Page 2

REV. MAY 3, 2018 NEBRASKA DEPARTMENT OF MEDICAID ELIGIBILITY MANUAL LETTER #43-2018 HEALTH AND HUMAN SERVICES 477-000-047

Alaskan Natives and American Indians who provide verification of their tribal affiliation are not required to pay a premium. This determination is handled by Central Office.

Example 1: Household consists of Mom (age 23) and one child, age 4. The first QRF indicates that the countable monthly income is $1,300. Mom does carry health insurance on both herself and her child. One hundred percent FPL for a two-person household is $1,293, so this family may be subject to a TMA premium. The last eligibility review was completed five months ago.

Note FPL figures are updated annually.

Factors to Consider:

The child is under age 6 so would be budgeted at 145% FPL. CHIP is not an option due to the health insurance coverage. The last eligibility renewal was less than six months ago, but because it was not the initial determination, the child is not assured of any period of continued eligibility so may be subject to a premium along with Mom, if the child fails the applicable Medicaid category.

Result: The Mom in this case must make a decision. The income exceeds the guidelines for a household size of two, so she would be subject to a SOC if we were to close the TMA and run her through “regular” Medicaid budgeting. The income is less than 145% FPL for two, so the child would remain eligible without a SOC. Mom would remain on TMA with a premium while the child would be eligible for Medicaid.

Example 2: Household consists of a married couple with two children, ages 16 and 14. Both parents work and the QRF shows their combined gross earned income to be $2,900 per month. TMA is entering Month 7. The countable income exceeds 100% FPL for a four-person household, yet it is less than 213% FPL. The children are covered by creditable health insurance.

Factors to Consider: The family’s countable income exceeds the medically needy income level (MNIL) for four (the parent’s income standard) and also exceeds 133% FPL for four (the children’s income standard). Although the countable income is less than 213% FPL, we cannot close the parents and run the children in CHIP because the children are insured.

Result: In this case, all four family members are subject to the TMA premium. TMA premium amounts are found in 477-000-012.

Example 3: Single parent mother, age 28 with one child, age 9. Household has been on TMA for six months as Mom is employed full-time. The QRF shows that Mom earns $1,400 per month and pays no child care. Mom does not have health insurance coverage on herself or her child.

Factors to consider:

Mom’s countable income falls between 100% and 185% FPL, so she would appear to be subject to a TMA premium. Mom’s income clearly exceeds the MNIL for two, so the result would be a large SOC. There is no health insurance coverage and the income is below 213% FPL, so the child would be Medicaid eligible.