medicaid. EQUITY VALUE—The current market value less any encumbrances (legal debts such as mortgages, loans, penalties, cost of sale, etc.) against the property as of the date of evaluation. ESSENTIAL FOR DAY-TO-DAY LIVING—As stated by the caretaker relative, the item is indispensable or necessary for the survival of the assistance unit. ESTOPPEL—A legal principle that when an individual represents a material fact to a second individual, and the second individual reasonably changes his or her position in reliance on the representation, the first individual may not deny that the condition or fact exists. All instances where estoppel may be an issue must be referred to the Office of Legal Affairs through Central Office policy specialist. EVIDENCE—Something that furnishes proof (a document or a statement attesting to the validity of a particular event). EXPANSION MEDICAID- The MAGI-based Adult Group (ACA Adult and ACA Adult Medicaid) covering individuals ages 19–64 with income 25% to 138% FPL who are not otherwise eligible for another Medicaid category. EX PARTE REVIEW—A review of household circumstances that is completed by the client service coordinator when a Medicaid program closes, or when other household circumstances change. The purpose of this review is to determine if the child/family qualifies for a different Medicaid program than currently open, or the one being closed. Current information, already contained in the case record, is used to complete this review. Additional or updated information is requested when needed. EXCLUDED RESOURCE—Any real or personal property that is not counted toward the general resource limitation. EXTRA PAYCHECK—A payment (earned income) in addition to the usual number of payments made in a month. Extra paychecks are received four times a year for people paid on a weekly basis and twice a year for people paid every other week. F FBDE—Full Benefit Dual Eligible FC—Foster Care FICA—Federal Insurance Compensation Act FMA—Family Medicaid FMV—Fair Market Value FAIR HEARING—An opportunity for any person whose claim for assistance has been denied, or who had other negative action taken on their case, to present convincing evidence to reverse the original decision. Another interested party to the benefits, such as a medical provider, may also request a fair hearing. FAIR MARKET VALUE (FMV) - The gross amount of money that the sale of property would bring on the open market in the community where the property is located. Encumbrances do not affect FMV. FAMILY CAREGIVER – An adult family member or other individual who has a significant relationship with, and who provides care within a broad range of assistance to, a dependent child or disabled individual.

FEDERAL POVERTY LEVEL (FPL) - The income level published each year by the U.S. Department of Health and Human Services to determine poverty guidelines. FEE PATENT LAND—Land located on an Indian Reservation, but not under the control of the tribe or any other government entity. The landowner may or may not be Native American. When fee-patent land is to be sold, the tribe must always be given the first opportunity to purchase the land. If the tribe declines the right to purchase, the owner does not need the permission of the tribe or BIA in order to sell the property and may sell it to anyone (does not have to be purchased by someone of Native American descent). Fee patent land is taxable land. FEDERALLY FACILITATED MARKETPLACE (FFM)—Federal website where consumers can apply for insurance and insurance affordability programs. Also known as the Marketplace. FILING UNIT—Those individuals whose income and resources must be considered in eligibility determination. Not all members of the filing unit may be included in the assistance unit and may not receive benefits. FINALIZE—In CHIMES, final authorization of a Medicaid determination resulting in issuance of benefits, denial of a request for coverage or closure of on-going eligibility. FOUNDATION—Mountain Pacific Quality Health Foundation. The Foundation is the contractor to Montana Medicaid for both nursing home level-of-care screening and Medicaid travel. Also known as MPQHF. FULL BENEFIT DUAL ELIGIBLE—An individual who is receiving both Medicare benefits (Part A and/or B) as well as a “full” Medicaid benefit (e.g. “regular Medicaid benefits”). G GARNISHMENT—A legal action to deduct a specified amount of money from an individual’s wages, unemployment compensation or other income to satisfy a creditor. GENERAL EQUIVALENCY DIPLOMA (GED) - Training provided to individuals who require a high school education or its equivalent, to obtain appropriate employment. The training prepares the individual for the GED test for a high school equivalency certificate. GOOD CAUSE—An acceptable reason for an individual's action that overrides the penalty of that action. This reason applies to asset transfers, cooperation with CSED, Program Compliance, Third Party Liability, etc. GRANTOR—The entity that creates a trust. The grantor may be a person, court or administrative body with legal authority to act on behalf of an individual. The grantor may be acting at the direction or request of an individual (aka donor or trustor). GROSS EARNED INCOME—The total money the person is entitled to receive prior to any deductions including garnishment. GUARDIAN – An adult appointed by the court to care for and make personal decisions for a dependent child or disabled individual who cannot care for themselves. H HELP— Medicaid coverage program for persons as authorized at Title 53, chapter 6, part 13, MCA, and 42 U.S.C. 1315 (2015), 42 U.S.C. 1396d(y) (2015), and other applicable state and federal authorities for those persons who are eligible for the HELP Program as authorized under 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) (2015).

HIFA—Health Insurance Flexibility and Accountability waiver HIPAA—Health Insurance Portability and Accountability Act of 1996 HARD CARD–The Montana Access to Health card. This is a Medicaid recipient’s permanent Medicaid ID card. Each recipient receives his/her own card, and should retain the card indefinitely, even if his/her Medicaid case closes. Health Insurance Premium Payment System (HIPPS): Payment of cost-effective individual or group health plan premiums as a Medicaid benefit HISPANIC OR LATINO—A person of Cuban, Mexican, Puerto Rican, South or Central America, or other Spanish culture or origin, regardless of race. The term, “Spanish origin,” can be used in addition to “Hispanic or Latino.” HOME—The principal place of residence of an individual and/or his or her spouse and/or his or her dependent child(ren). Principal place of residence (ACA/Family): the family setting in which the child lives with a caretaker relative who provides day-to-day care and control of the child. For resource purposes: a home is the principal place of residence, which is owned or being purchased, and which includes any building and the land upon which it is located, the land that appertains to the home and all the buildings and/or mobile homes located thereon. A mobile home (or mobile homes) located on real property may be excluded as part of a home if lived in by the individual and/or his or her spouse and/or his or her dependent child(ren). (See definition of principal place of residence.) HOMELESS INDIVIDUAL - An individual who lacks a fixed and regular nighttime residence or an individual whose primary nighttime residence is: 1. A supervised shelter designed to provide temporary accommodation (such as welfare hotel or congregate shelter). 2. A halfway house or similar institution that provides temporary residence for individuals intended to be institutionalized. 3. Temporary (no more than 90 days) accommodation in a shelter or church. 4. A place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings (a hallway, a bus station, a lobby or similar places). HOUSEHOLD FURNISHINGS—Furniture, appliances, clothing and personal items owned by the filing unit. HUB—Federal data services portal that states will use for electronic verification. I ICF—Intermediate Care Facility ICF/IID- Intermediate Care Facility for Individuals with Intellectual Disabilities (formerly known as ICR/MR) ICF/MR—Intermediate Care Facility for the Mentally Retarded (changed to ICF/IID) IDD- Individuals with Intellectual Disabilities IEVS—Income and Eligibility Verification System IIM—Individual Indian Monies INA—Immigration and Naturalization Act IRA—Individual Retirement Account IRS—Internal Revenue Service

IDENTIFICATION (ID) CARD—A hard plastic card that identifies the bearer and gives a provider access to Medicaid eligibility information for that person. Possession of the card does not guarantee that the individual is Medicaid eligible. INCAPACITY—A physical or mental defect, illness or impairment which is sufficiently serious as to eliminate or substantially reduce an* individual’s ability to function for day- to-day activities or employment. INCARCERATION—The condition of being in prison or city/county jail, a half-way house under the control of the corrections system, or a secure residential treatment facility as required by court order. INCOME—Money (earned or unearned) received from any source. INCOME GENERATING PROPERTY –Countable liquid resources, such as annuities, savings accounts, and CDs that generate dividends, interest, or other passive income without the active participation of the owner. ‘Income generating property’ is a characteristic of the property that is used in CHIMES to connect a resource to the income it generates. INCOME-PRODUCING PROPERTY—Non-liquid real or personal property that, in and of itself, produces income. For example, rental property is normally considered income- producing property. ‘Income producing property’ is a characteristic of property that is used in CHIMES to connect a resource to the income it generates, as well as triggering the 6%/$6000 resource exclusion test (see MA 402-1). INCUR—To become liable for something. INCURMENT—See Spend Down INDEMNITY INSURANCE POLICY—An insurance policy that pays a flat amount per day or per incidence only because a specific incident takes place (such as hospitalization or institutionalization), and not dependent on the insured incurring a financial obligation or expense due to the incident. INDEPENDENT LIVING ARRANGEMENT—A living arrangement where the person is self- sufficient and does not rely upon another person or an institution to provide his/her food and/or shelter. INDIAN LAND--Property owned jointly by the tribe or property that can be sold only with the permission of other individuals, the tribe or the Bureau of Indian Affairs. INDIAN TRUST LAND—Reservation land, held in government trust status, owned by either the tribal governing body or individual tribal members. The land may be used by the individual owner or leased to others for farming, grazing, mineral extraction or other uses. The land cannot be sold without BIA and/or tribal approval. INDIVIDUAL INDIAN MONEY (IIM) ACCOUNTS—Accounts, similar to bank accounts, that are administered and maintained by the Bureau of Indian Affairs (BIA) Area Office or a designated agency on the reservation. The designated official at each agency can restrict IIM Accounts. INDIVIDUAL RETIREMENT ACCOUNT (IRA)—A tax-deferred pension or plan which sets aside money now for the needs of the person after retirement. INELIGIBLE—Not entitled to receive benefits; does not meet one or more of the specified non-financial or financial eligibility requirements.

INELIGIBLE ALIENS—Those aliens who are not eligible for Medicaid due to the temporary nature of their admission status, the five-year ban, or not meeting Qualified Alien status. INELIGIBLE CHILD—ABD: A dependent child (that is not blind or disabled) of a deemed parent, stepparent, or ineligible spouse, who lives in the same household as the deemed parent, step-parent, or ineligible spouse, and may* be allowed an ineligible child allocation when deeming from the parent to an eligible child or from the ineligible spouse to an eligible spouse. An ineligible child must be under 18 if not attending school, or under 21 if they meet the definition of a student. *An ineligible child allocation cannot be allowed for an ineligible child who is receiving SSI benefits, TANF cash assistance, or BIA General Assistance. ACA/Family: A child (under age 19) who is not eligible for a specific Medicaid category, but who lives in the same household with their sibling/stepsibling who is eligible for that Medicaid category. The child may be an ineligible child for one category, and an eligible child for another. Examples of ineligible children include a child in a paid foster care placement. INELIGIBLE PARENT--An eligible child’s natural or adoptive parent who lives in the same household as the eligible child, but who is not eligible for the specific medical category being opened for the child. INELIGIBLE SPOUSE—The Medicaid applicant’s spouse, who is not eligible for Medicaid based on non-financial criteria (aged, blindness, disability, alien status, etc.). A spouse is not an ineligible spouse simply because s/he is not requesting or applying for Medicaid coverage. INHERITANCE—Property received or anticipated to be received from a relative or other person by legal succession or will. INITIAL ELIGIBILITY DETERMINATION—The act of evaluating eligibility factors for each applicant and finding each applicant eligible or ineligible. IN-KIND INCOME— See Vendor Payments. The receipt of goods or services (including vendor payments) instead of money that may be used to provide food or shelter and must be counted in the determination of eligibility. The receipt of good(s) or service(s) instead of money for the activities of an individual must be evaluated to determine a value. This value is considered earned income and must be counted in the determination of eligibility if provided in the form of food or shelter. INMATE OF A PUBLIC INSTITUTION—An individual from the date of actual incarceration in a prison, county, city or tribal jail until permanent release, bail, probation or parole. An individual released from prison or jail due to a medical emergency that would otherwise be incarcerated but for the medical emergency, is considered an inmate of a public institution. INSTITUTION—An establishment that furnishes (in single or multiple facilities) food, shelter and treatment or services to four or more persons who are unrelated to the proprietor. INSURANCE SETTLEMENTS—The money received by a person or persons from a company for damage of property or person. Insurance payments to repair or replace

damaged property are considered as excluded resources and are excluded for three months. Insurance payments for personal injuries are considered as income. INSURED—The person who is covered by an insurance policy. INSURER—The company or association that contracts with the insured person and is responsible for the payment of benefits. INTACT FAMILY--A filing unit consisting of both parents and their children living together in a place of residence INTENSIVE SERVICES REVIEW COMMITTEE (ISRC) - A statewide committee of representatives designated by the DD Program to review pre-admission screening materials and determine level of care requirements for individuals referred to intensive services. The ISRC maintains a register of individuals who meet level of care requirements to be used by the statewide local screening committees for selection decisions when an opening (in the waiver program) occurs. INTEREST—A charge for a loan, or an amount earned by an amount on deposit; usually a percentage of the amount loaned or deposited. INTERMEDIATE CARE FACILITY (IFC) - A residential medical facility, known in federal regulations as a nursing facility, that provides health-related services above the level of room and board, and is certified and recognized under State law as a provider of such medical services. Residents must be admitted by a physician and continuously remain under a physician’s care. An ICF is licensed and monitored by DPHHS. INTERMEDIATE CARE FACILITY FOR THE MENTALLY RETARDED—A facility that provides intermediate care and active treatment to the mentally retarded or otherwise developmentally disabled. An ICF/MR is licensed and monitored by DPHHS. INTERVIEW—To question or talk with a person (face-to-face or via phone call) to obtain and give information. The Department cannot require an interview for ANY Medicaid program. IRREGULAR INCOME—Income that is received at various time intervals or fluctuating amounts; does not follow a regular pattern. IRREVOCABLE—That, which cannot be terminated, amended or set aside. ITEMS OF UNUSUAL VALUE—Household goods or personal effects that have a current market value of $500 or more that are held as investments and not used for day-to-day living, which may be countable. J JOINT CUSTODY—ACA/Family: Agreements where both parents share in providing maintenance, physical care and guidance for the child(ren). Flexibility is used in 50/50 custody situations. Staff work with the family to determine what is the best option for the child(ren). The child(ren) can be included in each household on every other month, every three months, semi-annual, etc. basis. JOINT POLICY—A life insurance policy that includes more than one person; usually covers both husband and wife and pays out when the first of the insured individuals dies. Also known as a “first to die” policy. JOINTLY OWNED PROPERTY—Presumed to be owned in equal shares by each of the persons holding a legal interest, unless otherwise specified in a legal document such as

a deed or divorce decree. A court-ordered right of ownership takes precedence over any contrary verbal claim or stipulation on any document. JOINT TENANCY—Each tenant has undivided interest in the whole of the property. Upon the death of one of the tenants, the undivided interest in the property reverts to the surviving tenants. Any real property can be divided. Refusal of one party to sell does not create an excluded resource. The real property may be partitioned and is a countable resource to the applicant. JUDGMENT PAYMENTS—Per capita payments distributed to enrolled members of Indian tribes as a result of a lawsuit made against the United States Government. Such funds, as well as the interest they accrue, must be excluded from income and resources. K KEOGH—A tax deferred pension or plan for a self-employed individual to set aside money now for their needs after retirement. KNOWLEDGEABLE SOURCE—A person who has a considerable degree of familiarity of an individual or subject which has been gained through experience of or association with the individual or subject; a person who is professionally aware of the value of the property in the community or general area. For example, a real estate broker is a knowledgeable source on real property values; a person in the business of buying and selling contracts for deeds is a knowledgeable source on values of contracts for deeds. L LAPR—Lawfully Admitted to the United States for Permanent Residence LIEAP—Low Income Energy Assistance Program LTR - Lawful Temporary Resident LAWFULLY RESIDING— As relates to immigration, someone who is lawfully present and meets state residency rules. LEASE INCOME—Payment distributed in accordance with a lease agreement. LEGAL RECORDS—Documents of transactions conforming to or permitted by law. LEGALLY OBLIGATED—Court-ordered LEVEL OF CARE DETERMINATION—A determination completed by a department- designated entity resulting from an assessment of functional abilities, psychosocial needs and medical conditions verifying the need for long term care services (institutional or home and community-based services). LIEN—A security interest or claim upon real or personal property to ensure satisfaction of a debt. The lien amount must be paid up in order for title to property to be transferred from one owner to another. LIFE ESTATE--An interest in real or personal property that is limited in duration to the lifetime of its owner or some other designated person(s). A life estate is personal property, even when it is the right to use real property owned by others. LIFE INSURANCE—A contract (policy) where the policy owner pays premiums during his/her lifetime and the company pays the face value of the policy to the beneficiaries upon the death of the insured.

LIMITED LIABILITY COMPANY (LLC) - A business structure where owners have limited personal liability for an LLC’s debts and actions; like partnerships as there is management flexibility and pass-through taxation. LLC owners are called members. LIQUID RESOURCES—Cash and other non-cash resources that can be readily converted to cash. Examples of resources that are ordinarily liquid include (but are not limited to) stocks, bonds, mutual fund shares, promissory notes, mortgages, life insurance policies, and financial institution accounts. LIVING ARRANGEMENT—For Medicaid purposes, the situation in which an individual or couple is living, i.e. living independently, living in the household of another or living in a medical institution. LOAN—A transaction in which money is given to another and must be repaid. See also ‘Valid Loan’ LOAN VALUE—See “Cash Surrender Value” LOCAL SCREENING COMMITTEE—Statewide committees of representatives (designated by the Developmental Disabilities Program) responsible for placement decisions when intensive service openings occur. The committees review minimal needs and services for individuals accepted for intensive services to be used by the Individual Habilitation Planning Team in developing the plan of care. LOOKBACK- The period of time prior to the first date of eligibility determination in which eligibility requirements are to be evaluated. LONG TERM CARE—Extended medical care received on an in-patient basis. LUMP SUM PAYMENT—A payment of earned or unearned money; the total amount less (1) legal fees required to make the money available; and (2) the amount designated to the payer or source for medical expenses. Earned or unearned nonrecurring income considered as income in the month received, if the payment can be prospected. Becomes a resource to the extent retained in following months. M MA—Medicaid MAO—Medicaid Only MCA—Montana Codes Annotated MEDS–Medicaid Eligibility Disability Services MIMS–Montana Income Maintenance System MISTICS–Montana Integrated System to Improve Customer Services. The Montana DLI on-line system available to eligibility system users to verify unemployment insurance benefits. (Replaced with MUSE) MMIS–Medicaid Management Information System MNIL–Medically Needy Income Level MPQHF–Mountain Pacific Quality Health Foundation. MPQHF is the contractor to Montana Medicaid for both nursing home level of care screening and Medicaid travel. Also known as “The Foundation.” MQT–Medicaid Qualifying Trust MSH—Montana State Hospital (formerly known as Warm Springs State Hospital) MAINTENANCE—Providing the supplies or funds needed to live on.

MATERIALLY PARTICIPATES—Income earned is a direct result of the individual’s physical labor, services or goods produced; the individual is responsible for all aspects of the business; and income generated is directly related to the amount of time and effort the individual participates in the business. MEDICAID—The program that pays eligible individuals covered medical expenses MEDICAL INSTITUTION—An establishment organized to provide medical care (including nursing and convalescent care) by professional personnel in accordance with state licensing standards. Medical institutions include institutions for intellectual disability, mental disease and tuberculosis, or nursing homes. MEDICALLY FRAIL – Medically frail means an individual who is blind or disabled (as defined in section 1614 of the Social Security Act); or Has a physical, intellectual, or developmental disability that limits their ability to perform one or more activities of daily living (ADL); or Has a substance use disorder; or Has a disabling mental disorder; or Has a serious or complex medical condition, AND the individual's disability, disorder, or condition significantly impairs their ability to consistently work or participate in community engagement activities. MEDICALLY NECESSARY SERVICE—A service or item reimbursable under the Montana Medicaid program that is reasonably believed to prevent, diagnose, correct, cure, alleviate, or prevent the worsening of conditions that endanger life, cause suffering or pain, result in illness or infirmity, threaten to cause or aggravate a handicap or cause physical deformity or malfunction. A service or item is not medically necessary if there is another service or item that is equally safe and effective and substantially less costly including, when appropriate, no treatment at all. Experimental services or services that the medical profession generally regards as unacceptable treatment are not medically necessary for Medicaid purposes. Experimental services are procedures, items and prescribed drugs the U.S. Department of Health and Human Services (DHHS), Medicare program or the department's designated review organization considers experimental or investigational or procedures and items approved by the U.S. DHHS for use only in controlled studies to determine the effectiveness of such services. MEDICALLY NEEDY (MN) - An individual or couple that is otherwise eligible for Medicaid, but whose income exceeds the benefit standard for the categorically needy coverage. A medically needy case may or may not have a spend-down. MILITARY ALLOWANCES—A Family Subsistence Supplemental Allowance (FSSA) is paid to eligible service members and their families by the Department of Defense. The amount of FSSA is shown on the members’ Leave and Earnings Statement (LES). The Military Basic Allowance for Housing (BAH) is an allowance to offset the cost of housing for service members who do not receive government- provided housing. The BAH is based on civilian rental costs by paygrade, dependency status, and housing compensation based on comparable civilian housing costs. MINERAL RIGHTS—The ownership or interest in land below the surface. MINOR CHILD–ABD: A person who has not yet attained his or her 18th birthday.

ACA/Family: An individual who is under the age of nineteen (19) and is not living with an adult caretaker. See also “DEPENDENT CHILD”. MODIFIED ADJUSTED GROSS INCOME (MAGI) - A household’s adjusted gross income plus any Social Security, interest, and foreign income. MONTANA ACCESS TO HEALTH CARD–A Medicaid recipient’s permanent Medicaid ID card. Possession of the card does not guarantee Medicaid eligibility. MONTH RECEIVED—The benefit month in which money may be available to the applicant or recipient or in which the person will receive the money in-hand. SSA and SSI payments are exceptions to this definition, when the payment is made at the end of a month (usually because of holiday mail) for use during the following month. MUSE – Montana Unemployment Services Environment system (Replaced MISTIC) MUTUAL FUND—A company without fixed capitalization, freely buying and selling its own shares and using its capital to invest in other companies. N NADA—National Automobile Dealers’ Association NH—Nursing home NATIVE HAWAIIAN OR PACIFIC ISLANDER—A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands NAVIGATORS—Individuals trained to provide fair, impartial, and accurate information to assist consumers with applying, clarifying differences between qualified health plans, and helping qualified individuals make informed decisions during the health plan selection process. They also must provide additional assistance to disabled consumer and those with limited English proficiency NEGOTIABLE INSTRUMENT—A written unconditional agreement signed by a person who promises to pay a specific sum of money at a specific time or on demand to the person, company, corporation or institution named on the note. A negotiable instrument may or may not involve the loan of money or goods NET COUNTABLE INCOME—Includes all non-excluded earned income and all non- excluded unearned income, less applicable disregards and deductions NET MONTHLY INCOME (NMI) STANDARDS--(Need Standard) - Levels of net countable income for each size filing unit which cannot be exceeded if the unit is to be eligible NET PROFIT—Gross revenue less allowable business expenses NON-EXEMPT (COUNTABLE) - Income and resources counted, in whole or in part, to determine eligibility. NON-FILER—An individual who does not expect to file a tax return or be claimed as a dependent on someone’s tax return NON-HISPANIC/LATINO—A person who is not Hispanic or Latino according to the definition stated earlier NON-LIQUID RESOURCES—Resources which cannot reasonably be converted to cash within 20 working days. The term may be applied to either real or personal property. A resource which has been determined to be non-liquid for any reason is not considered inaccessible or excluded simply because the value of the asset cannot be accessed in the benefit month NON-RESCINDABLE—Cannot be voided, repealed or annulled

NOTICE OF ACTION— 1. CONTENT Complete Notice —Written notice that includes the action the agency intends to take, the reason for the action, the agency policy and state and federal regulations supporting the action, the right to request a fair hearing, the person to contact for additional information, the availability of continued benefits and liability for such benefits if found ineligible in the hearing decision. 2. TIMELINESS a. Adequate Notice — Written notification as stated above, to be received by the individual no later than the date of action or the date payment would have been received. b. Timely Notice — Written notification as stated above, mailed ten (10) days prior to the date of action. 3. System notices are mailed the working day after they are sent from the system and are not mailed on weekends or holidays. O OJT–On the Job Training OPA–Office of Public Assistance Field Services ON-GOING ELIGIBILITY DETERMINATION—The act of evaluating each open case and finding the case eligible or ineligible. ONE-THIRD REDUCTION RULE—Applies to an applicant or recipient for whom both food and shelter are provided by another household, individual, or entity for a full calendar month. The value of free food and shelter is considered to be one-third of the monthly SSI SPA. OTHERWISE ELIGIBLE—Means the individual is not precluded from eligibility by some other provision of Title IV-A XIX of the Social Security Act and the individual meets all the program requirements. OVERISSUANCE— Benefits received by or for an assistance unit for which that unit was not eligible. OWNER—In the case of a life insurance policy, the person who has the right to change the policy; normally the person who pays the premium. P PAB—Public Assistance Bureau PC—Program Compliance PCA—Program Compliance Auditor PMV—Presumed Maximum Value PPACA—Patient Protection and Affordable Care Act PRUCOL—Permanently Residing Under Color of Law PARENT—A natural, adoptive or stepparent. PARTNERSHIP—Entities with two or more partners; may include both working and silent partners. Partnership agreement defines each partner’s share of income, gains, losses, deductions and credits.

PASS—Plan to Achieve Self-Support. An agreement between a person with a disability or blindness, and Social Security, which allows the individual to set aside income or resources to reach a work goal. PATIENT TRUST ACCOUNT—An account administered by a nursing home or similar facility to accommodate a patient’s individual funds. PATRONAGE DIVIDEND—A dividend or distribution that a co-operative pays to its members or investors. Patronage dividends are given based on a proportion of business profit made and are calculated according to how much each member used the co-op’s services. PAYEE—The person in whose name the benefits are issued. The payee may be the individual to whom the payment is obligated, an eligible or ineligible parent, an eligible or ineligible caretaker relative or a protective payee. PAYMENT—The act of giving a check or warrant to the payee or the legal representative. PENAL INSTITUTION—Any facility in which an individual may be lawfully held against his will by federal, state, tribal, or local authorities. PENSION FUND–An investment account (typically with an employer) that is intended to provide income at retirement. PENSION PAYMENT—A sum of money paid regularly as a retirement or disability benefit. PER CAPITA PAYMENT–Income from Indian-owned property that is distributed equally to all tribal members. This may include Indian casino profits. PER DIEM—Per day; pertains to expenses for cost of meals and lodging. PERJURY—A willful false statement of a material fact; swearing to what is untrue; or, incompletely answering all questions under oath. PERCEPTIVE – Document management system (Replaced DMS) PERSONAL CARE ATTENDANT—An individual who provides daily personal care to qualified Medicaid clients. PERSONAL EFFECTS—Those items of personal property that are worn or carried on the person. Such items include but are not limited to clothing, jewelry, medical prosthetics, recreational equipment, musical instruments, etc. PERSONAL INJURY INSURANCE—A policy purchased from a company whereby the company makes cash payment to the policyholder in the event of proven medical injury or accident. A personal injury insurance policy is one type of indemnity insurance policy. PHYSICAL CARE--The attention given to the physical needs of a child or children. PLAN OF CARE—A written plan of treatment developed on the basis of an assessment and determination of the individual’s needs. POST SECONDARY EDUCATION (PSE)--Attendance at an institution of higher education such as a 4-year college or university, a 2-year vocational technical school, or a proprietary (privately owned and managed) school. PRE-ADMISSION SCREENING (PAS) - A screening that must be completed prior to enrolling in the Home and Community Based Services program or a nursing facility (or prior to Medicaid eligibility while residing in a nursing facility). It consists of a level of care determination and a Preadmission Screening and Annual Resident Review (PASARR).

PRE-ELIGIBILITY VERIFICATION (PEV) - Electronic validation of income and non- financial verifications at initial eligibility. PREMIUM—Amount paid for an insurance contract (policy). PRIMARY BENEFICIARY—For Social Security RSDI benefits, a person who has worked the specified number of quarters and is eligible for retirement or disability benefits in his/her own right. For a trust, the individual(s) who have first right to the benefits of the trust. PRIMARY EVIDENCE—A document or record by an official government agency or public institution that would be accepted in a judicial proceeding as establishing the truth. PRINCIPAL—The capital or main body of an estate or financial holding as distinguished from the interest or revenue from it. PRINCIPAL PLACE OF RESIDENCE—A person’s principal place of residence is the one property in which the individual, the individual’s spouse, or the individual’s dependent (minor or adult) child currently resides, or has resided in within the previous six months, provided they intend to return after temporary absences. A property ceases to be a principal place of residence if the person/family has been continuously residing off the property (including in a residential medical facility) for a period of six months or more. PROGRAM OPERATIONS MANUAL SYSTEM OF THE SOCIAL SECURITY ADMINISTRATION (POMS) - The operating procedures for the programs administered by the Social Security Administration, including SSI. PROGRAM REQUIREMENT—Specifications as to how eligibility factors are to be met. PROPERTY ESSENTIAL FOR PRODUCTION OF INCOME—Can include real and personal property (for example, land, buildings, equipment and supplies, motor vehicles, and tools, etc.) used in a trade or business, non-business income-producing property (houses or apartments for rent, land other than home property, etc.) and property used to produce goods or services essential to an individual’s daily activities. PROPERTY RESOURCES--Real, personal, tangible or intangible assets owned by an applicant or recipient. Property resources include, but are not limited to real property, vehicles, mobile homes, cash, stocks, bonds, savings accounts, the cash value of life insurance, and recreational equipment. PROPORTIONAL INTEREST—When there are two or more owners of real property, the property may be divided into equal or unequal shares (three individuals may own a whole property with the ownership interests being 50%, 25% and 25% respectively). PRORATE—Divide or distribute benefits proportionally based on number of days eligible. PROSPECTIVE OR PROSPECTED BUDGETING—Using the best estimate of the income and circumstances that may exist in the benefit month to determine eligibility and compute countable income. PROTECTIVE PAYEE—The person, other than the individual to whom the payment is legally obligated, to whom payment is made and who is managing the funds for the purpose of safeguarding the health and welfare of the person to whom the payment is legally obligated. PROVIDER—A person or business who provides goods or services to clients; usually a medical provider (e.g., physician, hospital, etc.)

PUBLIC (NON-MEDICAL) INSTITUTION—An institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control. Q QA—Quality Assurance QA REVIEWER—Quality Assurance Reviewer. This is a regional reviewer position. QC—Quality Control (a.k.a. Program Compliance) QDWI—Qualified Disabled Working Individual QHP—Qualified Health Plan under ACA QI—Qualifying Individual QMB—Qualified Medicare Beneficiary QPEP—Qualified Presumptive Eligibility Provider QUALIFIED ENTITY (QE) - An employee of a Montana health care facility trained to make Presumptive Eligibility determinations (QPEP). R RAC—Refugee Assistance Center RCA—Refugee Cash Assistance RMA—Refugee Medical Assistance R & R--Resource and Referral Agency RSDI—Retirement, Survivors and Disability Insurance REAL PROPERTY—Land and buildings or immovable objects permanently attached thereto. REASONABLE EXPLANATION- Any information the individual has to explain away the discrepancy in their self-attested income vs the income found in our interfaces. REASONABLY CURRENT—Information is considered reasonably current if the household or individual has verified income, resources, or other eligibility information within the last six (6) months and no changes have been reported or discovered at redetermination. RECIPIENT—A person who is eligible for and receiving benefits including a person who is under a program disqualified action. RECONCILE—To compare two events and adjust for the difference. REFUGEE—An alien who has been admitted to the United States under the classification of refugee. This person is required to carry a Form I-94 endorsed to show refugee status. Employment is permitted. REGIONAL PROGRAM OFFICER—A Department employee who represents the Community Services Bureau (Senior and Long-Term Care Division) for a district locality. REGULAR MEDICAID—Standard Medicaid coverage; not QMB, SLMB or QI. REMEDIAL EDUCATION—Training necessary to raise an individual’s functional educational level to the point at which they can successfully enter employment. RENEWAL—Periodic review of all financial and non-financial eligibility criteria that is subject to change. RESCIND—To make void; repeal or annul. RESIDENT—A person who states intent to reside in Montana, who is present in the State (or temporarily absent for a reason other than establishing residence in another state),

and who is not receiving assistance from another state or claiming residence in another state. RESIDENT OF A MEDICAL INSTITUTION—An individual living in a residential medical institution to receive professional services under a physician’s direction for maintenance, improvement or protection of health (e.g., a nursing home resident). RESOURCE LIMIT—The maximum amount of countable resources the filing unit can own, have access to or be a beneficiary of, and still remain Medicaid eligible. RESOURCES–Resources include but are not limited to all real and personal property owned by a person, as well as money or any property that can be converted into supplies, services or benefits; the means of raising money or supplies; the capabilities of raising wealth to supply necessary wants or needs; or the available means or capability of any kind. RETROACTIVE—To make effective as of a date prior to enactment. REVOCABLE—Can be amended, cancelled or terminated. ROOM AND/OR BOARD INCOME—Money received for providing meals and/or rooms to people not included in the filing unit. ROOMER—An individual living with a household and paying for lodging, but not meals. ROYALTY—Payment to the owner of a copyright, patent or mineral right. S SAVE— Systematic Alien Verification for Entitlement SCORE—Service Corps of Retired Executives SDMI—Severely Disabling Mental Illness SDX—State Data Exchange SEOG—Student Education Opportunity Grant SLMB—Special Low-Income Medicare Beneficiary SNF—Skilled Nursing Facility SOLQ—State Online Query. Montana’s access to Social Security Administration information. SPA—Standard Payment Amount (for SSI) SSA—Social Security Administration SSDI/SSDIB—Social Security Disability Insurance Benefits SSI—Supplemental Security Income SSIG—State Student Incentive Grant SSN—Social Security Number SSP—Self Service Portal SUA—Standard Utility Allowance SELF-ATTESTATION—The client’s sworn statement verifying the accuracy of information they provide, (such as income, household size, and residency) as reported on the application or as a change; may be verbal, electronic or in writing. SELF-EMPLOYMENT—The act of engaging in a trade or business with the goal of earning a profit. As long as a profit motive exists, the business doesn’t actually have to make a profit to be considered self-employment.

SKILLED NURSING FACILITY—A nursing home licensed by Medicare to provide residential medical services to patients that require a level of medical care as defined in Federal regulations. SOLE OWNERSHIP—When property is owned wholly and completely by one individual or entity, other than liens and other legal encumbrances. SPECIALIZED FAMILY CARE REVIEW PANEL (SFCRP) - A state level panel of representatives designated by the Developmental Disabilities Program for determination of level of care for children referred to Specialized Family Care services. The panel prioritizes children for the services according to need and reviews proposed minimal needs and services, to assist in administrative selection decisions for service openings. SPECIFIED CARETAKER RELATIVE—An adult (age 19 or older) living with the dependent child who is related to the child as: 1. Father, mother, grandfather, grandmother, brother, sister, uncle, aunt, first cousin, nephew, niece; or persons of preceding generations denoted by prefixes of “grand”, or “great”; first cousin once removed, 2. Stepmother, stepfather, stepbrother and stepsister, 3. One who legally adopts a child or his parent, as well as the natural and other legally adopted children of such persons, or 4. Spouses of any person mentioned above even though the marriage may have been terminated by death or divorce. SPEND DOWN—That portion of a medically needy recipient’s income that exceeds the Medically Needy Income Level for the filing unit size; the amount of medical expenses the individual is responsible for before Medicaid will begin paying any medical bills. SPOUSE—One who would be defined as married under applicable State (or tribal) law where the individual resides. May include a common-law spouse. STANDARD PAYMENT AMOUNT—The SSI monthly cash payment standard for qualifying individuals or couples. STEPPARENT—The spouse of the natural or adoptive child’s parent. STRAIGHT LIFE INSURANCE POLICY—See “Whole Life Insurance Policy.” STRIKE—Any concerted stoppage of work by employees, including a stoppage by reason of the expiration of a collective bargaining agreement, and any concerted slow- down or other concerted interruption of operations by employees. STUDENT—ACA: A disabled individual under age 22, or a non-disabled dependent child under age 21 who is in a college or university at least 8 hours per week, or in grades 7- 12 for at least 12 hours per week, or in a training course preparing for a paying job for at least 12 hours per week (15 hours if shop practice is involved), or for less time than indicated for reasons beyond the student‘s control such as illness, the nature of his/her disability, or lack of transportation. A dependent child attending school. Community engagement requirement: An individual enrolled in secondary, post- secondary, or vocational programs at least halftime. SUBSIDIZED--Support with partial financial payment by a governmental agency. SWING BED—A temporary bed for long term care in an approved hospital when a nursing home bed is not available within a 25-mile radius. T

TANF—Temporary Assistance for Needy Families TC—TANF Cash Assistance TMA—Family-Transitional Medicaid (Transitional Medicaid) TPL—Third Party Liability TPQY—Third Party Query TASK - A system reminder to the worker to reevaluate case circumstances. TAX DEPENDENT—An individual whom the Internal Revenue Service (IRS) considers to be a dependent TAX FILER—An individual who expects to file a tax return for the initial determination or renewal year and who does not expect to be claimed as a tax dependent by another taxpayer TAX YEAR—The year on which the income taxes are based, usually the calendar year. TEMPORARY ABSENCE—The condition created when a household member is away from the home for a specified period of time not to exceed 90 consecutive days. Individuals receiving medical services remain eligible and are not subject to the 90 days return to the home requirement. ACA/Family: If the absent member is a child, the caretaker relative must continue to exercise the responsibility for the care and control of the child. Children attending school away from home remain eligible and are not subject to the 90 days return to the home requirement. TENANCY BY THE ENTIRETY—The tenants are always husband and wife, and each has an undivided interest in the whole of the property. When the husband and wife are an aged/blind/disabled couple or a blind/disabled child’s deemed parents, the equity in the property is a countable resource. When one spouse is not financially responsible for the other (see MA 601-2), is not a deemed parent or an alien sponsor, only one-half of the equity is a countable resource to the spouse whose resources are being used to determine Medicaid eligibility. TENANCY IN COMMON—Each tenant (owner) has undivided possession of a distinct interest in, and title to, the whole of the property. Upon the death of one of the tenants, the interest in and title to the property descends to his/her heirs. When an individual is a tenant in common, the equity is the individual’s proportionate interest of the whole is a countable resource. Proportionate interest of the whole is not always one-half when there are two tenants or one-third when there are three tenants. Equity must be verified. TERM INSURANCE—One of the two basic types of life insurance policies. The owner pays premiums for a specified period and the insurer agrees to pay the face value of the policy only if the insured dies within the time specified by the policy. The face value of term life insurance may decrease over the life of the policy or remain static. This type of life insurance has no cash surrender value and is not a resource to the owner, the insured or the beneficiary. TERMINATION—To close a case and/or remove an individual from program eligibility. THIRD PARTY LIABILITY (TPL) - The legal liability of a third party to pay for services provided. A third party is any individual, entity or program that is or may be liable to pay all or part of the medical expenses

THIRD PARTY—Any individual, entity or program that is or may be liable to pay all or part of the medical costs of injury, disease or disability of an applicant or recipient. TIME DEPOSIT—A contract between an individual and a financial institution where the individual deposits funds for a specified period of time. TRANSFER DATE—The date on which delivery is made on a valid transfer. TRANSFER OF PROPERTY—Giving to another the legal or individual proportionate right or title to real or personal property or a stream of income. Transfers to joint tenancy or to tenancy in common are included in this definition. Includes such actions as selling property, giving property away, establishing a trust, contributing to a charity or other organization, removing one’s name from a joint bank account, adding another’s name to a deed or account, or forgiving a debt. TRANSPORTATION—Travel by public conveyance or private vehicle to secure medically necessary examination and treatment. Transportation does not include ambulance service or specialized transportation for the disabled. TRIAL WORK PERIOD—A period during which an SSI or SSDIB recipient may test his/her ability to work. During this period, the person is considered disabled. TRUST—Any arrangement in which a grantor transfers property (real or personal) with the intention that it be held, managed, or administered by a trustee(s) for the benefit of the grantor or other beneficiary(ies). Trusts are managed by individuals or entities with fiduciary obligations and may include (but are not limited to): 1. escrow accounts, 2. investment accounts, 3. future medical care accounts, and 4. other similar arrangements. A trust may or may not include the word “trust” in the document. TRUST BENEFICIARY—The individual designated in the trust instrument as benefiting in some way from the trust. The beneficiary can be the grantor or another individual. The beneficiary is sometimes referred to as the “beneficial owner” and has a “beneficial interest” in the trust. TRUST GRANTOR—The entity that creates the trust. The grantor may be any person, including a court or administrative body, with legal authority to act on behalf of the individual; or any person, including a court or administrative body, acting at the direction or request of the individual (aka the donor or trustor). TRUST PRINCIPAL—The real or personal property that is the object of a trust. TRUSTEE—Any individual(s) or entity (e.g., an insurance company or bank) that manages a trust and has fiduciary responsibilities. Sometimes referred to as the fiduciary or fiduciary owner. TRUSTOR—The entity that creates a trust. The trustor (a.k.a. “grantor”) may be any person or entity, including a court or administrative body, with legal authority to act on behalf of the individual or any person, including a court of administrative body, acting at the direction or request of the individual (aka Grantor). U UC or UIB—Unemployment Compensation or Unemployment Insurance Benefits USCIS—United States Citizenship & Immigration Services (formerly INS)

UNCOMPENSATED VALUE—The current market value of a resource minus the amount of compensation received by the individual in exchange for the resource (if less than the current market value). UNEARNED INCOME—All money received that is not earned by providing goods or services (work). Unearned income includes, but is not limited to gifts, Social Security benefits, Veterans’ benefits, Workers’ Compensation payments, Unemployment Compensation payments, and returns from capital investments in which the individual himself is not actively engaged. UNPAID PRINCIPAL—The amount that remains to be paid on an agreement or loan. UTILITIES—The services provided for water, sewer, electricity, garbage, telephone, and heating fuel. V VISTA—Volunteers in Service To America VR—Vocational Rehabilitation VALID LOAN—A loan where the borrower expresses either orally or in writing an obligation to repay the lender. Repayment cannot be contingent on the occurrence of an uncertain event. VEHICLE—Any conveyance used to provide transportation. VENDOR—The person or business that provides goods or services. See also, “Provider.” VERIFY—To check, confirm or establish whether a statement or condition is true or accurate by obtaining a copy, viewing a copy or obtaining a verbal description of the evidence. VERIFY LAWFUL PRESENCE (VLP) - Interface with the Department of Homeland Security that verifies immigration status for Medicaid/ HMK applicants. W WIC--Women, Infants and Children Program WIOA--Workforce Innovation and Opportunity Act WAGES—Payment for services to a worker; remuneration on an hourly, daily, or other periodic basis or by the piece. WARRANT--The written document (check) that authorizes the State of Montana to pay the stated amount to the specified person and which authorizes receipt of the payment. WHOLE LIFE INSURANCE POLICY—One of two basic types of life insurance policies where the owner pays premiums during his/her lifetime and the insurer pays the face value of the policy to the beneficiaries upon the death of the insured. Usually has a cash surrender value after a period of time. Also referred to as “straight life” insurance. WHITE—A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. WINDFALL—See lump sum payment. X Y Z Revised Date: 07/01/2026

COMBINED MEDICAID 101-1 Confidentiality Supersedes: MA 101-1 and FMA 101-1 (07/01/04) Reference: 42 CFR 431.300, .303, .305, .306; ARM 37.82.101 Overview: The Department of Public Health & Human Services (DPHHS) may share client information for purposes directly connected with the administration of the Medicaid programs with other federal programs and certain entitled entities. The client’s confidential information may be released without notice to or permission of the client, for the following purposes: 1. Reporting child abuse and neglect to the appropriate authority (MCA 41-3-205) if it pertains to the administration of the Medicaid program; 2. Conducting child support activities; and 3. Establishing eligibility and administering (including audits, investigations, prosecutions, etc.) Medicaid programs share only the minimum amount of data necessary to gather accurate information needed. 4. Reporting elder abuse and neglect to the appropriate authority, IF it pertains to the administration of the Medicaid program, reporting only name/age, alleged abuse/abuser, and perhaps an address, but certainly no financial data. Requests for information about current or past clients which do not meet the above criteria must be submitted in writing to the HCSD, Central Office. When there is a question about a breach of confidentiality, Central Office staff refers the request to the Office of Legal Affairs. NON-AGENCY PERSONNEL: Non-agency employees may conduct interviews or certify applicants when specifically allowed under federal regulation (e.g., federally declared disaster). Volunteers or others who are not employed by DPHHS may not determine eligibility. However, they may assist in related activities such as: 1. Obtaining necessary information; and 2. Helping applicants complete the application form. Non-agency personnel are restricted from disclosing confidential information. RELEASE TO LAW ENFORCEMENT:

No information regarding clients may be released to federal, state or local law enforcement officers without subpoena. If information is subpoenaed, contact DPHHS Office of Legal Affairs for further information and guidance. EMERGENCY SITUATIONS: When information is necessary to provide emergency medical care, the information must be released. As soon as possible thereafter, the client must be notified of the release of information. RELEASE TO CLIENTS: The client may review all information in the case file which was considered when making an eligibility determination. Privileged information, such as the name of individuals who have disclosed information about the household without the household's knowledge or the nature or status of pending criminal prosecution, may be withheld. The agency must also make available, without charge, the specific materials necessary for a household or its representative to determine whether a fair hearing should be requested or to prepare for a hearing. Medical documentation provided from any other source cannot be shared with client. Only medical documentation that the client provided can be returned to the client. Information gathered from DPHHS access to a query system from another agency (such as SOLQ, Dept. of Justice, MISTICS, CSED, SEARCHS, Vital Statistics, etc.) may not be released to the client for any purpose. RELEASE TO OTHERS: The same information that can be released to the client may be released to individuals outside the household in situations other than those already described only if the head of household, the spouse or other person authorized by the household provides a written HIPAA-compliant authorization to release information. HPS-402 is the Department-approved HIPAA-compliant authorization form. It is given to individuals who want to authorize release of their Medicaid records to others. NOTE: Certain types of information cannot be released by the Department, even with client authorization. This includes information such as birth control and psychiatric records. AUTHORIZATION TO RELEASE INFORMATION HCS-101: This form is used to assist the client in obtaining information necessary to determine eligibility. HCS-101 explains the client’s rights to confidentiality and gives the client the option of either authorizing or declining to authorize the release of information. As the authorization expires one year from the signature date, it must be completed at application and yearly thereafter. The client always has the right to rescind the authorization in writing. Because an individual cannot waive another’s right to confidentiality, each adult household member is given the opportunity to review and sign the HCS-101. NOTE: Signing the HCS-101 is not a condition of eligibility.

Effective Date: July 01, 2016

COMBINED MEDICAID 102-1 Civil Rights

Supersedes: FMA and MA 102-1 (01/01/07) Reference: MCA 49-2-308; ARM 37.78.102 and 37.82.101; Section 1557 of Affordable care Act

Overview: State and County staff shall not discriminate against any applicant or participant in any aspect of the program administration for reasons of race, color, national origin, age, disability, sex or disability.

RIGHT TO FILE A COMPLAINT Individuals who believe that they have been subject to discrimination can file a complaint in writing by mail, fax, e-mail, or via the Office for Civil Rights (OCR) Complaint Portal.

Office for Civil Rights 1961 Stout Street, Room 08-148 Denver, Colorado 80294 Phone: 303-844-7815 Email: ocrmail@hhs.gov Complaint portal web address: https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf [ocrportal.hhs.gov]

-OR- Civil Rights Coordinator Human and Community Services PO BOX 4210 Helena, MT 59604

COMPLAINT REQUIREMENTS Any individual wanting to file a discrimination complaint shall be advised immediately of their right to do so and shall be given the necessary information (listed below) to file the complaint. When an individual asks for assistance with the complaint filing process, DPHHS staff shall assist the individual.

A complaint must be filed no later than 180 days from the date of the alleged discrimination. All complaints shall contain the following information: 1. The name, address, telephone number, and email or other means of contacting the person filing the complaint. 2. The name and location of the organization or office accused of the discriminatory practice. 3. A description of the alleged discrimination incident. 4. The reason for the alleged discrimination (race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity). 5. The names, titles (if appropriate) and addresses of individuals who may have knowledge of the alleged discriminatory acts. 6. The date(s) the alleged discriminatory action(s) happened.

Language assistance services for OCR matters are available and provided free of charge. OCR services are accessible to persons with disabilities.

If a complainant makes allegations verbally and is unable or is reluctant to put the allegations in writing, the State employee to whom the allegations are made shall document the complaint in writing. Every effort shall be made by the individual accepting the complaint to have the complainant provide the information specified in 1- 6 above.

FIELD STAFF RESPONSIBILITIES 1. Inform individuals of their right to file a civil rights complaint with DPHHS. 2. Describe the process to everyone expressing an interest in filing a complaint. 3. Advise individuals of their right to file a complaint and that any complaint filed with the State Office is forwarded to the appropriate Federal Office for investigation. 4. If the individual indicates they will submit a complaint directly to the OCR (Office for Civil Rights) or State Agency, field staff will send an email to their direct supervisor within 1 business day alerting him/her that there is a potential civil rights complaint being submitted by the client – email must include the case number and brief description of the potential complaint. 5. If the individual makes verbal allegations and is reluctant to put their complaint into writing, field staff should attempt to obtain all required information from the client, document the complaint in writing and send this documentation to their direct supervisor within 1 business day. 6. Assure all complaints meet the requirements stated above. 7. Respond promptly to any requests from management regarding the complaint and include your direct supervisor in any responses. 8. Do not engage in any further discussion with the client about the complaint. If the client initiates additional conversation, assure them that they will hear from the

agency they submitted their complaint to within 10 business days and inform your direct supervisor of the discussion.

SUPERVISOR RESPONSIBILITIES 1. Acknowledge receipt of the information and remind staff member to not engage in any further discussion with the client regarding the complaint. 2. Forward information to Policy Bureau Chief within 1 business day of receipt. 3. Respond promptly to any requests from management regarding the complaint and include your direct supervisor on any response. 4. Train all staff involved with administering Medicaid on an ongoing basis about civil rights requirements. 5. Ensure all offices involved in determining eligibility or issuing Medicaid benefits display nondiscrimination posters approved or provided by OCR, 6. Provide bilingual Medicaid services in areas with a significant proportion of non- English or limited English-speaking persons. 7. Provide Language access services when needed.

CENTRAL OFFICE & CIVIL RIGHTS COORDINATOR RESPONSIBILITIES 1. Policy Bureau Chief will communicate complaints received with the Civil Rights Coordinator and DPHHS legal team. 2. Copies of complaints are sent to the Regional Office for Civil Rights within five days of receipt. 3. Publicize the federal procedures for filing a complaint regarding discrimination. 4. Respond to requests for information regarding nondiscrimination statutes and policies, complaint procedures, and the rights of clients within 10 days of the date of the request. 5. Include a nondiscrimination statement on all program informational material. 6. Ensure all graphics for Medicaid information convey the message of equal opportunity by displaying clients of different races, colors, sexes, and national origins. 7. Acknowledge receipt of any civil rights complaints received within five days and advise the complainant of the action(s) planned with a copy (cc) to the Office of Public Assistance (OPA). 8. Maintain a log of all complaints received including complainant's name, date of incident, date of complaint, basis of complaint, and the resolution of the complaint including the date of resolution. Forward the associated records to OCR prior to issuing a final disposition of the complaint. 9. Maintain a file of all discrimination and general complaints for review by federal and state reviewers. 10. Train all staff involved with administering Medicaid on an ongoing basis about civil rights requirements. 11. Inform households and grassroots Medicaid organizations of program changes OTHER COMPLAINTS:

Complaints, other than Civil Rights complaints, such as processing delays or general service, must be investigated and resolved by the: 1. Eligibility Supervisor, 2. Field Operation Manager, or 3. Regional Field Manager.

RACIAL/ETHNIC DATA COLLECTION

DPHHS obtains data on MEDICAID recipients by racial/ethnic category. Applicants are requested to voluntarily provide their race or ethnicity on application forms. The application form must clearly indicate that the information is voluntary, that it will not affect the eligibility or the level of benefits, and that the reason for the information is to assure that program benefits are distributed without regard to race, color, or national origin.

Effective Date: November 15, 2024

COMBINED MEDICAID 102-2 General Complaints Supersedes: ABD and FMA 102-2 (08/01/00) Reference: Overview: Federal law requires states to maintain a system for handling general program complaints filed by clients, potential clients, or other concerned individuals or groups. This does not include complaints alleging discrimination based on the protected classes outlined under Civil Rights law, or complaints that can be pursued through the fair hearing process. A general program complaint is any complaint regarding areas such as processing standards, or customer service to clients and potential clients. Complaint logs need to contain the following minimum information: • Name, address and phone number or other means of contacting the complainant. • Name and location of the organization, office, or person the complaint is against. • The date(s) on which the action causing the complaint occurred. • The reason for the complaint. • The action taken and the resolution or disposition of the complaint. Effective Date: July 01, 2016

COMBINED MEDICAID 103-1 Application, Eligibility Determination & Furnishing Assistance

Supersedes: CMA 103-1 (11/15/2024) Reference: 42 CFR 435.905-909, .911-914, .916(b)(2)(iii); .945-.956, 42 CFR 457.330; ARM 37.82.101, .201, .204-.206, & .904 Overview: Anyone who wants to apply for Medicaid must have the opportunity to do so without delay. Applications must be voluntary and initiated by the person in need, their authorized representative, or if the applicant is incompetent or incapacitated, someone acting responsibly for them. If the applicant voluntarily withdraws the application, document in case notes with the withdrawal reason and send About Your Case’ denial notice. APPLICATION FORM: The application must be a form prescribed by the Department, or a single streamlined application for all insurance affordability programs developed by the U.S. Department of Health and Human Services. The applicant must attest to the truth, accuracy, and completeness of the information provided and declare that they understand that any misinformation will be investigated and prosecuted. APPLICATION DATE: Unless received after hours, the Medicaid application date is: • Paper application: date the signed application or first page is received and date- stamped in a field office or central scanning. • Faxed application: date of the fax, or if received on a weekend or holiday the next business day • Online application: date the application arrives in the online application mailbox. • Telephonic application: date the client completes the telephonic application. All applications (paper, fax or online) received after normal business hours, are considered received and date-stamped with the following business day’s date.

PLACE OF APPLICATION: Individuals can apply at any field OPA, by mail, telephone or online. Field offices must allow individuals to drop off or pick up applications at any time during regular working hours and days, including the lunch hour. COMPLETE APPLICATION: Applicants can submit a signed first page of an application to establish their application date. Medicaid cannot be approved or authorized until a completed and signed application is received. RECEIVING MEDICAID IN ANOTHER STATE: Medicaid must be closed in the state the client moved from before a Montana Medicaid application can be approved. Medicaid can only overlap for a one-month period when a person moves to Montana and was receiving Medicaid in another state. ELIGIBILITY INVESTIGATION: A signed application authorizes an investigation to determine eligibility. Investigations include securing reasonably available information (e.g., income statements, medical bills, etc.) and gathering information from other sources including Universal Inquiry. The agency’s goal is not to prove or disprove eligibility, but rather to investigate information, determine eligibility if enough information is present, and render a decision. ELIGIBILITY DETERMINATION: Each decision is supported by facts documented in the case file, and a decision is rendered in each case within: • 90 days for applications requiring a disability determination; and • 45 days for all other applications. Time frames begin on the application date and end the day a decision notice is mailed to the applicant/authorized representative. These time frames are not used as waiting periods before determining eligibility. Once necessary information is submitted, the agency cannot delay the eligibility determination. The time frames are limits on the agency, rather than allowances for the agency. Medicaid cannot be denied simply because necessary verification is not provided within 45 days (or 90 days, as applicable) of the application. These timeframes can be extended based on continued communication with the client. See ‘Extension Requests’ below.

EXTENSION REQUESTS: As long as the individual is making appropriate attempts to obtain verification and requests an extension prior to the 45th or 90th day timeframe, 15-day extensions are granted. Additional extensions must be requested prior to the current extension expiration date. Case note all contact(s) with applicant and their attempts to obtain information. A new 15 day notice is needed each time the agency grants an extension and should list any outstanding verifications required. WAIVING TIMELY DETERMINATION: The 45-day processing time frame may be extended if the agency is unable to make an eligibility determination because of circumstances beyond the agency’s control (e.g., the applicant is having problems obtaining necessary verification). The agency is not obligated to extend this 45-day period if the applicant has failed to respond (without good cause) in a timely manner to the county’s request for documentation and verification necessary to determine eligibility. All processing delays must be fully explained and documented in case notes. Each extension requested by the applicant and granted by the agency must be documented with a new 15-day notice to the applicant. ELIGIBILITY START DATE: Eligibility begins the first day of the application month for applicants who are: 1. Categorically needy; or 2. Medically needy and choose and pay the 'cash option' or 3. Eligible for MWD and pay the cost share. For medically needy applicants who choose to use incurred medical expenses to meet the spend down obligation, eligibility begins the day the client has enough medical expenses to meet the spend down. This may or may not be the first day of the month. NEW COVERAGE REQUEST: A request to add another household member to an existing/open Medicaid case is considered a new “coverage request”; a new application cannot be required. The new "coverage request" is considered a reported change and is subject to change reporting timeliness requirements. When a household reports a new household member, the household must be given only 15 days from the "coverage request date" to provide information necessary to determine the individual's eligibility, as well as to redetermine eligibility for the existing household members' continued eligibility, which may be affected by the addition of the new household member.

A denial notice is sent for the new and/or existing household member if adequate information to determine their eligibility is not provided within the 15-day period, as well as a closure notice for any existing household members whose eligibility cannot be determined without the information about the new household member. The new "coverage request" is not considered a new application, as Medicaid is already open for some household members. The “application date” for an additional program or person is the date the coverage request is received. CHANGES BETWEEN MEDICAID PROGRAMS: If a recipient of one Medicaid program requests a change to another Medicaid program, a new application CANNOT be requested or required. If the case file contains sufficient information to determine eligibility for the new program, no additional information is requested. A redetermination/renewal form may be used to gather information, although failure to complete a redetermination form is not a reason for denial if all necessary verification is provided. In the case of changes to HCBS waiver or institutionalized Medicaid, use of HCS-463, "Nursing Home Redetermination" form is recommended in order to gather information about asset transfers during the look back period. When someone who is in the home (or joins the household) but not receiving Medicaid (such as a parent) requests Medicaid coverage, a new application cannot be required as long as there are other family members receiving Medicaid at the time coverage is requested. If an individual joins the household, the household composition change must be reported. Eligibility factors are evaluated according to the program requested. The following may be used to report this change: 1. HCS-261A (Adding a New TANF or Medicaid Household Member); 2. HCS-272M (redetermination/renewal form); 3. HCS-260A (change report form); 4. Self-Service Portal, ‘Report My Changes’; or 5. Verbal report, either in person or by phone EX PARTE REVIEW: When an open Medicaid case is closed for any reason other than at the request of the recipient, the case must be reviewed for eligibility for other Medicaid programs. This process is referred to as an exparte review and must be case noted for each Medicaid closure. Whenever possible, an exparte review should be based on the information already available in the existing case file. However, if changes have been reported but not verified by the household, if additional eligibility factors must be evaluated for other

Medicaid programs, or if financial information in the case file is not reasonably current, verification of the additional or updated information must be requested from the household or obtained by the eligibility case manager before the exparte review is completed. It may be helpful to obtain a completed Medicaid redetermination form from the household to use as a tool in determining eligibility for other Medicaid programs. However, the household's failure to complete and return a completed Medicaid redetermination form in an exparte process is not a basis for denial of Medicaid benefits. If the case is found to be eligible for another Medicaid program during an exparte process, the "new" Medicaid program should be opened. The household must not be instructed or required to reapply for benefits before the "new" Medicaid program can be opened. Before opening a medically needy program, contact the client to determine if a need exists. If the household fails to provide proof of previously reported changes or the eligibility staff member is unable to obtain the verification independently, the exparte review is considered complete. Case note the exparte process and the outcome. PROVIDER NOTICE OF ELIGIBILITY DETERMINATION: Providers can bill and receive payment for services up to 365 days after the date Medicaid eligibility is authorized, or the date of services, whichever is later. When the 365-day billing window has expired (or is nearly expired) prior to Medicaid authorization, the eligibility staff member creates and sends the provider notice of eligibility determination notice to known providers. The provider notice of eligibility determination may also be used when eligibility is approved retroactively. Certain services (such as ambulance services or psych-related services) require pre- authorization. If Medicaid is not authorized prior to the date of service, a provider notice of eligibility determination notice is required for the provider to receive Medicaid payment. The notice is not completed when: 1. Medicaid was open at the time of service, but the provider failed to bill timely, or 2. The Medicaid client did not tell the provider he/she had Medicaid coverage when the services were provided. REAPPLICATION: When a case has been correctly closed and the effective date of closure has passed, a new application is needed to reinstate Medicaid coverage. Reapplications are processed in the same manner as original applications.

When a Medicaid application has been denied due to failure to provide the requested verification and the individual provides ALL the verification(s) within 90 calendar days from the denial notice, a new application is not required. The effective date of coverage is the date when ALL verification(s) were received. When a Medicaid application has been denied for reason(s) other than failure to provide the requested verification(s), a new application is required (even if it’s within the 45 days of the original application date). The original application has already been processed and is no longer valid. Revised: 02/01/2025

COMBINED MEDICAID 103-2 Interview Supersedes: FMA and MA 103-2 (01/01/07) Reference: 42 CFR 435.905, .911 - .913; ARM 37.82.101, .201, & .204; PL 104-193 Overview: Medicaid applicants are not required to complete an interview. If an interview is requested, one must be scheduled. A completed application cannot be required prior to scheduling an interview. A Medicaid application cannot be denied for ‘failure to comply’ with providing necessary information/verification until the application is at least 45 days old (or 90 days for applicants who apply for Medicaid on the basis of disability). Extension may be available (see CMA 103-1). Medicaid application and eligibility information is provided to all individuals who request the information. PAMPHLETS & BROCHURES: Specifically developed bulletins and pamphlets explaining the rules regarding eligibility, appeals, HIPAA, and lien and estate recoveries in simple, understandable terms must be provided, if available. INFORMATION & VERIFICATION: ABD: Application processing includes securing specific information about the applicant's needs and circumstances. Applicants are requested to provide verification of specific financial and nonfinancial eligibility criteria (e.g., pay stubs, birth certificates, divorce decree, marriage license, etc.) (not to exceed 45 or 90 days for applicants who apply for Medicaid on the basis of disability except in unusual circumstances) from the application date to obtain verification and submit it to the field office or central scanning. Unusual circumstances must be documented in case notes. Effective Date: July 01, 2016

COMBINED MEDICAID 103-3 Client Rights and Responsibilities Supersedes: FMA 103-3 (07/01/05) Reference: 42 CFR 435.911, .912; ARM 37.82.101 Overview: Eligibility staff inform all Medicaid clients of their rights and responsibilities. Information is provided verbally or in writing, as appropriate, at the time of application and redetermination. CLIENT RIGHTS: Each Medicaid client has the right to: • apply for assistance without delay; • have someone of his or her choice assist them with application and redetermination; • ask about coverage, eligibility requirements, program scope, and related services, and to receive a response in writing and verbally; • be informed of the consequences for failure to comply with all nonfinancial and financial eligibility requirements; • be determined eligible or ineligible within 45 days (or 90 days for applicants who apply for Medicaid on the basis of disability) of application unless the county is unable to make a determination because of circumstances beyond the agency’s control; • request to receive an extension to provide required information; • receive timely and/or adequate written notice of denial, reduction or termination of assistance; • be informed of his or her rights to a fair hearing if he or she feels the case has not received proper treatment; • have confidentiality in his or her relationship with the agency; • tell the story in his or her own way; • continue to be responsible for him/herself; • claim good cause for refusal to cooperate in child support collection; • claim good cause for not providing certain information; • be informed of the services of Child Support Enforcement; Family Planning; and Early and Periodic Screening, Diagnosis and Treatment (EPSDT), as appropriate; and • not be discriminated against on the grounds of race, color, sex, culture, age, creed, marital status, physical disability, mental disability or national origin.

CLIENT RESPONSIBILITIES: Each adult Medicaid client is responsible for: • completing and signing the application and all required forms; • explaining his or her situation; • providing information, verification and/or documentation as required; • complying with all eligibility requirements including accessing all potential sources of income that can be developed to a state of availability; • cooperating with the following, as required: o Child Support Enforcement requirements; o Quality Assurance and Program Compliance requirements; o Managed Care (PASSPORT to Health) o Third Party Liability o Program Compliance reviews. REPORTING CHANGES: All adult Medicaid recipients are responsible for reporting changes affecting eligibility within 10 days of knowledge of the change. The following changes must be reported: • changes in income and employment status; • changes in resources (only for medically needy and ABD); • death of a household member; • any changes in household; • any other change that may affect eligibility; • changes in health insurance premiums; and • entering or discharging from a medical facility, including nursing home or assisted living. Effective Date: July 01, 2016

COMBINED MEDICAID 103-4 Verifications and Documentation

Supersedes: CMA 103-4 (4/1/2023) Reference: 42 CFR 435.403, .406, .522, .910, .913, .920, .940, .945, .948, .949, .952, .953, .956; 42 CFR 457.380; ARM 37.82.101, .401, .402 & .416; 42 USC 1396b; Deficit Reduction Act of 2005 Overview: All Medicaid Programs: Income and expenses reported on income tax forms are considered valid. However, if the client expects their income to change, additional information may be needed. ACA and Family Medically Needy: Self-attestation is accepted for most non-financial, and financial criteria. We must accept self-attestation from the individual, an adult who is in the client’s household or an authorized representative. Self-attestation is an oral or written client statement of information needed to determine eligibility. ABD Only: Unless otherwise noted, hard copy verification is required. Non-financial and financial criteria must be verified and/or documented for all ABD Medicaid clients. Certain criteria (e.g., household composition) only require documentation in case notes while other criteria (e.g., age, citizenship) must be verified. All information and verification must be established in the case prior to eligibility being determined. Verification must be from a knowledgeable source that does not have an interest in the property being verified. See ‘Knowledgeable Source’ in the glossary. Do not request information that is not needed to determine Medicaid eligibility. The following items may need to be verified and/or documented, depending on which Medicaid program is being evaluated. AGE: ACA and Family Medically Needy: If data source indicates an inconsistency, follow PEV inconsistency process.

ABD: Birth certificate, baptismal certificate, school records; hard copy is required. CITIZENSHIP/ IMMIGRATION STATUS: Citizenship/Immigration status must be verified by electronic means. If electronic interface is unable to provide verification, then a hard copy must be requested. Reasonable opportunity to provide citizenship or immigration status must be allowed (see CMA 301-1 Citizenship and Identity on reasonable opportunity). If hard copy is required, it must be an original or certified copy of the document. Citizenship/immigration status verification cannot be required for individuals not receiving/requesting Medicaid. CSED COOPERATION: Cooperation with Child Support is not required for ABD, and is optional for ACA Parent/Caretaker Relative, Qualified Pregnant Woman medically needy and Family medically needy. DISABILITY: When client is requesting Medicaid as a disabled individual. A current or ongoing SSA disability determination or a MEDS disability determination (using SSA criteria) is required. HEALTH INSURANCE POLICY INFORMATION: Adults in the household are required to provide information on all health insurance policies that cover any individual who is applying for or receiving Medicaid. If the adult fails to comply, the adult will lose their Medicaid coverage, but any children receiving Medicaid will continue to receive Medicaid, as long as the case remains otherwise eligible. HEALTH INSURANCE PREMIUM PAYMENT (HIPP): Client statement, employer statement, completed HCS-449. Adults must cooperate with HIPP as a condition Medicaid eligibility. HOUSEHOLD COMPOSITION: ACA and Family Medically Needy: If the data source indicates an inconsistency, follow PEV inconsistency process. ABD: Client statement.

NOTE: If the data source indicates an inconsistency or if the information currently provided contradicts information previously reported, verification (e.g., divorce decree) is needed. IDENTITY: Proof of identity is required for all Medicaid clients. Identify is verified electronically. If electronic interface is unable to provide verification, then a hard copy is requested. If hard copy is required, it must be an original or certified copy of the document. INCOME: ACA: Verify self-attested income using PEV. PEV is used for initial month of application and for subsequent eligibility. If the data sources indicate an inconsistency, follow the Electronic Verification for Medicaid Business Process. Family Medically Needy: Use self-attestation for initial month of eligibility. PEV is used for subsequent eligibility. If data sources indicate an inconsistency, follow PEV inconsistency process. ABD: Pay stubs, employer statements, MISTICS, SEARCHS, BENDEX (or other system inquiry screens), SOLQ, tax records. Income must be verified at application and anytime an income change is reported. Actual income must be verified when determining retroactive Medicaid eligibility. LIVING WITH A SPECIFIED RELATIVE: ACA and Family Medically Needy: If information in the data sources indicates an inconsistency, follow PEV inconsistency process. If hard copy verification is necessary, the following can be used: Birth certificate, adoption papers, baptismal certificate, marriage license, divorce decree, death certificate. If the specified relative is not the natural/adoptive parent, they must be related within the fifth degree of kinship. ABD: not required MEDICARE ELIGIBILITY, ENROLLMENT & MEDICARE NUMBER: ACA and Family Medically Needy: If information from data source indicates an inconsistency, follow PEV inconsistency process. ABD: If information from the data source indicates an inconsistency, hard copy verification is required. Interface queries, or other documents from Medicare can document eligibility, enrollment, and Medicare claim numbers.

PRE-ELIGIBILITY VERIFICATION (PEV): PEV is the act of validating self-attested information against various data sources to ensure the information provided at the time of application is ‘reasonably compatible’ with information contained in various electronic data sources. If the data source information is not reasonably compatible with self-attested information, a reasonable explanation may be provided before hard copy verification is requested. ABD: Not applicable See Business Process Medicaid Pre-Eligibility Verification (PEV) REASONABLE COMPATIBILITY: When PEV is used for ACA/Family Medicaid, it may be necessary to request additional information if the PEV data source information is inconsistent with the individual’s self- attested information. Montana uses a 10% reasonable compatibility threshold for income. Reasonable compatibility is the compatibility between an individual’s self-attested income and what is found during electronic data searches/matches. Montana has chosen 10% as the reasonable compatibility threshold. ABD: Not applicable RESIDENCE: ACA: The Department shall verify residency for individuals ages 19 and older by electronic data sources if available. If electronic data sources are not available to verify residency, then the individual is responsible for providing evidence of residency. Examples of evidence include but is not limited to driver’s license, state ID card, lease agreements, landlord statements, rent receipts, or mortgage statements. Some additional examples if someone doesn’t pay rent or mortgage include but is not limited to utility bill, water bill, phone bill, current wage stub, statement from someone they are living with. A Residency Certification may be used if the individual cannot verify residency any other way. Family Medically Needy: Client statement. ABD: Client statement; other verification (e.g., landlord statement, rent receipt) only required when residence is questionable.

RESOURCES: ACA and Family Medically Needy: Resources only need to be verified for medically needy coverage. ABD: Resource verification required for all ABD programs. Verifications that may be used but are not limited to bank statements, vehicle query, stock certificates, and safety deposit box contents. Tax appraisals cannot be used to determine the value of real property. Use information from knowledgeable sources, such as real estate brokers familiar with the area where the property is located. SOCIAL SECURITY NUMBER: Client statement; SSA interface will verify. Do not request copies of cards, unless there is a mismatch with SSA data. Parents have until the 1st of the month following a baby’s birth or release from the hospital (whichever is later) to provide verification of application for a Social Security number. The newborn’s Medicaid cannot be closed due to the parent’s failure to provide a Social Security number until the next case redetermination. Good cause may exist if the individual has well-established religious objections to obtaining a social security number. TPL TRAUMA QUESTIONNAIRES: Adult Medicaid clients are required to cooperate with TPL regarding trauma/injury questionnaires. A child’s eligibility will not be affected by the parents’ failure to cooperate. Effective Date: 8/1/2026

COMBINED MEDICAID 103-6 Voter Registration Supersedes: MA 103-6 (05/01/00); FMA 103-6 (02/01/00) Reference: National Voter’s Registration Act of 1993 (NVRA) 42 USC 1973gg, et seq., §13-2-221, MCA Overview: The NVRA and § 13-2-221, MCA, require DPHHS to offer the following voter registration assistance to individuals who apply for, recertify or renew public assistance or who notify DPHHS of a change of address: 1. The opportunity to register to vote; 2. Assistance in completing a Montana voter registration application (MT-VRA); and 3. Collecting complete MT-VRA’s from clients. The law requires DPHHS to provide individuals who do not decline voter registration or assistance in completing forms: 1. A MT-VRA; 2. Assistance in completing the MT-VRA; and 3. Collecting completed MT-VRAs from clients. DPHHS is also required to: 1. Provide specific notices to individuals regarding their NVRA rights; 2. Accept and submit completed MT-VRAs to the election administrator in the individual’s county of residence; and, 3. Report information to the Montana Secretary of State regarding the actions DPHHS undertakes to fulfill its duties under the NVRA and § 13-2-221, MCA. No DPHHS employee may: 1. Seek to influence an applicant’s political preference or decisions; 2. Display on State property any political preference or party allegiance; 3. Make any statement or take any action to discourage an applicant from registering to vote; 4. Make any statement or take any action that leaves an applicant with the impression that a decision to register or not register has any bearing on eligibility for, or receipt of, any program benefit; or, 5. Disclose the identity of any applicant for public assistance to the public or the voter registration agency. Effective Date: July 01, 2016

COMBINED MEDICAID 104-1 Retroactive Medicaid Supersedes: MA 104-3 (07/01/08); FMA 104-3 (01/01/08) Reference: ARM 37.82.101, .204, .704, .904, .1111, 37.83.202; 42 CFR 435.914; 42; CFR 435.915 Overview: Medicaid coverage may be provided for up to three months immediately preceding the month of application or a new coverage request. The request can be made any time after initial application or new coverage request as long as the requested retro month is within the 365 days that the provider has to bill. For pregnancy-related coverage, retroactive Medicaid cannot be established prior to the month of conception. For example: A household applies for Medicaid on 12/18/2016 and on 04/04/2017 requests retro coverage for 09/2016. Since 09/2016 is 3 months prior to the application month (12/2016) and the provider can still bill for a claim we can look at eligibility for that month. If the individual waited until 12/01/2017 to request retro for 09/2016 we would deny the request because the provider can no longer bill for 09/2016 services after 09/2017. If Medicaid is already open on a case and a new Medicaid request is received for an individual not currently receiving Medicaid, the 3 retro months are from the coverage request date. For example: Children in the household are open on Medicaid and mom requests coverage for herself on 03/14/2017, her retro months will be 12/2016, 01/2017, and 02/2017. Mom can request retro coverage any time after her initial request (03/2017) as long as the retro month is within the 365 days the provider has to bill. Retroactive coverage is available to clients who would have been eligible for Medicaid at the time services were received if they had applied or requested coverage. A system notice, either approving or denying retro coverage is sent any time retro coverage is requested. This information is included in the application approval/denial notice if retro is processed at the same time. If retro coverage is requested on the application (the applicant indicates that he/she has medical bills for any of the three months prior to application), the eligibility staff member must process that coverage request timely. If retro coverage is denied, a denial notice MUST be sent that provides the eligibility determination for all requested months. For SSA (Social Security Administration) applicants, see Disability Determination Overview ABD 105-1.

FINANCIAL ELIGIBILITY: Retroactive Medicaid coverage may be for any or all of the three Months immediately prior to the application or retro coverage request date, depending on when services were received. The client must meet all financial and non-financial eligibility requirements for each retro month. The applicant does not need to be eligible in the application month to be eligible for retroactive Medicaid coverage. As long they were eligible in each of the retro months, coverage for those months is provided. Use actual income received and expenses incurred in the retroactive month or months when determining retroactive eligibility. For programs with a resource limit, if the applicant is resource eligible any day of the month, he/she is considered resource eligible for the entire month. NOTE: Citizenship/qualified alien status and identity verification is required when processing retroactive Medicaid requests (if not already verified for ongoing Medicaid). CONTINUED BENEFITS: A retro month cannot be used to create an ongoing span if the client was not eligible in the application month or month after. RETROACTIVE COVERAGE FOR SSI RECIPIENTS: For SSA applicants, see Disability Determination Overview, ABD 105-1. Effective Date: May 01, 2017

COMBINED MEDICAID 202-1 Adding or Removing Household Members

Supersedes: FMA 202-1 (01/01/07); FMA 202-2 (01/01/06) Reference: 42 CFR 435.916; ARM 37.82.101, .204, .205, .704 Overview: The assistance unit’s eligibility must be redetermined if a required filing unit member moves into or out of the household. Medicaid coverage is effective the first of the month in which the new member’s presence is discovered/reported, and they are determined eligible. NOTE: The new member may receive up to three months retro Medicaid coverage from the month of discovery/report, provided ALL eligibility factors are met. It may be necessary to open a separate case to process eligibility for the months the individual was not physically present in the current household. NOTE: HMK does not allow retroactive coverage. If the presence of the new member(s) is reported to or discovered by the agency, redetermine the assistance unit’s eligibility by including the needs, income, and resources of all required filing unit members, including the new member(s). If a filing/assistance unit member leaves the household, the individual’s needs must be removed from the case. When redetermining eligibility, use the income standard based on the current number of household members. The income and resources of a disqualified individual must be counted, but the disqualified individual will not be included in the household size. VERIFICATION: The new member (or responsible adult) needs to provide sufficient verification of income, resources, citizenship/alien status, identity and relationship. HMK: Citizenship and identity are the only verifications required to add another child to the household. Reasonable opportunity applies. NEW MEMBER START DATE: When the new member’s presence is reported or discovered, and they are determined eligible, proceed as follows: • NEWBORN: START DATE for eligibility is the first day of the month in which the child was born if mom was receiving Medicaid at the time of birth. • EXISTING HOUSEHOLD MEMBER: The existing member’s START DATE would be the date the individual is required to be included in the filing unit. • REQUIRED MEMBER NEW TO THE HOUSEHOLD: START DATE is the first of the month in which it was discovered/reported he or she entered the household.

• FOSTER CHILD: When a child who was placed in foster care returns to the home, add him/her to the filing and assistance units the month after foster care Medicaid closes. RECEIVING MEDICAID IN ANOTHER STATE: If a new household member moves to Montana from another state and was receiving Medicaid in the previous state of residence, the eligibility case manager must ensure that Medicaid has been closed in the previous state of residence before opening Montana Medicaid. Medicaid can only overlap for a one-month period when a person moves to Montana and was receiving Medicaid in another state. It is against federal policy to allow an individual to receive Medicaid in more than one state for the same month, with the exception of the one-month overlap that is allowed for administrative purposes. REFUSAL TO COOPERATE: If an individual refuses to cooperate in meeting eligibility requirements, Medicaid for the individual will not begin until the month the requirement is actually met. HEALTHY MONTANA KIDS: When a new child is added to the household, the child is enrolled after proof of the following is provided: 1. Citizenship; and 2. Identity When HMK coverage is requested for a child joining a family with at least one currently enrolled child, the enrollment date for the new household member is the first day of the month or the following month if eligible. A new eligibility determination is not required when a new family member joins the household so long as at least one other child is currently enrolled in HMK. PERSON WHO LEAVES HOUSEHOLD APPLIES for BENEFITS: An individual cannot receive Medicaid in more than one case/household in any month. However, when a child leaves one specified caretaker relative’s home and moves to another specified caretaker relative’s home who subsequently applies for Medicaid, the 2nd relative may receive Medicaid because the eligible child is now living with them, but the child would not because they already received Medicaid that month with relative #1. NOTE: Relative #1 cannot continue to receive benefits if the child was the only eligible child living with them. Timely notice of adverse action must be given. REFERRAL TO FFM: If any household member loses eligibility for all Medicaid and HMK programs, they must be referred to the FFM for determination of eligibility under other insurance affordability programs. The system will automatically send an electronic referral to the FFM. SEE BUSINESS PROCESS: Adding Household Members to an Open Case SEE REFRESHER TRAINING: Course: Adding a Newborn (dphhselearn.org)

Revised Date: October 20, 2022

COMBINED Medicaid 300 Nonfinancial Requirements

Supersedes: 7/1/2016

Reference: 42 CFR 435.403, .406, .920; ARM 37.82.101, .702, .1102, .1310; 42 USC 1396b; P.L. 119-21

Overview: After identifying who is included in the filing unit, determine which filing unit members are included in the assistance unit and will receive Medicaid. Each filing unit member's nonfinancial (SSN, age, community engagement requirements or exclusion, etc.) and financial criteria (income and resources, as applicable) are considered when determining eligibility. Each assistance unit member must meet the following non-financial criteria:

1. Age (minor child and aged only); 2. Minor child living with a specified relative (ACA PCR and Family medically needy only) 3. Social Security Number (SS card is NOT required); 4. Montana residence 5. Citizenship and/or immigration status; 6. Identity (must be documented for all applicants and recipients) 7. May need to meet blind/disabled criteria (ABD only); 8. Level of care (ABD only) 9. Community engagement requirements as applies to ACA Adult Medicaid and ACA Adult (see CMA 310-1 Community Engagement and Exclusion Policy)

In addition, the applicant/child's parent/caretaker must cooperate with:

1. Primary Care Case Management (PASSPORT provider) 2. Program Compliance with Medicaid reviews; and 3. Third Party Liability (TPL) including

a. HIPPS b. Trauma questionnaires c. Providing information on available insurance and d. Insurance questionnaires

If the adult does not cooperate with program compliance or TPL, only the adult's eligibility is affected. The children's eligibility is not impacted by the adult's failure to cooperate. Effective Date: 7/1/2026

COMBINED MEDICAID 301-3 Emergency Medicaid

Supersedes: FMA 301-3 & MA 301-3 (01/01/08)

Reference: PL 104-193 SEC. 401(b)(1)(A); 42 CFR 435:403;435.406; .440.255; 489.24(b); ARM 37.82.102; P.L. 119.21

OVERVIEW: Emergency medical coverage is available to an individual who meets residency, nonfinancial, and financial standards but fails citizenship requirements. Coverage is limited to services necessary to treat an emergency medical condition and is available only for the duration of the emergency. Emergency Medicaid begins when treatment for the emergency condition is initiated and ends when the condition is no longer considered an emergency. This coverage is limited to emergency services and does not constitute full Medicaid coverage. Emergency coverage is provided from the time the individual is first given treatment until the medical condition is no longer an emergency.

Emergency medical services are provided for medical needs that require immediate medical attention and without treatment could result in: 1. placing the individual's health in serious jeopardy, this includes childbirth; 2. serious impairment to bodily functions; or 3. serious dysfunction of any bodily organ or part.

An emergency medical condition does not include care and services related to an organ transplant procedure.

Sponsor deeming does not apply to noncitizens applying for Emergency Medicaid. RESIDENCY:

Noncitizens must meet the state's residency rules. Residency means physical presence in the State of Montana with the intent to remain. Residency will be evaluated on a case-by-case basis using verifications such as Montana driver’s license or ID, lease or mortgage, employment records, school enrollment, etc.

RESOURCES: Individuals must be below the ABD resource limit ($2,000 resource limit for a single individual and a $3,000 resource limit for two individuals that have a spousal relationship) in order to be eligible for Emergency Medicaid.

INCOME: Income rules follow the income-level criteria for the program they would otherwise be eligible for. If income is below the threshold for ACA Adult Medicaid programs, they are eligible with no spend down. If income exceeds the ACA Adult threshold, Emergency Medicaid will require a spend-down.

Effective Date: 7/1/2026

COMBINED MEDICAID 301-2 Noncitizen Status

Supersedes: CMA 301-2 (12/1/2024) Reference: 42 CFR 435.406; 42 CFR 440.255; P.L. 104-193, P.L. 111-118; P.L. 119-21 Overview: Medicaid eligibility for noncitizens is based on whether they are qualified noncitizens and if all other program requirements are met. A qualified noncitizen is an individual who is legally present in the US based on their immigration status under various sections of the Immigration and Nationality Act (INA). Immigration status is determined by the Department of Homeland Security (DHS) and verified through the SAVE system administered by USCIS. A Qualified non-citizen includes individuals who are: 1. Lawfully admitted for permanent residence (LPR) (green card holders) 2. Citizens of the Compact of Free Association (COFA migrants) 3. Cuban/Haitian Entrant 4. Granted asylum 5. Admitted as a refugee 6. Paroled into the U.S. for at least one year 7. Individuals whose deportation is being withheld 8. Noncitizen subject to battery or extreme cruelty by spouse, child, or parent 9. Victim of trafficking 10. American Indian Born in Canada with at least 50% blood quantum in a US- recognized tribe. Students, visitors, non-immigrant status (including worker visas), and undocumented individuals are not eligible for Medicaid. Lawfully Residing Children. Medicaid is available for lawfully residing children who otherwise meet Medicaid or CHIP eligibility requirements. The federal guidelines allow expanded categories for children only. Children in the following statuses are considered lawfully residing: 1. A qualified non-citizen (see above);

2. An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission; 3. An alien who has been paroled into the United States for less than 1 year, except for an alien paroled for prosecution, for deferred inspection or pending removal proceedings; 4. An alien who belongs to one of the following classes: a. Aliens currently in temporary resident b. Aliens currently under Temporary Protected Status (TPS), and pending applicants for TPS who have been granted employment authorization; c. Aliens who have been granted employment authorization; d. Family Unity beneficiaries; e. Aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President; f. Aliens currently in deferred action status; or g. Aliens whose visa petition has been approved and who have a pending application for adjustment of status; 5. A pending applicant for asylum or for withholding of removal or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 who has had an application pending for at least 180 days; 6. An alien who has been granted withholding of removal under the Convention Against Torture; 7. A child who has a pending application for Special Immigrant Juvenile status; 8. An alien who is lawfully present in the Commonwealth of the Northern Mariana Islands; or 9. An alien who is lawfully present in American Samoa under the immigration laws of American Samoa.

Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process (DACA) shall not be considered lawfully present with respect to any of the above categories in paragraphs (I) through (9) of this definition.

Additional Verification for Lawful Permanent Resident (LPR) LPR’s must meet the Five-year waiting period (Five-Year Bar) or have 40 qualifying quarters of work (10 years) to meet the citizenship and immigration status requirement for Medicaid. If the qualifying quarters of work are not met and a noncitizen has a sponsor with an Affidavit of Support (I-864), then the sponsors’ income and resources will be evaluated for determining eligibility. 1) Five-Year Bar. LPR’s entering the U.S. on or after August 22, 1996, are NOT eligible for Medicaid for five (5) years after their date of entry and after being in a

qualified status for a period of five years. The date the five-year bar starts is the date on the noncitizen’s USCIC alien registration card.

NOTE: The five-year bar does not apply to individuals who are not subject to the 5-year bar and later adjust to LPR status including; COFA migrants, Cuban Haitian Entrants, refugees, asylees, individuals granted withholding of deportation or removal, certain Ukrainian or Afghan parolees, Iraqi or Afghan special immigrant visa holders, Amerasian immigrants, veterans or active-duty service members and their families, certain American Indians born abroad, and others. Under current law, if these exempt individuals become LPRs (e.g., upon admission or after adjusting their status), they can continue to receive Medicaid or CHIP without the five-year bar applying. The five-year bar does not apply to children in a lawfully residing status.

2) 40 quarters of work. If unable to verify work quarters through the system, the individual must provide verification of 10 or more years of earnings with employer statements, income tax forms, wage stubs, etc., or obtain verification from the regional SSA office. No work quarters are creditable for any period beginning after December 31, 1996, if either the noncitizen or the worker (the parent or spouse) received any Federal means-tested benefits during the period in which the work quarters were earned. LPRs who have been in the U.S. for 10 years or more are not required to have 40 qualifying work quarters to qualify for Medicaid. The eligibility requirements have been updated to allow LPRs to be eligible after five years of U.S. residency, regardless of whether they have any qualifying work quarters.

3) Sponsor Deeming of Income and Resources apply to some LPR individuals. • Sponsor deeming applies when: o -The sponsor signed Form I-864 or I-864A o -The form was signed on or after December 19, 1997 o Income and resources of the sponsor will be used to determine eligibility if there is not 40 quarters of work after the five-year bar. See CMA 603-1 Deeming • Sponsor Deeming ends when one of the following occurs: o -The LPR has 40 qualifying work quarters o -The LPR becomes a U.S. citizen o -The reason for termination of sponsor’s responsibilities occurs (e.g., death of sponsor, divorce in special cases, etc.). Emergency Medicaid: Remains available for services necessary to treat an emergency medical condition, regardless of noncitizen status. See CMA 301-3 Emergency Medicaid Immigration Status Verification

Immigration status must be verified through electronic data sources. When an electronic data source cannot validate immigration status or if it differs from the documentation provided to the OPA, additional verification is required. Acceptable verifications include current unexpired documents that verify entry date, status, document or ID numbers, and identifying information. See: Verify Lawful Presence Business Process REASONABLE OPPORTUNITY: If citizenship or satisfactory immigration status cannot be verified within the 45-day application processing time frame, the state must provide a 90-day reasonable opportunity period to allow an individual who has made a signed declaration of citizenship or satisfactory immigration status, and the state has not been able to verify with electronic sources, is allowed so the client can either provide proof of U.S. citizenship, national status, or satisfactory immigration status, or to provide evidence that they are trying to obtain that proof (such as providing a copy of the application requesting their birth certificate from another state). Reasonable opportunity is also allowed when a new immigration status is reported. The individual must respond to the initial request for verification of information and inform the state that they need additional time to complete the request if they are unable to provide the documentation. If the requested information is not returned, Medicaid is denied. The 90-day period starts when the person receives the notice requesting verification, which is 5 days after it is mailed. If the person is otherwise eligible, Medicaid coverage begins on the first day of the application that includes their statement about citizenship or immigration status. During the reasonable opportunity period, the state must continue efforts to complete verification of the individual's citizenship or satisfactory immigration status, or request documentation if necessary. If satisfactory proof of U.S. citizenship or immigration status is not provided by the end of the reasonable opportunity period, Medicaid coverage is closed, with timely notice provided.

Effective Date: 7/1/2026

COMBINED MEDICAID 301-3 Emergency Medicaid

Supersedes: FMA 301-3 & MA 301-3 (01/01/08)

Reference: PL 104-193 SEC. 401(b)(1)(A); 42 CFR 435:403;435.406; .440.255; 489.24(b); ARM 37.82.102; P.L. 119.21

OVERVIEW: Emergency medical coverage is available to an individual who meets residency, nonfinancial, and financial standards but fails citizenship requirements. Coverage is limited to services necessary to treat an emergency medical condition and is available only for the duration of the emergency. Emergency Medicaid begins when treatment for the emergency condition is initiated and ends when the condition is no longer considered an emergency. This coverage is limited to emergency services and does not constitute full Medicaid coverage. Emergency coverage is provided from the time the individual is first given treatment until the medical condition is no longer an emergency.

Emergency medical services are provided for medical needs that require immediate medical attention and without treatment could result in: 1. placing the individual's health in serious jeopardy, this includes childbirth; 2. serious impairment to bodily functions; or 3. serious dysfunction of any bodily organ or part.

An emergency medical condition does not include care and services related to an organ transplant procedure.

Sponsor deeming does not apply to noncitizens applying for Emergency Medicaid. RESIDENCY:

Noncitizens must meet the state's residency rules. Residency means physical presence in the State of Montana with the intent to remain. Residency will be evaluated on a case-by-case basis using verifications such as Montana driver’s license or ID, lease or mortgage, employment records, school enrollment, etc.

RESOURCES: Individuals must be below the ABD resource limit ($2,000 resource limit for a single individual and a $3,000 resource limit for two individuals that have a spousal relationship) in order to be eligible for Emergency Medicaid.

INCOME: Income rules follow the income-level criteria for the program they would otherwise be eligible for. If income is below the threshold for ACA Adult Medicaid programs, they are eligible with no spend down. If income exceeds the ACA Adult threshold, Emergency Medicaid will require a spend-down.

Effective Date: 7/1/2026

COMBINED MEDICAID 302-1 State Residency Supersedes: FMA 302-1 (01/01/08), MA 302-1 (07/01/08) Reference: 42 CFR 435.403; ARM 37.82.101, .402 Overview: Medicaid must be provided to otherwise eligible Montana residents. Residency is verified using self-attestation, unless questionable. Temporary residence without any intent to remain within the state does not fulfill the residency requirements except in the case of migrant workers or other persons who qualify as residents under the second definition of residency below. Residence does not depend on the reason the individual entered the state, except it may indicate whether he or she is here voluntarily or for a temporary purpose. RESIDENCY: Residency is established when an individual is: 1. Living in Montana voluntarily with the intention of making a home here and not for a temporary purpose, or 2. Living in Montana, and not eligible for/receiving benefits from another state and has a job commitment or is seeking employment in Montana (whether or not currently employed). NOTE: When an applicant is receiving Medicaid in another state and subsequently moves to Montana, Montana Medicaid may be furnished for the month of move. Medicaid in the other state must be closed before Montana Medicaid can continue. If they were receiving TANF cash assistance in another state, the assistance amount is excluded in determining Medicaid eligibility. ACA and Family Medically Needy: A child is a resident of the state in which the custodial specified caretaker relative is a resident. ABD: A non-institutionalized minor whose eligibility is based on blindness or disability is a resident of the state in which he/she is living. Residency is retained until abandoned. A client’s temporary absence (not to exceed 90 consecutive days) from the state does not interrupt continuity of residency. ACA and Family Medically Needy: Minor children who usually live with a custodial caretaker relative in another state, and are in Montana to visit their other parent (or other relative) during a summer

vacation or other school break are not Montana residents. They are ‘temporarily absent’ from their custodial parent, and could be eligible in the other state. TEMPORARY ABSENCE FROM THE HOME/STATE: Temporary absence occurs when an assistance unit member is away from his or her home for a period not to exceed 90 consecutive days Benefits continue for these members as long as the following conditions are met: 1. The absent member intends to return to his or her home within 90 days; 2. ACA and Family Medically Needy: If the child is required to live with a specified caretaker relative, the specified caretaker relative continues to exercise responsibility for the child while the child is away; and 3. ACA and Family Medically Needy: The specified caretaker relative plans to continue such responsibility for the child upon return to the home. ACA and Family Medically Needy: If the absent member does not return home within 90 days, without good cause, they are removed from the assistance unit. If he or she is the only eligible child, eligibility terminates for the assistance unit. If the absent member is the child’s specified caretaker relative, the child is no longer considered to be living with a specified caretaker relative. Eligibility ends if the open Medicaid program requires a child to live with a specified caretaker relative. The child may be eligible for other coverage; ex parte review must be completed. EXCEPTION: If the absent member is away from home for medical treatment, or a child is away attending school or another educational facility (e.g., 17 or 18 year old away at college), he or she is not subject to the temporary absence policy and, if otherwise eligible, may continue to receive benefits as a part of the household. When a required filing unit member is temporarily absent for longer than 90 days, but has good cause for not returning (such as military personnel, away for employment, etc.), that individual remains included in the filing and, if appropriate, assistance unit and their income and resources are counted in full. SSI STATE SUPPLEMENTAL PAYMENTS: Individuals receiving state supplemental payments are considered residents of the state in which the payment is being received. However, when the Social Security Administration (SSA) is advised of the move, Medicaid coverage can begin in a new resident state. Example: Jim recently moved from Washington to Montana. However, Jim did not notify the SSA that he moved; because the SSA continues to mail his SSI payment to Washington State, Jim is eligible for medical assistance in Washington. After notifying the SSA that he has moved to Montana, Jim may be eligible for Montana Medicaid coverage.

INSTITUTIONALIZED INDIVIDUALS: Eligibility may not be denied to an individual who did not establish residency in Montana prior to entering an institution. An institutionalized individual who became incapable of indicating intent at or after age 18 is a resident of Montana if physically present in the State of Montana, except in the case where another state makes a placement. An institutionalized individual under age 18 (or an individual age 18 or older who became incapable of indicating intent before age 18) is a resident of Montana if the: 1. Parent or legal guardian was a resident of Montana at the time of placement; 2. Parent or legal guardian is currently a resident of Montana; or 3. Individual or party who files an application is a resident of Montana, if the institutionalized individual has been abandoned by his/her parent(s), does not have a legal guardian and is institutionalized in the State. OUT-OF-STATE INSTITUTIONAL PLACEMENTS: Any individual placed in an out-of-state institution with prior approval of Montana Medicaid continues to be a Montana resident. Any individual placed in a Montana institution by another state continues to be a resident of the placing state. DISPUTED RESIDENCY: When two or more states cannot resolve which state is the resident state, the state where the individual is physically located is the state of residence. Effective Date: July 01, 2016

COMBINED MEDICAID 302-2 Temporary Absence from the Home Supersedes: FMA 302-2; 01/01/04 Reference: 42 CFR 435.403; ARM 37.82.101, .402 Overview: Medicaid may continue for clients during temporary absences from the home (for ACA/Family medically needy, this includes temporary absences of either the specified caretaker relative or the needy child) if: 1. The absent member continues to consider the home as their place of residence during the period of absence and intends to return to the same home; and 2. ACA and Family Medically Needy: While the child is temporarily away from home, the specified caretaker relative continues to exercise responsibility for the care and control of the child, which includes making plans for the child; or 3. The absent member is expected to return to the household within 90 days, or has good cause for not returning within 90 days If the conditions above are met, Medicaid continues unchanged. If an individual has left the home and is not expected to return, their Medicaid coverage is ended. TEMPORARY VISITS: ACA and Family Medically Needy: Minor children who usually live with a custodial parent or caretaker relative and are visiting their non-custodial parent or another caretaker relative for a temporary visit (not to exceed 90 days) are not considered to be living with the non-custodial parent, and could remain eligible in the custodial parent’s household. MEDICAL CARE: An individual away for the sole purpose of receiving medical care is NOT considered temporarily absent and is NOT subject to the 90-day rule. If otherwise eligible, the individual continues to receive Medicaid for as long as they are receiving medical treatment. SCHOOL ATTENDANCE: A dependent child away from home for the sole purpose of attending a school or other educational facility (i.e., 18 year old away at college) is not subject to the temporarily absence rule. If otherwise eligible, the child continues to receive assistance. INMATE OF A PUBLIC INSTITUTION:

An individual who is an inmate of a public institution, such as Pine Hills or the Deer Lodge State Prison, is NOT considered to be temporarily absent. An individual is considered an inmate of a public institution from the date of actual incarceration in a prison, county, city or tribal jail until permanent release, bail, probation or parole. The individual MAY be eligible to receive assistance under certain circumstances. GOOD CAUSE: When a required filing unit member is temporarily absent for longer than 90 days, but has good cause for not returning (such as military personnel, away for employment, etc.), that individual remains included in the filing and, if appropriate, assistance units and their income and resources are counted in full. See Good Cause in FMA 1508-1. Effective Date: July 01, 2016 Revised: January 11,2024

CMA 302-3 Incarcerated Individuals

Supersedes: N/A Reference: 42 CFR 435.907, .1010; 42 CFR 433.112; P.L. 117-328 Overview: Facilitating enrollment in Medicaid, for individuals not already Medicaid eligible, while individuals are incarcerated supports access to services following incarceration and has the potential to help individuals with disabilities obtain critical community services to avoid crises and unnecessary institutionalization. Individuals eligible for Medicaid at the time of incarceration should not have their Medicaid terminated but will be suspended during the time of their incarceration. They are eligible for inpatient hospital services only. An incarcerated individual, regardless of age, is an individual held involuntarily by law enforcement authorities in a carceral setting. This policy applies to eligible individuals held in carceral facilities to include: • State or Federal Prisons • Local jails • Tribal jails and prisons • Detention facilities • Other penal settings It will be necessary to get more information about the client’s status in some of these settings. HMK Plus/HMK Eligibility For those under age 19 the filing unit must include • natural, adoptive and stepparents and • siblings under age 19

Exception: if the child is in CFSD or court control, they will need to be processed on their own case.

Due to different carceral settings for children, an email should be sent to the Special Programs Unit for a possible suspension to be entered. hhsdocma@mt.gov

• If they apply while incarcerated, they can be eligible for HMK Plus, but a suspension span is entered.

• If they apply while incarcerated, they cannot be determined newly eligible for HMK, unless they are 30 days from release. (This is because incarceration is a criterion of eligibility.)

If the client is on HMK Plus or HMK when they become incarcerated, they are not closed unless there is another reason for closure. Children will remain in their continuous eligibility span.

When a release date is received, the client is eligible for certain services, including early and periodic screening, diagnostic and treatment (EPSDT). Coverage must continue for a minimum of 30 days post release.

Incarcerated individuals in pre-adjudication do have a suspension span entered.

Note: If an application is received and a parent or guardian is not available to sign and submit the application on behalf of a minor child who is incarcerated, an adult acting responsibly may apply on behalf the minor and can sign and submit the application. This could include an adult who is not the minor’s parent or legal guardian but who is assisting or taking care of the minor. If the incarcerated individual is under 19, the parents ‘or guardians’ information is required before a determination of eligibility can be made. Renewals Individuals who are incarcerated will not close unless closing for a reason other than incarceration. If the individual is aged 19 or over and not in a CE period, the state must redetermine eligibility prior to release unless the last redetermination occurred after individual was incarcerated and within 12 months of the date of release. • Eligible Juveniles If the child remains incarcerated after their Continuous Eligibility (CE) period ends and the state has not completed a redetermination within the past 12 months, the state is required to complete a redetermination of eligibility prior to the child’s release. If the child is in a CE period when they are released, a renewal is not required until their CE period ends.

See Business Processes: Incarceration and Medicaid Processing, Prisoner Match

Effective Date: 01/01/2025

COMBINED MEDICAID 303-1 Social Security Number Supersedes: FMA 303-1 (01/01/08), MA 303-1 (02/01/01) Reference: 42 CFR 435.910, .920, .960; ARM 37.82.101, .201 Overview: Each Medical applicant or recipient is required, as a condition of eligibility, to: 1. Furnish a social security number (SSN); or 2. Apply for a number if one has not been issued or is not known. Furnish means to simply provide the SSN either verbally or in writing. A hard copy is not required. VERIFICATION: All SSN’s are agency verified via an interface with the SSA. If the SSN cannot be agency verified (SSN does not match the individual), contact the recipient and request further information. All SSNs must be verified no later than the next redetermination date after the date of application unless good cause exists. The client’s benefits cannot continue to be issued until the SSN is verified. NEWBORN’S SSN: A newborn’s SSN must be applied for by the 1st day of the second month following either the child’s birth or release from the hospital, whichever is later. Verification is required. If an SSN isn’t provided by the next case redetermination, the child’s Medicaid is closed. The child’s Medicaid cannot be closed before the next case redetermination for failing to provide the child’s SSN. NEW HOUSEHOLD MEMBER: New household members who request Medicaid coverage must provide either an SSN or proof they’ve applied for an SSN. Unless good cause exists, all SSNs must be verified by the next case redetermination. FAILURE TO COMPLY: Required filing unit members who do not provide an SSN/application for SSN cannot receive Medicaid until they either provide an SSN or proof of application. Re-evaluate eligibility when either is received. GOOD CAUSE:

A client may have good cause for not providing an SSN. Good cause exists when the individual has a documented religious reason for not obtaining a social security number. Effective Date: July 01, 2016

COMBINED MEDICAID 304-1 Health Coverage Overview Supersedes: FMA 307-1 (01/01/07); MA 305-1 (01/01/07) Reference: 42 CFR 433.136, .137-.140, .145-.148; ARM 37.82.101, .424, 37.85.407 Overview: As a condition of the adult’s eligibility, all adult Medicaid clients and parents/adult caretakers in child-only Medicaid households must cooperate with the Third Party Liability (TPL) Unit regarding trauma questionnaires, by providing health insurance information to be used to identify legally liable third parties for Medicaid payable services and by maintaining group health insurance that has been determined to be cost-effective through HIPPS. When a questionnaire regarding a specific injury is sent to a Medicaid recipient, the requested information from the questionnaire must be submitted as directed on the questionnaire within the specified time frame. If the information is not received within the time frame, the TPL Unit will enter the appropriate system non-compliance. Health insurance information must be provided for all Medicaid clients during the application and redetermination processes, or upon specific request. Cooperation in providing health insurance information may include establishing paternity, pursuing medical support or payments, and cooperation in identifying and providing information to assist the agency in pursuing any liable third parties. All current health insurance must be entered into the eligibility system, regardless of who pays the premiums, unless otherwise noted. Adult Medicaid clients and 18 year olds who are not living with a parent/specified caretaker loses or is denied Medicaid eligibility until: 1. The TPL unit receives the completed trauma questionnaire. 2. Health insurance information is provided to the requestor (which may be the OPA, TPL Unit or CSED) or 3. The individual re-enrolls in cost-effective group health insurance (typically at the next open enrollment period). When the Medicaid client is a child, the following adults lose Medicaid eligibility due to non-cooperation until the required information is provided: 1. The child’s parent residing in the same household as the child, regardless of whether the parent is receiving Medicaid under the same coverage group as the child;

2. The child’s specified caretaker relative (who is not the child’s parent) when they are receiving Medicaid only because they are the child’s specified caretaker relative. Children will not lose Medicaid eligibility based solely on the responsible adult failing to comply with these requirements. However, children may lose Medicaid eligibility due to the reduced household size when the adult is in non-compliance. Children who lose eligibility due to the reduced household size are not eligible for HMK. NOTE: Eligibility staff members do not need to pursue health insurance TPL information from SSI cash assistance recipients. TPL information for these individuals is processed through Central Office. INDEMNITY INSURANCE POLICIES: Indemnity insurance policies pay based on a specific event occurring rather than general insurance policies that pay for a wide range of illness and medical needs (e.g., pays $50 per day while the insured is hospitalized, pays $600 if a medical doctors treats the insured for an accident-related injury). Medicaid does not consider indemnity policies to be TPL. These policies are not entered on the system, and premiums are not used to reduce the spend down. Indemnity policy payments are considered income to the recipient in the month received rather than being considered a reimbursement or TPL. NOTE: If the recipient has a history of receiving indemnity payments and the payments are expected to continue, or if any payment can be anticipated, it may be necessary to adjust future income (see 501-1). Effective Date: July 01, 2016

COMBINED MEDICAID 304-2 Health Insurance Premium Payment System Supersedes: FMA 307-2 (01/01/06); MA 305-2 (01/01/06) Reference: 42 CFR 433.136, .137-.140, .145-.148; ARM 37.82.101, .424, 37.85.407 Overview: As a condition of adult household members’ eligibility, all Medicaid households must cooperate with the HIPPS (Health Insurance Premium Payment System) process. Cooperation includes both cooperating with the HIPPS cost-effectiveness determination process and maintaining group health insurance that is identified as cost-effective. Medicaid pays or reimburses group plan premiums when the TPL Unit determines it is a cost-effective plan. Medicaid may pay an ineligible family member’s premiums if they must be enrolled to obtain coverage for the Medicaid eligible individual (e.g., parent must be enrolled in order to enroll the child). NOTE: Medicaid may also pay premiums for some non-Medicaid eligible individuals under the COBRA 75 Program. (See CMA 307-1) For cost-effective plans, premium payments typically begin the application month (for those enrolled in insurance at the time of application) or, for on-going cases, the month the completed HCS-449 is submitted to the OPA. When there is a waiting period before health insurance coverage begins, premium payments begin effective the enrollment date. HIPPS: Direct HIPPS/Cost effectiveness questions to: DPHHS HIPPS PO Box 202953 Helena, Montana 59620-2953 Phone: 1-800-694-3084 Fax: (406)444-1829 or 1-800-457-1978 Email: hhshippprogram@mt.gov Effective Date: July 01, 2016

COMBINED MEDICAID 304-3 Trauma Questionnaires Supersedes: FMA 307-3 (07/01/05); MA 305-3 (07/01/05) Reference: 42 CFR 433.136, .137-.140, .145-.148; ARM 37.82.101, 37.85.407 Overview: As a condition of the adult’s eligibility, all Medicaid households must cooperate with the TPL Unit by completing and returning all trauma questionnaires for any family member receiving Medicaid. Certain injury diagnosis codes trigger a trauma questionnaire to be sent to Medicaid households. The requested information from the questionnaire must be submitted as directed on the questionnaire within the specified time frame. If not provided within the time frame, the TPL Unit will enter the appropriate system non-compliance. An adult Medicaid recipient loses or is denied Medicaid eligibility until such time as the requested information is received. If the Medicaid recipient is a child, the responsible adult(s)/specified caretaker relative will lose Medicaid eligibility until such time as the required information is provided. Children will not lose Medicaid eligibility because the responsible adult failed to comply with these requirements. Effective Date: July 01, 2016

COMBINED MEDICAID 304-4 Lien and Estate Recovery Supersedes: FMA 307-4 (01/01/08); MA 1401-1 (04/01/11); FMA 307-5 (07/01/05); MA 1402-1 (01/01/08) Reference: MCA 53-6-165 through -169, 171, 175; ARM 37.82.101, .431 and .438; P.L. 110-275 Overview: The Medicaid Lien and Estate Recovery Program is the mechanism used to recover the cost of medical services. Medicaid Lien & Estate Recovery information is provided with each Medicaid application approval for individuals aged 55 or older. LIEN: Liens may be placed against real property owned by Medicaid clients who reside in a nursing home, intermediate care facility for the mentally retarded or institution for mental disease and who are not expected to return home. All institutionalized applicants and recipients must complete and sign Form HCS-121, "Real Property Liens for Nursing Home Residents" as a condition of eligibility. ESTATE RECOVERY: A deceased individual's estate consists of all property (both real and personal) which: 1. the decedent owned at the time of death; and/or 2. automatically transferred to beneficiaries upon death. This property includes property: 1. reported in probate; 2. owned in joint tenancy; and owned in tenancy-in-common Collection is only pursued for medical expenses Medicaid paid while the individual was: 1. a resident of: a. a nursing home or other institution; b. an intermediate care facility for the mentally retarded; c. an institution for mental disease; or 2. age 55 or older (determined from the actual date the person attains age 55). All institutionalized applicants and recipients must read and sign an HCS-120, “Estate Recovery for Nursing Home Residents" as a condition of eligibility. All Medicaid applicants and recipients aged 55 and older must be provided with a copy of HCS-122, "Estate Recovery for Individuals 55 and older"

although signing and returning the form is not a condition of eligibility. A signed HCS-120 on file meets this requirement. MEDICARE SAVINGS PROGRAM Effective January 1, 2010, the Medicare Improvements for Patients and Providers Act (MIPPA) requires that premiums paid through any Medicare Savings Program (QMB, SLMB or QI) or the Qualified Disabled Working Individuals (QDWI) program on or after 1/1/2010 are excluded from estate recoveries. ESTATE RECOVERY EXEMPTION If probate is opened and Medicaid files a claim against the estate, Medicaid will not collect if the recipient has a surviving: 1. spouse; 2. child under age 21; or 3. child who is blind or disabled according to the Social Security Administration’s criteria. RECOVERABLE EXPENSES Recoveries from a deceased recipient’s estate will include all expenses paid by Medicaid, including but not limited to: 1. health insurance premiums (including Medicare); 2. hospital services; 3. prescription drug services; 4. nursing home services; 5. home and community based services. Note: Total Recovered amount cannot exceed the total expenses paid by Medicaid. EXCESS BURIAL FUNDS Anyone who holds funds in excess of $5,000 which were specifically designated to pay for the disposition of a decedent's remains shall, after paying for the disposition, pay all remaining funds to the Department of Public Health & Human Services within thirty (30) days after the disposition. CHECKING/SAVINGS ACCOUNT BALANCES Whether the checking or savings account balance(s) may be applied toward the deceased recipient’s funeral expenses is contingent on where the individual was residing at the time of death. 1. If the recipient was not residing in a residential medical facility, account balance(s) may be applied toward funeral expenses (subject to probate laws). 2. If the recipient was residing in a residential medical facility, account balance(s) may not be applied toward funeral expenses. NOTE: When a recipient resided in a residential medical facility at the time of death, checking and savings account balances are considered to have been ‘personal needs funds.’ PERSONAL NEEDS FUNDS

Personal needs funds are monies set aside for a residential medical facility resident’s personal needs and medical expenses that are not covered by Medicaid. After the resident’s death, the balance must be paid to the Medicaid Program within thirty (30) days. Note: After the resident’s death, personal needs funds may be used to satisfy an outstanding debt to the nursing home. COUNTY BURIAL The Field Operation Manager may request a waiver to the retirement that deceased nursing home resident’s personal funds automatically be paid to the Medicaid Program (see form Page 5). Requests will be approved when: 1. The request does not exceed $1,200; 2. All other assets and resources of the deceased have been applied toward burial expenses prior to use of personal funds; and 3. Except for use of the deceased’s personal needs funds, burial expenses would be borne by the county. NOTE: This waiver is NOT available to assist surviving relatives in paying the deceased’s final expenses. HEIR WISHES TO RETAIN ESTATE When a Medicaid recipient’s heir(s) wishes to retain ownership of the estate property, the individual(s) may do so by paying the lesser of the: 1. Total amount Medicaid is entitled to recover; or 2. Fair Market value of the estate property. HARDSHIP EXEMPTION Recovery will not be pursued if it would cause an undue hardship for the heir(s). After action has been taken to recover Medicaid paid expenses, the heir(s) may request recovery be waived or compromised based on a hardship. The Estate Recovery Unit will consider all requests. LIEN and ESTATE RECOVERY UNIT: Direct all questions related to Medicaid liens or estate recovery to the Lien and Estate Recovery Program at: DPHHS Lien and Estate Recovery Program PO Box 202953 Helena, Montana 59620-2953 Phone: 1-800-694-3084 Fax: 1-800-444-1829 Effective Date: July 01, 2023

COMBINED MEDICAID 304-5 Out of Pocket Maximum Supersedes: CMA 304-5 (07/01/2016) Reference: SB 405 (MCA 17-7-502 and 27-2-205) and ARM 37.84.107 Overview: Medicaid households are required to pay copays and co-insurance. The amount paid out of pocket cannot exceed 5% of total countable household income. Once eligibility is determined and the 5% maximum out of pocket is calculated, it cannot be increased until the annual renewal, or when the client requests the amount be recalculated. Individuals receiving ACA Adult will have a 3% out of pocket maximum. Effective Date: January 01, 2018

COMBINED MEDICAID 305-1 Age Supersedes: FMA 304-1 (01/01/07) Reference: 42 CFR 435.201, .222, .308 and .520; ARM 37.82.101; PL 104-193 Overview: Certain coverage groups have age-related limits to be eligible to receive Medicaid coverage. ACA and Family Medically Needy: • Children may be eligible through the month of their 19th birthday; • Parents/Specified Caretaker relatives and pregnant women of any age may be eligible; • Adults age 19 through 64 may be eligible for ACA Adult or ACA Adult Medicaid coverage • Newborn children, eligible under the Child Newborn program, may be eligible through the month of their first birthday ABD: • Disabled children may be eligible through the month of their 18th birthday; • Disabled adults may be eligible through age 64 • Adults, age 65 or older are considered ‘aged’ • PRTF eligibility is limited to individuals age six through 17 • MWD eligibility is limited to individuals age 16 and older • Autism waiver is limited to children age 15 months up to 8 years old Effective Date: July 01, 2016

COMBINED MEDICAID 306-1 Managed Care Program Supersedes: FMA 306-1 (01/01/08); MA 306-1 (02/01/05) Reference: 42 CFR 441.60, .61; ARM 37.82.101, 37.86.5101 - .5104, .5110, .5120 Overview: ‘PASSPORT to Health’ is a managed care program designed to provide quality medical care to Montana Medicaid clients. Under the managed care program, Medicaid clients must choose a PASSPORT provider to serve as their primary care provider. A PASSPORT provider is a doctor, clinic, nurse practitioner, or physician assistant who has agreed to help manage the client's health care. Clients may call 1-800-362-8312 for more information on PASSPORT providers. Effective Date: July 01, 2016

COMBINED MEDICAID 307-1 Cobra 75 Supersedes: FMA 308-1 (01/01/08); MA 305-4 (07/01/05) Reference: 26 CFR 54.4980B-7. ARM 37.82.101, .430 Overview: When cost effective, COBRA 75 Continuation health plan premiums are paid for individuals who are not Medicaid eligible, but who meet COBRA 75 non-financial and financial guidelines. TPL administers health insurance premium payments. COBRA 75 applicants have only a 60 day window of opportunity to establish continued participation in a health care plan they would otherwise lose due to a qualifying event. NONFINANCIAL REQUIREMENTS: The following nonfinancial eligibility criteria must be met: 1. citizenship or alienage; 2. state residency; 3. Social Security number; and 4. Are eligible to receive continued health plan coverage through an employer with at least 75 employees because of a qualifying event. NOTE: Applicants do not have to meet categorical (i.e., aged, blind, disabled, pregnant, etc.) eligibility criteria. FINANCIAL REQUIREMENTS: Countable resources cannot exceed: 1. $4,000 for one individual; or 2. $6,000 for a family with two or more people. Countable monthly income cannot exceed 100% of the federal poverty guidelines based on family size. NOTE: Appropriate ABD (Aged, Blind, Disabled) Medicaid income disregards and exemptions apply; ABD deeming rules do not apply. QUALIFYING EVENT:

An event for which the insurance company may offer continued health insurance to covered individuals. Qualifying events include: 1. covered employee dies (the surviving spouse may continue participating in the health insurance plan as a private pay individual); 2. covered employee’s employment is terminated or work hours reduced; 3. covered employee is divorced or legally separated from his/her spouse; 4. covered employee becomes eligible for Medicare benefits; 5. a dependent child attains the maximum age allowed by the insurance company and is no longer considered a dependent child under the applicable plan requirements; or 6. employer files for Chapter 11 bankruptcy. DURATION OF BENEFITS: COBRA benefits will end when one of the following occurs: 1. 18 months after the qualifying event if that qualifying event is due to termination of employment or reduction in hours. For any other event, please submit to the Policy Specialist. Or… 2. The date the employer ceases to offer a group health plan. Or… 3. Upon enrollment in other health insurance or Medicare. COST EFFECTIVENESS: HIPPS/Cost effectiveness is determined by the TPL Unit. TPL UNIT: HIPPS/Cost effectiveness questions are directed to: DPHHS HIPPS PO Box 202953 Helena, Montana 59620-2953 Phone: 1-800-694-3084 Fax: 1-800-444-1829 Email: hhshippprogram@mt.gov Effective Date: October 01, 2017

COMBINED MEDICAID 308-1 Application for Other Benefits Supersedes: MA 304-1 (01/01/07) Reference: ARM 37.82.101, .415; 42 CFR 433.138(e), 433.147, 433.148, 435.608. Overview: Medicaid clients must take necessary steps to obtain all benefits to which they are entitled, unless there is good cause for not doing so. Applicants and recipients must be informed of this requirement. Clients are not required to apply for benefits that do not affect Medicaid eligibility. Do not deny eligibility for a client who does not apply for a benefit they do not know is available. GOOD CAUSE: Good cause may exist if the: 1. client could not apply due to illness; or 2. client previously applied for the benefit and the denial reason has not changed; or 3. benefit is health insurance that requires the individual to pay a premium, unless: a. the State or some other entity will pay the premium, or b. the premium is lower than the individual’s outstanding spend down or his/her liability toward cost of nursing home care. MEDICARE ENROLLMENT: An individual may be entitled to Medicare benefits when s/he is: 1. 65 or older (regardless of qualifying work quarters); or 2. disabled and has received SSDI (Social Security Disability Income) benefits for 24 consecutive months, and has enough work quarters to qualify for Medicare benefits. An individual may enroll in Medicare A and/or B during either the: 1. initial enrollment period; this includes the three months prior to, the month of and the three months after his/her 65th birthday or 24th month of disability; or 2. open enrollment period; January through March of each year (with coverage beginning the following July). An individual may enroll in Medicare Part D during either the:

1. initial enrollment period outlined above, or 2. Part D open enrollment period; November 15 through December 31 of each year (for enrollment in the following year). To qualify for Medicare Part D, a beneficiary must be entitled to and enrolled in Medicare Part A and/or Part B. Medicaid applicants who did not enroll in Medicare Part A and/or B during the initial enrollment period may receive Medicaid coverage provided they enroll in Medicare during the next open enrollment period. Medicaid applicants who did not enroll in Medicare Part D may be automatically enrolled within two months of Medicaid approval. VETERANS ADMINISTRATION REFERRALS: Veteran’s benefits may be available to: 1. An honorably discharged veteran; 2. A widow(er) of a wartime veteran; 3. A widow(er) of a veteran who died or was killed while on active duty, or as a result of a service related disability; 4. An individual who is not currently married but was married to a wartime veteran who died of non-service related disability; 5. An individual that is not currently married but who was married to a veteran who died or was killed while on active duty, or as a result of a service related disability; 6. An individual less than 23 years of age who is a child of a deceased veteran; 7. A parent of a veteran who died while on active duty, or as a result of a service related disability. AND the individual: 1. has a service related disability; 2. is totally disabled because of a non-service related disability; 3. is age 65 or older; or 4. needs in-home, residential, hospital, or nursing home care. Effective Date: July 01, 2016

COMBINED MEDICAID 310-1 Community Engagement and Exclusion Policy

Supersedes: New Reference: P.L. 119-21 Overview: All individuals aged 19-64 applying for or receiving ACA Medicaid Expansion (known as HELP Act) must meet community engagement requirements or have a temporary exception int the lookback period; or qualify for an exclusion. If they qualify for an exclusion, then they are not required to complete community engagement qualifying activities. Once enrolled in Medicaid, these individuals will be evaluated every (6) months to determine if they continue to meet community engagement requirements, still have an exception, or qualify for an exclusion. NOTE: American Indian/Alaska Natives are not subject to the 6-month redetermination requirement and only need to be redetermined annually or when changes are reported. Available information (i.e., Perceptive documents, electronic interfaces, meeting program requirements in SNAP/TANF program, etc.) will be used to validate qualifying community engagement activities and exclusions. Information that is not available will need to be verified by the client. Qualifying Activities: All members are required to participate at least 80 hours per month in qualifying community engagement activities or earn the equivalent of 80 hours at the federal minimum wage per month, unless excluded or eligible for an exception. A combination of activities can also meet this requirement. Note: The household income should be used when determining community engagement compliance. Activities that meet the community engagement requirement include:

• Working 80 hours x federal minimum wage; or the equivalent • Community service: (volunteering for a not-for-profit organization or facility) • Workforce training or job readiness programs through the State of Montana, Internships, or registered apprenticeships • Attending school at least half-time (secondary, college or vocational school)

Work: Unpaid work can count towards community engagement hours if it is part of a trial period when applying for a job, or unpaid work, such as an internship, to gain experience for a job or industry. The unpaid work of a family caregiver who is not a relative and does not reside with the child or disabled individual, would count towards demonstrating community engagement. In-Kind Work: Compensation in non-monetary form (housing, meals, utilities) would count towards community engagement. Verification of hours and value of the in-kind work is required. Community service: means unpaid work, completed voluntarily or because of a mandate by court order, with a structured program that is completed for the direct benefit of the community under the auspices of public or nonprofit organizations (including embedded activities of the program that allow an individual to develop skills necessary to complete community service). The individual can participate in programs or activities without compensation which may include volunteer work or work mandated by legal authority and must be completed with a not-for-profit facility or organization where the public can participate. Education: If an individual is not enrolled in an educational program at least half-time, they may use credit hours enrolled towards community engagement hours. The state will calculate the allowable hours based on the verified enrolled hours. Independent study and self-paced online preparation do not qualify as an activity for the purposes of community engagement. In addition, if the program is not in- person, the program must be able to monitor and document the program hours. Ex. High school virtual classes. Exclusions: Specified Excluded Individuals The following specified excluded individuals are not subject to community engagement requirements. If individuals have an exclusion in the month of application or redetermination, they are not evaluated for community engagement criteria. • American Indian or Alaska Native or determined eligible for Indian Health Services • Veteran with a total disability rating

• Parent, guardian, caretaker relative, or family caregiver of dependent children under 14 years of age, or of a disabled person. (see Family Caregiver information below) • Pregnant or entitled to postpartum (up to 12 months after delivery) • Currently incarcerated • Enrolled in substance use disorder treatment program • Medically Frail: (see Medically frail section below) • Meeting program requirements required by the TANF program • Meeting program requirements for the SNAP program • Former foster youth: an individual under age 26 who was in foster care and Medicaid at the time of turning 18. Mandatory Exceptions Individuals normally subject to the community engagement requirement can be excepted for months in which they demonstrate a mandatory exception. Mandatory exceptions are subject to community engagement requirements and are evaluated in the lookback month(s) at application and redetermination. • Under age 19 • Entitled to or enrolled in Medicare Part A or Part B • Eligible under another eligibility group (PCR, SSI, etc.) • Incarcerated at some in the last three months • Specified excluded individuals during the lookback month are evaluated as mandatory excepted individuals for the number of months the exclusion was applicable. Short-term Hardship Exceptions: Applicable individuals normally subject to the community engagement requirement can be excepted for months in which they demonstrate the exception. Short-term hardship exceptions are evaluated in the lookback month(s) at application and redetermination. Verification of the hardship and the expected duration is required.

• Receiving service in inpatient hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities, inpatient psychiatric or similar services. • Individual or dependent has necessary travel for an extended period of time for medical services not available in the community for a serious medical condition. o The duration of these exceptions will be dependent on the individual’s circumstances. • Reside in a county where there is a federal emergency or disaster declaration.

• Reside in a county with an unemployment rate greater than the lesser of 8% or 1.5 times the national unemployment rate. o Subject to Federal approval

Program Participation Individuals eligible for expansion adult Medicaid coverage will be required to meet community engagement requirements, have a short-term exception, or qualify for an exclusion. For applications, the lookback period is (1) month prior to application. For redetermination, the lookback period is (3) months since the last redetermination. Community engagement requirements, exceptions, and exclusions must be verified. If the state verifies with data matching sources, no further verification is required of the member. If the state is unable to verify, the member is required to verify that they have met the requirements or verify the exclusion.

ACA Medicaid Expansion members/clients have multiple ways to self-report compliance with community engagement requirements, exception, or qualify for an exclusion, including online at apply.mt.gov, through the Public Assistance Helpline, by mail, Fax, and in person. There are multiple ways to verify an participation in community engagement, such as a statement from a physician or facility, written statements, enrollment in qualified programs, court documents. Etc. Ongoing exceptions or exclusions may need to be reverified with additional verification at redetermination. Penalties for non-compliance Individuals who have not met the community engagement requirements or qualify for an exemption or exclusion at their redetermination, or when changes are reported, will be notified they have 30 days demonstrate compliance with community engagement. Failure to verify community engagement during the 30-day period will result in denial or closure of Medicaid coverage. Once the individual is closed, they will need to reapply and demonstrate they are in compliance with community engagement requirements, have an exception, or qualify for an exclusion. Family Caregiver: An individual may be a caregiver of a dependent child or a disabled individual if they are an adult family member or other individual with a significant relationship. The community engagement exclusion may apply to individuals who provide care and: 1. They are a relative and provide primary care and may or may not live with the dependent child or disabled individual, 2. They are a parent, guardian, caretaker relative residing with the dependent child or disabled individual, or

3. They do not reside with and are not a relative of the child or disabled individual. They must provide assistance 80 hours per month and not on an incidental basis (babysitting).

An individual who is not related to, or living with, the dependent child or disabled individual and has documented caregiving hours for a disabled person of less than 80 hours per month, may apply those hours to unpaid work to meet the community engagement requirement.

All caregivers must verify hours and that the person receiving care is a dependent child or a disabled individual.

Medically Frail: Medically frail includes an individual: Who is blind or disabled per SSA (as defined in section 1614 of the act) With a substance use disorder (but not in treatment program or stable recovery for 5 years or more); With a disabling mental disorder; With a physical, intellectual, or developmental disability that significantly impairs their ability to perform one or more activities of daily living; or With a serious or complex medical condition

Note: Substance use disorder (SUD): Individuals who are in a treatment program for an SUD are excluded from community engagement requirements. Those who are not in stable recovery fall under medically frail. Stable recovery refers to those in recovery for 5+ consecutive years.

Serious or complex medical condition is an acute illness or condition or a Chronic illness or condition. • Acute Illness or Condition: A condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of: o Death o Permanent harm • Chronic Illness or Condition: A condition that is: o Life-threatening, degenerative, potentially disabling, or congenital o Requires specialized medical care over a prolonged period of time

A medically frail individual is excluded from meeting the community engagement requirements if the condition impacts the ability to work or to meet community engagement requirements of 80 hours/month.

Effective Date: 07/01/2026

COMBINED MEDICAID 401-1 Resource Ownership, Accessibility and Equity Value

Supersedes: 7/1/2016 Reference: ARM 37.82.101; 42 CFR 435.601 Overview: Resources are real or personal property that have economic value. Resources can include, but are not limited to, cash, savings, investments, house, land, vehicles, etc. The filing unit’s resources are evaluated for ownership, accessibility, and equity value. All resources are countable unless specifically excluded by regulation. Exclusions listed in this section do not apply to property the filing and/or assistance unit does not own. This includes, but is not limited to, property owned by or held in: 1. A trust of any kind (whether or not any filing/assistance unit member is a trust beneficiary or a trustor), 2. A corporation of any kind (whether or not any filing/assistance unit member is a corporate shareholder), 3. A partnership of any kind (whether or not any filing/assistance unit member is a partner), 4. A limited liability company of any kind (whether or not any filing/assistance unit member is a member of the company), or 5. Any other legal entity, instrument, device or arrangement of any kind confirming the filing or assistance unit does not own the property. LIQUID AND NON-LIQUID RESOURCES: Liquid resources are cash and other resources that can easily be converted to cash. Examples include, but are not to, stocks, bonds, mutual fund shares, promissory notes, mortgages, life insurance policies, financial institution accounts (savings, checking, time deposits/CDs) and similar items. Non-liquid resources are resources that cannot reasonably be immediately converted into cash. Non- liquid resources are not considered inaccessible or excluded simply because the value cannot be accessed in the benefit month. RESOURCE ACCESSIBILITY & AVAILABILITY: Resources are considered accessible either when actually available to the individual or when the individual has a legal or equitable interest in the property or asset and has the legal or equitable ability to access funds or to convert non-cash property into cash, regardless of whether the individual has the practical ability to access the funds or to convert non-cash property into cash.

Consider jointly owned resources accessible according to the information above unless the individual rebuts ownership or accessibility and can verify to the satisfaction of the following policies that the joint ownership does block accessibility of the resource. RESOURCE OWNERSHIP & EXCLUSIONS: Property held in trust or owned by a corporation is not owned by individuals who have an interest in the corporation or trust; no exclusions are applied to property the filing or assistance unit members do not own. Resource exclusions do not apply to trust or corporate property. NOTE: Individuals who own an interest in a corporation own STOCK, they do not own property held by the corporation. The stock has countable value based on the corporation’s assets and liabilities. OWNERSHIP: Resource ownership is determined by the: 1. Name(s) on the account, title, deed, contract, etc., 2. Source of account funds, 3. Purpose for which the account/investment was opened, and 4. Account/investment activity. If only one name is listed on the title, deed, contract, account, etc., the resource belongs to that individual. If more than one name is listed, the resource is considered jointly-owned. Once joint- ownership is determined, the resource’s accessibility must be evaluated. JOINTLY-OWNED RESOURCES: Resources owned jointly with someone outside the household must be evaluated to determine accessibility to the household. Consider the resource 100% available to the household, unless the: 1. Household verifies they have access to only a portion of the resource; (count the available portion’s value); or a. The percent of jointly-owned real estate the client owns is considered the accessible portion; b. Jointly owned bank accounts or other liquid resources are considered 100% available unless otherwise restricted. 2. Resource cannot be practically subdivided and the household’s access is dependent on the joint owner’s agreement, and the joint-owner refuses to sell. This provision does not apply to real property. REBUTTING OWNERSHIP OR ACCESSIBILITY: Resource ownership and/or accessibility must be rebutted in writing, and, as appropriate, all co- owners must sign the rebuttal. The rebuttal must include explanation and verification of: 1. How, and/or why co-ownership was established; 2. The names of individuals whose funds were used to establish the account or purchase the asset, and the amounts each invested; 3. The names of individuals who have made withdrawals or have used the resource; and 4. For what the resource has been used or how the funds were spent. Acceptable verification includes bank statements, agreements, deeds, titles, or other collateral statements. The applicant’s/recipient’s statement alone is not sufficient verification. If 100%

ownership/accessibility is successfully rebutted, action must immediately be taken by the applicant/recipient to separate commingled funds, remove the applicant/recipient’s name from the account/resource, or restrict his/her access to the account; whichever may be applicable to the situation. INACCESSIBLE RESOURCES: Do not consider a resource inaccessible simply because it is non-liquid or the client does not have practical access to the resource. A resource may be considered inaccessible if: 1. The resource’s value cannot be accessed for a reason beyond the owner’s control, and they have exhausted all legal avenues to access the resource’s value; or NOTE: Undue hardship may exist if the cost of accessing the resource exceeds the resource’s value. 2. A joint owner refuses to allow the individual to possess the resource (such as a savings bond); or 3. A joint owner lives on the property AND selling the client’s share would make the joint owner homeless; or 4. The client continually lists the resource for sale at no more than FMV for six or more months, AND Continuously listed for sale means: a. A local broker has the property listing; OR b. All the following are met: i. The property is continuously advertised in appropriate local media, AND ii. A ‘For Sale’ sign in posted on the property in clear view, AND iii. Open houses/showings are conducted on a continual basis, AND iv. All other appropriate attempts to sell are continually made. No reasonable offers (2/3 or more of current market value) are received. If an offer of 2/3 of the current market value or higher is received, a new property value is established for Medicaid purposes. NOTE: Before a resource is deemed inaccessible, conditional must be applied to the resource, as appropriate DETERMINING FAIR MARKET VALUE: Fair market value (FMV) is determined in various ways, depending on the resource type. For example, bank accounts and cash values are based on the amount of money on hand or in deposit. CDs and other time deposits are based on the amount that can be withdrawn after early withdrawal penalties (but not after taxes are withheld). Car values are based on NADA (J.D. Power) values or knowledgeable source (e.g., area car dealers) statements. If the vehicle can not be found using NADA (J.D. Power), Kelly Blue Book (KBB) may be used to determine the average trade-in value of the vehicle. Real estate value is based on area realtor/real estate broker statements. Tax appraisals cannot be used to value real estate as the value isn’t necessarily current or based on true sales potential. Other resource types are valued based on knowledgeable source statements or other means that are reasonable and appropriate to the resource type being valued. EQUITY VALUE:

To determine equity value, subtract all legal encumbrances from the FMV. Only debts (amounts owed) that are secured by liens or other legal encumbrances against the resource can be subtracted from the FMV when determining equity. COMMINGLING EXCLUDED AND COUNTABLE RESOURCES: If excluded and countable resources are commingled (mixed) in the same account, the specific fund sources must be identified to determine if the excluded funds remain excluded once commingled. There must be clear records (financial institution or owner) identifying and tracing each source for the excluded funds to remain excluded. Withdrawals from a commingled account are considered to be from non-excluded funds first, and then from excluded funds after all non-excluded funds are exhausted. FUNDS PRORATED AS INCOME: Funds that are prorated as income remain excluded from resources for the period they are prorated as income (even if funds are commingled). Effective Date: 9/1/2025

COMBINED MEDICAID 402-1 Countable and Excluded Resources Supersedes: CMA 402-1 (01/01/2026) Reference: ARM 37.82.101, .102, .903, 20 CFR 416 Subpart L; 42 CFR 435.601; 42 U.S.C. 1396p; P.L. 109-171; P.L. 109-432 Overview: ABD and Family Medically Needy: the equity value of all resources (real and personal property) the filing/assistance unit owns is countable unless specifically excluded by regulation. Resources the filing/assistance unit has a beneficial interest in are also countable. Inaccessible resources may be excluded. ACA Medicaid programs are not subject to resource tests or limits. Exclusions listed in this section do not apply to property the filing and/or assistance unit does not own. This includes, but is not limited to property owned by or held in: 1. A trust of any kind (whether or not any filing/assistance unit member is a trust beneficiary or a trustor), 2. A corporation of any kind (whether or not any filing/assistance unit member is a corporate shareholder), 3. A partnership of any kind (whether or not any filing/assistance unit member is a partner), 4. A limited liability company of any kind (whether or not any filing/assistance unit member is a member of the company), or 5. Any other legal entity, instrument, device or arrangement of any kind confirming the filing or assistance unit does not own the property. See CMA 402-3 Trust Funds Trust Funds for information regarding trust-owned resources. ACHIEVING A BETTER LIFE EXPERIENCE (ABLE) ACCOUNT: The ABLE Act permits people with disabilities to save money in and withdraw funds from their ABLE accounts (similar to checking and savings) to pay for disability-related expenses, in support of their efforts to maintain health, independence and quality of life. Funds in an ABLE account, including earnings on the account (e.g., interest) are excluded.

ALIEN’S SPONSOR’S RESOURCES: An alien sponsor and their spouse’s income and resources are deemed to the sponsored alien (refugees do not have sponsors) until such time as the alien: 1. Achieves U.S. citizenship through naturalization, or 2. Has worked 40 qualifying quarters. ANNUITIES: All commercial and private annuities, including single premium life endowment policies must be evaluated to determine their availability for the household’s support and maintenance and whether the annuity must be assigned to Montana Medicaid prior to eligibility determination. Annuity contracts such as Civil Service pensions and Railroad Retirement Benefit pensions use the term ‘annuity’ but are not the type of annuities that must be reviewed under resource policy; they are reviewed under income policy. NOTE: Annuity ownership, accessibility and equity value must be evaluated. Never assume an annuity is inaccessible (see CMA 401-1 Resource Ownership, Accessibility and Equity Value). Determine annuity value by multiplying the total annual payments by the remaining annuity period on the date value is determined. When the annuity period is based on an annuitant’s lifetime, multiply the annual payment by the annuitant’s life expectancy (ABD 016 Life Expectancy Table). For a “period certain” annuity, multiply the annual payments by the lessor of the annuitant’s life expectancy, or the period certain. The client can rebut the calculated value by providing verified purchase offers from sources in the legitimate business of buying annuities. A growing secondary annuity market exists; even non-assignable annuities can be sold. An annuity company’s letter stating an annuity is valueless is only the company’s statement of contractual obligations regarding cash value, and has no bearing on true market value. To prove there is no market value/inaccessibility, two refusals on the secondary market are required. The client cannot purchase or pay for a refusal to meet this requirement. Annuities owned by a community spouse, ineligible spouse or deemed parent are always a countable resource. The only means to exclude these annuities is if the annuity is period certain and the term has expired. Annuities a Medicaid client purchased or converted on or after February 8, 2006, must be changed to name the Montana Medicaid program as the irrevocable residual beneficiary before Medicaid is approved or redetermined. Beneficiaries must be listed in the following order: 1. Community spouse 2. Minor child 3. Blind/disabled adult child 4. Montana Medicaid program

Only those listed may be named a beneficiary above the Medicaid program; all other beneficiaries must be listed below the Medicaid program. A community spouse cannot name an institutionalized spouse as a residual beneficiary in a position above the Medicaid program. Count annuities owned by the Medicaid client or an eligible spouse unless all exemption criteria are met. NOTE: An eligible spouse is the ABD spouse of a Medicaid applicant/recipient where neither spouse is institutionalized or open on Waiver. Count annuities purchased or converted by a Medicaid client on or after February 8, 2006, unless determined to be an uncompensated asset transfer, or ALL of the following are met: 1. The client or eligible spouse are receiving scheduled payments; AND 2. Scheduled payments are made at least annually; AND 3. The contract requires equal payments (no balloon payments): AND 4. Payment schedule is actuarially sound (equal payments resulting in full payout based on the annuitant’s life expectancy); AND 5. The annuity is irrevocable; AND 6. The contract and payments are non-assignable. Annuities that are not amended to meet the above criteria are treated as uncompensated asset transfers. Annuities the institutionalized or community spouse purchases on or after February 8, 2006, are evaluated under uncompensated asset transfer rules if within the 60-month asset transfer look-back period. The following are not considered uncompensated asset transfers and do not require beneficiary assignment to the Medicaid program when payments are made to the account owner: 1. An individual retirement annuity (section 408, subsection (b) of the IRS Code of 1986); or 2. A qualified employer plan annuity (section 408, subsection (q) of the IRS Code of 1986); or 3. Purchasing an annuity with an IRA, employer, or employer association account; or 4. A qualified salary reduction arrangement (section 408(a), (c) or (p) of the IRS Code of 1986); or 5. A simplified employee pension (within the meaning of section 408(k) of the IRS code of 1986). Request assistance through the Service Desk if one of these situations is alleged. Evaluate individual retirement annuities both to determine an uncompensated asset transfer and whether or not a countable resource.

BASIC MAINTENANCE ITEMS: Exclude household goods and personal effects essential to day-to-day living such as clothes, jewelry, furniture, and other similar items of value including a home computer or satellite TV dish. BONDS: Countable. Bonds include United States savings bonds and Treasury bills, notes, and bonds. If a joint owner has physical possession and refuses to surrender possession to the client, the bonds are considered inaccessible and are excluded as they must be presented to cash them in. BURIAL ACCOUNTS/ CONTRACTS: Burial accounts (bona fide funeral agreements) that exceed $1,500 equity value per individual are countable in full unless the agreement is irrevocable. Exclude funeral agreements that are inaccessible or irrevocable. A funeral agreement/contract is irrevocable if: 1. Both the client and funeral home representative have signed the agreement; 2. The price of each major service is specified; 3. The total dollar amount of the agreement is specified; 4. The client was neither a minor nor legally declared incompetent when the agreement was signed; and 5. The agreement specifies in writing that the money is not refundable under any circumstances. 6. Additionally, if the agreement is created in Montana; a. The client must have been receiving public assistance at the time the agreement was signed or, b. The client must have applied for public assistance within 6 months of the execution of the agreement. PLEASE NOTE: All burial accounts/contracts that are created in a state other than Montana must be sent to the Policy Unit for review. ABD: Certain otherwise countable resources may be excluded for burial. These resources must be separately identifiable and set aside for burial expenses and may not be commingled. They include: 1. Life insurance, if the total face value of all life insurance owned by the individual is $5000 or less. 2. Funds in an irrevocable burial trust (see CMA 402-3 Trust Funds) or contract (see above for irrevocable burial contract definition). 3. A maximum of $1500 per individual set aside in an account if designated by account title or via signing HCS-470 “Burial Designation”. This $1500 exclusion is reduced by the face value of ordinary life insurance whose cash surrender

value has been excluded, as well as by the value of any burial trusts or contracts or other resources designated for burial. The $1500 exclusion is not reduced by the value of burial plots. These funds are excluded effective the date they are designated as burial funds. Any funds (interest or principal) that are later withdrawn from an excluded burial fund will be considered income to the individual in the month after the month in which the withdrawal is discovered by/reported to OP. 4. Any interest earned on an account designated for burial which is left to accumulate and become part of the burial fund is excluded as income and as a resource. Do not enter the accumulated interest onto the system as income. NOTE: Funds may be designated for each household member. BURIAL PLOT: Exclude the value of one burial plot for each immediate family member. NOTE: Immediate family members include the client’s children, siblings, and parents. The family member need not be dependent upon or living with the client. Burial plots are real property for conditional assistance purposes (if a single individual has two burial spaces, but no family member to designate the second burial space to, for example). SEE REFRESHER TRAININGS: Course: ABD Resources - Overview (dphhselearn.org) & Course: Life Insurance & Burial Accounts (dphhselearn.org) BUSINESS ACCOUNT: Exclude funds held in a business account that represents necessary business capital, operating funds, or funds prorated as income. If funds have not been prorated as income, see ‘Property/Equipment Necessary for Employment’. CAMPER: Campers not intended to provide transportation (camp trailers, truck toppers, etc.) are countable unless otherwise excluded (e.g., used as a home). CASH ON HAND: Countable, unless it represents the current month’s income, then it is excluded. CERTIFICATE OF DEPOSIT (CD): Countable. A CD’s value is the net amount received after penalties for early withdrawal, if applicable. Taxes are not deducted. Determine the CD’s net value using a detailed breakdown from the institution holding the deposit. The breakdown must include the gross deposit and individually identify any/all deductions and penalties that are subtracted from the gross if funds are withdrawn.

CONTRACT FOR DEED: Exclude contract for deed value if: 1. The written contract terms include at least annual payments from the purchaser to the contract owner; and 2. The contract terms are being met. If the written contract terms are not being met, the household/owners must exhaust all available legal recourse to enforce the contract terms before Medicaid can be approved. If the contract terms do not include provisions for at least annual payments to the contract owner, the unpaid balance or highest purchase offer from a knowledgeable source is considered an available/countable resource, unless contract terms specifically prohibit sale. If a contract was entered into during the look-back period and did not contain these payment provisions, an asset transfer must be evaluated (CMA 404-1 Asset Transfers). If an unscheduled lump sum payment is made to the contract principal, the unscheduled payment is income in the month received and a resource thereafter, to the extent retained. Refer to CMA 501-1 Unearned Income for information regarding how contract for deed income is counted. CREDIT UNION ACCOUNTS: Countable, unless otherwise excluded (i.e., portion that is the current month’s income or funds prorated as income). DEBIT CARDS: Count the available balance, less current month income deposited or added to the card. Debit cards include prepaid or electronic funds deposit accounts where the individual has access to available funds (including, but not limited to Direct Express, Walmart Debit cards, prepaid credit cards, etc.). DOMESTIC VOLUNTEER SERVICES ACT: Excluded in month of receipt, countable the following month. This includes RSVP, Foster Grandparents, SCORE, and ACE programs funded through this act. EDUCATIONAL INCOME: Exclude all educational income (including Title IV, BIA, VA, Work Study for post- secondary education). The individual must be enrolled in school and attending classes to be considered a student. See CMA 401-1 Resource Ownership, Accessibility and Equity Value FAMILY SELF-SUFFICIENCY ESCROW PROGRAM ACCOUNTS: Exclude funds held in an escrow account while the household participates in a HUD (Housing and Urban Development) Family Self-Sufficiency Program.

FUND RAISING ACCOUNT: Account or fund-raising site established to provide financial and/or medical support for an individual (such as GoFundMe). Countable or excluded based on who established and who can access the account: · Excluded if someone other than the beneficiary set up the account, and the beneficiary does not have access to make withdrawals. Income provided to the beneficiary directly from the account is treated as unearned lump sum payment if it can be anticipated. Payments made directly to creditors are considered vendor payments and are excluded. · Countable if someone other than the beneficiary set up the account and the beneficiary has access to make withdrawals. · Countable if the beneficiary set up the account. HOME and SURROUNDING PROPERTY/LOT: Exclude the home and surrounding property. Property separated from the home property by a road or other right-of-way is not considered part of the property surrounding the home and is not excluded. Count a home located outside of Montana even if intent to return exists as maintaining a residence in another state indicates residency in that state. One vehicle used as a home may be excluded. If a vehicle is being excluded as a home, no other property may also be excluded as a home. Only one home that is the filing/assistance unit’s principal place of residence is excluded. See CMA 0-4 Acronyms and Glossary "Glossary" for the definition of principal place of residence. A home may continue to be the individual’s principal place of residence, even though the individual is temporarily absent from it. See CMA 302-2 Temporary Absence from the Home for temporary absence information. ABD: The exclusion is provided as long as the client, their spouse, Power of Attorney, legal guardian, or Medicaid authorized representative expresses the client’s intent to return to the client’s principal place of residence. ABD: Do not consider the home exclusion when determining the Home Maintenance Allowance (ABD 805-2 Post Eligibility Treatment of Income (PETI)) or applying Lien and Estate Recovery provisions (CMA 304-4 Lien and Estate Recovery). A home will also be excluded as the principal place of residence if it is newly purchased and the applicant/recipient has not yet moved in, but will move in within 30 days (i.e., newly purchased mobile home that must be set up prior to owner moving in). Count land on which the client is building on or intends to build. Nursing home and waiver benefits cannot be covered/paid for an applicant who has home equity greater than $752,000(effective 01/01/2026), regardless of whether or not they intend to return home or are still living in the home (waiver). This limit does not apply if a community spouse or a minor or disabled child lawfully resides in the home.

INCOME PRODUCING PROPERTY: For property used in a trade or business (e.g., farming), see ‘Property/Equipment necessary for Self-Employment.’ Exclude income producing property necessary for self-employment. Count the equity value of income-producing property not used for self-employment. Family Medically Needy: Rental Property is not excluded solely on the basis that it is being rented. Rental property is only excluded when the owner is in the property rental business (the owner must be materially participating in the rental operation and decision-making a minimum of 10 hours per week). If the owner is not materially participating at least 10 hours per week, the property’s equity value is countable. ABD: If the property owner is actively participating in the business operation and decision making at least 10 hours per throughout the year, states the business is self- employment, and, if filing income taxes, reports the income on Schedule C, F or SE, treat the property as necessary for self-employment. If the above requirements are not met, treat the property as income producing. ABD: Exclude $6,000 of the income producing property’s equity value (not necessary for self-employment) when the annual net income produced is at least 6% of the FMV. The $6000 exclusion applies to the total combined value of ALL income producing property the individual owns or jointly owns (except life estate property, which may be separately excluded). The 6% income production/$6000 equity exclusion does not apply to any resource used in self-employment or used to produce items for home consumption. INDEPENDENCE ACCOUNTS: Qualifying Independence Accounts (including the interest on and earnings from) are excluded while the client is receiving coverage under the Montana Medicaid Workers with Disabilities (MWD) program. There is no minimum or maximum limit to establish the account or that can be deposited into an existing account while the client is receiving coverage under MWD. In order to meet the resource exclusion, the Independence Account must meet all of the following criteria: 1. The account must be established by the beneficiary when MWD coverage begins or while receiving MWD coverage; AND 2. The account must meet the Department's approval and be designated as an Independence Account; AND 3. The funds in the account must be held separate from non-exempt resources. Once the client's coverage under MWD ends, the following rules apply: 1. The amounts contributed to the account (including the interest on and earnings from the account) during the individual's coverage under MWD shall be excluded.

2. No additional deposits into the account are permitted once the individual's MWD coverage ends. 3. Account activities are subject to standard eligibility resource policies including asset transfer evaluations. INDIVIDUAL DEVELOPMENT ACCOUNT: IDAs may be established by or on behalf of a TANF eligible individual. IDAs are created and funded through periodic IDA contributions and are matched by or through a not-for- profit organization or a State/Local government agency in cooperation with such organization. IDAs are designed to enable an individual to accumulate funds for post- secondary education, first home purchase or business capitalization. Montana has a TANF-funded IDA pilot program. Exclude account funds, including interest earned, as long as the individual maintains/makes contributions to the account. TANF-funded IDAs remain excluded after the individual’s TANF closes as long as the individual maintains/makes account contributions. Exclude matching funds, interest paid and disbursements for qualifying purposes. Emergency withdrawals are considered loans and are excluded income. ITEMS OF UNUSUAL VALUE: Countable. See also ‘Basic Maintenance Items’. Vehicles are not considered items of unusual value. LAND: Countable, unless specifically excluded. Count land the client is building on or intends to build on. Exclude land that is contiguous to the property the home is on. LAND IN CONSERVATION RESERVE PROGRAM (CRP): Countable or excluded, depending in circumstances. Exclude the CRP (Conservation Reserve Program) land as necessary to produce income if the individual is actively farming/ranching on land not in CRP. When the client is not farming/ranching other land, CRP land can only be excluded if the owner is in the property rental business (the owner must be materially participating in the rental operation and decision-making a minimum of 10 hours per week). If materially participating at least 10 hours per week, the CRP property is excluded as part of a self- employment business. Count the property’s equity value if the landowner is not materially participating at least 10 hours per week. ABD Only: If the landowner is not materially participating at least 10 hours per week, the CRP property is subject to the $6000/6% rule listed in “Income Producing Property”. LIFE ESTATES: A life estate is a durational property right limited to the life estate owner’s life, or to another person’s life. The life estate owner does not have the property title and cannot

sell the property. They can, however, sell their interest in the property, unless the contract terms restrict the sale (life estate value is excluded if the sale is restricted), and they are entitled to any property income. NOTE: Mineral or oil rights cannot be sold or leased without the titleholder’s specific consent. Determine life estate value by multiplying the property FMV by the percentage listed on the “Life Estate Interest Table” (ABD 017 Life Estate Interest Table) for the life estate owner’s age. NOTE: When more than one person owns a life estate, base the value on youngest owner’s age. Exclude a life estate if it is the client’s principal place of residence. Life estate value may be excluded if the property is used to produce income, and the annual net income produced is at least 6% of the FMV. This exclusion can apply to a life estate on: · A private residence that the life estate owner or his/her dependents do not occupy, and that does not meet the principal place of residence definition; or · A business property, such as a ranch or commercial property. NOTE: If the life estate property is business property (such as a ranch or other business property) and is excluded as a home, if ANYONE is using the property as part of a business, the life estate owner must be receiving income for the property’s use (rental or lease income). If the life estate owner is not receiving income from the user, evaluate this as an uncompensated transfer of income, per CMA 404-1 Asset Transfers. An uncompensated asset transfer penalty is evaluated when the client purchases a life estate in another person’s home. See CMA 404-1 Asset Transfers. The client can overcome the penalty if they live on the property as their principal place of residence for at least one full year after the purchase date. If the individual lives on the property for one year after purchasing the life estate, the life estate is excluded as the individual’s and/or their spouse’s home. If they move from the property, the property must be generating income consistent with the property’s value to remain excluded. Conditional assistance may be used to exclude a life estate. Because conditional assistance rules consider life estates as personal property, the six-month conditional assistance period applies. LIFE INSURANCE: Exclude term life insurance policies. Family Medically Needy: Exclude the cash and face values of all ordinary (whole life or straight life) life insurance policies. ABD: Exclude the cash and face values only when face value of all insurance policies for an individual is $5000 or less. If the client cashes in or borrows against their whole life insurance policy, the proceeds are countable resources in the month of receipt.

LIMITED LIABILITY COMPANIES (LLC): A type of business organization that offers the limited liability of a corporation and the tax benefit of a partnership. LLCs may have one or more members and are treated as corporations for resource purposes. Each LLC member’s proportionate interest is countable, unless an enforceable no-sell agreement exists, or the LLC is inaccessible. Value is determined by dividing the company’s net value (assets less liabilities) by each member’s documented individual interest. Evaluate an uncompensated asset transfer anytime an action is taken (such as entering into a no-sell agreement) that causes the LLC to become inaccessible. LIVESTOCK: Exclude livestock necessary for employment, raised for home consumption or that are pets. Income-producing property policy applies to livestock used to produce income not related to a business/self-employment. This may be referred to as a “run on shares” by another individual. LOANS GIVEN by the HOUSEHOLD/PROMISSORY NOTE: A promissory note or other loan given by an applicant or recipient is considered personal property (usually a liquid asset) and is countable, unless the note/loan is legally inaccessible. The lender holds legal interest and has the legal ability to make available his/her share in the note/loan. The equity value of the note/loan (the principal reduced by any third-party lien) is countable. If a household makes a loan that is considered inaccessible or is shown to have significantly lower market value than the unpaid balance of the loan, the loan will be considered to be an uncompensated transfer of assets (follow policy in CMA 404-1 Asset Transfers, including rebuttal period). The uncompensated asset transfer will be considered the outstanding balance due on the loan as of the date of the lender’s application for nursing home or waiver services. Examples of loans which might be considered inaccessible or have significantly lower market value include, but are not limited to: 1. A loan that is not secured by a lien against property of equal or greater value than the loan amount. 2. A loan that contains provisions for forgiving the loan upon the death of the lender (i.e., when the person loaning the money dies, the loan is considered paid in full). 3. The repayment terms of the loan are not “actuarially sound.” For example, a loan that contains unreasonable repayment provisions, such as a $10,000 loan with a repayment requirement of $10 per month, which cannot be expected to be repaid within the reasonable lifetime of either the lender or borrower. 4. A verbal loan agreement.

5. The loan allows for sporadic, unequal, deferred, or balloon payments. Also see CMA 401-1 Ownership, Accessibility and Equity Value Inaccessible Resources. LOANS RECEIVED by the HOUSEHOLD: Exclude loans in the month received and the following month. LUMP SUM PAYMENTS: Excluded income in month of receipt (if cannot be prospected); countable resource the following month, unless otherwise excluded. Countable lump sum payments may include, but are not limited to lottery winnings, gifts, gambling winnings, inheritance, etc. Exclude retroactive Social Security or SSI payments retained in bank accounts or as cash for nine months after the month of receipt. (P.L. 108-203). NON-HOME REAL PROPERTY: Count the equity value of non-home real property, whether listed for sale or not, unless the property’s value is inaccessible or otherwise excluded. Land on which the individual intends to build or is building is countable. Encumbrances against the property are considered in determining equity value. Medicaid liens are considered encumbrances if Lien & Estate Recovery Unit confirms the liens are currently enforceable. OIL and MINERAL RIGHTS: Exclude oil and mineral rights when the property’s surface rights are excluded (e.g., as the home). See ‘Royalty’ in CMA 501-1 Unearned Income, for oil and/or mineral right income. Acceptable verifications include deeds, lease agreements, titles, and homestead documents. If oil and/or mineral rights are producing income under a lease agreement, the owner may be constrained from selling or otherwise disposing of those rights. A knowledgeable source (e.g., area brokers, Bureau of Land Management or companies that lease mineral rights) may be able to provide fair market value. Equity value is determined by subtracting encumbrances/liens from the fair market value. PATIENT TRUST ACCOUNT of a NURSING HOME/ INSTITUTION RESIDENT: Countable. Patient trust accounts are administered by nursing homes or similar facilities and may hold only a small amount of spending money or may hold all of a patient’s unspent funds.

PERSONAL CHECKING ACCOUNT: Countable. Current month income deposited into a bank or credit union account is income in the month received and a countable resource in future months, to the extent retained. PLAN for ACHIEVING SELF-SUPPORT (PASS): Exclude income an SSI recipient deposits into an approved PASS account, as well as the PASS account itself. The exclusion continues until the PASS contract expires or ends or the individual no longer receives SSI payments. PREPAYMENT of MORTGAGE, RENT or OTHER EXPENSES: Prepaying rent is a countable resource unless the individual cannot receive the money back under any circumstances (i.e., lease agreement has a ‘no refund’ policy or the landlord states, in writing, that funds will not be returned to the renter). Unless the facility refuses to refund the payment, prepaying nursing home facility charges that exceed the estimated patient liability is a countable resource. Prepaying a mortgage is not considered a resource. PROPERTY/ EQUIPMENT ESSENTIAL for EMPLOYMENT: Excluded as essential for the production of earned income, unless otherwise indicated below. See also ‘Income Producing Property’ in this section and “Resources” in the Self-Employment Income section, CMA 503-1 Self-Employment Income Exclude resources that, as a condition of employment (other than self-employment), must be furnished by the employee. An employer-employee relationship must exist that requires the employee to furnish the resources/tools. NOTE: Other business structures, including LLCs, partnerships and other entities, may report income on Schedule C, F or SE. These entities are not self-employment businesses and property owned by them is not owned by the household; therefore, these resource exclusions do not apply. To exclude property as necessary for self-employment the property owner must be materially participating in the self-employment business a minimum of 10 hours per week. See ‘Income-Producing Property’ for more information. Self-employment/farm resources may include: · Tools/equipment such as those needed by a carpenter, mechanic, cosmetologist, etc.; · Stock (such as office supplies) or raw materials · Personal property essential for income production · Office equipment such as furniture, computers, calculators, etc. · Business loans for the purchase of capital assets · Inventory · Machinery and equipment

· Other items needed to produce income; and · Business/commercial checking account o Self-employment funds retain their exclusion for the period they are prorated as income, even when commingled. o Business/commercial checking account funds that are not prorated as income may be excluded as business working capital, business loans, etc. Resources may be excluded for up to one year due to temporary inactivity in the trade or self-employment business. The client must plan to actively return to the same trade/business within one year from the month they are no longer materially participating in the trade/business. If the client does not return to the business, the resources become countable. Exclusions are only applied to property the filing/assistance unit owns. Property owned by a partnership, incorporated business, LLC or other business structure is not excluded as necessary for self-support. PROPERTY IN PROBATE: Excluded; ownership must be evaluated once probate is settled. RESOURCES USED AS COLLATERAL: Count only the equity/accessible portion of a resource used as collateral for a loan. If the lien/agreement contains language specifically stating the resource cannot be sold, it is considered inaccessible. RETIREMENT ACCOUNTS/ PENSION PLANS: A retirement account or pension plan is an investment account that is intended to provide income at retirement. The equity value is the cash value minus any early withdrawal penalty. Clients must avail themselves of periodic payments when that option is available. Excluded when the client is receiving periodic payments, and the account principal is unavailable as a result of these payments. Countable (full account balance) when the client is receiving periodic payments, but the account principal is available as a lump sum. A breakdown from the institution holding the deposit, showing gross deposits and individual deductions as well as penalties for withdrawing the funds is needed to determine the account’s net value. Employment-related retirement accounts: Inaccessible when the individual remains employed with the business/entity holding the account. Countable the day after employment is ended, even when funds are not immediately distributed. 401-K: Excluded when the individual remains employed with the business/entity through which the account was established. Countable the day after employment is ended.

Individual retirement account (IRA): Count the equity value. If IRA funds are used to buy an annuity, the annuity is evaluated under annuity income and resource policies. KEOGH Plans: Countable, even when funds are not being accessed. SAFE DEPOSIT BOX: Contents must be reported and verified. SALE OF A RESOURCE: When an excluded or countable resource is sold, the proceeds remain excluded or countable in the month sold. Count any proceeds remaining the following month (e.g., cash, savings account, etc.) If a self-employment resource is sold, see CMA 503-1 Self- Employment Income, ‘Capital Gain or Loss’. SAVINGS ACCOUNT: Countable. Exclude current month income deposited into the account when determining account value. SECURITY DEPOSITS: Exclude rental and utility security deposits for both landlords and tenants. SELF-EMPLOYMENT RESOURCES: Exclude property essential to self-employment. For additional information, see ‘Business Accounts’, ‘Income Producing Property’, ‘Loans’ and ‘Property Essential for Self-Employment’ in this section and ‘Vehicles’ in CMA 403-1 Vehicles. NOTE: LLC, corporation, and other similar business arrangement owners do not own the company or business property; they own stock or shares in the business. SETTLEMENTS & RESTITUTION PAYMENTS: Proceeds of legal decisions and settlements are countable unless specifically excluded by rule or federal act. Agent Orange: Exclude payments made under the Agent Orange Compensation Act (P.L. 101-201). Count payments made to veterans under the Agent Orange Act of 1991 (P.L. 102-4). Asbestos: Count funds received from an asbestos settlement or lawsuit. The funds are countable the earlier of date available or date received. Cobell et al vs. Salazar: Exclude payments derived from this settlement (P.L. 111-5) Crime Victims Compensation Act: Exclude all payments received und this act. (P.L. 103-322). Disaster & Emergency Assistance: Exclude funds issued due to a presidentially declared disaster (PL 100-707) or due to a major disaster or emergency per the Disaster Relief

and Emergency Assistance Amendments of 1988. See also ‘Fire or Casualty Insurance Proceeds’ in this section. Governmental disaster payments designated to restore a home damaged in a disaster are excluded if the household can be legally sanctioned for not using the funds as intended. This includes some, but not all, Federal Emergency Management Agency (FEMA) payments. Factor VIII or IX Concentrate Blood Products Litigation, MDL 986 (No. 93-C-7452, Northern District of Illinois): Exclude payments hemophilia patients receive as a result of this class action lawsuit. Fire or Casualty Insurance Proceeds: Treat cash benefits received as proceeds of fire or casualty insurance claims to make repairs to or dispose of damaged property as follows: Exclude a settlement only when it is for replacement or repair of an excluded resource. If the settlement is related to a countable resource, the settlement is also countable. When the settlement is excluded as income, it is also excluded as a resource for up to 9 months. If good cause exists, an additional 9-month exclusion may be allowed if the repair/replacement is not completed within the original 9-month period. Keepseagle vs. Vislack – Settlement of Tribal Trust Accounting and Management Lawsuits: Count settlement payments in the month received, when they can be prospected. Nazi Persecution Victims Exclude restitution payments made under the Victims of Nazi Persecution Act of 1994 (P.L. 103-286) Nez Perce et. al. v. Salazar – Settlement of Tribal Trust Accounting and Management Lawsuits: Exclude payments derived from this settlement. Radiation Exposure: Exclude payments made under the Radiation Exposure Compensation Act (P.L. 101-426). Spina Bifida: Exclude payments made to children of Vietnam veterans for spina bifida related disabilities (P.L. 104-204). Structured Settlements: A structured settlement is a financial or insurance arrangement including periodic payments that a person (claimant) accepts to resolve a personal injury claim as an alternative to a lump sum settlement. Usually, the periodic payments portion of a structured settlement is funded through the purchase of an annuity. The annuity is not owned by the person to whom the settlement and payments are due (claimant). The annuity is owned by the entity that was liable for the injury/claim (usually an insurance company). Annuity criteria and regulations addressed earlier in this manual do not apply to annuities that fund structured settlements in personal injury claims, because annuities that fund structured settlements are not owned by the person to whom the payments are made. The injured party (claimant) only has a right to the stream of income, not to the annuity itself.

Structured settlement annuities which contain non-assignment language and in which no payments have been sold to third parties (usually companies in the business of purchasing structured settlements) are not resources to the injured party (claimant) entitled to the payments. If an injured party (claimant) has sold some, but not all of their rights to a structured settlement annuity to a third party, their right to any remaining stream of income is a countable resource---it has clearly been shown to be accessible in a lump sum by the past partial sale/assignment. Susan Walker V. Bayer Corporation, et al, 96-C-5024 (Northern District of Illinois Exclude payments made as a result of this class settlement and payments made as a result of a case entered into in lieu of the class settlement when signed by all affected parties on or before December 31, 1997. Wartime Relocation of Civilians: Exclude payments made to certain U.S. citizens of Japanese ancestry, resident Japanese aliens and certain eligible Aleuts under the Restitution for World War II Internment of Japanese Americans and Aleuts/Civil Liberties Act of 1988 (P.L. 100-383). STOCKS AND MUTUAL FUNDS: Countable, unless otherwise excluded as indicated below. NOTE: Exclude stock in a ‘close’ or ‘family corporation’ when there is a no-sell agreement among stockholders; the stock is considered inaccessible. TAX REFUND/ CREDIT: Treat tax refunds and credits as follows: Child Tax Credit: Excluded in month of receipt and following month. Earned Income Tax Credit (EITC): Excluded in month of receipt and following month. Income Tax Refund - Federal/State: Excluded in month of receipt; countable resource the following month. Renters/Homeowners Credit: Excluded in month of receipt; countable resource the following month. TRAILERS: Countable, unless otherwise excluded (e.g., home, income producing, etc.) This applies to all trailers, including 5th wheels. TRUMP ACCOUNT (TA): A tax advantaged traditional individual retirement account (IRA) established for children. Excluded through December 31 of the calendar year the beneficiary turns 17. Beginning January 1 of the calendar year the beneficiary turns 18, the TA is a countable

resource valued at the amount the beneficiary could withdraw after any early-withdrawal penalty, unless another exclusion applies. Effective date: 8/1/2026

COMBINED MEDICAID 402-2 Native American Resources Supersedes: FMA 402-2 (01/01/08); MA 402-2 (01/01/08); Bulletin FMA 53/MA 94 (12/19/08); Bulletin FMA 58/MA 99 (11/20/09); Bulletin FMA 68a/MA 111a (08/01/12); Bulletin FMA 68b/MA 111b (08/01/12); Bulletin FMA 70/MA 113 (11/05/12) Reference: OBRA ‘93; ARM 37.82.101, .903; 20 CFR 416, Subpart L; 42 CFR 435.601; P.L. 111-5 (American Recovery and Reinvestment Act of 2009) Overview: The equity value of the filing/assistance unit’s owned resources (real and personal property) are countable unless specifically excluded by regulation. COUNTABLE RESOURCES: Countable resources include, but are not limited to retained proceeds of the following payments: 1. Tribal payments unless otherwise excluded; 2. Tribally managed gaming revenues distributed per capita (P.L. 98-64); 3. Resources purchased with funds which are no longer clearly identifiable as excluded; 4. Bureau of Indian Affairs (BIA) payments, unless otherwise excluded; 5. Transfers of countable monies from other Native American agencies; 6. Fee patent land; and 7. Payments derived from the Keepseagle vs. Vilsack settlement of Tribal Trust Accounting and Management Lawsuits are countable income in the month received (to the extent they can be anticipated), and a countable resource in future months, if retained. EXCLUDED RESOURCES: Excluded Native American resources include: 1. 107th Meridian Settlement payments (AKA Senior Benefit payments) received by the Crow elders; 2. Retained proceeds of any payment that was an excluded Native American income when received. This may include, but is not limited to: a. All payments (regardless of amount) per individual per calendar year derived from leases or other uses of individual interests in trust or restricted lands; b. Farm and grazing leases, oil and gas royalties and mineral rights payments from land other than trust or restricted land;

c. Gravel sales; d. Timber sales; e. Estate payments; f. Oil and gas bonuses; g. Mineral rights bonuses; h. Right-of-way payments; i. Seismic payments; j. Land sale proceeds; k. Judgment claim payments as listed in CMA 501-2; l. Payments derived from sub-marginal lands held in trust; m. Per capita to enrolled members of certain tribes when distributed under specific public laws as listed in CMA 501-2; n. Ownership interests in rents, leases, royalties or usage rights related to natural resources. 3. Interest earned on all Native American funds/resources; 4. Resources purchased with excluded Native American funds; NOTE: This exclusion extends to only the original items purchased with excluded funds. 5. Individual enrolled tribal members’ interests in trust or restricted lands, oil and mineral rights, and improvements (buildings) on such land; 6. All compensation (including cash, stock, partnership interest, land, interest in land, and other benefits) received under Section 15 of P.L. 100-241, 2/3/88, (the Alaska Native Claims Settlement Act Amendments of 1987); 7. Reimbursements from the Uniform Relocation Assistance and Real Property Acquisition Policy Act of 1970 (P.L. 91-646, Section 216); 8. Funds paid to heirs of deceased Indians under the Old Age Assistance Claims Settlement Act; 9. Payments derived from the Cobell settlement are excluded as a resource as long as the funds can be specifically identified as being from this settlement, including Tribal land buyback program; and 10. Payments derived from the Nez Perce et.al, v. Salazar settlement of Tribal Trust Accounting and Management Lawsuits are excluded as a resource as long as the funds can be specifically identified as being from the this settlement. 11. The first purchase made with excluded Native American funds retains the exclusion. In the case of commingled funds, exclusion continues so long as the excluded funds are clearly identifiable. When excluded income/resources are no longer clearly identifiable in a commingled account, exclusion no longer applies. See ‘Commingled Funds’, CMA 401-1. INDIAN LANDS: Indian (Native American) land held jointly with the Tribe or land that can only be sold with the Bureau of Indian Affairs approval is excluded, as are any improvements (buildings, etc.) to the excluded trust land. Oil and mineral rights on Indian land are also excluded.

Fee patent land is countable, unless otherwise excluded (home, necessary for self-employment, etc.). See “Glossary” for further explanation of fee patent land. Oil and mineral rights connected to fee patent land are treated according to policies at CMA 402-1. INDIVIDUAL INDIAN MONEY (IIM) ACCOUNTS: IIM accounts are excluded. Normally it is not necessary to verify an IIM account. However, documentation may be needed to verify a resource exclusion if the resource was purchased with IIM funds. Effective Date: July 01, 2016

COMBINED MEDICAID 403-1 Vehicles Supersedes: FMA 403-1 (07/01/02); MA 403-1 (01/01/07) Reference: ARM 37.82.101, .703, 903; 20 CFR 416.1218 Overview: The equity values of all vehicles the filing/assistance unit members own are countable resources unless specifically excluded by policy. All vehicles must be evaluated to determine resource eligibility. OWNERSHIP: If the title of the vehicle lists only one name, the vehicle belongs to that individual, regardless of accessibility. Leased vehicles are not owned by the individual and therefore only need to be documented in case notes. If a vehicle is in the process of being bought or sold, clearly document in case notes verification used to determine ownership. NOTE: One vehicle may be used as a home even if it is also a means of transportation. The vehicle’s equity value is excluded as a resource as long as it is used as a home. When the vehicle is no longer used as a home, the information is updated. JOINTLY-OWNED VEHICLES: If the title lists more than one name, the vehicle is considered jointly-owned. A jointly-owned vehicle is assumed accessible to the client unless he/she can thoroughly explain and verify why it cannot be sold. DETERMINING ACCESSIBILITY: The following guidelines should be used to determine accessibility. 1. If the client has possession of his/her jointly-owned vehicle, the equity value is countable in full regardless of whether or not the other owner(s) agrees to sell the vehicle. NOTE: If a jointly- owned vehicle’s ownership is being considered in a legal proceeding and the owners are prohibited from selling the vehicle, it is considered inaccessible and, therefore, excluded until such time as the applicant/participant can legally sell the vehicle. (Legal prohibition includes, but is not limited to, court injunction and probate which might occur during a divorce action.) 2. If the individual does not have possession, he/she must document why he/she cannot access the vehicle. FAIR MARKET VALUE:

Use the average trade-in value as the vehicle’s current fair market value (FMV). EQUITY VALUE: The vehicle’s equity value is counted toward the resource limit. Equity value is determined by deducting the amount owed (liens/ encumbrances) from the fair market value. KNOWLEDGEABLE SOURCE: Valuations from a knowledgeable source, such as the county assessor or a car dealer, are needed for the following vehicles: 1. A new vehicle; 2. A vehicle where the stated value is questionable; 3. The owner does not agree with the established FMV; 4. A vehicle is considered an antique/classic or is custom built. EXCLUDED VEHICLES: The following vehicles are excluded: 1. Inaccessible vehicles; 2. One vehicle being used as a home; 3. Vehicles used primarily to produce income; e.g., taxi, semi-truck, fishing boat; 4. Vehicles previously used for self-employment (e.g., logging truck); that are no longer income producing because the client is no longer engaged in that business. The exclusion is only allowed if the individual intends to use the vehicle for self-employment within one year from the date the self-employment business was terminated. 5. Family Medically Needy: One vehicle with the highest equity value. 6. ABD: One vehicle is totally excluded regardless of value if it is used to transport the client or a household member. a. If more than one vehicle meets the ‘used for transportation criteria’, the vehicle with the highest equity value is excluded. The remaining vehicles’ equity values are countable resources. b. The equity values of any vehicles not used to transport the client or a household member are countable resources. SELF- EMPLOYMENT, INCOME PRODUCING & REQUIRED FOR EMPLOYMENT: Vehicles necessary for self-employment are exempt under provisions of “Property/Equipment Necessary for Employment or Self-employment” located in CMA 402-1. If self-employment ceases, the vehicles must be reevaluated. When self-employment stops temporarily the vehicles and other self-employment equipment may continue to be exempt for 12 months, as long as the client intends to return to the self- employment business.

ABD: Vehicles used to produce income, that are not related to self-employment (such as a taxi cab that is leased to someone else), are tested to the 6%/$6000 equity exemption rule. See CMA 402-1 “Income Producing Property”. Vehicles required as a condition of employment may be excluded. An employer-employee relationship must exist between the vehicle owner and the employer requiring the individual to furnish a vehicle as an employment condition. COUNTABLE VEHICLES: The equity value of all non-excluded accessible vehicles owned by any filing unit member is countable. Effective Date: July 01, 2016

COMBINED MEDICAID 404-1 Asset Transfers

Supersedes: CMA 404-1 (June 16, 2022)

Reference: 42 U.S.C. §1396p (c)(1)(F) through (I) and 42 U.S.C. 1396p (e); ARM 37.82.101 and .417; P.L. 109-171; P.L. 109-432

Overview: ACA and ABD: Institutionalized or Home and Community Based Service/Waiver (HCBS/Waiver) Medicaid benefits cannot be provided to otherwise eligible Medicaid clients if a disqualifying asset transfer has occurred. A disqualifying asset transfer occurs when: 1. Assets are transferred for less than FMV (Fair Market Value); 2. The transfer occurred during either the 60-month look-back period or after Medicaid eligibility is established, AND; 3. The transfer is not an exempt transfer as described later in this section.

In addition to selling and giving away property, disqualifying asset transfers may include, but are not limited to, actions such as: · Establishing a trust; · Forgiving a debt without obtaining fair market value; · Decreasing the extent of ownership interest in an asset; · Forfeiting or assigning the right to a stream of income; · Making an unsecured loan; or · Giving up or limiting their rights or access to or interest in an asset, or in some instances, purchasing an annuity.

LOOK-BACK PERIOD: The look-back period begins the date an institutionalized or HCBS/Waiver individual (married or single) requests Medicaid coverage. The look-back period is 60 months for all transfers, including trust payments to or for the benefit of a person or entity other than the Medicaid client.

NOTE: Uncompensated asset transfers made after application are also subject to penalty. The date of the first Medicaid application while the individual is either in a long- term care facility or qualifies for waiver services establishes the look-back period; application disposition (approved or denied for any reason) does not matter. Only one look-back period is established for each client, regardless of the number of times they are institutionalized or submit applications. Once the look-back period is established, all asset transfers after that date must be evaluated and, if necessary, a penalty calculated. When retroactive coverage is requested, the look-back period begins the first day of the first retro month requested, provided LTC eligibility exists (e.g., application received December 15, 2015, and retro coverage is requested and LTC eligibility begins October 1, 2015, look-back period begins October 1, 2010). ASSETS: Assets include all resources and retained income the client and/or their spouse: 1. Owns; 2. Is entitled to receive; 3. Is entitled to receive the benefit of (such as being a beneficiary of a trust); or 4. Would be entitled to receive except for some action or inaction which results in failure to obtain the asset.

NOTE: Assets that comprise the client’s $2000 allowable resources are NOT subject to asset transfer rules. However, excluded assets, specifically the client’s home, are subject to these rules.

PURCHASE OF AN ANNUITY: If either the client or their community spouse purchases an annuity, an uncompensated asset transfer is evaluated. Annuities purchased or converted on or after February 8, 2006, by a Medicaid client or community spouse are considered uncompensated asset transfers (subject to rebuttal) unless the: 1. The annuity payments are made to the Medicaid applicant/recipient or community spouse; 2. Periodic scheduled payments are required at least annually; 3. Payment contract calls for equal payments; no deferred or balloon payments; 4. Payment schedule is actuarially sound (equal payments are based on expectation of a full payout within the annuitant’s life); 5. Annuity is irrevocable; 6. Annuity is non-assignable; AND 7. Annuity names the Montana Medicaid Program as the irrevocable first position residual beneficiary. Refer to CMA 402-1 Countable and Excluded Resources.

Certain changes to an annuity are considered annuity conversions. These include annuitizing a previously un-annuitized annuity or change an annuity from one type to another. Automatic events such as the start of pre-arranged payments or other actions taken by the annuity company that are not voluntary on the part of the annuity owner are

not considered conversions. If payments are made to the account owner, the following are not considered uncompensated asset transfers and do not require beneficiary assignment to the State of Montana Medicaid Program: 1. an individual retirement annuity [subsection (b) of section 408 of the IRS Code of 1986], a qualified employer plan annuity [subsection (q) of section 408 of the IRS Code of 1986]; 2. purchase of an annuity with an IRA, employer or employee association account; 3. a qualified salary reduction arrangement [section 408(a), (c), or (p) of the IRS Code of 1986]; OR 4. a simplified employee pension [within the meaning of section 408(k) of the IRS code if 1986]. If one of these situations is alleged, request assistance from the policy specialist in determining whether the criteria are met.

ANNUITIES PURCHASED AFTER ELIGIBILITY DETERMINATION: If the Medicaid client or their community spouse purchase an annuity after eligibility has been determined, they must report that purchase following normal change reporting requirements and must amend the annuity to meet the above requirements to remain eligible. If the community spouse refuses to make the Montana Medicaid Program the primary remainder beneficiary, the purchase is considered an uncompensated asset transfer and results in a penalty being imposed against the nursing home spouse. The exemptions listed below do not apply to this requirement. Even if the annuity meets #1- 7 above, other events may result in an annuity being considered an uncompensated asset transfer. These include, but are not limited to, taking any action that causes the annuity to be inaccessible (versus irrevocable/non-assignable).

JOINTLY OWNED: Any action taken to reduce the Medicaid client’s or spouse’s ownership, or control of an asset held in sole ownership, or with another individual under joint tenancy, tenancy in common, joint ownership or another similar arrangement, is considered a transfer. EXAMPLES: 1. Jim adds his daughter’s name to his checking account. If she uses any of the funds for anything other than providing for Jim, an asset transfer has occurred. 2. Tom decides to add his daughter’s name to his home’s title. She now must agree to sell/dispose of the home, which wasn’t previously necessary. Because Tom’s right to sell/dispose of his home has been limited, adding his daughter’s name to the title is considered an asset transfer. 3. The community spouse (CS) removes her husband’s (nursing home spouse) name from a joint CD and adds her daughter’s name; this is done during the 90- day period when assets allocated to the CS must be transferred from the nursing home spouse to the CS. Substituting her daughter’s name for the nursing home spouse’s name on this document results in an uncompensated asset transfer.

The CS should have simply removed her husband’s name so she had full ownership. Replacing his name with her daughter’s is transferring his assets to a third party.

WHO TRANSFERRED ASSET: Assets transferred by the client and/or their spouse are evaluated as if the client made the transfer. Assets are also considered transferred by the client or their spouse when they are transferred by: · A parent; · A guardian; · A court; or · Anyone acting on behalf of or at the direction of the client or their spouse, such as an attorney; · A Community Spouse: NOTE: If the client or their spouse refuses to accept an asset, it is considered a transfer. This includes, but is not limited to, waiving pension income or right to inherit, spouse’s failure to seek their elective share of the deceased spouse’s estate. See ABD 404-5 Pursuing Claims on Property and Estates.

An asset transfer is evaluated when the: 1. institutionalized or community spouse transfers an individually or jointly owned asset to someone other than the community/institutionalized spouse prior to the Institutionalized or Waiver Medicaid be established for the institutionalized spouse or, within the 90-day Community Spouse Resource Maintenance Allowance (CSRMA) resource transfer process; and 2. institutionalized spouse transfers the own individually or jointly owned asset after the 90-day resource transfer process. a. If the Community Spouse transfers their own individually owned asset (or an asset jointly owned with someone other than the Institutionalized Spouse) after the 90-day CSRMA resource transfer process, the asset transfer will be evaluated if/when the Community Spouse later applies for Institutionalized or Waiver Medicaid for themselves.

Asset transfers are not evaluated when: 1. The asset was, under spousal impoverishment rules, transferred to a spouse prior to nursing home or waiver eligibility determination. 2. The institutionalized or waiver spouse transferred the asset to the community spouse during the 90-day transfer period or the asset was part of the Community Spouse Resource Maintenance Allowance. 3. The asset was transferred to the asset owner’s disabled/blind (per SSA criteria) minor or adult child. 4. The client’s home is transferred and the title is transferred to: a. The owner’s spouse; b. The owner’s child under age 21;

c. The owner’s permanently blind or disabled (per SSA criteria) adult child; d. The owner’s child (of any age) who: i. Lived with the client for two years immediately prior to the client entering the nursing home; AND ii. Provided care that allowed the client to remain at home (doctor’s statement must confirm that care provided delayed nursing home entry) e. The owner’s sibling who: i. Has equity interest in the home; AND ii. Continually lived in the home for at least one year prior to the client entering the nursing home. 5. The asset was transferred solely for a purpose other than qualifying for Medicaid, such as to satisfy a legally enforceable debt. The timing of debt payments must be considered. If an old debt that allegedly has been outstanding for years is suddenly remembered, but there is no convincing evidence that the client acknowledged or attempted to satisfy it or that the person(s) owed the debt previously attempted to collect it, debt validity and whether the debt is legally enforceable may be questionable. 6. The assets were transferred into the individual’s qualifying Special Needs Trust (see CMA 402-3 Trust Funds ). 7. The assets were transferred to the individual’s pooled trust (see CMA 402-3 Trust Funds) before the individual reached age 65. 8. Eligibility denial will cause the client undue hardship.

UNDUE HARDSHIP: An undue hardship exists only when: 1. The application of an asset transfer penalty 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; OR 2. Fraud, misrepresentation, or coercion against the client and/or their spouse resulted in the transfer; AND a. The client and/or their spouse have explored and pursued all reasonable legal recourse to reacquire the asset or its value.

Legal recourse includes, but is not necessarily limited to, filing a civil court action, and once filed, diligently pursuing the civil action to its conclusion. Mediation may be a reasonable step in resolving a legal claim. If the proven costs of legal pursuit exceed the transferred asset’s value, it is not considered reasonable legal recourse. Due to the potential availability of pro bono or reduced-fee legal services, costs of legal pursuit cannot be based solely on attorneys’ fees. NOTE: Filing criminal charges against the person who received the assets through fraud, misrepresentation or coercion or filing a police report does not fully satisfy the requirement to pursue all legal recourse.

The transferred resources are considered inaccessible once legal recourse is initiated (e.g., court action is filed) and remain inaccessible while legal recourse is diligently pursued to a conclusion.

RECOVERED ASSETS: If transferred resources are recovered in whole or in part, the recovered assets are treated as if they were never transferred when determining eligibility.

DETERMINING UNCOMPENSATED VALUE: An uncompensated asset transfer occurs when the owner receives less than the asset’s FMV on the transfer date. Compensation means money, real or personal property, food, shelter, or services: Compensation examples · The client or spouse receives at or after the transfer in exchange for the resource IF compensation was provided under a legally enforceable agreement in effect when the transfer occurred, OR · Received before the transfer occurred and provided under a legally enforceable agreement in which the client agreed to transfer the asset in exchange for the goods or services received. · Compensation may also include assumption of the client’s legal debt in exchange for the asset. Compensation does not include services or gifts previously provided to the client out of love or concern with no expectation or promise of payment.

Determine the value of future compensation (services, food, or shelter) based on the compensation’s FMV for the time period the client is reasonably expected to receive the support or maintenance beginning with either the date of transfer or date of contract, whichever is earlier (See ABD 016 Life Expectancy Table).

Services provided through a personal care contract cannot duplicate services that are being provided or are available as part of another existing contract, or encompassed by the package of services provided by a nursing home, assisted living facility, or adult foster home in which the individual is residing. For example, nursing homes provide dietary services, and, when necessary, assistance in eating; a separate contract paying a third party to also provide assistance in eating is not a valid personal care contract expense. Contracts and payments for duplicative services are considered uncompensated asset transfers.

Personal care contracts drafted after 05/31/2022 must include the following: 1. Agreement/contract must be in writing prior to the delivery of the personal care services

2. Agreement/contract must be created before an application for Aged, Blind, or Disabled 3. Medicaid is received or before an additional level request (Nursing Home and/or Waiver) is received. 4. Agreement/contract must detail which services are included and which are excluded for the purposes of compensation (e.g., non-medical care only, meal preparation, light housekeeping, bookkeeping, transportation, assistance with activities of daily living). 5. Must be signed by both the care recipient and the person agreeing to perform the services. (If the recipient is unable to sign due to mental incapacity, their power of attorney must sign). 6. Agreement/contract must have a begin date and end date Such as: a. § Contract will end once individual enters the nursing home b. § Contract will end upon individual’s death c. § Contract will end once personal care services are no longer needed 7. Must specify rates for services that are comparable to rates charged by commercial care provider located in the same general area – rates are charged at Fair Market Value. a. Based on the US Bureau of Labor Statistics Occupational Handbook (www.bls.gov) 8. Any unused amount of the contract is to be repaid to Montana Medicaid if the claimant passes away before their actuarial life expectancy. a. Providing that upon the death of the individual, the State Medicaid Program will receive all amounts of unpaid services remaining in the agreement/contract up to the total amount of medical assistance paid on behalf of the individual during his or her lifetime. 9. Services cannot be duplicative a. For example, nursing homes provide dietary services, and, when necessary, assistance in eating; a separate contract paying a third party to also provide assistance in eating is not a valid personal care contract expense. 10. Agreement/Contract is actuarially sound in accordance to the life expectancy table in ABD 016 Life Expectancy Table

Services will be considered an uncompensated asset transfer if: 1. Services are duplicative a. For example, nursing homes provide dietary services, and, when necessary, assistance in eating; a separate contract paying a third party to also provide assistance in eating is not a valid personal care contract expense. b. § Only the specific duplicative service will be looked at as an uncompensated asset transfer 2. Agreement/contract is created after an application for Medicaid is received

3. Service(s) provided is charged at a rate higher than Fair Market Value (FMV). a. FMV is determined by using the US Bureau of Labor Statistics Occupational Outlook Handbook (www.bls.gov) 4. Agreement/Contract is not actuarially sound in accordance to the life expectancy table in ABD-016 5. There is no repayment agreement to Montana Medicaid.

Legal Authority: Deficit Reduction Act of 2006

The uncompensated value is the asset’s FMV less any compensation received per the above policy. A stream of income’s FMV is the total annual payments multiplied by the life expectancy of the person on whose lifetime payments are based. EXAMPLE: Anthony, who is 85 years old, is entitled to $300 per month in annuity payments for the remainder of his life. The value of this ‘stream of income’ is $300/month X 12 months X 6.00 (Anthony’s life expectancy per ABD 016 Life Expectancy Table), or $21,600.

NOTIFICATION: The client must be notified that a disqualifying transfer penalty has been identified before eligibility is approved or denied. The notice must: 1. Notify the client an uncompensated asset transfer is identified; 2. Provide the transferred resource’s value; and 3. Explain the client’s right to rebut the presumption that the transfer was made to qualify for Medicaid. If the client fails to respond within 15 days, it is assumed that no rebuttal will be received. The asset transfer penalty is established and applied to the case.

TRANSFER REBUTTAL STATEMENT: All asset transfers are presumed to have been made in order to qualify for Medicaid. When the client rebuts the presumption that a transfer occurred to qualify for Medicaid, the client is responsible to provide proof the transfer occurred exclusively for another reason. The rebuttal statement must include: 1. The reason(s) the asset was transferred; 2. Documentation of attempts to sell the asset at fair market value; 3. Documentation that fair market value was received or the reason for accepting less than fair market value; 4. Proof the client had sufficient means to support themselves after the transfer; and 5. The client’s relationship to the individual who received the asset in transfer.

CONVINCING EVIDENCE: Factors that may indicate a transfer was not made to qualify for assistance include: · One of the following occurs after the asset is transferred:

o Traumatic onset disability; o Diagnosis of a previously undetected disabling condition; o Unexpected loss of income and/or resources with value sufficient to preclude Medicaid eligibility. · Total countable assets (including those transferred) are less than the $2000/$3000 resource limit during each month of the look back period; · The transfer was court-ordered in a contested court action; or · Hardship applies (see above on this subject). NOTE: Consider the transferred asset inaccessible when a civil suit has been filed in district court, and the suit is pending but being actively pursued, as required to maintain a hardship exemption.

LONG TERM CARE PARTNERSHIP ASSETS: Asset transfer provisions apply to assets held under a Long Term Care Partnership. If the client transfers these assets prior to their death, asset transfer penalties are evaluated and applied, subject to other exceptions.

SEE BUSINESS PROCESSES: Asset Transfer Evaluation, and Asset Transfer Undue Hardship Exception Process

Revised Date: July 01, 2024

COMBINED MEDICAID 404-2 Penalty Periods for Asset Transfers

Supersedes: CMA 404-2 (07/01/2024) Reference: 20 CFR 416.1246; ARM 37.82.101, .417; 42 U.S.C.1396p(c)(1)(E); P.L. 109- 171; P.L. 109-432 Overview: ABD and ACA: A penalty period may be imposed when an HCBS waiver or institutionalized Medicaid client and/or their community spouse transfers assets for less than fair market value. The client is ineligible for Medicaid payment of waiver or institutional services during the penalty period; however, the client may be eligible for other services during this time. Assets transferred prior to the month the client enters a nursing home are not considered in a resource assessment because neither the client nor their community spouse owns the asset once it has been transferred. The asset transfer penalty is a separate issue and may apply when the client requests nursing home or waiver Medicaid coverage. NOTE: No penalty can be imposed for assets transferred before the look-back period. CALCULATING PENALTY PERIOD: Calculate the penalty period by dividing the uncompensated value of the transferred assets by the average daily cost of nursing home care at the time of Medicaid application or transfer, whichever is later.

AVERAGE COST OF NURSING HOME CARE:

07/01/2025- ongoing 07/01/2024 – 06/30/2025 07/01/2023– 06/30/2024 Daily rate $322.72 $306.27 $286.71 Monthly rate $9816.05 $9315.71 $8720.76

The penalty period is the number of days the client or couple is ineligible for Medicaid payment of institutional or waiver services. Waiver/institutional eligibility cannot begin until after the full penalty period has passed, which may result in eligibility beginning after the first of the benefit month. The penalty period runs continuously from the first day through the last day of the penalty period, whether or not the client remains in the nursing home or waiver program.

PENALTY START DATE: The penalty period for uncompensated asset transfers begins on the date the client: 1. Transfers the asset or applies for Medicaid (the later of), AND 2. Is determined otherwise eligible (i.e., meets all other financial and non-financial criteria, including resource limit), AND 3. Is institutionalized or meets HCSB waiver criteria.

All the above criteria (1-3) must be met before the penalty period can begin. When retroactive institutional/waiver coverage is requested, the penalty period may begin in the retro period if all the above criteria (1-3) are met. An asset transfer penalty period applied to an ongoing institutionalized/HCBS waiver client begins on the first of the month following timely notice.

MULTIPLE TRANSFERS: The total combined uncompensated value of all transferred assets is used to calculate the penalty period length when multiple assets are transferred on or after the look-back date.

SPOUSAL TRANSFER RESULTS in PENALTY: In certain instances, a penalty period must be applied to both spouses. This occurs when either spouse made an uncompensated asset transfer and: 1. Both spouses are institutionalized or eligible for the Medicaid HCBS waiver; and 2. A portion of the penalty remains at the time the spouse applies for and is determined otherwise eligible for Medicaid.

When 1 and 2 are met, the remainder of the existing penalty period is divided between the two spouses. EXAMPLE: Harold is in a nursing home and applies for Medicaid. Prior to his application, his wife Alice transferred an asset that resulted in a 1080-day asset transfer penalty. After Harold has served 300 days of the penalty period, Alice enters a nursing home. The remaining 780 penalty days are applied equally to each spouse, so each ‘serves’ a portion of the penalty.

When both spouses are serving the penalty and one spouse dies or leaves the nursing home/waiver program, the surviving spouse/spouse remaining in the nursing home/waiver program must serve the remainder of the penalty period.

TRANSFERRED ASSETS ARE RETURNED: A transfer penalty may be modified if the client receives either the transferred asset or the financial equivalent back from the person(s) who received the asset. The effect on the individual’s eligibility depends on his/her application status.

ASSETS/VALUE RETURNED BEFORE DENIAL/CLOSURE: When the transferred asset/value is returned in full prior to denial/closure, the penalty is removed, and Medicaid eligibility is re-evaluated. When transferred assets are partially returned prior to denial/closure, the penalty is modified. The penalty period is recalculated based on the adjusted transfer value and the penalty start date is recalculated based on the new date that the individual may be

Medicaid-eligible. Whether returned in full or in-part, the returned asset/value is included in the resource determination when Medicaid eligibility is re-evaluated. Because a penalty period cannot begin until a person is otherwise eligible for Medicaid, the person likely is not Medicaid eligible with the returned assets; therefore, any penalty will start later, after the returned assets are spent down and the person establishes Medicaid resource eligibility.

ASSETS/VALUE RETURNED AFTER DENIAL/CLOSURE: If returned after denial/closure has already taken effect, a new application is required; retroactive eligibility can be evaluated.

BUSINESS PROCESS: Asset Transfer-Undue Hardship Exception Process

Effective Date: 07/01/2025

COMBINED MEDICAID 404-3 Asset Transfers Involving Life Estates Supersedes: MA 404-3 (01/01/07) Reference: OBRA '93; ARM 37.82.101 & .417; 20 CFR 416.1246; 42 CFR 435 Subpart G; Deficit Reduction Act of 2005 Overview: ABD and ACA: If a nursing home or HCBS/waiver client transfers an asset and retains a life estate in the property, the life estate and status of a remainder ownership must be evaluated to determine if the client received fair market value. LIFE ESTATE: A life estate is a durational property right limited to the life estate owner’s life, or to another person’s life. The life estate owner does not have the property title and cannot sell the property. They can, however, sell their interest in the property, unless the contract terms restrict the sale (life estate value is excluded if the sale is restricted), and they are entitled to any property income. GIVING UP RIGHTS TO LIFE ESTATE INCOME: A person holding a life estate generally has the right to do anything with the property that a full owner could do during his or her life. The life estate owner may not need to live on the property and use it as home, but instead may choose to rent it out. In addition, life estates are marketable which allow the life estate owners to sell their life estate interest in the property. Forfeiting rights to an income stream from a life estate is a disqualifying asset transfer. EXAMPLE: 1. John has life estate ownership in real property containing a home. John does not live in the home, instead, the home is rented for $1000 per month. John is entitled to this rental income as life estate owner, but his family members retain the rental income themselves. Every month the rental income is either transferred to or retained by the family is a disqualifying asset transfer. 2. Mary has life estate ownership in real property containing a home. Mary does not live in the home, instead, a family member resides in the home rent-free. Every month the house is occupied without rental compensation is a disqualifying asset transfer because Mary is forfeiting the potential rental income stream. The net transfer value of the asset is the current fair market rent amount minus the property’s taxes.

NOTE: An uncompensated asset transfer penalty is evaluated when the client purchases a life estate in another person’s home. The client can overcome the penalty if they live on the property as their principal place of residence for at least one full year after the purchase date. Effective Date: July 01, 2016

COMBINED MEDICAID 404-4 Asset Transfers to Trusts-On or After August 11, 1993 Supersedes: MA 404-5 (05/01/00) Reference: OBRA '93; ARM 37.82.417; 20 CFR 416.1246 Overview: ABD and ACA: An uncompensated asset transfer must be evaluated when any client applying for or receiving institutionalized or HCBS/waiver services transfers any asset, in whole or part to a trust on or after 8/11/93. Any portion of a trust that is not payable to the client is treated as an asset transfer. When a trust is established with resources belonging to both the client and to another person, only the portion the client transferred is reviewed for an uncompensated asset transfer. When a client establishes a revocable trust, any portion disbursed to anyone other than the client, or to anyone for the benefit of the client is considered an uncompensated asset transfer. Also, treat an irrevocable trust that cannot be disbursed to the client or on the client’s behalf as an uncompensated asset transfer. ASSET TRANSFER TO REVOCABLE TRUST: When assets are transferred to a revocable trust: 1. The trust principal is a countable asset; 2. Trust payments to or for the client’s benefit are countable income; and 3. Trust payments to or for another’s benefit are an uncompensated asset transfer. ASSET TRANSFER TO IRREVOCABLE TRUST: Any portion of the trust principal or trust-generated income that is not payable to the client is considered an uncompensated asset transfer. The asset transfer date is the later of the date: 1. The trust was established; or 2. Payments to the client stopped When establishing the portion that cannot be paid to the client, the portion’s value is not reduced by any payments made to someone other than the client after either the date the trust was established or the day payments to the client stopped, whichever is later. Additional assets transferred to the trust after either the date the trust was established or date payments to the client stopped, whichever is later, are treated as new uncompensated asset transfers.

Effective Date: July 01, 2016

COMBINED MEDICAID 500 Income Overview

Supersedes: CMA 500 (09/01/2025) Reference: ARM 37.82.101, .703 and .903; 42 CFR 435.601, .603; 20 CFR 416.1102 and .1103 Overview: MAGI (modified adjusted gross income) is used for all ACA Medicaid programs that have an income test. MAGI is an individual’s taxable income such as wages, dividends, capital gains, etc. minus any adjustments such as student loan interest deduction (max $2,500/year), pre-tax deductions taken out of wages (health insurance premiums, retirement plan contributions, or flexible spending accounts), self-employed health insurance deduction, tuition and fees (max $4,000/year), etc. When looking at the 1040 tax form, the income is listed on lines 7-22 and the adjustments are listed on lines 23-36. ACA: Whether income is earned or unearned does not change the budget; there are no income disregards or deductions under MAGI. NOTE: Self-employment expenses are not disregards or deductions; they are expenses associated with earning self- employment income and are allowed when determining countable net self-employment income. ABD: Gross income is always used except in cases of necessary for self-employment and for certain rental/lease income. INCOME DIVERTED: ABD: All income/money obligated to the household is considered available to the household, even if diverted to an outside entity. ACA: If the household pays taxes on the diverted income, it is countable. The household’s current and prospective circumstances are evaluated to determine financial eligibility. Income is divided into two categories: 1. Earned income that includes, but is not limited to: a. Wages and salaries, and

b. Net earnings from self-employment 2. Unearned income, which includes all income that is not earned. NOTE: Some income types may be earned or unearned depending on circumstances. AVAILABLE INCOME: All income, even if it is excluded per policy, must be entered on the appropriate screen. Consider income available both when: 1. Actually available, and 2. The client has a legal interest in and the legal authority to make the income available As a condition of eligibility, clients must apply for all countable income they may be eligible or entitled to receive. If they fail to pursue countable income they are entitled to, the amount they would have received is countable. If the amount the client would receive cannot be determined, close or deny the case due to insufficient income information to determine financial eligibility. COUNTING INCOME: Income that is NOT expected to be received monthly, such as quarterly interest payments, is prorated over the period intended to cover. Do not count or prorate periodic payments until the first payment is received after Medicaid application. Income received on a monthly or more frequent basis will be budgeted according to methods outlined in CMA 601-1 Prospective Budgeting. VERIFYING INCOME: ACA: Verify self-attested income using PEV. PEV is used to verify initial month of application and ongoing eligibility. If data sources indicate an inconsistency, follow the PEV inconsistency process. If a data source is not able to verify income i.e self employment, royalties, 1099 income), further information may be required. ABD & Family Medically Needy: Income must be verified at application and when a change is reported. The client’s written or verbal statement alone is not sufficient; collateral proof is required. ABD & Family Medically Needy: The client is primarily responsible to provide income verification; however, eligibility staff will help the client obtain verification, as necessary. UNEARNED INCOME VERIFICATION: Verify unearned income with any of the following sources:

· Organizational records or statements; · System Interfaces; · Benefit correspondence or award letters; · Any other reasonable verification. EARNED INCOME VERIFICATION: Verify earned income with any of the following sources: · Pay stubs or pay envelopes (if complete) · W2 form · Wage tax receipts · State or Federal income tax return or tax statements (only if they reflect current income) · Self-employment bookkeeping records showing all income and expenses · Employer’s statement (signed and dated by employer) o If the employer statement is verbal, case notes must clearly document all details (who, what, when, where and how) · Employment Security office records (DOLI interface) · Any other reasonable verification. INCOME OWNERSHIP: Count income to the individual(s) it is paid to. When paid to: 1. one individual, count in full to that individual; 2. two individuals (i.e., both spouses) count proportionately to each individual; 3. both spouses and another person, count proportionately to each individual. Clients can rebut income ownership. INCOME OF DISQUALIFIED/INELIGIBLE HH MEMBERS: Income of disqualified or ineligible household members is deemed to other household members as follows: · Ineligible parent’s income is deemed and earned income disregards are allowed. · Ineligible spouse’s income is deemed but earned income disregards are not allowed. Effective Date: 7/1/2026

COMBINED MEDICAID 501-1 Unearned Income

Supersedes: CMA 501-1 (3/1/2024)

Reference: ARM 37.82.101, .703 and .903; 42 CFR 435.601; 20 CFR 416 Subpart K; P.L. 111-5 ARRA); P.L.111-148, Section 4108 (PPACA)

Overview: All unearned income the filing unit receives is considered when determining Medicaid eligibility. All unearned income, whether countable or excluded per policy, is entered into the eligibility system.

ADOPTION SUBSIDIES (TITLE IV): ACA: Excluded ABD and Family Medically Needy: Countable unearned income to the child. All Medicaid Programs: Childcare reimbursements received as adoption subsidies are excluded.

ANNUITY PAYMENTS: Annuities are contracts or agreements that provide periodic payments at regular intervals (i.e., monthly, quarterly, annually, etc.) ACA: Count all annuity payments. ABD and Family Medically Needy: Count periodic payments received from an excluded annuity; exclude the payments when the annuity is countable. An annuity cannot be counted as both a resource and income at the same time. NOTE: As a condition of eligibility, the annuity must be annuitized, and the client must avail themselves of periodic annuity payments.

ASSISTANCE PROGRAMS:

Most federal, state, or local assistance paid directly to the household is countable unearned income. NOTE: Vendor payments from federal, state, or local assistance programs may also be countable. See ‘Vendor Payments’ and ‘In-kind Income’ in this section.

ACA: Exclude all assistance program payments, except RSDI. RSDI income is countable unless the RSDI is a child’s income, then only countable if the child has other income that would cause them to file a tax return. If the child doesn’t live with their natural/adoptive or stepparent, the RSDI income is countable. ABD and Family Medically Needy: Assistance payments include the following: 1. SSI (Supplemental Security Income; also known as Title 16 benefits); excluded for all Medicaid programs except when paid to a community spouse in the nursing home spousal income maintenance allowance calculations. 2. RSDI (Retirement, Survivors and Disability Insurance; also known as Title2 benefits or SSDI; Social Security Disability Insurance Benefits; Social Security Retirement); countable. 3. SSP (State Supplemental Payments); excluded except when paid to a community spouse in a nursing home spousal income maintenance allowance calculation. 4. TANF (Temporary Assistance for Needy Families) – excluded 5. Cash assistance – excluded 6. Supportive Services Payments – excluded Work Support Payments (WSP) – excluded Tribal TANF – excluded 7. BIA (Bureau of Indian Affairs) General Assistance – countable. 8. Foster Care - Exclude both child and adult foster care payments. 9. Community Services Administration - Exclude payments from the Crisis Intervention Program (CIP) administered by the Community Services Administration. 10.Energy Payments -Exclude energy payments made to the household, including LIHEAP, Section 8/HUD Utility Payments and Farmer’s Home Administration (FHA) Rent Subsidy Payments. 11.FEMA Funds- Exclude Federal Emergency Management Assistance (FEMA) payments related to a disaster (see Disaster Relief in this section). Count FEMA payments made to households to pay for rent, food and utility assistance when there is no major disaster or emergency, and the payment can be prospected.

CAPITAL GAINS: ACA: Countable. ABD and Family Medically Needy: Countable, when can be prospected (if from sale of personal property or a house and not in the business of buying and selling houses).See

‘Sale of a Resource’ later in this section when paid in installments and see CMA 503-1 Self-Employment Income related capital gains.

CASH SUPPORT ACTUALLY AVAILABLE: ACA: Count cash support that is actually available to a household member claimed as a tax dependent of an individual not in the filing unit. ABD and Family Medically Needy: See Gifts and Contributions in this section.

CHARITABLE DONATIONS: ACA: Exclude cash donations received based on need from one or more private nonprofit organizations. ABD and Family Medically Needy: Count cash donations received based on need from one or more private nonprofit organizations. See “Fund- Raising Account” in CMA 402-1 Countable and Excluded Resources

CHILD SUPPORT ARREARAGE: ACA: Exclude all child support payments; count all spousal support payments. ABD and Family Medically Needy: Count child support payments to the child the payments are intended to support. Count spousal support to the ex-spouse the payments are intended to support. See CMA 500 Income Overview ‘Counting Income’ to determine how to prospect child support received less often than monthly.

OVERPAID CHILD SUPPORT: Family Medically Needy: Count the amount received when child support is reduced to repay over-issued child support. ABD: Child under18: · Exclude the payment to the payee and count it to the child (if receiving Medicaid) if payment is passed to the child; · Count the payment to the payee if the payment is not passed to the child.

ABD: Child over 18:

· Exclude the payment to the payee and count it to the child (if receiving Medicaid) if payment is passed to the child; · Count the payment to both the child and the payee (entire payment is counted against both the child and the payee) if the payment is not passed to the child.

CONTRACT FOR DEED (CFD): ACA: Count only the interest portion of a contract for deed payment; the principal portion is excluded.

ABD and Family Medicaid: Count payments received from excluded CFDs. Deduct contract-related costs from gross income to determine countable net income. Prorate the net countable income over the period intended to cover. NOTE: Allowable contract-related costs include escrow fees, property taxes and insurance. Count the full payment (interest earned and principal) when the contract for deed is an excluded resource.

Exclude the full payment received from a countable CFD. The payment on principal is excluded because it is simply a resource changing form (from CFD to cash), and interest on countable assets is excluded. The unscheduled portion of an early contract for deed payment made on an excluded CFD is income in the month of receipt and a resource thereafter. An early payment received on a countable CFD is considered resource in the month of receipt and thereafter. Scheduled balloon payments are prorated over the period intended to cover.

CONTRIBUTIONS: Count contributions that can be prospected and cannot be excluded as either a valid loan or irregular/infrequent income. See Gifts later in this section.

DIVIDEND AND ROYALTY INCOME: Countable.

NOTE: See section CMA 501-2 Native American Income for royalties from Indian lands, oil, gas, and timber. Royalties received as part of a trade or business, or as the result of an individual’s work being published are countable earned income. All other royalties are countable unearned income. Income production costs, including production and/or severance taxes, can be deducted from unearned royalties. However, income taxes or windfall profit taxes withheld cannot be deducted. Expenses can only be deducted from earned royalties when the income is derived from a current self-employment business.

Dividend and royalty income is counted when received; recurrent payments may be averaged to prospect future payments.

EDUCATIONAL INCOME: Scholarships, grants, and similar educational assistance are excluded for ACA Medicaid when they are directly related to attendance at an institution of higher education. Any portion not used for educational purposes (such as room, board, transportation, or other non‑education expenses) is countable income. Loans, including student loans, are fully excluded for ACA Medicaid.

GARNISHMENT: ACA: Count the gross income amount. ABD and Family Medically Needy: Count the gross income amount when unearned income is garnished for something other than an overpayment from the same income source. ABD and Family Medically Needy: Payment of a legally obligated child support debt is an allowable expense. See CMA 602-1 Income Disregards and Deductions

See ‘Recoupments for Overpayments’ in this section if the income is being reduced to repay over-issued income from the same income source.

GIFTS: ACA: Exclude gifts up to $16,000 per person per year from the same source (e.g., mom, grandfather, sister, friend, etc.). Count gifts in excess of $16,000 per person per year from the same source in full.

ABD and Family Medically Needy:

· Exclude irregular or infrequent monetary gifts that cannot be prospected. · Count monetary gifts that can be prospected. Prorate countable gifts given to the entire household among the household members.

Family Medically Needy: Exclude gifts of money up to $50 per filing unit member per month. Gifts over $50.00 per person per month that can be prospected are countable in their entirety.

See also: ‘Irregular/Infrequent Income’, ‘Lump Sum’ and ‘Contributions’ in this manual section.

HOME EQUITY CONVERSION PLAN: Home Equity Conversion Plans allow a household to borrow money or receive payments against their home’s equity value. Reverse Annuity Mortgage Loan Program (RAM) and the Home Equity Conversion Sale Leaseback Program are the two most common conversion plans.

Reverse Annuity Mortgage (RAM):

· RAMs are loans against the home’s equity value and the income received is excluded. · Repayment is due when the house is sold, the owners no longer live in the house, or when the owners pass away (repayment is taken from the estate). A

copy of the loan agreement is needed to verify when the homeowner will repay the loan.

Home Equity Conversion Sale Leaseback Program:

· Under this program, an investor purchases the home and pays the purchase price in a series of payments while leasing the home to the homeowner for a specific period of time, sometimes until death.

ACA: Exclude monthly payments. ABD and Family Medically Needy: Each sale-leaseback transaction must be reviewed to determine if the proceeds are considered income or a resource.

INTEREST: ACA: Count all interest received.

ABD and Family Medically Needy:

· Exclude interest earned on a countable resource. · Count interest earned on an excluded resource. · Prorate income over period intended to cover. IRREGULAR OR INFREQUENT INCOME: ACA: Count or exclude based on income type (e.g. gifts, contributions, etc.). ABD and Family Medically Needy: Count any amount of income that can reasonably be prospected.

LEASE INCOME: Count lease income not related to Native American resources. See CMA 501-2 Native American Income for Native American lease income. Prorate lease income over period intended to cover.

Example: For a six-month lease that is paid only once in the six-month period, prorate the payment over six months beginning with the month of payment. Exclude all periodic lease payments received prior to Medicaid eligibility. Prorate lease payments received during a Medicaid eligibility month over the period intended to cover. Lease income is considered self-employment only when the client is in the business of buying and selling leases or managing lease property.

LOANS RECEIVED BY HOUSEHOLD: Exclude all valid loans. LOAN REPAYMENTS TO HOUSEHOLD: ACA: Count only the interest portion of the repayment. ABD and Family Medically Needy: Exclude the full repayment (principal and interest) of a loan given by the household when the loan is a countable resource. Count the full loan payment (principal and interest) for a loan excluded as a resource.

LUMP SUM PAYMENTS: ACA: Count taxable lump sum payments. ABD and Family Medically Needy: Count lump sum payments that can be prospected, unless received from an excluded source. Payments are countable income in the month received and a resource the following month, if retained.

Examples of lump sum payments include:

· Severance pay or sick leave (see CMA 501-1 Unearned Income and CMA 502-1 Earned Income); · Income tax refunds; · Rebates or credit refunds; · Crop insurance proceeds (see section CMA 503-1 Self-Employment Income); · Retroactive Social Security, retroactive SSI, retroactive TANF or Tribal TANF, retroactive Railroad Retirement or insurance settlements; · One-time or installment lottery payments; · Windfall or other one-time payments. MEDICAID INCENTIVES FOR PREVENTION OF CHRONIC DISEASE: Exclude incentives Medicaid clients receive under the Medicaid Incentives for Prevention of Chronic Disease (MIPCD) Grant Program. MEDICARE SUPPLEMENTAL FLEX CARD: Medicare Supplemental Flex Card Benefit provided by Medicare Advantage plans are excluded unearned income for Medicaid. These cards may also be referred to as “Food Cards”. Allowances for Health-related items like gym members and vitamins are excluded. When these cards or allowances are coming from a Medicare Advantage plan such as Humana, BCBS, etc. these are excluded income for Medicaid.

MILITARY ALLOWANCES: ACA: Exclude Military Basic Allowance for Housing (BAH), Basic Allowance for Subsistence (BAS), and Overseas Housing Allowance (OHA). ABD and Family Medically Needy: Count Family Subsistence Supplement Allowance (FSSA) and Military BAH payments received by service members or their families.

PAYMENTS TO PROTECTIVE PAYEE: ACA: Only counted when taxable. ABD and Family Medically Needy: Exclude money a protective payee receives for the care and maintenance of a third-party beneficiary (whether or not included in the protective payee’s home). Count any portion the protective payee keeps for their own use as income to the payee. Count the full payment/benefit issued on behalf of a beneficiary to the beneficiary, even if the payee retains a service fee or does not pass the income to the beneficiary. As a condition of eligibility, the client must avail themselves of all income they may be entitled to.

PENSION PAYMENTS: Count recurring pension payments, including government and Railroad Retirement payments as unearned income.

PLAN FOR ACHIEVING SELF-SUPPORT (PASS): Exclude income paid to an SSI recipient under a PASS during the period the PASS is effective.

RECOUPMENT FOR PRIOR OVERPAYMENTS: ACA: Count the gross amount ABD and Family Medically Needy: Count the net amount, after the repayment is taken, when money is withheld to repay a previous overpayment from the same source.

See Garnishments in this section for recoupments unrelated to an overpayment from the same source.

REIMBURSEMENTS: Exclude reimbursements that do not exceed actual expenses. Count any amount received that exceeds actual expenses. Review reimbursements for normal living expenses (i.e., mortgage, rent, clothing, food eaten at home) under ‘Contribution’ or ‘In-Kind Income’ policy. These payments cannot be excluded as reimbursements as they provide a benefit to the client.

Excluded reimbursements include, but are not limited to: 1. Exclude reimbursements provided over and above basic wages for job or training- related expenses (i.e., travel, per diem, uniforms and transportation to/from job or training site). However, these expenses, if not reimbursed, are not otherwise deductible. Exclude reimbursements to migrant workers for travel expenses. 2. Reimbursement of a volunteer’s out-of-pocket expenses incurred in their voluntary work; 3. Dependent care and medical reimbursements including VA reimbursements for unusual medical expenses; 4. Reimbursements the household receives to pay for services provided by Title 20 of the Social Security Act. 5. Renters Credit or Homeowners Credit.

RENTAL INCOME: Count as unearned income rental income and rental partnership income when the client is not materially participating in the rental operation and decision-making a minimum of 10 hours per week. Allowable expenses of producing the income (property tax, mortgage interest payment, etc. See CMA 503-1 Self-Employment Income) are deducted to determine net countable income.

SALE OF A RESOURCE: ACA: Any gain received from selling a resource is a capital gain and is taxable. All Medicaid Programs: When income from the sale of a personal resource is received in installment payments, the payments minus cost of doing business are countable income. ABD and Family Medically Needy: Exclude installment payments received on loans/contracts that are countable resources. Count the entire installment payment as income when received on an excluded sale/loan. Example: Joe sells his trailer for $1,000. He receives a down payment of $300 with the $700 balance to be paid in $100 monthly installments. If he can readily liquidate the installment contract, the $700 balance is a countable resource, and the monthly payments are excluded. If he cannot easily liquidate the installment contract (e.g., language states it cannot be sold) the contract is an excluded resource but the $300 down payment and $100 monthly payments are counted, in their entirety.

ABD and Family Medically Needy: When proceeds from the sale of a personal resource are received in ONE payment the payment is not considered income but instead a resource in the month received (the resource has simply changed forms).

See section CMA 503-1 Self-Employment Income ‘Capital Gains’ for sale of self- employment resources.

SETTLEMENTS AND RESTITUTION PAYMENTS: Agent Orange: Exclude payments made under the Agent Orange Compensation Act (P.L. 101-201). NOTE: Count Veteran’s benefits paid to veterans with service-connected disabilities resulting from exposure to Agent Orange (P.L. 102-14). Asbestos: Count monies received from an asbestos settlement or lawsuit the earlier of when available or when received. Cobell et al vs. Salazar: Exclude payments derived from this settlement (P.L. 111-5). Crime Victim Compensation: Exclude all payments received under this program. Disabled Children of Female Vietnam Veterans: Exclude payments the VA makes to disabled children (now adults) of women who served in Vietnam between February 1961 and May 1975. Disaster Relief Act: Exclude payments issued as a result of a presidentially-declared emergency or major disaster as defined in this Act. See ‘FEMA’ in this section.

Factor VIII or IX Concentrate Blood Products Litigation, MDL 986 (No. 93-C-7452, Northern District of Illinois): Exclude settlement payments made as a result of the class action lawsuit to hemophilia patients infected with HIV (Human Immunodeficiency Virus) through blood plasma products. Keepseagle vs.Vislack – Settlement of Tribal Trust Accounting and Management Lawsuits: Count settlement payments in the month received, when they can be prospected. Nazi Persecution Victims: Exclude restitution made to individuals because of their status as victims of Nazi Persecution (P.L.103-286). Nez Perce et. al. v. Salazar – Settlement of Tribal Trust Accounting and Management Lawsuits: Exclude payments derived from this settlement. Radiation Exposure Compensation Act: Exclude payments received under this Act (P.L. 101-425) Spina Bifida: Exclude payments made to children of Vietnam veterans for disabilities resulting from spina bifida. (P.L. 104-204) Susan Walker V. Bayer Corporation, et al, 96-C-5024 (Northern District of Illinois): Exclude payments made from any fund established pursuant to this class settlement and payments made pursuant to a release of all claims in a case that was entered into in lieu of the class settlement and that was signed by all affected parties in such case on or before December 31, 1997. Uniform Relocation Assistance: Exclude payments made under the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970.

Wartime Relocation of Civilians: Exclude “Wartime Relocation of Civilians” payments made to U.S. citizens of Japanese ancestry, resident Japanese aliens and eligible Aleuts under Title I of P.L. 100-383 or the Civil Liberties Act of 1988.

SICK LEAVE/ VACATION PAY: ACA: Sick leave or vacation paid after job termination is severance pay (earned income). ABD and Family Medically Needy: Sick leave paid out more than six months after job termination is countable unearned income. Sick leave paid out within six months of job termination is countable earned income in the month received. All Medicaid Programs: Sick leave or vacation pay received while still employed is wages. ABD and Family Medically Needy: Vacation paid after job termination is severance pay (earned income). See CMA 502-1 Earned Income for earned income types.

SOCIAL SERVICES: Exclude benefits received from complimentary social services assistance programs such as Ryan White CARE Act Programs (P.L. 101-381 & 104-146), Habitat for Humanity, WIC, LIHEAP, Weatherization, HUD/Section 8 utility payments, Farmers Home Administration rent subsidies, and Children’s Special Health Services.

SPONSORED ALIENS: ACA: Exclude income from a sponsor who is unrelated to the sponsored alien. Count cash support actually available to the alien when the alien is claimed as a tax dependent on the sponsor’s taxes. ABD and Family Medically Needy: Count the amount deemed from the sponsor to the sponsored alien. See CMA 603-1 Deeming

STRIKER INCOME: Count union-paid income (for participating in a picket line) as unearned income. Wages received while picketing are earned income.

SUBSIDIZED GUARDIANSHIP: Exclude subsidized guardianship payments.

TAX REFUND/CREDIT: ACA: Exclude Federal Income Tax refund sand Earned Income Tax Credit payments; count State Income Tax refunds included on State Income Tax returns.

ABD and Family Medically Needy: Exclude State and Federal income tax refund sand Earned Income Tax Credit payments.

Exclude the following tax credits: · Child Tax Credit; and · Renters/Homeowners Credit · TEMPORARY DISABILITY INSURANCE: ACA: Exclude disability payments paid through Workers’ Compensation. Count payments paid through an employer (considered disability payment when received prior to retirement age, and pension income once reach retirement age). ABD and Family Medically Needy: Countable, unless a reimbursement for specific costs.

UNEMPLOYMENT COMPENSATION: Countable. NOTE: Count the gross amount when child support or taxes are taken out of unemployment payments. The child support may be an allowable deduction.

VENDOR PAYMENTS (AKA IN-KIND): Benefits received in a form other than cash. Vendor payments/benefits can be earned or unearned and may be for food and/or shelter costs. Vendor payments may be paid directly to the household’s creditors or to a person/entity providing services to the household. Income or money obligated to the household from any source, even if diverted to an outside entity is considered available. See ‘Bartering’ in Section CMA 503- 1 Self-Employment Income for policy regarding in-kind services exchanged between two or more self-employment businesses.

ACA: Exclude vendor payments/in-kind income, unless it is taxable. Count taxable vendor/in-kind income. ACA Exception: Special rules apply to clergy; exclude income designated for housing that is included in their pay. Family Medically Needy: Excluded. Unearned vendor payments/in-kind income is food or shelter given to the household with no requirement to work. However, evaluate to determine if it is a contribution (e.g., the client is receiving money to buy groceries or pay rent). ABD: Count as vendor payments/in-kind income only those vendor payment/in-kind benefits received in the form of food or shelter or as something that can be used to get food or shelter (e.g. Walmart or other prepaid card that can be used to buy food).

ABD: Earned vs. Unearned Vendor/In-Kind Income Earned: Vendor/In-kind benefits (food or shelter) provided to an employee who has the option of either receiving in-kind benefits or increased wages. Unearned: Vendor/In-kind benefits (food or shelter) provided to an employee on the employer’s premises as a condition of employment and/or for the employer’s convenience.

ABD Vendor/In-kind Benefit Value When vendor/in-kind benefits are received in the form of food and/or shelter, the value is determined as follows:

One-third value reduction provision (all food and shelter): Consider unearned vendor/in-kind income equal to 1/3 the individual or couple categorically needy income standard when an individual/couple receives all food and shelter from:

1. Other household members while living in another person’s household throughout a month; or 2. Others outside their household while living in their own home.

Presumed Maximum Value (PMV) rule (food or shelter): Vendor/in-kind benefits for food OR shelter are valued using the PMV rule. Apply the PMV rule to situations such as, but not limited to an individual/couple:

1. Lives rent-free in a residence separate from other households; 2. Receives food; 3. Receives any other food or shelter from a third party.

The PMV is the lesser of:

1. One-third the individual or couple (as appropriate) categorically needy income standard amount (see ABD 008 Table of Standards-Categorically Needy Income) plus $20, or 2. The actual value of the food or shelter contributed (if proof is provided).

ABD and Family Medically Needy: Vendor/in-kind income is not included in any deeming process. Example: Ken works at the Q&C ranch. He is required to live on the ranch property; the rental value is $350. Ken is applying for ABD Medicaid for his wife. The PMV or rent value is entered as Ken’s unearned income. If Ken has the option of living on the ranch or renting in town (at his employer’s expense), the rental value is countable earned income. Exclude unearned vendor payments for goods and services other than food and shelter when made with funds not owed to the household (e.g., grandmother buys clothes for her grandchildren).

Count the following vendor payments: · Money legally owed/payable to the household that are diverted to a third party for household expenses. · Court-ordered support or spousal support payments diverted to a third party for household expenses. · Rent or mortgage payments made to landlords or mortgagees through County or BIA General Assistance.

ABD: Count the value of food and/or shelter received when paid via vendor payment.

VETERANS BENEFITS: Veterans may receive a variety of VA benefits, including retirement, pensions and compensation. Veteran’s compensation is paid to certain veterans who are disabled as a result of their military service. Veteran’s pensions are paid to wartime veterans with limited income who are no longer able to work or are age 65 or older.

ACA: Exclude all payments received from the VA. ABD and Family Medically Needy: Count Veteran’s benefits other than VA A&A.

Exclude VA A&A as income, instead VA A&A is treated as third party liability available to reduce the cost of care in the nursing home, or medical expenses for veterans living in the community or an Assisted Living Facility.

NOTE: For medically needy cases, reduce the veteran’s medical expenses by the A&A amount; apply remaining medical expenses to the spend down. Exclude VA pensions of $90 or less in post eligibility treatment of income/ patient liability for institutionalized veterans.

NOTE: Veterans are allowed the $50 personal needs allowance in addition to the $90 VA exclusion. WORKERS’ COMPENSATION: ACA: Generally excluded. Exception is if the workers comp reduces the amount of a Social Security RSDI payment, the amount by which the RSDI payment is reduced is countable income. It may be necessary to contact SSA directly to obtain the details of this situation for a non-filer. ABD and Family Medically Needy: Countable. Count the gross amount when attorney fees are deducted from Workers’ Compensation payments.

Effective Date: 01/01/2026

COMBINED MEDICAID 501-2 Native American Income Supersedes: MA & FMA 501-2 (01/01/08); Bulletins: MA 94, 98, 111a & 111b; FMA 53, 57, 68a & 68b Reference: 20 CFR 416.1102, .1103, .1120, .1121; .1123; .1124; .1150; ARM 37.82.101, .703 and .903; P.L. 103-444, ARRA of 2009; P.L. 111-5 Overview: All income the household receives must be evaluated when determining eligibility. For Native American income, the source dictates whether the income is counted or excluded. Treat unearned Native American income as follows: EXCLUDED SOURCES: 1. All payments derived from leases or other uses of individually-owned trust or restricted lands. 2. Interest earned on Native American funds/resources. 3. Ownership interests in rents, leases, royalties or usage rights related to natural resources. 4. Income derived from the following settlements: • Cobell et al vs. Salazar (P.L. 111-5). Payments derived from this settlement are excluded as income and as a resource as long as the funds can be specifically identified as being from that source. • Nez Perce et al vs. Salazar (P.L. 111-5). Payments derived from this settlement are excluded as income and as a resource as long as the funds can be specifically identified as being from that source. 5. Judgment claim payments to or under: • Blackfeet, Gros Ventre and Assiniboine Tribes of Montana and Papago, Arizona Tribe (P.L. 97-408); • Alaska Native Claims Settlement Act (P.L. 92-203); • Navajo or Hopi Indians as financial or relocation assistance (P.L. 93-531, Section 22); • Grand River Band of Ottawa Indians (P.L. 94-540); • Confederated Tribes and Bands of the Yakima Indian Nation or the Apache Tribe of the Mescalero Reservation by the Indian Claims Commission (P.L. 95-433); • Passamaquoddy Tribe and Penobscot Nation pursuant to the Maine Indian Claims Settlement Act of 1980 (P.L. 96-420); • Turtle Mountain Band of Chippewas (P.L. 97-403); • Red Lake Band of Chippewa Indians (P.L. 98-123, Section 3); • White Earth Band of Chippewa Indians in Minnesota (P.L. 99-264);

• Saginaw Chippewa Indian Tribe of Michigan (P.L. 99-346); • Puyallup Tribe of Indians Settlement Act to members of the Puyallup Tribe in Washington (P.L. 101-41); • Seneca Nation (P.L. 101-503, Section 8 (b)); • Grand Coulee Dam Settlement Act to the Confederated Tribes of the Colville Reservation (P.L. 103-436, Section 7 (b)); • Indian Child Welfare assistance (25 USCS 1931); • Old Age Assistance Claim Settlement Act. (P.L. 98-500, Section 8); • Seminole Nation of Oklahoma, Seminole Tribe of Florida, Miccosukee Tribe of Florida and independent Seminole Indians of Florida. 6. Payments derived from sub-marginal lands held in trust for the following tribes under P.L. 94- 114: • Assiniboine and Sioux Tribes; • Blackfeet Tribe; • Fort Belknap Indian Community; • Crow Creek Sioux Tribe; • Lower Brule Sioux Tribe; • Devils Lake Sioux Tribe; • Oglala Sioux Tribe; • Rosebud Sioux Tribe; • Shoshone-Bannock Tribes; • Standing Rock Sioux Tribe, • Bad River Band of the Lake Superior Tribe of Chippewa Indians of Wisconsin; • Cherokee Nation of Oklahoma; • Cheyenne River Sioux Tribe; • Lac Courte Oreilles Bank of Lake Superior; Chippewa Indians; • Keweenaw Bay Indian Community; • Minnesota Chippewa Tribe; • Navajo Tribe; 7. Per capita to enrolled members of the following tribes when distributed under: P.L. 98-124, Section 5 • Assiniboine Tribe of the Fort Belknap Indian Community and Assiniboine Tribe of the Fort Peck Indian Reservation. P.L. 99-146, Section 6 (b), Docket 18S and 18U • Bad River Reservation; • Lac du Flambeau Reservation; • Lac Courte Oreilles Reservation; • Sokaogon Chippewa Community; • Red Cliff Reservation; • St. Croix Reservation;

• Keweenaw Bay Indian Community; • Fond du Lac Reservation; • Grand Portage Reservation; • Nett Lake Reservation; • White Earth Reservation. P.L. 99-146, Section 6 (b), Docket 18C and 18T • Lac Courte Oreilles Band of the Lake Superior Bands of Chippewa Indians; • Bad River Bank of the Lake Superior Tribe of Chippewa Indians of the Bad River Reservation; • Sokaogon Chippewa Community of the Mole Lake Bank of Chippewa Indians; • St. Croix Chippewa Indians of Wisconsin. P.L. 99-377 Section 4 (b) • Chippewa of the Mississippi P.L. 94-189 • Sac and Fox Tribe of the Mississippi, Iowa and Oklahoma P.L. 97-458, 93-134 and 98-64 8. Senior Benefit payments received by the Crow elders under the Crow Boundary Settlement Act 1994 (P.L. 103-444). 9. The first purchase made with excluded Native American funds remains excluded. COUNTABLE SOURCES: 1. Bureau of Indian Affairs (BIA) payments; unless otherwise excluded; 2. Tribal payments unless otherwise excluded; 3. Tribally managed gaming revenues distributed per capita (P.L. 98-64); 4. Transfers of countable monies from other Native American agencies. Effective Date: June 01, 2016

COMBINED MEDICAID 502-1 Earned Income

Supersedes: CMA 502-1 04/01/2025 Reference: ARM 37.82.101, .903; 42 CFR 435.601; 20 CFR 416 Subpart K Overview: All earned income the filing unit receives is considered when determining Medicaid eligibility. All earned income, whether countable or excluded per policy is entered into the eligibility system. ADVANCE ON WAGES: Count advanced wages in the month the advance is expected. NOTE: Exclude the amount withheld from subsequent pay to repay the advance, even if the advance wasn’t counted when received. AMERICORPS/AMERICORPS VISTA: ACA: Count AmeriCorps VISTA, AmeriCorps State and National and AmeriCorps NCCC payments. ABD and Family Medically Needy: Exclude AmeriCorps VISTA, AmeriCorps State and National and AmeriCorps NCCC payments.

ATTENDANT CARE PAYMENT: Count attendant care pay only to the person who earns it. NOTE: Exclude attendant care pay paid to the disabled/elderly household member receiving the care; it is considered a reimbursement. BONUS PAY: Count bonus pay that can be prospected in the month received. CHILDREN’S EARNED INCOME: ACA: Student status has no bearing on whether a child’s earned income is counted or excluded. A child and/or dependent’s income is countable if they are required to file a tax return based on the current tax year. A child’s earned income is countable if the gross income amount meets/exceeds the 2024 Tax Threshold limit of $14,600. Family Medically Needy: Exclude a dependent child’s earned income when the child is attending school (any attendance at school qualifies the child as a student). Count the earnings if the child is not attending school. ABD: Countable. If the child is a disabled student, refer to the following: Exclude a disabled student under age 22’s earnings of up to $2410 per month up to a maximum of $9730 per calendar year for 2026. CLERGY: Salary/wages received from the church are earned income and coded as wages. A housing allowance paid to the individual is excluded income. Any income received from conducting marriages, baptisms, funerals, etc. are considered self-employment. ACA/ABD/Family Medicaid: countable as wages and self-employment COMMISSION: Count commissions that can be prospected. Count commissions received less often than monthly over period intended to cover). NOTE: Commissions are earned by and obligated to the wage earner; bonuses are not (see ‘Bonus’ caption). CONTRACTUAL INCOME: Contractual income is income paid over a specific, set period. For all categories, except ABD-related, the income is averaged over the months covered by the contract, regardless of whether the employee chooses to spread their income evenly throughout the contract period or chooses payment only during the times actually worked.

EXAMPLE: A school aid is employed under a yearly contract, but only receives a paycheck for the months of September through June. The total yearly income contracted should be divided by 12 to determine the monthly income.

ACA NOTE: When tax returns are the only verification provided, the amount is always averaged over 12 months. ABD: Contractual income is averaged over the number of months it is intended to cover. EXAMPLE: A school aid is employed under a yearly contract, but only receives a paycheck for the months of September through June. The pay for September through June should be divided by 9 months to determine the monthly income and be included in the budget from September to June. DISPLACED HOMEMAKER: Count State Displaced Homemaker program earnings. DOMESTIC VOLUNTEER SERVICE ACT: ACA: Count all Domestic Volunteer Service Act payments. ABD and Family Medically Needy: Exclude the following payments: • RSVP – Retired Senior Volunteer Program • Foster Grandparents Program • SCORE – Service Corps of Retired Executives • ACE – Active Corps of Executives • Senior Companion Program GARNISHMENTS DEDUCTED FROM WAGES: ACA: Count the gross income amount. ABD and Family Medically Needy: Count the gross wages when garnished for a debt. Count the net amount when wages are reduced for a previous advance. ABD and Family Medically Needy: Payment of a legally obligated child support debt is an allowable expense. See CMA 602-1 Income Disregards and Deductions GOVERNMENT TRAINING ALLOWANCES: ACA: Countable if taxed. ABD and Family Medically Needy: Count or exclude based on the specific funding source. INDIVIDUAL DEVELOPMENT ACCOUNTS:

Exclude funds withdrawn from a TANF-funded IDA. Exclude interest earned on an IDA. IRREGULAR/INFREQUENT INCOME: ACA: Count or exclude based on income type (e.g. gifts, contributions, etc.) ABD and Family Medically Needy: Count any amount of income that can reasonably be prospected. JURY DUTY: ACA: Countable, unless the client verifies that they gave the payment to their employer. ABD and Family Medically Needy: Count jury duty paid over a period of days or weeks at a specific rate (e.g., $15 per day) when it can be prospected. Exclude jury duty pay when it meets the definition of either irregular/infrequent income or a reimbursement, and when the client verifies that they gave the payment to their employer. LUMP SUM PAYMENTS: ACA: Count taxable lump sum payments. ABD and Family Medically Needy: Count lump sum payments that can be prospected, unless received from an excluded source. Payments are countable income in the month received and a resource the following month, if retained. Examples of lump sum payments include: · Severance pay or sick leave (see sections CMA 501-1 Unearned Income and CMA 502- 1 Earned Income); • Income tax refunds • Rebates or credit refunds • Crop insurance proceeds (see section CMA 503-1 Self-Employment Income); • Retroactive Social Security, retroactive SSI, retroactive TANF or Tribal TANF, retroactive Railroad Retirement or insurance settlements • One-time or installment lottery payments • Windfall or other one-time payments. MILITARY PAY: ACA: Exclude Combat Pay; count other earned military pay. ABD and Family Medically Needy: Count earned military pay. See section CMA 501-1 Unearned Income for Veteran’s Benefits and Military Allowances. OLDER AMERICANS ACT:

Count income earned under Title V of the Older Americans Act of 1987, including: • Experience Works aka Green Thumb • Forest Service • American Association of Retired People (AARP) • National Council on Aging • National Council of Senior Citizens PLAN FOR ACHIEVING SELF-SUPPORT (PASS): Exclude income paid to an SSI recipient under a PASS during the period the PASS is effective. ROYALTY INCOME: Countable. Royalties received as part of a trade or business, or as the result of an individual’s work being published is countable earned income. All other royalties are countable unearned income. Expenses can only be deducted from earned royalties when the income is derived from a current self-employment business. Royalty income is counted when received; recurrent payments may be averaged to prospect future payments. SALE OF BODILY FLUIDS: ACA: Excluded ABD and Family Medically Needy: Count earned income received from the sale of blood, blood plasma or other bodily fluids. SEVERENCE PAY: Counted in the month received. SICK LEAVE/ VACATION PAY: ACA: Sick leave or vacation paid after job termination is severance pay (earned income). ABD and Family Medically Needy: Sick leave paid out more than six months after job termination is countable unearned income. Sick leave paid out within six months of job termination is countable earned income in the month received. All Medicaid Programs: Sick leave or vacation pay received while still employed is wages. ABD and Family Medically Needy: Vacation paid after job termination is severance pay (earned income). TAX REFUND OR CREDIT:

ACA: Exclude Federal Income Tax refunds and Earned Income Tax Credit payments; Count State Income Tax refunds included on State Income Tax returns. ABD and Family Medically Needy: Exclude State and Federal income tax refunds and Earned Income Tax Credit payments.

TIPS: Tips given to people working in personal service occupations are often a significant part of their income. Wages and salaries paid to such persons are often quite low because tips are expected to provide a large portion of their income. Tips may vary seasonally or by the quality and type of service rendered. Some occupations for which tips may constitute a substantial portion of earnings are: • Food Servers • Taxi drivers/Uber drivers • Bartenders • Delivery persons • Barbers, cosmetologists, and hair stylist • Massage therapist • Caddies • Entertainers who play in restaurants, bars or nightclubs Since the list is not all inclusive, income from tips is considered for anyone who is engaged in a service occupation. VENDOR PAYMENTS (AKA IN-KIND): See ‘Vendor Payments’ in Section CMA 501-1 Unearned Income for additional information. See ‘Bartering’ in Section CMA 503-1 Self-Employment Income for policy regarding in-kind services exchanged between two or more self-employment businesses. ACA: Exclude vendor payments/in-kind income unless it is taxable. Count taxable vendor/in-kind income. ACA Exception: Special rules apply to clergy; exclude income designated for housing that is included in their pay.

ABD: Count as vendor payments/in-kind income only those vendor payment/in-kind benefits received in the form of food or shelter or as something that can be used to get food or shelter (e.g. Walmart or other prepaid card that can be used to buy food).

ABD: Earned Vendor/In-kind benefits (food or shelter) are those benefits provided to an employee who has the option of either receiving in-kind benefits or increased wages.

ABD Vendor/In-kind Benefit Value – see ‘Vendor Payments’ in CMA 501-1 Unearned Income for how to value vendor/in-kind benefits.

ABD and Family Medically Needy: Vendor/in-kind income is not included in any deeming process. Count earnings owed or otherwise payable to the household when diverted to a third party for a household expense (e.g., employer diverts $200 of wages to employee’s landlord for rent). WAGES: Count gross wages, including salary and commission. WORK STUDY INCOME: ACA: Countable. ABD and Family Medically Needy: Exclude all educational income, including work study, when directly related to attendance at an institution of higher education. WORKFORCE INNOVATION AND OPPORTUNITY ACT (WIOA): The Workforce Innovation and Opportunity Act (WIOA) replaced the Workforce Investment ACT (WIA). ACA: Countable. ABD and Family Medically Needy: Exclude all Workforce Innovation and Opportunity Act (WIOA) payments, including Work Experience (WEX) and On-the-Job Training (OJT). Count wages a client receives under OJT; WIOA OJT payments reimburse the employer for the client’s wages, but do not actually pay the wages. Effective Date: 01/01/2026

COMBINED MEDICAID 503-1 Self-Employment Income Supersedes: FMA 503-1, (07/01/08 &10/01/08); MA 503-1 (07/01/16) Reference: 42 CFR 435.601; 20 CFR 416.1110(b), 416.1111(b), and 404.1065 through .1096; ARM 37.82.101 Overview: Count net self-employment income when determining Medicaid eligibility. To be considered self-employed, an individual must meet the following criteria: 1. Income is earned directly from their business/trade; they do not receive wages or salary from an employer. 2. They are responsible for full payment of their Social Security and Federal withholding taxes; 3. The individual is not employed by another person and an employer does not control or direct the services the self-employed individual performs. 4. If they file taxes, they use self-employment tax forms (schedule C, C-EZ, F, SE, Form 1065, etc.); and 5. They “materially participate” in the income production. NOTE: Other indications of self-employment are used when a client states they are self-employed, but they haven’t yet filed income taxes. These include a business license, evidence of ongoing, regular business activities, financial accounts in the business name, periodic advertising, and business registration with the Secretary of State. SELF-EMPLOYMENT STRUCTURES: Clients may refer to being self-employed under a variety of business structures; however, not all business structures are considered self-employment for Medicaid purposes. The most common business structures include: 1. Sole Proprietorship: Unincorporated business structure owned by one or two individuals. The owners are responsible for business income and liabilities. NOTE: Limited Liability Companies (LLCs) are NOT sole proprietorships. 2. Independent Contractor: Individual who pays their own employment taxes and does not have an employee/employer relationship. Considered self-employed unless incorporated or an LLC. Should be registered with Department of Labor and Industry. 3. Sharecropper: When the individual pays the cost of doing business and receives a portion of net income in exchange for their labor they are considered self-employed. However, if they are not responsible for the costs of doing business, incorporated or an LLC, they are not considered self- employed. CORPORATIONS:

Incorporated businesses are not self-employment enterprises. Property owned by corporations and corporate stock cannot be excluded as necessary for self-employment or self-support because the individual does not own it. Even when the business started as self-employment, once it is incorporated, it is no longer considered self-employment. Income the individual receives while working for the corporation is considered countable wages. NOTE: Earnings paid to corporate offices are considered wages, however, fees paid to corporate directors are considered self-employment income. ACA: Count corporate income whether or not the client receives it. ABD and Family Medically Needy: Count any corporate income reported on Schedule E, Line 32 as unearned income only when received. ACA: Any loss reported on Schedule E, Line 32 can be used to offset other income and decrease MAGI income. ABD and Family Medically Needy: Losses reported on Schedule E, Line 32 are not used in any budget calculation. LIMITED LIABILITY COMPANIES (LLC) & PARTNERSHIPS: Medicaid treats LLCs and limited partnerships like corporations, partnerships are not considered self- employment. LLC’s can file taxes as either a corporation (Schedule E or 1120S) or self- proprietor (schedule F or C). Since LLC’s can choose how they want to file their taxes we will input into CHIMES as either corporate income or self-employment depending on how they file. If filing as a corporation, guaranteed salaries are treated as regular wages; all other income received from an LLC or partnership is considered unearned income. Property owned by an LLC or partnership cannot be excluded as necessary for self-employment or self- support because these arrangements are not considered self-employment, and the LLC/partnership owns the property, not the individual. Partnerships are entities with two or more partners and may include both “working” and “silent” partners. Partnerships are required to file 1065 and K-1 forms in addition to personal tax forms. All partners are responsible for business income and liabilities, with the partnership defining each partner’s share. Determine partnership income in the same manner as LLC and corporate income; income reported on a 1065 or K-1 is considered unearned, or passive income. Partnerships do not report or pay income taxes. Only wages paid to a working partner is considered earned income, however, there won’t be a W-2 or 1099 form issued so the eligibility staff member must work with the client to determine how much, if any, of the income reported on the 1065 or K-1 is earned. ACTIVITIES THAT ARE NOT SELF-EMPLOYMENT: The following are treated as unearned (i.e., passive) income, and are not considered self-employment: 1. Self-employment or partnership rental income where the individual does not participate in the business at least 10 hours per week or does not report it as self-employment on Schedule C or F (passive rental income is usually reported on Schedule E). See CMA 501-1 Unearned Income. 2. Contract for deed income (CMA 501-1 Unearned Income), 3. Certain boarder income (see Boarders heading in this section), or

4. Income a “silent” (i.e., non-participating) partner receives. RESOURCES: ACA: Resources are not considered for any ACA program. ABD and Family Medically Needy: See ‘Self-Employment Resources’ in CMA 402-1 Countable and Excluded Resources. PATRONAGE DIVIDENDS: Count patronage dividends as part of the self-employment income when paid to a self-employment business, even if paid in stock. AGRICULTURAL STABILIZATION & CONSERVATION SERVICES (ASCS): Count cash payments as earned self-employment income. These include, but are not limited to: Commodity Credit Corporation, acreage reduction and conservation payment and other one-time or installment payment made to farmers for crop or other losses unrelated to a presidentially declared disaster. Exclude payments due to a presidentially declared disaster as income under the Disaster Relief Act. CANCELED DEBT: Use canceled debt when determining net self-employment earnings, if reported on tax forms. CAPITAL GAINS & LOSSES: ACA: Count capital gains and subtract capital losses when determining MAGI income. ABD and Family Medically Needy: Exclude capital gains and losses from the sale of self-employment property. BARTERING: Exchanging one service for another (such as storage space for appliance repair) between two self- employed businesses is called bartering. The bartered goods or services must be evaluated to determine if the value received is countable income. Food and/or shelter provided by a self- employment business (including a farm) may be considered earned or unearned vendor/in-kind benefits. Valuing vendor/in-kind benefits: ABD: See ‘Vendor Payments’ in CMA 501-1 Unearned Income Family Medically Needy: If verification is not provided, use the Family Net Monthly Income (NMI) standard for a household of one as the shelter value, and the SNAP Thrifty Food Plan for the appropriate household size for any food provided. See ‘Vendor Payment’ in Sections CMA 501-1 Unearned Income and CMA 502-1 Earned Income for additional information. INCOME EXCLUSIONS:

Exclude the following when determining net self-employment income: ACA: Disaster payments. ABD and Family Med Needy: 1. Federal gasoline tax credit 2. State gas tax, 3. Disaster payments (see CMA 501-1 Unearned Income), 4. Crop insurance payments, and 5. Capital gains. EXPENSES: Allowable Expenses include: 1. Business transportation costs. If mileage is tracked, the Federal expense rate is used; if mileage is not tracked, allow fuel, vehicle repair and maintenance costs. NOTE: Only one expense method (Federal expense rate or vehicle repairs, maintenance, and fuel costs) may be allowed for a vehicle for the specified period. 2. Depreciation; 3. A 7.65% deduction for the ‘employer-paid’ portion of Social Security taxes is allowed when determining net self-employment income. This expense is manually calculated and entered into the system. 4. Meals and entertainment costs Other expenses allowed include: labor paid to individuals not included in the filing unit, materials, seeds, supplies, plants, fertilizer, interest payments on business loans, business portion of home property, repairs, etc. NOTE: Supplies are generally items that will be used up or consumed in the business, and include small tools, paper, pencils, scissors, gas, oil, envelopes, shampoo, crayons/coloring books, etc. Deduct allowable expenses when determining net self-employment income. Most costs of doing business are allowed, and the amounts listed on the income tax forms are acceptable verification, unless the client expects their income to change. The expenses must be current and are only allowed when paid, not when incurred. NOTE: Expenses expected to be due and payable in the prospective period can be anticipated when calculating income for a new self-employment business or one experiencing a significant change. To qualify for the Earned Income Tax Credit, some self-employed individuals may not claim all expenses on their Schedule C. Allowable expense not listed on the Schedule C can be verified and used to accurately determine countable self-employment earnings. Determining Cost of Dependent Care Meals: Self-employed dependent care providers (day care for children, elderly or disabled individuals) may choose one of the following methods to determine cost of meals provided to those they care for: 1. Actual documented meals; 2. A standard per day amount based on estimated meal costs; or 3. Current reimbursement amounts used in the Child and Adult Care Food Program.

Shelter Expenses: Self-Employment Business Connected to or on Home Property: When a farming or other self-employment business is connected to or on the same property as the client’s home, a breakdown of farm/business shelter expenses (e.g., rent or mortgage) from personal shelter expenses must be made. Do not allow questionable expenses when the client cannot or will not provide proof of separate business and personal shelter expenses. In-Home Self-Employment Business: If a self-employed client, who operates their self-employment business from their home, wants to claim part of their shelter expense as a business deduction, the personal shelter expenses must be separated from the business expenses. Only the expenses for the portion of the home that is exclusively used for the business are allowed. Home shelter costs may be allowed as a business deduction, if the client spends a significant amount of time conducting business activities in the home; and, if the business is NOT related to dependent care, ONE of the following may be allowed: 1. The expense for a portion of the home used exclusively for self-employment inventory storage; or 2. The expense for the portion of the home that is used exclusively to conduct business activities (the space cannot be used for any other purpose). Shelter expenses are not allowed when the majority of income is made outside the home and the home is used only for administrative purposes. Determining Allowable Shelter Expense: A breakdown is determined using one of the following: 1. The client’s expense calculation; 2. Amount listed on the client’s IRS form 8829 (when home used for dependent care or inventory storage) or other income tax form; 3. Expense verifications the client provides (for business connected to/on home property); or 4. The ratio of business square footage to square footage of entire home (for dependent care or other in-home business). The expense amounts listed on income tax forms is considered valid, and is only questioned if the information appears inaccurate, such as the client’s entire shelter expense is deducted. If this happens, the expense can be recalculated as listed above, or with the client’s consent, can be valued using vendor/in-kind policy in Section CMA 501-1 Unearned Income. Non-Allowable Expenses: Non-allowable expenses are added back into self-employment income when listed on tax forms or are not deducted when calculating monthly self-employment income. Examples of non-allowable expenses include:

1. Purchase costs of capital assets or durable goods, whether or not set up on a depreciation schedule. Durable goods and capital assets are business items expected to last a long time and include farm machinery, equipment, buildings, computers, swing sets, cribs, DVD players, furniture, highchairs, vehicles, hair dryers, tricycles, etc. All items purchased prior to a business opening are capital expenses. 2. Principal portion of loan repayment – the interest payment on a business loan may be deducted; 3. Federal, state, and local income taxes, 4. Transportation to and from work – the cost of commuting to the business from home is not allowed, including the cost of commuting to the job site if the business does not have a set place of business. EXCEPTION: When the client is transporting tools/supplies necessary to work at the job site (i.e., a “loaded” trip), transportation costs may be claimed. BUDGETING: Self-employment income and expenses are always annualized; expenses are allowed when paid, not when billed. The period the income is intended to cover is not considered. NOTE: When the client reports their self-employment business has ended, the annualized income is end-dated. Income tax forms are used for annualized self-employment, if available. Use the most current tax forms unless the client expects a substantial change in their business or income. NOTE: Substantial changes include starting or ending a business; increasing or reducing business operations, etc. If tax forms aren’t available, the income is still annualized, but other documentation must be provided to determine annualized income. NEW BUSINESS: Determine income for a new business by averaging the income and expenses for the months the business has been in operation. If there is no reliable history, the eligibility staff member and the client must agree on a reasonable projection. RENTAL INCOME: Rental income may be earned or unearned depending on whether or not the client is materially participating in the rental business (see ‘Activities that are Not Self-Employment’ in this section for more information), and is determined on a case-by-case basis. The cost of business is deducted to determine net income for both earned and unearned rental income. ROOMER INCOME: Countable. Roomer income may be earned or unearned depending on whether or not the client is materially participating in the business. If the client is materially participating, treat roomer income as earned self-employment. When the client is not materially participating, roomer income is unearned. Earned and unearned roomer income is offset based on prorated household expenses (i.e., the home has 5 total rooms, excluding bathrooms and attics/basements (unless converted to living spaces) and the roomer rents one room; 20% of the household shelter expenses are allowed). BOARDER INCOME:

Countable. Commercial boarding houses are treated as regular self-employment. Boarding situations that are not in a commercial boarding house may be earned or unearned depending on whether or not the client is materially participating in the business and are treated as follows: • Boarder income includes all payment made directly to the household, including payments for meals and shelter. Countable income is determined by subtracting the household’s costs of providing room and meals from the total boarder income received. Use one of the following methods to determine allowable expenses: 1. Actual documented expenses for room and meals, and pro rata share of food, utilities, etc.; or 2. Amount allowed for vendor/in-kind food and/or shelter (see ‘Vendor Payments’ in CMA 501-1 Unearned Income); or 3. ABD: One-third value reduction provision (see ‘Vendor Payments’ in CMA 501-1 Unearned Income). SELF-EMPLOYMENT LOSSES: ACA: Any loss reported on Schedule E, Line 32 can be used to offset any other income and decrease MAGI income. ABD and Family Medically Needy: Subtract verified self-employment losses from other self- employment gains. ABD: Self-employment losses can also be deducted from other earned income. BANKRUPTCY: Continue to use the projected monthly self-employment income until the client reports the business will have a substantial change in income and/or expenses. A statement from the bankruptcy trustee can verify the debt reorganization plan. Continue to count the self-employment income even when it’s diverted to a bank or other source. Deductions for trustee or conservator’s fees are not allowed. When equipment or land is repossessed or title is given to the lender, the property is no longer owned by the client; sale of this property is not considered income. A loan that is forgiven or written off is not considered income. Revised Date: April 01, 2023

COMBINED MEDICAID 601-1 Prospective Budgeting Supersedes: MA 601-1 (01/01/09); FMA 601-1 (01/01/09) Reference: 42 CFR 435.601; ARM 37.82.101, .703, .903; 20 CFR 416 Subpart K Overview: ACA: Income eligibility for all ACA programs and HMK is determined using MAGI (Modified Adjusted Gross Income). Income eligibility is based on current monthly income and household size. NOTE: When tax returns are not provided, ACA follows Family Medically Needy prospective budgeting policy. Financial eligibility will be prospectively budgeted. Best estimates of income, household composition and other circumstances for the benefit month will be used to determine eligibility. All Medicaid Programs: Financial eligibility is determined prospectively using the best estimates of income, household composition, resources (for programs with a resource limit) and other circumstances. Prospective budgeting methods can be used on both earned and unearned income. However, there are some income types and situations that require specific methods be used. For example, actual income must be used when determining retro eligibility and self-employment income is always annualized. MAGI HOUSEHOLD: Tax filing rules are used to determine countable income. In addition to counting taxable income, MAGI requires that other specific income be included in the countable income determination. These include: 1. All Social Security RSDI (but not SSI). 2. Foreign earned income 3. Tax-exempt interest GATHERING INFORMATION: Certain information must be gathered to correctly determine a client’s eligibility. Eligibility staff should use information provided verbally by the client, on the application, at renewal, reported changes and/or collateral verification to make a correct eligibility determination. 1. When determining income eligibility, the following information may be needed: a. income source/job type;

b. nature of job (e.g., seasonal, on-call, etc.); c. pay rate; d. pay frequency; e. number of hours worked per week/pay period, etc. (if income is from employment); and f. if work hours fluctuate NOTE: To ensure eligibility is correct going forward, eligibility staff may need to ask additional questions, such as if a change is expected to continue, if a payment is one- time or ongoing, etc. 2. Eligibility must be reevaluated upon receipt of more complete information or change report up to the point of the final eligibility determination. Always follow change reporting and notice requirements when redetermining ongoing eligibility. See CMA 1501-1. Information the client provides must be verified as required per policy listed in CMA 103- 4. PROSPECTING INCOME: Monthly income is prospected using one or more of the following methods. The method used will depend on household circumstances and income source. 1. Actual; 2. Anticipating; and NOTE: It may be necessary to use a combination of actual and anticipated income, even for the same month. For example, if at application, the client provides one paystub for the application month and expects to receive a second check that month, actual is used for the first pay period and the second is anticipated. 3. Factoring ACTUAL INCOME: Actual income can only be used when: 1. Computing an overpayment; 2. Determining past or retroactive Medicaid eligibility; or 3. When some or all pay in the current benefit month has already been received. ACA: The client’s most recent tax return may be used if it reflects current income and household composition. ANTICIPATING: Anticipate income when it isn’t appropriate to use actual income. Anticipating may be used with the following: 1. Averaging-when a reliable income history exists;

2. Prorating Over Period Intended to Cover-for contractual, self-employment or other income intended to cover more than a single month; 3. Rate/Unit/Frequency-when no other method is allowed or appropriate. FACTORING INCOME: ABD: Factoring is never used to determine monthly income and/or expenses. If the client is paid weekly or bi-weekly, the 3rd or 5th check cannot be averaged and must be counted in the month received. ACA and Family Medically Needy: Income is factored when all weekly/biweekly paystubs are provided for the application month. All income received weekly or bi-weekly (every two weeks) must be factored. It may be necessary to average and then factor if there is a reliable income history that is expected to continue. NOTE: Factor child support income and legally obligated (and paid) child support payments only when they are received/paid weekly or bi-weekly. NOTE: Child support income and legally-obligated child support payments, deductions can only be factored if truly received/paid on a weekly or biweekly basis. Average and factor weekly or bi-weekly checks provided for the application month, even when a 3rd or 5th check is not received that month. INCOME AVERAGING: Income is averaged when there is a reliable history but the income fluctuates from month to month or pay period to pay period. This could include wages, tips and irregular payments (child support, pension, etc.). Before averaging income, always ask the client if they expect the income and current fluctuations to continue and be sure to look for patterns, such as overtime. It may be necessary to average wages separately from overtime. If significant changes are expected in the prospective period, use the rate/unit/frequency option instead of averaging. Exclude payments that are unusually high or low. NOTE: When requesting pay stubs to average, always request pay stubs from a specific date through “present”. PRORATING OVER PERIOD INTENDED TO COVER: Contractual or other income expected to cover more than one month is prorated over the period intended to cover, or contract period. Do not count periodic payment until the first payment is received after Medicaid eligibility is established (CMA 500). ABD and Family Medically Needy: Self- employment income is always annualized (net annual self- employment is divided by 12) regardless of how many months per year the business is in operation (CMA 503-1). Contractual income is always prorated over the contract period (for example, a 9 month teaching contract is divided by 9). When significant income changes are expected for any payments included in the prospective period, the payments are still prorated over the period intended to cover, but the amount prorated will change.

RATE/UNIT/FREQUENCY METHOD: Use rate/unit/frequency to anticipate income when other methods aren’t allowed or appropriate, such as: 1. Income for any pay period is not expected to be “normal” because the client will be on extended unpaid sick leave, has new job, is not working their normal hours (covering extra shifts), promotion, job termination/lay-off, etc. is anticipated using rate/unit/frequency. 2. income is from a terminated source (e.g., lay-off or job termination); 3. income history is not reliable; 4. a significant income change is expected in the future (e.g., a promotion, part-time to full-time or vice versa, additional job duties, a raise in pay, a transfer, etc.). INCOME NOT COUNTED: In some instances, income is not counted prospectively. For example, a client has been unemployed, and reports on July 2nd that they begin a job on July 6th, and receive their first paycheck on July 21st. July’s earned income will not be counted. The client reported timely and the income was not known when July eligibility was determined in June. August eligibility is determined using rate/unit/frequency to prospect earned income. FLUCTUATION IN PAY SCHEDULE: Income is treated as if it is received on the regularly scheduled pay date when, for a reason beyond the client’s control, the pay date is either moved forward or back. Effective Date: July 01, 2016

COMBINED MEDICAID 602-1 Income Disregards and Deductions

Supersedes: CMA 602-1 (01/01/2025) Reference: ARM 37.82.101, .903; 42 CFR 435.601; 20 CFR 416.1112 Overview: Certain household income is disregarded or deducted when determining Medicaid eligibility. ACA: Households receive a 5% income disregard of the 100% FPL for that household size. No other disregards or deductions are applied to ACA Medicaid cases. ABD and Family Medically Needy: Specific earned and obligated income disregards are subtracted from household income when determining eligibility. WORK DISREGARDS: ABD: Disregard the first $65 and one-half of remaining earned income for each eligible ABD client. When the filing unit consists of an eligible client and an ineligible, deemed spouse, both spouse’s income is combined and then the $65 and ½ of remaining earned income disregard is applied once to the combined earnings. When both spouses qualify for ABD Medicaid (i.e., an eligible couple), the $65 and ½ of remaining earned income is disregarded from each spouse’s earned income. Blind or Disabled clients are allowed additional work expenses on top of the standard work disregard. BLIND/DISABLED WORK EXPENSES Each blind or disabled client living in the community may have their gross countable earned income reduced by allowable work expenses. Different expenses are allowed for blind and disabled clients. Work expenses must be verified and cannot be payable by a third party (e.g., Medicaid, insurance, etc.). When appropriate, reasonable transportation and lunch expenses are allowed, based on the client’s stated costs.

Monthly work expenses cannot exceed monthly income and cannot be carried into future months. The following expenses are allowed for both blind and disabled clients: 1. Transportation to and from work a. Actual bus/cab fare, or b. $.33/mile for private vehicle 2. Service animal (including care and upkeep) In addition to the expenses listed above, blind individuals are allowed the following work expenses (not all-inclusive): 1. Braille instruction 2. Optical aids 3. Uniforms 4. Lunches 5. Federal, State, and local income taxes and Social Security taxes In addition to the expenses allowed for both blind and disabled individuals, disabled individuals are allowed the following work expenses (not all-inclusive): 1. Adaptive equipment/durable medical equipment 2. Attendant care services (20 CFR 416.976(c)(1) 3. Prosthetic or medical devices necessary to work 4. Drugs/medical services not covered by Medicaid or other third party 5. Installation, maintenance, and repair costs for deductible items 6. Vehicle modifications necessary for a disabled person to operate/use the vehicle (cost of the vehicle is not allowed) Family Medically Needy: For households that pass the Gross Monthly Income (GMI) test (below), disregard the first $200 and 25% of remaining earned income for each wage earner. An additional disregard of up to $200 per dependent per month may also be deducted from household earnings for dependent care costs. Legally obligated and paid child support may also be disregarded. Income Limits Household 1 $683 Household 2 $923 Household 3 $1164 Household 4 $1404 Household 5 $1644

Household 6 $1884 Household 7 $2124 Household 8 $2365

CHILD SUPPORT/ALIMONY: ABD: Clients who verify they are paying legally obligated child support and/or alimony will have the actual amount paid (up to full obligation) deducted from their income before any other disregards or deductions are applied. The payments are deducted from unearned income first, and then any amount remaining is deducted from earned income. NOTE: Individuals who receive a spousal or family income maintenance allowance cannot also be allowed a child support/alimony disregard. If the payment includes both current support and arrears, the full amount is deducted as long as the arrears were legally obligated when incurred. Family Medically Needy: Clients who verify they are paying legally obligated child support have the amount actually paid deducted from their countable income after all other disregards are applied. DEPENDENT CARE DISREGARD: Family Medically Needy: Up to $200 per month may be deducted for each dependent or incapacitated adult who lives with the earner, receives Medicaid under any program, and who is cared for by someone outside the filing unit. Verified dependent care costs are allowed for a household member to accept/continue employment, seek employment, or attend school/training necessary to gain employment. GENERAL INCOME DISREGARD: ABD: A $20 general income disregard is first applied to unearned income; any disregard remaining is then applied to earned income. MEDICALLY NEEDY INCOME DEDUCTION: ABD: After a case has been determined medically needy, a $391 deduction (regardless of filing unit size) is applied that reduces the spend down by $391. If the spend down is less than $391, it is reduced to $0.00. This deduction will increase each year by the COLA increase.

The medically needy deduction is not applied to any non-medically needy program. Revised Date: 01/01/2026

COMBINED MEDICAID 603-1 Deeming

Supersedes: CMA 603-1 (01/01/2025) Reference: ARM 37.82.101, .903, .1106 & .1107; 42 CFR 435.601& .831; 20 CFR 416.1160, .1165, .1166, .1168; PL 104-193. Overview: ACA: Deeming does not apply. ABD and Family Medically Needy: Certain financially responsible individuals who live in the home but are not included in the assistance unit have a portion of their income deemed to the assistance unit. Family Medically Needy: Resources are not deemed, except in the case of Alien Sponsor deeming. PARENT TO CHILD DEEMING: ABD: Parents and stepparents are financially responsible for their minor child/stepchild. 1. When the minor child lives in the same home as the parent/stepparent, parent/stepparent income and resources are deemed to the child. 2. When the minor child lives somewhere other than with the parent/stepparent for at least 30 days and covering a full benefit month, only income and resources actually contributed to the child are considered in the child’s financial eligibility, beginning the month after they no longer live together. NOTE: If the child returns to the household for visits but does not intend to remain with the parent/stepparent, the rule in #2 above applies. Parental Deeming is not required in certain circumstances: 1. The blind/disabled child receives SSI, 2. Certain waiver program, and 3. Certain situations of institutional coverage.

Ineligible Child Allocation: Parents whose income is deemed to their child receive an ineligible child allocation for each ineligible child in their home. The ineligible child must be under age 21 and be the ineligible parent’s child or stepchild. The ineligible child allocation is the difference between the SPA (ABD 014 Poverty Guidelines) for one and two, less the ineligible child’s own income. NOTE: An ineligible child under age 18’s or a dependent student age 18 through 21’s earnings are reduced by up to $2410 per month (to a maximum of $9730 per calendar year for 2026) before determining the child’s ineligible child allocation (see CMA 502-1 Earned Income, ‘Children’s Earned Income’).

Family Medically Needy: Stepparent income is deemed to their stepchild when the stepchild is receiving medically needy Medicaid. NOTE: The stepparent must currently be married to the child’s parent, and the parent must be living in the home for deeming to apply. Stepparent income is not deemed if the child’s parent is not in the home. NOTE: If the stepparent’s child is included in the medically needy filing unit, income is not deemed as the stepparent’s income is considered in full.

SPOUSE TO SPOUSE DEEMING: ABD: When the client has a living spouse, income and resources are considered as follows: 1. Both spouses’ income and resources are considered for spouses who live together (as long as neither is applying for or enrolled in a HCBS Waiver program). NOTE: When they live together, both spouses’ income and resources are considered when determining MSP eligibility, even when one or both spouses are participating in an HCBS Waiver program. 2. Each spouse is treated as an individual beginning the calendar month after the spouses cease living together, and in months in which they live apart the entire month, as long as neither spouse resides in an institution or requests HCBS Waiver coverage. Income and resources of the estranged spouse are only considered if actually contributed. 3. When spouses no longer live together due to one entering a residential medical facility, or requesting waiver services, the institutionalized/waiver spouse’s resource eligibility is determined by completing a resource assessment using both spouses’ resources and calculating a resource maintenance allowance. 4. If both spouses are enrolled in a waiver program and/or institutionalized, each spouse is treated as an individual (each spouse must be residing in an institution/enrolled in waiver for a period of at least 30 days). Spousal impoverishment policies do not apply. NOTE: Common law marriage is a legal marriage in Montana, in exactly the same manner as any other legal marriage. If individuals claim common-law marriage, request a statement signed by both spouses which indicates the date the couple began to consider themselves as married.

ABD: In deeming spouse-to-spouse, the ineligible spouse receives an ineligible child allocation for each ineligible child in their home. See 'Ineligible Child Allocation’ above. Processing guidelines for institutionalized/waiver individuals and spouses are found in the ABD 800 Residential Medical Institutions Overview, based on the appropriate institutional setting.

ALIEN SPONSOR DEEMING: ABD: When a sponsored aged, blind or disabled alien, who does not receive SSI applies for Medicaid, their sponsor’s income (and sponsor’s spouse’s income, if living together) is deemed to the alien as income. Income policies in the 500 section apply to the sponsor’s income in the same manner as the applicant, with the exception that vendor/in-kind income is not included in the deeming process. When more than one alien is sponsored by the same sponsor/couple, the deemed income is considered available in full to each sponsored alien; it is not prorated among sponsored aliens. The current SPA (ABD 014 Poverty Guidelines) is used to determine the amount of income allocated to the alien. If the sponsor is single, or does not live with their spouse, use the SPA for one; the SPA for a couple is used when the sponsor is married & lives with their spouse or when the alien is co-sponsored by two single sponsors. If the alien is co-sponsored by two couples, income is deemed from each couple separately. The sponsor is allowed an income allocation for each dependent equal to ½ the current SPA; however, The dependent’s income is not subtracted from the dependent allocation. A dependent in this situation is the same as a dependent when determining Family Income Maintenance Allowance (FMA 805-1 Residential Chemical Dependency Treatment). Family Medically Needy: Sponsor income (sponsor and spouse, if married) is deemed to sponsored aliens. A sponsor is a U.S. citizen or alien admitted for permanent lawful residence who is: 1. 18 years or older, 2. Residing in any U.S. state or District of Columbia, and 3. Petitioning for the alien’s admission under Section 213 of the INA. When the sponsor signs an ‘Affidavit of Support’ (I-134) but refuses to cooperate in providing and verifying their income, the alien’s Medicaid may be authorized. Sponsors are required to reimburse all means-tested benefits the alien and their family receive. The sponsor and their spouse’s income and resources are deemed to the sponsored alien.

Effective Date: 01/01/2026

COMBINED MEDICAID 700 Medically Needy Overview Supersedes: CMA (07/01/16) Reference: 42 CFR 435.301, 320, .322, .324, .403, .811, .831, .840, .845; ARM 37.82.101, 37.82, 37.82.1101 - .1111 Overview: Eligibility is determined for medically needy clients who are expected to meet their monthly spend down (either with incurred medical expenses or through a cash option payment to the Department). The spend down is equal to the difference between their ‘total countable income’ and the appropriate ‘medically needy income level (MNIL)’. Medically needy Medicaid coverage is provided to clients who: 1. Meet all Medicaid non-financial requirements for the following programs a. Family; b. Qualified Pregnant Woman; c. Child-Medically Needy; d. Non IV-E Foster Care; or e. Aged, blind or disabled. 2. Have countable resources within the appropriate limits 3. A spend down is established; 4. Meet their spend down obligation by: a. incurring medical expenses equal to their spend down amount; b. making a cash payment to the department; or c. using a combination of incurred medical expenses and cash payment NOTE: All eligibility criteria must be met for each month of medically needy coverage. HOUSEHOLD COMPOSITION: Family Medically Needy: Unless pregnant, the needs of parent(s) or other specified caretaker relatives cannot be included in medically needy coverage. Only children and pregnant women can receive Family Medically Needy coverage. BENEFIT AUTHORIZATION: Medically needy Medicaid is authorized/issued after:

1. The client(s) incurs and verifies allowable medical expenses equal to the spend down amount; or 2. The Fiscal Bureau receives a cash option payment in the spend down amount. Fiscal Bureau staff complete the Medicaid authorization process after they receive the cash option payment. DATE MEDICAID COVERAGE BEGINS: Medicaid-covered expenses are paid: 1. Medical Expense Spend Down: from date the spend down obligation is met through month end; or 2. Cash Option: after s/he pays amount due, for the full month. Effective Date: March 01, 2017

COMBINED MEDICAID 701-2 Cash Option/Cost Share Refunds

Supersedes: CMA 701-2 (01/01/2026) Reference: 42 CFR 435.831 and ARM 37.82.101, & .1107

Overview: A medically needy client can request a cash option refund if: 1. They paid their cash option/cost share obligation, 2. Medicaid was issued for them, and 3. The client believes the cash option/cost share payment exceeded the value of medical services they received in the month. A cash option/cost share refund may be requested at any time after the payment is received. However, Medicaid providers have up to 365 days to bill Medicaid, so a cash option refund cannot be processed for up to 14 months after Medicaid was authorized for the month. NOTE: When a refund is requested for multiple months, the refund is held and not processed until 14 months after the last refund month. Because refunds are delayed, clients should be relatively certain they will need medical case/services equal to or exceeding the cash option amount before paying their cash option. Cash option/cost share refunds are limited to 36 months immediately preceding the month the refund is requested. Refunds due to administrative adjustments are not held for 14 months. Examples include death of the recipient prior to the start of the benefit month, administrative hearing, or policy change. For examples listed in this paragraph only, refunds will not be delayed by 14 months. SEE BUSINESS PROCESSES: Client Request Cash option refund and Processing MA under issuances

Effective Date: 07/01/2026

COMBINED MEDICAID 702-1 Medical Expense Option Supersedes: FMA & MA 703-1 (07/01/08) Reference: 42 CFR 435.831; 42 CFR 440.60, .170, 180, .441; and ARM 37.82.101, .1107, .1111 Overview: Clients must meet their spend down obligation before medically needy Medicaid coverage is established. Clients can choose to meet their spend down by incurring medical expenses equal to the spend down amount. EXPENSES THAT CAN BE USED TO MEET/REDUCE SPEND DOWN: Medical expenses that meet the following criteria can be used to reduce/meet the spend down obligation: 1. The client or a financially responsible relative received the service; 2. The service is recognized under Montana State law as Medicaid payable; 3. The client is financially responsible for the service; and, 4. The service is medically necessary. NOTE: Waiver services are those services furnished 'under a waiver' (i.e., a waiver program is open). Because private-pay charges in an assisted living facility are not furnished under a waiver, they are not recognized as medical expenses under either the Montana Medicaid State Plan or under state law. As such, assisted living facility private-pay charges cannot be used to reduce the spend down. FINANCIALLY RESPONSIBLE RELATIVE: Family: If living in the home, the client’s, their parents and their minor siblings expenses can be used to meet the client’s spend down. For Qualified Pregnant Woman, all filing unit member’s medical expenses can be used. ABD: Only the client’s and their deemed spouse’s (if married adult) or their deemed parents’ (if a minor) medical expenses can be used to reduce the spend down obligation. Use the following to determine whose bills can be used: 1. Only the client’s bills – deemed income was not used to determine the client’s eligibility; 2. The client’s and their ineligible parents’ bills – parental income was deemed to the client and used to determine income eligibility;

3. The client’s and their ineligible spouses’ bills – spousal income was deemed to the client and used to determine income eligibility; or 4. Both spouses’ bills – husband and wife both meet all eligibility criteria. EXPENSES THAT CAN BE USED TO SATISFY THE SPEND DOWN: Medical expenses paid by an insurance company or other third party cannot be used to meet or reduce the spend down amount. The following expenses can be used to meet or reduce the spend down amount, both prospectively and for retro eligibility: 1. Paid and unpaid medical expenses incurred during the benefit month; 2. Paid and unpaid medical expenses incurred during the three months preceding the benefit month; and 3. Current payments on bills incurred more than 3 months before the benefit month. Note: The paid and unpaid expenses for sections 1-3 must be for the provider or a collection agency for the provider; The bill must still be owed to the provider. Once the provider has been paid in full, the bill is no longer owed to them. If the client used a loan to pay the bill, it has changed form and is no longer an outstanding medical bill, but rather a bill to a lender. A collection agency is not a third party. The bill is still owed to the provider and the collection agency is simply assisting in collecting the debt. NOTE: Current payments on old bills can be used to meet the spend down in the month paid, and in the 3 months following the month paid or until the payment amount is used in full to reduce spend downs, whichever occurs earlier. Institution charges incurred while the client was serving an ineligibility period due to an uncompensated asset transfer cannot be used to reduce the spend down or as incurred medical expenses to reduce the patient liability toward cost-of-care in post-eligibility treatment of income. Medical bills/documentation not received during a time when they can be used to meet or reduce the spend down cannot be used. MEDICAL EXPENSE DEDUCTIONS: Medical expenses used to meet/reduce a spend down must: 1. Not have already been used to meet/reduce another month’s spend down; 2. Not be for a Medicaid-covered service in a month the client was receiving Medicaid, regardless of whether or not the provider accepts Medicaid; NOTE: Medical travel that occurs before the client applies for Medicaid can be used to reduce the spend down; however, medical travel in a Medicaid-covered month is a Medicaid-covered service and cannot be used. Medicaid travel in a non-Medicaid covered month is calculated based on the Medicaid Transportation mileage reimbursement rate of $.33/mile (or current rate verified with MPQH). 3. Not be a Medicare or Qualified Medicare Beneficiary (QMB) covered service incurred during a month of QMB eligibility;

4. Not be subject to payment by a third party (unless reasonable measures have been taken to determine the liability of the third party); 5. Expenses for a medical service not yet received cannot be anticipated. NOTE: Verified active health insurance and Medicare premiums for the benefit month can be used to reduce the cash option payment. 6. Be deducted in a specific order: a. Medical expenses incurred in the previous 3 months, chronologically; b. Medicare and/or health insurance premiums, regardless of date of month due, are used before other current month medical expenses; i. Medicaid pays Medicare Part B premiums for medically needy clients who also receive QMB or SLMB; do NOT use the Part B premium to reduce/meet the spend down. ii. Because Medicaid and MSP clients are automatically enrolled in Social Security Extra Help, these premiums are not allowed to reduce/meet the spend down. However, if the client is enrolled in enhanced or premium PDP, the difference between the basic and higher-level PDP premium can be allowed. c. Medically necessary care or any other type of remedial care recognized under Montana law, which must be furnished by a licensed medical practitioner within the scope and limitations of their medical practice as defined by state law, but which is not a benefit of the Medicaid program (e.g., chiropractic) are deducted chronologically after all Medicare and/or health insurance premiums. Examples (not all-inclusive): Goods and services that do not meet this definition include health club memberships, hot tubs, travel to services which themselves do not meet this definition, durable medical equipment that is not included in the Montana Medicaid State Plan, shoes, vitamins, etc., even if prescribed by a physician. d. Expenses for Medicaid-covered services are deducted chronologically after allowable expenses listed in a., b., and c. above. SERVICES RECOGNIZED UNDER STATE LAW: Services which State or federal law require a licensed medical practitioner to provide or prescribe can be used to reduce/meet the spend down. NOTE: Because naturopathic physicians are licensed to provide services in Montana, those expenses can be used to reduce/meet the spend down. However, they are not licensed to prescribe drugs, so the cost of any medicines purchased through naturopaths cannot be used. Services recognized under state law include services which are normally payable by Medicaid, but which exceed the agency's limits on amount, duration or scope of services. For example, if Medicaid limits the number of physical therapy visits per year to 25, the 26th and subsequent visits are allowable to reduce the spend down. Similarly, because Medicaid travel reimbursements are set at a minimal per diem amount, additional unreimbursed travel costs (such as hotel costs higher than reimbursed amount) can be used to reduce the spend down.

Except as listed below, products or services available without a prescription cannot be used to reduce the spend down. The following services/products are Medicaid-covered services recognized under state law and, as long as prescribed by a physician, must be used to reduce the spend down: NOTE: State law requires prescriptions to be renewed annually. 1. Diabetic supplies (including glucose test strips, insulin and syringes); 2. Antacids; 3. Analgesics containing aspirin; 4. Laxatives; 5. Medication to eradicate lice infestation; 6. H2 antagonist gastrointestinal products (such as Zantac); 7. Bronchosaline; 8. Nicoderm; 9. Adult diapers if the client: a. is over age three; b. has a diagnosis of incontinence; and c. does not reside in a nursing home; 10. Monthly personal vehicle costs for medical transportation at $.33 per mile provided Medicaid was not open on the travel date (medical transportation is a Medicaid-covered service). 11. Medically necessary personal care services provided by an enrolled Medicaid provider; NOTE: All medically needy clients, including waiver-eligible, can use medically necessary personal care services to reduce their spend down. 12. Mail order postage costs for prescription drugs and other services listed above when provided by a pharmacy in a community different than the client’s residence. Pharmacy delivery changes are not allowed. HEALTH INSURANCE PREMIUMS: Health insurance premiums due less frequently than monthly cannot be prorated over the coverage period. However, any premium amount exceeding the spend down obligation can be carried forward to reduce/meet future months’ spend down obligations. NOTE: This policy also applies to clients residing in a nursing home. Insurance premiums for specific illness/situation policies, such as cancer or long-term care polices can be used to reduce/meet the spend down, even if the client currently does not have the specific illness/situation. General indemnity policies that are not limited to a specific illness or situation cannot be used to reduce the spend down. BILLS WITH THIRD PARTY INVOLVEMENT: Take reasonable measures to determine a third party’s legal liability to pay a medical expense. However, an eligibility determination is not delayed because this liability cannot be verified.

VA AID & ATTENDANCE: VA Aid and Attendance (VA A&A) is a monetary compensation paid to a veteran that is expected to cover the veteran’s current month out-of-pocket medical costs. The out-of-pocket medical costs must be current month bills and generally include: • Current month medical bills, • Current month VA A&A approved medical services, and • Current month health insurance premiums NOTE: The VA considers some expenses as medical expenses that Medicaid does not. Expenses the VA considers medical expenses can be used to offset the VA A&A, but not the Medicaid portion of the spend down. VA A&A is not considered income, it is considered a third party liability payment and therefore is not included when determining the spend down amount. The only time a spend down is evaluated for an A&A case, is if the veteran’s out-of-pocket medical needs exceed the A&A payment they receive. Medical expenses used to offset the VA A&A are considered to be paid by a third party and cannot be carried forward to a future benefit month. Cash option cannot be used to meet/reduce the spend down for a veteran who receives A&A. The spend down can only be met when the veteran incurs enough bills to meet both their A&A amount AND their spend down amount. The medical expense option must be used if any filing unit member, whose income is used to determine eligibility and spend down amount, receives VA A&A. For information on calculating the amount of A&A in a VA payment, see CMA 501-1. MEDICAID PAYMENT: Montana Medicaid pays unpaid medical expenses that: 1. An eligible client incurs during a retroactive or prospective eligibility period; 2. Weren’t used to reduce/meet a spend down; 3. Are not the responsibility of a third party; and NOTE: If reasonable measures to determine the third party’s liability have been taken and the third party has not yet paid their portion of the expense, the portion that remains the client’s responsibility can be used to reduce/meet the spend down. 4. Are Medicaid-covered services. Effective Date: January 01, 2020

COMBINED MEDICAID 801-1 Penal Institutions Supersedes: MA 901-2 (07/01/16); FMA 1203-1 (07/01/16) Reference: 42 CFR 435.1009; ARM 37.82.101, and .1321; 905(a)(29)(A) Overview: Inmates in public institutions are not eligible for outpatient Medicaid services. An otherwise eligible (meets all financial and nonfinancial criteria) inmate may be eligible if they are: 1. Admitted to a hospital, nursing facility, IMD, ICF or juvenile psychiatric facility; and 2. Expected to stay in the facility for at least 24 hours. Medicaid cannot pay for outpatient services an inmate receives: 1. In a governmentally controlled facility; or 2. At a local hospital, emergency room, urgent care, physician’s office, prison hospital or dispensary or a Federally Qualified Health Center/Rural Health Clinic. INMATE: An inmate is someone who is in custody and held involuntarily by law enforcement authorities in a public institution (other than a childcare institution, publicly operated community residence that serves no more than 16 residents, or a public educational or vocational training institution for purposes of securing education or vocational training). Correctional institutions include facilities operated by, or under contract with, the United States, a state, a territory, a political subdivision of a state or territory, or an Indian tribe for the confinement or rehabilitation of individuals charged with/convicted of a criminal offense or other persons held involuntarily in lawful custody through operation of law enforcement authorities. Correctional institutions include state or federal prisons, local jails, detention facilities, or other penal settings (e.g., boot camps, wilderness camps). While correctional institutions may provide medical and related services, they are organized for the primary purpose of involuntary confinement. Individuals voluntarily residing in a public institution, pending other arrangements, may be eligible for Medicaid. When an individual has been arrested, taken into custody, and then transported directly to a medical facility, that individual has not obtained ‘inmate’ status in a public institution. Therefore, if they are otherwise eligible, Medicaid may pay for medical services provided even when the services are not provided on an inpatient basis. NOTE: Individuals who are committed to Montana State Hospital are not considered inmates. PUBLIC INSTITUTION:

An institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control, this includes correctional institutions. A public institution does not include: • childcare institutions, or • publicly operated community residences. ELIGIBLE INDIVIDUALS: If eligible, Medicaid is available for the following: 1. Infants living in a public institution with an inmate; 2. Parolees; 3. Individuals on probation; 4. Individuals voluntarily living in a detention center, jail or county penal facility awaiting other living arrangements (such as transfer to a community residence); 5. Inmates admitted as inpatients of a hospital, nursing facility, IMD, ICFMR (if they meet Medicaid eligibility requirements); and 6. Inmates involuntarily residing in a halfway house under government control. To qualify, the halfway house must allow residents to: a. work outside the facility in jobs available to the general public; b. use community resources (libraries, grocery stores, recreation, education, etc.) at will; and c. seek healthcare in the community the same as any other Montana Medicaid recipient. INELIGIBLE INDIVIDUALS: The following individuals are not eligible to receive Medicaid coverage: 1. Individuals, including juveniles, held involuntarily in a detention center while awaiting trial; 2. Inmates involuntarily residing at a government-controlled wilderness camp; 3. Inmates receiving outpatient care; and 4. Inmates receiving onsite medical care at a prison, jail, detention center or other penal setting. A suspension will be entered until the individual is released or they are admitted to a hospital, nursing facility, IMD, ICF or juvenile psychiatric facility; and are expected to stay in the facility for at least 24 hours.

Effective Date: January 01, 2023

COMBINED MEDICAID 802-1 Screening Determination

Supersedes: MA 902-1 (07/01/06) Reference: ARM 37.40.201, .202 Overview: ACA and ABD: A screening determination screening (AKA Level of Care) identifies the level of services a Medicaid client needs. HCBS waiver and nursing home services use the same screening criteria. NOTE: A screening determination screening is not required for hospitals, Montana State Hospital in Warm Springs and other psychiatric treatment centers. SCREENING DETERMINATION SCREENING: A screening determination screening remains valid for 90 days after the screening date. SCREENING EFFECTIVE DATE: Senior and Long Term Care Division criteria are used to determine the date a screening determination screening is effective. Screening determination screening questions not addressed in this section are referred to the ABD Policy Specialist via the Service Desk. SEE BUSINESS PROCESS: Screening Determination- Nursing Home and Screening Determination- Waiver Revised date: 04/2023

COMBINED MEDICAID 803-1 Institution and Waiver Resource Assessments

Supersedes: MA 803-1 (07/01/2016)CMA 05/01/2024 Reference: 42 U.S.C. 1396; 42 CFR 435.601; ARM 37.82.101, .1330, .1331, .1336, .1337 and .1338 Overview: The Community Spouse Resource Maintenance Allowance (CSRMA) is determined based on resources a married couple owns individually or jointly; • On the 1st day of the month one spouse is admitted to a residential medical institution for a continuous period. • On the first day of the month the individual is admitted to a waiver program or receives a screening and is eligible for an ABD type coverage. Only one resource assessment is completed for each spouse, no matter how many applications are filed or how many times the individual is institutionalized. A resource assessment is not completed if both spouses are enrolled in a waiver program and/or institutionalized. Each spouse is treated as an individual in these situations. NOTE: Pre- and post-nuptial agreements do not change the resource assessment process, as all resources the couple owns, whether individually or jointly, must be considered when completing a resource assessment. A resource assessment is not completed if the Waiver spouse is determined eligible for ACA Medicaid with a waiver until the Waiver spouse is no longer eligible for ACA. CONTINUOUS PERIOD OF INSTITUTIONALIZATION: A continuous period of institutionalization or waiver eligibility consists of 30 or more consecutive days of expected residence in an institution or waiver coverage. The 30 days may include days of hospitalization. COMMUNITY SPOUSE RESOURCE MAINTENANCE ALLOWANCE (CSRMA): The CSRMA amount is the greater of:

1. One-half (not to exceed maximum CSRMA – see CMA 001 General Resource Limits) the combined resources; 2. Montana’s minimum resource maintenance allowance (see CMA 001 General Resource Limits); 3. An amount a hearings officer designates; or 4. A court-order amount. Example: Client enters the nursing home (Medicaid) or requests HCBS waiver services (and meets level of care) in October 2024 but did not request a resource assessment until February 2025. The resource assessment is completed based on assets owned In October 2024 and the CSRMA is calculated using 2025 standards. REVISING THE CSRMA: The CSRMA amount can only be changed when: 1. The community spouse’s income, including the Spousal Income Maintenance Allowance, is less than the minimum spousal income allowance; NOTE: A hearings officer must determine the additional amount of resource allocated to the community spouse; the institutionalized/waiver spouse must agree to the amount. 2. A hearings officer confirms the allegation that the initial assessment was incorrect; or a. NOTE: Hearings to appeal CSRMA determinations must be conducted within 30 days of hearing request. 3. Eligibility staff received inaccurate information (from any source). TRANSFER OF RESOURCES COMPRISING THE CSRMA: All resources that comprise the CSRMA must be legally transferred to the community spouse within 90 days of Medicaid approval. NOTICE: Both spouses must receive notice of the CSRMA, and both have the right to appeal the resource maintenance allowance determination. Real property excluded as a “home” under the resource assessment is not required to be transferred to the community spouse as it is not included in the CSRMA. INSTITUTIONALIZED/WAIVER SPOUSE GAINS ADDITIONAL RESOURCES: If the institutionalized/waiver spouse receives additional resources after institutional/waiver coverage is established:

1. The new resources are combined with the institutionalized/waiver spouse’s other resources, and do not affect eligibility if the new total does not exceed the $2,000 resource limit. 2. If the institutionalized/waiver spouse intends to transfer the new resources to the community spouse, AND the community spouse’s initial CSRMA is less than the Montana minimum, the new resources are exempt for 90 days. To allocate new resources, the institutionalized/waiver spouse must: a. report the new resources within 10 days; and b. provide a statement showing their intent to transfer the new resources to the community spouse. 3. The resources are included in the institutionalized/waiver spouse’s resource determination if the community spouse’s initial CSRMA is at least equal to the Montana minimum resource maintenance allowance. If the institutionalized/waiver spouse diverts or transfers the new resources anyway, the diversion/transfer is treated as an uncompensated asset transfer. COMMUNITY SPOUSE GAINS ADDITIONAL RESOURCES: If, after Medicaid is approved for the institutionalized/waiver spouse, the community spouse receives additional resources, the additional resources do not affect the institutionalized/waiver spouse’s eligibility. However, if the new resources will generate income, the community spouse’s income maintenance allowance is recalculated. REAPPLICATION AFTER CLOSURE: When the Medicaid eligibility of an institutionalized spouse ends for any reason and a new Medicaid reapplication is submitted after the effective date of the closure, the individual may be considered a spouse or an individual for Medicaid eligibility determination purposes, depending on the length of the break in Medicaid eligibility and whether there was a break in institutionalization. If, after Medicaid is approved for the institutionalized/waiver spouse, the community spouse receives additional resources, the additional resources do not affect the institutionalized/waiver spouse’s eligibility. However, if the new resources will generate income, the community spouse’s income maintenance allowance is recalculated. Effective Date:12/01/2025

COMBINED MEDICAID 1300 Creditable Coverage and Release of Information Supersedes: FMA & MA 1301-1 & 1302-1 (01/01/04) Reference: HIPAA Federal Register April 8, 1997; ARM 37.82.101 Overview: The Health Insurance Portability and Accountability Act (HIPAA) of 1996 has two main purposes. The first purpose is to provide certificates of creditable coverage to individuals who lose health coverage, allowing them to obtain other health coverage without serving a preexisting condition waiting period. The second purpose is to ensure Medicaid clients’ Protected Health Information (PHI) is not released without a valid HIPAA-compliant release form. CREDITABLE COVERAGE: Because Medicaid is health coverage, individuals who lose Medicaid eligibility can obtain new health insurance coverage without serving a preexisting condition waiting period. Medicaid agencies must issue certificates of creditable coverage for all individuals upon request of the individual or new insurance carrier. RELEASE OF PHI: A Medicaid client’s Protected Health Information (PHI) is only released when a completed and signed HPS-402 (Authorization for the Use and Disclosure of Health Information) is received. Other ‘authorization to release’ forms cannot be used to release PHI. OPA staff cannot release PHI that originated from another entity (e.g., psychiatric evaluations, doctors records, etc.), even with a signed HPS-402. The client must request that information from the information source (i.e., doctor, psychiatrist, etc.). Refer to the HIPAA process guide for additional information. Effective Date: July 01, 2016

COMBINED MEDICAID 1501-1 Reporting Changes

Supersedes: CMA 1501-1 (1/1/2025) Reference: 42 CFR 431.213; 42 CFR 435.916 and .919; ARM 37.82.101 Overview: Medicaid clients are required to report changes as soon as possible, but within 10 days of their knowledge of the change. Clients may report changes at any time and are encouraged to report all changes even if they believe the change will not affect their eligibility. All SSI eligible individuals have specific reporting requirements for both SSA and Medicaid. If an SSI Medicaid recipient reports a change to OPA, eligibility staff must act on that change. If the reported change affects SSI eligibility, refer the client to SSA. When changes are not reported or not reported timely, the client may be subject to an overpayment and/or may receive incorrect benefits. Overpayments are evaluated using information as if it had been reported timely, and within the timeliness guidelines.

WHO IS REQUIRED TO REPORT? Anyone receiving, applying, or eligible for Medicaid is required to report changes in both their individual circumstances as well as their household’s circumstances and provide necessary verification. NOTE: The department will evaluate ongoing eligibility in light of the reported change and notify the client if verification is necessary.

WHAT MUST BE REPORTED? Changes that must be reported include: 1. Changes in income source or gross monthly income, including, but not limited to: a. Changes in hours worked or pay per hour/pay period b. Pay raises or pay cuts c. An additional job d. A different job e. Lump sum payments such as lottery winnings, settlements f. Disability/death benefits

g. Child support payments (received or paid out) 2. Someone moves into or out of the household. 3. Changes in residence and/or living arrangements. 4. Changes in resources (when cash on hand, stocks, bonds, and money in a checking or savings account increases or decreases). 5. Non-financial changes, such as: a. Pregnancy begins or ends. b. Moving into or out of a nursing home. c. Being determined disabled. d. Waiver services begin or end. 6. The date the change is reported is the new coverage request date. Retro coverage may be available, see CMA 104-1 Retroactive Medicaid. 7. New or changed health insurance coverage, premiums or other third-party liability. 8. Changes in medical expenses, for medically needy and nursing home clients. METHODS OF REPORTING CHANGES: Clients can report changes: 1. Through their account on the Self Service Portal 2. By calling or writing the OPA or PAHL 3. By completing a “Change Report Form” (HCS-260A) 4. In person NOTE: Eligibility staff may discover information from other sources (e.g., interfaces, other agencies, etc.). ACTING ON REPORTED CHANGES: Acting on changes may include: 1. Redetermining eligibility, 2. Requesting verification and/or more information, 3. Recalculating benefit/spend down amount, NOTE: A spend down cannot be increased retroactively. 4. Taking adverse action (reduction or termination of benefits), 5. Establishing an over issuance, (CMA 1504-1 Over and Under Issuance) 6. Evaluating community engagement requirements and exclusions, OR 7. Simply documenting in system case notes that a change was reported/discovered, evaluated, and no further action was required. Eligibility staff must act on all changes within 30 days of receipt of all verifications.

VERIFICATION: When a client reports a change affecting eligibility or spend down amount, verification may be required. Staff must always follow up verbal requests with an eligibility system notice. NOTE: Verification is not needed when the reported change will close current Medicaid coverage, and an ex parte review doesn’t indicate other eligibility. ADDING A HOUSEHOLD MEMBER: When the county discovers or the client reports a new household member, the existing assistance unit(s)’s eligibility is redetermined by including the new member’s presence, income, resources, etc. as required by policy. The new household member can receive 1 or 2 months retro Medicaid from month their presence is reported/discovered if ALL eligibility factors are met. All household members’ eligibility must be redetermined based on the new household member’s presence, even if the new member isn’t requesting coverage. Adding someone to the household could affect a variety of factors, including filing/assistance unit, deeming, income and resources. Request verification (e.g., relationship, income, resources, etc.) necessary to determine existing household’s ongoing eligibility. ABD: If adding the new household member may affect the existing household’s eligibility, verification of pertinent eligibility factors (e.g., income, relationships, resources, etc.) must be provided to accurately determine ongoing eligibility for all household members. NOTICES ON ACTION TAKEN: Adequate notice can be sent when a change is reported on a signed paper or electronic change report form, and enough information is provided to determine ongoing eligibility. Timely notice of adverse action is required when a change is reported by any other method, or when the signed HCS-260A does not provide enough information to determine continued eligibility. CHANGES – VERIFICATION REQUIREMENTS: WITHOUT VERIFICATION: ACA: See Electronic Verification for Medicaid Business Process. ABD: When eligibility is affected by a reported/discovered change, but necessary verification is not included or available, request verification to be provided within 15 days of the notice date. If verification is not received, or if the 15-day period extends into the following month, authorize benefits at the previous level and close the adults with timely notice.

If verification is received timely, eligibility is redetermined, if the household remains eligible, benefits are authorized. Unless an ex parte review indicates potential coverage under another health coverage program, Medicaid for adults and/or HMK is closed without verification when the reported change will close current coverage (children’s Medicaid will remain open throughout their span). If it is unclear whether or not the reported change will close current Medicaid coverage, verification is requested to ensure eligibility is correctly determined. If necessary verification is not received by the due date, and ongoing eligibility cannot be determined, Medicaid is closed with timely notice. If verification is received after the due date, but within the administrative month, redetermine eligibility and reopen and issue Medicaid, if appropriate. WITH VERIFICATION: When verification is received with the reported change, redetermine eligibility within 30 days.

Effective Date: 7/1/2026

COMBINED MEDICAID 1502-1 REDETERMINATIONS Supersedes: CMA 1502-1 (04/01/2023) Reference: 42 CFR 435.916,.919; 42 CFR 431 Subpart E, MCA 53.6.113, .142, P.L. 119-21 Overview: All Medicaid cases must be redetermined at least annually. A Medicaid redetermination consists of reviewing both financial and non- financial eligibility factors to determine ongoing eligibility. A timely closure notice is mailed if the updated information is not received by the due date. Appropriate notices must be sent when the redetermination is completed. See CMA 1503-1 Timely and Adequate Notice. Interviews cannot be required to complete a redetermination. However, if the client requests an interview, it must be scheduled. SSI Recipients: The Social Security Administration completes an SSI recipient’s annual Medicaid review. A renewal is not required if the individual is receiving or requesting additional coverage, such as Nursing Home, Waiver, QMB or SLMB and SSI/State Supplement is verified via SDX interface (IN). ACA/ABD/Family Medically Needy: Redetermined annually. All available electronic data sources are automatically queried; if there are no discrepancies between the queried and existing data, the program is automatically renewed. An approval notice is sent letting the household know benefits will continue. If a discrepancy is discovered or the auto-renewal process cannot run, a pre-populated -redetermination form is mailed to the household, allowing at least 30 days for the form to be returned. The client is required to respond and provide necessary information; they must either return the signed redetermination form, process the redetermination online, via the PAHL or in person.

Community Engagement - ACA Adult Expansion: (ACA Adult Medicaid and ACA Adult) If a discrepancy is discovered or the auto-renewal process cannot run at redetermination, a pre-populated redetermination form is mailed to the household, allowing 30 days for the form to be returned. The client is required to respond and provide necessary information; they must either return the signed redetermination form, complete the redetermination online, via the PAHL, or in person. The Medicaid participant must meet community engagement requirements or have an exception in any 3 months since the last redetermination; or qualify for an exclusion in the eligibility month. The 3 months do not have to be consecutive. Ongoing community engagement requirements can be met by participating in at least 80 hours per month of qualifying activities or earning the equivalent of 80 hours at the federal minimum wage per month. A combination of these activities can also meet this requirement. Available queries will be run as a part of the review. If the recipient/household reports a change at redetermination that may be verified by use of an available query or matches current information available in the case file, no further verification is requested from the client. Information related to community engagement requirements, exceptions, or exclusions may need further verification. See Community Engagement and Exclusion Policy Client’s self-attested income is required to be electronically verified at redetermination. If the electronic interface returns information with a reasonable compatibility, no further verification is required. If it is not reasonably compatible or the information is not matching, verification is required. A CSC may call and attempt to get a reasonable explanation of a discovered discrepancy. If the attempt to obtain a reasonable explanation is unsuccessful or the reported change can’t be verified, hard copy verification of the change is required. When verification is not submitted with the reported change, a request for information will be sent. If the requested information is not submitted, benefits will be terminated. If the reported change could result in a negative action, as a courtesy, send a request for information if timely notice of adverse action would still be possible by the due date on the notice. If timely notice would not be possible by the due date of the request for information notice, benefits will be closed

using timely notice. Include in the comments section of the negative action notice that if verification is received before the effective date of closure, the information will be used to reconsider eligibility. Penalties for Non-Compliance in Community Engagement Individuals who have not met the community engagement requirements, do not have an exception, or qualify for an exclusion at their redetermination will be notified that they have 30 days to come into demonstrate compliance with the criteria. This coincides with the end of the redetermination period. It is not an extension to the redetermination period. The notice of non-compliance must be sent separately from the redetermination packet. The 30-day non- compliance period starts from the date the non-compliance notice is sent. Failure to verify community engagement within the 30-day period will result in Medicaid closure with timely notice. If the closure would not allow timely notice, Medicaid will close no later than the end of the month following the 30- day period of non-compliance. A disenrolled individual will be required to reapply and demonstrate compliance or exception from community engagement requirements to regain coverage. EX-PARTE REVIEWS: Part of the redetermination process is to complete an ex parte review for any Medicaid client whose current Medicaid coverage is ending at redetermination for reasons other than failure to comply. See ‘Ex parte Review’ in CMA 103-1 Application Eligibility and Furnishing Assistance for more information. LATE PROCESSING: It is a requirement for late processing that the information, including due dates and received dates are noted in the case note. Failing to case note will result in an error. If the delay is due to obtaining verifications for community engagement, this should be stated specifically. Effective Date: 07/01/2026

COMBINED MEDICAID 1503-1 Timely and Adequate Notice

Supersedes: CMA 1503-1(1/1/2023) Reference: 42 CFR 431.206, .210, .211, .213 and .214; 435.919; ARM 37.5.505 and 37.82.101 Overview: Timely and/or adequate notice must be provided for all adverse actions. An adverse action is any action to close, suspend or decrease assistance, or to increase a spend down obligation for an ongoing case. CONTENT REQUIREMENTS: Complete Notice -- A written statement that informs the client of the: 1. Action taken and/or the eligibility period, 2. Reason for the action, 3. Specific agency policy and state and federal regulations supporting an adverse action, 4. Date the action will occur, 5. Person’s right to request a hearing, 6. How the person may request a fair hearing, 7. That the person may represent themselves or use legal counsel, a relative, a friend, or other spokesman, and 8. The timeframes by which the Department must take final administrative action.

TIMELINESS REQUIREMENTS: Adequate Notice -- Written notice mailed no more than two working days after system cutoff and received by the client no later than the date of action or date benefits would have been received. Timely Notice -- Written notification as stated above, mailed at least 10 calendar days prior to the date of action.

15 Day Notice Period -- the 15 consecutive days beginning the day the notice is mailed for requested verifications. ADEQUATE NOTICE SITUATIONS: Adequate notice is used in the following situations: 1. The client’s death is confirmed. 2. The client provides written request of closure. 3. Client is admitted or committed to an institution, or incarcerated in a penal institution, and further benefits to them do not qualify for federal financial participation. See Residential Medical Institutions, ABD 800 Residential Medical Institutions Overview. 4. Client’s whereabouts are unknown, and the Post Office returns agency mail indicating no forwarding address. 5. Verification is received confirming the client is receiving benefits in a different state. 6. Client submits a signed paper or electronic change report form containing information that causes their benefits to close. 7. Client is placed in skilled nursing care, intermediate care, or long-term hospitalization. Adequate notice is sent for a change in the client's liability for cost of care in a nursing home changes, unless a community spouse income maintenance allowance or family income maintenance allowance is involved. 8. A child is placed in foster care, either voluntarily or through court order. Timely notice must be given in all other adverse action situations. PROBABLE FRAUD NOTICE: The agency may shorten the period of advance notice to five (5) days if the: 1. Agency has facts indicating probable recipient fraud; and 2. Facts have been verified, if possible, through secondary sources.

Effective Date: January 1, 2025

COMBINED MEDICAID 1504-1 Over and Under Issuance Supersedes: FMA 1504-1 (07/01/08), MA 1504-1 (07/01/08) Reference: 42 U.S.C. 1396b(u) and 1396p(a); 42 CFR 431.210, .211, .213 and .214; 42 CFR 433.36(g)(1); 53-2-108, MCA; ARM 37.82.101, .207; ARM 37.5.505 Overview: Over issuance claims are established for all client-caused Medicaid eligibility errors, whether inadvertent or intentional on the client’s part. Over issuance claims are not established for agency- caused (administrative) Medicaid eligibility errors. Claims are also not established when the over issuance is due to the client receiving an SSI payment in error. Over issuance claims are established for continued benefits received pending a fair hearing when the hearing decision supports the agency action. Patient liability for nursing home coverage can only be changed prospectively; adequate notice must be given. A Medicaid over issuance is established for past months’ patient liability, if the incorrect liability was due to a client-error. DETERMINING OVERISSUANCE AMOUNT: The over issuance amount for each benefit month is the smaller of the: 1. total Medicaid benefits paid on the ineligible client’s behalf, OR 2. difference between the amount of an accurately calculated monthly spend down and the amount of monthly spend down the client paid toward an incorrectly calculated spend down. SETTLEMENTS: TPL pursues Medicaid repayment when a Medicaid client receives a settlement to reimburse their medical expenses caused by an accident or injury (i.e., auto insurance or workers’ comp settlement). UNDERISSUANCE: When information discovered/received results in an under issuance (i.e., lower cash option amount or earlier eligibility date), the under issuance business process is followed. Effective Date: July 01, 2016

COMBINED MEDICAID 1505-1 Fair Hearings, Administrative Reviews, and Appeals Supersedes: FMA 1506-1 and MA 1506-1 (01/01/08), FMA and MA 1506-2, 1506-3 & 1506-4 (01/01/07) Reference: ARM 37.5.101; 103; 301; .304; .305; .307; .313; .316; .318; .322; .325; .328; .331; .334; .337; .503; .505; ARM 37.82.101; 42 CFR 431.200 through .246 Overview: All clients have the right to due process and to request a hearing; staff may assist the claimant in submitting and processing a hearing request. Department staff will not interfere with these rights. Centralized Fair Hearing Unit staff conduct hearings. A fair hearing (FH) is granted to any client who requests a hearing because: 1. Their application is denied or not processed timely; 2. They do not agree with any action to reduce or terminate their benefits; establish an over issuance or impose specific conditions to receive benefits; or 3. Their request for an additional level of coverage is denied or changed. A hearing request is the client’s/authorized representative’s clear communication that they want to present their case to an authority above the OPA. State law grants any 'real party in interest' (e.g., medical providers) the right to request a fair hearing and/or appeal a hearing decision. Fair hearing rights as well as information on continuing benefits pending the hearing decision and repayment requirements (if the decision supports the Department) are listed on the back of all adverse action notices. ADMINISTRATIVE REVIEWS: An Administrative Review (AR) is a meeting between the client (claimant)/their representative and HCSD Fair Hearing Unit staff. The AR is a chance to review and potentially resolve a dispute on the Department’s action, or to lessen any confusion at the hearing. An AR: 1. Identifies issues related to the adverse action; and 2. If possible, resolves, to the claimant’s satisfaction, any questions or issues related to the adverse action. An AR does not diminish, delay or void a client’s right to a fair hearing. • When the disputed issue is not resolved to the claimant’s satisfaction at the AR, the Hearing Officer must proceed with the hearing.

• The claimant (and/or representative) has the right to waive an AR and continue to the fair hearing. • The claimant must withdraw their hearing request in writing. NOTE: When a client contests transfer or discharge by a nursing facility, the Department is not a party to the hearing, but instead must provide a forum. Rescheduling the AR: The claimant is allowed a reasonable opportunity to reschedule the AR; an additional opportunity is allowed when good cause exists. Representation at AR: The claimant may be represented by: 1. Him/herself; or 2. An authorized representative, such as legal counsel, a relative, friend or other spokesperson. Fair Hearing Unit staff represents the Department. When the disputed issue is complex, has legal ramification or the claimant is represented by an attorney, Fair Hearing Unit staff will request Office of Legal Affairs (OLA) assistance. OLA will prepare any briefs the Hearing Officer requests. NOTE: The eligibility staff member who processed the case may attend the AR, but cannot act as the OPA representative. If warranted, an adverse action may be reversed or modified during an AR. When this occurs the hearing is not held unless the claimant objects to the modified action and requests to proceed to the hearing. If satisfied with the reversed/modified determination, the claimant must sign the appeal withdrawal form. When the claimant (or representative) fails to appear for an AR, the Hearing Officer will proceed with the hearing schedule and notify the claimant. A group AR may be held when the: 1. Claimants agree to participate in a group rather than as individuals; and 2. Cases involve related issues of state and/or federal law, regulations or policies. Claimants (or representatives) involved must each be allotted time to present his/her case. FAIR HEARING REQUEST & APPEAL TIME LIMITS: Clients must file requests for hearing and/or appeals as follows: • Hearing request: The hearing request must be in writing and the Department must receive it within 90 days of the date the adverse action notice is mailed; the claimant’s signature is not required. EXCEPTION: A hearing request regarding a department determination of ability to pay for cost of institutional care must be received in writing, within 30 days of notice mailing.

• Board of Public Assistance Appeal: The appeal request must be received within 15 days of date the decision notice is mailed. The hearing officer’s decision becomes final when an appeal request is not received within the 15-day period, unless good cause is shown. When good cause exists, the 15-day period is extended to no more than 45 days. • District Court/Judicial Review: Any party to an appeal (claimant/authorized representative, real party of interest, Department) may appeal the Board’s final decision to district court. The appeal must be filed within 30 days of the Board’s final decision. EXPEDITED HEARING: Households who file a hearing request, but who will leave the state before a decision is made under normal time frames may be granted an expedited hearing. CONTINUED BENEFITS: Unless the claimant specifically states they do not want continued benefits, benefits are automatically continued at the same benefit level (reinstated) until the hearing decision when the hearing request is filed between the date the adverse action notice is mailed and the adverse action effective date. EXCEPTION: When timely notice of adverse action is not sent, benefits are only continued (reinstated) when the claimant files the hearing request within 10 days of receiving the notice. The notice is assumed to be received 5 days after it is mailed, unless the claimant proves they didn’t receive the notice within 5 days. The claimant may claim good cause for not requesting continued benefits timely. When appropriate, benefits are continued through the end of the month in which a hearing decision in the department’s favor is received. If the claimant requests a Board appeal, benefits are continued through the month in which the Board decision is received. Unless court ordered, benefits are not continued during an appeal to district court. Benefits cannot be continued if the hearing officer determines the issue is one of State or Federal law or policy. The claimant’s responsibility to repay continued benefits if the hearing decision is in the Department’s favor must clearly and thoroughly be explained. REDUCING CONTINUED BENEFITS: Continued/reinstated benefits are not reduced or terminated prior to the official hearing decision unless: 1. Eligibility ends due to time-limits or failure to meet another eligibility requirement; 2. While the hearing decision is pending, a change affecting the claimant’s eligibility occurs and a subsequent hearing request is not filed; 3. The Hearing Officer makes a written preliminary determination at the hearing that the sole issue is one of State or Federal law or policy and there has been no improper benefit calculation, misapplication or misinterpretation of State or Federal law or policy; or 4. A mass change affecting the claimant’s eligibility or benefit level occurs while the hearing decision is pending.

MASS CHANGE CONTINUATION: When benefits are reduced or terminated due to a mass change, benefits continue at the prior amount only if the contested issue is that: 1. Eligibility or benefits were improperly computed; or 2. Federal law or regulation was misapplied or misinterpreted. DURATION OF CONTINUED BENEFITS: If all financial and nonfinancial requirements, other than the disputed issue, are met, benefits will continue until: 1. A hearing decision is rendered, OR 2. The claimant exhausts the available administrative remedies including appeal to the Board of Public Assistance, OR 3. The time allowed to appeal to the Board has passed and neither the claimant nor the Department has made such an appeal. HEARING REQUEST DENIAL OR DISMISSAL: A hearing may be denied or dismissed when: 1. The claimant (or representative acting on his/her behalf) withdraws hearing request in writing; 2. The claimant (or representative) fails to appear at the hearing without good cause; 3. The Department receives the hearing request more than 90 days after the adverse action notice was mailed; 4. Either federal or state law requires automatic benefit changes (unless the issue is incorrect benefit adjustments); or 5. The Hearing Officer does not have jurisdiction over the subject matter or the appeal procedure. NOTE: The above list is not all inclusive. SCHEDULING A HEARING: The Office of Fair Hearings notifies all parties to a hearing of the hearing date, time and place. POSTPONING A HEARING: Both the claimant and the Department are entitled to postpone a scheduled hearing. The hearing cannot be postponed more than 30 days unless both parties agree. MATERIAL PRESENTED: The Department can only introduce documents, records, papers and materials that the claimant/representative had the opportunity to review; any documents not previously available to the claimant/representative cannot be introduced at the hearing or be used to influence the hearing

officer’s decision. Copies of all hearing exhibits the Department will enter into record must be made available to the claimant/representative and Fair Hearing Officer no less than 5 days prior to the hearing. HEARING RECORD AND TRANSCRIPTION: Fair Hearing Unit staff record all hearing proceedings. If the case is appealed to the Board of Public Assistance (Board), the recording must be transcribed. RIGHTS AND ROLES: The claimant/authorized representative has the right to examine their case file at any reasonable time prior to or during the hearing. When the claimant/representative requests copies of materials necessary to prepare for the AR and/or hearing, they are provided at no charge. The claimant/representative cannot view any information in their case file that: 1. Federal regulation prohibits the claimant from viewing; 2. A medical professional has stated the claimant cannot view; 3. Contains confidential information about a person other than the claimant; or 4. Certain information contained in case notes cannot be shared due to specific data source agreement. The claimant/representative may: 1. Review the department’s exhibits; 2. Present his/her case to establish all pertinent facts and circumstances; 3. Bring witnesses and/or legal representation; 4. Present their issues without unreasonable or unnecessary interference; 5. Submit evidence to support their claim at least 5 days prior to the hearing (although evidence presented at the hearing must be considered even though not previously submitted); and 6. Question or dispute testimony or evidence, including cross-examining witnesses. The Department's representative may: 1. Review, question and/or refute the claimant’s exhibits; 2. Present its own evidence; 3. Bring witnesses to testify on the Department's behalf; 4. Question or refute testimony of the claimant/authorized representative and his/her witnesses; and 5. Challenge and cross-examine the claimant/authorized representative and his/her witnesses. The Hearing Officer may require: 1. Witnesses; 2. Compliance with reasonable and appropriate orders or requests necessary to:

a. assure orderly conduction of pre-hearing and hearing procedures; and b. avoid unnecessary proceedings or expense. 3. Depositions upon oral examination, or written questions; 4. Written interrogatories; and, 5. Other materials as necessary for the hearing. NOTE: Upon request, the Hearing Officer may issue witness subpoenas or subpoenas duces tecum. The Hearing Officer has the right to: 1. File an affidavit disqualifying himself due to personal bias or other reasons; 2. Require all parties to attend a pre-hearing to define and simplify the hearing issues or other matters; 3. Allow a third party to act as the claimant’s authorized representative when good cause is shown for the authorization not being in writing. 4. Take judicial notice of state and federal laws and regulations and facts within the general knowledge of the public; and, 5. Grant summary judgment according to the provisions of Rule 56, Montana Rules of Civil Procedure. APPEALS TO BOARD OF PUBLIC ASSISTANCE: All parties to a hearing have the right to appeal the hearing officer’s decision to the Board of Public Assistance (Board). The Board’s final decision can be appealed to district court. The claimant/authorized representative may file exceptions, present briefs and present oral arguments. When the Department appeals the Board’s decision, Office of Legal Affairs represents the Department, and will file exceptions, present briefs and present oral arguments. Before providing a decision, the Board considers: 1. The Fair Hearing Officer's Proposed Decision; 2. Exceptions filed; 3. Briefs received; 4. Oral arguments; and 5. The hearing record. The Board must make its decision within 90 days of the original fair hearing request. NOTICE OF DECISION: The Fair Hearing Officer/Board notifies the claimant, Fair Hearing Unit and other interested parties of its decision, and of their right to appeal the decision. IMPLEMENTING DECISION:

Within 10 days of the Fair Hearing Officer or Board’s decision, Fair Hearing Unit staff must, depending on whether the decision is in favor of the claimant or Department, either correct any under issuance, or take action to collect any over issuance. NOTE: If the claimant appeals the Board’s decision, over issuance collection is suspended until the appeal is complete and a decision is rendered. HEARING RECORD: A record of the hearing proceedings is compiled. The hearing record contains: 1. Hearing Officer's/Board’s decision; 2. Verbatim transcript (if requested) or recording of testimony and exhibits; and 3. All exhibits, papers, and requests filed in the proceeding. The record is available to the: 1. Claimant to review/copy at a reasonable time and location acceptable to all parties; 2. Public to review/copy. All identifying information (e.g., name, address, etc.) must remain confidential. Fair Hearing and Appeal Chart:

Timeframe to submit appeal request Must be in writing? Continued benefits? How long are benefits continued? When must decision be implemented? Fair Hearing 90 days from date adverse action notice is mailed EXCEPTION: A hearing request regarding ability to pay for cost of care in an institution must be received within 30 days of notice mailing Yes Yes – if FH requested before effective date OR within 10 days of adverse action notice (when timely notice not sent) Through month FH decision is received

Within 10 days of receiving decision

Board Appeal 15 days after Fair Hearing decision is mailed Yes Yes – if benefits were continued through FH decision Through month Board decision is received Within 10 days of receiving decision District Court 30 days after Board’s final decision Yes No – unless court ordered

Within 10 days of receiving decision

Effective Date: July 01, 2016

COMBINED MEDICAID 1506-1 Case Notes Supersedes: FMA and MA 1507-1 (01/01/06) Reference: ARM 37.82.101 Overview: Case notes are the legal record of the Department’s actions, and contain additional explanations and clarifications of circumstances or actions that may be questionable or unclear. System case notes serve the following purposes: 1. Chronicle a series of events; 2. Summarize non-financial and financial eligibility requirements 3. Outline actions in cases of noncompliance; 4. List types and results of referrals; and 5. Document the family’s progress in finding alternatives to public assistance; identify barriers to employment and how they were addressed. Identify and facilitate the family’s access to services. The client and/or their authorized representative may view their case record, including case notes. Certain information contained in case notes cannot be shared due to specific data source agreement. The eligibility staff member’s personal opinions or judgments are not listed in case notes. Do not list a client’s specific medical conditions in case notes unless the condition is a basis for eligibility, and then only general terms are used (e.g., blind, disabled). Effective Date: July 01, 2016

COMBINED MEDICAID 1507-1 Program Compliance and Quality Control Reviews Supersedes: FMA 1508-2 (01/01/04); MA 1508-1 (02/01/02) Reference: 42 CFR 431.800 through .816; ARM 37.82.101 Overview: Quality Assurance Division (QAD) Program Compliance (PC) staff conduct case reviews based on statistical samples. These reviews provide: 1. a consistent method to measure case determination accuracy; 2. program error rates; and 3. information necessary to create effective corrective action plans. FAILURE/REFUSAL TO COOPERATE: A client who fails or refuses to provide information necessary for PC to complete the review is considered non-compliant. When notified of the non-cooperation, eligibility staff must close the adult client’s Medicaid, providing timely notice of adverse action. Medicaid is only closed when the non- compliance is related to a Medicaid Program Compliance review. The client’s Medicaid cannot be reinstated until they cooperate with the review, regardless of how long it has been since the non- compliance occurred. Effective Date: July 01, 2016

COMBINED MEDICAID 1509-1 Case File Retention

Supersedes: FMA, and MA 1510-1 (07/01/16) Reference: 42 CFR 431.17(c) and ARM 37.82.101 Overview: Accurate case files must be maintained to ensure all required documentation is available for future reference in accordance with state and federal regulations, with all required documentation available in Perceptive, the state’s (electronic content management system). RECORD RETENTION: Most case documentation must be retained for a minimum of three full federal fiscal years (e.g., October 1, 2024 through September 30, 2027). Some documents must be retained longer. Permanent documents are returned for three full federal fiscal years after the case is closed or the client dies. The following records must be retained when the applicant/beneficiary’s case is active, plus a minimum of three federal fiscal years after the death of one spouse or the case is closed 1. Application (Statement of Facts, FFM, Paper Application, etc.) 2. Any documents used to support a decision made at application, renewal and as a result of a change reported. 3. Authorization to release information/confidentiality forms 4. Rights and Responsibilities Form 5. All records pertaining to fair hearings requested. The following must be retained for three federal fiscal years after the death of one spouse: 1. Resource assessments (HCS-457) and all connected documentation.

2. Estate Recovery for Nursing Home Residents (HCS-120) and Real Property Liens for Nursing Home Residents (HCS-121) must be retained for three federal fiscal years after the death of the recipient, or until the state has satisfied the requirements relating to estate recovery, regardless of whether there is a surviving spouse. In the case of civil proceedings, information must be retained a minimum of five years following the completion (including appeals) of the civil case. Effective Date: 4/01/2025

COMBINED MEDICAID 402-3 Trust Funds Supersedes: CMA 402-3 (03/01/2017)

Reference: CFR 435.601; Social Security Act §1917; 42 U.S.C. 1396p(d) for trusts established after 8/11/93 or 42 U.S.C. 1396a(k) for trusts established prior to 8/11/93.

Overview: A trust and the income it generates may be countable or excluded depending on the trust creation date, the source of assets used to fund the trust, the nature of the trust, and other factors. All trusts must be evaluated to determine their availability for the household’s support and maintenance.

Exclusions listed in this section do not apply to property the filing and/or assistance unit does not own. This includes, but is not limited to property owned by or held in:

1. A trust of any kind (whether or not any filing/assistance unit member is a trust beneficiary or a trustor), 2. A corporation of any kind (whether or not any filing/assistance unit member is a corporate shareholder), 3. A partnership of any kind (whether or not any filing/assistance unit member is a partner), 4. A limited liability company of any kind (whether or not any filing/assistance unit member is a member of the company) 5. Any other legal entity, instrument, device or arrangement of any kind confirming the filing or assistance unit does not own the property.

NOTE: Property placed into a trust is not personally owned; it is owned by the trust. Therefore, personal resource exclusions (i.e., home and surrounding property, etc.) listed in CMA 402-1 cannot be used to reduce the trust value.

SUPPORT AGREEMENTS:

If any filing unit member has a written agreement stating that another person, entity or corporation agrees to support the household or household member (e.g., family farm corporation, communal living, fraternal organization, etc.), the agreement must be evaluated to determine if it meets:

1. the legal definition of a trust; 2. ownership; 3. accessibility; and 4. value

ACCESSIBILITY:

If the client verifies that only a portion of the trust is available to them, only that portion is counted. If this is not verified, the full trust value is considered available to each trust beneficiary. A trust may be designated as revocable or irrevocable.

A revocable trust is a trust that can be modified or terminated by the grantor, or someone else, according to the terms of the trust. An irrevocable trust is a trust that cannot be modified or terminated by the grantor or (in most cases) anyone else. A trust which is called irrevocable but which

terminates if the grantor (or someone else) takes some action is also considered a revocable trust. An irrevocable trust may be accessible and countable for Medicaid eligibility purposes.

For trusts created on or after 8/11/93, a revocable trust is considered an accessible resource. For example, if the trust document states the trust can only be modified or terminated by a court, it is considered to be available since the grantor/representative can petition the court to terminate the trust (regardless of whether or not the court chooses to modify or terminate the trust). See Medicaid Qualifying Trusts in this section for trusts established prior to 8/11/93. When the grantor, beneficiary, or trustee has access to a revocable or irrevocable trust created after 8/11/93, regardless of the stated use of the funds, the trust principal is treated as a countable resource. If the trust principal is available under any circumstances, it is a countable resource, if the trust was created after 8/11/93.

NOTE: Nearly any trust created on or after 8/11/93 can be counted when determining Medicaid eligibility, other than those special needs trusts and self-sufficiency trusts that comply with specific criteria in the federal law. No clause or requirement in a trust, no matter how specifically it applies to Medicaid or other federal or state programs, precludes a trust from being considered a resource.

EXAMPLE:

Accessible Trust - The grandparents of a child receiving family-related Medicaid are the sole contributors to an investment fund for the child’s benefit. The child’s mother is the custodian of the fund (trustee). The grandparents state that the money is intended for the child’s college education and not for basic necessities. ACTION: These funds are available as a resource to the child, and must be counted. Access to the funds is not restricted and the child is not obligated, in the legal sense, to use the funds for his/her college education. Further, the trust may be a countable resource to the grandparents if the trust is revocable.

TRUST INCOME:

This section applies to trusts created on or after 8/11/93.

Unless otherwise excluded, dividends, interest, rents and other trust income than can be paid to or for the trust beneficiary’s benefit is countable in the month it becomes available, regardless of whether the income is actually paid. Trust income that can be but is not distributed to the beneficiary, and is instead retained in the trust, is a countable resource beginning the month following the month the income could have been distributed. This is true even if the remainder of the trust principal is excluded.

Monies withdrawn from the principal of an inaccessible or excluded trust, unless otherwise excluded, are countable income in the month received; because an accessible or countable trust is a countable resource, funds withdrawn from the principal are excluded as income. The funds cannot be counted as both income and a resource in the same month. Monies received by the trustee and used for the care and maintenance of a third party beneficiary (adult or child) are excluded as income for the trustee.

MEDICAID QUALIFYING TRUSTS (MQT):

An MQT may be a revocable or irrevocable trust or similar legal device which:

1. was established with the client’s own resources; 2. was established by the client, client’s spouse, client’s parent or client’s legal guardian; 3. names the client as beneficiary of all or part of the payments;

4. has disbursements made by one or more trustees who are permitted to exercise discretion with respect to the amount disbursed; and 5. was established prior to 8/11/1993.

The maximum amount that can be distributed if the trustee exercises full authority under the trust terms, less any funds actually disbursed is a countable resource to the Medicaid client. Funds disbursed for any purpose are countable unearned income to the client.

The grantor’s intended use of a MQT must be considered when determining accessibility. If a trust created prior to 8/11/93 states its intended purpose is for education and the beneficiary is not pursuing education, the trust is inaccessible/ excluded for Medicaid purposes as it is not intended for anything except education.

SPECIAL NEEDS TRUST:

A Special Needs Trust is a trust:

1. Established for the sole benefit of a disabled individual (as defined by the Social Security Act) under age 65 by: a. the disabled individual (for SNT trusts established after 12-13-2016); b. a parent; c. a grandparent; d. a legal guardian; or e. the court. 2. Established with assets of the disabled individual under age 65, and 3. If the trust is terminated for any reason, including death of the disabled individual, the State Medicaid Program will receive all amounts remaining in the trust up to the total amount of medical assistance paid on behalf of the individual during his or her lifetime. NOTE: This trust exclusion continues after the individual reaches age 65. However, the trust cannot be added to nor otherwise augmented after the beneficiary reaches age 65.

Funds contained in a Special Needs Trust are excluded as resources. Income of a Special Needs Trust is not counted as income to the disabled individual (beneficiary of the trust) unless actually distributed in the form of cash or vendor payments for food or shelter (see MA 500, “In-kind Income).

POOLED TRUSTS:

Exclude funds contained in a pooled trust. A pooled trust is:

1. Established for a disabled (as defined by the Social Security Act) individual’s sole benefit by: a. the disabled individual (regardless of age); b. a parent; c. a grandparent; d. a legal guardian; or e. the court. 2. Established with disabled individual’s assets 3. Established and managed by a nonprofit association (e.g. PLUK---“People, Let’s Unite for Kids,” in the case of Self-Sufficiency Trusts of Montana); 4. With a separate account maintained for each trust beneficiary, but for purposes of investment and fund management, the trust pools these accounts; and

5. If the trust is terminated for any reason, including death of the disabled individual, the State Medicaid Program will receive all amounts remaining in the trust up to the total amount of medical assistance paid on behalf of the individual during his or her lifetime.

Income of a pooled trust is not counted as income to the disabled individual (trust beneficiary) unless actually distributed as a direct payment to the beneficiary or his/her agent or vendor payments for food or shelter (see MA 500, “In-kind Income).

BURIAL TRUSTS:

A trust established to set aside funds to pay burial expenses for the individual or someone else (normally a spouse or a family member). Burial trusts under this provision are not the same as funds held in trust by a funeral home in conjunction with a prepaid funeral agreement/burial contract.

Regardless of value, irrevocable burial trusts are excluded resources when determining Medicaid eligibility, unless the individual also obtains an irrevocable funeral agreement.

Revocable burial trusts with a value exceeding $1500 are countable resources when determining Medicaid eligibility if created on or after 8/11/93. Revocable burial trusts created before 8/11/93 are evaluated according to MQT provisions. The total value of a revocable burial trust and any other revocable burial account/contract cannot exceed $1500 equity per person. If the combined values exceed $1500, the burial trust and account/contract are countable in full. See CMA 402-1 for more information on burial accounts/contracts. Creation of an irrevocable burial trust up to $5,000 is not considered an uncompensated asset transfer. If an irrevocable burial trust is created with more than $5,000 (or augmented with additional funds to increase the value above $5,000 at any time after creation), the trust principal will continue to be considered an excluded resource, but the creation of or addition to a trust will be evaluated as an uncompensated asset transfer according to provisions in CMA 404-1 and 404-2. The uncompensated asset transfer policy is applied to the full trust value when initially funded with more than $5,000, and to the full amount added to an existing trust to increase the burial trust’s value to more than $5,000.

Effective Date: June 01, 2022

Combined Medicaid Manual Table of Contents Supersedes: MA 01-(07/01/2016) Section Number Title/Content 0-1 Table of Contents 0-2 Introduction

0-3 Acronyms and Glossary Revision Date 09/01/2026 07/01/2016 02/25/2025 000 Tables and Standards CMA 001 General Resource Limit 01/01/2026 CMA 002 Medically Needy Income Limit 01/01/2026 ACA FMA 003 ACA Parent Caretaker Relative 04/01/2026 ACA FMA004 ACA Pregnancy Income 07/01/2026 ACA FMA 005 Healthy Montana Kids (HMK and HMKP) 04/01/2026 ACA FMA 006 Breast and Cervical Cancer Treatment 04/01/2026 ACA FMA 007 ACA Adult 04/01/2026 ABD 008 Categorically Needy Income Limit 04/01/2026 ABD 009 Medicare Savings Program Income Limit 04/01/2026 ABD 010 Montana Medicaid for Workers with Disabilities (MWD) 04/01/2026 ABD 011 Pickle Eligibility Income Limit

01/01/2023

ABD 012 Qualified Disabled Working Individuals (QDWI) 04/01/2024 ABD 013 Nursing Home Residents 01/01/2024 ABD 014 Poverty Guild lines

04/01/2024 ABD 016 Life Expectancy Table 4/01/2022 ABD 017 Life Estate Interest Table 07/01/2017 ACA FMA 018 Table of Standards- Plan First 04/01/2025 100 Application Processing CMA 101-1 Confidentiality 07/01/2016 CMA 102-1 Civil Rights

11/15/2024 CMA 102-2 General Complaints

07/01/2016 CMA 103-1 Application Processing 02/01/2025 CMA 103-2 Interview 07/01/2016 CMA 103-3 Client Rights and Responsibilities 07/01/2016 CMA 103-4 Verification and Documentation 08/01/2026 CMA 103-6 Voter Registration 07/01/2016 CMA 104-1 Retroactive Medicaid Coverage 05/01/2017 ABD 105-1 Disability Determination 07/01/2017 FMA 105-1 Presumptive Medicaid 01/01/2026 200 Groups Covered ABD 200 General Overview 07/01/2016 FMA 200 Covered Groups Overview

07/16/2016 FMA 200-1

ACA Filing Unit 07/01/2023 ABD 201-1 SSI Eligibles

07/01/2016 FMA 201-1 ACA Parent Caretaker Relative 07/01/2016 ABD 201-2 Pickle Eligibility 07/01/2016 FMA 201-2 ACA Pregnancy 07/01/2016

ABD 201-3 Early Widows and Widowers 07/01/2016 FMA 201-3 Child Newborn 07/01/2016 ABD 201-4 Social Security Increase of 1972 07/01/2016 FMA 201-4 Healthy Montana Kids Plus 01/01/2026 ABD 201-5 Disabled Adult Children 07/01/2016 CMA 201-5 ACA Healthy Montana Kids (HMK) 01/01/2026 ABD 201-6 Medicaid for Workers with Disabilities (MWD) 10/01/2018 FMA 201-6 Former Foster Care 04/01/2023 ABD 201-7 Qualified Disabled Working Individual (QDWI) 07/01/2026 FMA 201-7 ACA Adult 05/01/2025 ABD 201-8 Medicare Savings Program 07/01/2016 FMA 201-8 ACA Adult Medicaid 05/02/2024 ABD 201-9 Residents in Medical Institutions prior to 10/1/198907/01/2016 FMA 201-9 Breast and Cervical Cancer 05/02/2024 FMA 201-10 Family Medicaid Needy 07/01/2016 FMA 201-11 ACA Qualified Pregnant Woman 02/01/2025 FMA 201-12 Extended Postpartum 07/01/2023 FMA 201-13 Transitional Medicaid 11/01/2025 FMA 201-14 Plan First 12/01/2020 CMA 202-1 Adding or Removing Household Members 10/20/2022 300 Non-Financial Requirements CMA 300 Non-Financial Overview 07/01/2026 CMA 301-1 Citizenship and Identity 7/01/2026 CMA 301-2 Alien Status 07/01/2026 CMA 301-3 Emergency Status for Aliens 07/01/2026 CMA 302-1 State Residency 07/01/2016 CMA 302-2 Temporary Absence 01/11/2024

CMA 302-3 Incarcerated Individual 01/01/2025 CMA 303-1 Social Security Number 06/04/2024 CMA 304-1 Health Insurance Coverage-Overview 07/01/2016 CMA 304-2 Health Insurance Coverage-HIPPS

07/01/2016 CMA 304-3 Trauma Questionnaires 07/01/2016 CMA 304-4 Liens and Estate Recovery

07/01/2023 CMA 304-5 Maximum Out of Pocket 01/01/2018 CMA 305-1 Age

07/01/2016 CMA 306-1 Managed Care Program 07/01/2016 CMA 307-1 COBRA 75 10/01/2017 CMA 308-1 Application for Other Benefits 07/01/2016 FMA 308-2 Common Law Marriage 07/01/2016 FMA 309-1 Healthy Montana Kids-Other Insurance 11/01/2022 CMA 310-1 Community Engagement and Exclusion 07/01/2026 400 Resources CMA 400 Resource Overview

06/30/2022 CMA 401-1

Ownership, Accessibility, Equity Value 09/01/2025 CMA 402-1 Countable and Excluded Resources 08/01/2026 CMA 402-2 Native American Resources 07/01/2016 CMA 402-3 Trust Funds 06/01/2022 ABD 402-4 Conditional Assistance 07/01/2016 CMA 403-1 Vehicles 07/01/2016 CMA 404-1 Asset Transfers 07/01/2024 CMA 404-2 Penalty Period for Asset Transfers

07/01/2025 CMA 404-3 Asset Transfers Involving Life Estates 07/01/2016

CMA 404-4 Asset Transfers to Trusts on or after 8/11/93 07/01/2016 ABD 404-5 Pursuing Claims on Property and Estates

07/01/2016 500 Income CMA 500 Income Overview 07/01/2026 CMA 501-1 Unearned Income 01/01/2026 CMA 501-2 Native American Income 06/01/2016 CMA 502-1 Earned Income 01/01/2026 CMA 503-1 Self-Employment 04/01/2023 600 Eligibility & Benefit Determination CMA 601-1 Prospective Budgeting 07/01/2016 CMA 602-1 Income Disregards and Deductions 01/01/2026 CMA 603-1 Deeming 01/01/2026 700 Medically Needy CMA 700 Medically Needy Overview 03/01/2017 CMA 701-1

Cash Option 07/01/2026 CMA 701-2

Cash Option Refunds 01/01/2026 CMA 702-1

Medical Expense 01/01/2020 800 Residential Medical Institutions ABD 800 Residential Medical Institutions Overview 07/01/2024 CMA 801-1

Penal Institutions 07/01/2023 CMA 802-1

Preadmission Screening 01/01/2023 CMA 803-1

Resource Assessment 12/01/2025 ABD 804-1 Long Term Care Partnership 07/01/2016 FMA HMK 804-1 Public and Mental Disease Institutions 07/01/2016 ABD 805-1 Budgeting 07/01/2016

FMA 805-1 Residential Chemical Dependency Treatment 07/01/2016 ABD 805-2 Post Eligibility Treatment of Income (PETI) 07/01/2026 ABD 806-1 Montana State Hospital 07/01/2016 FMA 806-1 Intermediate Care/Psychiatric Residential Treatment07/01/2016 ADB 900 Home & Community Based Services (HCBS)/Waiver FMA 900 Child Support Overview ABD 900 HCBS/Waiver Overview 02/01/2025 FMA 900 Child Support Overview 01/01/2016 ABD 901-1 HCBS/Waiver Income Budget 01/01/2026 FMA 901-1 Child Support Cooperation

01/01/2016 ABD 902-1 HCBS/Waiver Medically Needy 07/01/2016 FMA 1000 Foster Care Overview 07/01/2016 FMA 1001 Subsidized Adoption Overview 07/01/2016 1300 Health Insurance Portability and Accountability Act 1300 HIPAA Creditable Coverage & Release of Information07/01/2016 1500 Case Management CMA 1501-1 Reporting Changes 07/01/2026 CMA 1502-1 Renewals 07/01/2026 CMA 1503-1 Timely and Adequate Notice 01/01/2025 CMA 1504-1 Over Issuance/Under Issuance 07/01/2016 CMA 1505-1 Fair Hearing, Administrative Review & Appeals 07/01/2016 CMA 1506-1 Case Notes

07/01/2016 CMA 1507-1 Program Compliance/Quality Control Reviews 07/01/2016

Good Cause 07/01/2016 Case File Retention/Archive/Destruction 04/01/2025 CMA 1508-1 CMA 1509-1 Revised: 08/01/2026

ACA/FAMILY MEDICAID 105-1 Presumptive Eligibility

Supersedes: FMA 105-1 (07/01/06) Reference: ARM 37.82.101, .701; 42 CFR 435.1101-3; .1110 Overview: Presumptive eligibility (PE) allows eligible individuals to immediately receive Medicaid coverage while a full Medicaid application is processed. PE must be determined by a qualified entity. Pregnant women are only eligible for ambulatory prenatal care during the presumptive period while all other presumptive populations are eligible for all Medicaid services. Pregnant women are allowed only one PE period per pregnancy, while other presumptive populations are allowed one PE period in a 12-month period (from the most recent PE effective date). PRESUMPTIVE POPULATIONS: 1. ACA HMK Plus (FMA 201-4 Healthy Montana Kids Plus) 2. ACA HMK (CMA 201-5 ACA Healthy Montana Kids (HMK)) 3. ACA Former Foster Care Children (FMA 201-6 Former Foster Care) 4. ACA Parent/Caretaker Relative (FMA 201-1 ACA Parent Caretaker Relative) 5. ACA Pregnant Woman (FMA 201-2 ACA Pregnancy) 6. MBCCTP – Breast and Cervical Cancer (FMA 201-9 Breast and Cervical Cancer) 7. ACA Adult Medicaid (FMA 201-8 ACA Adult Medicaid) 8. Plan First (FMA 201-14 Plan First Coverage) QUALIFIED ENTITIES: Only qualified entities (QE), who have received appropriate training and certification can make presumptive eligibility determinations. QEs must be registered Medicaid providers, and include, but are not limited to: 1. Migrant Health Centers; 2. Public Health Departments; 3. Community Health Centers; 4. State Perinatal Programs; 5. WIC;

6. Indian Health Services/Tribal Health Programs; and 7. Qualified Hospitals NOTE: Presumptive pregnancy eligibility can be determined by any of the entities listed; however, only qualified hospitals can determine PE for the other PE populations listed above. PE FINANCIAL and NONFINANCIAL REQUIREMENTS: Individuals may be found presumptively eligible if: 1. Countable income is within allowable limits for the appropriate program; 2. The individual meets US citizen or qualified noncitizen status; 3. ACA Adult Expansion individuals meet community engagement requirement or have an exclusion, 4. There has not been a PE period for either the current pregnancy or previous 12- month period; and/or 5. Pregnancy and due date are self-attested. NOTE: Pregnancy information is only needed for women seeking presumptive pregnancy eligibility or those where pregnancy is the only exclusion to community engagement criteria. PRESUMPTIVE ELIGIBILITY PERIOD: Eligibility begins the day a qualified entity determines the individual is eligible. The QE will provide proof of eligibility that allows the individual to receive approved services. PE period ends the: 1. Day the individual is determined ineligible for Medicaid; or 2. Last day of the month following the month of PE (if no regular Medicaid application has been submitted); or 3. Day a pending Medicaid application is processed (if received prior to the PE period ending). PE may overlap a month of regular Medicaid coverage if a Medicaid application is pending at the time a PE determination is made. Effective Date: 7/1/2026

ACA/FAMILY MEDICAID 200 Groups Covered-Overview

Supersedes: FMA 200 (01/01/08); Bulletin FMA 73 (04/08/15) Reference: 42 CFR 435.110, .116, .118, .150; 42 CFR 457.310; State Medicaid Director Letter dated May 30, 2014 Overview: Provide Medicaid coverage to the following groups: ACA GROUPS: ACA Parent/Caretaker Relative, ACA Pregnancy, ACA HMK Plus, ACA HMK, and Former Foster Care Children, ACA Adult, and ACA Adult Medicaid. FAMILY GROUPS: Child Newborn, Pregnancy Extended, Child Medically Needy (child who does not live with a parent/specified caretaker relative), Qualified Pregnant Woman, Family Medically Needy (child living with parent/specified caretaker relative), Breast & Cervical Cancer, Subsidized Adoption, IV-E Foster Care and Non-IV-E Foster Care. SAME SEX MARRIAGE: Same-sex couples who marry in a jurisdiction that recognizes same-sex marriage are considered spouses. Same-sex marriages are permissible under Montana law, and Montana recognizes same-sex marriages performed in other jurisdictions. NOTE: Civil unions and domestic partnerships do not impact marital status and therefore these couples are not considered spouses when determining Medicaid eligibility. Effective Date: July 01, 2016

ACA/FAMILY MEDICAID 200-1 ACA Filing Unit Supersedes New Reference: 42 CFR 435.603(f) Overview: ACA filing units are based on IRS tax code and must be created for each applicant. Filing units are determined by answering the following questions. Step 1: 1. Does the individual plan to file current year taxes? a. If not, continue to step 2 b. If yes, do they expect someone to claim them as a tax dependent? i. If no, filling unit is based on tax payer’s household, including their spouse (if living with them) and everyone they plan to claim as a dependent ii. If yes, continue to step 2 Step 2: 1. Does the individual expect to be claimed as a tax dependent? a. If no, continue to step 3 b. If yes, do they meet one of the following exemptions? i. They expect to be claimed as a tax dependent by someone other than their biological, adoptive or step-parent 1. If yes, continue to step 3 2. If no, continue to ii ii. They are a child under age 19 and: 1. Are living with both parents, but parents don’t plan to file jointly; OR 2. Expect their non-custodial parent to claim them as a dependent a. If no to both, base the filing unit on the household of the tax payer who is claiming them as a dependent i. Are they married? If yes, include their spouse in the filing unit b. If yes to either, continue to step

c. If the dependent is over the age of 19 (month after 19th birthday), continue to step 3 Step 3: For those who: • Don’t plan to file a tax return (non-filer) and don’t expect to be claimed as a dependent; or • Are tax dependents who meet an exemption in Step 2 b or • Are a tax dependent over the age of 19 The filing unit consists of the individual, and the following, if living in the same house: a) Their spouse; b) Their natural, adoptive, and step-children under the age of 19; and c) For those under age 19 their natural, adoptive and step: i. Parents and ii. Siblings under age 19 d) For those over age 19: i. The individual and, ii. The tax payer(s) claiming them as a dependent (only if the taxpayer is a natural/adoptive or step-parent) and, iii. The tax dependent’s spouse if they live together.

Effective Date: July 1,2026 Revised Date: July 1, 2023

ACA/FAMILY MEDICAID 201-1 ACA Parent/Caretaker Relative (Family Medicaid)

Supersedes: FMA 201-1 (01/01/09) Reference:42 CFR 435.110, .602; ARM 37.82.101, .701, .702 & .703; PL 104-193; 42 USC 1396b Overview: Parents or Caretaker Relatives may qualify for ACA Parent/Caretaker Relative (PCR) Medicaid if they have an eligible child living in their home. An eligible child is a child under age 19 who is within the 5th degree of kinship of the caretaker relative, including children receiving SSI. NOTE: If the child’s parent is in the home, a caretaker relative cannot receive ACA PCR coverage. Total countable income is tested against the ACA PCR income standard (ACA FMA 003 Table of Standards- ACA Parent Caretaker Relative Income). NONFINANCIAL CRITERIA: Medicaid standard nonfinancial requirements are listed in section CMA 300 Non- Financial Overview. In addition to the standard criteria that applies to all Medicaid programs, the following non-financial criteria are specific to ACA PCR: · Child must be living with a parent/specified caretaker relative · Age (must be a dependent child under age 19 within 5th degree of kinship) Effective Date: July 01, 2016

ACA/FAMILY MEDICAID 201-2 ACA Pregnancy

Supersedes: FMA 201-2 (01/01/08) Reference: 42 CFR 435.116; ARM 37.82.101, 701; 42 USC 1396a and 42 USC 1396b Overview: Pregnant women who meet certain financial and nonfinancial criteria may be eligible for Medicaid coverage. Self-attestation is used as proof of pregnancy. Income must be at or below 157% of the Federal Poverty Level (ACA FMA 004 Table of Standards- ACA Pregnancy Income). If the due date is not provided, enter a date 9 months after the application date as the expected due date in the system. NON-FINANCIAL CRITERIA: Medicaid standard nonfinancial requirements are listed in section CMA 300 Non- Financial Overview. In addition to the standard criteria that applies to all Medicaid programs, the following non-financial criteria are specific to ACA Pregnancy: · Must be a pregnant woman CONTINUED COVERAGE: Pregnant women whose Medicaid (under non-pregnancy category) closes due to increase income may be eligible for continued Medicaid coverage through the end of their pregnancy. The woman must tell an eligibility staff member that she is pregnant prior to the effective date of closure. As long as the woman remains a Montana resident and continues to cooperate with TPL and Program Compliance, her Medicaid coverage will continue. To qualify for continued coverage, the woman must be eligible in the application month. If she is not eligible in the application month, continuous coverage begins with the first eligible month. The woman may be eligible for retroactive coverage, but retro months do not start a continuous coverage span. Effective Date: July 01, 2016

ACA/FAMILY MEDICAID 201-3 Child Newborn

Supersedes: FMA 201-5 (03/01/15) Reference: 42 CFR 435.117; ARM 37.82.101, .701; 42 USC 1396a(e)(4) and 1396b Overview: A newborn child whose mother was eligible for and receiving Medicaid at the time of birth is automatically eligible for Medicaid; a separate eligibility determination is not made and future income changes do not affect the newborn’s eligibility. As long as the newborn’s mother was receiving Medicaid, the newborn is automatically eligible, and eligibility may continue through the month of the newborn’s first birthday. However, if the mother was receiving medically needy coverage, she must have met her spend down as of the date the baby was born for the newborn to be eligible through the month of their first birthday. NOTE: Medicaid will not pay for any of the newborn’s medical services (including prescriptions) until the newborn’s Medicaid has been opened and issued. NON-FINANCIAL CRITERIA: Medicaid standard nonfinancial requirements are listed in section CMA 300 Non- Financial Overview. In addition to the standard criteria that applies to all Medicaid programs, the following nonfinancial criteria are specific to Child Newborn: · Citizenship and Identity o A “Certificate of Live Birth” from the hospital or a “Montana Vital Statistics Birth Registry” printout can be used as proof of both citizenship and identity until the child turns 1, at which time proof if identity is required. · SSN Application o Hospital Abstract showing an SSN has been requested (although proof of SSN application cannot be required prior to approving Medicaid). CHILD NEWBORN ENDS: Child Newborn eligibility closes at the end of the month in which the newborn: 1. turns one; or 2. no longer lives in Montana.

Effective Date: July 01, 2016

ACA/FAMILY MEDICAID 201-6 Former Foster Care Children under Age 26

Supersedes: FMA 201-6 (07/01/2016) Reference: 42 CFR 435.150 Overview: The Affordable Care Act created a new Medicaid eligibility group for young adults who aged out of foster care Medicaid at age 18 or older. Former foster care children can apply for Medicaid coverage under this group if they are under age 26 AND: 1. Were placed in state (any state) or tribal foster care AND 2. Were receiving Medicaid at the time they turned 18 (or older) and aged out of the foster care program in Montana; OR 3. If in foster care and receiving Medicaid in another state, the individual must have turned 18 on or after 01/01/2023. (If turned 18 on 12/31/2022, not eligible for FFC in Montana)

The individual may self-attest that they meet the above criteria; verification cannot be required. The filing unit is always a unit of one, the former foster child; no others are included. This program does not have an income or resource test. NON-FINANCIAL CRITERIA: Medicaid standard nonfinancial requirements are listed in section CMA 300 Non- Financial Overview. In addition to the standard criteria that applies to all Medicaid programs, the following nonfinancial criteria are specific to ACA Former Foster Care: · Must be under age 26; · Aged out of foster care; and · Were receiving Medicaid at the time they aged out COVERAGE ENDS: Medicaid closes when the client: 1. requests closure; 2. dies; 3. moves out of Montana

4. is non-compliant with TPL and/or Program Compliance; or 5. reaches age 26 (eligibility continues through the month of their 26th birthday). Revised date: April 1, 2023

ACA/FAMILY MEDICAID 201-8 ACA Adult Medicaid Supersedes: FMA 201-8 (07/01/2016) Reference: 42 CFR 435.119; ARM 37.82.101, .301, .702, .703; ARM 37.84.101 - .115; SB 405 (MCA 17-7-502) Overview: The Montana Health and Economic Livelihood Partnership (HELP) Act created two new coverage groups beginning January 1, 2016: ACA Adult and ACA Adult Medicaid. This section covers ACA Adult Medicaid; ACA Adult is covered in section ACA-FMA 201-7 ACA Adult ACA Adult Medicaid covers individuals age 19 through 64. Medically frail and Native Americans/Alaskan Natives with income of 51% to 133% FPL are covered under the ACA Adult Medicaid program. FINANCIAL CRITERIA: Income is determined under MAGI rules and must be 0% to 133% FPL (after a 5% disregard). NON-FINANCIAL CRITERIA: Medicaid standard nonfinancial requirements are listed in section CMA 300 Non-Financial Overview. In addition to the standard criteria that applies to all Medicaid programs, the following nonfinancial criteria are specific to ACA Adult Medicaid: · Must be age 19 through 64; · Cannot be eligible for or enrolled in Medicare Parts A and/or B; and · Cannot be pregnant at application. For individuals with income of 51% - 133% FPL, one of the following criteria must also be met: · Are medically frail; or · Are Native American or Alaskan Native FILING UNIT: Required filing unit members are determined based on tax filing rules. See FMA 200-1 ACA Filing Unit for ACA filing unit requirements.

ACA ADULT MEDICAID COVERAGE ENDS: ACA Adult coverage closes when the client: 1. requests closure; 2. dies; 3. moves out of Montana; 4. is non-compliant with PERM and/or Program Compliance; 5. becomes Medicare eligible; 6. we are unable to locate the individual; or 7. reaches age 65 (eligibility ends the month before their 65th birthday). Effective Date: January 01, 2018 Revised date: May 2, 2024

ACA/FAMILY MEDICAID 201-9 Breast and Cervical Cancer

Supersedes: FMA 201-11 (01/01/08) Reference: 42 U.S.C. 1396a (a)(10)(A)(ii)(XVIII); ARM 37.82.101, .701 Overview: Individuals who are screened by a Montana Breast and Cervical Health Program (MBCHP) and are subsequently diagnosed with breast and/or cervical cancer or pre-cancer may be eligible for Medicaid under the Montana Breast and Cervical Cancer Treatment Program (MBCCTP). APPLICATION DATE: The application date is the date the signed application (HCS/BCC-002) is received and date stamped in the PAB Central Office. Applications received at any other location are not considered filed. NONFINANCIAL CRITERIA: Medicaid standard nonfinancial requirements are listed in section CMA 300 Non-Financial Overview. In addition to the standard criterion that applies to all Medicaid programs, the following nonfinancial criteria are specific to the MBCCP program. The individual must: · Have received a breast and/or cervical health screening through the Montana Breast and Cervical Program; · Have been diagnosed with breast and/or cervical cancer or pre-cancer as a result of the screening; · Not have creditable health insurance or other coverage for breast and/or cervical cancer, including Medicare; · Not be eligible for any other categorically needy Medicaid program; and o If the individual is eligible for any categorically needy Medicaid coverage, that program must be opened; o If the individual is or would be eligible as medically needy, breast and cervical cancer coverage is opened; o If the individual fails to either follow through with applying for or complying with eligibility requirements for other Medicaid coverage, the individual is not eligible under the breast and cervical cancer program; · Be under the age of 65 FINANCIAL CRITERIA:

Countable income must be at or below 250% FPL. Income is self-attested. CREDITABLE COVERAGE: Individuals applying for Medicaid under the MBCCTP cannot have health insurance or other coverage that will pay for breast and/or cervical cancer treatment and meets the definition of ‘creditable coverage’. The deductible amount (such as $5,000 or more) does not change the determination; if the policy covers treatment and is considered creditable coverage, the individual is not eligible for the MBCCTP.

*Indian Health Service coverage is not considered creditable coverage for the BCC program. COVERAGE LENGTH: MBCCTP Medicaid coverage continues until the earlier of: 1. Cancer treatment is completed; or NOTE: Follow-up screenings are NOT considered treatment, and BCC Medicaid cannot remain open to cover follow-up. 2. The month prior to the individual’s 65th birthday, whether or not treatment is completed; Other factors that cause BCC Medicaid to close are when the individual: 1. Obtains creditable coverage; or 2. Fails to comply with any MBCCTP requirement, including renewal. RETROACTIVE COVERAGE: Up to three months of retroactive MBCCTP coverage is available to eligible individuals. Retroactive months are based on application date and cannot be opened prior to the month of diagnosis. SEE BUSINESS PROCESS: Montana Breast and Cervical Cancer Effective Date: November 03, 2018 Revised Date: May 2, 2024

ACA/FAMILY MEDICAID 201-10 Family Medically Needy

Supersedes: FMA 201-1 (01/01/09) Reference: 42 CFR 435.113, .602; ARM 37.82.101, .701, .702 & .703; PL 104-193; 42 U.S.C. 1396b Overview: Children who live with their parent or a caretaker relative may be eligible for medically needy coverage if the household’s countable income exceeds the limits for categorically needy Medicaid. Adults cannot receive coverage under the Family Medically Needy program. If the child(ren) is living with their natural or adoptive parent, the parent must be included in the filing unit, and the parent’s income and resources are counted in full. Stepparent income is deemed (see CMA 603-1 Deeming). The parent’s medical expenses can be used to reduce/meet the spend down. A child who is emancipated is no longer considered a dependent child, and does not meet eligibility criteria for this program. NON-FINANCIAL CRITERIA: Medicaid standard nonfinancial requirements are listed in section CMA 300 Non- Financial Overview. In addition to the standard criteria that applies to all Medicaid programs, the following nonfinancial criteria are specific to Family Medically Needy: · Child must live with a parent or specified caretaker relative (must be w/n 5th degree of kinship); and · Child must be under age 19 FINANCIAL CRITERIA: Countable income must be within allowable limits, and countable resources cannot exceed $3,000, regardless of household size. FILING UNIT: The standard medically needy filing unit must include: 1. The dependent child for whom application is being made; 2. The natural/adoptive parent(s) living in the same home; and

3. Stepparents (stepparent’s income is deemed; see CMA 603-1 Deeming). The following individuals may be included in the medically needy filing unit, but are not required. 1. The applicant child’s minor siblings (whole, half, step); and 2. Minor stepchildren. Effective Date: July 01, 2016

ACA/FAMILY MEDICAID 201-11 Qualified Pregnant Woman Medically Needy

Supersedes: FMA 201-3 (01/01/08) Reference: ARM 37.82.101, .701 and 1101; 42 CFR 435.116; 42 USC 1396b Overview: Pregnant women whose countable income exceeds the allowable limit for categorically needy Medicaid coverage may be eligible for medically needy coverage under the Qualified Pregnant Woman (QP) program. Once a spend down is established, it cannot be increased even if income increases. If income decreases, the spend down must also be decreased, and must remain at the lower amount, as long as there isn’t a break in Medicaid eligibility. EMANCIPATION: A child who is emancipated by court action or marriage is no longer considered a dependent child. Do not include an emancipated pregnant minor’s parents in the filing unit. NON-FINANCIAL CRITERIA: Medicaid standard nonfinancial requirements are listed in section CMA 300 Non- Financial Overview. In addition to the standard criteria that applies to all Medicaid programs, the following nonfinancial criteria are specific to Qualified Pregnant Woman: · Must be a pregnant woman (self-attestation is acceptable verification) FILING UNIT: The Qualified Pregnant Woman’s filing unit must include the following: 1. Pregnant woman; 2. Unborn child; 3. Unborn’s father (if living in the same home) and 4. Pregnant woman’s spouse (if living in the same home). The following individuals are not required, but may be included in the QP filing unit:

1. Minor siblings of either the pregnant woman or unborn; and 2. Pregnant woman’s minor stepchildren. If the QP woman is under age 19, lives with her natural/adoptive parents and is not married (or otherwise emancipated), the following must also be included in her filing unit: 1. Pregnant woman’s natural/adoptive parents; and 2. Pregnant woman’s stepparents (stepparent income is deemed – see CMA 603-1 Deeming). NOTE: Medical bills of all individuals whose income is included in the eligibility determination can be used to reduce/meet the QP spend down. Effective Date: February 01, 2025

ACA/FAMILY MEDICAID 201-12 Extended Postpartum Coverage

Supersedes: FMA 201-12 (7/01/2016) Reference: ARM 37.82.101, .701; 42 CFR 435.170; 42 CFR 435.116 Overview: Medicaid is extended toto provide 12 months of extended postpartum coverage to pregnant individuals enrolled in Medicaid and CHIP. Individuals are entitled to the extended postpartum coverage regardless of the reason the pregnancy ends. Women receiving medically needy Medicaid receive the extended coverage if their spend down is met as of the delivery date. The mother must remain a Montana resident during the extended period; Medicaid is closed if she moves out of state. The 12-month postpartum period begins on the last day of a beneficiary’s pregnancy and extends through the end of the month in which the 12-month period ends. This continuous eligibility ends if the beneficiary: • is no longer a Montana resident; • does not cooperate with TPL and/or Program Compliance; • requests closure; • the Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility due to: a. Agency error or b. fraud, abuse, or perjury attributed to the beneficiary • the beneficiary dies. NOTE: When pregnancy coverage is provided under Emergency Alien Medical (CMA 301- 3 Emergency Alien), neither the newborn nor the mother qualify for extended pregnancy coverage. The newborn may be eligible for other coverage (e.g., Child-Newborn, HMK Plus, etc.). RECEIVING MEDICAID:

If either of the following are met, the woman is considered to be receiving Medicaid on the day the pregnancy ends: 1. She has a pending application on the day the pregnancy ends, and is subsequently determined eligible; or 2. She applies for coverage after her baby is born and is determined Medicaid- eligible as of the delivery date, or earlier. Renewals Individuals receiving extended postpartum coverage remain eligible regardless of changes in circumstances that may affect eligibility such as a change in income, household composition, or categorical eligibility (e.g., reaching an age milestone or loss of Supplemental Security Income (SSI) for individuals eligible for Medicaid based on receipt of SSI). A renewal is required at the end of the 12-month period to evaluate ongoing Medicaid coverage. Effective Date: 7/1/2023

ACA/FAMILY MEDICAID 201-13 Family Transitional Medicaid

Supersedes: FMA 201-9, 02/01/2019 Reference: 42 CFR 435.112; ARM 37.82.101, .701; P.L. 100-485; and P.L. 103-194 Overview: ACA Transitional Medicaid (TMA) may be provided to parents, specified caretaker relatives, and children for up to 6 consecutive months following closure of non-medically needy ACA Medicaid (ACA PCR, ACA Adult Medicaid, and ACA Adult), when closure was due to a qualifying event. TMA coverage is available for all family members who are included in the assistance unit. There are no resource or income limits for TMA coverage. NOTE: TMA coverage is not available to any family who fraudulently received Family coverage during the six months prior to the beginning of the TMA period. Fraud must be determined by a court of law. If the household fails to report income timely, it is not fraud. It will be necessary to determine when, if the change had been reported timely, the TMA period would have begun and adjust the 6 months of TMA accordingly. QUALIFYING ADULT: A qualifying adult includes those individuals whose needs and income were included in the assistance unit in the eligibility determination of ACA PCR, ACA Adult Medicaid, and ACA Adult at the time the case closed/became medically needy. QUALIFYING CHILD: A qualifying child is one who: 1. Is under age 19; 2. Meets U.S. citizenship, U.S. National or qualified noncitizen status and: a. Was included in the ACA PCR, ACA Adult Medicaid, and ACA Adult household and related as child/stepchild or other related within 5th degree of kinship (niece/nephew, grandchild) at the time the case became medically need/closed; or b. Is a dependent child receiving Supplemental Security Income (SSI). QUALIFYING EVENT: To be eligible for TMA, the family must have: 1. Received non-medically needy ACA Medicaid in Montana during three of the previous six months prior to the case closing/becoming medically needy and

case closed/became medically needy due to a new or increased earned income to the household; AND 2. At least one qualifying child remains in the household, and 3. Not be eligible for any other type of Medicaid assistance.

Upon ACA PCR, ACA Adult, and ACA Adult Medicaid closing/becoming medically needy due to a qualifying event, notify the family via appropriate system notice of TMA eligibility. CONTINUING COVERAGE: TMA coverage continues for 6 consecutive months as long as: 1. There is a qualifying child in the home; 2. The family maintains Montana residency; 3. The parent/specified caretaker relative cooperates with: a. Program Compliance Medicaid reviews and b. TPL (HIPPS, Trauma Questionnaires, providing health insurance information and insurance questionnaires). If the parent/specified caretaker relative fails to cooperate with program compliance or TPL; they will be disqualified by entering appropriate data on either the ‘Person Compliance’ or ‘Health Coverage Compliance’ Web page. The children’s Medicaid is not closed due to the parent/specified caretaker relative’s failure to cooperate. NOTE: If income decreases significantly during the TMA eligibility period, it is good customer service to notify the family of potential ACA Medicaid coverage. This could allow for an additional TMA period should income increase again. CHIMES will automatically test for this coverage. and 4. Reporting requirements are met. EXAMPLES (QUALIFYING EVENT): 1. A family starts receiving unearned income that causes their ACA PCR, ACA Adult, and ACA Adult Medicaid case to become medically needy. As this was the result of new or increased unearned income, this is not a qualifying event and the family is not eligible for TMA. 2. Household consists of mom, mom’s two children, and mom’s boyfriend (not father of the children). The household does not include the boyfriend. Mom and boyfriend get married; his income causes mom’s ACA Medicaid case to become medically needy/close. The is no TMA eligibility for any household member as the closure was not due to a qualifying event. Closure was due to adding the boyfriend (now the spouse) and subsequently counting his income. CHIMES will automatically test eligibility for children under other programs through an ex parte review. 3. Household consists of mom and her child. The absent father returns to the home. When he is added to the case, his income causes closure. No household

member is eligible for TMA, Closure is not due to a qualifying event. Closure is due to adding a person (the father) and subsequently counting his income. The father was not a part of the household; therefore, the household’s income did not increase. 4. Dad and two children have received non-medically needy ACA Medicaid for 5 months. Dad gets a raise, and the total countable income closes the ACA coverage. Because there was a qualifying event (increase in household’s earned income), all family members are eligible for TMA. NOTE: If the case has been opened as medically needy, an increase in dad’s income would not be a qualifying event because he would not have been a member of the household. The increase in income would result in an increase in the spend down. 5. Household consists of mom, dad, and their daughter and they have been receiving non-medically needy ACA Medicaid for 7 months. Dad is not eligible because he cannot prove citizenship/noncitizen status (he is included in the filing unit because he is the spouse, his income is pulled in regardless of tax filing). Dad gets a job, and his earned income causes ACA Medicaid to become medically needy. Because dad is a required filing unit member who would have been included in the assistance unit if citizenship/noncitizen status could be verified, mom and their daughter are TMA eligible, but dad is not. REPORTING REQUIREMENTS: TMA households are subject to regular ten-day change reporting requirements. Job loss, with or without good cause, during the TMA 6-month period will not affect ongoing TMA coverage. Income changes reported during the TMA period only need to be verified if the family is requesting other Medicaid coverage (such as ACA), as there is no income limit for TMA. Decreased income may make some household members eligible for other types of assistance. Example: Mom, dad and two children are eligible for TMA. Dad reports a decrease in income that makes the two children eligible for HMK Plus, but the parents remain over income for an adult ACA program, so they remain on TMA, and the children move to HMK Plus. If there is a change and the children are no longer eligible for HMK Plus, they can transition back to TMA for the remainder of the eligibility period. CHANGES IN HOUSEHOLD COMPOSITION-MEMBER LEAVES: If the TMA household contains two parents, and one parent leaves the household with a qualifying child and another qualifying child remains in the household, evaluate for continued TMA eligibility for both households. Example: The household contains mom, dad, and two qualifying children. Dad leaves with one child. Evaluate both households for continued TMA eligibility. If both households continue to meet requirements, each household continues to be TMA

eligible. Create a task to close the “new” TMA case at the end of the original 6-month eligibility period. If one of the parents leaves and there is only one child, the parent with the child included in their assistance unit remains eligible for TMA. CHANGES IN HOUSEHOLD COMPOSITION-NEW MEMBER/NEWBORN: Individuals who return to or enter the home during the TMA period will be added to TMA if their needs and income would have been taken into account in determining ACA Medicaid eligibility. These include: 1. A child born or adopted after ACA PCR, ACA Adult, and ACA Adult Medicaid benefits are terminated but who would have been included in the assistance unit had they been born/adopted prior to closure, 2. A child who returns home whose needs would have been included in the assistance unit had they returned prior to closure, 3. A natural/adoptive/stepparent who returns to the home. Added individuals will be eligible for the remainder of the Transitional period. AUTO CLOSURE: CHIMES will automatically close the TMA case effective the end of the 6 months and send a closure notice. NOTE: It is very important that all cases not be in a pending status to ensure that this process works correctly. An ex parte review should be completed prior to the effective date of closure and a task will be created. CHIMES will automatically recalculate eligibility once TMA has closed, but additional information/documentation may be required (i.e. current income verification). The worker will need to send the appropriate notice requesting this information/documentation. Please follow the ex parte business process in the PAUG. TERMINATION OF BENEFITS: If Transitional benefits are terminated for either an individual or household, provide timely and adequate notice. If the eligibility case manager has enough information to finalize eligibility for another Medicaid coverage group, the coverage should be opened without further information being requested, unless there is a premium involved. If an individual is eligible for ACA Adult Medicaid program (ACA Adult or ACA Adult-Medicaid) with a premium, please check with the individual to make sure they want to pay for their coverage. If an individual is eligible for ACA Adult Medicaid or ACA Adult, evaluate for community engagement requirements or exception. If more information is needed, the eligibility case manager must immediately notify the household of what is needed and when it is due. If the information is provided prior to

the effective date of closure, a new application is not required to open additional coverage. If the required information isn’t provided until after the effective date of closure, a new application must be completed. Example: TMA eligibility for the Snow household ends effective 09/30/2025. The eligibility case manager sends timely notice of closure, other possible coverage and a list of needed information on 09/05/2025. On 09/9/2025, the family provides the requested information. The case worker enters the correct information and opens the appropriate program(s) if eligible. If the Snows hadn’t provided the requested information until 10/01/2025 or later, the case worker would have to require a new application. EFFECTIVE DATE: 7/01/2026

ACA/FAMILY MEDICAID 201-14 Plan First Supersedes: NEW Reference: 42 CFR 435.214; ARM 37.82.101, .701, .702, .703; Overview: Plan First is a Montana Medicaid Waiver that covers family planning services for eligible women age 19 through 44, that are not currently pregnant and able to bear children, with income up to 211% FPL; That are not eligible for any other program other than a MSP (Medicare Savings Program). FINANCIAL CRITERIA: Income is determined under MAGI rules and cannot exceed 211% FPL (plus a 5% disregard). Plan First is not eligible for retro coverage. NON-FINANCIAL CRITERIA: Medicaid standard nonfinancial requirements are listed in section CMA 300 Non- Financial Overview. In addition to the standard criteria that applies to all Medicaid programs, the following nonfinancial criteria are specific to Plan First: 1. Must be female age 19 through 44; 2. Montana Resident; 3. Able to Bear Children, and Not Currently Pregnant; 4. Cannot be eligible for any other Medicaid program other than MSP (Medicare Savings Program). FILING UNIT: Required filing unit members are determined based on tax filing rules. See FMA 200-1 ACA Filing Unit for ACA unit requirements. PLAN FIRST COVERAGE ENDS: Plan First coverage closes when the client: 1. Reports they have had a sterilization procedure (i.e. hysterectomy, tubal ligation), or are unable to bear children;

2. Through the month of their 45th birthday; 3. Requests closure; 4. Becomes pregnant 5. Dies; 6. Moves out of Montana; or 7. Becomes eligible for a higher Medicaid category. Effective Date: December 01, 2020

ACA/FAMILY MEDICAID 308-2 Common Law Marriage

Supersedes: FMA 305-1 (01/01/06) Reference: ARM 37.82.101, .701 - .703, 42 CFR 435.110, .510, .602; PL 104-193; 42 USC 1396b; MCA 40-1-403 Overview: In Montana, a couple may enter into a legally binding common law marriage, even though they have not gone through a formal marriage ceremony. ASSESSING COMMON LAW MARRIAGE: A common law marriage is NOT created simply because a couple live together and act as if they were married. The parties must INTEND to enter into marriage. Each individual must be old enough to marry and not married to anyone else to enter into a valid common law marriage. To determine marital status, relationship documentation is needed. A marriage license, divorce decree, separation agreement, or other documentation is provided. For a common law marriage to exist, three elements must be present: 1. Consent and agreement - the man and woman must mutually agree and consent to enter into a marriage relationship; 2. Competency - both are legally competent to enter into a marriage; and 3. Cohabitation and holding themselves out as married. The parties must live together and hold themselves out to relatives, friends, neighbors, co-workers and others as being married. Merely living together or having children together is NOT proof that a common law marriage exists. There must be evidence that the parties hold themselves out as a married couple. Evidence may include: a. Using the same last name; b. Referring to each other as husband and wife when introducing each other or talking to other people; c. Listing each other as spouse on health or life insurance policies, loan or credit applications, tax returns, and other documents. NOTE: Owning property such as a house or car jointly with another person is NOT evidence that they are holding themselves out as married

unless the deed, title or other proof of ownership indicates they own the property as husband and wife. PROVING COMMON LAW MARRIAGE: The most important element, and the hardest to prove is that the parties intend at some specific point in time to enter into a marriage. If the Department through the field office suspects that a client has entered into a common law marriage exists, the Department/field that office has the burden to prove the three necessary elements of a common law marriage are present, including intent. Under Montana law (26-1-602(30) MCA), there is a presumption presumes that a two individuals who behave as if they are married have entered into a lawful marriage contract. However, evidence to the contrary can overcome this presumption. Often there is conflicting evidence as to whether the parties hold themselves out as married. For example, the woman may continue to use her own name in some situations but use the alleged husband’s name at other times, or the parties may list each other as the spouse on some documents but not others. In these instances, a court or hearing officer may find that a common law marriage does NOT exist. DOCUMENTATION REQUIREMENTS: If the three elements of common law are not present, do not establish common law marriage. Evaluate household members per the appropriate program filing unit policy. NOTE: If there is any questionable evidence, do not consider the parties to be common law married. If all three elements are present, request a written statement attesting to these facts. Document action in system case notes. Effective Date: July 01, 2016

ACA/FAMILY MEDICAID/HEALTH MONTANA KIDS 309-1 Healthy Montana Kids-Other Insurance

Supersedes: FMA-HMK 309-1 (07/01/2016) Reference: 42 CFR 457.310, 435.926; ARM 37.79 Overview: Healthy Montana Kids (HMK) coverage is available to children who: 1. Are not insured by a creditable health insurance plan; and 2. Meet all other financial and non-financial eligibility requirements. CREDITABLE COVERAGE: Children covered by a creditable insurance policy are not eligible for HMK coverage. The deductible amount (such as $5,000) does not change the determination; the coverage is still considered creditable. A Letter or Certificate of Creditable Coverage is not required when a child’s health insurance coverage ended within the past three (3) months. DISCOVERY OF COVERAGE WHILE HMK ENROLLED: When it is reported or discovered that a child receiving HMK coverage is insured by another insurance carrier, we can no longer break the HMK continuous span for discovering/reporting other health insurance. The health insurance must be entered into CHIMES and HMK benefits will close at renewal. . Effective Date: 11/01/2022

ACA/FAMILY MEDICAID/HEALTHY MONTANA KIDS 804-1 Public and Mental Disease Institutions

Supersedes: HMK 3.8 (10/01/09) Reference: ARM 37.79 Overview: Children who are residing in an institution for mental disease (IMD) or are an inmate in a public institution are not eligible to receive Healthy Montana Kids (HMK) coverage. NOTE: A child enrolled in HMK who subsequently enters an IMD remains enrolled through their family span. At renewal, HMK coverage is closed if the child is still in an IMD or public institution. INSTITUTION for MENTAL DISEASE (IMD): An IMD is a facility that provides diagnosis, treatment and care for individuals with mental disease. IMDs in Montana include: 1. Montana State Hospital (Warm Springs); 2. Shodair Hospital and Residential Treatment Center (Helena); 3. Intermountain Children’s Home (Helena); 4. Acadia (Butte); and 5. Yellowstone Boys and Girls Ranch (Billings). PUBLIC INSTITUTIONS: Refer to CMA 801-1 Penal Institutions for information on public institutions. Public institutions in Montana include: 1. Pine Hills (Miles City); 2. Riverside (Boulder); 3. Montana State Prison for men (Deer Lodge); 4. Montana State Prison for women (Billings); 5. Regional prisons (Billings, Glendive, Great Falls and Missoula); 6. NEXUS Methamphetamine Treatment Center for men (Lewistown); and 7. Elkhorn Methamphetamine Treatment Center for women (Boulder).

Effective Date: July 01, 2016

ACA/FAMILY MEDICAID 806-1 Intermediate Care/Psychiatric Residential Treatment

Supersedes: FMA 1202-1 (01/01/06) Reference: 42 CFR 435.211, .222(a)(4), .712, .725 and .1009; ARM 37.82.101, .1310, .1312, and .1320 Overview: Medicaid may be available to Individuals under age 21 who are receiving inpatient treatment in an intermediate care facility (including those that serve the intellectually disabled) or psychiatric residential treatment facilities. The institution must be Medicaid-certified or a Medicaid provider of psychiatric residential treatment through an agreement with AMDD, and the individual must: 1. Meet all Medicaid nonfinancial requirements; 2. Be receiving psychiatric services in a residential treatment setting, AND is: a. Under court-ordered jurisdiction of DPHHS; or b. A ward of tribal court and under the supervision of: i. An Indian tribe; ii. BIA; or iii. The State of Montana; 3. Have countable resources that do not exceed $3,000; 4. Have countable income that is less than the cost of care at the facility. The treatment must also be medically necessary. NOTE: Children under age 19 may be eligible for other Medicaid coverage (HMK Plus) while residing in the above facilities, even if placement is not court ordered. Effective Date: July 01, 2016

ACA/FAMILY MEDICAID 900 Child Support Overview

Supersedes: FMA 900 (01/01/06) Reference: 42 CFR 433.145 - .148, .610; 42 CFR 435.916; ARM 37.82.101, .205, .206, .416; P.L. 111-3 Overview: Medicaid clients who want to avail themselves of child support services can complete a child support referral. There is no penalty when a client chooses not to cooperate. ASSIGNMENT OF RIGHTS: Assignment of rights to medical support is automatic when the client signs the ‘Application for Assistance’, the Streamlined Health Coverage application and the online application. The assignment begins when Medicaid is approved and ends when Medicaid is closed REFERRAL FORM (HCS/CS-332): Clients who want to receive child support services complete the HCS/CS-332 ‘Child Support Enforcement Referral’ with information regarding the non-custodial parent. Clients receiving coverage under any of the following programs can choose to complete a Child Support Referral: 1. ACA Parent/Caretaker Relative; 2. Qualified Pregnant Woman; and 3. Family Medically Needy. Effective Date: July 01, 2016

ACA/FAMILY MEDICAID 1000 Foster Care Overview

Supersedes: FMA 1000; FMA 1001-1; FMA 1001-2 & FMA 1002-1 (01/01/07) Reference: 42 CFR 435.145, .222(b)(1), .308(b)(1),.403(g); 45 CFR 233.90, 100, .110; ARM 37.82.101, .901; PL 104-193 Overview: IV-E and non-IV-E foster care Medicaid is provided to children in paid foster care placements. Child and Family Service Division (CFSD) IV-E unit in Helena processes and maintains all foster care cases, including Medicaid. CHILD & FAMILY SERVICES: Direct Foster Care questions to: Child and Family Services PO Box 8005 Helena MT 59604-8005 (406) 841-2400 (406) 841-2487 FAX Child&FamilyServicesDiv@mt.gov Effective Date: July 01, 2016

ACA/FAMILY MEDICAID 1001 Subsidized Adoption Overview

Supersedes: FMA 1100 & FMA 1101-1 (07/01/06) Reference: 42 CFR 435.145, .222(b)(2), .227, .308(b)(2); ARM 37.82.101, and .701 Overview: Children eligible for IV-E or non-IV-E adoption subsidies are automatically eligible for Subsidized Adoption Medicaid. NOTE: Subsidized adoption cases are not used for any program other than subsidized adoption. If the family applies for other coverage, a new case may need to be opened if one doesn’t already exist. PROCESSING: Policy Bureau in HCSD central office maintains the subsidized adoption caseload. CHILD & FAMILY SERVICES: Child and Family Services Division in Helena determines subsidized adoption Medicaid eligibility. Families moving into Montana who have questions about subsidized adoption are referred to: Child and Family Services PO Box 8005 Helena MT 59604-8005 (406) 841-2400 (406) 841-2487 FAX Child&FamilyServicesDiv@mt.gov Effective Date: July 01, 2016