Page 3

REV. MAY 3, 2018 NEBRASKA DEPARTMENT OF MEDICAID ELIGIBILITY MANUAL LETTER #43-2018 HEALTH AND HUMAN SERVICES 477-000-006

Examples of How to Construct a Medicaid/CHIP Household

STEP-BY-STEP EXAMPLE – MARY & FAMILY

Mary is a 56-year-old working grandmother who claims her daughter Samantha, age 18 and a full-time student, and her granddaughter Joy (Samantha’s daughter), age 2, as tax dependents. No one in the household is blind or disabled. No one in the household is pregnant. No one in the household has health insurance.

Relevant Information:  Mary earns $4,500/month ($54,000/year)  Samantha earns $300/month ($3,600/year)  There are no other sources of income  Tax filing threshold: Tax dependents with more than $6,300* per year of earned income must file taxes.  Nebraska’s Medicaid income standard for children ages 6 through 18 is 133% FPL  Nebraska’s Medicaid income standard for children ages 1 through 5 is 145% FPL  Nebraska’s CHIP income standard is 213% FPL  Nebraska’s Parent/Caretaker Relative income maximum is:

* Federal Poverty Levels and federal tax filing thresholds are subject to change yearly.

1. CONSTRUCT A MEDICAID/CHIP HOUSEHOLD FOR EACH APPLICANT.

 MARY expects to file taxes (A-ii) and she does not expect to be claimed as a tax dependent (A-ii-1), so her Medicaid eligibility will be determined under Nebraska Parent/Caretaker Relative standards. Mary’s household consists of the taxpayer (Mary) and all persons who the taxpayer expects to claim as a tax dependent. Mary expects to claim her daughter Samantha and her granddaughter Joy as tax dependents.

By household size/month: 1 - $569 2 - $704 3 - $841 4 - $976 5 - $1,112 6 - $1,247 7 - $1,383 Add- on for each additional family member - $133