us-nv/manual/dss/medicaid

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us-nv/manual/dss/medicaid · Axiom

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL States are required to coordinate eligibility across the different insurance affordability programs. The health reform law established new definitions of income – called Modified Adjusted Gross Income (MAGI) that is used in determining eligibility for advanced premium tax credits (APTC), Family Medical assistance and Nevada Check Up (NCU). Medical Assistance to the Aged, Blind and Disabled (MAABD) groups are exempt from the MAGI budgeting rules. Individuals applying online will be evaluated for APTC, Medicaid and NCU and the electronic application will be referred to the appropriate agency based on the application information. Individuals determined ineligible due to excess income will be referred to the exchange for an APTC eligibility determination. Medicaid and NCU eligibility determinations will be made using MAGI budgeting methodology to determine family size and household income. MAABD eligibility determinations use SSI budgeting methodology to determine family size and household income. A–110 COOPERATION All applicants and/or their authorized representative are required to furnish information and/or documentation necessary to establish initial and continuing eligibility in order to receive medical assistance. If a caregiver or household fails or refuses to cooperate with the Division of Welfare and Supportive Services (DWSS) district office, quality control, Investigations and Recovery or other designated DWSS officials in providing information which would impact pending or ongoing eligibility/benefits, the case will be denied or terminated. In a noncooperation situation resulting in termination, allow applicable adverse action and provide legal notification. A-115 PRIOR MEDICAL (435.915) Prior medical assistance is available for up to three months prior to the application month. If the individual is requesting the coverage for prior months they must meet all eligibility requirements for that month. A-115.1 Applying for Prior Medical Coverage A request for prior medical assistance is considered a separate application because it is for months predating the initial application. Prior medical requests may be added during the pending period and during the 12-month period after approval, provided the case remains open. Approval, denial or pending of a prior medical request must always be addressed in a notice of decision to the household. Division of Welfare and Supportive Services A-105 Medical Assistance Manual MEDICAL ASSISTANCE OVERVIEW 24 Sept MTL 07/24 MEDICAL ASSISTANCE OVERVIEW – APPLYING FOR PRIOR MEDICAL COVERAGE

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Prior medical assistance may be provided even if:  The household is not currently eligible for Medicaid; or  The person who received the medical care or services is deceased. Do not delay an ongoing eligibility decision while obtaining information to determine prior medical eligibility. In addition, if the household is only requesting prior coverage, provide an ongoing eligibility decision at the time of the application. If the individual is aged, blind or disabled and an SSI recipient determine if they would have been eligible for SSI had the Social Security Administration made a determination. This category of eligibility is used only after all other eligibility categories have been considered. Do not make an independent SSI determination if there is a pending SSI application covering the month(s) Medicaid is requested. Use the Social Security Administration's SSI disability decision (the disability onset date) for any month of requested prior medical assistance. All other factors of eligibility, e.g., residency, citizenship, income, resources, etc., must be evaluated by the case manager. Prior medical determinations must be made within 45 days from the application date for all categories except for disabled applicants which are given 90 days for processing. Exceptions: Nevada Check Up (NCU) applicants are eligible beginning the next administrative month after approval. Because these decisions are prospective, they are not eligible for prior medical coverage. Qualified Medicare Beneficiary (QMB) applicants are eligible beginning the month immediately following the month the decision is made. Because these decisions are prospective, they are not eligible for prior medical coverage. A-115.2 Verification of Prior Medical Assistance The following are required for approval of prior medical assistance:  Prior medical assistance must be requested; AND,  Actual income (i.e.: paper or electronic documents, or telephone call to employer) for the prior medical month(s) being requested must be used; AND  Citizenship documentation must be received prior to approval of prior medical months unless the eligibility evaluation is for the emergency medical services group. A-115.1 Division of Welfare and Supportive Services MEDICAL ASSISTANCE OVERVIEW Medical Assistance Manual APPLYING FOR PRIOR MEDICAL COVERAGE – 24 Sept MTL 07/24 VERIFICATION OF PRIOR MEDICAL ASSISTANCE

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL A-120 AUTHORIZED REPRESENTATIVE (A/R) Customers may designate anyone they choose to act on their behalf by completing the A/R section on the application, using the Authorized Representative Form 2525, OR they may complete and sign Form 2451 “Authorization for Release of Information” allowing the Division to release case information to individuals or agencies/organizations. A Court Order of Guardianship or a valid Power of Attorney is acceptable as a designation of authorized representation. Power of Attorney status may vary with each customer. Obtain a completed Form 2525 for the individual case member designating the Power of Attorney as an authorized representative. The authority to act as an A/R is valid until such time as the customer notifies the agency that the A/R is no longer authorized to act on his/her behalf, or the legal authority upon which their status was based has changed. The A/R may also notify the Division that they no longer wish to be listed as an authorized representative for the customer. The A/R must be:  An adult, 18 years of age or older.  Designated in writing with a valid signature by the customer or (if incapacitated) someone acting responsibly for the customer. This designation must include the name and address of the person chosen as an A/R, the signature of the household member making the choice, and the date.  Willing to take responsibility for fulfilling all responsibilities encompassed within the scope of the authorized representation, to the same extent as the individual he/she represents.  Able to maintain, or be legally bound to maintain, the confidentiality of any information regarding the applicant or beneficiary provided by the agency. NOTE: Valid signatures from the customer or responsible person may be handwritten and submitted in person, via mail, or through commonly available electronic means (i.e. facsimile, email, internet website, etc…) accepted by DWSS. Electronic signatures made as part of a DWSS Access Nevada application, and telephonically recorded signatures are also acceptable. If the designation is made by a household member who is unable to or cannot sign, their mark must be witnessed by someone other than the A/R. With each subsequent reapplication, a new request, Form 2525 and/or Release of Information is required. It is not necessary at redetermination, unless the customer indicates a change of A/R. Division of Welfare and Supportive A-120 Medical Assistance Manual MEDICAL ASSISTANCE OVERVIEW 24 Sept MTL 07/24 AUTHORIZED REPRESENTATIVE (A/R)

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL When a public guardian is appointed to manage the affairs of an individual by Court Order, the Order of Guardianship is acceptable as a designation of authorized representation. Any deputy public guardian acting on behalf of the public guardian may contact the Division and request or give information to any DWSS case worker or customer service representative without being required to complete Form 2525 (Designation of Authorized Representative). For Medical Assistance cases, all authorized representatives are considered a primary A/R. They receive all requests for information along with any attachments plus all notices. They hold the same responsibility as the customer in securing information for determining eligibility, reporting responsibilities and they are the only one authorized to sign on behalf of the customer. Primary representatives have the same access to case information as a customer. Legal guardians are always considered primary representatives. There will be only one primary representative. NOTE: If an applicant lists an individual on the application as an A/R, they will automatically be entered as a primary representative. Having more than one authorized representative (A/R) on a Medical Assistance case is allowable under certain circumstances. Customers who have the need for more than one A/R must select a single A/R as the primary A/R. Any additional A/R(s) must be entered as a Non-Primary authorized representative(s). Those who are a Non-Primary A/R’(s) receive the same requests for information and notices as the customer but are not responsible for securing or reporting information; however, if they choose to, they may secure and report the requested information to the Division. A Non-primary A/R has the same access to case information as a customer, but cannot sign on behalf of the customer. NOTE: If an applicant lists an organization or facility as an A/R on the application, they will automatically be entered as the primary representative unless another primary already exists. An individual representative of the organization or facility must be designated on the application. If a designated representative from the organization or facility is not listed on the application then obtain a completed form 2525. Exception: Department of Health and Human Services (DHHS) divisions administering home and community-based waiver programs are automatically entered as secondary authorized representatives to ensure they receive all notifications and are able to assist customers in completing necessary paperwork. Form 2525 is not required for DHHS divisions. This exception includes but not limited to the following DHHS division/departments:  Aging and Disability Services Division (ADSD)  Department of Health Care and Finance Policy (DHCFP)  Department of Public Behavioral Health (DPBH)  Department of Child and Family Services (DCFS) When applicants are unable to designate an A/R AND there are no family members or the existing family members do not wish to assist the applicant, the hospital, nursing home or county agency social service staff may designate themselves as an A/R. The hospital, nursing home or county agency must make good faith efforts to contact family members of the applicant for information to help determine eligibility. The hospital, nursing home or county agency must provide the names and addresses of family members they contacted or tried to contact. A-120 Division of Welfare and Supportive Services MEDICAL ASSISTANCE OVERVIEW Medical Assistance Manual AUTHORIZED REPRESENTATIVE (A/R) 24 Sept MTL 07/24

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL The case manager will send Form 2534 to the relatives advising them of the application, the hospital, nursing home or county agency representative and request any eligibility information to assist in processing the case. NOTE: Division employees may serve as an A/R for a Medicaid case. A-120.1 Spousal Authorization A spouse whose income and resources are countable in determining a customer’s financial eligibility, and is not applying for or receiving assistance, must sign an Interface Consent, Form 2179-EE, authorizing DWSS to interface with other federal and state agencies for information and verifications. A-125 MEDICAID CARD ISSUANCE AND RESTRICTED STATUS All newly approved Medicaid recipients are issued a permanent plastic Medicaid card. When a household reports non-receipt of their Medicaid card, verify the customer mailing address in AMPS and issue a new Medicaid card for the reported household member(s). A new Medicaid card is automatically issued if the customer’s name, date of birth or gender are changed and/or updated. A new card is NOT automatically issued when the address is changed. Households where the use of the Medicaid card is questionable may have their card stamped with a restrictive endorsement. A-130 MANAGED CARE ENROLLMENT Through the Division of Health Care Financing and Policy (DHCFP), Nevada Medicaid and Nevada Check Up operates both a fee-for-service (FFS) and a managed care reimbursement and service delivery system to provide covered medically necessary services to its eligible populations. Managed care is a method of payment and a care delivery model that allows providers to bill the managed care organization. FFS is a payment model that allows the medical provider or facility to bill the DHCFP’s fiscal agent directly. Managed care enrollment is only available for MAGI based medical groups for recipients in the urban areas of Washoe County and Clark County. Certain medical groups are voluntary enrollment in Managed Care Organization (MCO), such as Native Americans, children with special health care needs enrolled in a Title V program, and severely emotionally disturbed (SED) children Aged, blind and disabled populations, the Medicare eligible population and those receiving SSI benefits are not eligible for managed care. Division of Welfare and Supportive Services A-120 Medical Assistance Manual MEDICAL ASSISTANCE OVERVIEW 24 Sept MTL 07/24 AUTHORIZED REPRESENTATIVE (A/R) – MANAGED CARE ENROLLMENT

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Initial enrollment in managed care is processed based on the customer’s choice at application (this does not guarantee enrollment into their plan of choice). Individuals applying online will be given the choice online and the managed care choice should be entered into the “Other Application Information” on the Case Info Bap in AMPS or APPL screen in NOMADS when processing paper, telephonic, and virtual applications. Households must choose one managed care plan for all eligible household members. If a household fails to choose a managed care plan the case manager must select the “No MCO Selected” option from the MCO drop down in the MCO field and DHCFP will randomly assign them to one of the MCO’s. Renewals submitted less than 60 days after the loss of coverage will keep the same MCO preference or the random assignment as the previous application. Renewals submitted more than 60 days after the loss of coverage must include a new MCO preference selection. All recipients will be allowed the opportunity once a year, during Medicaid Managed Care open enrollment, to change MCO’s. Open Enrollment is October 1st through October 31st . When a request is made to change MCO, the recipient must write to Nevada Medicaid or email (preferred method) to NevadaManagedCareOpenEnrollment@gainwelltechnologies.com to change their MCO. The request must include:  their billing number;  what MCO they want to change to; and  signature and date of the request. Requests are mailed to: Nevada Medicaid PO Box 30042 Reno, NV 89520 Recipients will have 90 days from the effective date to make one (1) final MCO change. Once this final change has been processed, the household will remain in the selected MCO until the next open enrollment period. Please direct recipient to: https://dhcfp.nv.gov/members/blu/mco_open_enrollment/ NOTE: Recipients may submit an MCO change when they are not within their 90-day window, due to good cause. For good cause eligibility criteria, please direct recipient to: https://dhcfp.nv.gov/Members/BLU/MCO_Good_Cause_Disenrollment/ A-130 Division of Welfare and Supportive Services MEDICAL ASSISTANCE OVERVIEW Medical Assistance Manual MANAGED CARE ENROLLMENT 24 Sept MTL 07/24

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL A-135 SERVICES PROVIDED BY NEVADA MEDICAID Refer to the Division of Health Care Financing and Policy (DHCFP) website for information on services provided by Nevada Medicaid. DHCFP (nv.gov) NOTE: Refer recipients to local district Medicaid office staff if more detailed Medicaid service information is needed. A-140 MEDICAID ESTATE RECOVERY PROGRAM A-140.1 Legal Authority Authority for operating the Medicaid Estate Recovery (MER) Program is published in Section 1917 of the Social Security Act and Nevada Revised Statute 422.29302. A-140.2 Program Overview Federal and state law mandates state operation of a MER program whereby correctly paid Medicaid benefits are recoverable from the estate of a deceased Medicaid recipient. Recovery is accomplished only after the death of a recipient and at a time when there is no surviving spouse, children under the age of 21 or adult disabled children. Regulations of the MER program affect individuals who received Medicaid benefits on or after October 1, 1993. Collections will be pursued against the estate of the recipient up to the amount of Medicaid benefits correctly paid or up to the determined value of the recipient’s estate, whichever is less. The MER program is administered by DHCFP. A-140.3 Affected Individuals MER actions are imposed against Medicaid recipients who are: ● 55 years of age or older when they receive Medicaid assistance; or ● an inpatient in a nursing facility, intermediate care facility for individuals with intellectual disabilities (ICF/IID), or other medical institution, where they are required to pay patient liability for medical care. A-140.4 Notification to Affected Individuals Full disclosure of MER program operation is made during the application process. Statements regarding MER are included on the eligibility application and applicants (or their representatives) are provided Form NMO-6160-E, "Medicaid Estate Recovery Notification of Program Operation." Staff MUST attempt to review information provided on Form NMO-6160-E with the customer. However, if staff is unable to review information provided on Form NMO-6160-E with the applicant (or their representative) will NOT preclude DWSS’s pursuit of correctly paid benefits. Division of Welfare and Supportive Services A-135 Medical Assistance Manual MEDICAL ASSISTANCE OVERVIEW 24 Sept MTL 07/24 SERVICES PROVIDED BY NEVADA MEDICAID – NOTIFICATION TO AFFECTED INDIVIDUALS

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Form NMO-6160-E, Medicaid Estate Recovery Notification of Program Operation, must be given to all applicants for Medicaid assistance at the time of application for services and redetermination. Be sure the applicant receives the form in English or Spanish, whichever is appropriate. One copy of the form will be given to the applicant and one copy will be filed in DIS. NOTE: Medicare Savings Program (MSP) applicants were excluded from MER effective January 1, 2010. A-145 REFERRAL OF CASES TO MER UNIT When a MER-applicable recipient is no longer Medicaid eligible due to death, the case manager MUST forward the case file to the Division of Health Care Financing and Policy (DHCFP) by taking the following actions: 1. If the case is virtual-only (AMPS), immediately notify MER via email at MER@dhcfp.nv.govThe email must contain the recipient’s name, Medicaid billing number, and SSN or UPI. 2. If there is a physical case file, the case manager MUST forward the file to DHCFP via interoffice mail, Attention: MER, within three (3) working days after the closure of the Medicaid CASE. NOTE: DHCFP also has access to view records in DIS. Therefore, only those records currently maintained outside of DIS by specialized units will need to be forwarded to the MER unit. If the return of a paper case file is necessary, eligibility staff must request in writing the return of the case file. The written request must include the name and SSN of the recipient, the date of the request, the eligibility staff member requesting the file, and the district office where the file should be sent. The request may be faxed or forwarded to DHCFP, Attention; MER utilizing interoffice mail. MER staff will provide the case file within three (3) working days. Case files for Medicaid applicants who have been denied Medicaid eligibility and who do not have a history of prior approval should not be forwarded to the MER unit at DHCFP. A-145.1 INITIATION OF MER ACTIVITIES Upon receipt of the closed Medicaid eligibility casefile, DHCFP MER personnel will establish a MER recovery case. MER staff will validate the recipient's reported resource information. A-140.4 Division of Welfare and Supportive Services MEDICAL ASSISTANCE OVERVIEW Medical Assistance Manual NOTIFICATION TO AFFECTED INDIVIDUALS – 24 Sept MTL 07/24 NOTIFICATION OF MER ACTIVITIES

(a-200)Nevada Medical Assistance Manual (MAM): A-200 Definitions and Acronyms#

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DEFINITIONS AND ACRONYMS A-200 DEFINITIONS AND USE OF TERMS Absent Parent - a child's parent who is not residing in the home with the child, also known as a non custodial parent. Actual Income Budgeting - actual income amounts are used for calculating benefits when a full month has passed and an eligibility determination is made for prior medical months. Adequate Notice - a written notice which includes a statement of what action(s) will be taken, the reason for the intended action(s), and the specific manual reference(s) that supports the change, the right to a fair hearing and any change in federal or state law that requires the action(s). Advance Notice - adequate written notice which must be mailed at least 13 days before taking an action that would adversely affect eligibility of an ongoing or open case. Advance Premium - Tax Credit (APTC) - payment of the tax credits which are provided on an advance basis to an eligible individual enrolled in a Qualified Health Plan (QHP) through an exchange in accordance with the Affordable Care Act. Adverse Action - any action resulting in reduction or termination of benefits. Denied cases do not require adverse action. Affordable Care Act (ACA) - the Patient Protection and Affordable Care Act of 2010 - reforms that improve access to affordable health coverage for everyone and protect consumers from abusive insurance company practices. The law allows all Americans to make health insurance choices that work for them while guaranteeing access to care for our most vulnerable and provides new ways to bring down costs and improve quality of care. Affordable Insurance Exchanges - this term refers to any state, regional, subsidiary, or federal exchange or marketplace. See Exchange for additional information. Annual Open Enrollment Period - the period each year during which a qualified individual may enroll or change coverage in a Qualified Health Plan (QHP) through the exchange. Annualize - the process of averaging income over a 12-month period. Annuity - a fixed sum of money payable yearly or at other regular intervals. Appeal - an applicant/customer request for a fair hearing concerning an action to reduce, deny or terminate eligibility. Applicant - an individual who is seeking a medical eligibility determination for himself or herself through an application submission or a transfer from another agency or insurance affordability program. Division of Welfare and Supportive Services DEFINITIONS AND ACRONYMS Medical Assistance Manual DEFINITIONS AND USE OF TERMS MTL 10/24 Nov 24 A-200

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Application - the formal request in writing, by phone or electronically, as determined by regulation to apply for medical assistance. Application Date - the date a properly signed application is received. Assets - all items owned by an individual that have a monetary value. Assignment - the legal transfer of an individual's rights to benefits to the Nevada Division of Welfare and Supportive Services. This includes child/spousal and third-party liability (TPL). Assistance Unit - a group of individuals whose income, resources and needs are considered as a unit for the purpose of determining eligibility. Tax-filer - Rules associated to the household that determine the assistance unit members based on tax filing status of the members. Non-Filer - Rules associated to the household that determine the assistance unit members based on relationship. Authorized Representative (AR) – a person or organization acting responsibly for a customer in the various aspects of the application and redetermination process. Bendex (Beneficiary Data Exchange) - a computer match from Social Security Administration (SSA) giving Social Security and Medicare information on DWSS customers. Beneficiary - an individual who has been determined eligible and is currently receiving Medicaid. Benefit Month - any month for which eligibility has been determined. Budget (Income) Month - the calendar month from which income and household composition are used to determine eligibility. Budgeting - a procedure used to determine eligibility based on a calculation of income and circumstances which exists, or are expected to exist, in the month benefits are authorized. Capital Gain - financial profit from the sale or transfer of capital assets. Caretaker Relative - relative of a dependent child by blood, adoption, or marriage with whom the child is living, who assumes primary responsibility for the child's care and who is one of the following— 1. The child's father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece. 2. The spouse of such parent or relative, even after the marriage is terminated by death or divorce. 3. Another relative of the child based on blood (including those of half-blood), adoption, or marriage; the domestic partner of the parent or other caretaker relative. Division of Welfare and Supportive Services Medical Assistance Manual DEFINITIONS AND ACRONYMS MTL 10/24 Nov 24 DEFINITIONS AND USE OF TERMS A-200

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Cash Surrender Value (CSV) - the cash surrender value of an insurance policy or similar financial instrument. Child Support - money that is: 1. Ordered by a court of competent jurisdiction on behalf of a minor child or 2. Paid by the non-custodial parent, including voluntary payments. Child Support Enforcement Program (CSEP) - CSEP in Nevada is responsible for the administration and oversight of child support enforcement activity. Collateral Contact - person with no vested interest who the case manager can contact to verify customer information. Common Law Marriage - relationship in which the parties are free to marry, are living together, and hold out to the public that they are husband and wife. Nevada does not recognize common law marriage. Tribal marriages are legally recognized marriages. Confidential Address Program (CAP) - Program administered through the Division of Child and Family Services that provides protection to victims of domestic violence who are referred by a domestic violence advocacy group. Continued Benefits - continuing or restoring benefits to the level authorized immediately before the notice of adverse action pending the outcome of a hearing. Conversion - A process completed to change a customer’s eligibility from one category to another, e.g., SSI to State Institutional case. Cost of Living Adjustment (COLA) - yearly increase in benefits received from programs such as Social Security, VA, and pension benefits. Cost Sharing - any expenditure required by or on behalf of an enrollee with respect to essential health benefits; such term includes deductibles, coinsurance, copayments, or similar charges but excludes premiums, balance billing amounts for non-network providers, and spending for non-covered services. Custodial Parent (CST) - parent who has physical and/or legal custody of child(ren). Dependent Child/Children - a child or dependent child up to the age of 19. A dependent child is used in determining relationship and eligibility for the parent/caretaker group. Deputy Attorney General (DAG) - the attorney representing the Division in legal matters. Derivative Citizenship - United States citizenship that is claimed by a person born outside of the U.S. to one or both U.S. citizen parents. Division of Welfare and Supportive Services DEFINITIONS AND ACRONYMS Medical Assistance Manual DEFINITIONS AND USE OF TERMS MTL 10/24 Nov 24 A-200

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Diversion Payments - financial assistance payments designed to meet an immediate emergency need and which prevents the family from requiring ongoing cash assistance in accordance with Nevada’s or another state’s policy provisions. In Nevada, this is the Self-Sufficiency Grant (SSG) Program. Division of Health Care Financing and Policy (DHCFP) - Agency within the Department of Health and Human Services that is responsible for the administration of the Medicaid program. Division of Welfare and Supportive Services (DWSS) - Agency within the Department of Health and Human Services that is responsible for determining eligibility for public assistance programs including Medicaid. Domestic Partners - domestic partnership is not a marriage but rather a new type of civil contract that is recognized in Nevada. Domestic Partners are considered "spouses" and have the same rights, protections and benefits as are granted to and imposed upon spouses. The Nevada office of the Secretary of State shall issue a certificate of domestic partnership. Any reference to a certificate of marriage shall be deemed a reference to the registration of domestic partnership. Earned Income - earned income encompasses income in cash or in-kind earned by an individual through the receipt of wages, salary, commissions, or profit from activities in which s/he is engaged as a self-employed individual or as an employee. Earned Income Tax Credits (EITC) - payments from IRS to persons with tax dependents and gross monthly earnings at or below levels established by the IRS. Early Periodic Screening, Diagnosis, and Treatment (EPSDT) - services offered through Medicaid Support Services for Medicaid eligible children. This program is known as the Healthy Kids Program. Electronic Account - an electronic file that includes all information collected and generated by the State regarding each individual's Medicaid eligibility and enrollment, including all documentation. Eligibility Determination - an approval or denial of eligibility including redetermination or termination of eligibility. Emancipated Minor – a person who is:  under age 18 who has been married and the marriage has not been annulled; or  a child under age 18 that has been emancipated by a court decree. Equity - the fair market value of an item minus all money owed on it and the cost associated with its sale or transfer. Exchange - a governmental agency or non-profit entity that meets applicable standards and makes Qualified Health Plans (QHPs) available to qualified individuals and qualified employers. Unless otherwise identified, this term refers to state exchanges, regional exchanges, subsidiary exchanges, and a federally facilitated exchange. Fair Hearing - a meeting conducted by a state hearing officer with any applicant or customer who disagrees with and wishes to appeal some action taken on their case. Fair Market Value (FMV) - amount of money an item would bring if sold in the current local market. Division of Welfare and Supportive Services Medical Assistance Manual DEFINITIONS AND ACRONYMS MTL 10/24 Nov 24 DEFINITIONS AND USE OF TERMS A-200

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Family Preservation Program (FPP) - administered by the Aging and Disability Services Division (ADSD); provides financial assistance to family members caring for their relatives with profound or severe developmental disabilities so that the family member can remain at home avoiding costly out of home placements. Family Size - the number of persons counted as members of an individual's household. In the “case of determining the family size of a pregnant woman, the pregnant woman is counted as herself plus the number of infants she is expected to deliver. FAMIS (Family Assistance Management Information System) - specific federal design requirements which must be included in all new automated systems. Federal Benefit Rate (FBR) - the maximum dollar amount paid to an aged, blind, or disabled person who receives Social Security Disability benefits under SSI. Federal Poverty Level (FPL) - the minimum amount of gross income that a family needs for food, clothing, transportation, shelter and other necessities. In the United States, this level is determined by the Department of Health and Human Services. The number is adjusted for inflation and reported annually in the form of poverty guidelines. Fluctuating Income - income in which the amount varies because of an increase or decrease in hours worked, rate of pay, or inclusion of a bonus. Good Cause - term used to indicate that a customer had an acceptable reason for not complying with a program requirement. Guardianship – person who has the legal authority (and the corresponding duty) to care for the personal and property interests of another person, called a ward. Home Based Waiver (HBW) - a Medicaid program which provides non-medical services in the customer’s home to help them maintain independence, as an alternative to nursing home placement. Household Income - the sum of the MAGI-based income of all individuals in the assistance unit. Housing and Urban Development (HUD) - Federal housing agency providing funds to assist needy families/elderly/disabled individuals with housing/shelter costs/mortgages (e.g., the family pays a percentage of the rent/mortgage based on income). Ineligible Non-Citizen - a non-citizen living in the United States without proper approval from USCIS (United States Citizenship & Immigration Services). Immigrant - a non-citizen who is abandoning their residence in a foreign country to live in the United States as a permanent or temporary legal resident. Inaccessible Resources - resources not legally available to the customer. Division of Welfare and Supportive Services DEFINITIONS AND ACRONYMS Medical Assistance Manual DEFINITIONS AND USE OF TERMS MTL 10/24 Nov 24 A-200

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Incapacitated (INCAP) - individuals temporarily unable, due to illness/injury, to make decisions, be in attendance at interview, or sign documents. Also applies to an individual determined to be incapacitated/disabled by a certified physician(s), Social Security Administration, Veteran’s Administration, Vocational Rehabilitation, or any other agency utilizing Social Security criteria. Incompetent - an individual who has been declared permanently or on a long-term basis to be incapable of making legally binding decisions due to physical/mental illness or injury. This term also applies to minor children unable to make legally binding decisions until they are an adult. Statements from certified physicians, social workers, vocational rehabilitation counselors, Social Security Administration, Veterans Administration, court orders, and observation are means of verifying incompetence. Individual Case Identifier (ICI) Number - the additional state unique identification number assigned to each case. Individual Development Account (IDA) - Federal funds that match the amount of earnings of low- income working individuals and families which are intended to improve the economic independence and stability of individuals and families and to promote and support the transition to economic self- sufficiency. Informational Memorandum (IM) - Written document from an issuing chief providing guidance and/or clarification to field staff or other identified recipients regarding current policies and/or practices. In-kind Contribution - any gain or benefit to a person which is not in the form of money payable directly to the customer, such as clothing, public housing, or food. Inquiry - an application form which is not signed by the applicant or their authorized representative and/or legal guardian. This can also refer to a call from a customer or their representative regarding their case and/or benefits. Institution for Mental Disease (IMD) - a hospital, nursing facility or other institution of more than 16 beds which is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services. Individuals are severely psychotic, emotionally ill, suicidal and a danger to themselves, others or property. In Nevada, IMDs are commonly referred to as "psychiatric hospitals." Institution of Higher Education - usually requires a high school diploma or equivalency certificate such as GED to enter. (E.g., business, technical, trade, beauty, or vocational school, or enrolled in regular curriculum at a college or university that offers degree programs regardless of whether a high school diploma is required. This includes correspondence and off-campus home-study enrollment.) Insurance Affordability Program - a program that is one of the following: 1. A State Medicaid program. 2. A State children's health insurance program (Nevada Check-Up). 3. A State basic health program established under the Affordable Care Act. Division of Welfare and Supportive Services Medical Assistance Manual DEFINITIONS AND ACRONYMS MTL 10/24 Nov 24 DEFINITIONS AND USE OF TERMS A-200

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4. A program that makes coverage in a qualified health plan through the exchange with advance payments of the premium tax credit (APTC). 5. A program that makes available coverage in a qualified health plan through the exchange with cost-sharing reductions established under the Affordable Care Act. Intake - the eligibility determination process for an application for medical assistance. Intentional Program Violation (IPV) - Disqualification due to a purposeful or willful misstatement of information by a customer in order to receive more benefits to which they are not entitled. Investigations and Recovery (I&R) - Unit responsible for investigations, recovery of overpayments and prosecution. JTPA - (Changed to Workforce Investment Act of 1998) Job Training Partnership Act is a federal program offering job training. Katie Beckett - a Medicaid eligible category for at-home medical care of disabled children who are ineligible for SSI due to income and/or resources of the parents. Legal Parents - mother, by having given birth to the child, or by proof of adoption; father, by proof of adoption, legal document, court adjudication, or his declaration of paternity. Lump Sum Payment - a financial settlement which often involves funds accumulated over an extended period of time. Managed Care Health Plans - primary managed health care given through specified medical providers. Recipients must enroll in the health plans or receive regular Medicaid coverage. Managed Health Care Plans - expanded health care services/choices for Medicaid recipients. Managing Conservator - a person designated by a court to have daily legal responsibility for a child. Medicaid – Federal and State-paid insurance for low-income eligible individuals, families, pregnant women and children. Medicaid Card - an account card provided to approved Medicaid beneficiaries to use for allowable and necessary medical services. Medicaid Enrolled Health Plan (Primary Care Network/PCN) - the Medicaid Enrolled Health Plan is an alternative to the regular Medicaid program. When a recipient enrolls, they may only use doctors at the health plan facility. The health plan does not limit necessary doctor visits and prescriptions. Medical Review Team (MRT) - Medicaid staff involved in making a disability determination. Division of Welfare and Supportive Services DEFINITIONS AND ACRONYMS Medical Assistance Manual DEFINITIONS AND USE OF TERMS MTL 10/24 Nov 24 A-200

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Medical Support - the non-custodial parent may be ordered to obtain health insurance for their children who receive Medicaid when it is available at a reasonable cost. Available at a reasonable cost is usually defined as being available through the employer. Medicare - medical "insurance" program administered by the Social Security Administration. Medicare Part A - Hospital coverage. Individuals who paid Medicare taxes while working may receive this coverage for free. Medicare Part B - Medical services coverage. Individuals pay a premium each month for Medicare Part B coverage. Medicare Part D – Prescription drug coverage. Individuals pay a premium each month for this coverage. Minimum Essential Coverage - The type of coverage an individual needs to have to meet the individual responsibility requirement under the Affordable Care Act. This includes individual market policies, job- based coverage, Medicare, Medicaid, Nevada Check-Up, TRICARE and certain other coverage. Minor Child - a person under 18 years old. Note: for individuals applying for themselves, an application can be signed and submitted by someone age 18 or older. However, if the individual is under the age of 19, they will be considered a child and placed in the children’s (CH) coverage group. Minor Parent - an individual who is under the age of 19, has never been married, and is pregnant or the natural parent of a dependent child. Modified Adjusted Gross Income (MAGI) - a methodology for how income is counted and how household composition and family size are determined. MAGI used for public assistance programs is not the same as MAGI used on the IRS tax form. A review of allowable deductions between the IRS and public assistance programs will make the two dollar amounts different. Non-Applicant - an individual who is not seeking an eligibility determination for themselves and is included in an applicant's or beneficiary's household to determine eligibility for such applicant or beneficiary. Non-Custodial Parent (NCP) - parent absent from the home or the parent without physical custody. Notice of Decision (NOD) - notice sent to advise the household of a case decision. Patient Liability (P/L) - a recipient's share of medical costs while residing in a medical facility or receiving at-home care. Pending Case - a case in which an application has been registered and an eligibility determination has not yet been made. Personal Needs Allowance (PNA) - an amount of income institutionalized Medicaid recipients are allowed to keep to meet their own needs. Pickle - a Medicaid coverage group-Public Law 94-566, Pickle Amendment. Division of Welfare and Supportive Services Medical Assistance Manual DEFINITIONS AND ACRONYMS MTL 10/24 Nov 24 DEFINITIONS AND USE OF TERMS A-200

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Policy Transmittal – a memo issued by DWSS Administration containing new or revised policy information. The policy changes are effective with the issuance of the PT until the next manual update can be made. Post-Medical (PM) - Medicaid coverage that is extended for four months after ineligibility for Medicaid is caused by receipt of spousal support. Postpartum Period - begins the month after the pregnancy ends, extends 12-months, then ends on the last day of the month in which the 12-month period ends. Power of Attorney - a written statement allowing one person to act for another person. A power of attorney may be authorized generally for the management of a special business or enterprise or more often specifically for the accomplishment of a particular transaction. There is no court involvement or supervision in the appointment. The statement does not have to be notarized. Standard or Non-Durable Power of Attorney - automatically becomes null and void when the appointing individual becomes incompetent. Durable Power of Attorney - continues in effect even when the appointing individual becomes incompetent. The power of attorney document should clearly specify if it is a durable power of attorney. Prepaid Burial Insurance - insurance that pays for a specific funeral arrangement. Also known as preneed plan or prepaid funeral agreement. Primary Care Network (PCN) - Medicaid enrolled health plan provider. Prior Medical - medical assistance available for 3 months prior to the current Medicaid application. Processing Time Limits - number of days the case manager has to complete a particular action. Prudent Person Principle - reasonable decision made by staff based on the best information available and common sense in a particular situation. Public Administrator (PA) - a county official named guardian to handle an incompetent person's affairs. Public Laws (P.L.) - Laws enacted by specific congressional acts. Qualified Health Plan (QHP) - a health plan that has in effect a certification that meets the standards described, issued or recognized by the exchange. Qualified Non-Citizen Sponsor - someone who signed or signs a legal affidavit or statement agreeing to support a non-citizen as a condition of their entry into the United States. This definition includes the sponsor's spouse who lives with them even if they were not married when the legal affidavit was signed. Division of Welfare and Supportive Services DEFINITIONS AND ACRONYMS Medical Assistance Manual DEFINITIONS AND USE OF TERMS MTL 10/24 Nov 24 A-200

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Quality Control (QC) (also known as PRE - Program Review and Evaluation) - DWSS staff who conduct and complete federally-mandated reviews and report their findings to policy-setting officials and the federal government. This unit also participates in training activities and corrective action to ensure program integrity is maintained for the programs administered by the Nevada State Division of Welfare and Supportive Services. Questionable Information - information that could be considered contradictory or incomplete. Railroad Retirement - the Railroad Retirement Board (RRB) is an agency of the United States government administering a social insurance program providing retirement benefits to railroad workers. The RRB serves U.S. railroad workers and their families, and administers retirement, survivor, unemployment, and sickness benefits. Railroad workers do not pay money into Social Security, nor do they receive Social Security benefits. In connection with the retirement program, the RRB has administrative responsibilities for railroad workers’ Medicare coverage. Real Property - land and any improvements on it. Redetermination (RD) - a review or redetermination of Medicaid eligibility which is required annually. Reinstatement - term used regarding the process of reinstating cases that were denied/terminated. Residential Treatment Centers (RTC) - specialize in treating children with conduct, personality and emotional disorders, depression, hyperactivity, academic failure, and/or mild learning disabilities. In some situations, Medicaid can help pay for detox, addiction medications and inpatient treatment centers. Resources - assets, both real and personal, which an individual owns and can, apply, either directly or by sale, to meet basic needs of food, clothing, shelter and medical costs. Retirement, Survivor, Disability Insurance (Title II) (RSDI) - benefits administered by the Social Security Administration based on funds paid into the Social Security system. Benefits administered under Title II are not based on need. Review - an optional case evaluative review by the case manager, supervisor, manager or investigations, based on reported/unreported changes, other customer circumstances, a future action date for updating purposes, etc. Rights and Responsibilities - Instructions to the customer about their rights and responsibilities and associated penalties. These instructions are located on the application form/addendum. Royalty - a payment to an individual for permitting another to use or market his property (such as mineral rights, patents, or copyrights). Seamless Case - a case consisting of more than one program. Self-employment Income - earned or unearned income available from one's own business, trade, or profession rather than from an employer. Division of Welfare and Supportive Services Medical Assistance Manual DEFINITIONS AND ACRONYMS MTL 10/24 Nov 24 DEFINITIONS AND USE OF TERMS A-200

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Sibling - each of two or more children or offspring having one of both parents in common, through blood relationship or adoption. Special Enrollment Period - a period during which a qualified individual or enrollee who experiences certain qualifying events may enroll in, or change enrollment in, a Qualified Health Plan (QHP) through the exchange outside of the initial and annual open enrollment periods. Spousal Support - alimony or maintenance support for a spouse or former spouse. State Data Exchange (SDX) - SSI information received from Social Security. State Online Query (SOLQ) - a real-time online access to SSA's Social Security Number (SSN) verification service and retrieval of Title II and/or Title XVI data. SOLQ enables Nevada to rapidly obtain information needed to qualify individuals for programs. State Supplementary Payment (SSP) - funds paid in addition to the federal SSI payment. SSP amounts differ from state to state. State Wage Information Collection Agency (SWICA) - unemployment compensation and/or quarterly wage reporting; this data has been determined to be effective and timely in providing employment related income and eligibility data. Supplemental Security Income (SSI) - a needs-based benefit administered by the Social Security Administration providing monthly income to certain aged, blind, and disabled individuals. Tax Dependent - has the same meaning as the term “dependent”, an individual for whom another individual claims a deduction for a personal exemption under section 151 of the Internal Revenue Code for a taxable year. Term Life Insurance - life insurance with no cash or loan value. Terminated - terminology used for stopping benefits. Termination Month - the last month in which DWSS issued a Medicaid benefit. Third-Party - person or organization outside of the household. Third-Party Liability (TPL) - a source of payment for medical expenses other than the recipient or DWSS. Transitional Medicaid (TM) - Medicaid insurance coverage extended for a maximum of 12 months after termination of certain Medicaid cases because of new or increased earnings. Tribal Marriage - marriages conducted under the provisions of the laws established by each Tribe. These marriages are legally recognized in Nevada. Trust - property held by one person for the benefit of another. All trusts are sent to the Chief of Eligibility and Payments for evaluation. Division of Welfare and Supportive Services DEFINITIONS AND ACRONYMS Medical Assistance Manual DEFINITIONS AND USE OF TERMS MTL 10/24 Nov 24 A-200

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Unearned Income - income received without performing work-related activities, including benefits from other programs. Universal Life - life insurance which may or may not have a cash surrender value. Unusual Medical Expense (UME) - The VA considers unusual medical expenses when determining some needs-based pension and compensation payments. Unusual medical expenses may include expenses of the veteran or surviving spouse and any dependents of that individual. Unusual medical expenses may result in a lump sum payment, an increase in the ongoing VA pension or compensation payment, or both. Vendor Payments - payment made directly to the customer’s creditor or person providing the service by a person or organization outside the household. Veteran's Administration (VA) - the entity that administers veteran's benefits. Whole Life Insurance — life insurance policy that has a cash surrender value. Loans may be taken out against whole life policies. Withdrawal - a voluntary written retraction of an application. A-210 ACRONYMS A&A Aid and Attendance AAU Administrative Adjudications Unit ACA Affordable Care Act ADSD Aging and Disability Services Division AGCF Adult Group Care Facility - Aid codes GC & HG AMPS Application Modernization & Productivity Services APTC Advance Payments of the Premium Tax Credit AR Authorized Representative AU Assistance Unit BE Best Estimate Bendex Beneficiary Data Exchange BDA Bureau of Disability Adjudication - Rehabilitation Division BIA Bureau of Indian Affairs Division of Welfare and Supportive Services Medical Assistance Manual DEFINITIONS AND ACRONYMS MTL 10/24 Nov 24 DEFINITIONS AND USE OF TERMS A-200

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CAP Confidential address program CCS Crippled Children's Services CHRT Centralized Hearing Representative Team CMS Centers for Medicare and Medicaid Services COBRA Consolidated Omnibus Budget Reconciliation Act of 1985 COLA Cost of Living Adjustment CSEP Child Support Enforcement Program CST Custodial Parent CSV Cash Surrender Value CWS Child Welfare Services DAG Deputy Attorney General DCFS Division of Child and Family Services DETR Department of Employment, Training and Rehabilitation DHCFP Division of Health Care Financing and Policy DHHS Department of Health and Human Services DHRM Division of Human Resource Management – State of Nevada DIC Dependency and Indemnity Compensation DWSS Division of Welfare and Supportive Services E&P Eligibility and Payments E&T Employment and Training Program EAP Energy Assistance Program EITC Earned Income Tax Credits EITS Enterprise Information Technology Services Division of Welfare and Supportive Services DEFINITIONS AND ACRONYMS Medical Assistance Manual DEFINITIONS AND USE OF TERMS MTL 10/24 Nov 24 A-200

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EM Emergency Medical Assistance EOB Explanation of Benefits EPSDT Early Periodic Screening, Diagnosis, and Treatment ESI Employer Subsidized Insurance FA Future Action FAMIS Family Assistance Management Information System FBR Federal Benefit Rate FEMA Federal Emergency Management Agency FFS Fee-for-Service FMV Fair Market Value FPL Federal Poverty Level FPP Family Preservation Program FSS Family Services Specialist GA General Assistance HB Housebound HCBW Home and Community Based Waiver HHS Health and Human Services (federal) HOH Head of Household HUD Housing and Urban Development I&R Investigations and Recovery ICF Intermediate Care Facility ICF/IID Intermediate care facility for individuals with intellectual disabilities. ICI Individual Case Identifier Number IDA Individual Development Account IGA Indian General Assistance Division of Welfare and Supportive Services Medical Assistance Manual DEFINITIONS AND ACRONYMS MTL 10/24 Nov 24 DEFINITIONS AND USE OF TERMS A-200

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IM Informational Memorandum IMD Institution for Mental Disease INCAP Incapacitated IPV Intentional Program Violation IRS Internal Revenue Service IRWE Income-related work expense JTPA (Changed to Workforce Investment Act of 1998) Job Training Partnership Act MAABD Medical Assistance to the Aged, Blind and Disabled MAGI Modified Adjusted Gross Income MCB Medicaid Breast and Cervical Cancer Program MCO Managed Care Organization MER Medicaid Estate Recovery MMIS Medicaid Management Information System MRT Medical Review Team MSP Medicare Savings Program NCP Non-Custodial Parent NCU Nevada Check Up NF Nursing Facility NMO Nevada Medicaid Office - Location: DHCFP NOD Notice of Decision NOMADS Nevada Operations of Multi-Automated Data Systems OBRA Omnibus Budget Reconciliation Act of '86; '87; '89 and '90 P&P Policy and Procedures PA Public Administrator PAR Payment Authorization Request Division of Welfare and Supportive Services DEFINITIONS AND ACRONYMS Medical Assistance Manual DEFINITIONS AND USE OF TERMS MTL 10/24 Nov 24 A-200

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PCN Primary Care Network PIN Personal Identification Number PL Patient Liability P.L. Public Law PM Post-Medical PNA Personal Needs Allowance PRE Program Review and Evaluation (also known as QC) PRO Medicaid's Peer Review Organization PRWORA Personal Responsibility and Work Opportunity Reconciliation Act of 1996 PT Policy Transmittal QC Quality Control (also known as PRE) QDWI Qualified Disabled Working Individual QHP Qualified Health Plan QMB Qualified Medicare Beneficiaries RD Redetermination RRB Railroad Retirement Board RSDI Retirement, Survivors, Disability Insurance (Title II) RTC Residential Treatment Center SAVE Systematic Alien Verification for Entitlements SCHIP State Children's Health Insurance Program SDX State Data Exchange SGA Substantial Gainful Activity SLMB Special Low-Income Medicare Beneficiary SNAP Supplemental Nutrition Assistance Program Division of Welfare and Supportive Services Medical Assistance Manual DEFINITIONS AND ACRONYMS MTL 10/24 Nov 24 DEFINITIONS AND USE OF TERMS A-200

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SNF Skilled Nursing Facility SOLQ State Online Query SSA Social Security Administration SSHIX Silver State Health Insurance Exchange SSI Supplemental Security Income SSN Social Security Number SSP State Supplementary Payment SWICA State Wage Information Collection Agency TANF Temporary Assistance for Needy Families TITLE XIX Also known as Medicaid TM Transitional Medicaid TPL Third-Party Liability TR Treasury Report UME Unusual Medical Expense UPI Unique Person Identifier UR Utilization Review USCIS United States Citizenship & Immigration Service UTL Unable to Locate VA Veteran's Administration Division of Welfare and Supportive Services DEFINITIONS AND ACRONYMS Medical Assistance Manual DEFINITIONS AND USE OF TERMS MTL 10/24 Nov 24 A-200

(appendix-a)Nevada Medical Assistance Manual (MAM): Appendix A MAGI Income Charts Verification Plan AID Code Charts#

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NEVADA STATE DIVISION OF SOCIAL SERVICES MEDICAL ASSISTANCE PROGRAM MANUAL APPENDIX A INCOME/RESOURCE CHARTS VERIFICATION PLAN AID CODE CHARTS

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MAGI INCOME CHART Effective 4/1/2025 Household Size AM limit AM Limit w/Medicare 100% FPL 122% FPL 138% FPL 165% 190% 205% 1 $319 $385 $1,305 $1,592 $1,800 $2,152 $2,478 $2,674 2 $407 $496 $1,763 $2,151 $2,433 $2,909 $3,349 $3,614 3 $495 $607 $2,221 $2,710 $3,065 $3,665 $4,220 $4,553 4 $582 $716 $2,680 $3,269 $3,698 $4,421 $5,091 $5,493 5 $670 $827 $3,138 $3,828 $4,330 $5,177 $5,962 $6,432 6 $758 $938 $3,596 $4,387 $4,963 $5,934 $6,833 $7,372 7 $846 $1,049 $4,055 $4,947 $5,595 $6,690 $7,703 $8,312 8 $934 $1,160 $4,513 $5,506 $6,228 $7,446 $8,574 $9,251 Each Add +88 +111 +$458 $559 $633 $756 $871 $939 MAGI CASH GIFT COUNTABILITY TAX YEAR IRS ANNUAL EXCLUSION MAXIMUM EXCLUSIONS ALLOWED PER PERSON 2002-2005 $11,000 1 2006-2008 $12,000 1 2009-2012 $13,000 1 2013-2017 $14,000 1 2018-2021 $15,000 1 2022 $16,000 1 2023 $17,000 1 2024 $18,000 1 2025 $19,000 1 APPENDIX A INCOME RESOURCE CHARTS Division of Social Services Medical Assistance Manual 25 July MTL 06/25 MAGI INCOME CHART

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL VERIFICATION MATRIX MAABD Type of Verification MAGI Household Specialized Medicaid Institutional HCBW Medicare Beneficiary SSI Identification and Citizenship Verification of identity may be required as part of citizenship documentation. Identity documentation is not a separate requirement from citizenship. Verify Verify Verify Verify Verify Social Security Number Verified through the NUMIDENT system. Verify Verify Verify Verify Verify Household Composition Customer Statement Customer Statement Customer Statement Customer Statement Customer Statement Pregnancy & Unborn Count Customer Statement Customer Statement Customer Statement Customer Statement Customer Statement Caretaker Relative Customer Statement Customer Statement N/A N/A N/A Residency Customer Statement Customer Statement Customer Statement Customer Statement Verify Income (Earned/Unearned) Verify current monthly income using electronic data sources including SNAP/TANF case information. Use the most current source of information available. Verify Verify Verify Verify Verify Insurance/TPL Verify Post- Eligibility Verify Post- Eligibility Verify Post-Eligibility Verify Post-Eligibility Verify Post- Eligibility Duplicate Assistance (includes out of state benefits) Verify Verify Verify Verify Verify Resources N/A; *Verify only if Dual Eligible N/A Verify Verify N/A APPENDIX A INCOME RESOURCE CHARTS VERIFICATION MATRIX Division of Social Services Medical Assistance Manual 25 July MTL 06/25

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MAGI MEDICAL GROUPS ACA MAGI Medical Groups Definition Income Limits Exceptions/Rules AM Parents & Caretakers 1 - $319 2 - $407 3 - $495 4 - $582 5 - $670 6 - $758 7 - $846 8 - $934 $88 each additional Parent/Caretaker must have a dependent child in the home; AM with Medicare Dual Eligible Parents & Caretakers 1 - $385 2 - $496 3 - $607 4 - $716 5 - $827 6 - $938 7 - $1,049 8 - $1,160 $111 each additional Parent/Caretaker must have a dependent child in the home; Buy-in Eligible; Dual eligible. Must meet resource limits under a Medicare Beneficiary program for dual eligibility. AM1 Expanded Parent & Caretakers AM Limit – 138% FPL Cannot be Medicare eligible; Children must be enrolled in coverage for parent to be eligible. Cannot be pregnant. CH Poverty Level Children & Pregnant Women *CH/J – Incarcerated children, including pregnant women. Children 6-18: < 122% FPL Children under 6: < 165% FPL Pregnant Women < 190% FPL Buy-In Eligible; Can be dual eligible. *Incarcerated children 0-18, including pregnant women who are eligible 30 days prior to their release date for limited Medicaid services. CH1 Expanded Children’s Group Ages 6 – 18 123% - 138% FPL Cannot be enrolled in Medicare. CH4 Expanded Pregnant Women Pregnant Women < 205% FPL Cannot be enrolled in Medicare. APPENDIX A INCOME RESOURCE CHARTS Division of Social Services Medical Assistance Manual 25 July MTL 06/25 MAGI MEDICAL GROUPS

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL CH5 OBRA baby N/A Children born to Medicaid eligible mother deemed eligible for 12 months from month of birth. Only OBRA if not eligible under the child groups. CA Non-Parents 19–64 years old *CA/J- Incarcerated Non- Parents 19-20 years old < 138% FPL Cannot be pregnant; Cannot be Medicare eligible; Cannot be eligible in another Medical group. *CA/J- Incarcerated adults are eligible 30 days prior to their release date for limited Medicaid services. NC Nevada Check-Up – the state CHIP program for children under 19 *NC/J- Nevada Check-Up- the state CHIP program for incarcerated children under 19. Children under 6: 166%-205% Children 6-18: 139%-205% FPL Premium payment required; Cannot have other medical insurance at initial application or annual redetermination; Cannot be Medicaid eligible. *Incarcerated youth up to age 19 are eligible 30 days prior to their release date for limited Medicaid services. TR Transitional Medicaid > 139% 12 months of continuous eligibility for HH losing eligibility due to increase in earned income of a parent/caretaker, if HH parent/caretaker was eligible for and received AM in 3 of the last 6 months. PM Post Medical N/A 4 months continuous eligibility for household that lose AM eligibility due to an increase in Spousal Support. EM2 Emergency medical expanded adult group Adults with income >AM limit but less than 138% FPL Must meet all eligibility criteria of AM1 with exception of citizenship EM4 Emergency medical coverage for all groups covered prior to ACA Parents < AM Payment; Children 0-5 < 165% FPL; Children 6-18 < 122% FPL; Pregnant Women < 190% Must meet all eligibility criteria of AM, CH with the exception of citizenship. EM8 Emergency medical expanded children’s group Children 6-18 123%-138% Must meet all eligibility criteria of CH1 with exception of citizenship APPENDIX A INCOME RESOURCE CHARTS MAGI MEDICAL GROUPS, CONT Division of Social Services Medical Assistance Manual 25 July MTL 06/25

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL SPECIALIZED MEDICAL GROUPS ACA Specialized Medical Groups Definition Income Limits Exceptions/Rules AO Aged Out of Foster Care *AO/J- Incarcerated Youth who Aged Out of Foster Care 30 Days Pre-Release No income or resource determination Nevada Foster Youth • Under 26 years of age; • Not eligible or enrolled under any other mandatory Medicaid coverage groups; • AO youth who are approved for Childless Adult expanded Medicaid must be transitioned to AO; • Were in foster care and enrolled in Medicaid upon attaining 18 years of age. Out-of-State Foster Youth • Under 21 years of age if turned 18 years old and aged out prior to January 1, 2023; • Under 26 years of age if turned age 18 years old and aged out from another state on or after January 1, 2023. • Were in foster care upon attaining 18 years of age. 61 Children for Whom a Public Agency has Assumed Financial Responsibility No income or resource determination Public agency has assumed responsibility; Child cannot be in DCFS custody 61 Title IV-E eligible foster children at Rite of Passage No income or resource determination Children under 18 years of age residing at Rite of Passage receiving IV-E foster care benefits Applications processed at Yerington D.O. MCB Breast and Cervical cancer No income or resource determination by DSS. CDC screening includes income determination. Under age 65; Uninsured or under insured; Not eligible under any other medical assistance program; Screened by CDC and in need of treatment. Applications processed by Elko D.O. APPENDIX A INCOME RESOURCE CHARTS Division of Social Services Medical Assistance Manual 25 July MTL 06/25 SPECIALIZED MEDICAL GROUPS

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MAABD MEDICARE BENEFICIARIES Medicare Beneficiary Group Definition Income Limits Exceptions/Rules Covers only Medicare’s co pays, premiums, and deductibles Must be enrolled or eligible for Medicare Part A QM1 QM3 QM9 Qualified Medicare Beneficiary (QMB) Net income <100% of FPL Resources <$9,430 for individuals <$14,130 for couples Does not provide full Medicaid benefits Coverage starts the month after approval No prior medical Cannot be pregnant Covers only Medicare Part B premiums Must be enrolled or eligible for Medicare Part A SL1 SL3 SL9 Special Low-Income Medicare Beneficiary (SLMB) Net income between 100% 120% of FPL Resources <$9,430 for individuals <$14,130 for couples Does not pay co-payments or deductibles Medicaid card is not issued for this program Coverage starts application month Prior medical is available Cannot be pregnant APPENDIX A INCOME RESOURCE CHARTS MAABD MEDICARE BENEFICIARIES Division of Social Services Medical Assistance Manual 25 July MTL 06/25

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MAABD MEDICARE BENEFICIARIES (Cont’d) Covers only Medicare Part B premiums Must be currently enrolled or eligible for Medicare Part A QI1 QI3 QI9 Qualified Individual (QI) Net income between 120% 135% of FPL Resources <$9,430 for individuals <$14,130 for couples Not eligible for medical assistance under another Medicaid category Medicaid card is not issued for this program Coverage starts application month Prior medical is available Cannot be pregnant QD3 QD9 Qualified Disabled Working Individual (QDWI) Net income <200% of FPL Resources <$4,000 for individuals <$6000 for couples Covers only Medicare Part A premiums Must be under age 65 Must meet Social Security’s disability criteria Not eligible for medical assistance under another Medicaid category Medicaid card is not issued for this program Coverage starts application month Prior medical is available Cannot be pregnant APPENDIX A INCOME RESOURCE CHARTS Division of Social Services Medical Assistance Manual 25 July MTL 06/25 MAABD MEDICARE BENEFICIARIES (CONT’D)

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MAABD MEDICAL GROUPS ACA Non-MAGI Medical Groups Definition Income Limits Exceptions/Rules IN1 IN3 IN9 SSI Recipients Categorically eligible, income and resource determination made by SSI Receiving SSI as a Nevada resident AD1 AD3 AD9 Adult Disabled Child-Public Law Resource Limit $2,000 Received SSI based on disability which began prior to turning age 22; Lost SSI solely due to receipt of adult disabled child benefits; Would be eligible for SSI if the adult disabled child benefits were excluded. SDX will display “D” in Public Law column. PK1 PK3 PK9 Pickle Amendment – Public Law Resource Limit $2,000 Receiving RSDI; Previously received SSI/RSDI in same month; Became ineligible for SSI; And would be SSI eligible now if the RSDI cost of living increase was excluded from income. WW3 WW9 Widow/Widowers Public Law Resource Limit $2,000 At least 60, but not yet 65 years of age; Eligible for Widow/Widower benefits; Losing SSI due to Widow/Widower benefits; Not entitled to Medicare; Would be SSI eligible if Widow/Widower benefits were excluded. APPENDIX A INCOME RESOURCE CHARTS MAABD MEDICAL GROUPS Division of Social Services Medical Assistance Manual 25 July MTL 06/25

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MAABD MEDICAL GROUPS (Cont’d.) Were receiving SSI benefits; Lost SSI due to receipt of Title WS1 Widow/Widowers and II spousal benefits; WS3 WS9 Surviving Divorced Spouses Public Law Resource Limit $2,000 Not entitled to Medicare Part A. SDX will display “S” in Public Law column. SU1 SU3 SU9 Suspension of SSI due to Income Public Law Resource Limit $2,000 Social Security determines this status. SDX will display “I” in the Public Law column. SS1 SS3 SS9 SSI Institutional $30 SSI Institutional payment rate Categorically eligible, income and resource determination made by SSA. Residing in long term care. Over 65 years of age, blind or disabled; SI1 SI3 SI9 State Institutional special income group Income between SSI payment level and 142% of SSI payment; Resource limit $2,000 In-patient stay greater than 30 days; Requires spousal resource assessment; Patient liability determination post eligibility. WB1 WB3 WB9 Would be receiving SSI or State Supplement if not in LTC Income > 30 but < SSI; Resource limit $2,000 Over 65 years of age, blind or disabled. Over 65 years of age, blind or disabled; In-patient stay greater than 30 CM1 Income $1,339.40 days; CM3 County Match Institutional 300% SSI payment level; CM9 Resource limit $2,000 Requires spousal resource assessment; Patient liability determination post eligibility. APPENDIX A INCOME RESOURCE CHARTS Division of Social Services Medical Assistance Manual 25 July MTL 06/25 MAABD MEDICAL GROUPS (CONT’D)

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MAABD MEDICAL GROUPS (Cont’d.) GC1 GC3 GC9 Group Care Income < SSI payment level; Resource limit $2,000 Individuals receiving SSI and residing in group care; Facility retains a portion of the SSI payment for room and board. HC1 Home and Community based waiver for the Elderly (Frail Elderly Waiver) Income < 300% SSI payment level; Resource limit $2,000 Over 65 years of age; Meets the level of care assessment; Requires spousal resource assessment. AL1 Assisted Living Waiver Income < 300% SSI payment level; Resource limit $2,000 Over 65 years of age; Residing in approved assisted living facility; Requires spousal resource assessment. Over 65 years of age, blind or disabled; HD1 HD3 HD9 Home and Community based waiver for the aged, blind or disabled Income < 300% SSI payment level; Resource limit $2,000 Meets the level of care assessment; Requires spousal resource assessment. Over 65 years of age or blind; HG1 HG3 HG9 Group Care Waiver for the aged or blind Income < 300% SSI payment level; Resource limit $2,000 Meets the level of care assessment; Requires spousal resource assessment. HR1 HR3 HR9 Home and Community based waiver for individuals with intellectual or developmental disabilities. Income < 300% SSI payment level; Resource limit $2,000 Intellectual or developmental disabilities; Living in a community setting; Requires spousal resource assessment. APPENDIX A INCOME RESOURCE CHARTS MAABD MEDICAL GROUPS (CONT’D) Division of Social Services Medical Assistance Manual 25 July MTL 06/25

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MAABD MEDICAL GROUPS (Cont’d.) KB3 KB9 Katie Beckett Waiver for disabled children not eligible for SSI Income < 300% SSI payment level; Resource limit $2,000 Child under 19 years of age; Residing at home with parents; Denied SSI for excess income of parents; Meets level of care assessment and can be cared for at home for less cost than institutionalization; Only child income/resources used in eligibility determination. PR1 PR3 PR9 Prior medical for the aged, blind or disabled Income < SSI payment level; Resource limit $2,000 Disability determination made by DHCFP Not eligible for Medicaid under any other category; WY5 WY9 Health Insurance for working disabled Gross earned 450% FPL; Unearned $699; Net earned + unearned < 250% Between 16-64 years of age; Employment related disregards allowed; Must be disabled or blind. Must meet all eligibility criteria except for citizenship requirements. Residency requirements must EM1 EM3 EM9 Emergency medical assistance Income < SSI payment level; Resource limit $2,000 be met. Must be aged, blind, or disabled and would qualify for Medicaid as a state institutional case, or would be eligible for SSI, except for the fact they are ineligible non- citizens. APPENDIX A INCOME RESOURCE CHARTS Division of Social Services Medical Assistance Manual 25 July MTL 06/25 MAABD MEDICAL GROUPS (CONT’D)

(appendix-b)Nevada Medical Assistance Manual (MAM): Appendix B Possible Benefits Available to Division of Welfare and Supportive Services Clients#

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

NEVADA STATE DIVISION OF SOCIAL SERVICES MEDICAL ASSISTANCE PROGRAM MANUAL APPENDIX B POSSIBLE BENEFITS AVAILABLE TO CUSTOMERS APPENDIX B POSSIBLE BENEFITS AVAILABLE TO CUSTOMERS Division of Social Services Medical Assistance Manual 19 Aug 25 MTL 12/25

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL I. SOCIAL SECURITY RETIREMENT, SURVIVORS AND DISABILITY INSURANCE (RSDI) BENEFITS RSDI benefits are paid to beneficiaries based on the Social Security earnings of the retired or deceased worker. A. RETIREMENT BENEFITS Retirement is earned on a quarter or "credit" basis. Currently, $500 annually must be earned for each credit toward Social Security, with a maximum of four (4) credits earned annually. If a claimant is fully credited when retirement age (62 or older) is reached, both the claimant and certain family members may be eligible for benefits. If the claimant is receiving Social Security retirement benefits, benefits are also available to: 1. Unmarried children under age 18, or under age 19 if enrolled full-time in elementary or high school. (Includes stepchildren if parent and stepparent are married for one (1) year or more. Benefits may also be available if putative father dies prior to paternity verification or if children(ren) are illegitimate and paternity is established.) 2. Unmarried children age 18 or over who became severely disabled prior to age 22 and who continue to be disabled. 3. Spouse* who is age 62 or over. 4. Spouse who is under age 62 and is a caretaker for a disabled child or child under age 16 who is receiving Social Security benefits. *Benefits can be paid to divorced spouses who are age 62 or over if the marriage lasted 10 years or more. The divorced spouse may remarry after age 60 (50 if disabled) and continue to receive spousal benefits. Grandchildren and great-grandchildren may be eligible for Social Security benefits under certain conditions. Social Security retirement benefits may continue even if the claimant returns to work. After age 70, there is no reduction of Social Security benefits if the claimant also works. If you feel there are unusual circumstances involved with a Social Security claimant, contact the local Social Security Office directly. APPENDIX B POSSIBLE BENEFITS AVAILABLE TO CUSTOMERS RSDI BEFEFITS Division of Social Services Medical Assistance Manual 19 Aug 25 MTL 12/25

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL B. SURVIVORS BENEFITS Survivors’ benefits are "earned" on a quarter or "credit" basis, (credits are earned as described in I.A. Retirement Benefits). Only if the deceased worker had sufficient credits in Social Security are benefits payable. The exact amount of credits required to receive benefits depend on the worker's age at death. Generally, the older the worker at death, the more credits required for survivors’ payments. Benefits are available to a survivor who is a/an: 1. Widow(er) at any age who is caring for the deceased workers child (under age 16 or disabled). 2. Widow(er) who is age 60 (50 if disabled) who is not caring for a child. Remarriage after age 60 (50 if disabled) will not prevent payment if the worker died prior to remarriage. 3. Divorced widow(er) caring for an entitled child (under age 16 or disabled). Length of marriage does not apply. 4. Unmarried child under age 18, or between ages 18 and 19 if still attending elementary or high school full-time. If the child is disabled before age 22, they can receive benefits as long as they remain disabled. (Includes stepchildren if parent and stepparent are married one (1) year or more. Benefits may also be available if the putative father dies prior to paternity verification or if children(ren) are illegitimate and paternity is established.) C. DISABILITY BENEFITS Disability is earned on a quarter or "credit" basis as are retirement and survivor's benefits. The required amount of credit required to receive benefits depends on the age of the applicant at time of disability. If the applicant is younger than age 50 at the time of disability, credits needed vary between 6-20. Benefits are available to disabled applicants and their families for: 1. Unmarried children under age 18, or age 19 if attending elementary or high school full-time. If the child is disabled before age 22, they can receive benefits as long as the child remains disabled. (Stepchildren may also be eligible if the parent and stepparent have been married one (1) year or more. Benefits may also be available if the putative father dies prior to paternity verification or if child(ren) are illegitimate and paternity is established.) APPENDIX B POSSIBLE BENEFITS AVAILABLE TO CUSTOMERS Division of Social Services Medical Assistance Manual 19 Aug 25 MTL 12/25 SURVIVORS BENEFITS

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL 2. Spouse who is: a. Caring for disabled person's child (or stepchild if parent and stepparent were married one (1) year or more) under 16 or disabled and received checks. b. Age 62 or older. c. Disabled widow(er) at age 50. d. Disabled divorced spouse if married 10 years or longer. Benefits are payable at age 50. Disability of an applicant is determined by Social Security based on the following criteria: a. Medical evidence showing that the applicant’s condition is severe enough to prevent the applicant from working. b. The medical condition is expected to last (or has lasted) for at least one (1) year or is expected to result in death. Blindness is considered a disability. Blindness is defined by Social Security as vision that cannot be corrected to better than 20/200 in the better eye or if the vision field is less than 20 degrees with corrective lenses. II. SUPPLEMENTAL SECURITY INCOME (SSI) BENEFITS SSI is a different facet of Social Security payment. It is, in effect, a federal welfare program for those people who are aged (65 or older) or disabled and have resources and INCOME below allowable maximums. SSI has several rules that must be met for eligibility. These rules are: 1. The applicant must be a U.S. citizen or national, or a noncitizen in one of certain alien classifications granted by the Department of Homeland Security (DHS). 2. The applicant must reside within the United States or Northern Mariana Islands. 3. If the applicant is eligible for other benefits, they must apply for those benefits. 4. The applicant must be accepted and comply with vocational rehabilitation services if the services are offered. 5. Resources/property are evaluated to determine if they are countable or excluded. Countable resources cannot currently exceed $2,000 for an individual or $3,000 for a couple. APPENDIX B POSSIBLE BENEFITS AVAILABLE TO CUSTOMERS DISABILITY BENEFITS Division of Social Services Medical Assistance Manual 19 Aug 25 MTL 12/25

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL 6. Applicants/recipients must not have countable income in a month of more than the Federal Benefit Rate (FBR) for an individual or for a couple. Certain types of income are excluded in determining eligibility and benefit amount. Countable income of an eligible spouse, parent of an eligible child, an essential person or sponsor of an alien is considered (deemed) to be the applicant/recipient's income. III. VETERANS ADMINISTRATION (VA) BENEFITS The VA has several different types of assistance available to veterans and their families. The first (1st) type of benefit is a monetary payment for a service-connected disability or non-service connected disability. A. SERVICE-CONNECTED DISABILITY - VA COMPENSATION Veterans who became disabled while enlisted may receive VA Compensation payments. These payments are not based on need. Payment is determined by length of service and percent of determined disability. Under certain circumstances, these payments can be increased if the recipient can prove hardship to the VA. If the recipient is 30% or more disabled, both the spouse and children (under age 18 or full-time students to age 22) can be included in the payment amount. B. NON-SERVICE-CONNECTED DISABILITY - VA PENSION Veterans who became disabled after separation from active duty or become disabled after 90 days or more of wartime service may receive a VA pension. Payment is based on need. Both the spouse and children (under age 18 or a full-time student under age 22) can be included in the payment amount. Surviving spouses and unmarried children under age 18 (or until 23 if attending a VA- approved school) of deceased veterans with wartime service may be eligible for pension based on need. This is called non-service-connected death pension. C. AID AND ATTENDANCE - ADDITIONAL PAYMENT Veterans who are disabled or spouses of veterans who are disabled to the extent of being unable to care for their basic daily needs (i.e., shopping, housekeeping, personal hygiene, etc.) may be eligible for a disability payment. Eligibility is based on both need and a disability determination made by the discharging medical facility. This payment type is not currently counted in determining Medical Assistance for the Aged, Blind, and Disabled (MAABD) or Modified Adjusted Gross Income (MAGI) financial eligibility. D. EDUCATIONAL ASSISTANCE Customers, who are veterans or are surviving spouses and children, may also be eligible for student/educational assistance. APPENDIX B POSSIBLE BENEFITS AVAILABLE TO CUSTOMERS Division of Social Services Medical Assistance Manual 19 Aug 25 MTL 12/25 SSI BENEFITS

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL This assistance can be in the form of either: 1. Noncontributory Government Issue (GI) Bill - (education) a. Educational loans through the VA. b. Grants and reduced tuition through VA. c. Work-study and on-the-job training funds. 2. Contributory GI Bill - (education) a. Veterans Education Assistance Program (VEAP) This is a program under which educational benefits are paid to veterans who entered active service between January 1, 1977, and June 30, 1985. The maximum benefit from this program is $8,100 payable over a 36 month timeframe. b. "NEW" GI Bill - Active-Duty Educational Assistance Program. Benefits are payable, on a sliding scale determined by the active duty pay, for 36 months with an additional 36 months available for veterans with five (5) plus years of service. This is a program under which educational benefits are paid to veterans who entered active service on or after July 1, 1985. E. VOCATIONAL TRAINING - DISABLED VETERANS While a veteran is attending vocational training, they may receive a "subsistence allowance" in addition to the regular monthly VA disability payment. The allowance may continue for two (2) months after training has been completed. If the customer obtains a job within four (4) years after training, disability payments from VA will continue for 12 months. F. VA MEDICAL ASSISTANCE There are two (2) types of medical assistance available for spouses and dependent children of active, retired and disabled veterans. These medical programs are CHAMPUS and CHAMP VA. Both insurance programs are cost-sharing (i.e., deductible + percentage of cost of care). For specific information regarding eligibility and medical expense determination, contact the local VA office. G. VA LIFE INSURANCE There are five (5) types of life insurance available to veterans. Each category corresponds to a different time frame of duty (i.e., World War I [WWI], World War II [WWII], etc.). These policies are all term policies. They are as follows: APPENDIX B POSSIBLE BENEFITS AVAILABLE TO CUSTOMERS EDUCATIONAL ASSISTANCE Division of Social Services Medical Assistance Manual 19 Aug 25 MTL 12/25

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL 1. *USGL1 - WWI veterans through 10/7/40 2. *NSL1 - 10/8/40 - 4/24/51 (Includes WWII veterans) 3. VSL1 - 4/25/51 - 12/31/56 (Includes Korean War Veterans) 4. SDV1 - after 4/25/51 - 10% + disability 5. VR1 - 5/1/65 - 5/2/66 - WWII and Korean War Veterans only 6. SGL1 - All other veterans, or 7. VGL1 - All other veterans. * Will pay yearly dividends on yearly anniversary. Life insurance through the VA does have a surrender value. H. VA SURVIVOR’S BENEFITS Survivor's benefits are authorized for surviving spouses, unmarried children under age 18 (under age 23 if attending VA approved schools), severely disabled children and certain parents. The veteran must have: 1. Died from a disease or injury incurred or aggravated in the line of duty or while training for active duty; or 2. Died from an injury incurred or aggravated in the line of active duty or inactive duty training; or 2. Been rated totally disabled for 10 or more years; or 4. Been rated totally disabled for at least five (5) years and the rating was continuous from date of discharge. Eligibility for benefits is not based on need. To qualify, a surviving spouse generally must have been married one (1) year or more OR for any time if a child was born of or before the marriage. If the surviving spouse remarries, the remarriage usually makes the spouse ineligible for benefits unless the remarriage was void, annulled or terminated due to death or divorce. Contact the VA for specific case or eligibility information. IV. RAILROAD RETIREMENT AND DISABILITY BENEFITS A. RETIREMENT In general, the employee earns his retirement through the number of "creditable" months worked in railroad service. There are three (3) stages of eligibility for retirement benefits: APPENDIX B POSSIBLE BENEFITS AVAILABLE TO CUSTOMERS Division of Social Services Medical Assistance Manual 19 Aug 25 MTL 12/25 VA LIFE INSURANCE

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL 1. With 360 months or over of creditable service at age 60 (20% penalty if drawn prior to age 62). 2. With 120 - 359 months of creditable service at age 62 (1/180 reduction for each month the employee is under age 65 at the beginning of annuity payment). 3. With 120 months of creditable service at age 65 (no age reduction). There is a potential for "vested dual benefits," i.e., benefits paid both through Social Security and the railroad board. The employee must have been eligible for both benefits prior to 1975. Spousal annuity benefit requirements are different than Social Security benefit requirements. The spouse must be: 1. Married to the employee for one year, or 2. Is the natural parent of an employee's child, or 3. Previously eligible for an annuity prior to marrying the employee, or 4. Is living in the same household and de facto spouse is a person who would otherwise be a spouse if not for some legal impediment unknown at the time of the marriage ceremony. Spousal annuity payments are usually payable when the spouse reaches age 60 to 62 depending on individual circumstances. The one (1) exception to the age restriction on spousal annuity payments is if the employee is age 65 and the spouse is caring for the employee's child who is under 18 (age 16 if the spouse is male) or a child who became disabled before age 22. A divorced spouse must meet all of the following criteria to become eligible for payment: 1. The employee must be at least age 62 and drawing retirement benefits, and 2. The divorced spouse must be at least age 62, and 3. The marriage ended in a final decree of divorce, and 4. The marriage between the employee and the divorced spouse must have lasted a minimum of 10 years before the decree date, and 5. The divorced spouse is not currently married, and 6. The Social Security benefits the divorced spouse may be eligible for are less than the railroad annuity, and 7. The divorced spouse is not working for an employer covered by the Railroad Retirement Act. APPENDIX B POSSIBLE BENEFITS AVAILABLE TO CUSTOMERS RETIREMENT Division of Social Services Medical Assistance Manual 19 Aug 25 MTL 12/25

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(EICON) MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL B. DISABILITY PAYMENTS An employee can be eligible to receive disability payments if they are determined to be permanently disabled for all work. There are two (2) types of disability payments and corresponding eligibility criteria: 1. Non-work related - The employee must: a. Have a minimum of 120 creditable months of railroad service, or b. Be permanently disabled (expected to last at least 12 months or result in death). 2. Occupational related - The employee must: a. Have worked more for the railroad than any other occupation in the last five (5) years, or b. Have worked at least one half (1/2) of the months in the last 15 years (for any industry). V. SELF-INSURED WORKER’S COMPENSATION A. DISABILITY BENEFITS In general, most employed Nevada residents are covered by worker’s compensation. Employers are required to pay "premiums" to cover employees injured or disabled while at work or performing work-related or assigned duties. Even if employers do not pay the mandated premiums, employees may still receive State Industrial Insurance System (SIIS) benefits by filing suit or applying directly to the Department of Industrial Relations. 1. Eligibility - Eligibility for benefits is determined on a "no-fault" basis. This means that no matter how the injury or accident occurred, if the injury was within the scope of employment, benefits may be paid. (If the accident was self-inflicted or was caused due to the employee being under the influence of a controlled substance, benefits would not be available.) Injury and disability claims are reviewed and processed through medical evidence presented at the local Employers Insurance Company of Nevada (EICON) office. 2. Benefits - Once eligibility for benefits has been established, medical expenses related to the accident are covered. Payment will also be made while the employee is unable to return to work. Payments for "temporary total disability" are made until the injured employee is recovered and able to return to work (24 months maximum) OR reaches age 70, whichever occurs first. If disability is so great as to prevent the employee from ever returning to work, payments can continue until the employee's death. Payments may also be made as a "lump sum settlement." If a settlement is APPENDIX B POSSIBLE BENEFITS AVAILABLE TO CUSTOMERS Division of Social Services Medical Assistance Manual 19 Aug 25 MTL 12/25 DISABILITY PAYMENTS

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL made, future injury-related medical and monetary benefits are usually forfeited. A copy of the settlement document should be requested to verify third-party liability. VI. COUNTY GENERAL ASSISTANCE A. PAYMENT OF BENEFITS In general, county general assistance is a cash payment program designed to be temporary. The recipient is required to repay assistance when financially able. There are four (4) categories of eligibility for general assistance benefits: 1. Single Unemployables - the individual must be determined unemployable by a doctor's statement and meet financial eligibility criteria. The period of disability does not have to be permanent in nature to qualify for assistance. This category of customer is usually pending Social Security or another type of disability program determination. Payment is usually issued monthly. 2. Single Parents - The family must meet financial eligibility criteria to receive assistance. This category of customer is usually pending a TANF decision. Payment is usually issued monthly. 3. Incapacitated Head of Household - The head of household must be determined incapacitated, thus causing financial hardship to the family. Financial eligibility criteria must be met, and disability does have to be verified by doctor's statement and does not need to be permanent in nature. Payment is usually issued monthly. 4. Intact Family - The family must meet financial eligibility criteria to receive this type of assistance. Payment is normally issued on a weekly basis, and a job- search type of activity is routinely required. To qualify, applicants must meet income and asset guidelines. Both income and asset limits are set on a graduated scale depending on the number of household members. Actual income and asset breakdowns vary between counties and specific eligibility questions should be directed to the corresponding county office. VII. INDIAN GENERAL ASSISTANCE A. PAYMENT OF BENEFITS In general, Indian General Assistance (IGA) is a federal cash payment program administered by the tribal councils. Eligibility is based on two (2) eligibility criteria: 1. Tribal Affiliation - the tribe must be officially recognized by the federal government and the applicant must be an identifiable member of that tribe. 2. Need - the Indian applicant(s) must prove need to be considered eligible for an IGA grant. The amount of grant varies both between tribes and number of APPENDIX B POSSIBLE BENEFITS AVAILABLE TO CUSTOMERS DISABILITY PAYMENTS Division of Social Services Medical Assistance Manual 19 Aug 25 MTL 12/25

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL household members in the assistance unit. IGA is considered a temporary grant program while the recipient is pending approval for another type of assistance program or become financially ineligible for assistance. IGA grants are normally paid on a monthly or semi-monthly basis. Specific eligibility questions should be directed to the corresponding tribal assistance office. VIII. REFUGEE RESETTLEMENT GRANTS (LANDING GRANT) A. PAYMENT OF BENEFITS In general, refugees are sponsored either by private parties or through volunteer "helping" agencies. The sponsors assume responsibility for placing the refugee(s) in a suitable community and ensure that the refugee(s) will become self-sufficient. The federal government currently administers a federal resettlement grant to volunteer sponsoring agencies to assist them in their relocation efforts. The agency can administer the funds as it decides best meets the needs of the refugee(s). Most agencies do not give the grant directly to the customer in the form of cash, but rather as clothing or shelter. To determine if a refugee applicant has received countable assistance, the volunteer agency must be contacted directly. For information on how to contact the appropriate agency, contact: Catholic Charities of Southern Nevada (702) 383-8387 INTERACTION (Umbrella Agency) (212) 777-8210 Either of these agencies should be able to direct inquiries or give specific grant distribution information. IX. UNEMPLOYMENT INSURANCE BENEFITS A. PAYMENT OF BENEFITS In general, most employed Nevada residents are covered by unemployment insurance benefits. Individuals who are considered out-of-work through no fault of their own may be eligible to receive unemployment insurance benefits. Minimum qualifications for eligibility include, but are not limited to: 1. Have reported earnings in at least two (2) of the quarters within the Base Period. The Base Period is the period of employment prior to the loss of a job. Generally, the first four (4) of the last five (5) completed calendar quarters prior to the effective date of the claim for unemployment is the Base Period. The chart below shows the completed calendar quarters of a Base Period (shaded) depending on the quarter in which a claim is filed with the Nevada Department of Employment, Training, and Rehabilitation (DETR). APPENDIX B POSSIBLE BENEFITS AVAILABLE TO CUSTOMERS Division of Social Services Medical Assistance Manual 19 Aug 25 MTL 12/25 INDIAN GENERAL ASSISTANCE

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Regular Base Year Prior Year Last Year Current Year OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP DO NOT USE JAN FEB MAR If applicant files their claim in: JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC DO NOT USE APR MAY JUN APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR DO NOT USE JUL AUG SEP JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN DO NOT USE OCT NOV DEC 2. Must be wholly unemployed or employed less than full-time and have earnings less than their weekly entitlement; 3. Must be found to be out of work through no fault of their own; 4. Must be available to seek and accept work customary to their normal occupation; 5. Must be physically and mentally able to work at the time they initiate a claim for benefits; 6. Must not refuse suitable work when offered. APPENDIX B POSSIBLE BENEFITS AVAILABLE TO CUSTOMERS UNEMPLOYMENT INSURANCE BENEFITS Division of Social Services Medical Assistance Manual 19 Aug 25 MTL 12/25

(appendix-c)Nevada Medical Assistance Manual (MAM): Appendix C MAABD Income Standard Chart#

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NEVADA STATE DIVISION OF WELFARE AND SUPPORTIVE SERVICES

MEDICAL ASSISTANCE PROGRAM MANUAL

APPENDIX C

MAABD INCOME STANDARD CHART

(appendix-c)(page-2)Page 2#

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD

Division of Welfare and Supportive Services APPENDIX C Medical Assistance Manual MAABD Sept 24 MTL 08/24 INCOME STANDARD CHART 2024 MAABD INCOME STANDARD CHART SSI BUDGETING Child Allocation Amount $472.00 Parent Allocation Amount - One Parent $943.00 - Two Parents $1,415.00 Deeming Indicator Amount $472.00

HIWA BUDGETING Gross Unearned Income $699.00 Gross Earned Income (effective. 04/24) $5,648.00 Combined Net Income (effective. 04/24) $3,138.00

PATIENT LIABILITY Home and Community Based Waivers Personal Needs Allowance - DMH – MR Waiver Allowance $2,829.00 - Aged – Independent Living $2,829.00 - Aged – Group Care $2,829.00 - Disabled Waiver $2,829.00 HBW Spouse Allowance $707.50 Institutional Spouse Allowance $943.00 - Dependent Need Standard (effective. 04/24) $942.00 - Each Additional Child (effective. 04/24) $336.00

SPOUSAL IMPOVERISHMENT State Medicaid Maximum Resource Share $30,828.00 Federal Maximum Spousal Resource Share $154,140.00 Federal Maximum Maintenance Need Standard $3,853.50 Federal Minimum Maintenance Need Standard (effective. 04/24) $2,555.00 Federal Excess Shelter Deduction (effective. 04/24) $766.50

HOME EQUITY Individual Limit $713,000.00 Couple Limit $1,071,000.00

LONG TERM CARE/HOME BASED WAIVER CASES Gross Income Limit $2,829.00 Average Cost Private Nursing Care (effective. 04/24) $9,949.26

MEDICARE BENEFICIARY INCOME LIMITS (Effective 04/24) INDIVIDUAL COUPLE QMB $0 .00 - $1,255.00 $0 .00 - $1,704.00 SLMB $1,255.01 - $1,506.00 $1,704.01 - $2,044.00 QI1 $1,506.01 - $1,695.00 $2,044.01 - $2,300.00 QDWI $1,695.01 - $2,510.00 $2,300.01 - $3,407.00

MEDICARE MONTHLY PREMIUMS Part A Hospital $505.00 Part B Medical $174.70

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD

APPENDIX C Division of Welfare and Supportive Services MAABD Medical Assistance Manual SCHEDULE OF PAYMENTS Sept 24 MTL 08/24

NEVADA: January 1, 2024, to December 31, 2024

INDEPENDENT LIVING

LIVING IN HOUSEHOLD OF ANOTHER

DOMICILIARY CARE

TOTAL SSP SSI TOTAL SSP SSI TOTAL SSP SSI INDIVIDUAL

AGED $979.40 $36.40 $943.00 $652.94 $24.27 $628.67 $1,334.00 $391.00 $943.00 BLIND $1,052.30 $109.30 $943.00 $842.63 $213.96 $628.67 $1,334.00 $391.00 $943.00 DISABLED $943.00 $0.00 $943.00 $628.67 $0.00 $628.67 $943.00 $0.00 $943.00

COUPLES

AGED $1,489.46 $74.46 $1,415.00 $992.98 $49.64 $943.34 $2,296.00 $881.00 $1,415.00 BLIND $1,789.60 $374.60 $1,415.00 $1,475.28 $531.94 $943.34 $2,296.00 $881.00 $1,415.00 DISABLED $1,415.00 $0.00 $1,415.00 $943.34 $0.00 $943.34 $1,415.00 $0.00 $1,415.00

MEM OF COUPLE

AGED $744.73 $37.23 $707.50 $496.49 $24.82 $471.67 $1,148.00 $440.50 $707.50 BLIND $894.80 $187.30 $707.50 $737.64 $265.97 $471.67 $1,148.00 $440.50 $707.50 DISABLED $707.50 $0.00 $707.50 $471.67 $0.00 $471.67 $707.50 $0.00 $707.50

(appendix-d)Nevada Medical Assistance Manual (MAM): Appendix D Benefit Level Chart#

(appendix-d)(page-1)Page 1#

NEVADA STATE DIVISION OF WELFARE AND SUPPORTIVE SERVICES MEDICAL ASSISTANCE PROGRAM MANUAL APPENDIX D BENEFIT LEVEL CHART SSI VA QMB SLMB QI1 QI2 QDWI COUNTY MATCH SPOUSAL IMPOVERISHMENT

(appendix-d)(page-2)Page 2#

I MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD SSI INDIVIDUAL VA BENEFITS 300% OF SSI COUNTY MATCH Aged Blind Disable Medicare Vet A&A Widow A&A 2009 $710.40 $783.30 $674.00 $96.40 $985.00 $651.00 $661.00 $395.00 $1,051.01 $2,022.00 2010 $710.40 $783.30 $674.00 $96.40 $985.00 $651.00 $661.00 $395.00 $1,051.01 $2,022.00 2011 $710.40 $783.30 $674.00 $96.40 $985.00 $651.00 $661.00 $395.00 $957.01 $2,022.00 2012 $734.40 $807.30 $698.00 $99.90 $1,021.00 $682.00 $684.00 $410.00 $991.01 $2,094.00 2013 $746.40 $819.30 $710.00 $104.90 $1,038.00 $694.00 $696.00 $417.00 $1,009.01 $2,130.00 2014 $757.40 $830.30 $721.00 $104.90 $1,054.33 $705.58 $707.03 $423.17 $1,024.01 $2,163.00 2015 $769.40 $842.30 $733.00 $104.90 $1,072.33 $716.50 $719.16 $430.33 $1041.01 $2199.00 2016 $769.40 $842.30 $733.00 $121.80 $1,072.33 $716.50 $719.16 $430.33 $1041.01 $2199.00 2017 $771.40 $844.30 $735.00 $134.00 $1,075.58 $718.66 $721.33 $431.66 $1044.01 $2205.00 2018 $786.40 $859.30 $750.00 $134.00 $1,097.17 $732.91 $735.83 $440.25 $1,065.01 $2,250.00 2019 $807.40 $880.30 $771.00 $135.50 $1127.91 $753.50 $756.50 $452.58 $1,094.00 – $2,313,00 2020 $819.40 $892.30 $783.00 $144.60 $1,146.00 $765.58 $768.66 $459.84 $1,112.00 – $2,349.00 2021 $830.40 $903.30 $794.00 148.50 $1,160.00 $778.58 $778.66 $465.83 $1,126.00 – $2,382.00 2022 $877.40 $950.30 $841.00 $177.10 $1,229.42 $821.41 $824.67 $465.83 $1,194.00 – $2523.00 2023 $950.40 $1,023.30 $914.00 $164.90 $1,336.41 $889.83 $896.41 $536.25 $1,297.87 $2,742.00 2024 $979.40 $1,052.30 $943.00 $174.70 $1,379.25 $921.50 $925.16 $553.42 $1,339.40 $2,829.00 Division of Welfare and Supportive Services APPENDIX D Medical Assistance Manual POSSIBLE BENEFITS AVAILABLE TO DWSS CLIENTS 24 Sept MTL 06/24 SOCIAL SECURITY-RETIREMENT, SURVIVORS AND DISABILITY INSURANCE (RSDI) BENEFITS

(appendix-d)(page-3)Page 3#

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD SPOUSAL IMPOVERISHMENT DETERMINATION (Effective 9/30/89) Transfer of Assets MAINTENANCE ALLOWANCE (Effective 10/89) Medicaid Maximum Spousal Share Private Nursing Costs Standard Allowance (SUA) 30% of 150% Poverty 2 Person 150% Poverty 2 Person Maximum Monthly Maintenance Allowance 2009 $21,912.00 $109,560.00 $5,714.00 (5/07) $274.00 (10/08) $11.00 $546.38 $1,821.25 $2,739.00 2010 $21,912.00 $109,560.00 $6,345.00 (4/10) $289.00 (10/09) $28.00 $546.38 $1,821.25 $2,739.00 2011 $21,912.00 $109,560.00 $6,858.00 (4/11) $292.00 (10/10) $26.00 $551.63 $1,838.75 Effective 04/01/11 $2,739.00 2012 $22,728.00 $113,640.00 $6,858.00 (4/11) $292.00 (10/10) $26.00 $551.63 $1,896.20 Effective 04/01/12 $2,841.00 2013 $23,184.00 $115,920.00 $7,139.26 $275.00 (10/12) $20.00 $567.37 $1,938.75 Effective 04/01/13 $2,898.00 2014 $23,448.00 $117,240.00 $6,894.27 $259.00 (10/13) $14.00 Telephone Only $581.63 $1,966.25 Effective 04/01/14 $2,931.00 2015 $23,844.00 $119,220.00 $7,274.17 $295.00 (10/14) $23.00 Telephone Only $597.38 $1,991.25 Effective 04/01/15 $2,980.50 2016 $23,844.00 $119,220.00 $7,335.01 $295.00 (10/15) $23.00 Telephone Only $600.75 $2,002.50 Effective 04/01/16 $2,980.50 2017 $24,180.00 $120,900.00 $7,942.24 $276.00 (10/16) $26.00 Telephone Only $608.65 $2,029.50 Effective 04/01/17 $3,022.50 2018 $24,720.00 $123,600.00 $8,125.61 $266.00 (10/17) $17.00 Telephone Only $617.25 $2,058.00 Effective 04/01/18 $3,090.00 APPENDIX D Division of Welfare and Supportive Services POSSIBLE BENEFITS AVAILABLE TO DWSS CLIENTS Medical Assistance Manual SOCIAL SECURITY-RETIREMENT, SURVIVORS AND 24 Sept MTL 06/24 DISABILITY INSURANCE (RSDI) BENEFITS

(appendix-d)(page-4)Page 4#

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD $285.00 2019 $25,284.00 $126,420.00 $8,125.61 (10/18) $29.00 $634.20 $2,114.00 Effective 04/01/19 $3,160.50 Telephone Only $280.00 2020 $25,728.00 $128,640.00 $8,839.41 (10/19) $25.00 $646.50 $2,155.00 Effective 04/01/20 $3,216.50 Telephone Only $275.00 2021 $26,076.00 $130,380.00 $9,059.10 (10/20) $25.00 $653.25 $2,177.50 Effective 04/01/21 $3,259.50 Telephone Only 2022 $27,480.00 $137,400.00 $9,449.31 $284.00 (10/21) $25.00 Telephone Only $686.70 Effective 04/01/22 $2,289.50 Effective 04/01/22 $3,435.00 2023 $29,724.00 $148,620.00 $9,743.42 Effective 04/01/23 $370.00 (10/22) $27.00 Telephone Only $739.50 Effective 04/01/23 $2,465.00 Effective 04/01/23 $3,715.00 2024 $30,828.00 $154,140.00 $9,949.26 Effective 04/01/24 $412.00 (10/23) $27.00 Telephone Only $766.50 Effective 04/01/24 $2,555.00 Effective 04/01/24 $3,853.50 Division of Welfare and Supportive Services APPENDIX D Medical Assistance Manual POSSIBLE BENEFITS AVAILABLE TO DWSS CLIENTS 24 Sept MTL 06/24 SOCIAL SECURITY-RETIREMENT, SURVIVORS AND DISABILITY INSURANCE (RSDI) BENEFITS

(appendix-d)(page-5)Page 5#

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MEDICARE BENEFICIARIES 0% - 100% FPL QMB 100% - 120% FPL SLMB 120% - 135% FPL QI1 135% - 175% FPL QI2 200% FPL QDWI 4/09 Individual $903.00 Couple $1,214.00 Individual $903.01 – 1,083.00 Couple $1,214.01 – $1,457.00 Individual $1,083.01 – $1,218.00 Couple $1,457.01 – $1,639.00 Individual $1,805.00 Couple $2,428.00 4/11 Individual $908.00 Couple $1,226.00 Individual $908.01 – $1,089.00 Couple $1,226.01 – $1,471.00 Individual $1,089.01 – $1,225.00 Couple $1,471.01 – $1,655.00 Individual $1,815.00 Couple $2,452.00 4/12 Individual $931.00 Couple $1,261.00 Individual $931.01 – $1,117.00 Couple $1,261.01 – $1,513.00 Individual $1,117.01 – $1,257.00 Couple $1,513.01 – $1,703.00 Individual $1,862.00 Couple $2,522.00 4/13 Individual $958.00 Couple $1293.00 Individual $958.01 - $1149.00 Couple $1293.01 - $1551.00 Individual $1149.01 - $1293.00 Couple $1551.01 - $1745.00 Individual $1915.00 Couple $2,585.00 4/14 Individual $973.00 Couple $1,311.00 Individual $973.01 - $1,167.00 Couple $1,311.01 - $1,573.00 Individual $1,167.01 - $1,313.00 Couple $1,573.01 - $1,770.00 Individual $1,945.00 Couple $2,622.00 4/15 Individual $981.00 Couple $1,328.00 Individual $981.01 - $1,177.00 Couple $1,328.01 - $1,593.00 Individual $1,177.01 - $1,324.00 Couple $1,593.01 - $1,792.00 Individual $1962.00 Couple $2,655.00 4/16 Individual $990.00 Couple $1,335.00 Individual $990.01 - $1,188.00 Couple $1,335.01 - $1,602.00 Individual $1,188.01 - $1,337.00 Couple $1,602.01 - $1,802.00 Individual $1,980.00 Couple $2,670.00 4/17 Individual $1,005.00 Couple $1,353.00 Individual $1,005.01 $1,206.00 Couple $1,353.01 - $1,624.00 Individual $1,206.01 - $1,357.00 Couple $1,624.01 - $1,827.00 Individual $2,010.00 Couple $2,707.00 4/18 Individual $1,012.00 Couple $1,372.00 Individual $1,012.01 $1,214.00 Couple $1,372.01 - $1,646.00 Individual $1,214.01 - $1,366.00 Couple $1,646.01 - $1,852.00 Individual $2,023.00 Couple $2,743.00 4/19 Individual $1,041.00 Couple $1,409.00 Individual $1, 041.01 $1,249.00 Couple $1, 409.01 - $1,691.00 Individual $1, 249.01 - $1,405.00 Couple $1, 691.01 - $1,902.00 Individual $2,082.00 Couple $2,818.00 4/20 Individual $1,063.00 Couple $1,437.00 Individual $1, 063.01 $1,276.00 Couple $1, 437.01 - $1,724.00 Individual $1, 276.01 - $1,436.00 Couple $1, 724.01 - $1,940.00 Individual $2,127.00 Couple $2,873.00 4/21 Individual $1,074.00 Couple $1,452.00 Individual $1, 074.01 $1,289.00 Couple $1, 452.01 - $1,743.00 Individual $1, 289.01 - $1,450.00 Couple $1, 743.01 - $1,961.00 Individual $2,148.00 Couple $2,904.00 APPENDIX D Division of Welfare and Supportive Services POSSIBLE BENEFITS AVAILABLE TO DWSS CLIENTS Medical Assistance Manual SOCIAL SECURITY-RETIREMENT, SURVIVORS AND 24 Sept MTL 06/24 DISABILITY INSURANCE (RSDI) BENEFITS

(appendix-d)(page-6)Page 6#

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD 4/22 Individual $1,133.00 Couple $1,526.00 Individual $1, 133.01 $1,359.00 Couple $1, 526.01 - $1,831.00 Individual $1, 359.01 - $1,529.00 Couple $1, 831.01 - $2,060.00 Individual $2,265.00 Couple $3,052.00 4/23 Individual $1,215.00 Couple $1,643.00 Individual $1,215.01 $1,458.00 Couple $1,643.01 - $1,972.00 Individual $1,458.01 - $1,640.00 Couple $1,972.01 - $2,219.00 Individual $2,430.00 Couple $3,287.00 4/24 Individual $1,255.00 Couple $1,704.00 Individual $1,255.01 $1,506.00 Couple $1,704.01 - $2,044.00 Individual $1,506.01 - $1,695.00 Couple $2,044.01 - $2,300.00 Individual $2,510.00 Couple $3,407.00 *FPL = Federal Poverty Level Division of Welfare and Supportive Service APPENDIX D Medical Assistance Manual POSSIBLE BENEFITS AVAILABLE TO DWSS CLIENTS 24 Sept MTL 06/24 SOCIAL SECURITY-RETIREMENT, SURVIVORS AND DISABILITY INSURANCE (RSDI) BENEFITS

(appendix-e)Nevada Medical Assistance Manual (MAM): Appendix E BIC Code Values#

(appendix-e)(page-1)Page 1#

NEVADA STATE DIVISION OF WELFARE AND SUPPORTIVE SERVICES MEDICAL ASSISTANCE PROGRAM MANUAL APPENDIX E BIC CODE VALUES

(appendix-e)(page-2)Page 2#

MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL BIC CODE VALUES NOTE:

BIC Codes are listed in POMS SM 00550.010 & Combined A and B beneficiary in the same payment A Primary claimant B Aged wife, age 62 or over (1st claimant) B1 Aged husband, age 62 or over (1st claimant) B2 Young wife, with a child in her care (1st claimant) B3 Aged wife (2nd claimant) B4 Aged husband (2nd claimant) B5 Young wife (2nd claimant) B6 Divorced wife, age 62 or over (1st claimant) B7 Young wife (3rd claimant) B8 Aged wife (3rd claimant) B9 Divorced wife (2nd claimant) BA Aged wife (4th claimant) BD Aged wife (5th claimant) BG Aged husband (3rd claimant) BH Aged husband (4th claimant) BJ Aged husband (5th claimant) BK Young wife (4th claimant) BL Young wife (5th claimant) BN Divorced wife (3rd claimant) BP Divorced wife (4th claimant) BQ Divorced wife (5th claimant) BR Divorced husband, age 62 or older (1st claimant) BT Divorced husband (2nd claimant) BW Young husband (2nd claimant) BY Young husband, with a child in his care (1st claimant) C1-C9 Child (includes minor, student or disabled child) CA-CK Child (includes minor, student or disabled child) D Aged widow, age 60 or over (1st claimant) D1 Aged widower, age 60 or over (1st claimant) D2 Aged widow (2nd claimant) D3 Aged widower (2nd claimant) D4 Widow (remarried after attainment of age 60) (1st claimant) D5 Widower (remarried after attainment of age 60) (1st claimant) D6 Surviving divorced wife, age 60 or over (1st claimant) D7 Surviving divorced wife (2nd claimant) D8 Aged widow (3rd claimant)

Division of Welfare and Supportive Services APPENDIX E Medical Assistance Manual MEDICAL ASSISTANCE PROGRAM MANUAL MTL 02/13 01 Nov 13 BIC CODE VALUES

(appendix-e)(page-3)Page 3#

MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL D9 Remarried widow (2nd claimant) DA Remarried widow (3rd claimant) DC Surviving divorced husband, age 60 or over (1st claimant) DD Aged widow (4th claimant) DG Aged widow (5th claimant) DH Aged widower (3rd claimant) DJ Aged widower (4th claimant) DK Aged widower (5th claimant) DL Remarried widow (4th claimant) DM Surviving divorced husband (2nd claimant) DN Remarried widow (5th claimant) DP Remarried widower (2nd claimant) DQ Remarried widower (3rd claimant) DR Remarried widower (4th claimant) DS Surviving divorced husband (3rd claimant) DT Remarried widower (5th claimant) DV Surviving divorced wife (3rd claimant) DW Surviving divorced wife (4th claimant) DX Surviving divorced husband (4th claimant) DY Survived divorced wife (5th claimant) DZ Surviving divorced husband (5th claimant) E Mother (widow) (1st claimant) E1 Surviving divorced mother (1st claimant) E2 Mother (widow) (2nd claimant) E3 Surviving divorced mother (2nd claimant) E4 Father (widower) (1st claimant) E5 Surviving divorced father (widower) (1st claimant) E6 Father (widower) (2nd claimant) E7 Mother (widow) (3rd claimant) E8 Mother (widow) (4th claimant) E9 Surviving divorced father (widower) (1st claimant) EA Mother (widow) (5th claimant) EB Surviving divorced mother (3rd claimant) EC Surviving divorced mother (4th claimant) ED Surviving divorced mother (5th claimant) EF Father (widower) (3rd claimant) EG Father (widower) (4th claimant) EH Father (widower) (5th claimant) EJ Surviving divorced father (3rd claimant) EK Surviving divorced father (4th claimant) EM Surviving divorced father (5th claimant)

APPENDIX E Division of Welfare and Supportive Services MEDICAL ASSISTANCE PROGRAM MANUAL Medical Assistance Manual BIC CODE VALUES MTL 02/13 01 Nov 13

(appendix-e)(page-4)Page 4#

MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL F1 Parent (father) F2 Parent (mother) F3 Parent (stepfather) F4 Parent (stepmother) F5 Parent (adopting father) F6 Parent (adopting mother) F7 Parent (2nd alleged father) F8 Parent (2nd alleged mother) J1 Primary Prouty entitled to HIB (less than 3 qualifying quarters (QQs) (General Fund) J2 Primary Prouty entitled to HIB (over 2 QQs) (Retirement and Survivors Insurance (RSI) Trust Fund) J3 Primary Prouty not entitled to HIB (less than 3 QQs) (General Fund) J4 Primary Prouty not entitled to HIB (over 2 QQs) (RSI Trust Fund) K1 Prouty wife entitled to HIB (less than 3 QQs) (General Fund) (1st claimant) K2 Prouty wife entitled to HIB (over 2 QQs) (RSI Trust Fund) (1st claimant) K3 Prouty wife not entitled to HIB (less than 3 QQs) (General Fund) (1st claimant) K4 Prouty wife not entitled to HIB (over 2 QQs) (RSI Trust Fund) (1st claimant) K5 Prouty wife entitled to HIB (less than 3 QQs) (General Fund) (2nd claimant) K6 Prouty wife entitled to HIB (over 2 QQs) (RSI Trust Fund) (2nd claimant) K7 Prouty wife not entitled to HIB (less than 3 QQs) (General Fund) (2nd claimant) Prouty wife not entitled to HIB (less than 3 QQs) (RSI Trust Fund) (2nd K8 claimant) K9 Prouty wife entitled to HIB (less than 3 QQs) (General Fund) (3rd claimant) KA Prouty wife entitled to HIB (over 2 QQs) (RSI Trust Fund) (3rd claimant) Prouty wife not entitled to HIB (less than 3 QQs) (General Fund) (3rd KB claimant) KC Prouty wife not entitled to HIB (over 2 QQs) (RSI Trust Fund) (3rd claimant) Prouty wife not entitled to HIB (less than 3 QQs) (General Fund) (4th KD claimant) KE Prouty wife entitled to HIB (over 2 QQs) (RSI Trust Fund) (4th claimant) Prouty wife not entitled to HIB (less than 3 QQs) (General Fund) (4th KF claimant) KG Prouty wife not entitled to HIB (over 2 QQs) (RSI Trust Fund) (4th claimant) KH Prouty wife entitled to HIB (less than 3 QQs) (General Fund) (5th claimant) KJ Prouty wife entitled to HIB (over 2 QQs) (RSI Trust Fund) (5th claimant) Prouty wife not entitled to HIB (less than 3 QQs) (General Fund) (5th KL claimant) KM Prouty wife not entitled to HIB (over 2 QQs) (RSI Trust Fund) (5th claimant) M Uninsured beneficiary (not qualified for automatic HIB)

Division of Welfare and Supportive Services APPENDIX E Medical Assistance Manual MEDICAL ASSISTANCE PROGRAM MANUAL MTL 02/13 01 Nov 13 BIC CODE VALUES

(appendix-e)(page-5)Page 5#

MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL M1 Uninsured beneficiary (qualified for automatic HIB but requests only SMIB) O Combined A and B beneficiary in the same payment T *Fully insured beneficiaries who have elected entitlement only to HIB (usually but not always along with SMIB) *Uninsured beneficiary or renal disease beneficiary only *Deemed insured (hospital insurance only) TA Medicare Qualified Government Employment (MQGE) primary beneficiary TB MQGE aged spouse (1st claimant) TC MQGE childhood disability benefits (CDB) (1st claimant) TD MQGE aged widow(er) (1st claimant) TE MQGE young widow(er) (1st claimant) TF MQGE parent (male) TG MQGE aged spouse (2nd claimant) TH MQGE aged spouse (3rd claimant) TJ MQGE aged spouse (4th claimant) TK MQGE aged spouse (5th claimant) TL MQGE aged widow(er) (2nd claimant) TM MQGE aged widow(er) (3rd claimant) TN MQGE aged widow(er) (4th claimant) TP MQGE aged widow(er) (5th claimant) TQ MQGE parent (female) TR MQGE young widow(er) (2nd claimant) TS MQGE young widow(er) (3rd claimant) TT MQGE young widow(er) (4th claimant) TU MQGE young widow(er) (5th claimant) TV MQGE disabled widow(er) (1st claimant) TW MQGE disabled widow(er) (1st claimant) TX MQGE disabled widow(er) (2nd claimant) TY MQGE disabled widow(er) (3rd claimant) TZ MQGE disabled widow(er) (4th claimant) T2 MQGE (CDB) (2nd claimant) T3 MQGE (CDB) (3rd claimant) T4 MQGE (CDB) (4th claimant) T5 MQGE (CDB) (5th claimant) T6 MQGE (CDB) (6th claimant) T7 MQGE (CDB) (7th claimant) T8 MQGE (CDB) (8th claimant) T9 MQGE (CDB) (9th claimant) W Disabled widow, age 50 or over (1st claimant) W1 Disabled widower, age 50 or over (1st claimant) W2 Disabled widow (2nd claimant)

APPENDIX E Division of Welfare and Supportive Services MEDICAL ASSISTANCE PROGRAM MANUAL Medical Assistance Manual BIC CODE VALUES MTL 02/13 01 Nov 13

(appendix-e)(page-6)Page 6#

MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL W3 Disabled widower (2nd claimant) W4 Disabled widow (3rd claimant) W5 Disabled widower (3rd claimant) W6 Disabled surviving divorced wife (1st claimant) W7 Disabled surviving divorced wife (2nd claimant) W8 Disabled surviving divorced wife (3rd claimant) W9 Disabled widow (4th claimant) WB Disabled widower (4th claimant) WC Disabled surviving divorced wife (4th claimant) WF Disabled widow (5th claimant) WG Disabled widower (5th claimant) WJ Disabled surviving divorced wife (5th claimant) WR Disabled surviving divorced husband (1st claimant) WT Disabled surviving divorced husband (2nd claimant)

NOTE: Some BICs may be displayed as a three-position code (e.g., B01, C03, etc.). The “0” is a filler and should not be entered on the NOMADS screen.

Division of Welfare and Supportive Services APPENDIX E Medical Assistance Manual MEDICAL ASSISTANCE PROGRAM MANUAL MTL 02/13 01 Nov 13 BIC CODE VALUES

(appendix-f)Nevada Medical Assistance Manual (MAM): Appendix F MAABD Budgets#

(appendix-f)(page-1)Page 1#

NEVADA STATE DIVISION OF SOCIAL SERVICES MEDICAL ASSISTANCE PROGRAM MANUAL APPENDIX F MAABD BUDGETS

(appendix-f)(page-2)Page 2#

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD

NEVADA STATE DIVISION OF SOCIAL SERVICES VETERAN ADMINISTRATION (VA) UNUSUAL MEDICAL EXPENSE (UME) BUDGET — 2024 A. $ ______________ Maximum VA Annual Rate (from award letter) (–) B. $ ______________ Gross Annual Income (use reported income from VA award letter) C. $ ______________ Countable Annual VA Benefits If the amount in "C" is zero or a negative figure, stop here: the entire VA "payment" to the customer is UME and must be excluded in both financial eligibility and patient liability. If the amount in "C" is greater than zero, a portion of the VA payment is countable income. Divide amount in "C" by 12 to reach the monthly countable VA benefit. D. $ ______________ Countable Monthly VA Payment If the amount in "D" is less than the maximum Aid and Attendance (A&A) or House Bound (HB) benefit rate, stop here: this figure must be excluded in both financial eligibility and patient liability (PL). If the amount in "D" is greater than the maximum A&A or HB benefit rate, this figure includes a Base Pension which must be counted in both financial eligibility and patient liability. Proceed as follows: E. $ ______________ Monthly Countable VA Income (amount in "D" above) (–) F. $ ______________ Maximum A&A if HB Rate (excluded in financial eligibility and PL) G. $ ______________ Base Pension (counted in financial & PL) VA AMOUNTS FOR 2024: Maximum VA Annual Rate for A&A Veteran with a spouse = $32,729.00 ($1,806.16 Base + $921.25 A&A x 12) Maximum VA Annual Rate for A&A Veteran = $27,609.00 ($1,379.25 Base + $921.50 A&A x 12) Maximum VA Annual Rate for HB Veteran with a spouse = $25,348.00 ($1,806.16 Base + $306.16 HB x 12) Maximum VA Annual Rate for HB Veteran = $20,226.00 ($1,379.25 Base + $306.25 HB x 12) Maximum VA Annual Rate for A&A Widow = $17,743.00 ($925.16 Base + $553.42 A&A x 12) Maximum VA Annual Rate for HB Widow = $13,568.00 ($925.16 Base + $205.50 HB x 12) APPENDIX F MAABD BUDGETS Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25 VETERAN ADMINISTRATION (VA) UNUSUAL MEDICAL EXPENSE (UME) BUDGET

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD INSTRUCTIONS FOR FORM 2039-EE (2024) "VETERAN ADMINISTRATION (VA) UNUSUAL MEDICAL EXPENSE (UME) BUDGET" PURPOSE ⎯ To assist the case manager in determining the portion of a veteran's pension which is an UME reimbursement. UME is excluded as income for financial eligibility and patient liability. INSTRUCTIONS 1. Enter maximum VA annual rate in field "A". 2. Enter the customer’s/spouse's gross annual income as reported on VA award letter in field "B". CAUTION: Don’t use VA's indication of COUNTABLE ANNUAL INCOME as this amount is the result of "net countable income" less medical expenses. 3. Subtract the customer’s income from the VA rate. Enter the difference in field "C". If the answer is zero or a negative figure, the entire VA "payment" to the customer is UME. If the answer is greater than zero, a portion of the VA "payment" may be countable income. Divide this figure by twelve (12) to reach the monthly countable VA benefit. If the monthly countable VA income is less than the rate for Aid and Attendance (A&A) or House Bound (HB) payment, exclude this income in financial eligibility and patient liability. If the monthly countable VA income is greater than the A&A or HB rate: 1. Enter the monthly countable VA income in field "E". 2. Enter the maximum A&A or HB rate in field "F". 3. Subtract the A&A or HB rate from the monthly countable VA income. Enter the difference in field "G". NOTE: USE THE VA AWARD LETTER TO OBTAIN VA ANNUAL RATES AND THE CUSTOMER/SPOUSE'S INCOME. EXAMPLE #1 U . . .WE INCLUDED THE FOLLOWING SOURCES OF INCOME YOU REPORTED: SELF: EARNED $00000; SOCIAL SECURITY $06061; RETIREMENT $00000; INTEREST $00000: INSURANCE $00000; AND OTHER INCOME $00000. EXAMPLE #2  . . .OUR DETERMINATION THAT YOUR NET COUNTABLE INCOME IS $10367. WE ARE CONSIDERING YOUR OWN INCOME OF $0 FROM EARNINGS, $10297 FROM SOCIAL SECURITY BASED UPON A MONTHLY PAYMENT OF $858.10, $0 FROM ANNUITY/RETIREMENT AND $70 FROM OTHER SOURCES. APPENDIX F MAABD BUDGETS INSTRUCTIONS FOR FORM 2039-EE (2024) Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25

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□ □ □ □ □ □ □ □ _________________________________________ ______________ MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD NEVADA STATE DIVISION OF SOCIAL SERVICES MAABD BUDGET Case Name Case Number Date Case Manager FINANCIAL ELIGIBILITY I. GROSS COUNTABLE INCOME TEST INCOME MONTH: _______________________________ A. UNEARNED INCOME *GROSS – EXCLUSIONS = COUNTABLE RSDI __________ __________ ___________ Railroad Retirement __________ __________ ___________ Veteran Benefits __________ __________ ___________ Pension/ Retirement __________ __________ ___________ Contributions __________ __________ ___________ Other __________ __________ ___________ Total Countable Unearned Income.................................$___________ B. EARNED INCOME Gross Earnings…………………………………………………………………$___________ TOTAL GROSS COUNTABLE INCOME $___________ GROSS Income Limit………………………………………………………………..$___________ ELIGIBLE……………………………………………………………………………….. YES NO C. DIVISION OF INCOME Customer’s Gross Income...........................................................$___________ Spouse's Gross Income ...............................................................$___________ Total GROSS Community Income ...............................................$___________ Divide Community Income by 2..................................................$___________ Total Countable Income ....................................................$___________ GROSS Income Limit ...................................................................$___________ ELIGIBLE…………………………………………………………………………………. YES NO II. NET INCOME DETERMINATION A. UNEARNED INCOME 1. Total .......................................................................$_________ (COUNTABLE) LESS: (a) General Income Exclusion ................................. – 20.00 2. Countable Unearned Income .................................$_________ B. EARNED INCOME 1. Earnings...................................................................._________ LESS: (a) Remaining General Exclusion ..............................–_________ (b) Earnings Exclusions ................– 65.00 (c) IRWE.......................................– _____ Remaining Earned Income .................................=__________ (d) Less 1/2 of 1(c) ......................-__________ 2. Countable Earned Income.. ........_________ TOTAL COUNTABLE NET INCOME .................................... $_________ (Sum of A-2 and B-2) III. AID CODE DETERMINATION Receiving $30 SSI institutional payment (SS) Countable Net income greater than $30 and less than SSI Payment level. (WB) Countable Net income greater than SSI Payment level up to 142% of payment level. (SI) Countable Net is greater than 142% and less than 300% SSI payment level, County Match. (CM) REMARKS/DOCUMENTATION (Medicare Beneficiary Budget Side 2) APPENDIX F MAABD BUDGETS Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25 FINANCIAL ELIGIBILITY

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□ □ □ □ □ □ □ □ □ □ □ MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD NEVADA STATE DIVISION OF SOCIAL SERVICES MEDICARE BENEFICIARY BUDGET Case Name Case Number Date Worker Name/Number CHECK WHICH APPLIES Member of a Couple, With Ineligible Spouse Individual Member of a Couple, With Eligible Spouse A. DEEMING COMPUTATION 1. Ineligible spouse’s unearned income…………………………………………………. Subtract allocation for ineligible children (children not applying for/receiving any type of public assistance) No. 1 No. 2 No. 3 Allocation $472.00 $472.00 $472.00 Subtract child’s (under 18) income - - - + + = a. Total Allocation…………………………………………………………………………… - b. Remaining unearned income………………………………………………………… 2. Ineligible spouse’s gross earned income……………………………………………… a. Subtract balance of allocation for ineligible child(ren) not offset by unearned income……………………………………………………………………. - b. Remaining earned income………………………….………………………………… c. Add remaining unearned income from 1.b.…………………………………… + 3. Total income after allocations……………………………………........................ LESS THAN $472.00, Deeming does NOT apply. Proceed to Part B, second column, using only the customer’s income $ 472.00 OR MORE, Deeming DOES apply. Proceed to Part B, first column, adding the figure in 1.b. to the customer’s unearned income in B.1. and using the figure in 2.b. to the customer’s earned income in B.2. START HERE START HERE B. ELIGIBILITY DETERMINATION Use combined income (customer and ineligible spouse after ineligible child allocations when deeming applies OR Title 54 of NRS (Nevada Revised Statutes) refers to "Professions, Occupations and Businesses," encompassing regulations for various professional licenses and practices within the state of Nevada, including architects, contractors, engineers, accountants, and healthcare practitioners. and eligible spouse) OR customer’s income if using INDIVIDUAL column. 1. Unearned income…………………………………………………………………………….. Customer and ineligible spouse’s deemed Customer Customer and eligible spouse a. Subtract general income exclusion………………………………………………. - 20.00 - 20.00 - 20.00 b. Remaining unearned income...…………………………………................... 2. Gross earned income……………………………………………………………………….. a. Subtract balance of general exclusion not offset by unearned income ……………………………………………………………………………………… - - - b. Remaining earned income…………………………………………………………… c. Subtract work expense exclusion………………………………………………… - 65.00 - 65.00 - 65.00 d. Remaining earned income……………………………………........................ e. Subtract 1/2 of 2.d. amount…………………………………………………………. ÷ 2 = ÷ 2 = ÷ 2 = 3. Total countable income (sum of 1.b. and 2.e.)……………………………………. 4. Compare 3. to the appropriate income limit from Appendix C. If the amount is greater than the limit for a couple in the first or third columns, or greater than the limit for an individual in the second column, the customer is ineligible for Medicaid. (If ineligible in the third column, proceed to the first column.)………………………………................. Compare to Couple Income Limit Compare to INDIVIDUAL Income Limit Compare to Couple Income Limit Income Month(s) ________________ Benefit Month(s) ________________ ELIGIBLE INELIGIBLE ELIGIBLE INELIGIBLE ELIGIBLE INELIGIBLE APPENDIX F MAABD BUDGETS MEDICARE BENEFICIARY BUDGET Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD NEVADA STATE DIVISION OF SOCIAL SERVICES PATIENT LIABILITY (P/L) BUDGET ─ SPOUSAL IMPOVERISHMENT Case Name Case Number Date Worker MAINTENANCE ALLOWANCE PARTIAL MONTH PRORATION COMMUNITY SPOUSE MONTHLY INCOME ALLOWANCE Full Month Patient Liability................................. Number of Days in the Month ............................ Daily Rate…. Number of Days Institutionalized ....................... Patient Liability for _______________ ............... REMARKS/DOCUMENTATION $ ________ + ________ = ________ x ________ = $ ________ 1. Housing Costs ......................................... $________ 2. Standard Utility Allowance (SUA) ........... +________ 3. Shelter Costs........................................... ________ 4. Maximum Shelter (30% of 150% of 2-Person Poverty)...... -________ 5. Excess Shelter Allowance........................ ________ 6. 150% of 2-Person Poverty ...................... $________ Excess Shelter Allowance........................ +________ 7. Monthly Maintenance Allowance ............................................... ________ ▲ COMPARE ▼ 8. Federal Maximum Monthly Maintenance Allowance ..................... $________ 9. Lessor of #7 or #8 $________ _______ 10. Community Spouse Gross Income…… - _______ 11. Community Spouse Monthly Income Allowance .............................. $________ FAMILY ALLOWANCE Repeat this calculation for each family member: -1 -2 1. 150% of 2-Person Poverty.................. $________ $________ 2. Family Member Total......................... -________ -________ 3. Net Difference $________ $________ ÷ 3 ÷ 3 4. Family Member Allowance $________ $________ 5. Total All Family Member Allowances (1+2)................................ $________ PATIENT LIABILITY INCOME MONTH: ___________________ FOR: ______________ (MONTH) TOTAL GROSS MONTHLY INCOME.................................. $ _______ Less Involuntary Mandatory Deductions ........................ $-_______ Less Income Excluded from P/L ...................................... $-_______ TOTAL PATIENT LIABILITY INCOME ................................. $ _______ LESS: 1. Personal Needs Allowance ................. -________ $ _______ (SUBTOTAL) 2. Community Spouse Income Allowance .......................................... -________ 3. Family Allowance ............................... -________ 4. Payments for Health Insurance.......... -________ 5. Incurred Medical Expense.................. -________ TOTAL DEDUCTIONS (#s 2- 5) ......................................... $ _______ PATIENT LIABILITY (Full Month) ...................................... $ _______ APPENDIX F MAABD BUDGETS Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25 PATIENT LIABILITY (P/L) BUDGET ─ SPOUSAL IMPOVERISHMENT

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._______ ._________.I .____I _ ___. .____ __ ___. MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD NEVADA STATE DIVISION OF SOCIAL SERVICES PATIENT LIABILITY (P/L) BUDGET ─ NON-SPOUSAL IMPOVERISHMENT Case Name Case Number Date Worker MAINTENANCE ALLOWANCE REMARKS/DOCUMENTATION EARNED INCOME SPOUSE/DEPENDENT’S GROSS EARNINGS.........................................__________ LESS: 1. Tax and Social Security ......................____________ 2. Other .................................................____________ 3. Other .................................................____________ TOTAL EXPENSES ..............................................................................__________ NET EARNINGS...................................................................................__________ UNEARNED INCOME RSDI ...................................................................................................__________ SSI......................................................................................................__________ UIB.....................................................................................................__________ Pensions ............................................................................................__________ Other .................................................................................................__________ TOTAL UNEARNED INCOME...............................................................__________ ALLOWANCE SPOUSE/DEPENDENTS’ TOTAL NEEDS ...............................................__________ TOTAL NET INCOME (Earned and Unearned) ....................................__________ MAINTENANCE ALLOWANCE.............................................................__________ PATIENT LIABILITY INCOME MONTH:______________ FOR: _______________ (MONTH) TOTAL GROSS MONTHLY INCOME.............................................. $ __________ Less Involuntary Mandatory Deductions .................................... $−__________ Less Income Excluded from P/L .................................................. $−__________ TOTAL PATIENT LIABILITY INCOME............................................. $ __________ LESS: 1. Personal Needs Allowance................................__________ 2. Home Based Maintenance................................__________ 3. Spouse/Dependents’ Maintenance ..................__________ 4. Payments for Health Insurance.........................__________ 5. Incurred Medical Expenses ...............................__________ TOTAL DEDUCTIONS ................................................................... $ __________ PATIENT LIABILITY (Full Month) ................................................. $ __________ PARTIAL MONTH PRORATION Full Month Patient Liability......................................................... $ __________ Number of Days in the Month .................................................... ÷ __________ Daily Rate .......... = __________ Number of Days Institutionalized .............................................. x __________ Patient Liability for __________________ = $ __________ (MONTH) APPENDIX F MAABD BUDGETS PATIENT LIABILITY (P/L) BUDGET ─ NON- Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25 SPOUSAL IMPOVERISHMENT

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□ □ □ □ □ □ □ □ □ □ □ MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD NEVADA STATE DIVISION OF SOCIAL SERVICES Case Name: ________________________ SSI BUDGET Case No.: __________________________ CHECK WHICH APPLIES Member of a Couple, With Ineligible Spouse Individual Member of a Couple, With Eligible Spouse A. DEEMING COMPUTATION 1. Ineligible spouse’s unearned income………………………………………………… Subtract allocation for ineligible children (children not applying for/receiving any type of public assistance) No. 1 No. 2 No. 3 Allocation $472.00 $472.00 $472.00 Subtract child’s (under 18) income - - - + + = a. Total Allocation…………………………………………………………………………… - b. Remaining unearned income………………………………………………………. 2. Ineligible spouse’s gross earned income…………………………………………… a. Subtract balance of allocation for ineligible child(ren) not offset by unearned income………………………………………………………………. - b. Remaining earned income………………………….……………………………….. c. Add remaining unearned income from 1.b.………………………………….. + 3. Total income after allocations………………………………………..................... LESS THAN $472.00, Deeming does NOT apply. Proceed to Part B, second column, using only the customer’s income. $472.00OR MORE, Deeming DOES apply. Proceed to Part B, first column, adding the figure in 1.b. to the customer’s unearned income in B.1. and using the figure in 2.b. to the customer’s earned income in B.2. START HERE START HERE B. SSI ELIGIBILITY DETERMINATION Use combined income (customer and ineligible spouse after ineligible child allocations when deeming applies OR customer and eligible spouse) OR customer’s income if using INDIVIDUAL column. 1. Unearned income……………………………………………………………………………. Customer and ineligible spouse’s deemed Customer Customer and eligible spouse a. Subtract general income exclusion…………….……………………………….. - 20.00 - 20.00 - 20.00 b. Remaining unearned income……………………………………................... 2. Gross earned income……………………………………………………………………….. a. Subtract balance of general exclusion not offset by unearned income………………………………………………………………………. - - - b. Remaining earned income………………………………………………………….. c. Subtract work expense exclusion………………………………………………… - 65.00 - 65.00 - 65.00 d. Remaining earned income………………………………………………………….. e. Subtract 1/2 of 2.d. amount………………………………………………………… ÷ 2 = ÷ 2 = ÷ 2 = 3. Total countable income (sum of 1.b. and 2.e.)………………………………….. 4. Compare 3. to the appropriate SPA. If amount is equal or greater than the SPA in the first and second columns, the customer is ineligible for Medicaid. If ineligible in the third column, proceed to the first column……………………………………………………………………. Compare to Couple (SPA) Compare to INDIVIDUAL (SPA) Compare to Couple (SPA) Income Month(s) ________________ Benefit Month(s) ________________ ELIGIBLE INELIGIBLE ELIGIBLE INELIGIBLE ELIGIBLE INELIGIBLE Worker: ______________________________ Date: ________________________________ SSI PAYMENT AMOUNTS (SPA) Effective 1/1/24 through 12/31/24 Aged $979.40 $1,489.46 Blind $1,052.30 $1,789.60 Disabled $943.00 $1,415.00 Aged person and Blind spouse $1,639.53 Aged person and Disabled spouse $1,452.23 Blind person and Disabled spouse $1,602.30 APPENDIX F MAABD BUDGETS Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25 SSI BUDGET

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-------------------------------------------------------------------------------------- MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD PARENT TO CHILD DEEMING BUDGET Case Name: _________________________________________________ Case No.: ______________________________ DEEMING COMPUTATION 1. Ineligible parent’s unearned income……………………………………………………………………………………………………………… $ __________ Subtract allocation for ineligible children (children not applying for/receiving any type of public assistance) No. 1 No. 2 No. 3 Allocation………………….………………………………….. $472.00 $472.00 $472.00 Subtract child’s income …………………………. ─ ─ ─ + + + = (a) Subtract total allocation for ineligible children……………………………………………………….…………………………………… ─ (b) Remaining unearned income ..……………………………………………………….…….…………………………………………………… $ 2. Ineligible parent’s earned income………………………………………………………………………………………………………………………. (a) Subtract balance of allocation for ineligible child(ren) not offset by unearned income……………………..….…….. ─ (b) Remaining earned income……………………………………..…………………………..……………………………………………………… $ 3. PARENT DEDUCTION & ALLOCATION (a) Enter remaining unearned income…….…………………………………………………………..……..……………………………………. (b) Subtract general income exclusion……………………………………………………………….……………………………………………. ─ 20.00 (c) Countable unearned income…………….……………………………………………………………..…………………………………………. (d) Enter remaining earned income……………….……………………………………………………….……………………………………….. (e) Subtract balance of general income exclusion………….………………………………………….……..……………………………… ─ 20.00 (f) Remainder………………………..……………………………………………………………………….……………………………………………….. (g) Subtract work expense exclusion……………………………………………………………………..………………………………………… ─ 65.00 (h) Remainder…………………….………………………………………………………………………….………………………………………………… (i) Subtract 1/2 remainder……………………………………………………………………………………………………………………………… ─ (j) Countable earned income…………………………………………………………………………………………………………………………… (k) Add countable unearned income…………………………………………………………..……………...……………………………………. + (l) Total countable income……….……………………………………………………………………………………………………………………… (m) Subtract parent allocation…………….…………………………………………………………………………………………………………….. ─ (n) Deemed income…………………….…………………………………………………………………………………………………………………… 4. ELIGIBILITY DETERMINATION ELIGIBILITY Deemed income……………………………………………………. Add individual’s own unearned income.………… + INSTITUTIONAL LIMIT Total unearned income………………..….……………. $2,829 Subtract general income exclusion.….……………. ─ 20.00 Total countable unearned income…….…………… SSI PAYMENT AMOUNT (SPA) Total earned income………………….………………….. Effective 1/1/24 through 12/31/24 Subtract balance of general income exclusion……….. ─ Remainder…………………………….………………………. Blind………………………………………$1,052.30 Subtract work expense exclusions………………………… ─ 65.00 Disabled …………………………………..$943.00 Subtract 1/2 remainder……………………............... ─ Countable earned income…………………………………….. COMPARE TO INSTITUTIONAL LIMIT OR SPA Add countable unearned income…………………………… + □ Eligible □ Ineligible Total countable income…………………….…………………… PARENT ALLOCATION Benefit month(s) ______________________________________ $943.00 only one parent lives in the household; $1,415.00 if both parents live in the household. Income month(s) ______________________________________ Worker _____________________________________________ Date _______________________________________________ APPENDIX F MAABD BUDGETS PARTENT TO CHILD DEEMING BUDGET Division of Social Services Medical Assistance Manual XX MTL XX

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD NEVADA STATE DIVISION OF SOCIAL SERVICES RSDI COMPUTATION WORKSHEET Case Name Case Number Worker Date A. B. C. Percentage of Effective Previous RSDI Prior Cost of Date of Year RSDI Amount Living Increase Increase Amount ÷ 1. Enter the current RSDI amount on the top $ 1.032 (1/24) = $ line of Column A. $ ÷ 1.087 (1/23) = $ ÷ 2. Divide the Column A amount by the $ 1.059 (1/22) = $ Column B figure (percentage amount of the previous cost of living increase). Round to the nearest dime and enter that amount in $ $ ÷ 1.013 ÷ 1.016 (1/21) (1/20) = = $ $ Column C. ÷ $ 1.028 (1/19) = $ 3. Transfer the Column C figure to the next line in Column A. $ ÷ 1.020 (1/18) = $ ÷ $ 1.003 (1/17) = $ 4. Continue steps 2. and 3. for each year until ÷ you reach the last RSDI amount received $ 1.000 (1/16) = $ before clientcustomer became ineligible for SSI. $ ÷ 1.017 (1/15) = $ ÷ $ 1.015 (1/14) = $ 5. Transfer the final amount in Column C. to ÷ SSI Budget as the countable RSDI amount. $ 1.017 (1/13) = $ ÷ $ 1.036 (1/12) = $ $ ÷ 1.000 (1/11) = $ $ ÷ 1.000 (1/10) = $ $ ÷ 1.058 (1/09) = $ $ ÷ 1.023 (1/08) = $ $ ÷ 1.033 (1/07) = $ $ ÷ 1.041 (1/06) = $ $ ÷ 1.027 (1/05) = $ $ ÷ 1.021 (1/04) = $ $ ÷ 1.014 (1/03) = $ $ ÷ 1.026 (1/02) = $ $ ÷ 1.035 (1/01) = $ $ ÷ 1.024 (1/00) = $ $ ÷ 1.013 (1/99) = $ $ ÷ 1.021 (1/98) = $ $ ÷ 1.029 (1/97) = $ $ ÷ 1.026 (1/96) = $ $ ÷ 1.028 (1/95) = $ $ ÷ 1.026 (1/94) = $ $ ÷ 1.030 (1/93) = $ $ ÷ 1.037 (1/92) = $ $ ÷ 1.054 (1/91) = $ $ ÷ 1.047 (1/90) = $ $ ÷ 1.040 (1/89) = $ $ ÷ 1.042 (1/88) = $ $ ÷ 1.013 (1/87) = $ $ ÷ 1.031 (7/86) = $ $ ÷ 1.035 (7/85) = $ APPENDIX F MAABD BUDGETS Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25 RSDI COMPUTATION WORKSHEET

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________________ ________________ MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD NEVADA STATE DIVISION OF SOCIAL SERVICES SPOUSAL IMPOVERISHMENT RESOURCE DETERMINATION Case Name Case Number Date Worker I. SPOUSAL SHARE OF RESOURCES AT TIME OF INSTITUTIONALIZATION/HOME BASED WAIVER SERVICES Month/Year a. Community spouse's separate resources b. Customer’s separate resources c. Joint resources between spouses d. Total Resources e. Total resources divided equally f. A spousal share $____________ +____________ +____________ (Customer’s Spouse) $____________ ÷ 2 $____________ II. COMMUNITY SPOUSE RESOURCE ALLOWANCE a. Enter State Medicaid Maximum Resource Share from Appendix C $____________ b. Enter the spousal share up to the Federal Maximum from Appendix C $____________ c. Enter the amount established based on a hearing decision $____________ d. Enter the amount established in a court order $____________ e. Enter the greatest of a, b, c or d above $____________ f. The amount "considered" available to the community spouse (MAM F-115.2) −____________ g. Community Spouse Resource Allowance $____________ III. ASSIGNMENT OF RESOURCES AT TIME OF APPLICATION a. Community spouse's separate resources $____________ b. Customer’s separate resources +____________ c. Joint resources between spouses +____________ d. Total Resources e. Total amount from Section II, item e above *f. Countable resources for Customer’s eligibility (Customer’s Spouse) $____________ –____________ Month/Year $____________ *If the amount in item III.f is within Medicaid resource limits, then resources up to the amount in item II.g must be transferred to the community spouse within 30 days from the date of the approval notice. APPENDIX F MAABD BUDGETS SPOUSAL IMPOVERISHMENT DETERIMINATION Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25

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________________ ________________ III MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD NEVADA STATE DIVISION OF SOCIAL SERVICES SPOUSAL IMPOVERISHMENT RESOURCE DETERMINATION Case Name Case Number Date Worker I. SPOUSAL SHARE OF RESOURCES AT TIME OF INSTITUTIONALIZATION/HOME BASED WAIVER SERVICES a. Community spouse's separate resources b. Customer’s separate resources c. Joint resources between spouses d. Total Resources e. Total resources divided equally f. A spousal share Liquid/non-liquid in spouse's name and/or joint with others - not the customer. $____________ (customer’s Spouse) Liquid/non-liquid in customer’s name and/or joint with others - not the spouse. +____________ Liquid/non-liquid joint between spouses. Day of Admit +____________ ________________ Month/Year $____________ ÷ 2 $____________ II. COMMUNITY SPOUSE RESOURCE ALLOWANCE a. Enter the State Medicaid Maximum Resource Share from Appendix C $____________ b. Enter the spousal share up to the Federal Maximum from Appendix C $____________ c. Enter the amount established based on a hearing decision $____________ d. Enter the amount established in a court order $____________ e. Enter the greatest of a, b, c or d above $____________ Total of I.a. and 1/2 of non-liquid in I.c. f. The amount "considered" available to the community spouse (MAM F-115.2) –____________ g. Community Spouse Resource Allowance $____________ ASSIGNMENT OF RESOURCES AT TIME OF APPLICATION Liquid/non-liquid in spouse's name and/or joint with others - not the customer. a. Community spouse's separate resources $____________ (Customer’s Spouse) Liquid/non-liquid in customer’s name and/or joint with others - not the spouse. b. Customer’s separate resources +____________ Day of Application Month/Year Liquid/non-liquid joint between spouses. c. Joint resources between spouses +____________ Second and ongoing month(s) use low resource balance. *If the amount in item III.f is within Medicaid d. Total Resources $____________ resource limits, then resources up to the amount in item II.g must be transferred to the e. Total amount from Section II, item e above –____________ community spouse within 30 days from the date of the approval notice. $____________ APPENDIX F MAABD BUDGETS *f. Countable resources for customer’s eligibility Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25 SPOUSAL IMPOVERISHMENT RESOURCE DETERIMINATION

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□ □ □ □ □ □ MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD NEVADA STATE DIVISION OF SOCIAL SERVICES HEALTH INSURANCE WORK ADVANCEMENT (HIWA) BUDGET Case Name Case Number Date Worker FINANCIAL ELIGIBILITY INCOME MONTH: I. GROSS COUNTABLE INCOME TEST A. UNEARNED INCOME *GROSS – RSDI ................................................................... Railroad Retirement .......................................... Veteran Benefits ................................................ Pension / Retirement......................................... Contributions..................................................... Other ................................................................. Total Countable Unearned Income..........................$ GROSS UNEARNED INCOME LIMIT...........................$ ELIGIBLE YES NO B. EARNED INCOME Gross Earnings .................................................... GROSS EARNED INCOME LIMIT .............................. $ ELIGIBLE YES NO II. NET INCOME TEST A. UNEARNED INCOME 1. Total.......................................................................... $ LESS (a) General Income Exclusion ................................... 2. Net Countable Unearned Income ............................. $ B. EARNED INCOME 1. Gross Earnings .......................................................... $ LESS (a) Remaining General Exclusion ................................. – (b) Earnings Exclusions ................. – 65.00 (c) Remaining Earned Income.................................... (d) Less 1/2 of 1(c) 2. Countable Net Earned Income.................................... LESS Total Employment Related Disregards....................... 3. Net Countable Earned Income TOTAL COUNTABLE NET INCOME ...................................$ (Sum of A-2 and B-3) COMBINED NET INCOME LIMIT $ (COUNTABLE) – 20.00 – ELIGIBLE YES NO APPENDIX F MAABD BUDGETS HIWA BUDGET Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25

(appendix-f)(page-14)Page 14#

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD INSTRUCTIONS FOR FORM 2046-EM (04/24), “HEALTH INSURANCE WORK ADVANCEMENT (HIWA) BUDGET” PURPOSE The budget is used to calculate income for determining eligibility for the HIWA program. INSTRUCTIONS Complete section I.A., entering all gross unearned income received by the applicant. Compare the total unearned income to the Gross Unearned Income Limit. If the income exceeds the limit, the budget stops here, and the applicant is ineligible. If the income does not exceed the limit, proceed to I.B. Complete section I.B., entering the total gross earned income received by the applicant. Compare the total to the Gross Earned Income Limit. If the total gross earned income exceeds the limit, the budget stops here, and the applicant is ineligible. If the income does not exceed the limit, proceed to section II. Complete section II.A., entering the total unearned income minus the $20 General Income Exclusion to determine the net unearned income. Complete section II.B., entering the total gross earned income minus a) any General Income Exclusion not offset by the unearned income, and b) minus the $65 Earnings Exclusion. Divide the remaining earned income by 2 to determine the Countable Net Earned Income. Subtract any Employment Related Expenses to determine the final net earned income. Combine the net unearned income and the net earned income. Compare the total to the Net Income Limit. If the income exceeds the limit, the applicant is ineligible. If the income is below the limit, the applicant is eligible for the HIWA program. APPENDIX F MAABD BUDGETS Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25 INSTRUCTIONS FOR FORM 2046

(appendix-g)Nevada Medical Assistance Manual (MAM): Appendix G PRUCOL Verification#

(appendix-g)(page-1)Page 1#

NEVADA STATE DIVISION OF WELFARE AND SUPPORTIVE SERVICES MEDICAL ASSISTANCE PROGRAM MANUAL APPENDIX G PRUCOL VERIFICATION

(appendix-g)(page-2)Page 2#

MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL SSN'S ISSUED PRIOR TO JANUARY 1, 1972 FOR PRUCOL VERIFICATION First Three Digits 001 Odd Even Second Two Digits 01-09 10-48 First Three Digits 151-158 Second Two Digits Odd Even 01-09 10-50 First Three Digits 261-266 Second Two Digits Odd 01-35 Even 02-98 002-003 Odd Even 01-09 10-46 159-176 Odd Even 01-09 10-48 267 Odd Even 01-33 02-98 004-006 Odd Even 01-09 10-60 177 Odd Even 01-09 10-46 268-290 Odd Even 01-09 10-58 007 Odd Even 01-09 10-58 178 Odd Even 01-09 10-48 291 Odd Even 01-09 10-56 008-009 Odd Even 01-09 10-46 179 Odd Even 01-09 10-46 292 Odd Even 01-09 10-58 010-025 Odd Even 01-09 10-48 180 Odd Even 01-09 10-48 293 Odd Even 01-09 10-56 026-028 Odd Even 01-09 10-46 181-211 Odd Even 01-09 10-46 294 Odd Even 01-09 10-58 029 Odd Even 01-09 10-48 212-218 Odd Even 01-09 10-70 295-302 Odd Even 01-09 10-56 030-034 Odd Even 01-09 10-46 219-220 Odd Even 01-09 10-68 303-314 Odd Even 01-09 10-66 035-039 Odd Even 01-09 10-38 221-222 Odd Even 01-09 10-44 315-316 Odd Even 01-09 10-64 040-044 Odd Even 01-09 10-54 223-227 Odd Even 01-09 10-88 317 Odd Even 01-09 10-66 045-049 Odd Even 01-09 10-52 228-231 Odd Even 01-09 10-86 318 Odd Even 01-09 10-54 050-100 Odd Even 01-09 10-50 232-236 Odd Even 01-09 10-92 319-320 Odd Even 01-09 10-52 101-125 Odd Even 01-09 10-48 237-246 Odd Even 01-09 02;10-98 321-323 Odd Even 01-09 10-54 126-133 Odd Even 01-09 10-50 247-248 Odd Even 01-11 02-98 324-325 Odd Even 01-09 10-52 134 Odd Even 01-09 10-48 249-251 Odd Even 01-09 02-98 326-327 Odd Even 01-09 10-54 135-150 Odd Even 01-09 10-52 252-260 Odd Even 01-09 02;10-98 328-361 Odd Even 01-09 10-52 Division of Welfare and Supportive Services Medical Assistance Manual MTL 02/13 01 Nov 13 APPENDIX G MEDICAL ASSISTANCE PROGRAM MANUAL PRUCOL VERIFICATION

(appendix-g)(page-3)Page 3#

MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL 362-384 Odd Even 01-09 10-64 442-447 Odd Even 01-09 10-60 505 Odd Even 01-09 10-82 385 Odd Even 01-09 10-62 448 Odd Even 01-09 10-58 506-508 Odd Even 01-09 10-80 386-396 Odd Even 01-09 10-64 449-451 Odd Even 01-13 02-98 509-514 Odd Even 01-09 10-64 397-398 Odd Even 01-09 10-62 452 Odd Even 01-11 02-98 515 Odd Even 01-09 10-62 399 Odd Even 01-09 10-64 453-457 Odd Even 01-13 02-98 516 Odd Even 01-09 10-74 400-405 Odd Even 01-09 10-86 458-465 Odd Even 01-11 02-98 517 Odd Even 01-09 10-72 406-407 Odd Even 01-09 10-84 466 Odd Even 01-09 02-98 518-519 Odd Even 01-09 10-74 408 Odd Even 01-09 02;10-98 467 Odd Even 01-11 02-98 520 Odd Even 01-09 10-70 409 Odd Even 01-09 02-04;

10-98 468-470 Odd Even 01-09 10-72 521-524 Odd Even 01-09 10-90 410-415 Odd Even 01-09 02;10-98 471-477 Odd Even 01-09 10-70 525 Odd Even 01-09 10-98 416-420 Odd Even 01-09 10-82 478-479 Odd Even 01-09 10-78 526-527 Odd Even 01-21 02-98 421-424 Odd Even 01-09 10-80 480-485 Odd Even 01-09 10-76 528-529 Odd Even 01-09 10-92 425 Odd Even 01-09 02-98 486-489 Odd Even 01-09 10-66 530 Odd Even 01-09 10-56 426-428 Odd Even 01-09 2-06;10-98 490-500 Odd Even 01-09 10-64 531-534 Odd Even 01-09 10-64 429 Odd Even 01-15 02-98 501 Odd Even 01-09 10-74 535-539 Odd Even 01-09 10-62 430-432 Odd Even 01-13 02-98 502 Odd Even 01-09 10-72 540-544 Odd Even 01-09 10-74 433-439 Odd Even 01-09 02;10-98 503 Odd Even 01-09 10-76 545-546 Odd Even 01-11 02-98 440-441 Odd Even 01-09 10-62 504 Odd Even 01-09 10-74 547 Odd Even 01-09 02-98

APPENDIX G Division of Welfare and Supportive Services MEDICAL ASSISTANCE PROGRAM MANUAL Medical Assistance Manual PRUCOL VERIFICATION MTL 02/13 01 Nov 13

(appendix-g)(page-4)Page 4#

MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL 548 Odd Even 01-11 02-98 574 Odd Even 01-09 10-30 587 Odd Even 01-19 02-98 549 Odd Even 01-09 02-98 575 Odd Even 01-09 10-76 700-723 Odd Even 01-09 10-18 550-551 Odd Even 01-11 02-98 576 Odd Even 01-09 10-74 724 Odd Even 01-09 10-28 552 Odd Even 01-09 02-98 577-579 Odd Even 01-09 10-78 725-726 Odd Even 01-09 10-18 553-558 Odd Even 01-11 02-98 580-582 Odd Even 01-09 10-98 727 Odd Even 01-09 10 559-560 Odd Even 01-09 02-98 583-584 Odd Even 01-09 10-84 728 Odd Even 01-09 10-14 561 Odd Even 01-11 02-98 585 Odd Even 01-09 10-88 729 Odd Even 01-09 (No Even) 562-573 Odd Even 01-09 02-98 586 Odd Even 01-09 10-60 Division of Welfare and Supportive Services APPENDIX G Medical Assistance Manual MEDICAL ASSISTANCE PROGRAM MANUAL MTL 02/13 01 Nov 13 PRUCOL VERIFICATION

(appendix-h)Nevada Medical Assistance Manual (MAM): Appendix H Determining Countable RSDI Payments for MAGI Budgeting#

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

NEVADA STATE DIVISION OF WELFARE AND SUPPORTIVE SERVICES

MEDICAL ASSISTANCE PROGRAM MANUAL

APPENDIX H

DETERMINING COUNTABLE RSDI PAYMENTS FOR MAGI BUDGETING

(appendix-h)(page-2)Page 2#

MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services APPENDIX H Medical Assistance Manual DETERMINING COUNTABLE 17 Jul 01 MTL 04/17 RSDI FOR MAGI BUDGETING SOCIAL SECURITY AND EQUIVALENT RAILROAD BENEFITS (See IRS Publication 915) Effective 1/1/2017 Are any RSDI / RR Benefits taxable and countable for MAGI budgeting? To find out whether any benefits may be taxable, compare the base amount for the individual’s filing status, with the total of: - One-half of the annualized RSDI / RRB (SSEB portion of tier 1) benefits, plus - All other income received by the individual, including tax-exempt interest. Exceptions: When determining the total income, do not reduce the total income by: - Interest from qualified U.S. savings bonds, - Employer-provided adoption benefits, - Foreign earned income or foreign housing, or - Income earned by bona fide residents of American Samoa or Puerto Rico. Children's benefits: These rules also apply to benefits received by children. Figuring total income: Worksheet A is used to calculate the total of one-half of RSDI / RRB benefits plus any other income. If the resulting total is more than the base amount for the individual, part of that individual’s RSDI / RRB benefits may be countable for MAGI. Married couples filing a joint tax return must combine their income and RSDI / RRB benefits together in determining if any benefits are taxable. Even if the spouse did not receive any RSDI / RRB benefits, the spouse's other income must be added to the total income to determine if any benefits are taxable. Base amount: The base amount is: - $25,000 if single, head of household, or qualifying widow(er); or; - $25,000 if married filing separately and lived apart from spouse for tax yea r; or - $32,000 if married filing jointly; or - $-0- if married filing separately and lived with spouse at any time during ta x year. Worksheet A: Worksheet A is attached below to help compare income with the base amount.

(appendix-h)(page-3)Page 3#

MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services APPENDIX H Medical Assistance Manual DETERMINING COUNTABLE 17 Jull 01 MTL 04/17 RSDI FOR MAGI BUDGETING WORKSHEET A (see IRS Publication 915)

(appendix-h)(page-4)Page 4#

MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL APPENDIX H Division of Welfare and Supportive Services DETERMINING COUNTABLE

Medical Assistance Manual RSDI FOR MAGI BUDGETING 17 Jul 01 MTL 04/17

WORKSHEET 1 – INSTRUCTIONS (see IRS Publication 915)

How Much RSDI / RRB Is Taxable and countable in MAGI budgeting? If part of the RSDI / RRB benefits are potentially taxable after completing worksheet A, how much is countable depends on the total amount of benefits and other income.

Maximum taxable part: A maximum of 50% of the total RSDI / RRB benefits could be taxable. Individuals meeting the specific situations below may have up to 85% RSDI / RRB as taxable:

- The total of one-half of the RSDI / RRB benefits and all other income is more than $34,000 ($44,000 if married filing jointly); or

- Married filing separately and lived with spouse at any time during tax year.

Worksheet 1 may not apply to all individuals: Worksheet 1 can be used to figure the actual taxable RSDI / RRB benefits. In addition, there are other forms available to applicants in determining taxable RSDI / RRB. These include:

- IRS Form 1040 or 1040A instructions: The instruction booklets for either form have a worksheet included that can calculate the taxability of RSDI / RRB benefits.

- Appendix B of IRS Publication 590-A: This form maybe used to figure IRA deductions and taxable RSDI benefits.

- Worksheets 2, 3 and 4 of IRS Publication 915: These forms are used when a lump-sum payment of RSDI / RRB is received for an earlier tax year and included in the annualized total. Example: RSDI approved retroactively to October 2016 but payment was issued as a lump- sum in February 2017.

(appendix-h)(page-5)Page 5#

MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL

Division of Welfare and Supportive Services APPENDIX H Medical Assistance Manual DETERMINING COUNTABLE 17 Jul 01 MTL 04/17 PUBLICATION 915

WORKSHEET 1 - Example (see IRS Publication 915)

Example 1: George White is single and files Form 1040 for 2016. In addition to receiving social security payments, he received a fully taxable pension of $18,600, wages from a part- time job of $9,400, and taxable interest income of $990, for a total of $28,990. He received a Form SSA-1099 in January 2017 that shows his net social security benefits of $5,980 in box 5. To figure his taxable benefits, George completes Worksheet 1, shown below. On line 20a of his Form 1040, George enters his net benefits of $5,980. On line 20b, he enters his taxable benefits of $2,990.

(appendix-h)(page-6)Page 6#

MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL

APPENDIX H Division of Welfare and Supportive Services

DETERMINING COUNTABLE Medical Assistance Manual

RSDI FOR MAGI BUDGETING 17Jul 01 MTL 04/17

WORKSHEET 1 - Blank (see IRS Publication 915)

(appendix-i)Nevada Medical Assistance Manual (MAM): Appendix I Non-Citizen Documentation Matrix#

(appendix-i)(page-1)Page 1#

NEVADA STATE DIVISION OF WELFARE AND SUPPORTIVE SERVICES MEDICAL ASSISTANCE PROGRAM MANUAL APPENDIX I NON-CITIZEN DOCUMENTATION MATRIX

(appendix-i)(page-2)Page 2#

MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL APPENDIX I NON-CITIZEN DOCUMENTATION MATRIX Division of Welfare and Supportive Services Medical Assistance Manual 23 Jan 05 MTL 01/23

NON-CITIZEN DOCUMENTATION MATRIX

U.S. Immigrations Category U.S. Immigrations Documents Document Comments Paroled as Cuban Haitian Entrant (CHE) – Status • Form I-94, Arrival/Departure Record, with a Dept. of • U.S. immigration documentation is evidence of nationality. No additional Pending Homeland Security or legacy Immigration and Naturalization evidence of nationality is required. Service stamp noting “Cuban0Haitian Entrant (status Pending).” Paroled as a Refugee or Asylee • Form I-94 or Cuban or Haitian passport with a Dept. of • To be eligible under this provision, the I-94 must note that the individual is a  Acceptable documents for individuals paroled Homeland and Naturalization Service stamp noting “parole refugee or asylee as refugees or asylees under 212(d)(5) under 212(d)(5).” *

• Form I-766, Employment Authorization Document (EAD), • NONE with category code “C11” or “ao4”. The C11 code indicates that the individual was paroled into the United States.

*Documentation issued by U.S. Immigration and Customs • ****See Passport and/or Birth Certificate requirements listed at the end of the Enforcement (ICE), such as Form I-830m Notice to EOIR: document Alien Address containing information that the individual was released from ICE custody and paroled pursuant to 8 C.F.R 212.5 • “Memo of Agreement” with Migration and Refugee Services Pending Asylum Application • An EAD with a category code of “C08”. The C08 code • ****See Passport and/or Birth Certificate requirements listed at the end of the  Acceptable documents for individuals who indicates that the individual has a pending application for document have applied for Asylum but are still pending asylum. a decision • Form I797C, Notice of Action confirming USCIS receipt of the individual’s Application for Asylum and Withholding of Removal, Form I-589 Individual in Removal Proceedings • Documentation issued by the Department of Homeland • ****See Passport and/or Birth Certificate requirements listed at the end of the  Acceptable documents for Individuals in Security (DHS) or the Department of Justice (DOJ) document Removal Proceedings Executive Office for Immigration Review (EOIR) showing pending removal proceeding, such as Notice to Appear, DHS Form Refugees • I-94 Arrival/departure record noting that the individual has • Notations may include references to employment authorization, indefinite  Acceptable documents for refugees admitted been admitted under 207 of the INA status, and the requirement to obtain permission before leaving the United under 207 of the INA (Immigration and • RE-1 admission code on the I-94 States. Nationality Act) • RE-2 admission code on the I-94 • Principal Refugee • RE-3 admission code on the I-94 • Spouse of Principal Refugee • RE-4 admission code on the I-94 • Child of Principal Refugee

• Collateral relatives of a Principal Refugee (siblings, nieces, nephews, • RE-5 admission code on the I-94 cousins etc.) • 1-766 Employment Authorization Document with the code • Certain Haitian refugees A03 • NONE • DHS form I571

(appendix-i)(page-3)Page 3#

U.S. Immigrations Category U.S. Immigrations Documents Document Comments

• 1-730 letter • United States Refugee Travel Document

• The I-730 Approval Letter may be used as proof of refugee status for • Visa 93 or V-93 on the I-94 Arrival/departure card derivatives

• May be accompanied by the words “section 207”, individual is the spouse or • “Memo of Agreement” with Migration and Refugee Services minor child of a previously admitted refugee Asylees • I-94 Arrival/departure record referencing 208 of the • Notations may include references to employment authorization, indefinity  Acceptable documents for asylees whose INA status, and the requirement to obtain permission before leaving the United status was granted under 208 of the INA

States. • AS-1 admission code on the I-94 • Approved asylee principal • AS-2 admission code on the I-94 • Approved spouse of an asylee principal • AS-3 admission code on the I-94 • Approved child of an asylee principal • DHS Form I-571 • United States Refugee Travel Document • I-766 Employment Authorization Document with the • NONE code A05

• Order of an Immigration Judge Granting Asylum • An order of an Immigration Judge will serve as proof of asylee status if DHS under 208 of the INA has waived the right to appeal the case. • Asylum Approval Letter from a USCIS Asylum Office • Letter will note that the individual has been granted asylum pursuant to 208

of the INA and may include information concerning date of asylum, refugee

and asylee relative petition, work authorization and the refugee travel

document. • Written decision from the Board of Immigration

• NONE Appeals (BIA).

• I-730 Approval Letter • Visa 92 or V-92 on the I-94 Arrival/departure record • The I-730 Approval Letter may be used as proof of asylee status for • “Memo of Agreement” with Migration and Refugee derivatives Services • May be accompanied by the words “section 208”; individual is the spouse or minor child of a Cuban & Haitian Entrants I • An I-94 Arrival/departure record with a stamp • I-94 may refer to 212(d)(5)  Acceptable documents for Cuban & Haitian showing parole at any time as a “Cuban/Haitian

entrants, in accordance with the requirements Entrant (Status Pending)”

in 45 CFR 401.2 • CH6 adjustment code on the I-551 • “Memo of Agreement” with Migration and Refugee • Even after the Cuban/Haitian Entrant (Status Pending) becomes a Services permanent resident, he/she is still considered to be a Cuban and Haitian entrant Cuban & Haitian Entrants II • An I-94 Arrival/departure record showing parole into • I-94 may be to 212(d)(5)  A national of Cuba or Haiti who was paroled the United States on or after April 12, 1980

into the United States and has not acquired • A Cuban or Haitian passports with a 212(d)(5) any other status under the INA & with respect stamp dated on or after October 10, 1980 • NONE to whom a final, non-appealable, and legally • An I-94 Arrival/departure record showing parole into

enforceable order of removal, deportation or the United States • I-94 may refer to 212(d)(5), humanitarian or public interest parole exclusion has not been entered • I-766 Employment Authorization Document with the • NONE code A04

• I-766 Employment Authorization Document with the • NONE code C11 • “Memo of Agreement” with Migration and Refugee Services

(appendix-i)(page-4)Page 4#

U.S. Immigrations Category U.S. Immigrations Documents Document Comments Cuban & Haitian Entrants III • DHS Form I-221 • Order to Show Cause and Notice of Hearing  A national of Cuba or Haiti who is the • DHS Form I-862 • Notice to Appear subject of removal, deportation or • DHS Form I-220A • Order of Release on Recognizance exclusion proceedings under the INA and • DHS Form I-122 • Notice to Applicant Detained for a Hearing Before an Immigration with respect to whom a final, non-

Judge appealable, and legally enforceable order • DHS Form I-221S • Order to Show Cause, Notice of Hearing and Warrant for Arrest of removal, deportation or exclusion has

not been entered

• Application for Asylum and Withholding of Removal; Individual is • Copy of DHS Form I-589 date stamped by the subject of removal, exclusion or deportation proceedings. Executive Office for Immigration Review (EOIR) • Application to Register Permanent Residence or to Adjust Status; • Copy of DHS Form I-485 date stamped EOIR Individual is subject of removal, exclusion or deportation proceedings.

• Notice of Appeal from a Decision of an Immigration Judge, date • EOIR-26 stamped by the Board of Immigration Appeals

• Application for suspension of deportation/cancellation of removal submitted to DHS or EOIR • I-766 Employment Authorization Document with the • NONE code C10

• Other applications for relief that have been date • Example: a notice of a hearing date before an Immigration Judge or a stamped EIOR case appeal filing receipt from the Board of Immigration Appeals • Other documentation pertaining to an applicant’s removal, exclusion or deportation proceedings • “Memo of Agreement” with Migration and Refugee Services Cuban & Haitians Entrants IV • USCIS receipt for filing Form I-589 • Application for Asylum and Withholding of Removal  A national of Cuba or Haiti who has an • I-766 Employment Authorization document with the • NONE application for asylum pending with the code C08 DHS/USCIS or with an EOIR Immigration • “Memo of Agreement” with Migration and Refugee Court or the Board of Immigration Appeals Services and with respect to whom a final, non- appealable, and legally enforceable order of removal, deportation or exclusion has not been entered. Amerasians • AM-1 admission code on the I-94 • Amerasian born in Vietnam after Jan. 1, 1962, and before Jan. 1, 1976, who  Acceptable documents for certain Amerasians was fathered by a U.S. citizen (certain Amerasians from Vietnam who are • AM-2 admission code on the I-94 • Spouse or child of Amerasian admitted to the United States as immigrants • AM-3 admission code on the I-94 • Mother, guardian or next-of-kin of Amerasian pursuant to 584 of the Foreign Operations, • AM-6 adjustment code on Form I-551 • Permanent Resident Card (or Resident Alien Card) of Amerasian Export Financing, and Related Programs

• Permanent Resident Card (or Resident Alien Card) Spouse or child of Appropriations Act, 1988 of Public Law) • AM-7 adjustment code on Form I-551 Amerasian

• Permanent Resident Card (or Resident Alien Card) of Mother, guardian or • AM-8 adjustment code on Form I-551 next-of-kin of Amerasian

• “Laissez Passer”; may have temporary I-551 stamp • Vietnamese Exit Visa with codes AM-1, AM-2 or AM-3 • Vietnamese passport with codes AM-1, AM-2, AM-3 • May have temporary I-551 stamp • United States passport with codes AM-1, AM-2 or AM- 3 • NONE • “Memo of Agreement” with Migration and Refugee Services

(appendix-i)(page-5)Page 5#

APPENDIX I NON-CITIZEN DOCUMENTATION MATRIX Division of Welfare and Supportive Services Medical Assistance Manual 23 Jan 05 MTL 01/23

MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL

U.S. Immigrations Category U.S. Immigrations Documents Document Comments Lawful Permanent Residents • Form I-551 Permanent Resident Card (or Resident

 Acceptable documents for lawful permanent Alien Card) with the following codes:

residents who previously held one of the  RE6 above identified statuses.  RE7 • Adjusted Principal Refugee  Note that this DOES NOT refer to  RE8 • Spouse of Principal Refugee Amerasians or Iraqi and Afghan  RE9 • Child of Principal Refugee Special Immigrants, who are admitted  AS6 • Collateral Relatives of Principal Refugee as lawful permanent residents.  AS7 • Adjusted Principal Asylee  AS8 • Spouse of principal Asylee  CH6 • Child of Principal Asylee  HA6 • Adjusted Cuban/Haitian Entrant (Status Pending)  HB6 • Adjusted Cuban/Haitian Entrant (Haitian national who had applied for

asylum)  GA6

• Adjusted Cuban/Haitian Entrant (Haitian national who had been  GA7 paroled)  GA8 • Adjusted Iraqi asylee  ST6 • Souse of GA6  ST7 • Child of GA6  ST8 • Victim of a Severe Form of Trafficking  ST0 • Spouse of a ST6  ST9 • Parent of a Victim of a ST6

• Sibling of a Victim of a ST6 • Foreign Passport with unexpired, temporary I-551

stamp and the following codes:  RE6

 RE7 • Adjusted Principal Refugee  RE8 • Spouse of Principal Refugee  RE9 • Child of Principal Refugee  AS6 • Collateral Relatives of Principal Refugee  AS7 • Adjusted Principal Asylee  AS8 • Spouse of Principal Asylee

• •

Child of Principal Asylee

Employment Authorization Documents:  Form I-766 Employment Authorization Document with the code A10  Note: this code only confirms eligibility for Cuban or Haitian nationals. Iraqi & Afghan Special Immigrants • Principal Applicant Iraqi or Afghan Special Immigrant • Iraqi or Afghan passport with an immigrant visa stamp noting that  Acceptable documents for Iraqi & Afghan

the individual has been classified under IV (Immigrant Visa) Special Immigrants

Category SI1 or SQ1 and DHS stamp or notation on passport or I-94 showing date of admission • Spouse of Principal Applicant Iraqi or Afghan Special • Iraqi or Afghan passport with an immigrant visa stamp noting that Immigrant the individual has been classified under IV (Immigrant Visa)

Category SI2 or SQ2 and DHS stamp or notation on passport of I-94

showing date of admission • •

Iraqi or Afghan passport with an immigrant visa stamp noting that

Unmarried Child Under 21 Years of Age of Iraqi or the individual has been classified under IV (Immigrant Visa) Afghan Special Immigrant Category SI3 or SQ3 and DHS stamp or notation on passport of I-94 showing date of admission • DHS Form I-551 (“green card”) with an IV (immigrant visa) code for

(appendix-i)(page-6)Page 6#

U.S. Immigrations Category U.S. Immigrations Documents Document Comments

category SI6 or SQ6

• DHS Form I-551 (“green card”) with an IV (immigrant visa) code for • Principal Applicant Iraqi or Afghan Special Immigrant category SI7 or SQ7 Status in the United States

• Spouse of Principal Applicant Iraqi or Afghan Special • DHS form I-551 (“green card”) with an IV (immigrant visa) code for Principal Applicant Adjusting Status in the United category SI8 or SQ8 States

• Unmarried Child Under 21 Years of Age of Iraqi or • Same as above Afghan Special Immigrant • Principal Applicant Adjusting Status in the United States. • “Memo of Agreement” with Migration and Refugee Services Unaccompanied Refugee Minors  Unaccompanied Minor who holds one of the following • In addition to unaccompanied minors in the above categories,  Acceptable Documents for the ORR statuses: the following are eligible for the ORR Unaccompanied Refugee Unaccompanied Refugee Minors (URM)  Refugee, Asylee, Cuban/Haitian Entrant, Victim of Minors (URM) Program: Program Trafficking with an Eligibility Letter from OTIP, LPR  Unaccompanied Minor with Special Immigrant Juvenile who has held one of those statuses, Amerasian, Status (SIJS) under 8 U.S.C 1101(a)(2)(J), who was in the Iraqi/Afghan Special Immigrant custody of the Secretary of Health and Human Services at  Minor with Special Immigrant Juvenile Status (SIJS) the time the dependency order was granted for such child  Unaccompanied Minor who holds U status or U visa or was receiving service pursuant to section 501(a) of the  “Memo of Agreement” with Migration and Refugee Refugee Education Assistance Act of 1980 (8 U.S.C. 1522 Services note) at the time such dependency order was granted.  Unaccompanied Minor who has been granted U status per section 101(a)(15)(U) of the Immigration and Nationality Act (8 U.S.C 1101 (a)(15)(U). • 1-797 Notice of Action indicating SIJS status, i.e. evidence of approved I-360, or evidence of approved I-360 and approved I-485 OR • Visa indicating SIJS status with SL class of admission code OR • I-551 indicating SIJS status with SL class of admission code AND • Evidence that at the time a Dependency Order was issued, was either: in the custody of the ORR Unaccompanied Children’s (UC) Program OR • Receiving federal benefits or services as a Cuban/Haitian Entrant • I-797 Notice of Action indicating U status • U Visa • I-94 Arrival/departure record showing admission U status Victims of Human Trafficking • Victims of a Severe Form of Trafficking in Persons • Certification Letter, Eligibility Letter, or Interim Assistance Letter from  Acceptable documents for Victims of a

ACF Office (Administration for Children & Families) on Trafficking in Severe Form of Trafficking in Persons

Persons (OTP) • Call the trafficking verification line at (866)401-5510 to confirm the

validity of the Certification Letter

• Certification and Eligibility Letters DO NOT expire

• Derivative T status: T-2, T-3, T-4, T-5 or T-6 (D • The date of eligibility for benefits and services is the Notice Date on • Family member of Victim of a Severe Form of the I-797, Notice of Action of approval of that individual’s Derivative Trafficking in Persons: T status. • Family member already in United States on date T • Persons with derivative T status do not receive and are not required status granted to present a Certification Letter or Eligibility Letter to demonstrate eligibility for benefits or services

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U.S. Immigrations Category U.S. Immigrations Documents Document Comments

• Derivative T visa: T-2, T-3, T-4, T-5 or T-6 visa

• The of entry for benefits and services is the date of admission stamped on that individual’s passport or I-94 Arrival Record • Family member of a Victim of a Severe Form of • Persons with derivative T visas do not receive and are not required Trafficking: to present a Certification Letter or Eligibility Letter to demonstrate • Family Member enters the United States on the basis eligibility for benefits or services of a derivative T Visa • “Memo of Agreement” with Migration and Refugee Services ****The information below pertains to individuals Paroled as Refugee or Asylee, Pending Asylum Application or Individual in Removal Proceedings

If Born In Cuba: • Expired or unexpired Cuban passport that lists the holder's place of birth as being Cuba; or • Cuban birth certificate issued by the appropriate civil registry in Cuba If Born Outside Cuba: • Unexpired Cuban passport; • Nationality Certificate or • Citizenship Letter

Note: A Cuban consular certificate documenting an individual's birth outside of Cuba to at least one Cuban parent is not sufficient evidence to establish Cuban citizenship. This is true even if the consular certificate states that the individual to whom the certificate was issued is a Cuban citizen.

Note: A Cuban birth certificate acknowledging a birth outside of Cuba or Cuban consular birth record issued for a principal applicant who was not born in Cuba is not sufficient to prove Cuban citizenship. A birth certificate issued by an entity outside of Cuba is not sufficient evidence to establish Cuban citizenship. If Born In Haiti: • Expired or unexpired Haitian passport; • National Identity Card (also known as a Voting Card); • Birth certificate with photo identification; or • Birth Extract Issued by Haitian National Archives accompanied by photo identification If Born Outside Haiti: • Unexpired Haitian passport; • National Identity Card (also known as a Voting Card); or • Certificate of naturalization or certificate of citizenship issued by the Haitian government accompanied by photo identification

(b-100)Nevada Medical Assistance Manual (MAM): B-100 Modified Adjusted Gross Income (MAGI) Medical Categories#

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MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI B-100 MAGI MEDICAL CATEGORIES Division of Welfare and Supportive Services Medical Assistance Manual 24 Apr 02 MTL 03/24 OVERVIEW MAGI MEDICAL CATEGORIES B-100 OVERVIEW Eligibility for medical assistance is categorized in groups based on budgeting methodologies associated to the eligibility determination. Family Medical groups - cover individuals, families and children in Medicaid and Nevada Check Up, eligibility is determined using the MAGI budgeting methodologies. These groups have no resource test. Specialized Medical groups - cover individuals in specialized groups such as Aged Out of Foster Care, Rite of Passage, and Breast and Cervical. This group allows for exemptions from income and resource determinations. MAABD groups - cover aged, blind, and disabled individuals using non-MAGI and SSI budgeting methodologies. These groups can have a resource test for some programs. Individuals requesting medical assistance must be evaluated under all potential medical groups including Nevada Check Up prior to being referred to the insurance marketplace. Individuals determined ineligible due to excess income will be referred to the insurance marketplace where they can apply for either a cost- sharing reduction or an advanced premium tax credit they can use to shop for private insurance. Lawful Permanent Residents (LPRs), which are ineligible for Medicaid because they are serving the 5-year bar, may still be eligible to purchase private insurance through the insurance marketplace and may even receive a cost-sharing reduction or an advance premium tax credit. Individuals Pending an SSI Decision If an individual is pending an SSI decision, staff must evaluate the individual’s eligibility for any of the Medicaid groups listed above, including the new childless adult group, until a decision is made by SSA. If the individual is determined to be eligible in another Medicaid group: • approve eligibility under the new Medicaid group in the appropriate month; and • deny the MAABD pending SSI case effective the same month you are approving; and • keep the MAABD SSI pending for months which are not covered by another category, until an SSI decision is received from SSI for those months. A new application is not required to move between a MAGI group and non-MAGI groups. Additional information may be required to complete the conversion. See Conversions section in MAM D-540 for more information. For each individual applying for Medicaid in the household, determine what Medicaid coverage group the individual qualifies for based on the following hierarchy.

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MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI B-140 MAGI MEDICAL CATEGORIES Division of Welfare and Supportive Services Medical Assistance Manual 24 Apr 02 MTL 03/24 EMERGENCY MEDICAID MAGI • Children 18 years old and under • Pregnant or Postpartum Woman • Parents or Caretaker Relatives • Aged Out of Foster Care Adults 19-26 years old • Childless Adults or Parents where all their children are 19 years and older For example, if an individual is both a child (Age 0-18) and a parent and/or pregnant they would start their eligibility evaluation with the child coverage group. B-105 FAMILY MEDICAL COVERAGE GROUPS B-110 PARENTS AND OTHER CARETAKER RELATIVES (435.4, 435.110, 435.911) Provides medical assistance to: • A relative of a dependent child by blood, adoption, or marriage with whom the child is living, who assumes primary responsibility for the child's care, and who is one of the following: • the child's father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew or niece; or • the spouse of such parent or relative, even after the marriage is terminated by death or divorce; or • another relative of the child based on blood (including those of half-blood), adoption, or marriage; or • the domestic partner of the parent or other caretaker relative; or • an adult with whom the child is living and who assumes primary responsibility for the dependent child's care. b. Parents and caretakers with household income that is at or below the AM income limit for the applicable family size. c. Parents and caretakers with income between the AM income limit and 138% of FPL (AM1 aid code) who are; 1. age 19 and under age 65; and 2. not pregnant; and 3. not entitled to or enrolled in Medicare under Part A or B; and 4. not otherwise eligible for medical coverage in any other group; and 5. not eligible if living with a dependent child under the age 19 who is not receiving benefits under Medicaid, Nevada Check Up, or otherwise is enrolled in minimum essential coverage. Note: Caretaker relative cases will list the child as the head of household with the caretaker listed as a specified caretaker.

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MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI B-140 MAGI MEDICAL CATEGORIES Division of Welfare and Supportive Services Medical Assistance Manual 24 Apr 02 MTL 03/24 EMERGENCY MEDICAID MAGI B-110.1 Joint Custody In cases involving parents with joint custody (parents share physical custody of the children), regardless of a court order, the worker should assume the applicant (parent submitting the application) is the primary custodial parent unless evidence to the contrary is presented. If the applicant states s/he is the primary custodial parent, no additional information is required. The case should be processed using normal case processing policy. a. When the applicant is uncertain whether s/he is the primary custodial parent, the worker must inquire further. By gathering the facts such as where the child(ren) are zoned for school, the parent responsible for providing daycare and/or medical care, which parent claims the child(ren) as dependent(s) on the income tax return, etc., the worker should be able, using prudent judgment, to determine if the applicant is the primary custodial parent. If the facts obtained from the inquiry indicate the applicant is the primary custodial parent, the case should be processed using normal case processing policy. Consider the time spent with the other parent as a temporary absence. b. When the applicant claims “true” joint custody, all of the following must exist: • the child(ren) actually alternate between parents each week (or some period less than a month); and • both parents exercise parental guidance and control; and • both parents provide equal financial support (no child support ordered or voluntarily being paid); and • the applicant is unwilling to indicate the primary custodial parent. If any one of the statements in “b” above is not present, “true” joint custody does not exist and the worker should process the case according to “a” above. B-115 PREGNANT WOMAN AND POSTPARTUM (435.4, 435.116, 435.911) Provides medical assistance to: a. Pregnant women during pregnancy and the extended 12-month postpartum period. Note: Postpartum services are provided for 12-months following the child’s birth month. Pregnant women must apply for assistance while pregnant to receive postpartum services. A Medicaid eligible woman who becomes pregnant is considered to have applied for assistance while pregnant and is eligible for postpartum services. • Pregnant women with countable household income that is at or below 190% FPL for the applicable family size. Note: Each unborn is counted as an additional member when determining the assistance unit size for the pregnant woman’s assistance unit. Once eligibility is established, a pregnant woman remains eligible for medical coverage throughout the pregnancy and postpartum period regardless of changes in countable income and cooperation with child support. The pregnant and postpartum woman must still meet residency and TPL requirements.

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MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI B-140 MAGI MEDICAL CATEGORIES Division of Welfare and Supportive Services Medical Assistance Manual 24 Apr 02 MTL 03/24 EMERGENCY MEDICAID MAGI Verification: Customer attestation must be accepted for verification of pregnancy, estimated date of confinement and the number of unborns. B-120 INFANTS AND CHILDREN UNDER AGE 19 (435.118, 435.911) Provides medical assistance to children who are: a. Under the age of 19; and b. Household income that is at or below the FPL for the child’s age and applicable family size. 1. Children 0 through 5 up to 165% (CH aid code) 2. Children 6 through 18 up to 122% (CH aid code) 3. Children 6 through 18 above CH up to 138% (CH1 aid code) ➢ Children under this category cannot be enrolled in Medicare. ➢ Children under this category cannot have other major medical coverage. Note: Individuals under the age of 19 who claim either Tax-Filer or Non-Filer status must follow all rules associated with their tax status (see MAM E-105). B-120.1 Deemed Newborn Children (also known as OBRA) (435.117) Provides medical assistance to children from birth until the child's first birthday without application if, for the date of the child's birth, the child's mother was eligible for and received covered services under: a. Medicaid (including during a period of retroactive eligibility) regardless of whether services for the mother is limited to an emergency medical condition; or b. Nevada Check Up as a low-income pregnant woman, with household income at or below 205% of FPL; or c. A lawfully residing non-citizen pregnant woman, who does not meet the 5-year bar, who qualifies under the CHIPRA 214 option with income at or below 190% of FPL. The child is deemed to have applied and been determined eligible effective from the date of birth, and remains eligible regardless of changes in circumstances until the child's first birthday, unless: a. the child dies; or b. the child is no longer a resident of the State; or c. the child's representative requests a voluntary termination of eligibility.

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MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI B-140 MAGI MEDICAL CATEGORIES Division of Welfare and Supportive Services Medical Assistance Manual 24 Apr 02 MTL 03/24 EMERGENCY MEDICAID MAGI Eligibility for OBRA cannot continue after the child becomes 13 months old. (e.g., if the child is born on 1/5/14, eligibility for OBRA Medicaid is provided from 1/5/14 through 1/31/15. An RD must be completed for February 2015 and ongoing eligibility). Newborns no longer receive the mother’s aid code. Newborns born to a Medicaid eligible women will be determined eligible for Medicaid based on the household size and income limit starting with CH, then CH1, and will move to CH5 only if the countable income is too high and the newborn would be otherwise ineligible. B-120.2 Nevada Check Up (NCU) - Children with Income Above Medicaid Limits and Below 205% FPL (42 CFR 457) Provides medical assistance to children who: a. are children under 6 with income between 166-205% FPL and children 6-18 with income between 139%-205% and eligible for at least one month of coverage; and b. are not eligible for or currently enrolled in any other Medicaid assistance group; and c. are not currently insured at initial application or annual redetermination (RD) (children with dental, vision and/or insurance coverage inaccessible in Nevada may be evaluated for NCU eligibility. Families may maintain any of the coverage listed here); and • If other medical insurance coverage is obtained during the 12-month NCU enrollment period, enrollment will continue until the time of RD. If at the time of RD, the child/ren have medical insurance coverage, the child/ren must be terminated. d. are not an inmate of a public or penal institution (i.e., Juvenile Justice Centers, law enforcement, etc). Once released, the child will be reinstated to the previously established household status beginning the next administrative month; • Children that are in the custody of Child Welfare Services (such as Division of Child and Family Services) will be terminated from NCU even when there is a reunification plan in place. Note: It is possible for one child in a household to be covered by Medicaid, while another child in the same household is eligible for Nevada Check Up. Verification: Customer statement must be accepted for verification of other insurance and current enrollment status. B-125 CHILDLESS ADULTS / INDIVIDUALS AGE 19 THRU 64 (435.119, 435.911) Provides medical assistance to individuals who are: a. age 19 and under age 65; and b. not pregnant; and

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MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI B-140 MAGI MEDICAL CATEGORIES Division of Welfare and Supportive Services Medical Assistance Manual 24 Apr 02 MTL 03/24 EMERGENCY MEDICAID MAGI c. not entitled to or enrolled in Medicare benefits under Part A or B; and d. not otherwise eligible for medical coverage in any other group; and e. members of a household that has income that is at or below 138% FPL for the applicable family size. B-130 TRANSITIONAL MEDICAID COVERAGE (1925, 435.112) Extended Medicaid coverage is provided to parents or other caretaker relatives who were eligible and approved under the AM aid code in at least 3 out of the 6 months immediately preceding the month that eligibility is lost due to increased income from employment. Households with parents or other caretaker relatives who are eligible under aid codes other than AM, such as AM1, CH/P, CA, etc., do not initiate transitional Medicaid. The agency must continue to provide transitional Medicaid for 12 months to all members of the household. The 12-calendar month period begins the month after AM eligibility for the parent/caretaker is terminated. Transitional Medicaid continues for 12 months regardless of changes in income. Note: Prior to approving Transitional Medicaid, if information is received by the agency which indicates a household was incorrectly determined eligible for AM, the household would be ineligible for Transitional Medicaid. Re-evaluate the Medicaid case for any other possible category before terminating assistance, allowing for adverse. A referral to Investigations & Recovery would be needed for any potential Medicaid overpayments. If Transitional Medicaid is already approved and there is no adverse to stop the initial month of Transitional Medicaid, the household cannot be terminated from Transitional Medicaid unless it meets one of the failure reasons listed below. Transitional Medicaid will only terminate if: a. The assistance unit ceases to include a child. Terminate the Transitional Medicaid case, allowing for adverse, in the first month after the child is no longer residing in the home. Evaluate the assistance unit members for other applicable medical categories. b. The household moves out of state. c. Non-cooperation with Third-Party Liability (TPL). For more information see MAM C-600 & C- 610.1.

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MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI B-140 MAGI MEDICAL CATEGORIES Division of Welfare and Supportive Services Medical Assistance Manual 24 Apr 02 MTL 03/24 EMERGENCY MEDICAID MAGI B-135 POST MEDICAL (435.115) Extended medical assistance is provided to individuals eligible under AM who were eligible and enrolled in Medicaid in at least 3 out of the 6 months immediately preceding the month that eligibility is lost due to increased income from the collection of spousal support under IV-D. Post Medical eligibility includes all parents or other caretaker relatives and children of such parents and caretaker relatives who were eligible and enrolled in at least 3 of the 6 months. Note: The system does not determine Post Medical eligibility automatically and requires an override to create eligibility. B-140 EMERGENCY MEDICAID MAGI (435.139, 435.406) Provides limited medical assistance for emergency services to residents of the state who meet the eligibility requirements of any MAGI medical group (except Nevada Check Up) and who are qualified non- citizens who have not met the 5-year bar or are non-qualified non-citizens. Non-qualified non-citizens are not required to provide verification of a social security number or documentation of immigration status. These individuals are only entitled to coverage for emergency services. Some non-citizens may be lawfully admitted, but only for a temporary or specified time period. These individuals do not meet Nevada residency requirements, and include: – foreign government representatives on official business, and their families and servants; – visitors for business or pleasure, including exchange visitors; – aliens in travel status while traveling directly through the U.S.; – crewman on shore leave; – treaty traders and investors, and their families; – foreign students; – international organization representation and personnel, and their families and servants; – temporary workers including agricultural contract workers; and – members of foreign press, radio, film, or other information media and their families. Individuals who request assistance under this category must meet all eligibility criteria, with the exception of citizenship, including: a. residency; and b. income eligibility for one of the MAGI groups;

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MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI MAGI B-140 MAGI MEDICAL CATEGORIES Division of Welfare and Supportive Services Medical Assistance Manual 24 Apr 02 MTL 03/24 EMERGENCY MEDICAID MAGI Exception: Emergency medical does not apply to Nevada Check Up. Individuals are approved for emergency medical only for the months requested and determined eligible. Individuals with recurrent applications may remain eligible under the emergency medical category as an ongoing Medicaid case without having to submit a separate application for each month. A redetermination is required every 12 months.

(b-200)Nevada Medical Assistance Manual (MAM): B-200 Specialized Medical Categories#

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL

Division of Welfare and Supportive Services B-200 Medical Assistance Manual SPECIALIZED MEDICAL CATEGORIES 13 Oct 01 MTL 01/13 OVERVIEW SPECIALIZED MEDICAL CATEGORIES B-200 OVERVIEW Eligibility for medical assistance is categorized in groups based on budgeting methodologies associated to the eligibility determination. Family Medical groups - cover individuals, families and children in Nevada Check Up using the MAGI budget methodologies. These groups have no resource test. Specialized Medical groups - cover individuals in specialized groups such as Aged Out, Rite of Passage and Breast and Cervical and allows for exemptions from income and resource determinations. MAABD groups - cover aged, blind and disabled individuals using SSI budgeting methodologies. These groups have a resource test. Individuals requesting medical assistance must be evaluated under all potential medical groups including Nevada Check Up prior to being referred to the exchange. Individuals determined ineligible due to excess income will be referred to the Nevada Health Link to apply for advanced premium tax credits and shop for insurance. LPRs, which are ineligible because they are serving the 5 year bar, may be eligible to purchase insurance through the exchange and receive advance premium tax credit. If an applicant is pending an SSI decision, evaluate eligibility for all Medicaid categories, including the new childless adult group, until a decision is made by SSA. If the individual is determined to be eligible in another category:  approve eligibility in the appropriate month; and  deny the MAABD pending SSI case effective the same month of approval; and  keep SSI pending for months which are not covered by another category, until an SSI decision is received. A new application is not required to move between a MAGI group and non-MAGI groups. Additional information may be required to process the conversion. See Conversions section in D-500 for more information.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL

B-205 Division of Welfare and Supportive Services SPECIALIZED MEDICAL CATEGORIES Medical Assistance Manual SPECIALIZED MEDICAID ELIGIBILITY GROUPS MTL 01/13 01 Oct 13 B-205 SPECIALIZED MEDICAID ELIGIBILITY GROUPS The following eligibility groups provide exemptions from income and resource calculations when determining Medicaid eligibility. Exempt all income and resources of the children when determining eligibility in the Specialized Medicaid eligibility groups. B-210 MEDICAID FOR CHILDREN FOR WHOM A PUBLIC AGENCY HAS ASSUMED FINANCIAL RESPONSIBILITY Medicaid is available for some children for whom financial responsibility is assumed in whole or in part by a public agency. Public agencies include county, state and Native American social service agencies. The Division of Child and Family Services (DCFS) is a qualifying public agency only if: a. the agency is assuming partial or full financial responsibility for the child; and b. the child is placed at Desert Willow; and c. DCFS DOES NOT have custody of the child. Children must be: a. less than 18 years of age; or 18 years of age and full time student in a secondary school; or in an equivalent level of vocational or technical school; and b. expected to complete secondary school or the vocational/technical school program before reaching age 19. B-215 MEDICAID ELIGIBILITY FOR TITLE IV-E ELIGIBLE FOSTER CHILDREN AT RITE OF PASSAGE This category provides medical assistance to children who are: a. less than 18 years of age; and b. residing at the Rite of Passage facility in Nevada; and c. eligible for and receiving IV-E foster care benefits from the custodial state.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL

Division of Welfare and Supportive Services B-220 Medical Assistance Manual SPECIALIZED MEDICAL CATEGORIES 16 Nov 01 MTL 05/16 AGED OUT OF FOSTER CARE PROGRAM B-220 AGED OUT OF FOSTER CARE PROGRAM (435.150, 435.226) This category provides medical assistance to children who are:

a. under 26 years of age; and

b. were in foster care in Nevada, under the responsibility of the state or a tribal entity at the time they turned 18 years of age; and

c. were enrolled in Medicaid while in foster care;

d. under 21 years of age; and

e. were in foster care under the responsibility of a state or tribal entity at the time they turned 18 years of age. B-225 BREAST\CERVICAL CANCER MEDICAID (Public Law 106-354) Medical assistance is provided to women who: a. are under age 65;

b. are uninsured or underinsured;

c. are not eligible under any other Medicaid eligibility group;

d. are enrolled and active in the Women’s Health Connection program for breast and cervical cancer by the “Centers for Disease Control and Prevention” (CDC); and

e. are found to need treatment for either breast or cervical cancer. A woman is considered to be underinsured when she:

a. is in a period of exclusion (such as a preexisting condition exclusion or an HMO affiliation period);

b. is not actually covered for treatment of breast or cervical cancer; or

c. has contract health care coverage through Indian Health Services or Tribal

Clinics.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL B-225 Division of Welfare and Supportive Services SPECIALIZED MEDICAL CATEGORIES Medical Assistance Manual BREAST/CERVICAL CANCER MEDICAID 17 Jul 01 MTL 04/17 A woman is considered to have been screened if she: a. has received a screening mammogram, clinical breast exam, or pap test; OR b. has received diagnosis of breast or cervical cancer or of a pre-cancerous condition of the breast or cervix as the result of the screening under the CDC program. A woman is considered to need treatment if: a. in the opinion of her treating health professional, the diagnostic evaluation following the clinical screening indicates she is in need of treatment services. Note: Services include diagnostic services necessary to determine the extent and proper course of treatment, as well as treatment itself. B-225.1 MCB Presumptive Eligibility Eligibility begins the date on which the Women’s Health Connection’s (WHC) contracted provider determines the individual meets the above eligibility requirements. Once approved, the DWSS case manager sends an application for assistance to the individual. If the individual does not file an application for assistance by the last day of the month following the month during which presumptive eligibility was determined, medical assistance may be terminated. A woman’s Medicaid eligibility ends when her course of treatment is completed or she no longer meets the criteria for this eligibility category. A woman eligible in this category is eligible for all Medicaid services. Note: The MCB presumptive eligibility program is not currently approved through the hospital presumptive eligibility portal. Applications and Form 2591-EM are submitted directly to DWSS and will be referred to the Elko District Office.

(b-300)Nevada Medical Assistance Manual (MAM): B-300 Medical Assistance for the Aged, Blind, and Disabled (MAABD) Medical Categories#

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD B-300 MAABD MEDICAL CATEGORIES Division of Welfare and Supportive Services Medical Assistance Manual 25 Mar MTL 02/25 OVERVIEW MAABD MEDICAL CATEGORIES B-300 OVERVIEW Eligibility for medical assistance is categorized in groups based on budgeting methodologies associated to the eligibility determination. Family Medical Groups - cover individuals, families and children in Nevada Check Up using the MAGI budget methodologies. These groups have no resource test. Specialized Medical Groups - cover individuals in specialized groups such as Aged Out, Rite of Passage and Breast and Cervical and allows for exemptions from income and resource determinations. MAABD Groups - cover aged, blind and disabled individuals using SSI budgeting methodologies. These groups have a resource test. Individuals requesting medical assistance must be evaluated under all potential medical groups including Nevada Check Up prior to being referred to the exchange. Individuals determined ineligible due to excess income will be referred to the Nevada Health Link to apply for advanced premium tax credits and shop for insurance. LPRs, who are ineligible because they are serving the 5-year bar, may be eligible to purchase insurance through the exchange and receive advance premium tax credit. If an applicant is pending an SSI decision, evaluate eligibility for all Medicaid categories, including the childless adult group, until a decision is made by SSA. If the individual is determined to be eligible in another category: • Approve eligibility in the appropriate month; and • Deny the MAABD pending SSI case effective the same month of approval; and • Keep SSI pending for months which are not covered by another category, until an SSI decision is received. A new application is not required to move between a MAGI group and non-MAGI groups. Additional information may be required to process the conversion. See Conversions section in D-500 for more information. B-305 AGED BLIND AND DISABLED Medicaid eligibility under the Aged, Blind and Disabled groups are determined using Social Security Income (SSI) budget methodologies and are exempt from the MAGI methodology. SSI budgeting methodologies include a resource determination. Individuals 65 years of age or older, blind or disabled, should be evaluated for eligibility under the MAABD groups.

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD B-305 MAABD MEDICAL CATEGORIES AGED BLIND AND DISABLED Division of Welfare and Supportive Services Medical Assistance Manual 25 Mar MTL 02/25 Aged Individuals -must be 65 years or older. Blind – determined blind according to Social Security Administration criteria. Disabled Individuals – individual must meet the disability criteria established by the Social Security Administration (SSA). The determination can be made by Social Security or the Division of Health Care Financing and Policy (DHCFP). B-310 MEDICARE BENEFICIARIES The Medicare Beneficiary program provides qualified Medicare eligible individuals with coverage of their Medicare premiums, as well as co-pays and deductibles for some qualified beneficiaries. Individuals enrolled in the Medicare Beneficiary program are also entitled to have reduced Part D prescription drug premiums through Social Security’s Low-Income Subsidy program. Individuals eligible under the QMB and SLMB Medicare Beneficiary groups may also be eligible for full Medicaid benefits under the AM, SSI, Institutional and Home-Based Waiver categories. These individuals are referred to as dual eligible. When an applicant is enrolled in Medicare Part A but is not enrolled in Part B, do not make them apply for Part B. Part B can be initiated by accretion to the Buy-In. Add the MEDI record, and post eligibility. This will generate an accretion request by the system and allow enrollment at no cost to the recipient. If an open enrollment start date is reflected in the SOLQ, Medicare Beneficiary eligibility will override the open enrollment start date. Note: For ongoing full Medicaid recipients who are enrolled in Part A only, see Section C-605.1. When an applicant is already enrolled in Part B, but is not enrolled in Part A, do not make them apply for Part A. Add MEDI record and post eligibility to cover their Part B premium. If they are QMB, the system will generate an accretion request to initiate Part A at no cost to the recipient. When an applicant is aged and has met the 5-year bar citizenship requirement but has never enrolled into Medicare and does not qualify for full Medicaid - add MEDI record based on their entitlement to enroll, then post eligibility. Complete a Public Welfare Accretion (PWA) letter and advise the customer to present the completed form to Social Security when they apply for Medicare. The PWA form allows enrollment at no cost to the recipient. Allow the individual 10 days from their first day of eligibility to provide verification of enrollment. Terminate the case for noncooperation if they do not enroll. NOTE: PWA is needed for customers who DO NOT qualify for the premium free Medicare Part A and whose countable income would be at the Medicare Savings Program level of SLMB, QI and/or QDWI. Conditional Part A – If an aged applicant appears to have not worked the 40 quarters (10 years) necessary for free Part A and appears to be eligible for QMB only, pend for enrollment into Conditional Part A and Part B. Complete the Conditional Part A Enrollment Form (2776-EM) and advise the customer to take the form to SSA to enroll into Conditional Part A and Part B. Allow 20 days in which to provide proof of

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD B-310 MAABD MEDICAL CATEGORIES Division of Welfare and Supportive Services Medical Assistance Manual 25 Mar MTL 02/25 MEDICAL BENEFICIARIES enrollment. Once proof of enrollment is received, post QMB eligibility and send an email to the DHCFP Buy-In Inbox (buyin@dhcfp.nv.gov) requesting accretion for both Part A and Part B effective the first month of QMB. DHCFP will alert SSA that the customer’s premiums are being paid by the State and the “conditional” piece of their Part A will be removed allowing the customer to be enrolled into premium- free Part A and Part B Medicare and Buy-In. If the customer does not return proof of enrollment into Medicare within 20 days, deny MAABD due to non-cooperation. Note: Coverage of Part A premiums is available only to QMB recipients. SLMB and QI covers Part B only. If a customer appears to be eligible for SLMB or QI, do not send them to enroll into Conditional Part A. If the aged applicant appears to have worked the 40 quarters (10 years) necessary for free Part A, either by working or deemed from a spouse, pend for enrollment into free Part A only. Do not send them with the Conditional Part A Enrollment form, as Conditional Enrollment into Part A is only necessary for individuals who do not have free Part A. Allow 20 days in which to provide proof of enrollment. Once received, DWSS will initiate Part B from the first month of approval by a manual accretion performed by DHCFP, thereby avoiding any billing to the customer for Part B. Send an email to the Buy-In Inbox (buyin@dhcfp.nv.gov) once QMB, SLMB, or QI is approved, requesting the accretion to Part B. If the customer does not return proof of enrollment into Medicare within 20 days, deny MAABD due to non- cooperation. Note: For ongoing full Medicaid recipients who become entitled to Medicare see section C-605.1. Note: Individuals eligible for Medicare are not eligible to receive benefits under the NCU, CH1, AM1 or CA groups. B-310.1 Low Income Subsidy (LIS) Referrals Individuals eligible for Social Security’s LIS program receive reduced premium payments for their Part D prescription drug program. The Social Security Administration transmits applicant information from LIS applicants to DWSS. DWSS must treat this data as an application for the Medicare Beneficiary programs. Application processing timeframes are determined by the date the file is received by DWSS. The eligibility determination is established based on the date the LIS application was received by Social Security. QMB effective dates remain the same when processing LIS referral applications. Example: LIS file is received by DWSS on January 29, 2024. Application effective date (date LIS application is received at Social Security) is December 2, 2023. Applicant meets all eligibility requirements for QI eligibility, decision date is February 20, 2024, first month of eligibility would be December 2023. If the same applicant was determined eligible for QMB, first month of eligibility would be March 2024. B-310.2 Qualified Medicare Beneficiaries (QMB) Covers only Medicare co-pays, premium and deductible charges for individuals who: a. Are currently enrolled or eligible to enroll in Medicare Part A; and

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD B-310.2 MAABD MEDICAL CATEGORIES QUALIFIED MEDICARE BENEFICARIES (QMB) Division of Welfare and Supportive Services Medical Assistance Manual 25 Mar MTL 02/25 b. Have net countable income at or below 100% of FPL; and c. Have countable resources at or below $9,430 for individuals and $14,130 for married couples. Note: Individuals with QMB coverage receive a Medicaid card for billing Medicare co-pays and deductibles only. QMB coverage includes having their Part A and Part B premiums paid for by the Division, and payment for deductibles and co-insurance for services covered by Medicare but not normally covered by Medicaid. This category of assistance is different from all other categories. In addition to not receiving full Medicaid benefits: a. They do not have to pay patient liability if they are institutionalized, unless the case is converted to a state institutional case. b. They are eligible beginning the month immediately following the month the eligibility decision is made (they are not eligible for prior medical coverage). Note: If it is found QMB coverage was denied in error, use the denial decision date and approve benefits the month following this date. If QMB is terminated in error, reinstate coverage so there is no break in benefits. c. Individuals applying for QMB are not required to apply for benefits which may be available to them. Note: If a QMB eligible woman reports she is pregnant, evaluate Medicaid under the pregnant woman group. B-310.3 Special Low-Income Medicare Beneficiaries (SLMB) Covers only the Part B Medicare premium payment for aged and disabled individuals who: a. Are currently enrolled or eligible to enroll in Medicare Part A; and b. Have net countable income 100% - 120% of FPL; and c. Have countable resources at or below $9,430 for individuals and $14,130 for married couples. Note: SLMB does not pay for co-payments or deductibles. A Medicaid card will not be issued. Coverage begins with the application month, and prior medical coverage is available for up to three months prior to the application month to cover the Medicare premiums. The Medicare premium is considered proof of service for prior medical requests.

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD Division of Welfare and Supportive Services B-310.3 Medical Assistance Manual MAABD MEDICAL CATEGORIES 25 Mar MTL 02/25 SPECIAL LOW-INCOME MEDICARE BENEFICARIES (SLMB) Note: If a SLMB eligible woman reports she is pregnant, evaluate Medicaid under the pregnant woman group. B-310.4 Qualified Individuals (QI) Covers only the Part B Medicare premium payment for aged and disabled individuals who: a. Are currently enrolled in or eligible to enroll in Medicare Part A; and b. Have net countable income 120% - 135% of FPL; and c. Have countable resources at or below $9,430 for individuals and $14,130 for married couples; and d. Are not eligible under any other Medicaid category Note: A Medicaid card is not issued for this program. This individual cannot be eligible for Medicaid under another category and be eligible as a qualified individual. Coverage begins with the application month, and prior medical coverage is available for up to three months prior to the application month. The Medicare premium is considered proof of service for prior medical requests. Note: If a QI eligible woman reports she is pregnant, evaluate Medicaid under the pregnant woman group. B-310.5 Qualified Disabled Working Individuals (QDWI) Covers ONLY special Medicare Part A hospital insurance premiums for disabled individuals who lose their free hospital coverage due solely to earnings which exceed the Substantial Gainful Activity (SGA) limits established by the Social Security Administration (SSA). These individuals must: a. Be under age 65; and b. Continue to meet Social Security's disability criteria; and c. Not be otherwise entitled to Medicare hospital coverage. Medicaid coverage of the Medicare hospital insurance premium is limited to individuals who: a. Have enrolled in the special Medicare hospital insurance at the SSA office; and b. Have net countable income below 200% of FPL; and c. Have countable resources which do not exceed $4,000 for individuals and $6,000 for married couples; and

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD B-310.5 MAABD MEDICAL CATEGORIES Division of Welfare and Supportive Services Medical Assistance Manual 25 Mar MTL 02/25 QUALIFIED DISABLED WORKING INDIVIDUALS (QDWI) d. Are not eligible for medical assistance under another Medicaid category. Note: A Medicaid card is not issued for this program. At the time premium-free Medicare coverage ends, SSA will mail a notice informing individuals of their right to enroll in the special Medicare hospital insurance (now at a cost) and their potential eligibility to have the premium paid by Medicaid. They will have a seven-month period to enroll, beginning with the month of notice. If they do not enroll during this time, they may still enroll during the annual general enrollment period (January through March) if they continue to meet the special requirements. Entitlement to this special Medicare hospital insurance can begin no earlier than July 1, 1990. Coverage of the special Medicare premium can begin the month of application (including three months prior to the month of application) if ALL eligibility criteria is met. Example: If an applicant applies for benefits on October 5th and is already enrolled in the special Medicare hospital insurance, eligibility can begin effective October (including three months prior). However, if in this example, the applicant's enrollment is not effective until November 1st, the applicant is not eligible any earlier than November. If the customer appears to be eligible under another category of assistance, pursue eligibility under that category first. If the customer is not eligible under any other Medicaid category, determine eligibility as a Qualified Disabled Working Individual. B-315 SUPPLEMENTAL SECURITY INCOME (SSI) Provides medical assistance to individuals who are: a. Verified SSI recipients; or b. Recipients of presumptive SSI payments; or c. In CO1 pay status per SOLQ/SDX but without monetary payment, due to an overpayment collection; or d. In EO2 status per SOLQ/SDX the month(s) prior to CO1 status; AND apply for Medicaid and meet the requirements under Cooperation, Residency, and Insurance Coverage. SSI Recipients could be living: a. Independently in the community; b. In an Adult Group Care Facility (AGCF) or in appropriate settings as determined by Medicaid; or c. In a medical facility when countable income is less than $30 a month.

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD B-315.1 Division of Welfare and Supportive Services Medical Assistance Manual 25 Mar MTL 02/25 MAABD MEDICAL CATEGORIES ELIGIBILITY EXCEPTIONS B-315.1 Eligibility Exceptions a. Individuals determined by SSI to have received SSI payments for which they were not eligible, are eligible for Medicaid for the period in which SSI payments were made on their behalf. b. Individuals under 22 receiving inpatient psychiatric services in a residential treatment center (RTC) are eligible for Medicaid when SSI eligible. c. Individuals under 65 who are residing in an institution for mental disease (IMD) i.e., a free- standing psychiatric hospital, are not eligible for Medicaid. An institution for individuals with intellectual disabilities IS NOT an institution for mental disease. B-315.2 SSI Resources All resources must be reported. All resources will be evaluated by the Social Security Administration. a. Transfer of Resources If an SSI recipient has an inpatient stay in a medical facility, see Transfer of Assets policy (F-405). b. Resource Limits Resource limits are $2,000 for an individual and $3,000 for a couple. When countable resources exceed the limit do not terminate eligibility. Notify the Social Security Administration of the assets using SSA Form 3911. B-320 PUBLIC LAW CASES Certain individuals who have lost SSI eligibility, but would still be eligible for SSI if some of their income was disregarded, may be Medicaid eligible if all other eligibility requirements are met. Public law dictates what income is disregarded for each group. Special attention is required for these individuals, so they do not have their Medicaid eligibility interrupted. Countable net income (after disregards) must be less than the applicable SSI payment amounts (SPA). Resource limits are the same as for SSI cases. B-320.1 Pickle Amendment - Public Law 94-566 Section 503 Customers are eligible for continued Medicaid assistance if: a. They currently receive RSDI, and

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD B-320.1 MAABD MEDICAL CATEGORIES Division of Welfare and Supportive Services Medical Assistance Manual 25 Mar MTL 02/25 PICKLE AMENDMENT b. After April 1977 they were eligible for and receiving SSI and entitled to RSDI in the same month, and c. They became ineligible for SSI for any reason, and d. They would now be eligible for SSI if their RSDI cost-of-living increases received after they were last eligible for and received SSI and entitled to RSDI in the same month are excluded from their countable income, and e. All other eligibility factors are met. Entitlement to RSDI benefits can be determined by: a. Being "eligible for and receiving" the RSDI benefit; or b. Being eligible for the RSDI benefit without receiving the benefit due to the "windfall off- set" requirements of Social Security. The purpose of the "windfall off–set" is to ensure the individual who is currently eligible for either SSI or RSDI and subsequently becomes retroactively eligible for the other benefit does not receive more benefits than they would have received if payments for both benefits (SSI & RSDI) had been paid when regularly due. Example: A customer is currently applying for Medicaid. If: a. The customer was eligible for and receiving SSI and entitled to RSDI in April 1982; and b. Excess resources caused him to become ineligible for SSI in May 1982; and c. The customer’s resources are now within the current resource limitations; and d. If all RSDI cost-of-living increases made after May 1982 are excluded from his countable income, the customer would be eligible for SSI. Then, the customer is categorically eligible for Medicaid under the Pickle Amendment. When a customer applies for Medicaid and does not receive SSI or reside in a medical facility, use the above criteria to determine if they may be eligible under the Pickle Amendment. Verification: When an RSDI cost-of-living increase occurs, a special SDX will be produced for ongoing SSI recipients who may become eligible under this Public Law. These cases are identified in the SDX Public Law column by Alpha Code "B." If a customer resides with their spouse and spousal deeming applies, deduct the RSDI cost–of–living increases from the spouse's RSDI income which were received after the customer last received SSI. The last RSDI amount the customer was entitled to can be obtained through the Social Security Administration.

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD B-320.1 Division of Welfare and Supportive Services Medical Assistance Manual 25 Mar MTL 02/25 MAABD MEDICAL CATEGORIES PICKLE AMENDMENT Use Form 2022–EM, Pickle Amendment Certification or the RSDI Computation Worksheet Form 2654–EE. Disabled persons must continue to meet disability criteria. Verification used to support "Pickle" status must remain in the permanent section of the case file. When re–evaluating eligibility because of changes in income, if the customer would now be eligible for SSI (using SSI rules) before disregarding cost–of–living increases, they no longer meet the criteria for Medicaid eligibility under Public Law 94–566 (Pickle Amendment). Note: To be eligible for Medicaid under the Pickle Amendment, the Center for Medicare and Medicaid Services (CMS) has always interpreted SSI eligibility to mean receipt of an actual cash benefit, not just eligible to receive a benefit. SSA considers eligibility under these circumstances to be a benefit under the Social Security Law and qualifies an individual for eligibility under the Pickle Amendment, provided all other requirements for eligibility under the Pickle Amendment are met. B-320.2 Adult Disabled Child - Public Law 99-643 Continues medical assistance for certain blind/disabled individuals age 18 years or older if: a. They received SSI benefits which were based upon a disability or blindness which began prior to the individual turning age 22; and b. They lost SSI eligibility on or after July 1, 1987 solely because they became eligible for SSA benefits as an "adult disabled child" or because of an increase in their "adult disabled child" SSA benefits; and c. They would now be eligible for SSI if the Social Security "adult disabled child" benefit or the increase in their "adult disabled child" benefits received after July 1, 1987 was excluded from their countable income; and d. All other eligibility factors are met. Note: The SSI benefits did not have to begin prior to age 22; only the disability or blindness on which the SSI was based had to begin before age 22. Verification: Social Security identifies individuals who are possibly eligible under this category with a "D" in the SDX Public Law column. Individuals must still meet all other eligibility criteria. If a subsequent SDX is received and the Alpha Code “D” has disappeared, it is the responsibility of the case manager to determine if the individual continues to meet the above criteria and document the case accordingly. The case manager shall document the case to show what amount of benefit is being disregarded. If the case manager cannot tell from the SDX what amount should be disregarded, Social Security should be contacted to verify. Use Form 2022-EM (Public Law Certification). For example, if a customer does not have enough quarters to receive a social security payment under their own record and receives only a payment on a parent’s record, the case worker can determine that all

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD B-320.2 MAABD MEDICAL CATEGORIES Division of Welfare and Supportive Services Medical Assistance Manual 25 Mar MTL 02/25 ADULT DISABLED CHILD income received from the parent’s record should be disregarded. If the customer receives a payment from their own record as well as a parent’s record and the case worker is unable to determine what amount is being received from the parent’s record, Social Security should be contacted using Form 2022. B-320.3 Widow/Widowers - Public Law 100-203 Provides medical assistance to widows and widower’s who are: a. At least 60 years of age but not yet 65; and b. Eligible for SSA Widow's or Widower's benefits or are eligible for SSA Widow's or Widower's benefits in combination with another SSA Benefit(s); and c. Losing SSI eligibility because of the receipt of the SSA Widow/Widower's benefits or combination of Widow/Widower's benefits and other SSA Benefits; and d. Not entitled to Medicare Part A; and e. Would now be eligible for SSI if the Widow/Widower's benefits, and other SSA benefits were disregarded (SSA Disability benefits are not disregarded); and f. All other eligibility criteria are met. When an individual who is a widow/widower is terminated from SSI, their termination letter will inform them of possible eligibility for Medicaid. The following verifications from Social Security must be in the case file to determine eligibility under this category: a. The date and reason SSI was terminated. If SSI was terminated more than a year from the date of the Medicaid application, an DHCFP disability determination must be done to verify the person is still disabled, unless they are currently receiving SSA Disability benefits. b. The type of Social Security benefits the person is receiving. c. The amount of each Social Security benefit. d. Proof the individual is entitled to Medicare Part A. Note: Individuals eligible for Medicaid under this provision will lose Medicaid eligibility at the time they reach age 65 or become eligible for Medicare, whichever comes first, unless they are found to be eligible for Medicaid under another category. B-320.4 Widows, Widowers and Surviving Divorced Spouses – Public Law 101–508 Provides medical assistance to disabled widows, widowers and surviving divorced spouses who lose SSI because of receipt of Title II (RSDI) benefits from the changed disability criteria. These individuals are deemed to be receiving SSI if:

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD B-320.4 Division of Welfare and Supportive Services Medical Assistance Manual 25 Mar MTL 02/25 MAABD MEDICAL CATEGORIES WIDOWS, WIDOWERS AND SURVIVING DIVORCED SPOUCES a. They were receiving SSI for the month prior to the month they began receiving Title II benefits; and b. They would continue to be eligible for SSI if the amount of the Title II benefit was not counted as income; and c. They are NOT entitled to Medicare Part A hospital insurance. Verification: Social Security identifies individuals who are possibly eligible under this category with an "S" in the SDX Public Law column. If an SDX is received identifying an individual as such, it is the responsibility of the case manager to determine if the individual meets the above criteria. Note: Individuals eligible for medical assistance under this provision will lose Medicaid eligibility at the time they reach age 65 or become eligible for Medicare, whichever comes first, unless they are found to be eligible for Medicaid under another category. The case manager shall document the case to show what amount of benefit is being disregarded. If the case manager cannot tell from the SDX what amount should be disregarded, Social Security should be contacted to verify. B-320.5 Suspension of SSI Due to Income – Public Law 96-265 Provides extended medical assistance for certain disabled/blind persons whose SSI is suspended due to excess earned income. Verification: Social Security determines this Public Law status and identifies these cases via the SDX. When the Payment status code is NO1 or PO1 and SSA has determined the case to be one which falls under Public Law 96-265, Alpha Code "I" will appear in the SDX Public Law column. If a subsequent SDX is received and Alpha Code "I" has disappeared, it is the responsibility of the case manager to determine if the individual continues to meet the above criteria. The case manager must document the case and Social Security should be contacted to verify ongoing eligibility status. Disabled individuals who work can continue to receive SSI, and categorical Medicaid, even if their earned income exceeds the Substantial Gainful Activity (SGA) limits. SSA pays no cash benefit in this situation but individuals remain eligible for Medicaid as if they were still receiving an SSI payment. B-320.6 Persons Ineligible for SSI Due to Alien Sponsor Deeming (CFR 416.1160) Aged and disabled individuals who are ineligible for SSI due to alien sponsor deeming are considered SSI eligible, and therefore, Medicaid eligible IF they meet all other eligibility requirements. Verification: Obtain verification of SSI ineligibility due to sponsor deeming.

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD B-320.6 Division of Welfare and Supportive Services MAABD MEDICAL CATEGORIES Medical Assistance Manual 25 Mar MTL 02/25 PERSONS INELIGABLE FOR SSI DUE TO ALIEN SPONSOR DEEMING a. Persons under age 65 require a disability decision from the Division of Health Care Financing and Policy (DHCFP). b. Parent and spouse deeming requirements still apply. Determine any contributions which may be provided by the sponsor(s) to the customer. SSA considers sponsor income for 3 years after the individual is admitted to the United States. If applicable, create an ALERT with a due date when sponsor deeming no longer applies, to refer the customer to apply for SSI. If SSI eligible, convert to a MAABD SSI case. If not SSI eligible, terminate Medicaid benefits unless the customer is eligible under another medical assistance group. B-325 INSTITUTIONALIZED INDIVIDUALS B-325.1 Persons Institutionalized Less Than 30 Consecutive Days Provides medical assistance to individuals who: a. Meet the definition of aged, blind or disabled; and b. Have countable income below the SSI payment level; and c. Have countable resources less than $2,000 for an individual and $3,000 for a married couple; and d. Have an inpatient stay at a skilled nursing facility (SNF), intermediate care facility (ICF or ICF/MR), or hospital less than 30 consecutive days. An 'outpatient' stay is less than a 24-hour period regardless of the hour of admission, whether a bed is used or whether the patient remains in the facility past midnight. B-325.2 Persons Institutionalized at Least 30 Consecutive Days Provides medical assistance to individuals who: a. Meet the definition of aged, blind or disabled; and b. Have countable income at or below 300% of the SSI payment level; and c. Have countable resources no more than $2,000 for an individual and $3,000 for a married couple (spousal resource assessment required); and d. Have an inpatient stay at a skilled nursing facility (SNF), intermediate care facility (ICF or ICF/MR), or hospital for at least 30 consecutive days. Time spent in an institution for mental disease (IMD) is considered when determining institutionalization for 30 consecutive days when going to or from the IMD. If, when going from the IMD to a SNF, ICF or

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD B-325.2 Division of Welfare and Supportive Services Medical Assistance Manual 25 Mar MTL 02/25 MAABD MEDICAL CATEGORIES PERSONS INSTITUTIONALIZED AT LEASE 30 CONSECUTIVE DAYS hospital, the customer was only temporarily transferred and not actually discharged, the time in the IMD cannot be counted toward length of time institutionalized. The individual must be in the institution at least 30 consecutive days. In determining the number of days in a medical institution for eligibility purposes, include the day of admission, but not the day of discharge/death. Applications may be processed under this category prior to the 30th day based on a licensed physician’s statement confirming that the customer is likely to be in the institution at least 30 days. Eligibility will begin the first day of the month in which the customer entered the medical facility, provided application is made and all other eligibility requirements are met. See Long Term Care Services for more information regarding processing eligibility for this category. B-330 HOME AND COMMUNITY BASED SERVICES Provides medical assistance to aged, blind or disabled individuals who require a level of care provided in a medical facility but who can appropriately be cared for at home or in a community setting for less cost. Individuals must meet the following eligibility criteria: a. Meet the definition of aged, blind or disabled; and b. Have countable income at or below 300% of the SSI payment level; and c. Have countable resources no more than $2,000 for an individual and $3,000 for a married couple (spousal resource assessment required); and d. Require a level of care provided in a nursing facility (determined by DHCFP or agency administering the waiver services). See Long Term Care Services for more information regarding processing eligibility for this category. B-335 KATIE BECKETT Provides medical assistance to disabled children who require a level of care provided in a medical facility, but can be appropriately cared for at home for less cost, and are not eligible for SSI due to their parent’s income and/or resources. Children in this category must meet each of the following: a. Disability criteria (determined by SSA or DHCFP); and Note: Do not delay sending the DHCFP disability decision while waiting for an SSI decision. The DHCFP decision can be pursued at same time as SSI for Katie Beckett. If the child previously received SSI and was denied for income, use the SSA disability determination. b. Be under age 19; and

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD B-335 MAABD MEDICAL CATEGORIES Division of Welfare and Supportive Services Medical Assistance Manual 25 Mar MTL 02/25 KATIE BECKETT c. Be living at home; and d. Require a level of care provided in a nursing facility (determined by DHCFP); and e. Have medical costs for home care which are less than if the customer were institutionalized (determined by DHCFP); and f. Child’s countable income at or below 300% of SSI payments level; g. Child’s countable resources no more than $2,000. Note: Applications must first be evaluated for all other MAGI coverage groups. If determined ineligible for any MAGI programs, then evaluate for the Katie Beckett program following policy in MAM D-380 through MAM D-385. B-340 PRIOR MEDICAL This category, under the MAABD program, is used only after all other eligibility categories have been considered. If the customer is not eligible in another MAABD category, determine if they would have been eligible for SSI had SSA made a determination. Provides medical assistance to individuals who: a. Meet the definition of aged, blind or disabled; DHCFP makes the disability determination if SSA determination is unavailable due to death or lack of SSI application for a particular month. b. Have countable income less than the SSI payment amount; c. Have countable resources less than $2,000; d. Would have been eligible for SSI had they applied, regardless of whether the individual is alive when the application for Medicaid is received. B-345 HEALTH INSURANCE FOR WORK ADVANCEMENT (HIWA) Allows employed people with disabilities the opportunity to obtain/maintain healthcare coverage. Provides medical coverage to individuals who: a. Are at least age 16 but less than 65 years of age; b. Meet the Social Security criteria for disability; c. Are employed; d. Have less than $699 per month unearned income; e. Have gross earned income (prior to income disregard) of less than 450% of FPL;

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD B-345 Division of Welfare and Supportive Services Medical Assistance Manual 25 Mar MTL 02/25 MAABD MEDICAL CATEGORIES HEALTH INSURANCE FOR WORK ADVANCEMENT (HIWA) f. Have total net income (net earned plus net unearned) of less than 250% of FPL g. Have countable resources less than $15,000. Customers must be employed and are required to pay an insurance premium to be eligible under this category. Individuals receiving assistance under the HIWA program who are no longer employed due to hospitalization, an inability to work that is directly related to the individual's disability, a worksite closure, or a loss of current transportation with no other alternative means of transportation available, will continue eligibility for an additional 3 months after the month in which their employment ended, as long as premiums are paid by the due date. B-350 AGED, BLIND AND DISABLED SPECIALIZED MEDICAL GROUPS B-350.1 CONTINUATION OF 'PREGNANCY RELATED' MEDICAL COVERAGE Once a MAABD-eligible individual has been converted to the pregnant woman coverage group, individuals in this group are covered through the postpartum period, which ends the last day of the 12th month immediately following the month the pregnancy ends. Example: If the pregnancy ends on June 22nd, the postpartum period will end the last day of June the following year. See B-115 for additional information. B-350.2 EMERGENCY MEDICAL FOR INELIGIBLE NON-CITIZENS (Public Law 99-509 Section 9406) Authorizes Medicaid coverage for emergency medical situations to individuals who do not meet the criteria of a qualified non-citizen, but who otherwise meet eligibility criteria of a MAABD group. These cases are only entitled to coverage for emergency services. Some non-citizens may be lawfully admitted, but only for a temporary or specified time period. These individuals do not meet Nevada residency requirements. They are: – Foreign government representatives on official business, and their families and servants; – Visitors for business or pleasure, including exchange visitors; – Aliens in travel status while traveling directly through the U.S.; – Crewman on shore leave; – Treaty traders and investors, and their families; – Foreign students; – International organization representation and personnel, and their families and servants;

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD B-350.2 MAABD MEDICAL CATEGORIES Division of Welfare and Supportive Services Medical Assistance Manual 25 Mar MTL 02/25 EMERGENCY MEDICAL FOR INELEGIBLE NON-CITIZENS – Temporary workers including agricultural contract workers; and – Members of foreign press, radio, film, or other information media and their families. Individuals who request assistance under this category must meet the following: a. Meet all eligibility criteria except the citizenship requirements. Residency requirements must be met; and b. Be aged, blind, or disabled and would qualify for Medicaid as a state institutional case, or would be eligible for SSI, except for the fact they are ineligible non-citizens. In determining whether an applicant is eligible as a state institutional case, eligibility is determined the same as a state institutional case except for meeting the citizenship requirements. If the customer does not qualify as a state institutional case, the case manager must make a determination of whether the applicant would be eligible for SSI except for meeting the citizenship requirements. If the customer is or becomes pregnant, evaluate eligibility using the pregnant woman criteria rather than institutional or SSI criteria. The case can remain ongoing provided the individual continues to meet all the requirements of an emergency Medicaid case.

(c-100)Nevada Medical Assistance Manual (MAM): C-100 General Eligibility Requirements#

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL C-100 GENERAL ELIGIBILITY REQUIREMENTS Division of Welfare and Supportive Services Medical Assistance Manual 24 Jan 26 MTL 02/24 RESIDENCE REQUIREMENTS GENERAL ELIGIBILITY REQUIREMENTS General eligibility requirements are applicable to all medical assistance programs unless otherwise noted. C-100 RESIDENCE REQUIREMENTS (435.403) Customers must be living in Nevada with the intention of making Nevada their home permanently OR must be living in Nevada with a job commitment or seeking employment. Customers are not required to have a fixed place of residence to meet this requirement. C-100.1 SSI Recipients Receiving a State Supplementary Payment (SSP) from Another State When the customer is receiving SSI/SSP through another state, the state paying the State Supplementary Payment is the state of residence UNLESS SSA acknowledges Nevada residency. In this instance ONLY, use SSA's effective date of residency. C-100.2 Verification Accept customer statement for residency. When a discrepancy exists in the current case file, contact the household or a collateral contact to clarify circumstances and document the information. C-105 EXCEPTION TO RESIDENCY RULES For the purposes of this section, a person is incapable of indicating their intent to reside when they: a. have an IQ of 49 or less or have a mental age of 7 or less; or b. are found incapable of indicating their intent to reside as verified through medical documentation by a physician or licensed psychologist; or c. are judged legally incompetent C-105.1 Individuals Placed In an Out-of-State Institution Residence is the State making or arranging placement of the individual. Any agency of the State that arranges for an individual to be placed in an institution (includes foster care homes) located in another State, is recognized as acting on behalf of the State making a placement. Note: This includes an entity recognized under state law as being under contract with the State for such purposes.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services Medical Assistance Manual 24 Jan 26 MTL 02/24 C-105.1 GENERAL ELIGIBILITY REQUIREMENTS INDIVIDUALS PLACED IN AN OUT-OF-STATE INSTITUTION When a competent individual leaves the facility in which the individual is placed by a State, the individual’s State of residence, for Medicaid purposes, is the State where the individual is physically located. Note: Children who receive Title IV-E adoption assistance or foster care payments are considered residents of the State in which the child lives. C-105.2 Individuals Under the Age 21 The State of residence for individuals under age 21 who are not receiving Title IV-E payments and not receiving a State supplement is as follows: a. An individual capable of indicating intent and who is emancipated from his or her parents or who is married, the State of residence is the state where the individual intends to reside or has entered the State with a job commitment or seeking employment. b. An individual not capable of indicating intent, not living in an institution, not receiving Title IV-E and not receiving a State Supplementary Payment the State of residence is: 1. the State where the individual resides; or 2. the State of residency of the parents or caretaker with whom the individual resides. c. For any individual under the age of 21 who is institutionalized and, neither married nor emancipated, the State of residency is determined as follows: 1. the parent’s or legal guardian’s State of residence at the time of placement; or 2. the current State of residence of the parent or legal guardian who files the application if the individual is institutionalized in the State; or 3. the State of residence of the individual or party who filed an application is used if the individual has been abandoned by his or her parent(s), does not have a legal guardian, and is institutionalized in that State. NOTE: A legal guardian must be appointed by the court, and the parental rights terminated. When the legal guardian applies on behalf of the institutionalized individual, the State of residence of the guardian is used instead of the parents’ State of residence. C-105.3 Individuals Age 21 and Over The State of residence for an individual residing in an institution that became incapable of indicating intent before age 21 is:

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services Medical Assistance Manual 24 Jan 26 MTL 02/24 C-105.3 GENERAL ELIGIBILITY REQUIREMENTS INDIVIDUALS AGE 21 AND OVER a. the State of residence of the parent or legal guardian applying for Medicaid on behalf of the individual if the parent or legal guardian resides in a separate State; or b. the State of residence of the parent or legal guardian at the time of placement; or c. the current State of residence of the parent or legal guardian who files the application if the individual is institutionalized in that State. Individuals residing in an institution who became incapable of indicating intent after age 21, the State of residence is: a. the State in which the individual is physically present, except where another State makes a placement. An individual residing in an institution that has been abandoned by his or her parent(s) and does not have a legal guardian, the State of residence is the State of residence of the individual or party who files an application. C-110 DISPUTED RESIDENCY When Nevada Medicaid determines a customer is a resident of another State and that State disagrees, the following procedures apply: a. require the customer to provide a copy of the disputing State's denial/termination letter. b. process the Nevada Medicaid application to determine eligibility. c. notify the Chief of E&P by memo. Include: 1. case name and number. 2. copy of denial/termination letter from the disputing State. 3. copy of NOMADS NOD showing approval/denial. 4. verification (not all inclusive) a. rent/mortgage receipt b. landlord statement c. Nevada driver's license d. Nevada vehicle registration e. utility bills/receipts

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services Medical Assistance Manual 24 Jan 26 MTL 02/24 C-110 GENERAL ELIGIBILITY REQUIREMENTS DISPUTED RESIDENCY f. Victims of Domestic Violence approved for fictitious address receive a notice from the Division of Child and Family Services which contain an individual authorization code and substitute mailing address. Request and keep a copy of this notice in the case file for verification. Request the customer to provide a statement from the Division of Child and Family Services to verify a pending CAP application. Persons pending a determination for CAP may use an alternative address (i.e., friend, relative, or shelter address). g. award letter for Social Security h. employer's statement i. statement from a friend, relative or other person who is knowledgeable about the customer's residency j. State Data Exchange (SDX). k. SSA State Online Query (SOLQ) C-115 TEMPORARY ABSENCE Medical may not be denied or terminated because of an individual’s temporary absence from State. Nevada residency continues when a customer is temporarily absent IF he/she intends to return to Nevada when the purpose of the absence has been accomplished. Children attending school out of State who have not indicated their intent to return to Nevada and/or who have been approved for Medicaid in another state, do not meet Nevada residency rules. Document in the case file the temporary absence situation and obtain the customer/representative's statement concerning the intent of residency and the purpose of the absence. C-120 CAP PROGRAM (NRS 217) The confidential Address Program (CAP) is administered by the Division of Child and Family Services and helps victims of domestic violence, sexual assault, human trafficking and/or stalking from being located by the perpetrator through public records. CAP provides a fictitious address and confidential mail forwarding services to individuals and families across Nevada. When an individual is approved for the program, they are given a notice which contains the individual’s CAP Authorization Code and the fictitious address. The CAP authorization Code ensures mail is delivered correctly and confidentially without further delay. The following are the requirements for DWSS cases with individuals enrolled in the Confidential Address Program.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services Medical Assistance Manual 24 Jan 26 MTL 02/24 C-200 GENERAL ELIGIBILITY REQUIREMENTS EVIDENCE OF U.S CITIZENSHIP OR NATIONALITY • When a fictitious CAP address is provided to the DWSS, staff must accept the fictitious address and NOT require the individual to provide their actual residential or mailing address. • The CAP Authorization Code must be entered in the system under the address field “Other” with the PO Box number. The authorization code assists with directing the mail to the individual. o Example: Jane Doe PO BOX 9876 1234567 Carson City, NV 89702 *See task guide Case Management – 03 for instructions on how to complete/update this information on the customer’s address screen. • Individuals enrolled in the program are allowed 17 days to provide requested information. C-200 SOCIAL SECURITY NUMBERS (435.910) The agency must require, as a condition of eligibility, each individual (including children) seeking Medicaid, furnish their Social Security Number (SSN). If an applicant cannot recall his SSN(s) or has not been issued an SSN, the agency must-

a. assist the applicant in completing an application for an SSN; b. obtain evidence required under SSA regulations to establish the age, the citizenship or alien status, and the true identity of the applicant; and c. either send the application to SSA or, if there is evidence that the applicant has previously been issued an SSN, request the applicant to apply for a replacement card as SSA no longer provides SSN printouts in their field offices. Do not deny or delay services to an otherwise eligible individual pending issuance or verification of the individual's SSN by SSA or if the individual meets one of the following exceptions. Exceptions: a. the individual is not eligible to receive an SSN; b. the individual does not have an SSN and may only be issued an SSN for a valid non-work reasons; or c. the individual refuses to obtain an SSN because of well-established religious objections. d. a newborn may be enrolled without a social security number (SSN); however, an SSN is required by the child’s first birthday.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services Medical Assistance Manual 24 Jan 26 MTL 02/24 C-200.2 GENERAL ELIGIBILITY REQUIREMENTS WORKER ACTION AT APPLICATION C-200.1 Verification The agency must verify the SSN furnished by an applicant or beneficiary to insure the SSN was issued to that individual, and to determine whether any other SSNs were issued to that individual. The SSN is verified through the NUMIDENT system, which is Social Security’s database of SSNs. If there is a discrepancy in the SSN-Match, follow-up action must be accomplished and a resend completed within 30 days. Check the application and other available information in the case file to make sure the customer’s SSN, last name, date of birth and sex were entered into the computer correctly. Check SOLQ to see if the discrepancy can be identified. If Social Security records need to be updated, refer the customer to the Social Security Administration. Types of verification: a. SDX b. copy of a Social Security check c. completed Form 1610 d. letter from the Social Security Administration e. copy of the SSA Benefit Letter C-200.2 Worker Action at Application If a SSN is not provided, the case manager shall notify all household members they must apply directly with the Social Security Administration (SSA) to obtain an SSN. Pend the household, allowing 20 days, to provide verification of the SSN application. Applicants or recipients can also obtain from SSA a replacement card or request a new card be issued because of a change to their name (marriage, divorce, court order or any other reason). When a child is born in a hospital, the parent(s) are provided a receipt Form SSA-2853, that the application to apply for an SSN for the child was made. Note: A newborn may be enrolled without a social security number (SSN); however, an SSN is required by the child’s first birthday. C-200.3 Failure To Comply If a member of the household fails or refuses to comply, without good cause, with SSN requirements, deny or terminate medical coverage.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services Medical Assistance Manual 24 Jan 26 MTL 02/24 C-305 GENERAL ELIGIBILITY REQUIREMENTS CHILD SUPPORT NON-COOPERATION C-300 CHILD SUPPORT ENFORCEMENT (Proposed Rule 433.138, 433.145, 433.147, 433.148, 433.152 and 435.610) As a condition of eligibility for Medicaid, parents and caretaker relatives seeking medical assistance must agree to cooperate with the state in establishing paternity and in obtaining medical support and payments. While parents and caretaker relatives can be denied Medicaid eligibility or terminated from coverage for refusal to cooperate, children cannot be denied Medicaid eligibility or terminated from coverage due to a parent or caretaker relative’s failure to do so. Individuals must attest on the application that they agree to cooperate in establishing paternity and obtaining medical support at application. If the individual refuses to attest to agree to cooperate with child support on the application the individual is denied medical assistance. Medicaid eligible individuals are provided information about accessing child support services and how those interested may benefit from child support services. Language containing required information and contact numbers for child support offices will be added to the approval notice. Form 4046-EC (child support information brochure) must be made available to any individual requesting information regarding child support services. If an individual wishes to request child support services, they must submit an application Form 4000 to the local child support office. Pregnant women are exempt from the requirements to cooperate in establishing paternity of a child born out-of-wedlock. Although they must assign the right to medical support and payment for themselves and the child, they are not required to obtain medical support and payments. C-305 CHILD SUPPORT NON-COOPERATION By signing the application, individuals agree to cooperate with Child Support in pursuing medical support and establishing paternity. If a previous member was denied for child support cooperation and re-applies, they are only required to agree to cooperate and are not required to provide verification of cooperation prior to being enrolled. CSEP will notify the responsible office, via email, of a customer who has failed to cooperate on their existing TANF case. This parent and/or caretaker can also lose their Medicaid eligibility. C-400 CITIZENSHIP AND IDENTIFICATION REQUIREMENTS (435.406, 435.407, 435.940, 435.956)

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services Medical Assistance Manual 24 Jan 26 MTL 02/24 C-405.1 GENERAL ELIGIBILITY REQUIREMENTS VERIFICATION AND DOCUMENTATION All persons applying for Medical Assistance must provide satisfactory evidence of citizenship or immigration status prior to the approval of benefits. All individuals will have their citizenship verified electronically through the federal data services hub (FHUB). Note: This information is available on the FHUB screen which provides the status and results of the information sent and/or received from the federal hub. This screen also gives the case manager the ability to resend or request to have information sent to the FHUB for verification. Exception: Children who become eligible for Medicaid based on their mother’s Medicaid eligibility are considered to have provided satisfactory evidence of citizenship and shall not be required to provide further documentation, even after the end of the OBRA coverage period. C-405 ELIGIBILITY REQUIREMENT By completing and signing the application, the head of household is attesting to the citizenship status of all members. Individuals requesting medical assistance must be: a. U.S. citizens, or b. have legal immigration status. C-405.1 Verification and Documentation If the FHUB service is not available, the case manager must use alternative electronic data sources such as vital statistics, SAVE or SDX. Paper documentation may only be required when: a. no electronic data source is available; or there is a discrepancy between the electronic data and customer attestation. Paper documentation can be a photocopy, facsimile, scanned or other copies of documents, unless information on the copy is inconsistent with information available to the agency, or the agency has reason to question the validity of the information on the document. The documentation of citizenship is a one-time occurrence. Once the verification of citizenship and identity is received, the recipient must not be required to provide it again. Proof of citizenship verification for each individual must be maintained in the case file or in an electronic database. If verification of citizenship is received via the federal hub an

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services Medical Assistance Manual 24 Jan 26 MTL 02/24 C-405.2 GENERAL ELIGIBILITY REQUIREMENTS REASONABLE OPPORTUNITY electronic record will automatically be maintained. If the customer provided paper documentation of citizenship, a copy should be scanned and indexed to the permanent section of the case jacket and never purged. Individuals declaring to be a citizen or national of the United States who are eligible for Medicaid are not required to provide documentation of citizenship status if they: a. are entitled to or enrolled in Medicare benefits; b. are receiving Social Security disability (SSDI) or SSI benefits; or c. are receiving child welfare benefits under Title IV-B, adoption or foster care assistance under Title IV-E; or d. were eligible at birth for Nevada Medicaid due to OBRA eligibility. C-405.2 Reasonable Opportunity (435.956(g)) If the agency is unable to promptly verify citizenship or immigration status using an electronic data source and the individual meets all other eligibility factors and would otherwise be Medicaid eligible, the agency must approve the case and allow the household 90 days to provide satisfactory documentation of citizenship or immigration status. During the 90-day period the agency must: a. attempt to resolve any inconsistencies; b. resubmit any correct information to the electronic data source; and c. provide the individual with information on how to contact the source of the electronic data so they can attempt to resolve inconsistencies. If the required citizenship or immigration status documentation is not provided by the end of the 90-day period, terminate assistance allowing for adverse. The 90-day period does not apply to prior medical months. Citizenship documentation must be provided prior to approval of prior medical months. C-405.3 Stand-Alone Evidence of U.S. Citizenship or Nationality The following must be accepted as satisfactory documentary evidence of citizenship: a. U.S. Passport, including a U.S. Passport Card issued by the Department of State, without regard to any expiration date as long as such passport or Card was issued without limitation. Exception: Do not accept any passport as evidence of U.S. citizenship when it was issued with a limitation. However, such a passport may be used as proof of identity.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services Medical Assistance Manual 15 Jul 01 MTL 01/15 C-405.3 GENERAL ELIGIBILITY REQUIREMENTS EVIDENCE OF U.S CITIZENSHIP OR NATIONALITY b. Certificate of Naturalization c. Certificate of U.S. Citizenship d. a valid State-issued driver’s license, if the State issuing the license requires proof of U.S. citizenship and obtains a social security number from the applicant who is a citizen before issuing such license. e. documentary evidence issued by a Federally recognized Indian Tribe, as published in the Federal Register by the Bureau of Indian Affairs within the U.S. Department of the Interior, and including Tribes located in a State that has an international border, which; 1. identifies the Federally recognized Indian Tribe that issued the document; 2. identifies the individual by name; and 3. confirms the individual’s membership, enrollment, or affiliation with the Tribe. Documents used as evidence of Tribal enrollment include, but are not limited to: 1. Tribal enrollment card; 2. Certificate of Degree of Indian Blood; 3. Tribal census document; 4. documents on Tribal letterhead, issued under the signature of the appropriate Tribal official, issued by a Federally recognized Tribe. Note: See E&P manual section C-700 for a list of federally recognized tribes. If the household is able to provide one of these documents no further documentation is required. When these documents are not available or cannot be obtained within a reasonable period, look at the next tier of acceptable forms of documentation to meet this requirement.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services C-405.4 Medical Assistance Manual GENERAL ELIGIBILITY REQUIREMENTS 15 Jul 01 MTL 01/15 EVIDENCE OF U.S CITIZENSHIP OR NATIONALITY C-405.4 Evidence of U.S. Citizenship or Nationality If an applicant does not provide documentary evidence from the list of stand-alone evidence, the following must be accepted as satisfactory evidence to establish citizenship if also accompanied by an identity document. a. U.S. public birth certificate showing birth in one of the 50 States, the District of Columbia, Puerto Rico, (if born on or after January 13, 1941), Guam, the Virgin Islands of the U.S. (on or after January 17, 1917), American Samoa, Swain’s Island, or the Commonwealth of Northern Mariana Islands (after November 4, 1986). The birth record document may be issued by the State, Commonwealth, Territory, or local jurisdiction. Note: If the document shows the individual was born in Puerto Rico, the Virgin Islands of the U.S., or the CNMI before these areas became part of the U.S., the individual may be a collectively naturalized citizen. b. State of Nevada Vital Statistics Birth Details printout. c. Certification of Report of Birth, issued to U.S. citizens who were born outside the U.S. d. Report of Birth Abroad of a U.S. Citizen. e. Certification of birth. f. U.S. Citizen I.D. card. g. Northern Marianas Identification Card, issued to a collectively naturalized citizen, who was born in the CNMI before November 4, 1986. h. Final adoption decree showing the child’s name and U.S. place of birth, or if an adoption is not final, a Statement from a State-approved adoption agency that shows the child’s name and U.S. place of birth. i. Evidence of U.S. Civil Service employment before June 1, 1976. j. U.S. Military Record showing a U.S. place of birth. k. A data match with the SAVE Program or any other process established by the Department of Homeland Security to verify that an individual is a citizen. l. Documentation that a child meets the requirements of Section 101 of the Child Citizenship Act of 2000 (8 U.S.C. 1431). m. Medical records, including, but not limited to, hospital, clinic, or doctor records or admission papers from a nursing facility, skilled care facility, or other institution that indicate a U.S. place of birth.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services C-405.4 Medical Assistance Manual GENERAL ELIGIBILITY REQUIREMENTS 15 Jul 01 MTL 01/15 EVIDENCE OF U.S CITIZENSHIP OR NATIONALITY n. Life, health, or other insurance record that indicates a U.S. place of birth. o. Official religious record recorded in the U.S. showing that the birth occurred in the U.S. p. School records, including pre-school, Head Start and daycare, showing the child’s name and U.S. place of birth. q. Federal or State census record showing U.S. citizenship or a U.S. place of birth. r. If the applicant does not have one of the documents listed he or she may submit an affidavit signed by another individual under penalty of perjury who can reasonably attest to the applicant’s citizenship and that contains the applicant’s name, date of birth, and place of U.S. birth. The affidavit does not have to be notarized. Note: In December 2009, the government of Puerto Rico enacted Law 191 of 2009 which voided all Puerto Rican birth certificates issued prior to July 1, 2010. Effective October 30, 2010, all Puerto Rican birth certificates issued prior to July 1, 2010 will become voided. A voided Puerto Rican birth certificate may not be used to verify identity or citizenship for the Medical programs. Previously accepted Puerto Rican birth certificates will remain acceptable for Medicaid determinations made prior to November 1, 2010. There will be no need to re-verify citizenship or identity at recertification or review of eligibility. C-410 ACCEPTABLE VERIFICATION OF IDENTITY The agency must accept the following as proof of identity, provided such document has a photograph or other identifying information, including, but not limited to, name, age, sex, race, height, weight, eye color or address. The following documents can be accepted as proof of identity when required as part of citizenship documentation. Identity documentation is not a separate requirement from citizenship documentation; it is a form of documentation used to verify citizenship or immigration status when using secondary evidence paper verification sources. • Driver’s license issued by the State or Territory either with a photograph of the individual or other identifying information of the individual such as name, age, sex, race, height, weight or eye color.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL C-410 Division of Welfare and Supportive Services GENERAL ELIGIBILITY REQUIREMENTS Medical Assistance Manual ACCEPTABLE VERIFICATION OF IDENTITY 15 Jul 01 MTL 01/15 • Certificate of Degree of Indian Blood, or other U.S. American Indian/Alaska Native tribal document if the document carries a photograph or other personal identifying information. • Identification card issued by the Federal, State or local government with the same information included on driver’s licenses. • School identification card with a photograph of the individual. • U.S. military card or draft record. • Military dependent’s identification card. • U.S. Coast Guard Merchant Mariner card. • Children who are under the age of 16 or younger may have their identity documented using other means, when the child does not have or cannot get any of the documents listed above. These include: ➢School record; ➢Clinic, doctor or hospital record; ➢Daycare or nursery school record; ➢Affidavit signed under penalty of perjury by a parent or guardian or caretaker relative attesting to the child’s identity. The affidavit can only be used after establishing that no other means of identity exist. The unavailability of the other sources must be documented in the case history. • Any combination of three or more corroborating documents to prove identity, such as marriage license, divorce decree, high school and college diploma, employer ID cards and property deeds and/or title. • Disabled individuals living in institutional care facilities may have their identity documented using an affidavit signed by a director or administrator where the individual resides. C-415 VERIFICATION OF COLLECTIVE NATURALIZATION If the applicant cannot present one of the documents listed above, the following will establish U.S. citizenship for collectively naturalized individuals: C-415.1 Puerto Rico ● Evidence of birth in Puerto Rico on or after April 11, 1899 and the applicant’s statement they were residing in the U.S., a U.S. possession or Puerto Rico on January 13, 1941; or ● Evidence the applicant was a Puerto Rican citizen and their statement they were residing in Puerto Rico on March 1, 1917 and they did not take an oath of allegiance to Spain.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL C-415.2 Division of Welfare and Supportive Services Medical Assistance Manual GENERAL ELIGIBILITY REQUIREMENTS U.S. VIRGIN ISLANDS 23 Jan 05 MTL 01/23 C-415. 2 U.S. Virgin Islands ● Evidence of birth in the U.S. Virgin Islands and the applicant’s statement of residence in the U.S. possession or the U.S. Virgin Islands on February 25, 1927; ● The applicant’s statement indicating residence in the U.S. Virgin Islands as a Danish citizen on January 17, 1917 and residence in the U.S., a U.S. possession or the U.S. Virgin Islands on February 25, 1927, and that they did not make a declaration to maintain Danish citizenship; or ● Evidence of birth in the U.S. Virgin Islands and the applicant’s statement indicating residence in the U.S., a U.S. possession or territory or the Canal Zone on June 28, 1932. C-415.3 Northern Mariana Islands (NMI) The Northern Mariana Islands were formerly part of the Trust Territory of the Pacific Islands (TTPI). All dates given in this section are NMI local time due to the International Dateline. ● Evidence of birth in the NMI, TTPI citizenship and residence in the NMI, the U.S., or a U.S. territory or possession as of November 3, 1986 and the applicant’s statement they did not owe allegiance to a foreign state on November 4, 1986. ● Evidence of TTPI citizenship, continuous residence in the NMI since before November 3, 1981, voter registration prior to January 1, 1975 and the applicant’s statement they did not owe allegiance to a foreign state on November 4, 1986; or ● Evidence of continuous domicile in the NMI since before January 1, 1974 and the applicant’s statement they did not owe allegiance to a foreign state on November 4, 1986. Note: If the person entered the NMI as a nonimmigrant and lived in the NMI since January 1, 1974, this does not constitute continuous domicile and the individual is not a U.S. citizen.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL C-420 Division of Welfare and Supportive Services GENERAL ELIGIBILITY REQUIREMENTS Medical Assistance Manual NON-CITIZEN MEDICAL ASSISTANCE ELIGIBILITY CHART 23 Jan 05 MTL 01/23 C-420 NON-CITIZEN MEDICAL ASSISTANCE ELIGIBILITY CHART Applicants must be a U.S. citizen or a non-citizen who meets the eligibility criteria in the table below: Program “Qualified” Non- Citizens Who Entered the U.S. Before 8/22/96 “Qualified” Non- Citizens Who Entered the U.S. on or After 8/22/96 “Not Qualified” Non-Citizens Medicaid Eligible if: ● LPR ● attains citizenship ● battered*** non- citizen Eligible only if: were granted status as - refugee* - asylee* - withholding of Deportation* - Cuban/Haitian* - Amerasian Immigrant* Veteran, active duty military; spouse, unremarried surviving spouse or child have been in “qualified” non- citizen status for 5 years or more battered*** non- citizen who has served 5-year bar conditional entrant paroled into the U.S. for a period of at least one year certain abused non- citizens attains citizenship Compact of Free Association (COFA) migrants. Paroled as a Refugee Eligible only if: ●were receiving SSI on 8/22/96 ●American Indian born abroad ** ●victim of trafficking and their spouse and children

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services C-420 Medical Assistance Manual GENERAL ELIGIBILITY REQUIREMENTS 21 Oct 01 MTL 04/21 NON-CITIZEN MEDICAL ASSISTANCE ELIGIBILITY CHART Medicaid and NCU (ages 0-18 only) N/A Eligible only if: ●individual meets any of the criteria listed above Eligible only if:  lawfully admitted for permanent residence (LPR) that has not met the 5- year bar  alien in nonimmigrant status who has not violated the terms of the status under which he/she was admitted or to which he/she has changed after admission  currently under Temporary Protected Status (TPS) and pending applicants for TPS who have been granted employment authorization  granted employment authorization  Family Unity beneficiaries  Deferred Enforced Departure (DED)  deferred action status (Deferred Action for Childhood Arrivals (DACA) do not qualify under this category  aliens whose visa petition has been approved and who have a pending application for adjustment of status  a pending applicant for asylum or for withholding of removal or under the Convention Against Torture who has been granted employment

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL C-420 Division of Welfare and Supportive Services GENERAL ELIGIBILITY REQUIREMENTS Medical Assistance Manual NON-CITIZEN MEDICAL ASSISTANCE ELIGIBILITY CHART 21 Oct 01 MTL 04/21 Eligible only if: ●individual meets any of the criteria listed above authorization, and such an applicant under the age of 14 who has had an application pending for at least 180 days alien granted withholding of removal under the Convention Against Torture pending application for Special Immigrant Juvenile status alien who is lawfully present in the Commonwealth of the Northern Mariana islands alien who is lawfully present in American Samoa under the immigration laws of American Samoa. Emergency Medicaid Eligible if: ● does not meet any of the criteria listed above Eligible Medicare "Premium Free" Part A (hospitalization) (eligibility based on work history) Eligible Eligible Eligible only if: ●Lawfully present, and eligibility for assistance is based on authorized employment Premium "Buy-in" Medicare Eligible only if: ● Lawful permanent resident who has resided continuously in the U.S. for at least 5 years Eligible only if: ●Lawful permanent resident who has resided continuously in the U.S. for at least 5 years. Not Eligible Key – * Status as refugee, asylee, withholding of deportation/removal, Cuban/Haitian Entrant or Amerasian but only during the first 7 years after attaining status. Eligibility continues for these individuals after the first 7 years as they have now been in qualified non-citizen status for over 5 years and have met the 5-year bar.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services C-420.1 GENERAL ELIGIBILITY REQUIREMENTS Medical Assistance Manual 24 Jan 26 MTL 02/24 VERIFICATION OF NON-CITIZEN STATUS Note: Cuban Entrants originally admitted to the U.S. as a refugee, asylee or parolee does not lose eligibility for public benefits due to a change in status. ** Eligible if a Native American born in Canada possessing at least 50% blood of an American Indian race or a member of an Indian tribe as listed in E&P manual section C-700. *** Battered non-citizens must meet the requirements listed in manual section C-440 to be eligible. Note: See section 420.3 for additional information regarding Paroled as a Refugee or Cuban/Haitian Entrant C-420.1 Verification of Non-Citizen Status Non-citizens must provide documentation that verifies qualified non-citizen status and will have their status verified electronically through the federal data services hub. If the federal data hub is not available, alternative electronic data sources such as vital statistics, SAVE or SDX must be used prior to requesting paper documentation. Refer to the Qualified Non-Citizen Documentation Matrix (see Appendix I) for acceptable forms to document and verify citizenship. C-420.2 Verifying Non-Citizen Status Using the Systematic Alien Verification to Entitlements (SAVE) System Non-citizen status must be verified by: • obtaining documentation of non-citizen status, and accessing the Department of Homeland Security Systematic Alien Verification for Entitlement (SAVE) System Exception: For newly arrived non-citizens, the information provided by SAVE may not reflect the most current non-citizen status. Before making an eligibility determination, follow any additional instructions provided on the SAVE response, obtain verification(s) from the applicant and determine if the submitted verification(s) align with one of the acceptable forms listed in the Qualified Non-Citizen Documentation Matrix. To verify non-citizen status access the SAVE system through the ZENworks link. Verification directly through the SAVE system is only required when there is a discrepancy or other electronic data sources (such as the FHUB service) are unavailable. The system shows the date of adjustment rather than the date the customer entered the U.S. If the applicant claims an earlier date of entry into the U.S., they must provide proof. If the applicant claims to be a United States citizen, the system can verify that information as well. If you need additional information, please refer to the tutorial in the upper right- hand corner of the Verification Information System (VIS) screen. Complete an electronic additional verification if: a. the SAVE website advises the caseworker to complete “Additional Verification.”

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL C-420.2 Division of Welfare and Supportive Services GENERAL ELIGIBILITY REQUIREMENTS Medical Assistance Manual VERIFYING NON-CITIZEN STATUS USING SAVE SYSTEM 14 Mar 01 MTL 14/01 b. the COA code indicates the LPR non-citizen may be sponsored. c. The LPR non-citizen indicates they have been sponsored Request an “Additional Verification” directly from USCIS if: a. items presented as documentation appear counterfeit or altered. b. individual presents unfamiliar USCIS documentation, or a document that indicates immigration status, but does not contain an A-Number. c. document contains an A-Number in the A60 000 000 or A70 000 000 series. These ranges have not been issued. d. document contains an A-Number in the A80 000 000 series. This range is used for illegal border crossings. e. document presented as a Form I-689 or Form I-688 annotated with 210(a). These documents will always contain A-Numbers in the A90 000 000 series. This range is used for participants in the legalization (amnesty) or Special Agriculture Worker (SAW) programs. Because they are amnesty participants, policy requires the non-citizen’s authorization, with original signature before secondary verification is performed. f. document presented is a letter, a fee receipt, or anything other than an established USCIS form. g. document presented is an I-181, or an I-94 in a foreign passport that bears the endorsement “Processed for I-551, Temporary Evidence of Lawful Permanent Residence,” AND the I-181 or I-94 is over one year old. Complete a Form G-845S, SAVE Document Verification Request electronically for each person requiring additional verification. Include the Alien registration Number or I-94 Number, name, nationality, date of birth, SSN, ASVI verification number, benefit type and case number. Scan and upload readable copies (front and back) of immigration documents containing the registration number. If the individual’s name has changed since the USCIS registration card was issued, also attach a document that verifies the name change. USCIS will research the non-citizen’s records, complete the response portion of the form through the SAVE system within ten working days of receipt. The Immigration Status Verifier (ISV) checks all appropriate statements on the lower half and back of the form to indicate the applicant’s immigration status and work eligibility. When using secondary verification, if the non-citizen is otherwise eligible, do not delay, deny, or reduce the household’s benefits while waiting for a response from USCIS. When the G-845 is received and the response indicates the non-citizen’s document is not valid, disqualify the individual (allowing adverse action) or deny the application as appropriate and refer to I&R as possible fraud. When the G-845 is received and the response indicates the non-citizen’s documents are valid, file the form in the permanent section of the eligibility file.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services C-420.3 Medical Assistance Manual GENERAL ELIGIBILITY REQUIREMENTS 23 Jan 05 MTL 01/23 PAROLED AS REFUGEES AND CUBAN/HAITIAN ENTRANTS C-420.3 Paroled as Refugees and Cuban/Haitian Entrants Paroled as a Refugee and Cuban/Haitian Entrants: Some persons who fear persecution are “paroled” into the U.S. as refugees when the number of refugees allowed to enter that year has been exceeded. Such parolees are given an I-94 with “paroled as a refugee”, “207”, “paroled as humanitarian”, or “212(d)(5)” stamped or written on it. In the past, INS paroled in Cubans and Haitians under the designation “Cuban/Haitian entrant” or “Mariel Cuban.” All nationals of Cuba and Haiti are eligible for refugee assistance as “Cuban/Haitian entrants” so long as they have been granted parole under 207 or 212(d)(5) with form I-94 and/or a Cuban or Haitian passport, applied for asylum (form I- 797C) or are in exclusion or deportation proceedings but have not yet received a final order of deportation. Cuban and Haitian nationals paroled into the United States under section 212(d)(5) of the Immigration and Nationality Act since October 10, 1980 are considered paroled in a “special status” for Cuban or Haitian nationals unless the parole into the United States was (1) in the custody of a Federal, State, or local law enforcement or prosecutorial authority for purposes of criminal prosecution in the Unites States, or (2) solely to testify as a witness in proceedings before a judicial, administrative, or legislative body in the United States. 8 C.F.R. § 212.5(h). If an applicant does not have another qualifying immigration status or category or has a qualifying immigration status that is subject to the five-year bar reflected in 8 U.S.C. § 1613, then the benefit-granting agency may need to determine that an applicant is a Cuban/Haitian Entrant (CHE). For example, an applicant may be a “qualified alien” under PRWORA due to having an eligible immigration status such as Lawful Permanent Resident or being paroled into the U.S. for more than one year, but they may still be subject to a five-year bar. However, if they are also a CHE, they are a “qualified alien” and exempt from the five-year bar requirement.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL C-425 Division of Welfare and Supportive Services GENERAL ELIGIBILITY REQUIREMENTS Medical Assistance Manual NON-CITIZEN STATUS 21 Oct 01 MTL 4/21 C-425 NON-CITIZEN STATUS Determine if the individual claiming non-citizen status is a “qualified” or a “not qualified” non-citizen. “Qualified” non-citizens include the following: a. Lawful Permanent Residents (LPRs) b. Refugees c. Asylees d. Persons granted withholding of deportation or removal e. Conditional Entrants f. Persons granted parole for a period of at least one year g. Cuban/Haitian entrants h. Certain Abused non-citizens i. Compact of Free Association (COFA) migrants “Not-Qualified” non-citizens include all non-citizens without status in the above categories. This includes non-citizen students and undocumented non-citizens. Note: COFA migrants are individuals who are citizens of the Federated States of Micronesia, the Marshall Islands and the Republic of Palau. These individuals have special rights under the Compacts of Free Association signed by the United States. Although they are technically non-immigrants, they are allowed to enter, reside and work in the United States. Effective December 27, 2020, these individuals are eligible for full Medicaid and NCU as “qualified” non-citizens and are not required to serve a 5-year bar. Use the non-citizen’s USCIS document(s), USCIS letter, a court order or a passport and other resources listed in the following sections to determine the non-citizen’s qualified status. Determine when individuals currently in “Qualified” non-citizen status began residing in the United States. For individuals who entered the United States prior to August 22, 1996: Determine the date the individual began residing in the United States using the earliest verified date the person entered and continually resided in the country, regardless of the individual’s legal status at the time they entered the United States.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services C-425 Medical Assistance Manual GENERAL ELIGIBILITY REQUIREMENTS 23 Jan 05 MTL 01/23 NON-CITIZEN STATUS For individuals who entered the United States on or after August 22, 1996: These individuals must meet one of the categories listed in the non-citizen medical assistance eligibility chart. For those individuals who must serve the five-year bar, the five-year bar begins with the date the individuals attained “Qualified” non-citizen status as determined by USCIS. C-430 RE-VERIFICATION OF IMMIGRATION STATUS DUE TO AN INS DOCUMENT'S EXPIRATION DATE When an eligible non-citizen’s INS document has an expiration date, schedule a redetermination in the month prior to the month the document expires (unless the regular review occurs first). Re-verify the individual’s status using SAVE if they want to continue receiving or are reapplying for benefits. Allow the person ninety (90) days to update their status with INS if they cannot provide an updated document. Disqualify the individual who no longer has acceptable immigration status. Cuban/Haitian entrants whose Form I-94 has an expiration date of 1/15/81 may have a different current resident status assigned to them. Re-verify their status using SAVE. If an individual has been in prison since they last applied, regardless of the expiration date on the document on file, request to review their current document or call SAVE. Their residence may have been revoked, or they may have been issued a different status affecting their eligibility. C-435 DOCUMENTATION OF VETERAN STATUS Non-citizens may be eligible for certain benefits if they are veterans, on active military duty, or are the spouse or dependent child of a veteran or person on active military duty. This category also applies to certain reserve members, as specified in this section. Definition of a Veteran- Individuals who actively served with the United States Armed Services whether or not they were citizens who: a. meet the minimum active duty requirement of 24 months, served for the period of time they were called to active duty, or have an honorable discharge; b. were military personnel and died during active duty; or c. were Filipinos who served in the Philippine Commonwealth Army during World War II or as Philippine Scouts after the war.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL C-435 Division of Welfare and Supportive Services GENERAL ELIGIBILITY REQUIREMENTS Medical Assistance Manual DOCUMENTATION OF VETERAN STATUS 14 Mar 01 MTL 14/01 Individuals may qualify for certain benefits if they are a spouse, surviving spouse, or dependent child of a veteran and meet the appropriate criteria. Individuals claiming this status must show the same documentation as the veteran or active duty member. If the documentation is not available, they should be referred to the local VA regional office for verification of veteran status. Note: The VA will not verify the relationship, so relationship must be established using regular verification procedures for this requirement. Definition of a Spouse of a Veteran - The individual must be currently married to the veteran. Definition of a Surviving Spouse of a Veteran - a. Must not have remarried; and b. Was married to the veteran or active-duty personnel within fifteen years after the termination of the period of service in which the injury or disease causing the death of the veteran was incurred or aggravated; and c. Was married to the veteran or active-duty personnel for one year or more; or a child was born of the relationship between the surviving spouse and the veteran or active-duty personnel, either during or before the marriage. Definition of a Dependent Child of a Veteran - a. Must be unmarried; and b. Must meet program criteria under which benefits are being applied for to be considered as a dependent child. C-435.1 Verification of Veteran Status C-435.1.1 Discharged Members A discharge certificate, DD-214 or equivalent, which meets the following criteria, is acceptable verification without further inquiry, unless the certificate appears to be altered or is otherwise irregular: a. It must show active duty in either the United States Army, Navy, Air Force, Marine Corps or Coast Guard; and b. It must show “Honorable” discharge (“Under Honorable Conditions” is not acceptable); and c. The individual must meet a minimum active duty requirement of two years or more in one of the branches listed above, unless their certificate shows an enlistment date prior to September 7, 1980 (there is no minimum active duty requirement for these individuals).

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services C-435.1.1 Medical Assistance Manual GENERAL ELIGIBILITY REQUIREMENTS MTL 14/01 01 Mar 14 Discharged Members Refer the individual to the local Veteran’s Administration Office to have VA staff determine satisfaction of the minimum active duty service and provide the applicant with documentation of their military status in the following circumstances: a. The discharge certificate shows “Honorable,” but shows a branch of service not listed above. (Examples include: National Guard, active duty for training, inactive duty, etc.); b. The individual claims veteran status but has no documentation; or c. The document shows active duty of less than two years with an original enlistment date on or after September 7, 1980. C-435.1.2 Active Duty Members Active duty as a member of the U.S. Armed Forces means the individual is on full-time duty in the United States Army, Navy, Air Force, Marine Corps or Coast Guard. It does not include full-time National Guard duty. Service members on active duty may establish their status by presenting a current Military Identification Card (DD Form2 - Active), that lists an expiration date of more than one year from the date of the eligibility determination. If the Military Identification Card is due to expire within one year from the date of determination, the service member may verify active duty by showing a copy of their current military orders. If the service member is unable to furnish a copy of their orders, active duty may be verified through the nearest RAPIDS (Real Time Automated Personnel Identification System) which is located at many military installations, or by notifying the following in writing (which can be faxed): DEERS Support Office ATTN: Research and Analysis 400 GIGLING ROAD SEASIDE, CA 93955-6771 FAX: (408) 655-8317 C-435.1.3 Reserve Members (Not On Active Duty For Training) Active duty for training is temporary full-time duty in the Armed Forces performed by members of the Reserves, Army, National Guard, or Air National Guard for training purposes. Active duty for training does not establish eligible status. However, a discharge from active duty for training may establish veteran status and the applicant should be referred to the VA for a determination.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services Medical Assistance Manual C-435.1.3 GENERAL ELIGIBILITY REQUIREMENTS RESERVE MEMBERS 17 Sep 01 MTL 05/17 A member of a Reserve Component must establish their status by showing a current DD Form 2 - Reserve (red) and military active duty orders showing they are on active duty, but not on active duty for training. No other method for verifying this status is currently available. C-440 DEFINITION OF BATTERED NON-CITIZEN A battered non-citizen is: An adult or their child(ren), lawfully residing in the United States on August 22, 1996, who has been battered or subjected to extreme cruelty in the United States by a U.S. citizen or LPR who is: a. a spouse or a parent, or b. a member of the spouse or parent’s family residing in the same household as the non-citizen (and the spouse or parent consented to, or acquiesced in the battery or cruelty). A non-citizen, lawfully residing in the United States on August 22, 1996, whose child has been battered or subjected to extreme cruelty in the United States by a U.S. citizen or LPR who is: a. a spouse or a parent of the non-citizen (without the active participation of the non-citizen in the battery or cruelty), or b. a member of the spouse or parent’s family residing in the same household as the non-citizen (and the spouse or parent consented to, or acquiesced in the battery or cruelty and the non-citizen did not actively participate). C-445 IRAQI AND AFGHANI SPECIAL IMMIGRANTS Effective December 26, 2007, Public Law 110-161, the Consolidated Appropriations Act of 2008 granted Iraqi and Afghan non-citizens special immigrant status under section 101(a)(27) of the Immigration and Nationality Act (INA). Individuals and family members granted this special immigrant status are eligible for resettlement assistance, TANF and entitlement programs including Medicaid and SNAP and other benefits the same as other refugees admitted under section 207 of the INA. Effective December 19, 2009, the Department of Defense Appropriations Act of 2010 (Section 8120, P.L. 111-2009) provides that Iraqi and Afghan Special Immigrants are eligible for federal public benefits to the same extent and for the same time period as refugees. Verification of Special Immigrant Status For Medicaid program purposes, Iraqi and Afghan non-citizens and family members who claim special immigrant status must provide verification they have been admitted under section 101(a)(27) of the INA.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services C-445 Medical Assistance Manual GENERAL ELIGIBILITY REQUIREMENTS 17 Sep 01 MTL 05/17 IRAQI AND AFGHANI SPECIAL IMMIGRANTS Afghans and some Iraqi special immigrants will have an Immigrant Visa category of SL1 S19 and some Iraqis will have an Immigrant Visa category of SQ1–SQ9. Date of Eligibility and Certification Period The effective date of eligibility as a qualified non-citizen is from the date the special immigrant enters the United States. The effective date of eligibility is the date of application for all programs. These immigrants must meet all eligibility requirements for any program applied for. Special immigrants applying under this status are not eligible for prior medical coverage. C-450 VICTIMS OF HUMAN TRAFFICKING Under the Trafficking Victims Protection Act, adult victims of trafficking who are certified by the Office of Refugee Resettlement (ORR) at the Department of Health and Human Services are eligible for benefits to the same extent as refugees. Children who have been subjected to trafficking are also eligible like refugees but do not need to be certified. As of November 6, 2001, certification letters issued for adults and eligibility letters for children will no longer contain an expiration date. Individuals who were certified before this date received letters with 8-month expiration dates. As these letters expire, ORR will issue recertification letters without expiration dates. Victims of Trafficking are awarded a T-Visa for entry. Certain members of their family may also apply for and receive a Derivative T-Visa and meet eligibility under refugee criteria. If the victim of trafficking is under 21 at the time the T-Visa application was filed, Derivative T-Visas are available to the following members of their immediate family: spouse, children, unmarried siblings (under 18 at the time the application was filed) and parents of the victim of trafficking. In the case where an application is filed after the individual turns 21, only the victim’s spouse and children are eligible to apply for the Derivative T-Visa. When a victim of trafficking applies for benefits, all eligibility requirements must be met except the following: a. Victims are not required to provide any documentation of their immigration status. Accept the original, recertification letter or letter for children in place of INS documentation. The “entry date” will not change on the recertification letter.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL C-450 Division of Welfare and Supportive Services GENERAL ELIGIBILITY REQUIREMENTS Medical Assistance Manual VICTIMS OF HUMAN TRAFFICKING 23 Dec 22 MTL 07/23 b. Call the trafficking verification line at (866) 401-5510 to confirm the validity of the certification letter or letter for children and notify ORR at HHS of the benefits for which the individual is applying. c. Note the “entry date” for refugee benefit purposes. The individual’s “entry date” is the certification date listed in the letter. d. Call the trafficking verification line at (866) 401-5510 for assistance when having difficulty confirming identity. e. Assist the individual in applying for a non-work Social Security Number. f. Issue benefits to the same extent as a refugee. g. Record the expiration date of certification letters dated before November 6, 2001 so a review of eligibility will be done at the appropriate time. Certification letters dated after November 6, 2001 will have no expiration date. If case managers have any concerns or questions, contact: a. The Office on Trafficking in Person (OTIP) Phone: (866) 401-5510 Email: trafficking@acf.hhs.gov or b. The Office of Refugee Resettlement (ORR) Thomas Pabst, ORR Immigration Specialist Phone: (202) 401-5398 Email: Thomas.Pabst@acf.hhs.gov C-500 APPLYING FOR AVAILABLE BENEFITS (435.608, 435.610) Income is considered available both when actually available and when the individual has a legal interest in the income and has the ability to make such sum available. Individuals applying for medical assistance must pursue and take advantage of all income which is or may be available for maintenance and support. When benefits may be available such as Retirement, Survivor’s and Disability Insurance (RSDI), Railroad Retirement (RR), Veteran’s Administration (VA) benefits, Unemployment Insurance (UIB), Public Employee’s Retirement benefits, etc., inform the household, in writing, of the obligation to pursue and make the income available to the customer, notify the customer/ representative in writing that application for such benefits must be made within 10 calendar days for ongoing case processing. Individuals should be referred for unemployment insurance benefits only when there is a reasonable certainty that they will be eligible for the benefit. If the customer’s potential eligibility is not reasonably clear, do not request them to apply for assistance.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services C-500 Medical Assistance Manual GENERAL ELIGIBILITY REQUIREMENTS 20 Apr 01 MTL 02/20 APPLYING FOR AVAILABLE BENEFITS Refer individuals who: a. Are physically and mentally able to work; and b. Are out of work through no fault of their own; and c. Have reported earnings in at least two of the quarters within the Base Period. The Base Period is the period of employment prior to the loss of a job. Generally, the first four of the last five completed calendar quarters prior to the effective date of the claim for unemployment is the Base Period. The chart below shows the completed calendar quarters of a Base Period (shaded) depending on the quarter in which a claim is filed with the Nevada Department of Employment, Training and Rehabilitation (DETR). Regular Base Year Prior Year Last Year Current Year OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP DO NOT USE JAN FEB MAR If applicant files their claim in: JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC DO NOT USE APR MAY JUN APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR DO NOT USE JUL AUG SEP JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN DO NOT USE OCT NOV DEC To evaluate for potential eligibility for benefits from another Federal, State or local agency, see Appendix "B". Failure to apply for, pursue and accept a claim or failure to provide information essential to establish the claim will result in termination of assistance for the individual. If the individual can show good cause for not pursuing income they may not be required to pursue the income. Good cause exists when the applicant can show; a. The cost to pursue exceeds the potential income or causes financial hardship. b. Pursuing the income would endanger the household member(s) health or safety. c. Legal action is required but a private attorney or legal service refuses to accept the case. A reasonable effort to obtain legal assistance must be made and evidence provided.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL C-500 Division of Welfare and Supportive Services GENERAL ELIGIBILITY REQUIREMENTS Medical Assistance Manual APPLYING FOR AVAILABLE BENEFITS 21 Oct 01 MTL 04/21 Exceptions: 1. Persons qualifying under the QMB category do not have to apply for benefits for which they may be eligible. 2. Nevada Check Up only households do not have to apply for benefits for which they may be eligible, unless the child may be eligible for SSI. 3. Do not terminate a child’s coverage if the parent, caretaker or relative fails to pursue available benefits for the child. C-505 SSI APPLICATION AND DETERMINATION C-505.1 Required Verification of Supplemental Security Income (SSI) application or receipt of SSI as a Nevada Resident must be obtained for applicants meeting the criteria below. Allow applicants 20 calendar days to provide this proof if it is not available electronically. Failure to provide proof of SSI application or receipt of SSI within the specified time will cause denial. Failure to pursue an SSI claim or failure to provide information essential to establish the claim will result in denial or termination of assistance including all prior medical requests associated with the application. C-505.1.1 Aged, Blind and Disabled Persons Not In an Institution with Total Countable Income Less than SSI Payment Levels Medicaid under the MAABD program will NOT be approved until the applicant is approved for SSI by SSA. This includes individuals who have temporary residency status. If the applicant may be eligible under another program, such as expanded Medicaid, gather the correct information/forms needed and process the case (see MAM D-340.3) C-505.1.2 Persons In an Institution with Total Countable Income Less Than $30 Evaluate the individual for eligibility in other Medicaid categories while the SSI determination is pending. This includes individuals who have temporary residency status. (See State Institutional Category for possible eligibility if SSI is denied.) Exception: Children receiving Medicaid under 1902(e)(3) (Katie Beckett) of the Social Security Act who enter an institution for long-term care, including an RTC. An SSI application must be made; however, there will be no break in Medicaid eligibility pending a decision from SSI.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services C-505.2 Medical Assistance Manual GENERAL ELIGIBILITY REQUIREMENTS 23 Dec 22 MTL 07/23 NOT REQUIRED C-505.2 Not Required SSI application and determination by SSA is not required for: a. deceased individuals who were institutionalized during the period Medicaid is requested. b. applications requesting only prior Medicaid eligibility as long as the customer does not have an outstanding pending SSI determination for those months. c. institutionalized individuals with total net countable income of $30 or more. C-600 THIRD PARTY LIABILITY (TPL) (435.610) TPL is any individual, entity, or program that is, or may be, liable to pay all or part of the medical cost for medical assistance furnished to a Medicaid recipient. Nevada Check Up monitors previous insurance coverage to prevent the substitution of group health coverage or other commercial health insurance with public funded coverage. Enter current medical insurance information on the MINS and MEDI screen. The purpose of TPL is to reduce erroneous expenditures by maximizing use of third party resources. Medicaid is the payer of last resort whenever another resource is available, with the exception of Children with Special Health Care Needs, Indian Public Health Service (IHS) or Victims of Crime. Do not enter a MINS screens for IHS. Income maintenance insurance policies not related to actual medical expenses are not third-party liability resources unless the policy is assignable to a hospital or other medical provider. Note: If the case manager becomes aware of the pregnant woman being a surrogate, request a copy of the contract and notify the TPL Unit at DHCFP. When insurance coverage is available at no cost to the customer (e.g., through employment or Tricare, or as a veteran through the Veterans Administration), request the customer to enroll. Assistance will be denied or terminated if the customer refuses to apply for, pursue, or provide information necessary to establish insurance coverage/claims and/or fails to cooperate in the collection process from a third party. Exception: Do not deny coverage for a child if the parent refused to provide insurance information. C-605 MEDICARE AS TPL Medicare is Social Security's health insurance program. Medicare has two types of coverage; Part A - Hospital Insurance and Part B-Supplementary Medical Insurance.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL C-605.1 Division of Welfare and Supportive Services GENERAL ELIGIBILITY REQUIREMENTS Medical Assistance Manual PERSONS ELIGIBLE FOR MEDICARE 23 Dec 22 MTL 07/23 C-605.1 Persons Eligible for Medicare  all persons OVER AGE 65 who are either a U.S. citizen; or an alien lawfully admitted for permanent residency who has resided in the U.S. continuously for 5 years.  all persons UNDER AGE 65 who have received monthly Social Security/Railroad Retirement disability benefits for 24 months.  persons with End-Stage renal disease. A Medicaid applicant or recipient must cooperate in pursuing Medicare Part B, if available, as a condition of continuing eligibility, since it would be available at no cost as a result of the state Buy-In process, if eligible. When a Medicaid eligible customer with an open Medicaid case becomes eligible to enroll in Medicare the Division of Healthcare Financing and Policy (DHCFP) will send the customer a letter requesting the customer to apply for Medicare Part B. DHCFP will track enrollment and report non-cooperation to DWSS for termination from Medicaid allowing for adverse notice. When an ongoing full Medicaid recipient is already enrolled in Medicare Part A, do not send them to Social Security to apply for Part B. Add the MEDI screen and post eligibility current and ongoing, then send an email to the DHCFP Buy-In Lead asking for a manual accretion of Part B. The manual accretion will allow enrollment into Part B at no cost to the recipient from their first month of eligibility. If a customer already has other health coverage, Nevada Medicaid is not liable for health care services if the customer elects to seek treatment from a provider not authorized by their health care coverage. C-610 NOTIFICATION OF THIRD PARTY LIABILITY (TPL) TO THE FISCAL AGENT The fiscal agent is notified of current TPL and changes to such coverage through the MINS and MEDI screen. Complete or update these screens when the following occurs:  notification is provided of all verified insurance or changes in coverage.  if there is enough verification or information for the insurance to be pursued but coverage cannot be verified, refer the information to the fiscal agent. Exception: When a non-custodial parent is providing medical coverage for their dependents, provide the information to Child Support Enforcement (CSE) on the Non- Custodial Parent Form 2906.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services C-610 Medical Assistance Manual GENERAL ELIGIBILITY REQUIREMENTS 23 Dec 22 MTL 07/23 NOTIFICATION OF THIRD PARTY LIABILITY Note: If insurance coverage is available through a source that is not part of the household, assistance is not denied or terminated if the policyholder refuses to cooperate. C-610.1 Verification Obtain verification for any household member who has medical/group health insurance coverage. Types of verification (not all inclusive): ● Insurance card ● Insurance policy ● Letter from insurance company C-615 TPL AND ACCIDENTS Households are required to immediately report any accident-related injuries requiring medical care or any accident-related unsettled legal claims. When the customer has an accident or job related injury, was injured while in the custody of a law enforcement agency, or received insurance reimbursements for Medicaid-paid bills, the Medical Subrogation Form 2511 must be completed providing details and any legal action involved. The worker may contact the customer to obtain the required information. If the worker is unable to contact the customer, the form will be sent and the case will be pended for 10 days and terminated if the required information is not received. Once completed, the SETT screen is completed and the form is forwarded along with any supporting information to the fiscal intermediary. Note: See Medical Subrogation Form 2511 for fiscal intermediary address. C-620 HEALTH INSURANCE PREMIUM PAYMENT (HIPP) PROGRAM FOR COST EFFECTIVE EMPLOYER GROUP HEALTH INSURANCE Section 4402 of OBRA 1990 added section 1906 of the Social Security Act which established authorization for States to offer the Health Insurance Premium Payment (HIPP) program. HIPP pays for the health care insurance premiums for eligible Medicaid recipients who have high cost medical claims and access to group health care insurance. The program intent is to defer the cost of high health care claims to other liable insurance. Upon enrollment into the HIPP program, Medicaid will pay the premium directly to the insurer, or reimburse the premium if deducted from wages so the Medicaid individual and any other family member included on the eligible group health care policy receives coverage provided it is cost effective for the State. Enrollment in the health plan is not a condition of eligibility

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL C-620 Division of Welfare and Supportive Services GENERAL ELIGIBILITY REQUIREMENTS Medical Assistance Manual HEALTH INSURANCE PREMIUM PAYMENT 23 Dec 22 MTL 07/23 The case manager will forward the customer Form NMO-5000, HIPP Application and the customer will mail the completed HIPP form to the address provided on the HIPP application. Note: The NMO-5000 is not required if the individual is: • eligible for Nevada Check Up; • enrolled in a Managed Care Organization (MCO); • receiving unemployment benefits; • eligible for Medicare. HIPP is a cost-savings program that identifies Medicaid recipients who have access to group health insurance available through an employer. The program assists eligible recipients in paying private insurance premiums they otherwise may not be able to afford when it is determined to be cost-effective. It also benefits the recipients because they have more doctors to choose from and other medical services may be covered through private insurance that are not covered by Medicaid. The DHCFP HIPP website can be accessed at http://dhcfp.nv.gov/Pgms/CPT/HIPP/. This website can be used to gather information as well as download English/Spanish applications and brochures. This website can also be provided to recipients for easy access to program information, applications, brochures and fiscal intermediary contact information. Form NMO-5000 must be completed and forwarded to the fiscal intermediary to make this determination. Note: See NMO Form 5000 for fiscal intermediary address. If the health insurance is determined to be cost effective, premiums will be paid to the employer or insurance carrier through Medicaid. Premiums which can only be paid through a payroll deduction will be reimbursed directly to the customer. These reimbursements are exempt income to the customer. C-700 MEDICARE BUY-IN The Buy-In process is the system that allows the state to pay Medicare Part A and B premiums directly to Medicare for eligible individuals. DWSS is responsible for approving eligibility for Buy-In; however, DHCFP processes the Buy-In accretion/deletion file exchange with CMS. The state of Nevada has elected to pay the Part B premium for all Medicaid eligible individuals as well as Medicare only recipients who qualify for QMB, SLMB, or QI. In most instances, there is no premium associated with Medicare Part A; however, there are some individuals who must pay a premium for Part A. Those who must pay for this premium have a suffix "M" on their Medicare claim number. The state of Nevada has elected to pay the Part A premium for recipients who do not have free Part A if they are approved in the QMB category of eligibility.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services C-705 Medical Assistance Manual GENERAL ELIGIBILITY REQUIREMENTS 23 Dec 22 MTL 07/23 EFFECTIVE DATES FOR BUY-IN C-705 EFFECTIVE DATES FOR BUY-IN The accretion effective date is based on the category of medical assistance which the person is enrolled. The following are the guidelines for Buy-In effective dates: a. QMB: • Part A and Part B buy-in effective the month after the month of approval. b. SLMB: • Part B buy-in effective the application month and up to three months prior to the application month (prior med). c. QI: • Part B buy-in effective the application month and up to three months prior to the application month (prior med). C-720 CASE MANAGER RESPONSIBILITIES IN THE BUY-IN PROCESS The case manager must ensure that when a customer is enrolled in Medicare, the Medicare (MEDI) screen is entered into the system and eligibility is updated to the appropriate AID and Eligibility code combination. The Buy-In file exchange depends upon the correct AID/ELIG code in order to generate an accretion request for Buy-In. When an individual is no longer reflecting Medicare eligibility, the case manager must add END DT (end dates) to Part A and Part B in the MEDI screen and update eligibility to reflect loss of Medicare. All Buy-In inquiries or requests for assistance should be sent to: buyin@dhcfp.nv.gov. C-800 INCARCERATION An inmate of a public institution is ineligible for the Medicare Beneficiary program, UNLESS the institution is a medical institution. An inmate of a penal institution is never eligible for Medicaid or the Medicare Beneficiary Program while in the custody of law enforcement officials, UNLESS admitted as an inpatient to a hospital, nursing facility, juvenile psychiatric facility, or intermediate care facility. This individual is eligible for Medicaid and any Medicaid covered services provided to them while an inpatient in these facilities. If this individual becomes an inpatient of a long-term care facility, they must meet level of care and plan of care assessments to become eligible. Note: Inmates under house arrest, and supervised by Parole and Probation, may qualify for Medicaid as long as the penal institution is not supplying their food and shelter. Persons who are released on parole from a penal institution are not considered a resident of a public institution and therefore may be eligible for SSI or Medicaid if they meet all other eligibility requirements.

(d-100)Nevada Medical Assistance Manual (MAM): D-100 MAGI Application Processing#

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MODIFIED ADJUSTED GROSS INCOME (MAGI) APPLICATION PROCESSING (42 CFR 435.906, 42 CFR 435.907)

This section provides guidance on processing applications for MAGI groups. An in-person interview is NOT required as part of the application process. ONLY schedule a face-to-face interview if requested by the household or authorized representative (A/R). D-100 OVERVIEW Accept any application form designated for medical assistance programs. Applications must be accepted via: • Internet; • Telephone; • Mail; • Fax; or • In person. Applications can be submitted online at the Division’s web page www.dwss.nv.gov. The agency also accepts telephonic applications through their customer service call centers and field offices: • Northern Nevada: 775-684-7200 • Southern Nevada: 702-486-1646 • Statewide: 877-543-7669 Paper applications completed by the customer service center and field offices over the telephone with the customer must be documented to indicate a telephone signature was obtained with Amazon Web Services (AWS). Once completed and the telephonic signature is obtained with AWS, a signed and date-stamped, a copy of the paper application must be mailed to the customer as confirmation an application was received by the Division. D-101 APPLICATION An application must contain: • The applicant’s name; • Address; and • Signature. D-100 MAGI APPLICATION PROCESSING OVERVIEW Division of Social Services Medical Assistance Manual 25 July MTL 07/25

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL The Division must accept applications signed by: • An adult who has a parent/dependent child (under the age of 19) relationship or tax relationship to the applicant(s); • An A/R; • If the applicant is a minor or incapacitated, someone acting responsibly for the applicant; • An emancipated minor; or • The spouse/domestic partner of an individual. Electronic, including telephonically recorded, signatures and handwritten signatures transmitted via any other electronic transmission are acceptable. Applicants who cannot sign their name must have their mark witnessed by at least one (1) other person. Applicants with no ability to understand what they are signing must have a competent adult family member sign for them. Example: [customer name] by [family member name]. If there are no family members or the existing family members do not wish to assist the applicant, the hospital, nursing home or county agency social service staff may sign on behalf of the applicant. Example: [customer name] by [the hospital, nursing home or county agency social service worker name] In this case, a public guardian referral is required. When applicants are unable to designate an A/R and there are no family members or the existing family members do not wish to assist the applicant, the hospital, nursing home or county agency social service staff may designate themselves as an authorized representative. The hospital, nursing home or county agency must make a reasonable effort to contact family members of the applicant for information to help determine eligibility. The hospital, nursing home or county agency must provide the names and addresses of family members they contacted or tried to contact. The case manager will send Form 2534 Relative Inquiry Letter to the relatives advising of the application, the hospital, nursing home or county A/R and request any eligibility information to assist in processing the case. D-101.1 Unsigned Applications An application which is not signed by the head of household, or an A/R is an inquiry only. Staff should make a reasonable attempt to contact the Head of Household (HOH), or A/R to obtain a signature telephonically via all phone number(s) available on the application and the AMPS system. If no contact is made, do not date stamp the application, it is an inquiry only. The application is incomplete and should not be retained. NOTE: Unsigned applications received for a case with open benefits must be retained and evaluated for changes only. D-101.2 No Program Selected If the application is signed but no program is selected, staff must register and evaluate all applicable Medicaid programs for all listed household members, using prudent person principle. D-101 MAGI APPLICATION PROCESSING Division of Social Services Medical Assistance Manual 25 July MTL 07/25 APPLICATION

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL If any household member is over age 65 and/or lists any disability, impairment, need for additional services, or institutionalization, the Division must evaluate for Medical Assistance for the Aged, Blind, and Disabled (MAABD). D-101.3 No Mailing Address Provided If the application is new with no open programs, and no mailing address is provided, staff must not date stamp nor register the application until the mailing address is obtained. Staff must attempt to contact the household via all available phone number(s) to obtain the mailing address. If contact is not made, it is an inquiry only and should not be retained. For redeterminations, the address is pre-printed on the form. If the customer does not state their address has changed and there is no reason to question the mailing address on file, including for customers who have previously used General Delivery, the mailing address on file is considered valid and the redetermination should be evaluated following normal eligibility guidelines. This includes redeterminations where the customer chooses to use other application methods instead of the Redetermination of Medical Eligibility form - NRD1, as they are known to the system, and they currently have an open ongoing case. NOTE: It is not allowable to simply enter General Delivery for a mailing address when the information is missing on the application. A General Delivery address should only be entered when provided by the customer or A/R. Staff should make every attempt to collect the information, but if unsuccessful, it is an inquiry only and should not be retained. D-105 REQUESTS FOR AN APPLICATION The applicant or their representative may request an application by contacting customer service, the district office or downloading an application from the Division’s web page at dwss.nv.gov. Applicants should be encouraged to visit the website to complete an online application for medical assistance. See D-125 Registration of the Application for more information. Form 2960, Application for Health Insurance should be provided to anyone requesting medical assistance for non-elderly, non-disabled individuals and families. Form 2920, Application for Assistance to Aged, Blind and Disabled (MAABD) should be provided to anyone requesting medical assistance for aged, blind or disabled individuals. Individuals applying for medical assistance under the specialized groups should apply using the specialized applications for each group. (See Medical Assistance Manual D-200 Specialized Group Application Processing). Accept any approved medical application form, if the application requires additional information, contact the household to obtain the information needed to process the application for the appropriate medical category. If unable to contact the applicant, mail an Insufficient Information Form requesting the additional information. D-101.2 MAGI APPLICATION PROCESSING NO PROGRAM SELECTED Division of Social Services Medical Assistance Manual 25 July MTL 07/25

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL D-110 APPLICATION ASSISTANCE (42 CFR 435.908) If an individual needs help completing the application or redetermination, a volunteer or staff member must help. Anyone helping complete the application form must initial the parts completed or sign the form showing they helped complete it. D-115 FILING THE APPLICATION The application date is the day the district office receives an application form containing the applicant’s name, address, and appropriate signature. Applications received by the Division outside of normal business hours, through electronic sources such as Access Nevada, the Exchange, or local office drop boxes, are considered received and date stamped the next business day. This is the first (1st) day these applications are available to the Division for processing. D-120 WITHDRAWAL OF APPLICATION An individual may voluntarily withdraw an application any time before a case decision is made. D-125 REGISTRATION OF THE APPLICATION All paper applications for medical assistance, received via fax, mail, drop-box, telephonically and in- person are documented and date stamped by the Division. These applications will be electronically scanned and registered timely for an eligibility determination. Applications for multiple programs submitted online through Access Nevada will produce a PDF document for Medical, Supplemental Nutrition Assistance Program (SNAP) and/or Temporary Assistance for Needy Families (TANF). These PDF documents are application summaries only and may not be re printed and used as a new paper application. D-130 DUPLICATE ASSISTANCE SCREENING All household members requesting or applying for initial or continued assistance must be screened by social security number and name to avoid duplicating assistance. Assistance can only be provided from one (1) Nevada Medicaid/Children’s Health Insurance Program (CHIP) program at a time. Nevada Medicaid/CHIP Programs include: Family Medical Coverage (FMC) Infants and Children under age 19; Parent/Caretaker Relative; Pregnant Women and Postpartum; Childless Adult; Transitional Medicaid; Post Medical, Emergency Medicaid; Omnibus Budget Reconciliation Act (OBRA) Nevada Check Up (NCU) Nevada Check Up D-110 MAGI APPLICATION PROCESSING Division of Social Services Medical Assistance Manual 25 July MTL 07/25 APPLICATION ASSISTANCE

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Child and Family Services Medicaid Specialized Groups Breast and Cervical Cancer; Aged Out of Foster Care; Children in the Custody of a Public Agency, Justice Involved Re-Entry MAABD Medical Assistance to the Aged, Blind & Disabled When moving a customer to another household, do not post downgrades to eligibility after cut-off for the next month, Medicaid Management Information System (MMIS) cannot recognize this action, and the eligibility will not be terminated. Note: A system notification is sent to Healthcare.gov when an individual is enrolled in Medicaid. Healthcare.gov will notify the individual of disenrollment in Advanced Premium Tax Credits (APTC) received through Healthcare.gov. D-135 TIME FRAMES (42 CFR 435.912) Process MAGI based eligibility determinations no later than the 45th day from the application date. D-140 PRE-ELIGIBILITY VERIFICATION If customer statement indicates ineligibility, deny the application based on customer statement and notify the household. There is no need to verify the information. D-140.1 Non-Financial • Citizenship – Citizenship or immigrant status must be verified prior to approval. Citizenship is verified electronically through the federal hub or using current case information. Refer to Medical Assistance Manual (MAM) C-400 Citizenship and Identification Requirements for citizenship verification requirements including additional procedures on case approvals using the “Reasonable Opportunity” policy when electronic information is unavailable to the Division. • Social Security Number – Verified via NUMIDENT. When a discrepancy exists follow procedures outlined in MAM C-200 Social Security Numbers for SSN discrepancies. • Residency – Accept customer statement for residency. When a discrepancy exists in the current case file, contact the household or a collateral contact to clarify circumstances and document the information. See MAM C-100 Residence Requirements for residency verification requirements. • Age/Date of Birth (DOB) – Verified via NUMIDENT. Follow MAM C-200 Social Security Numbers if a NUMIDENT discrepancy exists. If no data source is available accept customer statement for age. • Household Composition – Accept customer statement for verification of household composition. D-130 MAGI APPLICATION PROCESSING DUPLICATE ASSISTANCE SCREENING Division of Social Services Medical Assistance Manual 25 July MTL 07/25

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL • Pregnancy – Accept customer statement for pregnancy. When the customer does not provide an expected due date (EDD) on the application, contact the customer to obtain the EDC. If unable to obtain an EDC via phone, staff should update the PREG record and the unborn’ s MEMB screen with a due date eight months out from the date of application and process the case. Medicaid Assistance Applications received from the Exchange will not have an EDC on the PDF as the Exchange does not ask this question. The Division systems require an EDC entered to process correct eligibility for pregnant women. A default date of 12/31/9999 will be entered and must be updated by staff during processing. Note: Currently the system does not create an AMPS task when the EDC has passed, however staff should still receive an alert in AMPS/NOMADS. When subsequent applications are received, staff should review and verify the PREG record and unborn’ s MEMB details are accurate and update if necessary. • Caretaker Relative – Accept customer statement for verification of relationship. • Domestic Partnership – Accept customer statement for verification of relationship. D-140.2 Financial Verify current monthly income using available electronic data sources. When an open TANF/SNAP case exists, always use that data source as a primary verification. If new income is reported on the application, follow TANF/SNAP verification rules. If no data source is available, request verification of current monthly income from the applicant/household. The request should include the 30-day period beginning with the day prior to the date of application and extending back 30 calendar days. Note: When a 30-day best estimate does not provide a clear presentation of the household’s income, a 60 day best estimate should be evaluated. D-145 POST ELIGIBILITY VERIFICATION If all factors of eligibility (Financial & Non-Financial) required during the Pre-Eligibility process are verified, staff must complete case processing and determine Medicaid eligibility. When there is additional information reported on the application but not required for a Medicaid determination, send an Insufficient Information Form after posting the case and allow the applicant 10 days to provide the requested information. Post Eligibility Verifications can include: • Third Party Liability – when the application indicates insurance coverage is available at no cost to the customer send an Insufficient Information Form requesting the customer to enroll. D-140.1 MAGI APPLICATION PROCESSING Division of Social Services Medical Assistance Manual 25 July MTL 07/25 NON-FINANCIAL

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL • Tribal Enrollment – when information on the application indicates a child eligible for Nevada Check Up (NCU) is a member of an American Indian tribe, send an Insufficient Information Form requesting verification of American Indian descent. D-150 VERIFICATION SOURCES Electronic verifications must be used when available and prior to sending an Insufficient Information Form requesting any paper documentation. When an open TANF/SNAP case exists, always use that data source as a primary verification. If new income is reported on the application, follow TANF/SNAP verification rules. Electronic data sources include but are not limited to: • TANF and SNAP open case file verification • State Online Query (SOLQ) - Income, Citizenship, residency if questionable • Unemployment Insurance Benefit (UIB) – Unearned income • Federal data services hub (FHUB)/United States (US) Citizen – Citizenship information received from VLP (Verify Lawful Presence) in FHUB • Systematic Alien Verification for Entitlement (SAVE) – Immigration status • ANSRS – Employment income and vital statistics • BENDEX/ State Data Exchange (SDX) – Social Security income Other data sources include but are not limited to: • Collateral contact – document name, number and information received. Examples: Customer reports earned income. Work income can be viewed in FHUB when customer has an open SNAP case with a 30-day history from three (3) months prior. Use the FHUB. Customer reports earned income. The only data source available is Automated Nevada Server-based Reference System(ANSRS). If the quarterly income from three (3) months ago is the same employer and the income amount is reasonably compatible with the customer statement of income, then use the ANSRS data as verification. D-150.1 Reasonable Compatibility (42 CFR 435.952) When processing a new application, if the information received from a data source is relatively consistent and does not vary significantly from the customer stated information, it is considered reasonably compatible. Income verification obtained through a data source is reasonably compatible with information provided by the individual when both are either above or both are below the D-145 MAGI APPLICATION PROCESSING POST ELIGIBILITY VERIFICATION Division of Social Services Medical Assistance Manual 25 July MTL 07/25

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL applicable income standard. When there is a discrepancy between the customer statement of income and the data source, certain households are allowed an additional opportunity to provide verification of income. Follow the reasonable compatibility rules to determine when to allow the household an opportunity to provide additional verifications. a. The data source indicates income is under the income limit; and the customer attested income is under the income limit; • Consider the income verified. b. The data source indicates income is over the income limit; and the customer attested income is under the income limit; and the data source is over the income limit for the assistance unit size by less than $225; • Contact the customer to obtain a reasonable explanation and verification of income discrepancy. If unable to provide verification showing their income is below the income limit, deny the application using the data source as verification. c. The data source indicates income is over the income limits; and the customer attested income is under the income limit; and the data source is over the income limit for the assistance unit size by greater than $225; • Deny the application based on the data source verification. d. There is no data source available; and the customer attested income is below the income limit. • Request the individual/household to verify income prior to enrollment. Example: 138% Federal Poverty Level (FPL) for a household of three (3) is $3,065 • Application indicates monthly income of $2,950 month for a household of three (3). • ANSR reports quarterly wages of $8,751/3= $2,917 month. (No other more current data source is available. • The data source verification is over the income limit by less than $225 ($3,065-2,917= $148) therefore the customer is given a reasonable opportunity. Contact the household to obtain reasonable explanation and verification of income. D-150.1 MAGI APPLICATION PROCESSING Division of Social Services Medical Assistance Manual 25 July MTL 07/25 REASONABLE COMPATIBILITY

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL D-150.2 MAGI Discrepancy with Supported State-Based Marketplace Applications (42 CFR 435.603(h)(3)(i)) Applications for Medicaid received through the Exchange are sent to the state when the applicant’s stated annual income is determined to be below 100 percent of the FPL. This type of income is attested income provided by the applicant to the Exchange and may or may not be verified. The information is populated on the application as verified income and the Exchange will attempt to match this information with approved electronic data sources via the Exchange datalink with the Federal data services hub (FHUB). However, the application does not reflect whether or not the attested information was verified. If an individual is determined to be ineligible for Medicaid due to current monthly income budgeting and the application for the individual was received from the Exchange stating that the income is below 100 percent FPL, Medicaid financial eligibility will be determined in accordance with the annual income budgeting method (See MAM E-135 Application of Modified Adjusted Gross Income). Income used by the Exchange must be reasonably compatible to the current MAGI monthly income as verified by the Division. If a discrepancy between the Exchange’s stated annual income and the current of MAGI monthly income are not reasonably compatible or the difference explainable, additional verification of the stated annual income will be needed before an eligibility determination can be made. Example: It is reported on the Exchange application that the customer expects to make $22,000 this year. MAGI budgeting shows excess income of $2,500/month or $30,000 annually. The $8,000 discrepancy between the Exchange and MAGI must be verified. The customer will need to provide additional verification to explain the difference in income. Verifications may include (not all inclusive): 1. Copy of seasonal work contract 2. Migrant farmer contract 3. Statement from Employer D-155 PENDING INFORMATION Give the applicant an Insufficient Information Form, detailing what verifications are needed, allowing the household at least 10 days to provide requested verifications. When the due date falls on a weekend or holiday, the due date is the next working day. A copy of the Insufficient Information Form must be stored in the case file with the current application, reflecting the verification request due date. D-150.2 MAGI APPLICATION PROCESSING MAGI DISCREPANCY WITH SUPPORTED STATE-BASED MARKETPLACE APPLICATIONS Division of Social Servi ces Medical Assistance Man ual 25 July MTL 07/25

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL If information is not provided within the time period given, deny the application or terminate assistance allowing adverse action. Do not deny individuals if the pending information is not used in that individual’s eligibility determination. Example: Household consists of grandma, adult child and grandchild. Grandma claims all members on her taxes. Household fails to provide grandmother’s income verifications. The grandchild would not be denied because the grandmother’s income is not used in her eligibility determination. If information is provided prior to the denial/termination action being taken, process the case using the verifications. Note: When proof of pregnancy ending/birth of child is requested but not provided, and no information is available through collateral contact or approved electronic data source, the ongoing eligibility of the pregnant woman must be re-evaluated for all other Medicaid coverage groups (without the unborn member) prior to termination. The unborn member record(s) and pregnancy information should be updated to reflect the unborn as no longer present in the household (see MAM D-520 Questionable Information and/or Unreported Changes). D-155.1 Future Actions If staff has information about anticipated changes in circumstances that may affect ongoing eligibility of a case, they must re-evaluate eligibility at the appropriate time based on such changes. Create a future action for the date of the anticipated change to affect the change timely. Example: Critical age changes, birth of a child(ren), seasonal employment. D-160 CERTIFICATION PERIOD Medical assistance is approved ongoing from the first (1st) month of eligibility. Individuals remain eligible for Medicaid until information is received indicating they no longer meet eligibility criteria. A redetermination of eligibility must be completed at least every 12 months. D-160.1 Nevada Check Up NCU is approved effective the month following the month of approval. If processed after cut-off the effective date is the second (2nd) month after the month of approval. Approve NCU for 12 months from the enrollment date. Child(ren) are entitled to 12 months continuous eligibility. An enrollee’s 12-month continuous eligibility may be terminated for the following federally recognized exceptions: • The child attains the age 19; • The child or child’s representative requests a voluntary disenrollment; • The child is no longer a resident of the State; D-155 MAGI APPLICATION PROCESSING Division of Social Services Medical Assistance Manual 25 July MTL 07/25 PENDING INFORMATION

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL • The Division determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of the Division’s error or fraud, abuse, or perjury attributed to the child or the child’s representative; • The child dies; • The child becomes eligible for Medicaid; or • Failure to pay premiums. Note: If a child in a continuous eligibility period no longer has a satisfactory immigration status, Medicaid benefits will be limited to emergency medical coverage for the remainder of the continuous eligibility period. When a household has members eligible under NCU and Medicaid, the 12-month certification period is effective the month of approval. D-160.2 Newborns (AKA OBRA) OBRA eligibility is approved for 12 months from the child’s DOB if their mother was receiving Medicaid in the same month of the child’s birth. These children are entitled to 12 months continuous eligibility, as long as they remain a Nevada resident (see MAM B-120.1 Deemed Newborn Children). When approving OBRA coverage, staff need to manually change the redetermination (RD) date to the month the child turns age one (1). D-160.3 Transitional Medicaid Transitional Medicaid eligibility is approved for 12 months continuous eligibility, as long as they continue to meet eligibility criteria as indicated in MAM B-130 Transitional Medicaid Coverage. When approving Transitional Medicaid coverage, staff need to manually change the RD date to 12 months from the date the case rolls to Transitional Medicaid. D-165 NEVADA CHECK UP PREMIUMS Families with children enrolled in NCU are charged a quarterly premium based on the family’s monthly taxable income. Premiums are charged per family, not per child. NCU premium payments must be paid using a check, money order, Visa, Mastercard or Discover Card. Customers should be advised to include their Unique Person Indicator (UPI) number on the payment. • Cash payments are not accepted • Payments are accepted via: D-160.1 MAGI APPLICATION PROCESSING NEVADA CHECK UP Division of Social Services Medical Assistance Manual 25 July MTL 07/25

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL o Online, visit www.e-billexpress.com/ebpp/NVMedicaid/; o Over the phone, call 775-684-3660; or o Mail to: Nevada Check Up Program PO Box 847346 Los Angeles, CA 90084-7346 Late payments paid in-person will be accepted at the following locations: Carson City 1000 E. William St. Ste. 118 Carson City, NV 89701 (775) 684-3660 Elko 1010 Ruby Vista Dr. Ste. 103 Elko, NV 89801 (775) 753-1191 Las Vegas 1210 S. Valley View Blvd Ste. 104 Las Vegas, NV 89102 (702) 668-4200 Reno 745 W. Moana Ln. Ste 200 Reno, NV 89509 (775) 687-1900 Households with children who are Native American and Alaskan Natives are not charged a monthly premium. Children of American Indian descent are exempt from the premium. Verification of American Indian descent must be provided in order to waive the premium. The child’s tribal affiliation should be entered on the Members BAP. Premiums are calculated by the system and transmitted for collection. Disenrollment will occur if a household is 60 days or two (2) full months past due. Staff will be notified with a task in the system when non-payment has occurred. See D-500 Changes for processing non-payment. D-170 CASE DOCUMENTATION (42 CFR 435.913) Staff must include in each individual's case record facts to support the decision on the application. Documentation must be clear and concise. Provide enough information so anyone reviewing the case can determine the reason, logic and accuracy of the case manager’s decisions and actions. MAGI APPLICATION PROCESSING Division of Social Services Medical Assistance Manual 25 July MTL 07/25 NEVADA CHECK UP PREMIUMS D-165

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL D-170.1 Case Records (NRS 239.080, NRS 230.125) The Division must maintain case files in accordance with the state’s record retention schedule. Records must be maintained for 37 months after the case closure date. D-175 PRIOR MEDICAL COVERAGE Prior medical coverage is available for up to three (3) months prior to the application month if the individual requesting the coverage meets all eligibility requirements for that month. See MAM A-115 Prior Medical. D-180 REINSTATEMENTS Reinstatements are allowed for the following reasons: • The household provided verification within 10 days from date of denial. • The household provides verifications prior to the termination action being taken. • The customer provides RD form and all verifications within 90 days from termination of RD. (See MAM D-400 Redeterminations) Reinstatements for other reasons are made at the discretion of the social services manager (SSM) or supervisor. D-185 "PRUDENT PERSON" PRINCIPLE The policies included in the manual are rules for determining eligibility. It is impossible to foresee and give examples for all situations; therefore, staff are encouraged to use reason and apply good judgment in making eligibility decisions when rare and unusual situations are encountered. Reasonable decisions made by staff based on the best information available using good judgment, program knowledge, experience, and expertise in a particular situation are referred to as prudent person principle. Document the rationale used to make a decision and any applicable manual references and policy interpretations. Follow local office procedures for obtaining an interpretation from Eligibility and Payments (E&P) Program Specialists, when it is impossible or inadvisable to follow the prudent person principle because of a lack of information or program knowledge. Note: All questionable circumstances should be referred to Investigations and Recovery (I&R) following applicable I&R referral processes. D-170.1 MAGI APPLICATION PROCESSING CASE RECORDS Division of Social Services Medical Assistance Manual 25 July MTL 07/25

(d-200)Nevada Medical Assistance Manual (MAM): D-200 Specialized Group Application Processing#

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL SPECIALIZED GROUPS - APPLICATION PROCESSING This section provides guidance on processing applications for Specialized Medical Groups such as Aged-Out of Foster Care, Breast and Cervical, CCPA and Title IV-E Rite of Passage Foster Children. An in-person interview is NOT required as part of the application process. ONLY schedule a face-to-face interview if requested by the household or authorized representative. D-200 OVERVIEW Each specialized medical group has their own application and process for determining eligibility. D-200.1 Income All income of the applicant is excluded in determining eligibility in the specialized groups.

D-200.2 Resources All resources of the applicant are excluded in determining eligibility in the specialized groups.

D-205 AGED OUT OF FOSTER CARE Effective July 1, 2005, young adults who have “aged out” of foster care may receive Medicaid as an “Independent Foster Care Adolescent”. This includes children who were in the custody/in foster care through the Division of Child and Family services (DCFS), DCFS-Youth Parole, Clark County DFS, Washoe County DSS, tribal social service agencies, or in foster care in another state. Young adults, who age out of foster care in Nevada, will be given the opportunity to apply through their state or county DCFS worker when they are exiting foster care. If they choose not to apply at that time, but later decide they need assistance, they can apply at any time prior to their 26th birthday. a. Division of Child and Family Services (DCFS) DCFS will submit a one-page application, along with verification the individual has aged out of foster care; at the same time they terminate their case. . Division of Welfare and Supportive Services D-200 Medical Assistance Manual SPECIALIZED GROUPS-APPLICATION PROCESSING 15 Jul 01 MTL 01/15 OVERVIEW

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL b. Division of Welfare and Supportive Services (DWSS) Individuals who fail to apply at the time they age out of foster care, can apply through DWSS using the DCFS one-page application or a regular Medicaid application. Upon receipt of the application, the case manager must verify: ● current age; ● citizenship; and ● aged out of foster care at age 18. Individuals who age out of foster care at age 18 through DCFS will have a specific code entered in NOMADS from the UNITY system to identify them. Use this as verification of aging out. D-205.1 Aged Out of Foster Care in Another State Young adults who age out of foster care in another state may apply for benefits in Nevada. These individuals need to provide proof they aged out of foster care at age 18 and meet all other eligibility requirements. Note: These individuals are eligible through their 21st birthday. Proof can be in the form of a letter from the family services agency in the other state notifying the individual they are no longer eligible for their program, or through collateral contact. D-205.2 Reporting Requirements Recipients are required to report the following changes: ● address ● moving to another state ● pregnancy ● birth of newborn ● third party insurance

D-205.3 Denial/Termination Medicaid is terminated allowing for adverse when: ● the recipient reaches age 21(for those children not on Nevada Medicaid at 18);or ● the recipient reaches age 26; or ● moves to another state; or ● is placed/lives in an ineligible facility (jail/detention) Note: Closure of an Aged Out of Foster Care case is done at the individual member level. The AO Closure reason codes are located on the individual’s MEMB screen. D-205 Division of Welfare and Supportive Services SPECIALIZED GROUPS-APPLICATION PROCESSING Medical Assistance Manual AGED OUT OF FOSTER CARE 16 May 01 MTL 02/16

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL D-210 BREAST/CERVICAL CANCER MEDICAID

Public Law 106-354 authorizes Medicaid to uninsured women under age 65 who are identified through the Centers for Disease Control and Prevention’s (CDC) National Breast and Cervical Cancer Early Detection Program for further diagnosis or are in need of treatment. The Women’s Health Connection under Access to Healthcare Network is Nevada’s Breast and Cervical Cancer Early Detection Program. Breast/Cervical Cancer Medicaid begins July 1, 2002. Case managers with the Women’s Health Connection identify and refer uninsured women under age 65 who have been screened through them. A referral Form 2591-EM is submitted to DWSS for approval. Note: Referrals and redetermination applications will be processed at the Elko District Office. D-210.1 Verification Citizenship must be verified for all MCB applicants. Follow the policy outlined in manual section C-400 for obtaining verifications electronically. D-210.2 MCB Presumptive Eligibility Eligibility begins the date on which the Women’s Health Connection’s (WHC) contracted provider determines the individual meets the eligibility requirements. Once approved, the DWSS case manager sends an application for assistance to the individual. If the individual does not return the application for assistance by the last day of the month following the month during which presumptive eligibility was determined, medical assistance may be terminated. Note: The MCB presumptive eligibility program is not currently approved through the hospital presumptive eligibility portal. Applications and Form 2591-EM are submitted directly to DWSS and will be referred to the Elko District Office.

D-210.3 Eligibility Requirements Individuals who apply for Breast and Cervical Cancer Medicaid must meet the following requirements: • Must be a Nevada resident; ● Must be under age 65; ● Must be uninsured or underinsured; ● Not eligible under any other Medicaid eligibility group; ● Must have been screened for breast or cervical cancer by the “Disease Control and Prevention (CDC)”. In Nevada Women’s Health Connection is the CDC licensed provider; and ● Found to need treatment for either breast or cervical cancer. Division of Welfare and Supportive Services D-210 Medical Assistance Manual SPECIALIZED GROUPS-APPLICATION PROCESSING 17 Jul 01 MTL 04/17 BREAST/CERVICAL CANCER MEDICAID

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL A woman is considered to be underinsured when she; ● Is in a period of exclusion (such as a preexisting condition exclusion or an HMO affiliation period); ● Is not actually covered for treatment of breast or cervical cancer; or ● Has contract health care coverage through Indian Health Services or Tribal Clinics. A woman is considered to have been screened if she has received a screening mammogram, clinical breast exam, or Pap test; or she has received diagnosis of breast or cervical cancer or of a pre-cancerous condition of the breast or cervix as the result of the screening under the CDC program. A women is considered to need treatment if, in the opinion of the individual’s treating health professional, the diagnostic evaluation following the clinical screening indicates the woman is in need of treatment services. Services include diagnostic services necessary to determine the extent and proper course of treatment, as well as treatment itself. D-210.4 Do Not Apply the Following Eligibility Requirements ● SNAP Joint Processing ● Household Determination ● Resources and Income ● Applicant Job Search/Employment Services/NEON ● Assistance Unit Needs Budgeting ● Transitional Medicaid ● Third Party Liability ● Medicaid Managed Care Health Plans (MCHP) ● Financial Management ● Cooperation with Child Support Enforcement D-210.5 Termination A woman’s Medicaid eligibility ends when her course of treatment is completed or she no longer meets the criteria for this eligibility category. A woman eligible in this category is eligible for all Medicaid services. D-215 CHILDREN FOR WHOM A PUBLIC AGENCY HAS ASSUMED FINANCIAL RESPONSIBILITY Medicaid is available for some children for whom financial responsibility is assumed in whole or in part by a public agency. Public agencies include county, state and Native American social service agencies. D-210.3 Division of Welfare and Supportive Services SPECIALIZED GROUPS-APPLICATION PROCESSING Medical Assistance Manual ELIGIBILITY REQUIREMENTS MTL 01/13 01 Oct 13

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL The Division of Child and Family Services (DCFS) is a qualifying public agency only if: ● the agency is assuming partial or full financial responsibility for the child; and ● the child is placed at Desert Willow; and ● DCFS DOES NOT have custody of the child. D-215.1 Application To apply for Medicaid, the responsible agency must: • Complete and return Form 2447-EM, Medicaid Application for Children in the Custody of a Public Agency; and • Provide the information required for an eligibility determination. The DWSS case manager must make an eligibility determination within 3 working days from receiving the completed application AND the information required to process the case, unless unusual circumstances exist. The public agency must be mailed notification of the eligibility decision on the date the determination is made. If unusual circumstances prevent the application from being processed within this time frame, the reason for the delay must be documented in the case record. Medical benefits are approved when eligibility criteria are met. Notify the applying agency of the approval with the Notice of Decision, Form 2447-EM (page 3). D-215.2 Verifications By signing the application, public agencies (except DCFS) are attesting to having full or partial financial responsibility of the child for whom they are making application. If the agency is requesting prior medical assistance under this category, the agency must have had supervision of the child for a portion of the month for which assistance is being requested.  Children in the custody of DCFS ARE NOT eligible for this category of assistance. Children for whom DCFS is NOT taking custody, but for whom DCFS is assuming partial or full financial responsibility, may be eligible if the child meets all other eligibility criteria.  The public agency is required to provide legal documentation showing physical or legal supervision or wardship, copies of Agreements for Substitute Care Placement, reports to the court, or other pertinent documents showing changes in legal or physical supervision status as the documents become available. Division of Welfare and Supportive Services D-215 Medical Assistance Manual SPECIALIZED GROUPS-APPLICATION PROCESSING 17 Jul 01 MTL 04/17 CHILDREN FOR WHOM A PUBLIC AGENCY HAS ASSUMED FINANCIAL RESPONSIBILITY

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL o When documents are not available at the time of application, do not delay Medicaid assistance for the child. The agency’s statement on the application will be accepted until formal documentation is available. Request documentation in writing, and allow thirty (30) days for the agency to respond. If the agency indicates the documents will not be available by the due date, document the reason for the delay and when the documents are expected. (i.e., when is the court date scheduled? How long after the court date do you expect to receive the court order?) • Age/School - Verify school attendance and expected date of graduation for every child who is age 18. • Financial Responsibility -To qualify for Medicaid under this category, a public agency must have assumed full or partial financial responsibility for the child. The child must not be receiving cash assistance under any program. The agency’s statement on the application is acceptable verification. • Citizenship – Follow citizenship rules in C-100. • SSN – Follow SSN rules in C-100. • Third Party Liability – Follow TPL rules in C-100. • Living Arrangement (placement)-To qualify for Medicaid under this category, a child must reside in: a. A group family foster home (this may include the home of a relative in or out of state, other than the child’s parent); or b. A private institution (including hospitals, residential treatment centers); or c. A detention facility or public institution such as Kids Kottage or Child Haven (only when temporarily placed pending other arrangements appropriate for their needs). At the time of application, the facility must indicate the anticipated date and long term placement of the child. The child must not be considered an inmate of a training school, forestry camp or other facility for the detention of delinquent children. If the child’s stay has exceeded thirty (30) days, the child is not considered temporarily placed, unless the public agency provides evidence of reasonable efforts to place the child. The agency’s statement on the application is acceptable verification of placement. D-215.2 Division of Welfare and Supportive Services SPECIALIZED GROUPS-APPLICATION PROCESSING Medical Assistance Manual VERIFICATIONS MTL 14/01 01 Mar 14

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL D-215.3 Denial/Termination Assistance is denied or terminated when: ● eligibility criteria is not met; and/or ● child is receiving cash assistance; and/or ● information essential for determining eligibility was requested in writing is not provided by the required date. ● the agency fails to provide the child’s current status as requested on the monthly report. Notify the applying agency of the denial/termination and the reason with the Notice of Decision, Form 2447-EM (page 3) Thirteen (13) days adverse action notice is required; unless the responsible agency reports the child is no longer under their supervision or the child has been moved to an ineligible placement. If the child may be eligible for medical assistance under a different category of Medicaid or Nevada Check Up, inform the agency of the child’s potential eligibility and attach the appropriate application to the Notice of Decision. D-215.4 Reporting Requirements Public agencies are required to report the status of children receiving Medicaid or for whom a Medicaid application has been submitted to the Division by the 10th of each month. D-220 MEDICAID ELIGIBILITY FOR TITLE IV-E ELIGIBLE FOSTER CHILDREN AT RITE OF PASSAGE Medicaid coverage may be provided for children residing at Rite of Passage facilities in Nevada and receiving Title IV-E foster care payments from another state. If an agency fails to respond to the monthly report by the end of the month it is due, the eligibility worker will terminate the case(s).

D-220.1 Application Rite of Passage staff must: • complete and sign Form 2447-EM, Medicaid Application for Children in the Custody of a Public Agency; and • provide all of the information required for an eligibility determination. Division of Welfare and Supportive Services D-215.3 Medical Assistance Manual SPECIALIZED GROUPS-APPLICATION PROCESSING 17 Jan 01 MTL 01/17 DENIAL/TERMINATION

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Applications will be processed in the Yerington District Office regardless of the location of the child. Applications will be processed within 3 working days of receipt of the application AND the required documentation, unless unusual circumstances exist. The redetermination date in the system should be set to coincide with the IV-E redetermination. If the child may be eligible for medical assistance under a different category of Medicaid or Nevada Check Up, inform the agency of the child’s potential eligibility and attach the appropriate application to the Notice of Decision. D-220.2 Verifications Title IV-E eligibility - Staff at Rite of Passage must provide the following written verification from the custodial state (the state making placement): ● Child’s name ● Child’s Social Security Number ● Child’s gender ● Verification of the type of IV-E assistance (adoption or foster) provided ● The amount of IV-E cash assistance the child receives each month ● Proof of any other medical insurance coverage (Third Party Liability) ● The next redetermination due date for IV-E eligibility Citizenship – follow citizenship rules in C-100 Age – Child must be less than 18 years of age. Living arrangement – child must be residing at Rite of Passage facility in Nevada D-220.3 Denial/Termination Assistance is denied when: ● One or more of the eligibility criteria is not met; and/or ● Information essential for determining eligibility is requested in writing, but not provided by the required date. ● Rite of Passage fails to provide the information needed to complete the redetermination process, and/or ● the recipient no longer meets the eligibility criteria for this category of assistance. Notify the applying agency of the denial and the reason for the denial/termination. Note: If the child may be eligible for medical assistance under a different category of Medicaid or Nevada Check Up, inform the agency of the child’s potential eligibility and attach the appropriate application to the Notice of Decision. D-220.1 Division of Welfare and Supportive Services SPECIALIZED GROUPS-APPLICATION PROCESSING Medical Assistance Manual APPLICATION MTL 01/13 01 Oct 13

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL D-220.4 Reporting Requirements Rite of Passage staff must report if a child no longer resides at their facility or if the child’s IV-E eligibility ceases. D-220.5 Case Management A Medicaid redetermination (RD) must be timed to coincide with the Title IV-E eligibility review. The custodial state must provide the IV-E RD date prior to approval, and the Medicaid RD due date should be adjusted in the system at approval to ensure the case comes up for review at the appropriate time. Request a new application and written verification from the custodial state regarding continued IV-E eligibility from Rite of Passage staff. Continue the case if all eligibility criteria continue to be met. D-225 REQUEST FOR INFORMATION For all specialized medical applications, when the application is incomplete or information required for an eligibility decision is not provided at the time of application, send a written request to the agency allowing at least 10 working days for the agency to complete the application and/or provide the information. A copy of the application and the request must be kept in the eligibility file until the information is returned.

D-230 WITHDRAWAL OF APPLICATION An individual may voluntarily withdraw an application anytime before a case decision is made.

D-235 DUPLICATE ASSISTANCE SCREENING All household members applying for or requesting initial or continued assistance must be screened by Social Security Number and name to avoid duplicating assistance. Assistance can only be provided from one Nevada Medicaid program at a time. Nevada Medicaid Programs include: FMC Dependent Child; Parent/Caretaker Relative; Pregnant Women; Childless Adult NCU Nevada Check Up CWS Child Welfare Services (Division of Child and Family Services) SPECIALIZED Breast and Cervical Cancer, Aged Out of Foster Care, Child in GROUPS Custody Of Public Agency MAABD Medical Assistance to the Aged, Blind & Disabled Division of Welfare and Supportive Services D-220.4 Medical Assistance Manual SPECIALIZED GROUPS-APPLICATION PROCESSING 13 Oct 01 MTL 01/13 REPORTING REQUIREMENTS

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Exception: When a child(ren) moves from one household to another household, there may be overlapping months of eligibility. When moving an individual to another household, do not post downgrades to eligibility after cut-off for the next month, MMIS cannot recognize this action and the eligibility will not be terminated. D-240 "PRUDENT PERSON" PRINCIPLE

The policies included in the manual are rules for determining eligibility. It is impossible to foresee and give examples for all situations; therefore, case managers are encouraged to use reason and apply good judgment in making eligibility decisions when rare and unusual situations are encountered. Reasonable decisions made by staff based on the best information available using good judgment, program knowledge, experience, and expertise in a particular situation is referred to as the prudent person principle Document the rationale used to make a decision and any applicable manual references and policy interpretations. Follow local office procedures for obtaining an interpretation from Eligibility and Payments (E&P) Program Specialists in Central Office, or submit Form 6018, Policy and Procedure Inquiry requesting clarification or directives, to the Chief of E&P, when it is impossible or inadvisable to follow the prudent person principle because of a lack of information or program knowledge. Note: Suspicious circumstances should be referred to I&R using Investigative Referral Form (2683-EE). D-245 PRIOR MEDICAL COVERAGE Prior medical coverage is available for up to 3 months prior to the application month if the individual requesting the coverage meets all eligibility requirements, in that month, for the specialized group. Eligibility is determined on a month-by-month basis for each individual requesting coverage. D-245.1 How to Apply for Prior Coverage A request for prior medical coverage may be made on any medical assistance application and is considered a separate application because it is for months predating the initial application. Prior medical requests may be added during the pending period and during the 12 month period after approval provided the case remains open. Therefore, approval, denial or pending of a prior medical request must always be addressed in a notice to the household. Do not delay an ongoing eligibility decision while obtaining information to determine prior medical eligibility. In addition, if the household is only requesting prior coverage, provide an ongoing eligibility decision at the time of application. D-235 Division of Welfare and Supportive Services SPECIALIZED GROUPS-APPLICATION PROCESSING Medical Assistance Manual DUPLICATE ASSISTANCE SCREENING 16 Jul 01 MTL 03/16

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL D-245.2 Eligibility for Prior Coverage Approve medical assistance for the person requesting coverage in the three months prior to the application month only for those months in which the individual met all eligibility requirements for the specialized group including citizenship. Individuals determined eligible for a month of prior medical coverage are eligible from the first day of month, regardless of when the eligibility requirements were met. D-245.3 Prior Medical Determinations For Rite of Passage applicants, the custodial state must verify payment of IV-E foster care funds on behalf of the child for the month of requested coverage. Division of Welfare and Supportive Services D-245.2 Medical Assistance Manual SPECIALIZED GROUPS-APPLICATION PROCESSING 16 Jul 01 MTL 03/16 ELIGIBILITY FOR PRIOR COVERAGE

(d-300)Nevada Medical Assistance Manual (MAM): D-300 MAABD Application Processing#

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD Medical Assistance to the Aged, Blind, and Disabled (MAABD) APPLICATION PROCESSING This section provides guidance on processing applications for MAABD groups. An in-person interview is NOT required as part of the application process. ONLY schedule a face-to-face interview if requested by the household or authorized representative (A/R). D-300 OVERVIEW Accept any application form designated for medical assistance programs. When a request for medical assistance is received on a form other than MAABD application Form 2920 and additional information is needed to determine MAABD eligibility; • Contact the household to obtain the information needed to process the application for the appropriate medical category, or • Request additional information by mail, if staff are unable to reach the customer. Applications must be accepted via: • Internet; • Telephone; • Mail; • Fax; or • In person. Applications can be submitted online at the Division’s web page www. accessnevada.nv.gov. The Division also accepts telephonic applications through their customer service centers and field offices: • Northern Nevada: 775-684-7200 • Southern Nevada: 702-486-1646 • Statewide: 877-543-7669 Paper applications completed by the customer service center and field offices over the telephone with the customer must be documented to indicate a telephonic signature was obtained with Amazon Web Services (AWS). Once completed and the telephonic signature is obtained with AWS, a signed and date-stamped copy of the paper application must be mailed to the customer as confirmation an application was received by the Division. D-300 MAABD APPLICATION PROCESSING OVERVIEW Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD D-301 APPLICATION An application must contain: • The applicant’s name; • Address; and • Signature. The Division must accept applications signed by: • An adult who has a parent/dependent child (under the age of 19) relationship or tax relationship to the applicant(s); • An A/R; • If the applicant is a minor or incapacitated, someone acting responsibly for the applicant; • An emancipated minor; or • The spouse/domestic partner of an individual. Electronic, including telephonically recorded signatures and handwritten signatures transmitted via any other electronic transmission are acceptable. Applications for the Medicare Beneficiary program received through the Low-Income Subsidy (LIS) referral process do not require a signature. The applicant’s signature is obtained by Social Security Administration (SSA). Applicants who cannot sign their name must have their mark witnessed by at least one (1) other person. Applicants with no ability to understand what they are signing must have a competent adult family member sign for them. Example: [customer name] by [family member name]. If there are no family members or the existing family members do not wish to assist the applicant, the hospital, nursing home or county agency social service staff may sign on behalf of the applicant. Example: [customer name] by [the hospital, nursing home or county agency social service worker name]. In this case, a public guardian referral is required. When applicants are unable to designate an A/R and there are no family members or the existing family members do not wish to assist the applicant, the hospital, nursing home or county agency social service staff may designate themselves as an A/R. The hospital, nursing home or county agency must make a reasonable effort to contact family members of the applicant for information to help determine eligibility. The hospital, nursing home or county agency must provide the names and addresses of family members they contacted or tried to contact. The case manager will send Form 2534 Relative Inquiry Letter to the relatives advising them of the application, the hospital, nursing home or county agency representative and request any eligibility information to assist in processing the case. D-301 MAABD APPLICATION PROCESSING Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25 APPLICATION

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD D-301.1 Unsigned Application An application which is not signed by the customer or A/R is an inquiry only. Staff should make a reasonable attempt to contact the Head of Household (HOH), or A/R to obtain a signature telephonically via all phone number(s) available on the application and the AMPS system. If no contact is made, do not date stamp the application, it is an inquiry only. The application is incomplete and should not be retained. NOTE: Unsigned applications received for a case with open benefits must be retained and evaluated for changes only. D-301.2 No Program Selected If the application is signed but no program is selected, staff must register and evaluate all applicable Medicaid programs for all listed household members, using prudent person principle. If any household member is over age 65 and/or lists any disability, impairment, need for additional services, or institutionalization, the Division must evaluate for MAABD. D-301.3 No Mailing Address Provided If the application is new, with no open programs, and no mailing address is provided, staff must not date stamp nor register the application until the mailing address is obtained. Staff must attempt to contact the household via all available phone number(s) to obtain the mailing address. If contact is not made, it is an inquiry only and should not be retained. For redeterminations, the address is pre-printed on the form. If the customer does not state their address has changed and there is no reason to question the mailing address on file, including for individuals who have previously used General Delivery, the mailing address on file is considered valid and the redetermination should be evaluated following normal eligibility guidelines. This includes redeterminations where the customer chooses to use other application methods instead of the Redetermination of Medical Eligibility Form - NRD1 Form, as they are known to the system, and they currently have an open and ongoing case. NOTE: It is not allowable to simply enter General Delivery for a mailing address when the information is missing on the application. A General Delivery address should only be entered when provided by the customer or A/R. Staff should make a reasonable attempt to collect the information, but if unsuccessful, it is an inquiry only and should not be retained. D-301.1 MAABD APPLICATION PROCESSING Unsigned Application Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD D-305 REQUESTS FOR AN APPLICATION The applicant or their representative may request an application by contacting customer service, the district office or downloading an application from the Division’s web page at www.dwss.nv.gov. Applicants should be encouraged to visit accessnevada.nv.gov to complete an online application for medical assistance. Form 2960, Application for Health Insurance should be provided to anyone requesting medical assistance for non-elderly, non-disabled individuals and families. Form 2920, Application for Assistance to Aged, Blind and Disabled (MAABD) should be provided to anyone requesting medical assistance for aged, blind or disabled individuals. Individuals applying for medical assistance under the specialized groups should apply using the specialized applications for each group. (See Medical Assistance Manual [MAM] D-200 Specialized Group Application Processing). D-305.1 Forms Given to the Customer with Application 1. 2179-EE Interface Consent Form 2. NMO 6160-E Medicaid Estate Recovery Notification of Program Operation D-310 APPLICATION ASSISTANCE If an individual needs help completing the application or redetermination, a volunteer or staff member must help. Anyone helping complete the application form must initial the parts completed or sign the form showing they helped complete it. D-315 FILING THE APPLICATION The application date is the day the district office receives an application form containing the applicant’s name, address, and appropriate signature. Applications received by the Division outside of normal business hours, through electronic sources such as Access Nevada, the Exchange, or local office drop boxes, are considered received and date stamped the next business day. This is the first (1st) day these applications are available to the Division for processing. D-320 WITHDRAWAL OF APPLICATION An applicant and/or A/R may voluntarily withdraw an application any time before a case decision is made. D-325 REGISTRATION OF THE APPLICATION All applications must be entered into the system in a timely manner. Pending applicants must be registered in the system to ensure medical providers and other agencies/states can obtain correct eligibility information. D-305 MAABD APPLICATION PROCESSING Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25 REQUESTS FOR AN APPLICATION

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD Applications for multiple benefits submitted online through Access Nevada will produce a PDF document for Medical, Supplemental Nutrition Assistance Program (SNAP) and/or Temporary Assistance for Needy Families (TANF). These PDF documents are application summaries only and may not be re-printed and used as a new paper application. If the household requests to add TANF and/or SNAP during the pending process, advise the household a separate application is required. D-325.1 Application from a Facility When a facility is named as the A/R, the facility must provide proof that a copy of the application and request for information was provided to the responsible relative, if applicable. Allow 20 calendar days from the mailing date for the applicant or A/R to provide the necessary information unless the customer or A/R has agreed in writing to a shorter time allowance. When the due date falls on a weekend or holiday, the due date will be extended until the close of the next working day. If the customer or A/R does not provide the requested information within the time period given, send a denial notice. Should the A/R/ family member experience non-cooperation with a third-party, they must notify the office in writing and request assistance in obtaining the information prior to the 20-day deadline. Proof that a request was made to the third-party is required. Should additional information be required during the case processing period, allow 10 days to provide the additional information. Additional information is defined as information needed after the initial request or as a result of receiving information from the initial request. D-330 DUPLICATE ASSISTANCE SCREENING All household members applying for or requesting initial or continued assistance must be screened by Social Security Number and name to avoid duplicating assistance. Assistance can only be provided from one (1) Nevada Medicaid program at a time. Nevada Medicaid programs include: 0B Family Medical Coverage (FMC) 1B Infants and Children under age 19; Parent/Caretaker Relative; Pregnant Women and Postpartum; Childless Adult; Transitional Medicaid; Post Medical, Emergency Medicaid; Omnibus Budget Reconciliation Act (OBRA) 2B Nevada Check Up (NCU) 3B Nevada Check Up 4B Division of Child and family 5B Medicaid Services 7B Breast and Cervical Cancer; Aged Out of Foster Care; Children in the 6B Specialized Groups Custody of a Public Agency, Justice Involved Re-Entry 8B MAABD 9B Medical Assistance to the Aged, Blind & Disabled D-325 MAABD APPLICATION PROCESSING REGISTRATION OF THE APPLICATION Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD When moving a customer to another household, do not post downgrades to eligibility after cut-off for the next month, Medicaid Management Information System (MMIS) cannot recognize this action and the eligibility will not be terminated. D-335 TIME FRAMES • Process MAABD eligibility no later than 45 days from the application date, and • No later than 90 days from the application date for individuals applying for MAABD on the basis of disability, • Within 10 working days from the date the staff receives the Supplemental Security Income (SSI) determination, unless extenuating circumstances exist. D-340 PRE-ELIGIBILITY VERIFICATION When processing a new application, if the customer’s statement indicates ineligibility, deny the application based on customer statement and notify the household. Verify all pre-eligibility factors prior to approval. Use electronic verification sources when available. D-340.1 Non-Financial Verification • Citizenship – Citizenship or immigrant status must be verified prior to approval. Citizenship is verified electronically through the federal hub or using current case information. Refer to MAM C-400 Citizenship and Identification Requirements for citizenship verification requirements including additional procedures on case approvals using the “Reasonable Opportunity” policy when electronic information is unavailable to the Division. • Social Security Number (SSN) – Verified via the Numerical Index File (NUMIDENT). When a discrepancy exists follow procedures outlined in MAM C-200 Social Security Numbers for SSN discrepancies. • Residency – Accept customer statement for residency. If a discrepancy is discovered, contact the household or a collateral contact to clarify circumstances and document the information. See MAM C-100 Residence Requirements for residency verification information. • Aged, Blind and Disability • Aged – Age is verified via NUMIDENT. Follow MAM C-200 Social Security Numbers if a NUMIDENT discrepancy exists. If no data source is available accept customer statement for age. • Blind/Disability - Customers less than 65 years of age must be blind or disabled. The Division uses the same blindness/disability criteria as SSA. When SSA determines a customer is not blind or disabled, deny Medicaid for all months requested, whether or not the SSA determination covers each month of the Medicaid D-330 MAABD APPLICATION PROCESSING Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25 DUPLICATE ASSISTANCE SCREENING

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD requested period, unless it is apparent SSA's decision is based on a disability different from that of the Medicaid period. When SSA determines a customer is disabled, use the SSA disability onset/start date as proof of blindness/disability for any months covered by the onset date. If the SSI disability onset date is greater than the SSA application date, deny all months prior to the onset date including months not covered by SSA determination. If the SSI disability onset date is the same as the SSA application date and Medicaid is requested for months prior to the SSI application date request a disability determination by sending a Disability/Incapacity Determination Request Form (3304) to the Division of Health Care Financing and Policy (DHCFP) district office. Health Insurance for Work Advancement (HIWA) Applicants - Prior SSI recipients and/or current or prior Social Security Disability Insurance recipients, whose benefits ended for a reason other than loss of disability, do not need a new disability determination unless SSA’s decision was based on a disability different from what is presented to the Division. If the disability is different or their SSI or RSDI benefits ended for loss of disability, a new disability decision is needed. If a person has never received SSI or RSDI benefits, they must provide a determination or other verification of their disability. Example: Medicaid application date 10/20/2009 with prior medical request for three (3) months. Customer applied for SSI on 10/30/2009. SSI is approved with an onset date of 11/10/2009. 10/2009 and all prior medical months would be denied for no disability and no 3004 would be requested. Example: Medicaid application date 3/20/2010 with prior medical request. Customer applied for SSI 04/10/2010 and is approved with an onset date of 4/01/2010. Approve 4/2010 ongoing and send a 3004 to DHCFP district office for 3/2010 and prior medical months requested. D-340.2 Division of Health Care Finance and Policy (DHCFP) Disability Determination Submit a completed Home and Community Based Services Waiver Eligibility Status Form NMO-3010, completed Incapacity/Disability determination Questionnaire Form, and the release page of the Application for Assistance, directly to DHCFP Central Office at 1100 E. Williams Street, Suite 101, Carson City, NV 89701 requesting a disability decision for the month’s assistance is requested. The Home and Community Based Services Waiver Eligibility Status Form NMO-3010 must include dates of service and provider information. • Examinations will only be required when deemed necessary by DHCFP. Katie Beckett and Nevada’s Medicaid Home and Community Based Waivers needing a DHCFP determination are to be routed to the appropriate DHCFP district office rather than central office. • DHCFP will notify the staff of a disability decision on the Home and Community Based Services Waiver Eligibility Status Form NMO-3010. D-340.1 MAABD APPLICATION PROCESSING Non-Financial Verification Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD D-340.3 Pending SSI Determinations When a pending SSI application is approved by SSA, an eligibility decision must be made within 10 working days from the date the staff receives the SSI determination, unless extenuating circumstances exist. When a pending SSI application is denied by SSA, deny the pending Medicaid application. If the applicant requests reinstatement of a denied Medicaid application, request proof of filing a timely reconsideration with the SSA, if provided return the Medicaid application to pending status. The timely reconsideration must be for the same Social Security application that the original Medicaid application was based on and not a new claim. Do not request verification of citizenship during the pending SSI period. If the applicant is approved for SSI, they will meet the citizenship documentation requirements. If the applicant moves out of state while pending SSI: • Terminate ongoing eligibility months for no residency; and • Leave previous months pending the SSI determination; and • When SSI decision is received, approve any verified Nevada SSI months. If the applicant becomes eligible in another Medicaid category while pending SSI: • Terminate the SSI pending months for duplicate assistance; and • Leave any months not covered by another category pending in the system until the SSI determination is made; and • Do not approve SSI eligibility for months the applicant was eligible under another Medicaid category. Terminate the other Medicaid eligibility and begin the SSI eligibility in the next available month. D-340.4 Financial Verification D-340.4.1 Income Verify the income of the applicant and their spouse if the applicant is married and residing with their spouse or when the couple is separated due to institutionalization. Electronic verifications must be used when available and prior to sending an Insufficient Information Form requesting any paper documentation. Request paper documentation only when no electronic data sources are available. D-340.4.2 Resources Verify all countable resources of the applicant and their spouse if the applicant is married and residing with their spouse or when the couple is separated due to institutionalization. Institutional and Home-Based Waiver (HBW) Spousal Resource Assessment – Resources of an institutionalized individual or HBW applicant and their spouse must be verified regardless of living circumstances. Individuals are considered married until divorced for the purposes of the spousal resource assessment. D-340.3 MAABD APPLICATION PROCESSING Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25 Pending SSI Determinations

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD SSI Recipients - All resources will be evaluated by the SSA. If an SSI recipient has an inpatient stay in a medical facility, see Transfer of Assets policy in MAM F-400. • When countable resources exceed the limit for an SSI recipient, notify the SSA of the assets using Report of Change – SSI DATA Form SSA-3911-U4. D-340.5 Post Eligibility Verification If all factors of eligibility (Financial & Non-Financial) required during the Pre-Eligibility process are verified, staff must complete case processing and determine Medicaid eligibility. When there is additional information reported on the application but not required for a Medicaid determination, send an Insufficient Information Form after posting the case and allow the applicant 10 days to provide the requested information. Post Eligibility Verifications can include: • Third Party Liability – when the application indicates insurance coverage is available at no cost to the customer send an Insufficient Information Form requesting the customer to enroll. D-340.6 Verification Sources Electronic verifications must be used when available and prior to sending an Insufficient Information Form requesting paper documentation. Electronic data sources include but are not limited to: • State Online Query (SOLQ) - Income, Citizenship, residency if questionable • Unemployment Insurance Benefit (UIB) – Unearned income • Federal data services hub (FHUB)/United States (US) Citizen – Citizenship information received from the FHUB • Systematic Alien Verification for Entitlement (SAVE) – Immigration status • FHUB/Current Income – Earned income • BENDEX/State Data Exchange (SDX) – Social Security benefits Other data sources include but are not limited to: • Collateral contact – document name, number and information received. D-345 PENDING INFORMATION - INTAKE CASES Give the applicant an Insufficient Information Form, detailing what verifications are needed, allowing the household at least 20 days to provide requested verifications. When the due date falls on a weekend or holiday, the due date is the next working day. File a copy of the Insufficient Information Form with the current application, reflecting the verification request due date. If information is not provided or postmarked within the time period given, deny the application. D-340.4.2 MAABD APPLICATION PROCESSING Resources Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD If additional information is required during the case processing period, allow 10 days to provide the additional information. Additional information is defined as information needed after the initial request, or as a result of receiving information from the initial request. D-345.1 Future Actions If staff has information about anticipated changes in circumstances that may affect his or her eligibility, they must re-evaluate eligibility at the appropriate time based on such changes. Create a future action for the date of the anticipated change to affect the change timely. D-350 DISPOSITION OF APPLICATION Individually determine eligibility for each month using the policy in effect for each month. When processing applications, authorize assistance for each eligible month. Customers may be determined eligible for some months and ineligible for others. D-350.1 Certification Period Medical assistance is approved for 12 months for all MAABD based eligibility determinations. Individuals receiving Medical assistance must report changes by the fifth (5th) of the month following the month of the change. D-355 MEDICAID, SPECIAL LOW-INCOME MEDICARE BENEFICIARY (SLMB) & QUALIFIED INDIVIDUALS (QI) Medicaid assistance begins with the first (1st) day of the month for which a customer is determined eligible. There is no partial month eligibility. Example: Customer applies November 11 and is approved effective November and ongoing. Medicaid eligibility coverage begins November 1st and ongoing. If all information needed to determine Qualified Medicare Beneficiary (QMB)/SLMB eligibility is received, approve the case as a QMB/SLMB only case and future action the case for determining eligibility under the other category. If the customer is later determined eligible under the other category, the Medicaid is approved with the first month of eligibility. If the customer states in writing they do not want the Medicaid coverage and only want the QMB/SLMB coverage, staff will convert the case to a QMB/SLMB only case (a new application is not needed unless a Redetermination [RD] is due). When the customer is determined ineligible for another category for any reason, the customer may be eligible for QMB/SLMB only coverage as long as all the requirements are met and all the necessary information for QMB/SLMB coverage has been obtained. The QMB/SLMB only coverage CANNOT be denied because the customer did not meet a requirement or did not cooperate in providing verifications specifically needed for another medical category. D-355.1 Medicaid, Qualified Medicare Beneficiary (QMB) Coverage begins with the first (1st) of the month following the month an eligibility decision is made. Examples: D-345 MAABD APPLICATION PROCESSING Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25 PENDING INFORMATION – INTAKE CASES

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD QMB Only: Customer applies November 11th. The eligibility decision is made in December. QMB coverage begins effective January 1st and ongoing. QMB and Medicaid (Dual Eligible): Applicant applies 12/3 as a state institutional case and is currently enrolled in Medicare Part A. The customer cooperates and is determined eligible as a state institutional case. Because this customer has Medicare Part A, staff must also determine whether the customer is eligible for QMB coverage. If the customer's income and resources meet QMB criteria, they will qualify for both Medicaid and QMB coverage. QMB and SSI: Applicant applies 12/3 and has $250 SSA disability income. The customer has not applied for SSI, but is probably eligible. The customer meets all the other requirements of a QMB. Request the customer apply for SSI and give the normal time limit for applying. However, once staff is able to determine the customer is eligible for QMB coverage (all verifications needed are in), the case would be approved as a QMB only case. Future action the case for the SSI information. If the customer failed to cooperate in applying for SSI, or was determined ineligible, the case would remain open as a QMB only case as long as they continued to meet the criteria. If the customer were approved for SSI, the case would be converted to an SSI case effective with the month of SSI eligibility (this could include prior med). QMB and <30 day hospital stay: Applicant applies and is approved for QMB coverage. Sometime after approval, the customer enters the hospital for seven (7) days. The case would continue as QMB and NO PATIENT LIABILITY would be determined, UNLESS the customer qualified as a state institutional case (if income is less than SSI payment level, the customer does not have to be in 30 consecutive days). If the case qualifies as a state institutional case, the case would be converted, and the customer would receive full Medicaid coverage and QMB coverage. When the customer is released from the institution, the case would be converted back to a QMB only case, allowing adverse action, as long as all requirements were still met. D-360 CASE DOCUMENTATION Staff must include in each applicant's case record facts to support the decision on the application. Documentation must be clear and concise. Provide enough information so anyone reviewing the case can determine the reason, logic and accuracy of the staff’s decisions and actions. D-355.1 MAABD APPLICATION PROCESSING Medicaid, QMB Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD D-360.1 Case Records (NRS 239.080, NRS 239.125) The Division must maintain case files in accordance with the State’s record retention schedule. Records must be maintained for 37 months after the case closure date. The MAABD case file should include: • The original application. It must be retained in the current case file and not purged. • A copy of the Medicaid Estate Recovery (MER) notice; and • A copy of the original spousal resource assessment. D-365 PRIOR MEDICAL COVERAGE Prior medical coverage is available for up to three (3) months prior to the application month if the individual requesting the coverage meets all eligibility requirements for that month. Eligibility is determined on a month-by-month basis for each individual requesting coverage. Follow eligibility budgeting rules for the appropriate medical category to determine financial eligibility for each month coverage is requested. Exceptions: • QMB categories are not eligible for prior medical coverage. Eligibility for these groups is effective in a future month. • Prior Medical under the HIWA program CANNOT exist prior to July 1, 2004. D-365.1 How to Apply for Prior Coverage A request for prior medical coverage may be made on any medical assistance application and is considered a separate application because it is for months predating the initial application. Prior medical requests may be added during the pending period and during the 12-month period after approval provided the case remains open. Therefore, approval, denial or pending of a prior medical request must always be addressed in a notice to the household. Do not delay an ongoing eligibility decision while obtaining information to determine prior medical eligibility. In addition, if the household is only requesting prior coverage, provide an ongoing eligibility decision at the time of application. D-365.2 Eligibility for Prior Coverage Approve medical assistance for the person requesting coverage in the three (3) months prior to the application month only for those months in which the individual met all eligibility requirements including citizenship. D-360.1 MAABD APPLICATION PROCESSING Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25 Case Records (NRS 239.080, NRS 239.125)

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD Prior Medicaid coverage may be provided even if the: • Household is not currently eligible for Medicaid; or • Person who received the medical care or services is deceased. Individuals determined eligible for a month of prior medical coverage are eligible from the first (1st) day of month, regardless of when the eligibility requirements were met. D-365.3 Prior Medical Income Computation Use actual income and expenses when determining eligibility for prior medical coverage. Determine the assistance unit’s countable income. Compare the countable income to the income limit for each month that eligibility is being determined. D-370 REINSTATEMENTS Reinstatements are allowed for the following reasons: • The household provided verification within 10 days from date of denial. • The household provides verifications prior to the termination action being taken. • The customer provides RD form and all verifications within 90 days from termination of RD. (see Mam D-400 Redeterminations) Reinstatements for other reasons are made at the discretion of the Social Services Manager (SSM) or supervisor. D-375 “PRUDENT PERSON" PRINCIPLE The policies included in the manual are rules for determining eligibility. It is impossible to foresee and give examples for all situations; therefore, staff are encouraged to use reason and apply good judgment in making eligibility decisions when rare and unusual situations are encountered. Reasonable decisions made by staff based on the best information available using good judgment, program knowledge, experience, and expertise in a particular situation is referred to as the prudent person principle. Document the rationale used to make a decision and any applicable manual references and policy interpretations. Follow local office procedures for obtaining an interpretation from Eligibility and Payments (E&P) Program Specialists requesting clarification or directives, when it is impossible or inadvisable to follow the prudent person principle because of a lack of information or program knowledge. Note: Suspicious circumstances should be referred to Investigations and Recovery (I&R) using the appropriate I&R referral process. D-380 KATIE BECKETT Applications must first be evaluated for all other Modified Adjusted Gross Income (MAGI) coverage groups. If determined ineligible for any MAGI programs, follow the process below for evaluation of the Katie Beckett program. D-365.2 MAABD APPLICATION PROCESSING Eligibility for Prior Coverage Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD Send the Home and Community Based Services Waiver Eligibility Status Form NMO-3010 to DHCFP district office requesting a Katie Beckett determination and, if necessary, a disability determination. If DHCFP disability determination is needed, the Division must obtain Form 2325-Incapacity/Disability Questionnaire, completed by parent(s) of applicant prior to submission of the Home and Community Based Services Waiver Eligibility Status Form NMO-3010 to DHCFP. Do not delay sending the DHCFP disability request while waiting for an SSI decision. The DHCFP decision can be pursued at same time as SSI for Katie Beckett. If the child previously received SSI and was denied for income, use the SSA disability determination. At the same time the Home and Community Based Services Waiver Eligibility Status Form NMO-3010 and if applicable Form 2325-Incapacity/Disability Questionnaire is sent to DHCFP for level of care and/or disability determination, request required verification if needed. Verifications: • Citizenship - Only verify citizenship of the applicant • SSA verification that SSI has been applied for “applicant” • Income – “Applicant” parent’s tax return for the prior year or if no tax return available; all earned and unearned income received for the parent(s) of applicant for the past 3 months • Form 2451 – Authorization for Release of Information for applicant • Form 2325 – Incapacity/Disability Questionnaire for applicant (if applicable) • Form 2525 – Designation of Authorized Representative (if applicable) • Add DHCFP as secondary Designated Authorized Representative Note: Katie Beckett eligibility decision must wait until the Division receives the level of care determination from DHCFP on the Home and Community Based Services Waiver Eligibility Status Form 3010 and if applicable, disability determination. When the Division receives verification that applicant meets the level of care requirement, the Division staff will complete the following steps: 1. Determine financial and non-financial eligibility for Katie Beckett program. 2. Complete section #5 on the Home and Community Based Services Waiver Eligibility Status Form NMO-3010. 3. Send completed the Home and Community Based Services Waiver Eligibility Status Form NMO- 3010 back to DHCFP. 4. If the applicant is determined eligible for Katie Beckett, the Division will calculate monthly parent premium. Calculating Monthly Parental Premiums Based on the applicant parent(s) federal income tax return or gross monthly income, use Form NMO 7011B-Payment Agreement Guide, (Katie Beckett Premium Matrix), to determine family monthly premium amount. The Division will use this matrix to complete Form NMO-7011 Income Review/Premium Payment Agreement. The Division will send completed Form NMO-7011 Income Review/Premium Payment Agreement to parent of applicant to sign and agree to monthly premium payment determination. The parent(s) will be allowed a 10-calendar day timeframe to return Form NMO-7011 Income Review/Premium Payment Agreement. Once the Division receives signed Form NMO-7011 Income Review/Premium Payment Agreement from parent of applicant, the Division will email completed Form NMO-7011 Form to DHCFP at dhcfpkatiebeckett@dhcfp.nv.gov. D-380 MAABD APPLICATION PROCESSING Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25 KATIE BECKETT

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD If parent of applicant does not return completed Form NMO-7011 Income Review/Premium Payment Agreement, the Division Institutional staff will email DHCFP at dhcfpkatiebeckett@dhcfp.nv.gov, advising that no signed Form NMO-7011 Income Review/Premium Payment Agreement was received. If no signed Form NMO-7011 Income Review/Premium Payment Agreement is received back from a parent of applicant DHCFP will assess the maximum monthly premium of $250.00 Note: DO NOT terminate a case for not receiving a signed Form NMO-7011 Income Review/Premium Payment Agreement back from the applicant’s parent. Change in Income and/or Household Size Reported: Verify reported change in income and/or household size. The Division will complete Form NMO-7013 Income Review/Payment Agreement Amendment. The Division will use Form NMO-7011B Payment Agreement Guide, (Katie Beckett Premium Matrix), to determine family’s monthly premium amount. The Division will request a signature by parent of applicant on Form NMO-7013 Income Review/Payment Agreement Amendment and allow 10 calendar days to return. Once completed NMO 7013 Income Review/Payment Agreement Amendment is received, the Division will email form to DHCFP at dhcfpkatiebeckett@dhcfp.nv.gov. Note: If no signed NMO-7013 Income Review/Payment Agreement Amendment Form is returned, Katie Beckett monthly premium will remain unchanged, and the Division Institutional Unit will take NO NEGATIVE action on case. Households with children who are American Indian (AI)/Alaska Native (AN) are not charged a monthly premium. Child of AI/AN descent are exempt from the premium. Verification of AI/AN descent must be provided to waive the premium. The child’s tribal affiliation should be entered on the Member BAP. Disenrollment will occur if a household is 60 days or two full months past due. DHCFP will notify the Division of households who are 60 days or two full months past due. Staff will be notified with a task in the system when non-payment has occurred. See D-500 Changes for processing non-payment. D-380.1 Division of Health Care Finance and Policy (DHCFP) Determination DHCFP Central Office processes disability determinations and DHCFP district offices complete level of care assessments. After all other eligibility requirements are met, the DHCFP Central Office will determine disability, level of care, medical costs, and if home care is appropriate. DHCFP determinations are made per the Medicaid Operations Manual. Staff or, if appropriate, the Title XIX Social Worker will send Form NMO 3010 to DHCFP. DHCFP will notify the district office of the review board's decision of disability and/or final eligibility under 1902(e)(3) on the Home and Community Based Services Waiver Eligibility Status Form NMO-3010. DHCFP will send Katie Beckett Premium invoices/notices to families with detailed information on how to make premium payments. Families with children enrolled in Katie Beckett option are charged a monthly premium based on the family’s monthly taxable income and household size. Premiums are charged per family, not per child. Payment arrangements may be made monthly, annually, or anything in-between with DHCFP. D-380 MAABD APPLICATION PROCESSING KATIE BECKETT Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD Katie Beckett premium payments must be paid using a check or money order. Customers should be advised to include their Medicaid number on the payment. • Cash Payments are not accepted • Payments are accepted via: o Online, visit www.e-billexpress.com/ebpp/NVMedicaid/; o Over the phone, call 775-684-3660; o Mail to: Katie Beckett 745 W. Moana Ln. Ste 200 Reno, NV 89509 Late payments paid in-person will be accepted at the following locations: Carson City 1919 College Pkwy. Ste. 120 Carson City, NV 89706 (775) 684-3660 Elko 1010 Ruby Vista Dr. Ste. 103 Elko, NV 89801 (775) 753-1191 Las Vegas 1210 S. Valley View Blvd. Ste 104 Las Vegas, NV 89102 (702) 668-4200 D-385 PARENTAL FINANCIAL RESPONSIBILITY FOR SERVICES PROVIDED TO DISABLED CHILDREN Parents are financially responsible for their children's medical expenses paid by Medicaid. Financially able parents will be assessed a monthly payment amount to reimburse the DHCFP for incurred medical costs. This section applies to disabled children under age 19 eligible for Medicaid in categories in which there is no deeming of parental income/resources in determining eligibility for public assistance programs. These categories include, without limitation: • State Institutional Category (including SSI recipients residing in medical facilities); • Physically Disabled Waiver Program; D-380.1 MAABD APPLICATION PROCESSING Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25 DHCFP Determination

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD • Nevada Division of Public and Behavioral Health (DPBH) Waiver Program (including SSI recipients residing in Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/ID) facilities); and SSI recipient, age 0-19, residing in appropriate settings as determined by Medicaid. Under no circumstances will the policy in this section affect the child's Medicaid eligibility. D-385.1 Definitions • Parent – natural/adoptive parents and stepparents. • Income – all earned and unearned income to include but not limited to the sources described in MAM E-300 Types of Earned and Unearned Income without regard to any exclusions. D-385.2 Calculating Monthly Parental Reimbursements Based on the parent(s) gross monthly income and considering court ordered child support/alimony, home care credit, medical expenses, and health insurance covering the disabled child, the amount of monthly reimbursement is determined as: 1. Family Size Determine family size, choosing one (1) of the following methods, whichever is greater (most benefits the parent(s) in allowing the family deduction): • Count the disabled child(ren), their blood-related siblings, and natural/adoptive parent(s) living in the home; or • Allow the total number of exemptions claimed on last year’s Federal Income Tax Form 1040 or 1040A. 2. Countable Income Determine the amount of the natural/adoptive parent(s) adjusted gross income using Federal Income Tax Form 1040, 1040A, or Form W-2. Parent(s) who are self-employed must provide copies of their last two (2) income tax returns. Parent(s) claiming their current income is substantially different than the income reported on their tax forms must provide proof of their actual income. If the natural/adoptive parent is married and living with an individual who is not the natural/adoptive parent of the disabled child (stepparent to the disabled child), total the natural/adoptive parent’s and stepparent’s gross annual income and divide it equally. This one-half (1/2) share will be considered the natural/adoptive parent's annual gross income to determine the reimbursement amount. 3. Court Ordered Child Support or Alimony Court ordered child support obligations paid by the natural/adoptive parent will be deducted as an annual cost from the gross annual income. When the custodial parent and non-custodial (NCP) live D-385 MAABD APPLICATION PROCESSING PARENTAL FINANCIAL RESPONSIBILITY FOR Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25 SERVICES PROVIDED TO DISABLED CHILDREN

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD separate and apart, consider their income separately. Alimony paid by the NCP is deducted from the NCP income and counted in the ex-spouse’s income when determining amount of reimbursement. 4. Annual Family Deduction Subtract the following family deduction amount (200% of Federal Poverty Guidelines) from the adjusted annual gross income (total annual gross income less child support deduction) to arrive at the net annual gross income amount: 2025 Federal Poverty Limit Family Size 200% FPL Amount Family Size 200% FPL Amount 1 2 3 4 $31,300 $42,300 $53,300 $64,300 5 6 7 8 $75,300 $86,300 $97,300 $108,300 Add $11,000 for each additional family member. 5. Net Annual Gross Income Multiply the net annual gross income which is: a. Up to $50,000 by 10% b. Additional income between $50,000 - $60,000 by 13% c. Additional income between $60,000 - $75,000 by 16% d. Any additional income over $75,000 by 19% Add the percentage increase amounts in a, b, c and d, then divide the total by 12 to reach the Monthly Reimbursement Amount. 6. Home Care Credit Natural/adoptive parents who care for their disabled child(ren) in their home will receive a $300 deduction from the monthly reimbursement amount. 7. Medical Expenses Allow medical deductions claimed on last year’s Federal Income Tax Form 1040, line 4 (Medical and Dental Expenses) of Schedule A – Itemized Deductions. 8. Health Insurance If a parent carries private or group comprehensive health insurance which covers the disabled child, the entire amount of the monthly insurance premium is deducted from the monthly reimbursement amount. A health insurance penalty of 5% is imposed if the natural/adoptive parent has health insurance available and does not elect to secure coverage for the disabled child. D-385.2 MAABD APPLICATION PROCESSING Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25 Caculating Monthly Parental Reimbursements

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD DO NOT apply the insurance penalty if the health insurance coverage would cost more than 5% of their gross annual income. 9. Court Orders If a parent alleges a court order which specifies the noncustodial parent is responsible for all medical costs, obtain a copy of the court order and forward to the local child support enforcement unit AND the Chief of E&P. In this instance, DO NOT assess a monthly reimbursement until directed by the Chief of E&P. 10. Noncooperation If a parent fails to provide income information, provides false or misleading statements; misrepresents, conceals or withholds facts to avoid financial responsibility, a monthly reimbursement of $1,900 is assessed. If a parent provides only partial information/verification, request the remaining information/verification giving 10 days. If all the information/ verification is not received by the deadline given, assess $1,900. If, after receiving notification of the $1,900 obligation, the parent later provides needed verifications, determine monthly reimbursement amount and notify I&R of change in monthly obligation effective the month after the month of cooperation. D-385.3 Redetermination of Eligibility At each scheduled redetermination of eligibility (at least once per year), the monthly reimbursement is recalculated for the upcoming year. Adjustments to the previous year's assessment will be reported to I&R via Form 6009-AG. D-385.4 Undue Hardship Responsible parents may apply for a "hardship waiver" if they are unable to pay their assessed monthly reimbursement amount due to: 1. A change in family’s monthly income (25% or more); or 2. Payment of the monthly reimbursement amount would severely compromise the health, shelter or subsistence needs of their family. Individuals seeking a hardship waiver should fully document their circumstances in writing and submit their request to the Chief of I&R. No adjustment of the monthly parental reimbursement amount will be made without the prior approval of the Chief of I&R. D-385.2 MAABD APPLICATION PROCESSING Caculating Monthly Parental Reimbursements Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD D-385.5 Responsibilities of Eligibility Staff The staff: • Requests completion of Form 2069–EM "Parent Income and Household Information" and verification of income, court-ordered child support/alimony, medical expenses and health insurance coverage at application and redetermination. • Determines the monthly reimbursement amount based on the family size, annual income, child support/alimony, home care credit, medical expenses and medical insurance using Form 2028- EE, "Parental Reimbursement Worksheet." Notify the parents of their monthly reimbursement amount using Form 2849-EM. • If the monthly reimbursement is greater than zero (0), send copies of the parent questionnaire and copy of Form 2849-EM with the recovery referral form to I&R in their service area. • If a parent's whereabouts is unknown, the staff will refer eligibility information to I&R for parent locate services using Form 2683–EE "Investigation Referral Form." • If eligibility for the child terminates, the staff will notify I&R on Form 6009-AG. Example computation: A family of four (4) has an annual gross income of $150,000. $150,000 - 1,200 Child Support $148,800 -64,300 Annual Family Deduction $84,500 Net Annual Gross Income a. $50,000 of net annual gross income is multiplied by 10% or 15% (5% Insurance Penalty) • $50,000 X 10% = $5,000 or 15% = $7,500 b. The net annual gross income is also between $50,000 - $60,000, multiply $10,000 by 13% or 18% (5% Insurance Penalty) • $10,000 X 13% = $1,300 or 18% = $1,800 c. The net annual gross income is also between $60,000 - $75,000, multiply $15,000 by 16% or 21% (5% Insurance Penalty) • $15,000 X 16% = $2,400 or 21% = $3,150 d. The net annual gross income is also OVER $75,000, multiply the amount which is over $75,000 by 19% or 24% (5% Insurance Penalty) • $9,500 X 19% = $1,805 or 24% = $2,280 Add the results of a, b, c and d, then divide by 12 for the monthly reimbursement amount. D-385.5 MAABD APPLICATION PROCESSING Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25 Responsibilities of Eligibility Staff

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MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD No Insurance Penalty Insurance Penalty 5% $ 5,000 $ 7,500 1,300 1,800 2,400 3,150 + 1,805 + 2,280 $10,505/12 $14,730/12 = $875.42 = $1,227.50 From either of these two (2) monthly reimbursement amounts, the home care credit, medical expenses and/or health insurance premium would be deducted to reach the net monthly reimbursement amount. D-385.6 Investigations and Recovery (I&R) Staff Responsibilities • Create a case file for each referred case. • Send the initial notice of monthly reimbursement letter along with a copy of the worksheet, Form 2028-EE. A monthly reimbursement will be calculated for each month the disabled child is Medicaid eligible. • Control and receive the monthly reimbursement funds. • Send delinquent letters, file small claims court actions and make referrals to the Deputy Attorney General, as appropriate. • Evaluate and negotiate undue hardship requests. • On an annual basis, review the child's medical costs in comparison to paid reimbursement amounts and provide a credit against future month reimbursement amounts for any funds in excess of the child's medical costs. Medicaid-paid Provider 60 amounts are not included in the “child’s medical costs” for these purposes. D-385.5 MAABD APPLICATION PROCESSING Responsibilities of Eligibility Staff Division of Social Services Medical Assistance Manual 14 Aug 25 MTL 11/25

(d-400)Nevada Medical Assistance Manual (MAM): D-400 Redeterminations#

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services D-400 Medical Assistance Manual REDETERMINATIONS 16 May 01 MTL 02/16 MAGI REDETERMINATIONS REDETERMINATIONS D-400 MAGI REDETERMINATIONS (435.916) Redeterminations for MAGI medical assistance groups must: a. have eligibility renewed once every 12 months; and b. be completed without requiring information from the individual when all information needed to redetermine eligibility is available via electronic data sources; or c. When data sources are unavailable, a pre-populated Redetermination Form 2006-EM is mailed to the recipient and if applicable the AR, at least 60 days prior to the redetermination date. Request the client to provide any required verifications and to sign and return the form within 30 days. Evaluate eligibility under all medical assistance programs when processing a redetermination. If a signed redetermination and requested verifications are not returned, medical assistance may terminate, allowing adverse. Note: D-400.2 contains specific guidance in verifications due at redetermination. If an unsigned redetermination is received without the Head of Household’s, or AR’s signature, the case manager should attempt to contact the Head of Household or AR to obtain a verbal signature over the telephone. If the case manager is unable to reach the Head of Household or AR, terminate the case allowing adverse. If the individual subsequently submits the signed renewal within 90 days after the termination notice date, use the RD in lieu of a new application to evaluate ongoing eligibility. Prior medical may be evaluated if requested during the 90 day grace period. After the 90 day grace period a new application is required. A medical redetermination may be completed between regular renewals any time DWSS receives information about a change in circumstances that may affect eligibility. See D-440 for more information. D-400.1 Reserved D-400.2 Verification At Redetermination Verify the following eligibility factors at redetermination:  Income:  If the individual returns verification of income and a 30/60 day be st estimate of their pay history accurately reflects their current circumstances, consider the income verified and continue ca se

processing.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL D-400.2 Division of Welfare and Supportive Services REDETERMINATIONS Medical Assistance Manual VERIFICATION AT REDETERMINATION 16 May 01 MTL 02/16  If the individual has an open TANF or SNAP case with verified income information and this verification reflects their current circumstances, consider the income verified and continue with case processing. Note: If the individual does not provide their paystubs, and the information cannot be obtained via an electronic data source, pend the client allowing 10- days to return the necessary verifications. Do not automatically terminate the case for non-cooperation.  Tax filing status/Household – accept client statement  Authorized representative changes -Assume there is no change in the status of the A/R for the client unless they report a change.  Residency – accept client statement D-410 MAABD REDETERMINATIONS Redeterminations for MAABD medical assistance groups must: a. have eligibility renewed once every 12 months; and b. be completed without requiring information from the individual when all information needed to redetermine eligibility is available via electronic data sources; or c. When data sources are unavailable, the MAABD Only Redetermination, Form 2930-EM, is mailed to the recipient and if applicable the AR, at least 60 days prior to the redetermination date. Request the client to provide any required verifications and to sign and return the verifications and form within 30 days. d. Process the redetermination no later than the month it is due, ensuring the correct aid codes, eligibility codes, Medicare claim numbers and buy-in are correct in the system. Evaluate eligibility under all medical assistance programs when processing a redetermination. If a signed redetermination and requested verifications are not returned, medical assistance may terminate, allowing adverse. Note: D-410.1 contains specific guidance in verifications due at redetermination. If an unsigned redetermination is received without the Head of Household’s, or AR’s signature, the case manager should attempt to contact the Head of Household or AR to obtain a verbal signature over the telephone. If the case manager is unable to reach the Head of Household or AR, terminate the case allowing adverse.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services D-410 Medical Assistance Manual REDETERMINATIONS 16 May 01 MTL 02/16 MAABD REDETERMINATIONS If the individual subsequently submits the signed renewal within 90 days after the termination notice date, use the RD form in lieu of a new application to evaluate ongoing eligibility. Prior medical may be evaluated if requested during the 90 day grace period. After the 90 day grace period a new application is required. A medical redetermination may be completed between regular renewals any time DWSS receives information about a change in circumstances that may affect eligibility. See D-440 for more information. D-410.1 Verification at Redetermination Verify the following eligibility factors at redetermination:  SSI Recipients – Verify receipt of SSI as a Nevada resident using SOLQ or any other available electronic data source. Complete the redetermination without requesting any further information from the client.  Resources  Expenses – verify monthly expenses used in the patient liability calculation. If not provided calculate patient liability without the expenses.  Authorized representative changes - Assume there is no change in the status of the A/R for the client unless they report a change.  Residency – accept client statement Do not re-verify:  Disability - unless Nevada Medicaid Office determines that a beneficiary's disability no longer meets the definition of disability or SOLQ indicates disability has ended.  Income:  If the individual returns verification of income and a 30/60 day best estimate of their pay history accurately reflects their current circumstances, consider the income verified and continue ca se processing.  If the individual has an open TANF or SNAP case with verified income information and this verification reflects their current circumstances, consider the income verified and continue with case processing. Note: If the individual does not provide their paystubs, and the information cannot be obtained via an electronic data source, pend the client allowing 10- days to return the necessary verifications. Do not automatically terminate the case for non-cooperation.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL D-410.1 Division of Welfare and Supportive Services REDETERMINATIONS Medical Assistance Manual VERIFICATION AT REDETERMINATION 14 Mar 01 MTL 14/01  Blindness - unless a physician determines that a beneficiary's vision has improved beyond the definition of blindness or SOLQ indicates blindness has ended. D-410.2 Public Laws Verification used to support the Public Law status must remain in the permanent section of the case file.

Pickle Amendment – Public Law 94–566 CASES - Income & resources are re- evaluated. Financial eligibility is determined using SSI Budget Form 2646. Exclude from countable income RSDI cost of living increases received after client was last eligible for and receiving SSI and entitled to RSDI in the same month.

Adult Disabled Child – Public Law 99–643 CASES - Income and resources are re- evaluated. Financial eligibility is determined using SSI Budget Form 2646. Exclude from countable income the 'adult disabled child' benefit OR the increase in their 'adult disabled child' benefit received after July 1, 1987.

Widow/Widowers – Public Law 100–203 CASES - Income and resources are re- evaluated. Financial eligibility is determined using SSI Budget Form 2646. Exclude from countable income widow/widower's benefits and SSA retirement/survivors benefits (SSA Dis¬ability benefits are not disregarded). They cannot be entitled to Medicare Part A hospital insurance.

Widow, Widowers and Surviving Divorced Spouses – Public Law 101–508 CASES - Income and resources are re-evaluated. Financial eligibility is determined using SSI Budget Form 2646. Exclude from countable income the Title II disability benefits. They cannot be entitled to Medicare Part A hospital insurance.

Suspension of SSI Due to Income – Public Law 96–265 CASES - The most current SDX must contain Public Law Code "I". If it does not, the client is not eligible for Medicaid under this public law.

Social security Independence and Program Improvements Act of 1994 – Public Law 103-296 CASES - The most current SDX must contain Public Law Code "A". If it does not, the client is not eligible for Medicaid under this public law.

Sponsor Deeming Cases - Income and resources are re-evaluated. Financial eligibility is determined using SSI Budget Form 2646. Disability for persons under age 65 may need re-evaluation by NMO (see most recent Form 3004). Parent and spouse deeming requirements may apply. Determine any contributions by the sponsor(s). Case file should have an indicator when sponsor deeming ends for a referral to apply for SSI.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services D-420 Medical Assistance Manual REDETERMINATIONS 16 May 01 MTL 02/16 TITLE IV-E ELIGIBLE FOSTER CHILDREN AT RITE OF PASSAGE D-420 TITLE IV-E ELIGIBLE FOSTER CHILDREN AT RITE OF PASSAGE A Medicaid redetermination (RD) must be timed to coincide with the Title IV-E eligibility review. The custodial state must provide the IV-E RD date prior to approval, and the Medicaid RD due date should be adjusted in the system at approval to ensure the case comes up for review at the appropriate time. D-420.1 Verification at Redetermination  Request a new application  Written verification from the custodial state regarding continued IV-E eligibility. Continue medical assistance if all eligibility criteria continues to be met. D-420.2 Termination of Foster Children at Rite of Passage Terminate assistance allowing adverse action if: a. Rite of Passage fails to provide the information needed to complete the RD process, and/or b. the recipient no longer meets the eligibility criteria for this category of assistance. D-425 AGED OUT OF FOSTER CARE A redetermination is to be completed every 12 months. D-425.1 Verification at Redetermination  Residency is the only required verification at RD. D-425.2 Termination of Aged Out of Foster Care Medicaid must be terminated, allowing adverse action when: a. the recipient reaches age 21, if the child was not enrolled in Nevada Medicaid at the time of aging out of foster care; or b. the recipient reaches age 26; or c. moves to another state; or d. is placed/lives in an ineligible facility (jail/detention). Note: Closure of an Aged Out of Foster Care case is done at the individual member level. The AO Closure reason codes are located on the individual’s MEMB screen.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL D-430 Division of Welfare and Supportive Services REDETERMINATIONS Medical Assistance Manual TREATMENT FOR BREAST AND CERVICAL MTL 01/13 01 Oct 13 D-430 TREATMENT FOR BREAST AND CERVICAL A redetermination is to be completed every 12 months. Complete a desk audit by contacting Access to Health Care case manager to confirm the recipient is still residing in Nevada and is still receiving treatment.

Access to HealthCare Network can be reached at 775-284-1904.

Document the information in the case file and complete the redetermination. D-430.1 Termination of Breast and Cervical Medicaid eligibility ends when her course of treatment is completed, or she no longer meets the criteria for this eligibility category. D-435 TRANSITIONAL MEDICAID A redetermination will be completed to determine potential eligibility for other medical coverage groups after the end of the TR period. Evaluate current circumstances and all household members for any other category of eligibility. D-440 REDETERMINATION BASED ON CHANGES

Information received between redeterminations, which may affect eligibility must be evaluated and acted on when applicable. Limit any request for additional information to verification related to the change only.

When processing the change if the case manager has enough information available to re-evaluate eligibility, complete a redetermination and approve an additional 12 months, even if the redetermination was not due.

Exception: Nevada Check Up provides 12 months continuous eligibility and clients are not required to report changes. Only act on changes listed in D-535 for Nevada Check- Up. D-445 OTHER INSURANCE AFFORDABILITY PROGRAMS

When processing a redetermination and the recipient is determined not eligible due to excess income an electronic referral is sent to the Silver State Health Insurance Exchange (SSHIX) upon posting of the denial. The individual will be provided contact information in their denial notice regarding where to apply for Advanced Premium Tax Credit (APTC) and Qualified Health Plans (QHP).

D-450 TERMINATIONS When processing a redetermination and the recipient no longer meets the criteria of one of the eligible categories or has failed to cooperate in providing information, the case must be terminated allowing for adverse action. When posting a termination, two future months must be posted in order to ensure closure in the MMIS system. Adverse actions taken after cutoff will not be reflected in the MMIS (Medicaid billing) system. If done, an additional month of Medicaid billing will take place and capitation fees will be charged.

(d-500)Nevada Medical Assistance Manual (MAM): D-500 Changes#

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services D-500 Medical Assistance Manual CHANGES 24 Jan 25 MTL 02/24 OVERVIEW CHANGES

D-500 OVERVIEW

Changes are situations that occur in a household which may affect eligibility. Action must be taken on reported changes, regardless of the customer’s reporting requirements, to ensure program integrity is maintained.

D-505 REPORTING REQUIREMENTS

Households are advised of their responsibility to report changes in:

● Income (earned and unearned); ● Household composition/household member’s extended absence; ● Marital status; ● Residence or mailing address; ● Medical insurance coverage; ● Other circumstances or anticipated changes which may affect eligibility; ● Social Security number for a required household member.

MAABD Exception: In addition to the above reporting requirements, MAABD households are required to report changes in resources.

D-510 WHEN TO REPORT

Changes must be reported immediately from the date of application up to the date of approval.

After approval, any change in circumstances must be reported no later than the fifth of the month following the month the change occurred.

MAABD Exception: After approval, any change in circumstances must be reported no later than the tenth of the month following the month the change occurred.

D-515 HOW TO REPORT

Household members or someone acting on their behalf may report changes:

● in person; ● by telephone; ● by mail, fax or email; ● on the Change Report Form 2584; and ● changes received by Nevada Health Link will be received as a task in AMPS.

Applications submitted to the Division are another method of reporting changes. Each application should be evaluated for changes that would affect ongoing benefits, such as a member moving out of one household into another.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL D-520 Division of Welfare and Supportive Services CHANGES

Medical Assistance Manual QUESTIONABLE INFORMATION AND/OR UNREPORTED 24 Jan 25 MTL 02/24 D-520 QUESTIONABLE INFORMATION AND/OR UNREPORTED CHANGES

If a household has circumstances that are questionable due to a reported change, third party information, or because the household fails to report a change (i.e., birth of a child, critical age change, obtains insurance from a job, etc.), take the following steps:

a. Contact the household to obtain an explanation for factors of eligibility that allow customer statement.

b. Send a request for information using Form 2429–EE when clarification and/or verification are required to determine continuing eligibility.

c. Allow the household at least 10 days to respond to the request for information, clarification and/or verification.

Exception: Victims of domestic violence approved for fictitious address through the Secretary of State's CAP program must be allowed 17 days to provide verifications due to mail forwarding. Follow adverse action and processing time frames.

d. If the household fails to respond or does not provide enough information to continue the case, resulting in a reduction or termination of benefits, a Notice of Decision must be mailed at least 13 days prior to the effective date of the reduction/termination.

If a third party (other than the authorized representative) does not cooperate in providing information or provides incomplete information, DO NOT close the case. Work with the customer and information already on file (includes income) to arrive at a prudent decision or resolution based on the best information available. Document the circumstances in the CLOG.

D-525 PROCESSING REQUIREMENTS

Update the mailing address as soon as a change is reported. If a reported change of address is not updated by cut-off, the Notice of Decision (NOD) and/or Medicaid card will be mailed to the old address. The NOD and Medicaid card will also be returned if the address is not updated.

D-525.1 Returned Mail

If mail is returned by the U.S. Post Office with an out-of-state forwarding address or no forwarding address; ensure the out-of-state address is updated on the case prior to posting and close the case waiving adverse action.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services D-525.1.2 Medical Assistance Manual CHANGES 24 Jan 25 MTL 02/24 GENERAL DELIVERY D-525.1.2 General Delivery

Las Vegas & Unincorporated Clark County North Las Vegas Henderson Recipient’s Name GENERAL DELIVERY Las Vegas, NV 89165 Recipient’s Name GENERAL DELIVERY North Las Vegas, NV 89030 Recipient’s Name GENERAL DELIVERY Henderson, NV 89015 Where customer picks up Where customer picks up Where customer picks up 4885 E. Carey Ave. Las Vegas, NV 89115 1414 E. Lake Mead Blvd. North Las Vegas, NV 89030 404 S. Boulder Highway Henderson, NV 89015 Carson City Rural Nevada Reno/Sparks Adjacent Valley Recipient’s Name GENERAL DELIVERY Carson City, NV 89701 Recipient’s Name GENERAL DELIVERY Rural City, NV (rural zip) Recipient’s Name GENERAL DELIVERY Reno, NV 89501 Where customer picks up Where customer picks up Where customer picks up 1111 S. Roop St. Carson City, NV 89701 Mail will be delivered to the local rural office 135 N. Sierra St. Reno, NV 89501

D-525.2 Actions on Changes

Upon receipt of a change, ensure the following actions are completed:

1. Check the system to identify all related cases affected by the change.

2. Review the change to determine the effect on the household's benefits.

a. If the change results in additional members becoming eligible, verification must be obtained prior to taking action on the case. If verification is not received within the allotted time frames, deny the request for the additional member(s).

b. If the change results in members becoming ineligible, act on the change and reduce or terminate benefits, allowing adverse action.

• Verification is not needed if entire household becomes ineligible; use customer statement and update the case. • Request verification only if at least one member remains eligible.

c. If the reported change does not change the current eligibility of any members, do not request verification, use customer statement.

Example: Pregnant mother and one child in the household. Monthly income of $1,000.00 is being budgeted and mother calls to report her income is reduced to $800.00 monthly. The new income amount does not change the medical eligibility for any household members. Therefore, update the income based on customer statement and do not require verification for the medical programs.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL D-525.2 Division of Welfare and Supportive Services CHANGES Medical Assistance Manual ACTIONS ON CHANGES 24 Jan 25 MTL 02/24

3. Evaluate all electronic verification sources available, prior to requesting verification from the customer. Do not request verification of non-taxable income for MAGI cases.

a. If no electronic data source is available, request verification required to update the case based on the reported change. Allow 10 calendar days from the mailing date for the client/representative to provide requested information.

b. When requested verifications are not provided, terminate assistance allowing for adverse action. If verifications are provided on or before the effective date of closure, reinstate assistance.

4. Document

– the reported change; – the date the change occurred; and – the date the change was reported; and – the actions taken on the case.

5. Re-evaluate eligibility for all medical programs and update the case. If all necessary information is available to complete a redetermination, process the RD and approve an additional 12 months 6. Notify the household of the action taken.

D-525.3 Mass Changes

The state or federal government initiates changes which affect all or a large number of households. Reporting these changes is not required. Mass changes generally occur in:

● the income eligibility standards;

● cost-of-living adjustments (COLA) for Social Security, SSI, VA, and other federal benefits; and

● other eligibility criteria based on legislative or regulatory actions.

Generally, individual notices are produced for automated mass changes whenever a change in the benefit amount occurs.

D-525.4 Additions to the Household

Re-determine eligibility when a new member must be added; If:

● the new member is active in another household, do not add them until they are removed from the other household.

● a new member of the tax filing unit is not reported timely and the change results in a decrease in eligibility, the case is updated the following month, allowing adverse action.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services D-525.4 Medical Assistance Manual CHANGES 24 Jan 25 MTL 02/24 ADDITIONS TO THE HOUSEHOLD ● a new member is requesting coverage and the change results in an increase in eligibility, the case is updated the month in which it is reported by the assistance unit.

● information or verification needed to add a household member is not provided by the date requested, terminate assistance.

● a newborn is reported, and all eligibility requirements are met, add them to the assistance unit effective their date of birth. Use the most readily available verification to add the child to the medical case. Example: Customer statement, hospital discharge forms, managed care alert, birth confirmation.

Newborns are eligible for Medicaid for one year without a separate application when the mother was eligible for Medicaid at the time of the birth.

A newborn may be enrolled without a Social Security Number (SSN); however, an SSN will be required by the child’s first birthday.

D-525.4.1 Exceptions for Adding Newborns to NCU Cases

 A newborn will be retro enrolled in Nevada Check Up if the following criterion is met:

● The agency is notified within 14 days from the date of birth (the first day begins the day after the date of birth).

If the notification criterion is not met, the newborn will be enrolled the next administrative month following notification if deemed eligible. Exception: if the mother has other health insurance that provides 30 days of coverage for the newborn, the newborn will be enrolled as of the first day of the next administrative month following the date of birth. Upon notification of birth, NCU will confirm that the newborn does not have other insurance coverage prior to enrollment.

 A newborn cannot be enrolled prior to a family’s start date.

 A newborn may be enrolled without a Social Security Number (SSN); however, an SSN will be required by the child’s first birthday.

D-525.4.2 NCU Enrollment

Once determined to be eligible for NCU, a child(ren) will be enrolled beginning the next administrative month.

D-530 TERMINATIONS FOR MEDICAID

Prospectively determine ongoing medical assistance using the policy in effect for the future month.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL D-530 Division of Welfare and Supportive Services CHANGES Medical Assistance Manual TERMINATIONS FOR MEDICAID 24 Jan 25 MTL 02/24 When a recipient can no longer meet the requirements of one of the eligible categories or has failed to cooperate in providing information, the case must be closed. When posting a termination, two future months must be posted in order to ensure closure in the MMIS system.

Note: Regardless of changes in income, pregnant women remain eligible through the post-partum period and Nevada Check Up eligible children remain eligible through the 12-month eligibility period.

If the customer cooperates prior to the effective date of termination, reinstate the case and evaluate medical eligibility.

D-530.1 Non-Payment of Nevada Check Up Premiums

When a household is 60 days, or two full months past due, the case will be terminated. A non-payment of premium task will be created in AMPS and must be acted on for the future month. Case workers will be notified with a task in the system when non-payment has occurred.

Once a termination for non-payment of premium has occurred, the household must serve a 90 day sit-out period. If payment is received within the 90 days, DHCFP will notify DWSS, and the child/ren will be enrolled beginning the next administrative month. If payment is received after the 90-day period, a new application is required.

If a child is terminated due to non-payment of premium, the time spent serving the sit-out is not included in the child/ren’s 12 months continuous eligibility. A full 12 months of coverage (less the time spent serving the sit-out) will be granted; however, in the Instance of a sit-out, the coverage will not be continuous. Case workers must adjust the annual re- determination due date, to ensure that a full 12 months of coverage is provided and that an annual re-determination is completed by the 12th month of coverage.

If all other eligibility criteria is met and the 90 day sit-out has been served, a child/ren cannot be denied eligibility, even if a past due balance exists. The child/ren will be enrolled and any outstanding debt will be managed by DHCFP.

D-530.2 Adverse Action

When assistance is terminated, a Notice of Decision (NOD) must be sent to both the customer and the representative/legal guardian a minimum of 13 days before the proposed action is effective. When counting the 13 days, weekends and holidays must be included; however, if this date falls on a Friday, weekend or holiday, the action must be taken the prior workday. To meet the advance notice requirements, the action to reduce or terminate benefits must be taken (posted) in the computer at least 14 days prior to the last day of the month, to ensure the computer-generated Notice of Adverse Action (NOAA) is mailed on time. If case circumstances require posting as late as the 13th day of the adverse action notice period, local print must be done to meet advance notice requirements.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services D-530.2 Medical Assistance Manual CHANGES 24 Jan 25 MTL 02/24 ADVERSE ACTION The following is a chart showing the adverse action dates for 2024.

NOTE: ** Indicates Adverse has been moved to a prior day due to Adverse falling on a Friday, weekend, or Holiday.

D-530.3 Adverse Action NOT Required

Adverse action may be waived in certain circumstances, however, cannot be waived after cutoff.

The case manager may waive adverse action if:

 The case manager has factual information confirming the death of a recipient;

 The case manager receives a clear written statement signed by a recipient that: 1. They no longer wish to have services; or

2. Gives information that requires termination or reduction of services and indicates they understand this must be the result of supplying that information;

 The recipient has been admitted to an institution where he/she is ineligible under the plan for further services;

 The recipient’s whereabouts are unknown, and the post office returns agency mail directed to him indicating no forwarding address;

 The case manager verifies the recipient has been accepted for Medicaid services by another local jurisdiction, State, territory, or commonwealth;

 A change in the level of medical care is prescribed by the recipient’s physician;

 Nevada Check Up child obtains other creditable health insurance coverage.

 Non-citizenship status is verified. Month Adverse Action January 01/18/24 February 02/15/24** March 03/18/24 April 04/17/24 May 05/17/24** June 06/17/24 July 07/18/24** August 08/16/24 September 09/17/24 October 10/17/24** November 11/15/24** December 12/18/24

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL D-530.4 Division of Welfare and Supportive Services CHANGES Medical Assistance Manual CUT-OFF 24 Jan 25 MTL 02/24 D-530.4 Cut-Off

Medicaid actions that do not adversely affect benefits, such as a change in aid code, can be taken up to the second to the last workday of the month. Adverse actions taken after cutoff will not be reflected in the MMIS (Medicaid billing) system. An additional month of Medicaid billing will take place and capitation fees will be charged when termination is posted after cutoff for the following month.

The following is a chart showing the cut-off dates for 2024.

Month Cut-Off January 01/24/24 February 02/21/24 March 03/22/24 April 04/19/24 May 05/24/24 June 06/21/24 July 07/24/24 August 08/20/24 September 09/20/24 October 10/24/24 November 11/22/24 December 12/20/24

D-535 RE-EVALUATIONS - NEVADA CHECK UP

a. Cases will only be re-evaluated at the time of RD unless one of the following occur:

• NCU discovers or is notified that the information used to enroll a child/ren was incomplete or inaccurate;

• The participant requests to add a child (child/ren currently enrolled will remain enrolled until the time of RD).

• The participant requests a reduction in premium when household income has changed (child/ren will remain enrolled until the time of RD).

b. Re-evaluations must be processed before the corresponding cut-off but not to exceed 30 days.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services D-540 Medical Assistance Manual CHANGES 24 Jan 25 MTL 02/24 CONVERSIONS D-540 CONVERSIONS

During a period of eligibility, there may be changes in case circumstances where another category of eligibility must be evaluated. Converting between categories does not require a new application but may require additional forms to be completed or information to be gathered by the case manager. When converting to an equivalent category, i.e., home based waiver to institutional, do not request additional information unless a change in income or resources is reported.

When converting a case to a new aid code, ensure the action is taken prior to cut-off. Actions taken after cut-off for the next month do not update in the MMIS system.

The following types of conversions identify procedures required to re-evaluate factors of eligibility.

Expanded eligibility under the new adult group (AM1 and CA) is an optional group which must be considered only after all mandatory groups are evaluated. When a recipient is eligible under this group and they become institutionalized, they must be evaluated under the institutional group; if not eligible under institutional, they can remain eligible under AM1 or CA.

Customers with ongoing CA or AM1 Medicaid cases who attain age 65 and/or become entitled to enroll in Medicare must be terminated from that coverage group allowing adverse re-evaluated for MAABD eligibility.

Persons who are eligible for Medicare include:

a. All persons over age 65 who are either U.S. citizens or a non-citizen lawfully

admitted for permanent residency who has resided in the U.S. continuously 5

years immediately preceding the month they apply for Medicare.

b. Person under age 65 who have received monthly Social Security/Railroad

Retirement disability benefits for 24 months.

c. Persons with chronic renal disease.

Exception: Use the following steps when converting a Nevada Check-Up (NCU) case to another Family Medical aid code or to a MAABD program: 1- Nevada Check-up to Family Medical

a. Initiate a REHA in the appropriate footer month based on the reported change. The REHA action will instruct the system to evaluate all family medical programs for each individual in the household.

b. The conversion of eligibility is effective the first administrative month after the month in which the action was taken. An administrative month requires all case actions be completed prior to cut-off. If the REHA action is done after

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL D-540 Division of Welfare and Supportive Services CHANGES Medical Assistance Manual CONVERSIONS 24 Jan 25 MTL 02/24 c. cut-off, allow the change in eligibility to take effect in the next administrative month. (Example 1) REHA 05/15/2015, change effective 6/01/2015. (Example 2) REHA 05/29/2015, change effective 7/01/2015. 2- Nevada Check-up to SSI Case

a. Verify SSI eligibility. Create a sub-case if SSI recipient is not head of household, or if others in household have Medicaid.

b. Terminate eligibility under current category prior to cut-off and approve SSI eligibility for the following month. View and post a corrected version to update the aid code and eligibility code and then notify the customer of the change in benefits. Evaluate for parental financial obligation for children under 18 if there is no deeming of parental income/resources in determining eligibility.

3- Requesting a Refund of Premiums

a. If after case processing the household is determined eligible for a new family medical aid code or a new MAABD subcase has been created, a refund may be requested from DHCFP for any future months in which NCU premiums have already been paid by the household. Only months that were converted from NCU to another aid code/program can be included in this request.

Note: Retro refund requests will be evaluated on a case-by-case basis and

authorized only if deemed appropriate.

b. DWSS staff should email the NCU Specialist with case information regarding any refund to the household. The NCU Specialist will review each case and forward the information to DHCFP as necessary.

D-540.1 Converting to Institutional Eligibility

Do not terminate eligibility for individuals currently eligible under another medical group while institutional eligibility is being evaluated if they continue to meet eligibility criteria.

a. Evaluate current resources and compare to institutional resource limit. When the applicant is married (living separate or together), request the couples’ current resources and complete a spousal resource assessment.

Note: This step is not necessary when converting from home-based waiver category unless a change in resources is reported.

b. Evaluate current income. Do not request verification unless a change in income due to institutionalization occurs. Complete a spousal impoverishment determination if a community spouse is involved. If recipient is SSI eligible and payment has not been reduced to the $30.00 institutional level, notify Social Security using form 3911.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services D-540.1 Medical Assistance Manual CHANGES 24 Jan 25 MTL 02/24 CONVERSIONS c. Ensure the medical facility is added as an authorized representative (use category 4 if not signed on as primary or secondary by applicant).

d. Evaluate case for transfer of resources when converting from any category other than home based waiver.

e. Evaluate court orders and income trusts if applicable.

f. Evaluate for other possible benefits; veterans or widows of veterans may be eligible for Aid and Attendance or have VA insurance benefits. The pension of a veteran residing in a Nevada State Veteran’s home is not reduced to $90.

g. Complete a redetermination if all required factors of eligibility are available and verified.

h. Update the appropriate screens in the system, view, and post versions to update to appropriate aid and eligibility code. Allow adverse action for any reduction in benefits, including QMB.

Note: Customers have multiple GRIN screens when they enter/leave different facilities. One screen should be entered for each facility stay.

i. Notify the customer and authorized representative of the change in benefits and patient liability amount. Add free form text to ensure a notice is generated.

j. Evaluate for parental financial obligation for children under 18.

D-540.2 Converting to Home Based Waiver Eligibility

a. Ensure Form 2734 authorizing home based services is completed, and that if the customer is under age 65, there is a current disability decision by SSA or DHCFP through Form 3004.

b. Evaluate current resources and compare to institutional resource limit. When the applicant is married (living separate or together), request the couples’ current resources and complete a spousal resource assessment.

Note: This step is not necessary when converting from institutional > 30days unless a change in resources is reported. c. Evaluate current income; do not request verification unless a change in income occurs.

d. Ensure the appropriate agency is added as an authorized representative.

e. Evaluate case for transfer of resources when converting from any category other than institutional >30 days.

f. Evaluate court orders and income trusts if applicable.

g. Complete a redetermination if all required factors of eligibility are available and verified.

h. Update the appropriate screens in the system, view and post versions to update appropriate aid and eligibility code.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL D-540.2 Division of Welfare and Supportive Services CHANGES Medical Assistance Manual CONVERTING TO HOME BASED WAIVER ELIGIBILITY 24 Jan 25 MTL 02/24 i. Notify the customer and authorized representative of the change in benefits. Allow adverse action for any reduction in benefits, including QMB. Add free form text to ensure a notice is generated.

j. Evaluate for parental financial obligation for children under 18 if there is no deeming of parental income/resources in determining eligibility.

Note: When a customer is converting from Institutional to a Home and Community Based Waiver in the middle of a month, post the HBW aid code for the waiver approval month. The GRIN screen must be completed with the date they leave the facility to allow Medicaid to pay the facility bills as well as provide Home based services in the same month. Complete Form 2817, Partial Month, to advise DHCFP of the partial institutional month.

D-540.3 Other MAGI Groups to SSI Case

a. Verify SSI eligibility. Create a sub-case if SSI recipient is not head of household, or if others in household have Medicaid.

b. Terminate eligibility under current category prior to cut-off and approve SSI eligibility for the following month. View and post a correct version to update the aid code, eligibility code and notify the customer of the change in benefits.

c. Evaluate for parental financial obligation for children under 18 if there is no deeming of parental income/resources in determining eligibility.

D-540.4 SSI Eligibility Terminating

a. When SSI eligibility terminates, evaluate each Public Law category. Update the appropriate information/STAT screens in NOMADS, view and post a correct version to update the aid code, eligibility code, and to notify the customer of the change in benefits.

b. Evaluate eligibility for Medicare beneficiary programs.

c. If Public Law criteria are not met and the recipient is a disabled child under age 18, terminate eligibility allowing 13 days adverse action time. Evaluate eligibility under the Child group and Nevada Check Up; if not eligible, advise the customer of possible Medicaid eligibility under the Katie Beckett program. (1902(e)(3) of the Social Security Act)

D-540.5 QMB/SLMB/QI1 Only to Medicaid with QMB/SLMB

a. Establish eligibility for the appropriate Medicaid category, e.g., SSI, State Institutional, etc.

b. Evaluate income and resources if applicable for Medicaid category.

c. Determine Patient Liability (P/L).

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services D-540.5 Medical Assistance Manual CHANGES 24 Jan 25 MTL 02/24 QMB/SLMB/QI1 Only to Medicaid with QMB/SLMB d. Update the appropriate information/STAT screens in the system, view and post a correct version to update the aid code, eligibility code, and notify the customer of the change in benefits. Ensure QMB/SLMB eligibility code is not removed if posting past months.

D-540.6 Medicaid Only to Medicaid with QMB/SLMB

a. Verify current Medicare Part A enrollment/effective date of entitlement.

b. Evaluate current resources and compare to Medicare beneficiary program resource limits. If information on resources is not provided, re-evaluate for the appropriate Medicaid category.

Note: Does not apply to SSI cases, as the resource evaluation is completed by Social Security. c. Update the appropriate information/STAT screens in the system, view and post a correct version to update the aid and eligibility code. Notify the customer of the change in benefits.

Note: When Converting from MAGI Medicaid to QMB, the (ineligible) first month of QMB must be posted in the last month of Medicaid eligibility to prevent a break in Medicaid coverage.

Note: AM1 and CA recipients cannot be eligible for Medicare and remain Medicaid eligible; convert to QMB/SLMB only.

D-540.7 Medicaid - QMB/SLMB to QMB/SLMB/QI1 Only

a. Update the appropriate information/STAT screens in the system, view and post a correct version to update the aid and eligibility code. Notify the customer of the change in benefits allowing for adverse.

D-540.8 Medicaid - QMB/SLMB to Medicaid Only

a. Evaluate current monthly income; do not request verification unless a change in income occurs.

b. Notify the customer of the change in benefits allowing for adverse action.

D-540.9 Katie Beckett to SSI

a. If a child becomes SSI eligible, terminate eligibility under Katie Beckett and approve SSI eligibility the following month. The following are examples of conversions:

1. Applicant applies in December as a state institutional case and is currently enrolled in Medicare Part A. The customer cooperates and is determined eligible as a state institutional case in December. Because this customer has Medicare Part A, the case manager must also determine whether the customer is eligible for QMB coverage. If the customer’s income and resources meet QMB criteria, QMB coverage is effective January.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL D-540.9 Division of Welfare and Supportive Services CHANGES Medical Assistance Manual KATIE BECKETT TO SSI 24 Jan 25 MTL 02/24 2. Applicant applies January and has $250 SSA disability income. The customer has not applied for SSI but is potentially eligible. The customer meets all the other requirements of a QMB.

Once the worker is able to determine the customer is eligible for QMB coverage (all verifications needed are in), the case would be approved as a QMB only case. Request the customer apply for SSI and give the normal time limit for applying.

The case would be future actioned for the SSI information. If the customer failed to cooperate in applying for SSI, or was determined ineligible, the case would remain open as a QMB only case as long as he continued to meet the criteria. If the customer were approved for SSI, the case would be converted to an SSI/QMB case effective with the month of SSI eligibility (this could include prior months).

3. Applicant applies and is approved for QMB coverage. Sometime after approval, the customer enters the hospital for seven (7) days. The case would continue as QMB and NO PATIENT LIABILITY would be determined, UNLESS the customer qualified as a state institutional case (if income is less than SSI payment level, the customer does not have to be in 30 consecutive days). If the case qualifies as a state institutional case, the case would be converted, and customer would receive full Medicaid coverage and QMB coverage for the month of hospital stay. When the customer is released from the institution, the case would be converted back to a QMB only case, allowing adverse action, as long as all disability requirements are still met. 4. Applicant applies for medical assistance in December and is pending SSI. Eligibility is evaluated under MAGI groups and the case is approved under a MAGI group. In June SSI is approved. MAGI eligibility is terminated the next month allowing for cut-off and Medicaid under the SSI group is approved the same month MAGI eligibility ends.

D-540.10 QMB and < 30 Day Hospital Stay

1. Applicant applies and is approved for QMB coverage. Sometime after approval,

the customer enters the hospital for 7 days. The case would continue as QMB and

NO PATIENT LIABILITY would be determined, UNLESS the customer qualified as a state institutional case (if income is less than SSI payment level, the customer does

not have to be in 30 consecutive days).

2. If the case qualifies as a state institutional case, the eligibility for the month of

hospitalization would be updated to reflect the full Medicaid and QMB coverage.

3. When the customer is released from the institution, the case would be converted

back to a QMB only case, allowing adverse action, as long as all requirements

were still met.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services D-540.11 Medical Assistance Manual CHANGES 16 Jan 01 MTL 01/16 FORMS USED FOR CONVERSION D-540.11 Forms Used for Conversion 2179 – Interface Consent: Request when spouse did not sign the application. Needed to access interfaces for verifying spouse’s income.

2734 – Home and Community Based Waiver Eligibility Status Form: Must be filed in permanent section to verify recipient meets level of care requirements.

3004 – Disability/Incapacity Determination Request: Must be filed in permanent section to verify recipient meets disability criteria. Applicable to institutional less than 30 days, home and community-based waivers, emergency medical, Katie Beckett, and prior medical.

(e-100)Nevada Medical Assistance Manual (MAM): E-100 MAGI Budget Methodology#

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Division of Welfare and Supportive Services E-105 Medical Assistance Manual MAGI BUDGETING 22 Jul 01 MTL 03/22 ASSISTANCE UNIT DETERMINATION MAGI BUDGETING

E-105 ASSISTANCE UNIT DETERMINATION (435.603(f))

For each applying member of the household, evaluate the individual’s tax filing status to determine which members are included in the individual’s assistance unit. Eligibility is determined at the individual level so there may be more than one assistance unit within a household. Apply non-filer rules when determining the assistance unit for individuals who do not file a tax return.

The size of an assistance unit is determined by the number of persons included as members of each individual’s assistance unit. In the case of determining the assistance unit size of a pregnant woman, the pregnant woman is counted as herself plus the number of children she is expected to deliver. In the case of determining the family size of other individuals who have a pregnant woman in their assistance unit the number of children she is expecting are not included.

Example: Married couple filing jointly, wife, if pregnant, and they have 1 child who is claimed as a tax dependent.

Father's assistance unit = Father, mother, child (3)

Mother's assistance unit = Father, mother, child, unborn (4)

Child’s assistance unit = Father, mother, child (3)

The assistance unit may include tax dependents or tax filers not residing in the same home and not applying for assistance. Members outside the household who are included in the assistance unit are listed on the MBRO screen. See task guide Workflow-14 for MBRO data entry. Non-applying members cannot be required to provide a SSN or citizenship status.

Note: For all medical assistance applications received that show an individual as pregnant with Estimated Date of Confinement (EDC) or Due Date indicated:

• Contact the applicant via telephone to gather the correct EDC; or • If unable to contact the applicant, staff should enter a date eight months from the application date and continue to process the case; and • At the next opportunity, either while processing a subsequent application, the applicant reports a change in circumstance, or the hospital reports the birth, staff should review and verify the pregnancy information and unborn member information for accuracy.

E-105.1 Tax Filing Status

There are five filing statuses:

• Single • Married Filing Jointly • Married Filing Separately • Head of Household • Qualifying Widow(er) With Dependent Child

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E-105.1 Division of Welfare and Supportive Services MAGI BUDGETING Medical Assistance Manual Tax Filing Status 22 Jul 01 MTL 03/22 Note: Unmarried couples or Domestic Partners cannot claim a tax status of Married Filing Jointly or Married Filing Separately.

Use the attested statement on the application to determine each household member’s filing status. If the household reports a change in filing status on the new application that is different from the last application or redetermination, update the household member’s filing status effective the next available month, allowing for adverse if the change reduces benefits.

If the client reports a change in their filing status after the self-attested statement on the application, the change should be due to a verifiable life event (with exceptions).

Verifiable life events include: • Divorce • Marriage • Death • Birth of a child • Adoption

E-105.2 Tax-Filer Not Claimed As a Tax Dependent

For individuals who:

a. expects to file a tax return for the current year in which an eligibility determination is being made; and

b. do not expect to be claimed as a tax dependent by another tax-filer;

the assistance unit consists of the tax-filer, the joint filer, and all persons whom the individual expects to claim as a tax dependent (including tax dependents not living in the home).

E-105.3 Individuals Claimed As Tax Dependents

For an individual who:

a. expects to be claimed as a tax dependent by another tax-filer for the current year in which an eligibility determination is being made;

the assistance unit is the assistance unit of the tax-filer claiming the individual UNLESS the individual claimed as a tax dependent meet any of the following exceptions:

1. The individual expects to be claimed as a tax dependent by someone other than a parent (natural, adopted, or step);

2. The individual is a child under age 19, living with both parents, (natural, adopted or step) but the parents do not expect to file a joint tax return;

3. The individual is a child under age 19 who expects to be claimed by a non-custodial parent.

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Division of Welfare and Supportive Services E-105.3 Medical Assistance Manual MAGI BUDGETING 22 Jul 01 MTL 03/22 Individuals Claimed As Tax Dependents

If the individual meets one of these exceptions, determine their assistance unit using the non-filer rules.

Note: Married spouses cannot claim each other as a tax dependent.

E-105.4 Married Couples

In the case of a married couple living together, each spouse is included in the assistance unit of the other spouse regardless of whether they expect to file a joint tax return.

E-105.4.1 Divorced Couples

If a couple is divorced under a final decree by the last day of the year, they are considered unmarried for the whole year.

E-105.4.2 Domestic Couples (NRS 122A)

Domestic partners will be treated as spouses in Nevada for determining Medicaid eligibility with the following MAGI budgeting exceptions:

Domestic partners:

a. Are not considered married for purposes of MAM E-105.4; and

b. Must claim a tax status of single or Head of Household (if qualified with a dependent other than the domestic partner); and

c. Cannot claim the other partner as a dependent unless they meet the rule for qualifying dependents after splitting the combined community income; and

d. Will be evaluated using half the combined community income earned by both partners for use in their individual MAGI assistance unit budgets. Combined income includes any earnings made during the partnership and income from jointly owned businesses, properties or the interest earned from accounts opened and paid for during the partnership. Combined income does not include RSDI/SSI. Unemployment income may be considered combined if eligibility for UIB was obtained solely during the partnership; and

e. Will have any separate income included in their individual MAGI assistance unit budget. Separate income includes RSDI/SSI, some UIB and other income not considered as community income; and

f. May be considered a stepparent to their partner’s minor children; and

g. May claim any children that were adopted by both partners as a dependent of either partner but cannot be claimed by both; and

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E-105.4.2 Division of Welfare and Supportive Services MAGI BUDGETING Medical Assistance Manual Domestic Couples (NRS 122A) 22 Jul 01 MTL 03/22 h. Must provide verification of a domestic partnership as a pre-eligibility requirement (see MAM D-140.1). Failure to provide verification may cause ineligibility for the entire household. Registration with the Secretary of State in Nevada is no longer required.

E-105.5 Non-Filer Rules

For an individual who:

a. does not expect to file a federal tax return; and

b. does not expect to be claimed as a tax dependent for the taxable year in which an eligibility determination is being made; or

c. who meets an exception to the tax dependent rules,

the household consists of the individual and, if living with the individual;

a. The individual's spouse; and

b. The individual's natural, adopted and step children under the age19; and

c. In the case of children under the age 19:

1. the child’s natural, adopted and step parents; and

2. natural, adoptive and step siblings under the age 19.

E-110 Assistance Unit Budgeting

Budget the current monthly taxable income of every individual included in the assistance unit with the following exception:

a. The assistance unit budget for a parent or primary/joint tax filer would not include the income of a child or tax dependent unless the child/tax dependent is required to file a tax return for the taxable year in which eligibility is being determined. A child/tax dependent does not need to actually file a tax return for the income to be required in the budget (see MAM E-110.1).

b. When determining the assistance unit budget for a child who is not living with a parent (e.g., a child living with a grandparent), the child’s MAGI-based income is always counted in determining the child’s eligibility, even if the child’s income is below the tax filing threshold.

c. When determining the assistance unit budget of a tax dependent who is claimed by someone other than a parent, the tax dependent’s MAGI-based income is always counted in determining his/her own eligibility, even if the income does not meet the tax filing threshold.

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Division of Welfare and Supportive Services E-110 Medical Assistance Manual MAGI BUDGETING 22 Jul 01 MTL 03/22 Assistance Unit Budgeting Note: In circumstances where a tax dependent’s assistance unit, per non-filer rules, includes the tax dependent’s parent, the tax dependent’s MAGI-based income would be excluded from the assistance unit budget.

Example: 1. Sarah age 50 claims Stephanie her 17-year-old daughter and Beth her 2 year old grandchild. Sarah earns $3,000 a month in wages and Stephanie earns $500 a month in wages.

Sarah’s assistance unit = Sarah, Stephanie, Beth Assistance unit income = $3,000 Sarah. Stephanie’s income is not included because she is a tax dependent included in her parent’s assistance unit and is not required to file.

Stephanie’s assistance unit = Sarah, Stephanie and Beth Assistance unit income = $3,000 Sarah. Stephanie’s income is not included because she is a tax dependent included in her parent’s assistance unit and is not required to file.

Beth’s assistance unit = Stephanie and Beth

Assistance unit income = $500 Stephanie. Stephanie’s income is included because she is not a child or tax dependent in Beth’s assistance unit.

2. Joan age 45 claims her nephew Steven age 17 and her niece Maria age 14. Joan earns $1,200 a month in wages and Steven earns $250 a month in wages.

Joan’s assistance unit = Joan, Steven and Maria Assistance unit income = $1,200 Joan. Steven’s income is not included as he is a tax dependent, not required to file.

Steven’s assistance unit = Steven and Maria Assistance unit income = $250 Steven. Steven’s income is included because his parent or tax filer is not in the assistance unit.

Maria’s assistance unit = Steven and Maria Assistance unit income = $250 Steven. Steven’s income is included because his parent or tax filer is not in the assistance unit.

E-110.1 Annual Income Guidelines for Children and Tax Dependents

The following annual income guidelines are provided to determine if a child or tax dependent is required to file a tax return. Only the individual MAGI-based income of a child or tax dependent is used to make this determination. Do not deem or prorate income from other household members. Any taxable portion of Social Security benefits for the child or tax dependent are applied toward the tax filing threshold determination. If no portion of Social Security is taxable, none of the Social Security benefits are applied to the tax filing threshold.

The relationship between Social Security benefits and the tax filing threshold is only relevant in determining whether a child or tax dependent’s MAGI-based income (including Social Security benefits) are included in the assistance unit budgeting of the parent or

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E-110.1 Division of Welfare and Supportive Services MAGI BUDGETING Medical Assistance Manual Annual Income Guidelines for Children and Tax Dependents 23 Oct 01 MTL 04/23

primary/joint tax filer.

Children and tax dependents who are required to file taxes will have their total MAGI- based income budgeted toward the total household income. This includes both the taxable and non-taxable portions of their Social Security benefits.

Note: MAGI-based income of a child or tax dependent is always countable on their own assistance unit budget regardless of any requirements to file taxes or taxability.

Children and Tax Dependents must file a return if ANY of the following apply:

a. Single person, under 65, not blind; and Married persons under 65, not blind:

1. Has Earned Income only > $12,950

2. Has Unearned Income only > $1,150

3. Has combined income (earned and unearned) > $1,150; OR has

earned income (up to $12,550) plus $400 unearned income.

Note: Married individuals with gross income of at least $5, whose spouse

files a separate return with itemized deductions, are required to file

a tax return.

b. Single person, 65 or older or blind:

1. Has Earned Income only > $14,700

2. Has Unearned Income only > $2,900

3. Has combined income (earned and unearned) > $2,900; OR has

earned income (up to $12,550) plus $2,150 unearned income.

c. Single person, 65 or older AND blind:

1. Has Earned Income only > $16,450

2. Has Unearned Income only > $4,650

3. Has combined income (earned and unearned) > $4,650; OR has

earned income (up to $12,550) plus $3,900 unearned income.

d. Married person, 65 or older or blind:

1. Has Earned Income only > $14,350

2. Has Unearned Income only > $2,550

3. Has combined income (earned and unearned) > $2,550; OR has

earned income (up to $12,550) plus $1,800 unearned income.

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Division of Welfare and Supportive Services E-110.1 Medical Assistance Manual MAGI BUDGETING 23 Oct 01 MTL 04/23 Annual Income Guidelines for Children and Tax Dependents

Note: Married individuals with gross income of at least $5, whose spouse files a separate return with itemized deductions, are required to file a tax return.

e. Married person, 65 or older AND blind:

1. Has Earned Income only > $15,750

2. Has Unearned Income only > $3,950

3. Has combined income (earned and unearned) > $3,800; OR has

earned income (up to $12,550) plus $3,200 unearned income.

Note: Married individuals with gross income of at least $5, whose spouse files a separate return with itemized deductions, are required to file a tax return.

E-115 BUDGET PERIOD

Financial eligibility for applicants and ongoing beneficiaries must be based on current monthly income.

Current monthly income includes a best estimate of net earned income and any unearned income received regularly.

Note: When the application reflects a specific source of income has started or terminated in the application month, budget only the actual income received or expected to be received from that source in the application month.

E-120 EARNED INCOME

Earned income is cash received through salary, self-employment or tips, including wage advances, commissions, military pay, jury duty, on-the-job, honorarium payments and work assessment programs through Vocational Rehabilitation. Wage advances are budgeted when received and are deducted when the employer deducts them from gross pay. Note: meals included in the gross taxable income, are considered part of the earnings.

Determine the after tax net amount of all wages, salaries, and commissions by reducing the gross figure by any pre-tax deductions. Advanced EITC received with wages from an employer must be deducted from gross earnings.

Income earned in foreign currency, such as Canadian dollars or Mexican pesos, must be converted to U.S. dollars in order to determine what the actual earned income is. Use the exchange rate on the last day of the budget month, unless there is a dramatic change in the foreign exchange rate impacting the amount of the earnings.

E-120.1 Self-Employment

Annualize self-employment income intended for the household’s annual support, whether the income is received monthly or less often. This figure is used to determine the monthly

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E-120.1 Division of Welfare and Supportive Services MAGI BUDGETING Medical Assistance Manual Self-Employment 22 Jul 01 MTL 03/22

self-employment income.

Client statement of gross self-employment income can be accepted when the gross amount (before expenses) is under the income limit for the household size. When the gross self-employment exceeds the income limit, but the net income (after expenses) is under the income limit for the household size request verification of self-employment.

E-120.2 Verification of Self-Employment

If the household has had self-employment income for the past year:

1. Use the adjusted gross income figures from the previous year’s tax return.

• Add to the adjusted gross income any: RSDI benefits received; Foreign income received; Any tax-exempt interest received.

2. If the current income appears to be substantially different from the previous year, use more current information, such as updated business ledgers or day books.

Determine net self-employment income by subtracting allowable costs of producing the income such as identifiable costs of labor, sales tax, stock, raw materials, seed and fertilizer, advertisement, insurance premiums, utilities, repairs that maintain income-producing property, supplies, fuel, linen service, property tax and interest paid to purchase income-producing property.

Note: Cost of labor may include wages paid to the business owner. This expense is countable as both an expense to the business and earned income to the business owner. Fuel expenses are not allowed without a detailed mileage record/log or other documentation showing beginning and ending mileage, destination, which supports the expense. The current state mileage rate is used to determine fuel expense. Documentation acceptable to the IRS is acceptable to the Division.

If the household has not had the self-employment income for the past year average the income over the period of time the business has been in operation, and project that income.

3. Form 2011, Self-Employment worksheet completed by the client with receipts and records may be used.

Note: Uber/Lyft and other rideshare drivers are required to keep detailed records of any mileage or expenses related to their business (refer to manual section E-300).

E-125 UNEARNED INCOME

Unearned income is income received without performing work-related activities. It includes benefits from other programs.

Regular unearned income deposited directly into a financial institution is considered received in the month for which it is intended to be received.

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Division of Welfare and Supportive Services E-125 Medical Assistance Manual MAGI BUDGETING 23 Oct 01 MTL 04/23 UNEARNED INCOME

When an individual receives and returns a check (e.g., UIB, RSDI, VA, etc.) to the issuing agency, determine whether to budget the payment using the following guidelines:

a. If there is evidence the check was incorrectly paid and it is verified the check was returned, do not budget the amount as income.

b. If the check was correctly paid and was voluntarily returned, budget the amount as income in the month received.

Do not count RSDI, SSI, VA, or other such benefits which a member of the household is entitled to receive if the benefits are paid to someone outside the household who:

a. receives the funds, and

b. does not make the money available to the beneficiary.

If the payee provides a portion of the funds to the beneficiary, count the amount made available in cash or by vendor payment as unearned income to the beneficiary's assistance unit. Any portion of the funds the payee keeps for their own use is budgeted as unearned income to the payee's assistance unit.

If the income is not made available, the individual must follow the requirements for pursuing legally obligated income (refer to manual section C-500).

E-128 ZERO INCOME

If the household reports zero income for a required member:

1. Verify the zero income of that member using the best available information (not all inclusive): a. Check the available electronic interfaces used by DWSS; or b. Check if other active programs (SNAP, TANF, etc.) already have the income verified;

2. At this time zero income will not show in a data source that is currently retained in the case record.

All situations of zero income will need to be documented using the documentation template.

Note: The annual redetermination of Medicaid eligibility requires a new verification of income. Do not re-use a verification of income provided with a previous medical assistance application to process the current redetermination.

E-130 BEST ESTIMATE OF INCOME

A reasonable method must be used when determining current monthly income for any income not expected to be received on a monthly basis. This may include a 30- or 60-day prior period as used for other DWSS programs such as TANF or SNAP (see E&P A-640), or it may be based on available electronic data sources and information gathered during processing. Workers must document the methodology used to calculate the best estimate

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E-130 Division of Welfare and Supportive Services MAGI BUDGETING Medical Assistance Manual BEST ESTIMATE OF INCOME 22 Jul 01 MTL 03/22

of the current monthly income.

If the client provides any additional verification of income or a change in income is discovered by the agency between the date of application and the date of processing the income change will be evaluated in the best estimate calculation.

If the client reports new employment or a new benefit, without a pay history, a projection of income based on hourly rate, hours worked and pay frequency will be used to determine ongoing monthly income.

It is acceptable to exclude a check from the best estimate when the check does not provide a clear representation of a household’s current circumstances (e.g. one check provided is abnormal due to excess sick leave).

E-130.1 Converting Income to Monthly Amounts

If income is not received monthly, convert it to monthly amounts using one of the following methods (not all inclusive):

a. Multiply weekly income by 4.3.

b. Add amounts received semi-monthly (twice a month).

c. Multiply bi-weekly (amounts received every other week) by 2.15.

d. Divide annual income by 12.

e. Divide semi-annual income by 6.

f. Divide quarterly income by 3.

g. Divide bi-monthly income by 2.

E-130.2 Unpredictable Income

Irregular and unpredictable income is exempt. Consider income irregular and unpredictable if both of the following conditions apply:

a. the anticipated income will be less than or equal to $30 in a calendar quarter, and

b. the income is received too infrequently or too irregularly to be reasonably anticipated.

E-130.3 Irregular Income

When converting and projecting earnings, do not include bonuses, holiday pay, commissions and/or overtime, unless it is received on a regular basis or the holiday pay is received in lieu of regular pay (i.e., vacation pay). If bonuses, overtime, commission, etc., is received once a month, convert the regular earnings and then add the monthly overtime, bonus, commission, etc., to the total converted amount of earnings. Ensure the budgeting method is documented in the case

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Division of Welfare and Supportive Services E-130.3 Medical Assistance Manual MAGI BUDGETING 22 Jul 01 MTL 03/22 Irregular Income

record.

Households which, by contract or self-employment, receive their annual income in a period of time shorter than one year shall also have that income averaged over a 12-month period provided the income from the contract is not received on an hourly or piecework basis. These households may include some school employees, sharecroppers, farmers, and other self-employed households. This does not include migrant or seasonal farm workers.

E-130.4 Converting New Income

Use the following procedures if the household has a new source of income and there is not enough history from which a monthly amount of income can be accurately projected:

a. Determine the estimated number of hours to be worked per week,

b. Estimate weekly gross income by multiplying the weekly estimated hours by the hourly wage.

c. Determine the monthly projected gross income by multiplying the estimated weekly gross income by 4.3.

Note: If verification substantiates the use of a specific factoring method which is more accurate than multiplying weekly gross income by 4.3, use what will accurately reflect the income to be received.

E-135 APPLICATION OF MODIFIED ADJUSTED GROSS INCOME

Modified adjusted gross income consists of four types of income that are counted in determining eligibility: (see MAM E300 for list of taxable/non-taxable income types).

• Taxable income • Social Security (RSDI) benefits not included in taxable income • Tax-exempt interest • Foreign earned income

E-135.1

Allowable Deductions

MAGI budgeting rules require the use of current monthly income in the Medicaid determination and annual income used in the advance premium tax credit (APTC) determination.

Current monthly income budgeting only allows pre-tax deductions taken on a monthly basis or taken in the budget month to be included in the current monthly income budget. Deductions taken on an annual basis are not included in a current monthly income budget determination. The APTC eligibility determination is made using annual income and annual deduction amounts. The difference in budgeting methodology may cause an individual to be determined Medicaid eligible based on annual income and Medicaid ineligible based on current monthly income.

When this occurs, and the application attests annual income, the case manager should request verification of the expected annual income amount listed on the application. If the verified annual income divided by 12 makes the individual Medicaid eligible and there have

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E-135.1 Division of Welfare and Supportive Services MAGI BUDGETING Medical Assistance Manual Allowable Deductions 22 Jul 01 MTL 03/22

been no changes in circumstances use the annual figure divided by 12 to determine eligibility.

Examples of verification of annual vs. monthly income discrepancy would include; a tax return, seasonal work contract, statement from employer regarding temporary assignment, substitute teaching contract.

Certain tax deductions allowed by the IRS are not included in MAGI budgeting. If an individual lists deduction under “OTHER” on the application, verify the deduction type before allowing the deduction in the budget.

Allowable pre-tax deductions taken from earned income are used in the current monthly income budget. Pre-tax deductions must be clearly designated on the employee’s paystub or W-2 forms showing both the total gross earnings and the adjusted taxable gross earnings.

The deductions listed below are only allowable when they belong to someone in the tax filing unit or in the household (for non-filers).

Pre-tax deductions may include but are not limited to:

Deduction Type Explanation of Allowable Deduction Maximum Amount Commuter Expenses Employer provided qualified transportation fringe benefit such as:

• Transportation in a commuter highway vehicle (such as a van that seats at least 6) between your home and workplace.

• A transit pass (any pass, token, farecard, voucher, or similar item entitling a person to ride mass transit (whether public or private)

• Qualified parking provided to an employee at or near the employer’s place of business. Includes parking provided on or near a location from which the employee commutes to work by mass transit, in a commuter highway vehicle, or by carpool.

Expenses reimbursed under a bona fide reimbursement arrangement. Up to $270/month

Up to $270/month

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Division of Welfare and Supportive Services E-135.1 Medical Assistance Manual MAGI BUDGETING 22 Jul 01 MTL 03/22 Allowable Deductions Dependent Care Expense Employer provided dependent care benefits under a qualified plan may be excluded from wages. Self-employed individuals who receive benefits from a qualified dependent care benefit plan, are treated as both employer and employee. Not excluded from wages but a deduction on IRS Form 2441. Variable (up to IRS allowed maximum)

Income limits apply Health Flexible Spending Account (FSA) Employer provided Health FSA that qualifies as an accident or health plan. Salary reduction, and reimbursements of medical care expenses, in most cases, aren't included in income.

Note: Health FSAs are subject to a limit on salary reduction contributions for plan years beginning after 2012. As of 2021 the limit on employee contributions to health FSAs is $2,750/year. Health Insurance Premiums Premium payments for employer provided accident or health plan made by salary reduction aren't included in income. Variable Retirement Contributions Contributions to a qualified retirement plan made by salary reduction or paid by an employer. Employers can verify if the plan qualifies. Variable

Allowable annual deductions include but are not limited to:

• Schedule 1 of IRS Form 1040

Additional deductions may include but not limited to:

Deduction Type Explanation of Allowable Deduction Maximum Amount Charitable Contributions Up to allowable annual maximum. Up to $600/year. Student Loan Interest Deduction for interest paid on student loans. Loans must have been used for qualifying educational expenses while attending an educational institution. Principle payments are not deductible. The loan payments must be for the individual, their spouse, or their tax dependents (for tax filers) or their children in the household (for non-filers). The lesser of $2500/year or the actual interest paid if MAGI is less than $70,000 ($140,000 couples) Not available if MAGI is greater than $85,000 ($170,000 couples)

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E-135.1 Division of Welfare and Supportive Services MAGI BUDGETING Medical Assistance Manual Allowable Deductions 22 Jul 01 MTL 03/22 Student Tuition Deduction for Qualified Educational Expenses. Not available for tax year 2021 Moving Expenses for members of the Armed Forces Deductions for members of the Armed Forces on active duty and due to a permanent military order move. Variable Spousal Support/Alimony Deduction for court ordered spousal support/ alimony with a court order date prior to 1/1/2019 (per Tax Cuts and Jobs Act 2017). Variable

After-tax contributions are contributions from income (other than ROTH contributions), that an employee must include as income on their taxes. If a retirement plan allows after-tax contributions, those contributions are not excluded from income. After-tax contributions are not an allowable deduction in MAGI current monthly or APTC annual income budgeting.

After-tax contributions may include but are not limited to:

• Public Employees Retirement System (PERS) contributions made by the employee.

Allowable deductions will not reduce the countable amount of RSDI benefits received by any household members.

Example: Client reports self-employment income loss of $3,000.00 and RSDI income of $1,022.00. The current monthly income budget would be $1,022.00.

E-140 STEP-BY-STEP ASSISTANCE UNIT AND INCOME DETERMINATION

E-140.1 Construct a Medicaid/NCU Assistance Unit for Each Applicant

a. Does the individual expect to file taxes? 1. If no – continue to step b 2. If yes – does the individual expect to be claimed as a tax dependent by anyone else? a) If no – the assistance unit consists of the tax-filer, a spouse living with the tax-filer, and all persons whom the tax-filer expects to claim as a tax dependent. b) If yes – continue to step b.

b. Does the individual expect to be claimed as a tax dependent?

i. If no – continue to step c

ii. If yes – does the individual meet any of the following exceptions? a) The individual expects to be claimed as a tax dependent of someone other than a spouse or a biological, adopted, or step parent.

b) The individual is a child under age 19 living with both parents, but the parents do not expect to file a joint tax return.

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Division of Welfare and Supportive Services E-140.1 Medical Assistance Manual MAGI BUDGETING 22 Jul 01 MTL 03/22 Construct a Medicaid/NCU Assistance Unit for Each Applicant c) The individual is a child who expects to be claimed by a non- custodial parent.

1) If no – the assistance unit is the assistance unit of the tax-filer claiming her/him as a tax dependent.

• Is the individual married? If yes- the assistance unit also includes the individual’s spouse

2) If yes – continue to step c

c. For individuals who neither expect to file a tax return nor expect to be claimed as a tax dependent as well as tax dependents who meet one of the exceptions in b.2., the household consists of the individual and, if living with the individual;

1. The individual’s spouse 2. The individual’s natural, adopted and step children under the age 19. 3. In the case of an individual under age 19, the natural, adopted and step parents and natural, adoptive and step siblings under age 19.

E-140.2 Determine the Medicaid/NCU Income for Each Assistance Unit

a. Is any member of the assistance unit a child or expected tax dependent of another member of the assistance unit?

1. If yes – is the child or tax dependent expected to be required to file a tax return?

a) If yes - continue to step b and include the child’s income in total assistance unit income.

b) If no - continue to step b, but do not include the child’s income in total assistance unit income.

2. If no - continue to step b

b. Determine income of each member of the individual’s assistance unit, unless income of such member is flagged as not being counted in step a.

c. Assistance unit income equals the sum of the income of every member of the individual’s assistance unit determined in step b.

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E-145 Division of Welfare and Supportive Services MAGI BUDGETING Medical Assistance Manual MAGI EXEMPTIONS 22 Jul 01 MTL 03/22

E-145 MAGI EXEMPTIONS

MAGI methodologies do not apply to individuals applying for Medicaid and Medicare Beneficiary benefits under the aged, blind and disabled categories (MAABD).

When an applicant indicates on the application they are disabled or pursuing home and community-based services, process a MAABD application. IF the individual also meets eligibility under a MAGI group, they may receive Medicaid under the MAGI group until the MAABD determination is made.

When an individual is pending a SSI determination:

a. approve Medicaid under the appropriate MAGI group and document pending SSI determination, DO NOT apply for MAABD in AMPS.

If SSI is approved:

a. terminate MAGI eligibility in the next month prior to cut-off and approve Medicaid under the appropriate MAABD category for the month after the MAGI eligibility ended.

Note: DO NOT approve MAABD for months an individual has already received Medicaid under a MAGI group, this may adversely affect patient billing as well as federal funding levels.

(e-200)Nevada Medical Assistance Manual (MAM): E-200 MAABD Budget Methodology#

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MAABD INCOME AND BUDGETING E-200 APPLICATION OF SOCIAL SECURITY INCOME (SSI) BUDGET METHODOLOGY SSI budgeting methodology is used to determine eligibility for all MAABD eligibility groups. The methodology follows the same rules used by Social Security to determine Social Security benefits and allows states options to be less restrictive than the SSI program. E-205 HOUSEHOLD DETERMINATION Determine whether the customer is considered an individual or a member of a couple with an SSI eligible or ineligible spouse by applying the definitions in this section. NOTE: Sections E-205 through E-210.2 do not apply to Institutional >30 days or Home and Community- Based Waiver (HCBW) categories. When the applicant is applying for Medicaid under Institutional or HCBW, they are considered married, even if separated but not divorced. When the customer is considered an individual, only the customer's income is counted in the eligibility determination. Additionally, when the customer is considered a member of a couple, the spouse's income is counted for a specified time period. Spouses separated temporarily for economic (employment), emergency reasons (hospitalization), vacations or visits are NOT considered "separated" (ceased living together) for purposes of income consideration. The separation must be expected to continue. If the spouse expects to return to the household in the same month or the following month, they are included in the household. When income of the spouse must be considered the income will be verified. If unable to verify the spouse's income, document the circumstances and accept the customer's statement. E-205.1 Definition Related to Household Determination Assistance Based on Need (ABON) – Assistance which is:  Provided under a program which uses income as a factor of eligibility; and  Funded wholly by a State (including the District of Columbia, Indian tribes and the Northern Mariana Islands), a political subdivision of a State, or a combination of such jurisdictions. ABON is a payment made to an individual or household; therefore, Medicaid is NOT considered assistance based on need. SSI Eligible Spouse - The customer's spouse who meets the requirements in both a) and b) below: a. Is pending SSI, received SSI or would have been eligible for SSI: To determine if the spouse would have been eligible for SSI, the spouse: 1. Must have been aged, blind or disabled. Blindness and disability are established when the spouse has been determined eligible for any type of permanent disability/blind benefits (e.g., SSA, VA, or Retirement Disability Benefits), and 2. Must be determined financially eligible Division of Welfare and Supportive Services Medical Assistance Manual MAABD INCOME AND BUDGETING MTL 09/24 NOV 24 APPLICATION OF SOCIAL SECURITY INCOME (SSI) BUDGET METHODOLOGY E-200

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b. Is living with the customer or has not been separated longer than the specified time frames: Consider the customer a member of a couple with an eligible spouse only for the month they ceased living together. SSI Ineligible Spouse - The customer's spouse who is not pending SSI, not receiving SSI and would not have been eligible for SSI. When the spouse is not aged or has not been determined eligible for some type of permanent disability/ blindness benefits, consider the spouse an SSI ineligible spouse. E-205.2 Income Consideration The ineligible spouse's income must always be considered when the customer is living with the spouse. When the customer and ineligible spouse are separated, the ineligible spouse's income is only considered in the month of separation. When the customer is considered an individual, only the customer's income is counted. Additionally, when the customer is considered a member of a couple, the spouse's income is counted. When income of the spouse must be considered, the income will be verified. If unable to verify the spouse's income, document the circumstances and accept the customer's statement. Individual - Consider customers as individuals when they are: a. NOT married; b. Married but have been separated from their SSI ELIGIBLE spouse for a specified time frame: The customer will be considered an individual beginning the month after the month they ceased living together. c. Married but have been separated from their SSI INELIGIBLE spouse for a specified time frame: Consider the customer an individual the month FOLLOWING the month they ceased living together; d. Had an SSI INELIGIBLE spouse who received TANF, VA pension or other assistance based on need for the month Medicaid is requested. E-210 SSI - MAABD - INCOME BUDGETING Income means the receipt of money in the month for which an eligibility determination is being made. All income or changes in income must be reported. All income must be evaluated for financial eligibility. Budget income for the month it is received. Do not deem income from a community spouse to an institutionalized spouse for any month of institutionalization. E-205.1 Division of Welfare and Supportive Services MAABD INCOME AND BUDGETING Medical Assistance Manual Definition Related to Household Determination MTL 09/24 NOV 24

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Spouses separated temporarily, for economic (employment) or emergency reasons (hospitalization), vacations or visits are NOT considered "separated" (ceased living together) for purposes of income consideration. The separation must be expected to continue. A temporary absence is one where the individual leaves and returns to the household in the same month or the following month. Regular unearned income deposited directly into a financial institution is considered received in the month for which it is intended to be received. When a one-time lump sum payment is received and it will not affect ongoing benefits, adjust patient liability for the month of receipt, not to exceed the actual cost of care for the month. Financial eligibility is always determined prospectively (future month). When information becomes known which causes ineligibility prospectively, terminate benefits allowing adverse action time. E-210.1 Ownership/Availability of Income All income which a payor designates as the customer's will be considered in determining eligibility. When a benefit or income is received for more than one person or family member, only the customer's portion of the income is considered. E-210.2 Income Deeming Applicable in the following groups:  Medicare Beneficiary  Public Law  Institutional <30  Prior medical If the customer is a child, under age 18, and was living with his/her parent(s) at the time of institutionalization, deem the parent(s)' income using Form 2646-EE/A. 1. Deeming applies from a parent to a child when they live together in the same household. 2. Deeming stops the month following the month of institutionalization in a medical facility. 3. Deeming begins the month following the month the child returns home from a medical facility. Medicare Beneficiary - If the customer is married and living with his/her ineligible spouse, use the first column on Medicare Beneficiaries budget Form 2203 to determine if deeming applies. E-210.3 Dividing Income Applicable in the following groups:  Institutional >30)  Home and community-based waivers When an institutional applicant is ineligible due to excess income for home-based waiver and institutional eligibility. Division of Welfare and Supportive Services Medical Assistance Manual MAABD INCOME AND BUDGETING MTL 09/24 NOV 24 SSI-MAABD-INCOME BUDGETING E-210

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 Divide the total income of spouses who are living separate and apart (due to institutionalization only) equally between them.  Determine eligibility only using the applicant’s share. If a portion of the spouse's income is made available to the applicant, that portion would be counted as income to the customer in determining eligibility. Dividing income takes precedence over the joint bank account procedures; therefore, income deposited in a joint bank account held by both spouses will NOT be considered "being made available." E-210.4 Court Order/Trust Income: If the customer has a court order or trust, complete form 6009 (Intra-Office Referral Report), including the signature of the case worker completing the 6009, and the supervisor approving the 6009. Send the 6009 and supporting documents, including a complete copy of the court order or trust, all schedules notated within the trust; and bank statements (if applicable), via inter-office mail to the Chief of Eligibility & Payments for a decision on whether the Division of Welfare and Supportive Services (DWSS) can recognize the court order or trust. E-220 BUDGETING PROCEDURES FOR SSI FINANCIAL ELIGIBILITY – SPOUSE TO SPOUSE DEEMING – (SSI BUDGET FORM 2646–EE) E-220.1 SSI Budget Form 2646–EE Use this budget to determine eligibility in the following groups;  Institutional <30 days  Institutional >30 days – If a child was living with parents at time of institutionalization.  Prior Medical – would have been eligible for SSI  Public Law E-220.1.1 Member of Couple with Eligible Spouse Any time the spouse appears potentially SSI eligible, treat as an eligible spouse until determined ineligible. Use the member of a couple, with eligible spouse column. a. If ineligibility results, consider the spouse ineligible and go through the deeming computation by using the member of a couple, with ineligible spouse column, to determine if deeming applies. b. If deeming doesn't apply, proceed to Part B using the individual column. c. If deeming does apply, proceed with the budget under the member of a couple with ineligible spouse column. If this process also results in ineligibility, the customer is ineligible for Medicaid. E-220.1.2 Member of Couple with Ineligible Spouse Use the member of a couple, with ineligible spouse column, items A–1 through 3 to determine if deeming applies. E-210.3 Division of Welfare and Supportive Services MAABD INCOME AND BUDGETING Medical Assistance Manual Dividing Income MTL 09/24 NOV 24

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a. If deeming doesn't apply, proceed to the individual column of the budget. Deeming never applies when the SSI ineligible spouse receives TANF, VA pension or other federal or state assistance based on need. E-220.1.3 Individual Use the individual column, when the person meets the definition of an individual. E-220.1.4 Deeming Computation Deeming never applies when the SSI ineligible spouse receives TANF, VA pension or other federal or state assistance based on need. a. Determine the ineligible spouse's total unearned income. b. Determine if SSI ineligible child(ren) allocation is applicable. The allocation is applicable if there are any dependent children who are: 1. Under age 18 OR under age 22 and are students regularly attending a school, college or university or a course of vocational or technical training to prepare for gainful employment; and 2. The child(ren) are not receiving TANF, VA pension or other federal or state assistance based on need. c. If the allocation deduction is applicable, for each ineligible child, subtract the child's income from the child allocation amount. Subtract the remainder from the ineligible spouse's unearned income. d. Determine the ineligible spouse's gross earned income. e. Subtract the balance of any allocation for ineligible children not offset by unearned income. f. Add the remaining unearned income to the remaining earned income, after the allocation deductions. g. Compare the total income after allocations to the deeming indicator amount. If less than the deeming indicator amount, deeming does not apply. Proceed to Part B, individual column of the SSI budget using only the customer's income. If equal to or more than the deeming indicator amount, deeming DOES APPLY. Proceed to Part B member of a couple with an ineligible spouse column adding the unearned income after allocations to the customer's unearned income and the remaining earned income to the customer's earned income. E-220.1.5 SSI Eligibility Determination In this section of the budget, use only the customer's income when using the individual column. Use Division of Welfare and Supportive Services E-220.1.2 Medical Assistance Manual MAABD INCOME AND BUDGETING MTL 09/24 NOV 24 Member of Couple with Ineligible Spouse

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combined incomes of the customer and eligible or ineligible spouse when using the member of a couple with an eligible or ineligible spouse column. a. Determine unearned income. b. Subtract the general income exclusion of $20 to arrive at the remaining unearned income. c. Determine total gross earned income. d. Subtract any balance of the general exclusion not offset by unearned income. e. Subtract the work expense exclusion of $65. f. Impairment–related work expenses (IRWE). This exclusion is applied to earned income of disabled (but not blind) individuals under age 65. The expense must be reasonable; for items/services which are directly related to enabling an impaired individual to work, and which are necessarily incurred by the individual because of a physical or mental impairment. IRWEs are excluded when the cost is paid by the disabled individual and is not reimbursable from another source. g. Subtract 1/2 of the remaining earned income after the above deductions. h. Determine the total countable income by adding Items B–1–b and B–2–e. i. Compare the total countable income (Item B–3) to the appropriate SSI payment amount (SPA). If the amount is equal to or greater than the SPA in the member of a couple with ineligible spouse or individual columns, the customer is ineligible for Medicaid. If ineligible in the member of a couple with eligible spouse column, proceed to the member of a couple with ineligible spouse column to complete the eligibility determination. E-225 INCOME DISREGARDS BY PUBLIC LAW E-225.1 Pickle Amendment – Public Law 94–566 Exclude from countable income the RSDI cost–of–living increases received after the customer was last eligible for and received SSI and entitled to RSDI in the same month. If the customer resides with his/her spouse and spousal deeming applies, deduct the RSDI cost–of–living increases from the spouse's RSDI income which were received after the customer last received SSI. The last RSDI amount received when the customer was entitled to can be obtained through the Social Security Administration using Form 2022-EM, Pickle Amendment Certification, the annual Pickle Report or by using the RSDI Computation Worksheet Form 2654-EE. Verification used to support "Pickle" status must be uploaded to DIS. E-220.1.5 Division of Welfare and Supportive Services MAABD INCOME AND BUDGETING Medical Assistance Manual SSI Eligibility Determination MTL 09/24 NOV 24

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When there are changes in income and/or amounts, re-evaluate eligibility excluding only the RSDI cost– of–living increases received after the customer was last eligible for and received SSI and entitled to RSDI in the same month. If the customer would now be eligible (based on SSI rules) for SSI before disregarding cost–of–living increases, they no longer meet the criteria for Medicaid eligibility under Public Law 94–566 (Pickle Amendment). Refer the customer to apply for SSI benefits. Transfer the net countable income to the SSI Budget. E-225.2 Adult Disabled Child – Public Law 99–643 Disregard the adult disabled child benefit or the increase in this benefit received after July 1, 1987. When there are changes in income and/or amounts, re-evaluate eligibility excluding the adult disabled child benefit or the increase in this benefit received after July 1, 1987. If the customer would now be eligible (based on SSI rules) for SSI before disregarding cost–of–living increases, they no longer meet the criteria for Medicaid eligibility under Public Law 99-643 (Adult Disabled Child). Refer the customer to apply for SSI benefits. Transfer the net countable income to the SSI Budget. E-225.3 Widow/Widowers – Public Law 100–203 Disregard the widow/widower's benefits in addition to other SSA benefits which are not disability benefits. When there are changes in income and/or amounts, re-evaluate eligibility excluding the widow/widower's benefits in addition to the other SSA benefits which are not disability benefits. If the customer would now be eligible (based on SSI rules) for SSI before disregarding cost–of–living increases, they no longer meet the criteria for Medicaid eligibility under Public Law 100-203 (Widow/Widowers). Refer the customer to apply for SSI benefits. Transfer the net countable income to the SSI Budget. E-225.4 Widows, Widowers and Surviving Divorced Spouses – Public Law 101–508 Disregard the Title II (RSDI) disability benefit which was based on application of new disability criteria. When there are changes in income and/or amounts, re-evaluate eligibility excluding the Title II disability benefit which was based on application of new disability criteria. If the customer would now be eligible (based on SSI rules) for SSI before disregarding cost–of–living increases, they no longer meet the criteria for Medicaid eligibility under Public Law 101-508 (Widow, Widows and Surviving Divorced Spouses). Refer the customer to apply for SSI benefits. Transfer the net countable income to the SSI Budget. Division of Welfare and Supportive Services E-225.1 Medical Assistance Manual MAABD INCOME AND BUDGETING MTL 09/24 NOV 24 Pickle Amendment – Public Law 94-566

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E-230 MEDICARE BENEFICIARIES (QMBs, SLMBs and QDWIs) Couple Computation- If the customer is married, and living with his/her eligible spouse, evaluate their combined income using the third column on the “Medicare Beneficiaries Budget” Form 2203-EM. Deeming Income - If the customer is married and living with his/her ineligible spouse, use the first column on the “Medicare Beneficiaries Budget” Form 2203-EM to determine if deeming applies. Exceptions:  Do not deem income from a spouse receiving Medicaid under a waiver. A spouse who is under a waiver is considered to be institutionalized.  The division of income policy is not applicable to the Medicare beneficiary groups. E-235 MEDICARE BENEFICIARIES BUDGET METHOD E-235.1 Medicare Beneficiary Budget Form 2203 Use this budget to determine eligibility for the following groups;  Qualified Medicare Beneficiary (QMB)  Special Low Income Medicare Beneficiary (SLMB)  Qualified Low Income Medicare Beneficiary (QI)  Qualified disabled working Individual (QDWI) E-235.1.1 Determine Whether The Customer Is Considered An Individual Or A Member Of A Couple With A QMB/SLMB/QI/QDWI Eligible Spouse By Applying The Definitions In This Section. NOTE: This section does not apply to Institutional >30 days or Home and Community-Based Waiver (HCBW) categories. When the applicant is applying for Medicaid under Institutional or HCBW, they are considered married, even if separated but not divorced. a. Eligible Spouse The customer’s spouse who meets the requirements below: 1. Has applied for, is receiving, or would be eligible to receive SSI/QMB/SLMB/QI/QDWI: To determine if the spouse would have been eligible for one of these categories, the spouse: a) must be aged, blind or disabled; and b) must be determined financially eligible. 2. Is living in the same household as the customer. b. Ineligible Spouse The customer’s spouse who meets the requirements below: 1. Is not receiving or has not applied for SSI/QMB/SLMB/QI/QDWI; or Division of Welfare and Supportive Services MAABD INCOME AND BUDGETING Medical Assistance Manual MEDICARE BENEFICIARIES (QMBs, SLMBs and QDWIs) MTL 09/24 NOV 24 E-230

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2. Exceeds the income limit for couple computation. 3. Is living in the same household as the client. c. Individual Consider customers as individuals when they are: 1. NOT married. 2. Married but have been separated from their spouse for a specified time frame. The customer will be considered an individual beginning the month after the month they cease living together. E-235.1.2 Medicare Beneficiaries Budget Form 2203-EM a. Member of Couple with Eligible Spouse Any time the spouse appears eligible for SSI or a Medicare beneficiary category, treat them as eligible until determined otherwise. Use the member of a couple with eligible spouse column. 1. If ineligibility results, consider the spouse ineligible and go through the deeming computation, using the member of a couple with ineligible spouse column to determine if deeming applies. b. Member of Couple with Ineligible Spouse 1. Use the member of a couple with ineligible spouse column to determine if deeming applies. Deeming never applies when the ineligible spouse receives TANF, VA pension or other federal or state assistance based on need. 2. If deeming does not apply, proceed to the individual column of the budget. c. Individual Use the individual column when the person meets the definition of an individual. Exceptions: Do not count income of a spouse who is receiving assistance under a Waiver. If a customer is entitled to both Social Security and an additional income source such as long-term disability which offsets the amount of Social Security the customer receives, budget only the resulting Social Security amount and the gross amount of the additional income source. When income of the spouse must be considered, the income will be verified. If impossible to verify the Division of Welfare and Supportive Services E-235.1.1 Medical Assistance Manual MAABD INCOME AND BUDGETING MTL 09/24 NOV 24 Determine whether the Customer is Considered an Individual or a Member of a QMB/SLMB/QI/QDWI Eligible Spouse by Applying the Definitions in This Section

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spouse’s income, document the circumstances and accept the customer’s statement. E-235.2 Budgeting – Specific Instructions a. Deeming Computation 1. Determine the ineligible spouse’s total unearned income. 2. Determine if an ineligible child allocation is applicable. To apply this, the child must: a) be under age 18 or age 22, and a student regularly attending a school, college, university or vocational/technical training to prepare for gainful employment; and b) not be receiving TANF, VA pension or other federal or state assistance based on need (SNAP is not considered assistance based on need for SSI budgeting purposes). 3. If the allocation deduction is applicable, subtract any unearned income of the child from the child allocation amount. Add the remaining amounts and subtract the total from the ineligible spouse’s unearned income. 4. Determine the ineligible spouse’s gross earned income. 5. Subtract the balance of any allocation for ineligible children not offset by unearned income. 6. Add the remaining unearned income to the earned income after the allocation deduction. 7. Compare the total income after allocations to the deeming indicator amount. 8. If less than the deeming indicator amount, deeming does not apply. Proceed to the individual column of the budget using only the customer’s income. If equal to or greater than the deeming indicator amount, deeming does apply. Continue through the second section in this column adding the deemed unearned income to the customer’s unearned and the deemed earned income to the customer’s earned income. b. QMB/SLMB/QI/QDWI Eligibility Determination In this section of the budget, use only the customer’s income when using the individual column. Use combined income of the customer and the eligible or ineligible spouse when using either of the columns for a couple. 1. Determine unearned income. This may be the individual’s own income or include income of a spouse. 2. Subtract the general income exclusion of $20 to arrive at the remaining unearned income. E-235.2 Division of Welfare and Supportive Services MAABD INCOME AND BUDGETING Medical Assistance Manual Budgeting – Specific Instructions MTL 09/24 NOV 24

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- 3. Determine total gross earned income. 4. Subtract any balance of the general exclusion not offset by unearned income. 5. Subtract the work expense exclusion of $65. 6. Subtract one half (1/2) of the remaining earned income after the above deductions. 7. Determine the total countable income by adding the total unearned and earned income. 8. Compare the total countable income to the income limit for the appropriate Medicare Beneficiaries category. If countable net income is less than or equal to the income limit, the customer is QMB/SLMB/QI1/QDWI eligible. NOTE: Use the income limit for a COUPLE if spousal income was computed or deemed. Examples: The following are examples to help clarify this eligible category: 1. Applicant applies 12/3 as a state institutional case and is currently enrolled in Medicare Part A. The customer cooperates and is determined eligible as a state institutional case. Because this customer has Medicare Part A, the case manager must also determine whether the customer is eligible for QMB coverage. If the customer's income and resources meet QMB criteria, they will qualify for both Medicaid and QMB coverage. 2. Applicant applies 12/3 and has $250 SSA disability income. The customer has not applied for SSI, but is probably eligible. The customer meets all the other requirements of a QMB. Request the customer to apply for SSI and give the normal time limit for applying; however, do not delay QMB eligibility once verifications for QMB are received. The case would be future actioned for the SSI information. If the customer fails to cooperate in applying for SSI, or is determined ineligible, the case will remain open as a QMB only case as long as the customer continues to meet the criteria. If the customer is approved for SSI, the case will be converted to an SSI case effective with the month of SSI eligibility (this could include prior med). Additionally, if the person also has Part B Medicare, send Form 1056 to Eligibility and Payments in the Carson City Administrative Office (CCAO). Also Buy-In coverage can begin with the first month of SSI eligibility. 3. Applicant applies and is approved for QMB coverage. Sometime after approval, the customer enters the hospital for 7 days. The case continues as QMB and no patient liability is determined, UNLESS the customer qualifies as a state institutional case Division of Welfare and Supportive Services E-235.2 Medical Assistance Manual MAABD INCOME AND BUDGETING MTL 09/24 NOV 24 Budgeting – Specific Instructions

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(if income is less than SSI payment level, the customer does not have to be in 30 consecutive days). If the case qualifies as a state institutional case, the case should be converted and customer will receive full Medicaid coverage and QMB coverage. When the customer is released from the institution, the case should be converted back to a QMB only case, allowing adverse action, as long as all requirements were still met. 4. Applicant applies 12/29. The case manager is able to determine eligibility on January 10 and approve as a QMB case. The case would be eligible beginning February 1. If in this same example, the customer qualifies under another category, the other category should be approved effective December with the regular Medicaid eligibility code, and beginning in February, the code should change to the Medicaid and QMB eligibility code. E-240 HEALTH INSURANCE FOR WORK ADVANCEMENT (HIWA) E-240.1 HIWA Employment-Related Work Disregards In addition to the $20 General Income Exclusion and $65 Earnings Exclusion, participants in the HIWA program are allowed Employment-Related Work Disregards (ERWD) to be subtracted from their countable earned income. The disregard must be directly related to enabling the individual with a disability to work. Expenses paid for by the employer or another party are not an allowable deduction. A. Employment-Related Transportation Expense  To and from work in personal vehicle - Allow a mileage allowance based on the current state mileage rate. (See State Administrative Manual)  To and from work in a modified vehicle - In addition to the mileage allowance, allow the cost of modifications to a vehicle necessary for the individual to get to and from work. The modification must be directly related to the individual’s impairment. NOTE: Only the cost of the modifications is allowable, not the cost of the vehicle.  Other transportation - When the individual does not have a vehicle, allow the cost of: ─ Bus fare ─ Cab fare ─ Amount paid to another individual to transport the customer to and from work. B. Employment-Related Personal Care Aid (PCA) Services Expense  Services at work or to and from work - Allow the cost for services needed in the work setting, or traveling to and from work. The cost must be incurred by the individual and not provided by the employer.  Services at home -All the cost of services needed for preparation for going to work, or needed E-235.2 Division of Welfare and Supportive Services MAABD INCOME AND BUDGETING Medical Assistance Manual Budgeting – Specific Instructions MTL 09/24 NOV 24

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upon the individual’s return home from work. Examples of In-Home Services (not all inclusive) ─ Bathing and dressing ─ Cooking and eating ─ Administering medications ─ Adjusting or arranging medical devices or equipment ─ Transportation to and from work The deduction is limited to services provided on normal workdays and does not include services for shopping or general homemaking. C. Service Animal Expense Allow the cost if the animal enables the individual to overcome functional limitations to work. Allowable expenses include: ─ Cost of purchasing the animal ─ Food and maintenance costs ─ Veterinary services D. Educational Expenses to Enhance Employability Allow the costs for education directly related to enabling the individual to work. Allowable expenses include but are not limited to: ─ Tuition and fees ─ Books and supplies ─ Parking permits ─ Tutoring expenses E. Medical Equipment/Supplies and Services Allow the cost of medical equipment, supplies or services necessary to enable the individual to work. This includes the cost of the item and any costs related to maintenance and repair. The cost for certain medications and services is allowable if they are necessary to control a condition and enable the individual to function in their work activity. Routine medical and dental services not directly related to the customer’s impairment and ability to work are not allowable. Allowable expenses include: (not all inclusive) ─ Braces ─ Inhalers ─ Pacemakers ─ Respirators ─ Wheelchairs ─ Prostheses (not cosmetic) Division of Welfare and Supportive Services E-240.1 Medical Assistance Manual MAABD INCOME AND BUDGETING MTL 09/24 NOV 24 HIWA Employment-Related Work Disregards

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─ Physical therapy ─ Blood level monitors ─ Radiation treatments ─ Catheters and irrigating kits ─ Bandages and incontinence pads F. Work-Related Equipment/Services Allow the cost of equipment/services essential for the individual to function in their work activity. This includes any cost for maintenance or repair. Allowable expenses include: (not all inclusive) ─ Vision and sensory aids ─ One-handed keyboards ─ Typing aids ─ Telecommunication devices ─ Tools designed to accommodate the workplace ─ Translation into Braille ─ Child care costs (work hours only) ─ Safety equipment/apparel G. Training on Work-Related Equipment Allow the cost of training needed to use impairment-related equipment and services. Examples of allowable training costs include: (not all inclusive) ─ Braille ─ Computer program courses ─ Stenotype instruction ─ Use of impairment-related equipment NOTE: Training does not include general education courses. H. Interpreting Services Allow the cost of services essential for the individual to function on the job. Employed at Home - Allow the cost of modifications essential to create a working space that accommodates the individual’s impairment to enable them to perform their job. E-240.2 Computing Monthly Employment-Related Work Disregards Use the amount the customer pays each month. If an individual incurs a one-time cost, but is making payments, allow the monthly payment amount. If the expense is incurred less often than monthly allow the entire amount in the month paid or allocate the amount over the months in the payment period, whichever the customer chooses. Example: A customer is billed every three months for a contained oxygen supply. Allow the billed E-240.1 Division of Welfare and Supportive Services MAABD INCOME AND BUDGETING Medical Assistance Manual HIWA Employment-Related Work Disregards MTL 09/24 NOV 24

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amount in the month the customer pays it, or divide the amount over the three months. Obtain verification of each Employment-Related Work Expense claimed, including the frequency of the payments. E-240.3 HIWA Income Determination a. Determine countable unearned income (MS 220). b. Subtract the general income exclusion of $20 to arrive at the net countable unearned income amount. c. Determine the gross earned income. d. Subtract any balance of the general income exclusion not offset by unearned income. e. Subtract the work expense exclusion of $65. f. Divide the remaining income by two and the remainder is considered the countable earned income. g. Subtract allowable Employment-Related Work Disregards (ERWD) from the countable earned income. The remainder is considered the net countable

earned income. h. Determine the total countable income by adding the net countable unearned income and the net countable earned income. i. Compare the total countable income to 250% FPL (see Appendix C). E-240.4 HIWA Premiums Individual applying for or receiving assistance under the HIWA program are required to pay a premium based on their monthly combined net income as a percentage of the Federal Poverty Level (FPL). At initial approval, the customer is “conditionally eligible,” awaiting verification from the Division of Health Care, Financing and Policy, the customer has paid their premium. Once verification is received, the customer is either approved for full Medicaid or denied for failing to pay the premium.  Individuals whose combined net income is less than 200% FPL will pay a monthly premium of 5% of their combined net income.  Individuals whose combined net income is between 200% and 250% FPL will pay a monthly premium of 7.5% of their combined net income. Prior medical month premiums are based on the combined net income for the months requested. The individual’s Medicaid premiums are recalculated any time a change in income is reported, but not less than once a year at the time of the annual eligibility redetermination. The Medicaid premiums are due on the first day of each month. If an individual fails to submit a premium payment, Nevada Medicaid will notify the Division around the 11th of the month, to terminate Medicaid effective the end of the month. If the customer subsequently pays their premium, they must submit an application to have the program reinstated. Individuals who are terminated from the HIWA program for failure to pay premiums will not be eligible for the HIWA program for two (2) years from the date of the past due premium(s) unless the past due premiums are paid in full. Division of Welfare and Supportive Services E-240.2 Medical Assistance Manual MAABD INCOME AND BUDGETING MTL 09/24 NOV 24 Computing Monthly Employment-Related Work Disregards

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E-245 RESOURCES Resources are defined as those assets, both real and personal, which an individual owns and can apply, either directly or by sale, to meet their basic needs of food, clothing, shelter and medical costs. All resources and changes in resources must be reported. E-245.1 Ownership/Availability of Resources Sole Ownership - Sole ownership of real or personal property means only one person may sell, transfer or otherwise dispose of the property. All of the resources evaluated at market value less encumbrances is available to the customer. Shared Ownership - Shared ownership of real or personal property means two or more people own it simultaneously. The following are common types of shared ownership:  Tenancy-In-Common -Two or more persons each have an undivided fractional interest in the whole property for the duration of the tenancy. These interests are not necessarily equal. One owner may sell, transfer or otherwise dispose of his share of the property without permission of the other owner(s); but cannot take these actions with the entire property. If a tenant-in-common dies, the deceased’s interest passes to his/her estate or heirs. Count the fair market value less encumbrances of the customer’s property share.  Joint Tenancy - Each of two or more persons have one and the same undivided ownership interest and possession of the whole property for the duration of the tenancy. This means each owner owns ALL the property. If a joint tenant dies, the survivor becomes the sole owner. If more than one joint tenant survives, the survivors become joint tenants of the entire property interest. Count the total fair market value less encumbrances of the entire property.  Tenancy By The Entirety (Married Couples only) -This type of ownership can only exist between married couples. The wife and husband as a unit own the entire property and can be sold only with the consent of both parties. However, if a legal divorce occurs, the former spouses become tenants-in-common, and one can sell his/her share without the consent of the other. If one spouse dies, the survivor becomes the sole owner. Verify whether the customer’s spouse will give permission to sell the property. If permission cannot be obtained, DO NOT count the customer’s one-half share of the property. Exceptions: When a resource is owned jointly by more than one TANF/Medicaid applicant/recipient (other than a community spouse), divide the resource equally among those applicants/recipients to whom available. When a customer is a representative payee or legal guardian managing someone else's funds, these funds are not considered the customer's resource when they are kept in an account separate and apart from the customer's monies AND can be identified as being received and designated for someone other than the customer. E-245.2 Treatment of Resources Resource counting rules vary by MAABD group. Apply the following rules based on the MAABD program being evaluated E-245 Division of Welfare and Supportive Services MAABD INCOME AND BUDGETING Medical Assistance Manual RESOURCES MTL 09/24 NOV 24

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E-245.2.1 Resource Deeming Applicable in the following groups:  Medicare Beneficiary  Public Law  Institutional <30  Institutional >30 Spouse to Spouse: If the applicant/recipient is married and living with his/her spouse, spouse to spouse deeming rules apply. Use the resource limit for a couple when determining resource eligibility. Deeming stops the month following the month of institutionalization in a medical facility. Deeming begins the month following the month the spouse returns home from a medical facility. The value of the customer's and spouse's countable resources (whether owned separately by each or jointly by both) are counted. Only one automobile and home may be excluded per couple. Parent to Child (Institutional <30, Institutional>30): Deeming applies from a parent to a child when they live together in the same household. Deeming stops the month following the month of institutionalization in a medical facility. Deeming begins the month following the month the child returns home from a medical facility. 1. Determine the value of countable resources of the child’s natural/adoptive parent(s) or spouse of a parent. 2. Subtract the resource limit of:  An individual, if one natural/adoptive parent lives in the home; or  A couple, if two parents (or one natural/adoptive and one stepparent) live in the home. 3. The remaining value of resources is considered the child’s countable resources, compare this amount to the individual resource limit. Exceptions to Deeming:  If the child lives with only a stepparent;  Beginning the month following the month the child turns 18;  If the spouse or parent(s) are recipients of SSI, TANF, Refugee Assistance, General Assistance (GA) or VA Pension, VA Compensation as a surviving parent of a veteran, VA Aid and Attendance and VA Payment for Unusual Medical Expenses. This is because these benefits are paid based on need, not entitlement. E-245.2.2 Dividing Resources Applicable in the following groups:  Institutional <30  Institutional >30  Home and Community-Based Waivers Division of Welfare and Supportive Services E-245.2.1 Medical Assistance Manual MAABD INCOME AND BUDGETING MTL 09/24 NOV 24 Resource Deeming

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If a married person is living separate and apart from his/her spouse and they enter into a written agreement dividing the total resources of both spouses equally between them, only the portion the agreement specifies as the customers will be counted in determining/continuing eligibility. The agreement will be effective the month it is signed as long as the spouses were living separate and apart at least part of the month. An agreement cannot be effective for months prior to the date the arrangement was signed. Married persons are considered to be living separate and apart when both spouses are residing in a medical facility. The written agreement must include the following:  A specific listing of all resources being divided and a stated value for each item/resource.  A statement specifying which resources are being given to whom. EXAMPLE: A couple has resources totaling $2,000. The resources consist of $1,000 in savings, $500 in a CD and $500 in stocks. The agreement must specify exactly which resources the agreement is designating as the customer’s, and which are the spouse's. They cannot simply state $1,000 of the total resources belong to the customer and $1,000 belong to the spouse. In this example, an acceptable written agreement would:  Designate to the customer $500 of the savings account and the $500 CD.  Designate to the spouse $500 of the savings account and $500 in stocks. Do not require couples to liquidate resources when considering an equal division. As long as the written agreement specifically designates which resources or a portion of resources belong to the customer and spouse.  The signature of the customer and the customer's spouse or the signature of a legal representative of the customer and the customer's spouse. A legal representative is defined as a person who has legal authority such as a legal guardian, power of attorney, etc. Being an authorized representative does not give that person legal authority. If the spouse of the customer makes a portion of his/her resources available to the customer, that portion will be counted as a resource to the customer. E-245.2.3 Court Order Applicable in the following groups:  Institutional <30  Institutional >30  Home and Community-Based Waivers When a court order equally divides resources between spouses, only the portion the court order specifies as the customers will be counted when determining eligibility, UNLESS the spouse makes a portion of his/her resources available to the customer. The portion made available to the customer will be counted as a resource in determining eligibility. E-245.2.2 Division of Welfare and Supportive Services MAABD INCOME AND BUDGETING Medical Assistance Manual Dividing Resources MTL 09/24 NOV 24

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If the customer has a court order dividing resources unequally, a copy of the complete court order must be sent to the Chief of Eligibility and Payments for a decision on whether the Division of Welfare and Supportive Services (DWSS) can recognize the court order. E-245.3 Transfer of Resources Resources cannot be transferred by an individual in order to become eligible for Medicaid or to retain Medicaid eligibility. See Transfer of Asset policy in F-400. E-245.4 Inaccessible Resource The cash value of resources which are not legally available to the household are exempt. If the Medicaid applicant/recipient or authorized representative is able to verify a resource is unavailable due to the customer’s inability to access the resource due to incapacity and no one else has the ability to access the resource on their behalf, exempt the value of the resource as long as reasonable and timely steps are being taken to access the account on the customer’s behalf, (i.e., referral to the public guardian’s office). Once the resource becomes accessible, the resource becomes countable, and eligibility must be reevaluated for future months. Resources held in Probate are considered inaccessible until the administrator or executor distributes the property. E-245.5 Resource Limits Resource limits for QMB, SLMB and QI are $9,430 for an individual OR $14,130 for a married couple when one OR both spouses are applying. When countable resources exceed the limit, the customer is ineligible. Resource limits for QDWI are $4,000 for an individual or $6,000 for a couple when one OR both spouses are applying. Division of Welfare and Supportive Services E-245.2.3 Medical Assistance Manual MAABD INCOME AND BUDGETING MTL 09/24 NOV 24 Court Order

(e-300)Nevada Medical Assistance Manual (MAM): E-300 Types of Earned and Unearned Income#

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Division of Welfare and Supportive Services E-3001 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 14 Mar 01 MTL 14/01 E-300 TYPES OF EARNED AND UNEARNED INCOME (not all inclusive)

If income is not identified as excluded, it should be counted.

INCOME TYPE DESCRIPTION ACTION PROGRAMS

1. Earned/Unearned

2. Excluded in Financial

3. Excluded in Patient Liability

4. Non-Taxable

Payments to volunteers under Chapter 66 of Title 42 of the U.S. Code Domestic Volunteer Services, including:

* University Year for Action (UYA) * Special and Demonstration Volunteer Program * Senior Companion Program

Verification: (not all inclusive)

- Copy of check - Documents from the agency paying benefits

ADOPTION SUBSIDIES

1. Unearned

2. Excluded in Financial

3. Excluded in Patient Liability

4. Non-taxable

Payments made to adoptive families to assist in the support of the adoption.

Verification:

- Copy of check - Documents from agency paying benefits ADVANCES

1. Earned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable

Advanced income from the employer.

Verification: (not all inclusive)

- Form 2074 “Earnings Verification” - Copy of paycheck stub - Signed and dated statement from employer

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INCOME TYPE DESCRIPTION

E-3002 Division of Welfare and Supportive Services TYPES OF EARNED AND UNEARNED INCOME Medical Assistance Manual

14 Mar 01 MTL 14/01 AGENT ORANGE SETTLEMENTS

1. Unearned

2. Excluded in Financial

3. Excluded in Patient Liability

4. Non-Taxable

Payments pursuant to Public Law 101-201.

Verification: (not all inclusive)

- Copy of check - Documents from the agency paying benefits ALASKA NATIVE CORPORATION

1. Earned/Unearned

2. Excluded in Financial

3. Excluded in Patient Liability

4. Non-Taxable Pursuant to Public Law 100-241, none of the following received from a Native Corporation is counted as income to an Alaska Native or a descendant of an Alaska Native: Cash (including cash dividends on stock) to the extent it does not exceed $2,000 per individual per year.

Verification: (not all inclusive)

- Copy of check - Documents from the agency paying benefits

ALIMONY

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable

Payments from an ex-spouse.

Verification: (not all inclusive)

- Court Ordered Decree - Copy of check or money order

ANNUAL LEAVE

1. Earned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable

Income from the employer for annual leave time.

Verification: (not all inclusive)

- Form 2074 “Earnings Verification” - Paycheck stubs - Signed and dated statement from employer

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INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-3003 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 14 Mar 01 MTL 14/01

ANNUITIES

1. Earned or Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable Income from annuities which were purchased with an employee’s funds are earned income.

Other annuities purchased through a bank or insurance company are unearned income. These payments may continue for a fixed period of time or for as long as the individual lives.

Verification: (not all inclusive)

- Copy of check - Documents from the agency paying benefits

ASSISTANCE BASED ON NEED

1. Unearned

2. Excluded in Financial

3. Counted in Patient Liability

4. Non-Taxable Any assistance from government agencies which is intended to supplement needs, and is NOT federally funded. Including, but not limited to: Family Preservation Program.

Verification: (not all inclusive)

- Copy of check - Documents from the agency paying benefits

AUSTRIAN SOCIAL INSURANCE PAYMENTS

1. Unearned

2. Excluded in Financial

3. Excluded in Patient Liability

4. Taxable Austrian Social Insurance payments based, in whole or in part, on wage credits granted under Paragraphs 500-506 of the Austrian General Social Insurance Act.

Interest earned on these payments is counted as income.

Verification: (not all inclusive)

- Copy of check - Documents from the agency paying benefits

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INCOME TYPE DESCRIPTION

E-3004 Division of Welfare and Supportive Services TYPES OF EARNED AND UNEARNED INCOME Medical Assistance Manual

16 Nov 01 MTL 05/16 AWARDS

1. Unearned

2. Excluded in Financial

3. Excluded in Patient Liability

4. Taxable An award is usually something received as the result of a decision by a court, board of arbitration, or the like.

Subtract essential expenses incurred in obtaining the payment, such as legal and medical expenses. Deduct from the first and any subsequent amounts of related income until all expenses have been eliminated. Deduct even those verified expenses which the recipient has previously paid, as long as the expenses are essential. If an expense has been incurred but not paid, assume the individual will pay the expense unless you have reason to question the situation.

Verification: (not all inclusive)

-Copy of bills or receipts BANK ACCOUNTS Checking, Savings, Time Certificates, Money Markets Certificates of Deposit (CD)

1. Earned/Unearned

2. Counted/excluded in Financial or Patient Liability-Varies by income type

3. Taxable

Refer to Individual Development Account (IDA) section for consideration of funds deposited and interest earned on funds in an IDA savings account.

Money deposited to a bank account is considered income in the month it is deposited. (Then considered a resource beginning with the month following the month it is deposited.)

Exception: In determining patient liability for spousal impoverishment cases only, income the payor designates as the client’s is budgeted. Income of the other joint holder(s) (i.e., the spouse or anyone else) deposited into the account is not considered the client’s income.

A. Sole Ownership

The client is designated as owner of the account, ALL the deposits are the client’s income.

Deposits made for another individual for the intent purpose of disbursing those funds on behalf of the individual are not considered income.

The client must provide proof deposits are made and used on behalf of another individual.

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INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-3005 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 14 Mar 01 MTL 14/01

BANK ACCOUNTS (Cont’d)

B. Shared Ownership (joint account)

Account holders are: - married couples - parent and minor child

When deeming applies in determining eligibility for the coverage group (e.g., Public Laws, institutional less than 30 days, etc.), rebutting ownership is NOT REQUIRED because deeming income takes precedence.

Account holders are not: - married couples - parent and minor child

All deposits to the account will be presumed available to the client unless the client can successfully prove all or part of the funds are not his/hers. Exception: when the client is acting as an agent for the other account holder(s).

If a bank account is owned jointly by more than one TANF/SSI/Medicaid applicant/recipient, any income deposited into the account is considered income to the person who is named payee by the source of payment. If more than one person is named payee, divide the amount equally among those named by the payment source.

Inform the individual: (using Form-2614) 1. The deposits in the account belong to the applicant/recipient. 2. The implications are: All deposits are countable income when determining Medicaid eligibility. 3. Of his/her right to provide evidence re-butting the ownership if he/she disagrees.

If an account holder is a minor or incompetent, at least one account holder and a third party who has knowledge of the circumstances surrounding the establishment of the joint account must complete the form.

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INCOME TYPE DESCRIPTION

E-3006 Division of Welfare and Supportive Services TYPES OF EARNED AND UNEARNED INCOME Medical Assistance Manual

14 Mar 01 MTL 14/01 BANK ACCOUNTS (Cont’d)

If the client does not complete and return Form 2614 by the specified date, deny or terminate the case for failure to cooperate.

C. Court Order Designating Income

A copy of the order must be sent with a request to the Chief of Eligibility and Payments for a determination of availability.

When deeming does not apply (e.g., home based waivers, institutionalized at least 30 days, etc.), verify who owns the funds deposited in the account. Once the ownership of funds is known, only the income verified to be the client’s is used in determining financial eligibility and patient liability.

D. Court Order/Written Agreement

If a written agreement or court order designates ownership of the joint account to either spouse, the account will be considered the resource of that spouse. Deposits made or interest posted will be considered income to that spouse. Disproving ownership does not apply.

E. Equal Division of Income

If an equal division of TOTAL community income has been applied, consider only the one-half portion as income to the client in determining financial eligibility. Disproving ownership does not apply.

F. Client Chooses Not to Disprove Ownership (Form 2614 completed and in Case Record)

- All deposits are countable income when determining eligibility and patient liabilityer

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INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-3007 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 14 Mar 01 MTL 14/01 BANK ACCOUNTS (Cont’d)

G. Disproving Ownership

If an individual wishes to disprove ownership, obtain his or her statement on Form 2615: ● who owns the funds;

● why there is a joint account; ● who has made deposits to and withdrawals from the account; and

● how withdrawals have been spent.

A copy of a financial institution record such as a passbook, or bank statements which show the deposits, withdrawals, and interest for the period of time they are rebutting ownership. Proof of deposits, source of deposits, withdrawals, and how withdrawals were spent is required.

Any unidentified deposits, deposits identified as the client’s income and all withdrawals made by the client in excess of his/her own income, will be considered the client’s income in that month.

Vendor payments made on behalf of the client by the other account holder and loans made by the account holder to the client are not considered the client’s income.

The client has successfully disproved ownership when proof from the financial institution shows: 1) the client’s name has been removed from the joint account; OR 2) access to the account has been restricted and the funds are not available to the client; OR 3) the account has been changed so only the client’s money is in the account.

If the client can show they are in the process of removing their name from the account, but the action cannot be completed for a time due to a specified reason, the client has successfully disproved ownership. The case should be future actioned to verify the account was closed/name removed.

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INCOME TYPE DESCRIPTION

E-3008 Division of Welfare and Supportive Services TYPES OF EARNED AND UNEARNED INCOME Medical Assistance Manual

16 Nov 01 MTL 05/16 BANK ACCOUNTS (Cont’d)

Example: Client applies June 30 and wishes to disprove ownership of a joint checking account. On July 10, the statements made by the account holders report in June and July $800 of the money in the account was the client’s funds. Verification of deposits substantiate their statement and there is proof the joint account is closed. When looking at the withdrawals from this account, however, the client actually used $1,000 in the month of JuneBecause the client has shown a portion of the funds were not his in June and has closed the account, he has successfully disproved ownership. However, in the month of June the evidence shows he used $200 more than his portion of the fund. Therefore, in June, $200 will be counted as income to the client when determining eligibility and patient liability.

In cases where the client did not successfully disprove ownership, notify the client in writing that ownership was not disproved and explain how income and resources are being evaluated.

H. Client Does Not Disprove Ownership

All deposits are countable income when determining eligibility and patient liability.

BLOOD DONATIONS

1. Unearned

2. Excluded in Financial (Conditional)

3. Counted in Patient Liability

4. Taxable Income received from donating blood.

Depending on the circumstance and/or amount of income received, the individual may not be required to claim the income on their taxes. If the individual reports this type of income on their application, then the income is counted in the MAGI budgeting.

Verification (not all inclusive)

- Documents from the source of payment

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INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-3009 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 14 Mar 01 MTL 14/01 BONUS

1. Earned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable

Bonuses paid by the employer.

Verification: (not all inclusive)

- Copy of check - Statement from employer CAPITAL GAINS

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable The profit that results from the sale of an asset when the amount realized from the sale exceeds the purchase price. The gain is the difference between the higher selling price and the lower purchase price.

CASH CONTRIBUTIONS

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable Money received which is NOT determined to be a cash gift for holidays. If the amount is $20 or less, see INFREQUENT AND IRREGULAR INCOME for possible exclusions.

Verification: (not all inclusive)

- Statement from the source of payment

CENSUS INCOME

1. Earned

2. Excluded in Financial

3. Excluded in Patient Liability

4. Taxable

Income received from working for the decennial census is exempt from the eligibility and post- eligibility process for all applicants applying for medical assistance.

Verification: (not all inclusive)

- Documents from the source of payment

CHILD SUPPORT

1. Unearned

2. Excluded in Financial (1/3)

3. Counted in Patient Liability

4. Non-Taxable MAABD Budgeting: Child support paid to or on behalf of a child by an absent parent or stepparent shall be considered income to the child for which it is paid. However, one-third (1/3) of the support will be excluded in financial eligibility only. The full payment will be counted when determining patient liability.

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INCOME TYPE DESCRIPTION

E-30010 Division of Welfare and Supportive Services TYPES OF EARNED AND UNEARNED INCOME Medical Assistance Manual

16 Jan 01 MTL 01/16 CHILD SUPPORT (Cont’d)

Child support arrears paid to the parent after the child turns 18 shall be considered income to the parent. Verification: (not all inclusive) - Copy of court order or check - Client’s statement

CIVIL SERVICE ANNUITIES (CSA)

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable If the client has been a federal government employee or is the widow/widower or dependent child (under 18) of a deceased federal employee, Civil Service retirement or disability may be available. Cost-of-living increases usually occur effective March, reflected on April checks.

Verification: (not all inclusive)

- Copy of award letter - Copy of disallowance letter CLERGY INCOME

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable

Offerings and fees received for marriages, baptisms, funerals, masses, etc. in addition to salary, is counted as income. Offerings made directly to the religious institution are non-taxable to the client and not counted as income. Members of a religious organization that give their outside earnings to the organization must still include the earnings in their income.

Verification: (not all inclusive) - Copy of paycheck stubs - Copy of ledger sheets receipts and/or income tax records (if self-employed) - Schedule SE (Form 1040 if self- employed)

Ministerial Business Expenses as an Employee: The employee must itemize deductions on Schedule A (Form 1040) to claim allowable deductions for ministerial trade or business expenses incurred while working as an employee. Employees must also file Form 2106, Employee Business Expenses (or Form 2106-EZ, Unreimbursed Employee Business Expenses).

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INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-30011 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 16 Jan 01 MTL 01/16

CLERGY HOUSING

1. Earned (if self-employed)

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable (if self-employed)

Include the rental value of the home or the housing allowance as earnings from self-employment on Schedule SE (Form 1040), Self-Employment Tax, if the individual is subject to self-employment tax.

Verification:

- Copy of ledger sheets receipts and/or income tax records

- Schedule SE (form 1040)

Note: The rental value of a home (including utilities) or a designated housing allowance is not counted as income if the individual is not self- employed. The exclusion cannot be more than reasonable pay for services and the home or allowance must be provided as compensation for services as an ordained, licensed, or commissioned minister.

COMMUNITY SPOUSE MONTHLY INCOME ALLOWANCE

1. Unearned

2. Counted in Financial

3. Non-Taxable Income allocated to the community spouse for maintenance as required by the spousal impoverishment provisions. The case manager must advise the community spouse how this additional income allowance will affect other public assistance benefits such as SSI, QMB or SNAP.

Verification: (not all inclusive)

- Patient liability deduction amount from institutionalized spouse’s case

COMPENSATION FOR INJURY OR SICKNESS

1. Unearned

2. Counted in Financial

3. Non-Taxable (Conditional) Any assignment of a liability to make periodic payments as damages or as compensation on account of personal injury or sickness.

If the employee paid the entire cost of the accident or health plan, do not include any amounts received from the plan for personal injury as income.

MAGI – Payments received for damages as Qualified assignments are non-taxable. Any portion of the payment that is not for damages, including punitive damages, is taxable.

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INCOME TYPE DESCRIPTION

E-30012 Division of Welfare and Supportive Services TYPES OF EARNED AND UNEARNED INCOME Medical Assistance Manual

17 Jul 01 MTL 04/17 COST OF LIVING ADJUSTMENT “COLA” (RSDI ONLY)

1. Unearned

2. Excluded in Financial

3. Counted in Patient Liability

4. Taxable For QMB/SLMB/QDWI coverage, the annual cost- of-living increase for RSDI benefits must be disregarded from January through March each calendar year. Effective April, the RSDI COLA is then compared to the new poverty income limit. The same disregard is applied to a spouse’s RSDI for comparison to the couple limit.

Verification: (not all inclusive)

- SSA Benefit letter or SOLQ

CROWDFUNDING ACCOUNTS

1. Earned

2. Included in Financial (Conditional)

3. Counted in Patient Liability (Conditional)

4. Taxable (Conditional)

Crowdfunding websites such as GoFundMe, Kickstarter, and Indiegogo are online platforms that allow individual donors to fund specific campaigns such as charity, individuals in need, research projects, and business ventures.

How these funds are treated for MAGI purposes depends on the reason the funds are being donated/provided. Some examples include:

1. Funds being raised to help an individual pay for personal/medical expenses. • Donors to this campaign intend for their contributions to be used as a gift or donation and are not expecting any return. Funds are not countable in MAGI budgeting.

2. Funds being raised by an individual to support a website or other business with no advertisers. The contributions are solicited to allow the individual to continue working. • Donors to this campaign are expecting something in return. Funds contributed are countable in MAGI budgeting.

3. Funds being raised to support research into a new invention or product development in exchange for a percentage of revenue from that invention or product upon completion.

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INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-30013 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 17 Sep 01 MTL 05/17 CROWDFUNDING ACCOUNTS (Cont’d) • Donors to this campaign would be considered investors contributing to capital. Contributions to capital are not taxable and considered equity interest for investment. Not Countable in MAGI budgeting.

Verification: (not all inclusive) - Documents from the source of payment

DEATH BENEFITS

1. Unearned

2. Counted/Excluded in Financial or Patient Liability Varies by Income Type

3. Non-taxable with exception A Death Benefit is money a client receives as the result of another’s death. These benefits include the following: - Proceeds of life insurance policies received due to the death of the insured; - Lump Sum Death Benefits from Social Security; - Railroad burial benefits; - VA burial benefits; - Cash inheritances; - Cash gifts from relatives, friends, or a community group to “help out” with expenses related to the death. NOTE: Recurring survivor benefits such as those received from Social Security, private pension programs, etc., are not death benefits.

Death benefits received by the client are income to the client in the month received, except for any portion the client verifies was used for the expenses of the deceased person’s last illness and/or burial.

Last illness and burial expenses include but are not limited to: related hospital and medical expenses, funeral, burial plot, and interment expenses, and other related expenses. Other related expenses include but are not limited to: new clothing to wear to the funeral, food for visiting relatives, taxi fare to and from the hospital and funeral home, etc.

Any portion of the Death Benefits which is left after deducting these expenses is counted as income in the month of receipt.

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INCOME TYPE DESCRIPTION

E-30014 Division of Welfare and Supportive Services TYPES OF EARNED AND UNEARNED INCOME Medical Assistance Manual

17 Sep 01 MTL 05/17 DEATH BENEFITS (Cont’d)

MAGI Exception: Interest earned on payments received via installment (i.e. Annually, Quarterly, Monthly, etc.) are taxable and countable in MAGI budgeting. (see income type INTEREST/DIVIDENDS.

Verification: ( not all inclusive)

- Copy of life insurance - Award letter from SSA, RR, VA - Copy of Will - Statements from individuals giving money to the client - Bills and/or receipts - Contact with provider DISABILITY

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable Benefits for disability received from a business, agency or organization.

Verification: (not all inclusive)

- Statement from agency or business establishment. - Form 2339 DISMISSAL PAY

1. Earned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable Final pay from an employer.

Verification: (not all inclusive)

- Copy of check - Statement from the employer, Form 2074 EARNINGS

1. Earned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable Income received through employment and/or tips.

Verification: (not all inclusive)

- Copy of check - Tip records - Statement from employer, Form 2074

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INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-30015 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 17 Sep 01 MTL 05/17 EARNINGS (workshop)

1. Earned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable Wages from workshops or work activity centers such as WARC, ALPHA Industries, FAST, Opportunity Village and NAAH.

Verification: (not all inclusive)

- Copy of check - Statement from employer, Form 2074 EDUCATIONAL ASSISTANCE

1. Earned/Unearned

2. Excluded in Financial (Conditional)

3. Excluded in Patient Liability (Conditional)

4. Non-Taxable (Conditional)

Educational assistance is provided in many forms i.e., Scholarships, Fellowships, Need-Based Education Grants (Pell Grant and Qualified Tuition Reductions). Student Loans are not included in educational assistance. (See income type “LOANS”).

For Medicaid budgeting, treatment will vary depending on the source and use of the assistance.

Educational assistance from the following sources are exempt for all medical programs: Bureau of Indian Affairs, Title IV Assistance (Work-study, Pell grant), AmeriCorps State and National, AmeriCorps NCCC, and Nevada’s Millennium Scholarship.

VA Educational benefits are non-taxable and exempt in MAGI budgeting.

Other non-exempt educational assistance used for educational expenses are excluded from income. Educational expenses include tuition, books, lab fees, student fees, supplies and equipment.

Any non-exempt assistance remaining after deducting the allowable educational expenses or which is used only for daily living expenses can be counted as income.

NOTE: Deduct allowable educational expenses from the total of all remaining non-exempt educational assistance received by the individual.

Expenses that DO NOT qualify include: room and board, travel, research, clerical help or equipment not required for enrollment or class attendance.

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INCOME TYPE DESCRIPTION

E-30016 Division of Welfare and Supportive Services TYPES OF EARNED AND UNEARNED INCOME Medical Assistance Manual

23 Oct 01 MTL 04/23 EDUCATIONAL ASSISTANCE (Cont’d)

Verification: (not all inclusive)

- Copy of documents from source of payment. - Form 2020 - Receipt of educational expenses. EMERGENCY ENERGY CONSERVATION SERVICE AND ENERGY CRISIS ASSISTANCE PROGRAM

1. Unearned

2. Excluded in Financial

3. Counted in Patient Liability

4. Non-Taxable Energy assistance payments to needy persons.

Verification: (not all inclusive)

- Statement from the source of payment EMPLOYERS INSURANCE COMPANY OF NEVADA (EICON)

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable

Nevada disability program benefits to employees

Verification: (not all inclusive)

- Copy of check - Copy of award or denial letter FAMILY PRESERVATION PROGRAM

See income type “Assistance Based on Need”

FEDERAL EMERGENCY MANAGEMENT ADMIN.

1. Unearned

2. Excluded in Financial

3. Counted in Patient Liability

4. Non-Taxable Funds for disaster relief, or comparable assistance provided by states, local governments (FEMA) or private disaster assistance organizations pursuant to Section 312 of the Stafford Act.

Verification: (not all inclusive)

- Client statement

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INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-30017 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 17 Sep 01 MTL 05/17 FEDERAL TAX REFUNDS

1. Excluded in Financial

2. Excluded in Patient Liability

3. Non-Taxable Funds received December 31, 2009 or later, either as an advance or as a refund regardless of the tax year involved are excluded for a period of 12 months.

Verification: (not all inclusive)

- Copy of check - Copy of client’s tax forms

FOSTER CARE PAYMENTS See income type “Assistance Based on Need” GAMBLING WINNINGS

1. Unearned

2. Excluded in Financial (Conditional)

3. Counted in Patient Liability

4. Taxable

Income received from gambling winnings.

NON-MAGI: Evaluate gambling winnings under irregular and infrequent income rules. If not irregular or infrequent count in financial.

MAGI: Gambling winnings are taxable income.

Verification:

- Client statement - Statement from casino paying proceeds

GENERAL ASSISTANCE

See income type “Assistance Based on Need”

GIFTS GIVEN AWAY BY THE HOUSEHOLD (GIFTOR)

1. Taxable/Non-Taxable

2. $14,000 Annual allowance per Giftee

Any gift of money or property given away by the giftor to an individual, either directly or indirectly, where an equal exchange (in Money or Fair Market Value) is not received in return. This may include money given for special occasions (e.g., Christmas, birthdays, anniversary, etc.)

Gifts are evaluated per recipient. Each individual gift made is compared to the annual allowance. Gifts made that are $14,000 or less is non-taxable. A gift that exceeds the annual allowance of $14,000 is taxable and countable in the annualized income of the giftor.

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INCOME TYPE DESCRIPTION

E-30018 Division of Welfare and Supportive Services TYPES OF EARNED AND UNEARNED INCOME Medical Assistance Manual

17 Sep 01 MTL 05/17

GIFTS GIVEN AWAY BY THE HOUSEHOLD (GIFTOR) (Cont’d)

Fair Market Value: The fair market value is the price at which the property would change hands between a willing buyer and a willing seller.

MAGI Exception: Gifts given away by a giftor are taxable unless a valid arrangement has been made with the Giftee to pay the taxes on the gift.

Verification: (not all inclusive)

- Statement from the person receiving the gift - Copy of appraisal - Form 2506

GIFTS RECEIVED BY THE HOUSEHOLD (GIFTEE)

1. Unearned

2. Excluded in Financial

3. Counted in Patient Liability

4. Non-Taxable with exception Any gift of money or property received by the giftee, either directly or indirectly, where an equal exchange (in Money or Fair Market Value) is not received in return. This may include money received for special occasions (e.g., Christmas, birthdays, anniversary, etc.).

Fair Market Value: The fair market value is the price at which the property would change hands between a willing buyer and a willing seller.

MAGI Exceptions: Gifts received by an individual are taxable only if the individual has a valid arrangement with the giftor to pay the taxes on the gift.

Verification: (not all inclusive)

- Statement from the person giving the gift - Copy of appraisal - Form 2506

HOLIDAY PAY

1. Earned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable Employer paid holiday pay.

Verification: (not all inclusive)

- Copy of pay check - Statement from Employer, Form 2074

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INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-30019 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 14 Mar 01 MTL 14/01

HOUSING and URBAN DEVELOPMENT (HUD)

1. Unearned

2. Excluded in Financial

3. Counted in Patient Liability

4. Non-Taxable Subsidized housing assistance. Provided by HUD.

Verification: (not all inclusive)

- Copy of check - Statement from HUD

INDIAN GENERAL ASSISTANCE (IGA)

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Non-Taxable

Federal payments to needy American Indians.

Verification: (not all inclusive)

- Copy of check or award letter INDIAN MONIES

1. Unearned

2. Excluded in Financial

3. Counted in Patient Liability

4. Non-Taxable Judgment funds received by members of an Indian tribe and per capita payments made under Public Law.

Per capita payment made under Public Law 108- 270 “Western Shoshone Claims Distribution Act” is exempt in Patient Liability.

Verification: (not all inclusive)

- Copy of check or award letter

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INCOME TYPE DESCRIPTION

E-30020 Division of Welfare and Supportive Services TYPES OF EARNED AND UNEARNED INCOME Medical Assistance Manual

14 Mar 01 MTL 14/01 INDIAN TRUSTS OR RESTRICTED LANDS

1. Unearned

2. Excluded in Financial

3. Counted in Patient Liability

4. Non-Taxable This income (often called individual Indian trust or lease income) generally comes from interests in lands that were allotted to individual Indians many years ago.

Effective January 1, 1994, up to $2,000 per year in payments derived from individual interests in Indian trust or restricted lands is excluded from income.

MAGI – exclude all income received from interest in Indian lands.

Verification: (not all inclusive)

- Statement from the source of payment

INDIVIDUAL DEVELOPMENT ACCOUNT (IDA)

1. Earned/Unearned

2. Excluded in Financial

3. Excluded in Patient Liability

3. Non-Taxable Intended to improve the economic independence and stability of individuals and families and to promote and support the transition to economic self-sufficiency. An IDA participant can only deposit earned income into an IDA. Federal funds match the amount of earnings low-income working individuals and families deposit into an IDA. IDA savings are to be used for a first home purchase, post-secondary educational expenses, or business capitalization.

The Social Security Act provides for State Family Assistance Grant funds (i.e., TANF, WtW) to be used to establish IDA. The Assets for Independence Act (AFIA) provides for IDAs to be established under Head Start, Low Income Home Energy Assistance (LIHEA), and Community Services.

Income in an IDA includes:

- Participant contribution (earned income); - Interest earned on participant earned income contributions; - Matching funds; and - Interest accrued on matching funds.

Note: Count the participant’s gross earned income MINUS the participant’s contribution amount. An individual, whose participation in the IDA program has terminated, voluntarily or otherwise, is no longer covered by the income exclusion.

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INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-30021 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 14 Mar 01 MTL 14/01 INFREQUENT AND IRREGULAR INCOME

1. Earned/Unearned

2. Excluded in Financial

3. Counted in Patient Liability

4. If infrequent or irregular, exclude first $30 per calendar quarter of earned income; and first $60 per calendar quarter of unearned income.

5. $10 per month of earned income; and $20 per month of unearned income.

6. Non-Taxable

Income excluded which is received either infrequently or irregularly.

Irregular income is considered received if an individual cannot reasonably expect to receive it.

Beginning September 8, 2006, income is considered infrequent if received only once during a calendar quarter from a single source and the individual did not receive it in the month immediately preceding that month or in the month immediately subsequent to that month, regardless of whether or not these payments occur in different calendar quarter.

Verification: (not all inclusive)

- Type, amount, frequency, or predictability of income. - Copy of check - Document from source of payment

IN-KIND WAGES

1. Earned

2. Counted in Financial

3. Counted in Patient Liability

4. Non-Taxable

The value of goods or services given to the client for work performed instead of cash payment.

Verification: (not all inclusive)

- Statement from employer

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INCOME TYPE DESCRIPTION

E-30022 Division of Welfare and Supportive Services TYPES OF EARNED AND UNEARNED INCOME Medical Assistance Manual 14 Mar 01 MTL 14/01 INTEREST/DIVIDENDS

1. Unearned

2. Counted in Financial

(Conditional)

3. Counted in Patient Liability

(Conditional)

4. Taxable Accrued interest and dividend payments are excluded in financial eligibility when posted quarterly, semi-annually or annually from a single source. For example: Insurance is one source; banking is one source; burial is one source; bonds are one source; Reparation payments are one source. Interest is counted as income for patient liability when the amount posted is $5 or more in any month.

Interest and dividends paid monthly are counted in financial eligibility and patient liability.

MAGI: Include any tax exempt interest received in assistance unit income.

Verification: (not all inclusive)

- Current bank statement - Computer printout from bank - Written statement from the bank IRA WITHDRAW/DISTRIBUTION

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable (Conditional) Individuals can receive one time or scheduled distributions from their IRA account. If an early withdrawal is taken, reduce the gross amount by any penalty paid.

MAABD – Evaluate the IRA account as an available resource prior to the income determination.

Distributions from a regular IRA account are taxable.

Distributions from a ROTH IRA are non-taxable income.

JOB CORP

1. Earned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable Paid from the Economic Opportunity Act.

Verification: (not all inclusive)

- Copy of check or award letter

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INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-30023 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 16 Nov 01 MTL 05/16 JUDGMENTS

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable

Any money paid to an employee from a judgment resulting from legal action for wages.

Verification: (not all inclusive)

- Copy of Judgment JURY DUTY COMPENSATION

1. Unearned

2. Excluded in Financial (Conditional)

3. Counted in Patient Liability

4. Taxable

Income earned from serving jury duty.

Verification: (not all inclusive)

- Documents from the source of payment LEASE/RENTAL INCOME

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable Gross lease income less expenses. Lease expenses may include interest on mortgage, property taxes, maintenance/repair costs, insurance on structure, advertising and utilities when paid by the landlord. Lease expenses do NOT include the amount of a mortgage applied toward the principal balance of the loan.

Verification: (not all inclusive)

- Copy of receipt book - Copy of check or money order - Tenant’s statement of payment - Proof of operating expenses

LIFE INSURANCE PAYMENTS

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable Accelerated life insurance payments are proceeds paid to a policy holder PRIOR to death. These payments are income in the month received and a resource if retained into the following month.

Verification: (not all inclusive)

- Insurance policy - Form 2015 from insurance company - Written statement from insurance company

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INCOME TYPE DESCRIPTION

E-30024 Division of Welfare and Supportive Services TYPES OF EARNED AND UNEARNED INCOME Medical Assistance Manual

17 Jul 01 MTL 04/17 LOANS

1. Unearned

2. Excluded in Financial

3. Excluded in Patient Liability

4. Non-Taxable Money a person borrows or money received as repayment of the principal of a loan is not counted.

If a loan is NOT bona fide (not legally valid and made in good faith), the proceeds are counted in the month received. Interest received is also counted the month received.

Verification: (not all inclusive)

- Client’s statement is acceptable - Form 2506 LONG TERM CARE INSURANCE

1. Unearned

2. Counted in Financial

(conditional)

3. Counted in Patient Liability

(conditional)

4. Taxable (Conditional) Long Term Care policies that pay directly to the facility should be considered a third party payment and not counted in financial eligibility or patient liability.

Long Term Care policies that pay directly to the recipient without restriction on use of funds are counted as income in financial eligibility and patient liability.

Long Term Care policies that pay directly to the recipient for reimbursement of care already paid for are considered third party payments and not counted in financial eligibility. These payments are counted in patient liability.

MAGI: Long Term Care payments received by individuals are excluded from MAGI budgeting only if the premiums for the insurance were paid for with after-tax dollars. If the insurance premiums are paid with pre-tax dollars or the insurance is provided by the employer, any payments received from this insurance becomes countable on MAGI.

Verification: (not all inclusive)

- Insurance policy - Form 2015 from insurance company - Written statement from insurance company

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INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-30025 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 14 Mar 01 MTL 14/01 LUMP SUM PAYMENTS

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

(not to exceed actual cost of

care)

4. Taxable Lump sum payments are considered income in the month received. Exception: SSI lump sum payments.

For retroactive Social Security Disability benefits which must be paid in installments due to the Drug Alcohol Addiction (DA&A) law, count the entire lump sum entitlement (sum of all installment payments) amount in the first month an installment payment is made.

Verification: (not all inclusive)

- Copy of check or money order - Legal documentation - Client’s sworn and dated statement - Documents from public agencies (SSA, SIIS, VA, etc.)

MEDICAL INSURANCE CASH PAYMENTS

1. Unearned

2. Excluded in Financial

3. Excluded in Patient Liability

4. Non-Taxable REIMBURSEMENT for medical costs paid by the client and medical insurance cash payments the client proves were applied toward medical bills.

Verification: (not all inclusive)

- Explanation of Benefits (EOB) from the insurance company - Receipts for medical payments

MEDICARE PREMIUM REIMBURSEMENTS

1. Unearned

2. Excluded in Financial

3. Excluded in Patient Liability

4. Non-Taxable Medicare reimbursements are exempt ONLY if the client paid the premium.

Verification: (not all inclusive)

- Copy of the check or award letter

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INCOME TYPE DESCRIPTION

E-30026 Division of Welfare and Supportive Services TYPES OF EARNED AND UNEARNED INCOME Medical Assistance Manual

14 Mar 01 MTL 14/01 MILITARY DEPENDENT ALLOTMENTS

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable Enlisted service individuals may make an allowance for dependents.

Verification: (not all inclusive)

- SSA Benefit Record - Written statement from Military Allotment Branch

MILITARY HOSTILE FIRE PAY

1. Unearned

2. Excluded in Financial

3. Counted in Patient Liability

4. Taxable

Hostile fire pay is a special type of pay to a service member who is:

- subject to hostile fire or explosion of hostile mines; or

- on duty in an area in which he/she is in imminent danger of being exposed to hostile fire or explosion of hostile mines, AND

- while on duty in that area, other service members in the same area are subject to hostile fire or explosion of hostile mines; or

- killed, injured, or wounded by hostile fire, explosion of a hostile mine, or any other hostile action.

Verification: (not all inclusive) - Copy of check - Documents from the source of payment

OLDER AMERICANS ACT

1. Earned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable The Federal Government through the Administration on Aging is involved in a variety of programs for older Americans. The programs may be operated by State or local governments or community organizations. Some program types include health and nutrition services, legal assistance and community service employment.

A wage or salary paid under Chapter 35 of Title 42 of the U.S. Code, the Older Americans Act is earned income.

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INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-30027 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 16 Nov 01 MTL 05/16

OLDER AMERICANS ACT (Cont'd)

Exception: Anything other than a wage or salary is excluded in financial eligibility and patient liability and non-taxable.

Verification: (not all inclusive)

- Copy of check - Documents from the source of payment

PANHANDLING

1. Unearned

2. Excluded in Financial

3. Counted in Patient Liability

4. Taxable

Income received from panhandling.

Verifications: (not all inclusive) - Documents from the source of payment

P.A.S.S.

1. Unearned

2. Excluded in Financial

3. Counted in Patient Liability

4. Taxable Income necessary to fulfill a Plan for Achieving Self-Support for BLIND and DISABLED indivi- duals. The plan must be an individual plan in writing and approved by Social Security.

Verification: (not all inclusive)

- Award letter from Social Security

PENSIONS

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable Benefits paid to a pensioner following retirement from employment. Any portion of a pension paid directly to the spouse per a divorce settlement is not countable toward the client for financial eligibility or patient liability. (Divorce settlement must have occurred prior to Medicaid application.)

Verification: (not all inclusive)

- Copy of check or award letter - Form 2339

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INCOME TYPE DESCRIPTION

E-30028 Division of Welfare and Supportive Services TYPES OF EARNED AND UNEARNED INCOME Medical Assistance Manual

14 Mar 01 MTL 14/01 PROFIT SHARING PLAN

1. Earned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable

Profit gained from shares owned in the business of employer.

Verification: (not all inclusive)

- Copy of financial statement or check PROMISSORY NOTES, FORMAL WRITTEN AGREEMENTS AND PROPERTY AGREEMENTS

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable If the note or agreement is determined to be a resource, that portion of any payment received representing payment on the principal is also a resource. The portion of any payment which represents interest on the principal is unearned income. If the note or agreement is determined NOT to be a resource, total payments received, whether principal and/or interest, are unearned income.

Verification: (not all inclusive)

- Copy of the Note or Agreement

PUBLIC EMPLOYEES RETIREMENT (PERS)

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable If the client has been a public employee or is the widow/widower or dependent child (under 18) of a deceased public employee, retirement, survivors, or disability benefits may be available.

Verification: (not all inclusive)

- Copy of Award letter or Form 2339 - SSA Benefit Record

PUBLIC LAW 92-336 (1972 RSDI DISREGARD)

1. Unearned

2. Excluded in Financial

3. Counted in Patient Liability Disregard the amount of the October 1972 twenty percent (20%) RSDI increase.

Verification: (not all inclusive)

- Copy of Check or Award Letter - Statement from SSA

(e-300)(page-29)Page 29#

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INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-30029 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 16 Nov 01 MTL 05/16 RADIATION EXPOSURE PAYMENTS

1. Unearned

2. Excluded in Financial

3. Excluded in Patient Liability

4. Non-taxable

Payments made under the Radiation Exposure Compensation Act.

Verification: (not all inclusive)

- Documents from the source payment RAILROAD RETIREMENT BENEFITS

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable Persons who may be eligible must apply to the Railroad Retirement Board District Office. Cost-of- living increases usually occur effective December, reflected on January checks.

Verification: (not all inclusive)

- Copy of Award Letter - SSA Benefit Record - Form 2339

RECYCLING

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable Income received from collecting recyclable goods.

Verification: (not all inclusive)

- Documents from the source payment

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INCOME TYPE DESCRIPTION

E-30030 Division of Welfare and Supportive Services TYPES OF EARNED AND UNEARNED INCOME Medical Assistance Manual

18 Jan 01 MTL 01/18 REFUGEE CASH ASSISTANCE (RCA) PAYMENTS

1. Unearned

2. Excluded in Financial

3. Counted in Patient Liability

4. Non-Taxable Refuge Cash Assistance (RCA) is a state funded, employment based cash assistance program. RCA is for clients who are not eligible for assistance under the Temporary Assistance for Needy Families (TANF) program. Assistance is available for the first eight months after arrival in the United States.

See “Assistance Based on Need”

Verification: (not all inclusive)

- Documents from the source of payment

REFUND ON TAXES

1. Unearned

2. Excluded in Financial

3. Counted in Patient Liability

4. Non-Taxable Taxes refunded to the client from the federal or state government.

Verification: (not all inclusive)

- Documents from the source of payment

REIMBURSEMENTS; REFUNDS FOR DEPOSITS AND OVERCHARGES

1. Unearned

2. Excluded in Financial

3. Excluded in Patient Liability

4. Non-Taxable Reimbursements, deposits and overcharges refunded to the client from any source.

Verification: (not all inclusive)

- Documents from the source of payment

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INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-30031 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 16 Nov 01 MTL 05/16 RELOCATION ASSISTANCE

1. Unearned

2. Excluded in Financial

3. Counted in Patient Liability

4. Non-Taxable Assistance provided under TITLE II of the UNIFORM RELOCATION ASSISTANCE and REAL PROPERTY ACQUISITIONS POLICIES ACT of 1970 from a federal or federally-assisted project.

RELOCATION AS provided by a state or local government or through a state-assisted or locally- assisted project is excluded effective May 1, 1991.

Verification: (not all inclusive)

- Copy of check or award letter

ROOMER/BOARDER INCOME

1. Unearned

2. Counted in Financial 3. Counted in Patient Liability 4. Taxable

Applicants must own or be purchasing the property to consider “roomer/boarder income.” When all household members are renting a single dwelling, it is considered shared expenses, not roomer/boarder income.

When a recipient receives contributions for shared expenses that exceed the household’s total expenses, the excess is considered unearned income to the recipient.

Roomer/Boarder income is determined by using gross room/board amount less actual rental expenses. Expenses may include interest on mortgage, property taxes, maintenance/repair costs, insurance on structure, advertising and utilities when paid by the landlord.

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INCOME TYPE DESCRIPTION

E-30032 Division of Welfare and Supportive Services TYPES OF EARNED AND UNEARNED INCOME Medical Assistance Manual

16 Nov 01 MTL 05/16 ROOMER/BOARDER INCOME (Cont'd)

Expenses are prorated in roomer/boarder situations. Prorate expenses based on the number of rooms designated for rent compared to the number of rooms in the house (do not count bathrooms, basements and attics).

Verification: (not all inclusive)

- Copy of receipt book, check (money order), tenants’ statement of payment or proof of operating expenses.

REPARATION PAYMENTS

1. Unearned

2. Excluded in Financial

3. Excluded in Patient Liability

4. Non-Taxable REPARATION PAYMENTS from the FEDERAL REPUBLIC OF GERMANY received on or after 11/1/84.

WAR REPARATIONS paid under the AUSTRIAN government pension system. However, any interest earned on these payments is countable income.

REPARATION PAYMENTS issued to JAPANESE INTERNEES (EXCEPT INTEREST) and ALEUTS pursuant to Public Law 100-383. However, any interest earned on these payments is countable income.

Verification: (not all inclusive)

- Award letter or copy of check

REPLACEMENT/REPAIR DESTROYED OR DAMAGED PROPERTY

1. Unearned

2. Excluded in Financial

3. Excluded in Patient Liability

4. Non-Taxable The amount of money received for replacement or repair of lost, destroyed, damaged or stolen resources is considered a change in type of resource and is not counted as income.

Verification: (not all inclusive)

- Copy of check - Documents from source of payment - Receipts for expenses

(e-300)(page-33)Page 33#

MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL

INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-30033 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 17 Jul 01 MTL 04/17 RETIRED SENIOR VOLUNTEER (RSVP)

1. Unearned

2. Excluded in Financial

3. Excluded in Patient Liability

4. Non-Taxable Stipends received for services rendered.

Verification: (not all inclusive)

- Copy of check - Documents from source of payment

RETIREMENT PAY

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable Benefits paid to a retiree by the company they worked for:

Verification: (not all inclusive)

- Copy of check - Documents from source of payment

RETIREMENT, SURVIVORS, DISABILITY INSURANCE (RSDI)

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable (Conditional) Persons who may be eligible must apply at the local Social Security office. Budget the gross amount. Cost-of-living increases usually occur effective December, reflected on January checks.

MAGI: A Child or Tax Dependent’s RSDI income is excluded from MAGI budgeting unless their income meets certain qualifications or if they are the Primary Tax Filer. To determine if the Child or Tax dependent’s RSDI is countable proceed with the following test as listed on IRS Publication 915 Worksheet A (see appendix H).

Only the income of the individual child/tax dependent is used for this test.

MAGI RSDI Taxability Test: 1- Annualize the individual child or tax dependent’s gross RSDI income (pro-rate if received less than a full year). 2- Divide your annualized RSDI by 50% to determine the adjusted total. 3- Annualize any gross earnings, wages, etc. for the child/tax dependent and add to your adjusted total to get your adjusted income.

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL

INCOME TYPE DESCRIPTION

E-30034 Division of Welfare and Supportive Services TYPES OF EARNED AND UNEARNED INCOME Medical Assistance Manual

17 Jul 01 MTL 04/17

4- Annualize any taxable interest or dividends received by the child/tax dependent and add to your adjusted income to get a grand total. 5- Compare the grand total income to the IRS baseline of $25,000/single, or $32,000/married.

If the grand total is equal to or less than the baseline, none of the RSDI income for the child/tax dependent is countable for MAGI.

If the adjusted income is greater than the baseline, a second test must be completed using IRS Worksheet 1 (see appendix H).

Verification: (not all inclusive)

- Copy of award letter - Copy of disallowance letter - SSA Benefit Record - SOLQ - IRS Publication 915 – Worksheet A - IRS Worksheet 1

REVERSE MORTGAGES

1. Unearned

2. Excluded in Financial

3. Excluded in Patient Liability

4. Non-Taxable A reverse mortgage is a type of home equity loan, which allows a person to convert some of the equity in their home into cash while retaining home ownership.

Funds obtained from a reverse mortgage may be used for any purpose, including meeting housing expenses such as taxes, insurance, fuel, and maintenance costs.

The funds may be received in a lump sum, in monthly advances, through a line-of-credit or in a combination of distribution methods.

Depending on the agreement with the lender, the loan becomes due with interest when the individual moves, sells the home, dies, or reaches the end of the pre-selected loan term.

Verification: (not all inclusive)

- A copy of the reverse mortgage agreement with the lender - Documentation of the payments and source

(e-300)(page-35)Page 35#

MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL

INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-30035 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 16 Nov 01 MTL 05/16 ROYALTIES

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable

Income from copyrights on literary, musical, or artistic works, and similar property, or from patents on inventions, paid for the right to use the work over a specified period of time. Usually based on the number of units sold, such as the number of books, tickets, or machines sold.

Income from oil, gas, and mineral properties received when natural resources are extracted from an individual’s leased property. Based on units, such as barrels, tons, etc., and paid by the leasee.

Verification: (not all inclusive)

- Copy of check - Documents from source of payment

SELF-EMPLOYMENT WAGES - Wages - Business income

1. Earned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable Gross income from self-employment less expenses is self-employment wages.

Gross business income less all business operating costs is gross wages from self-employment.

The client is responsible for keeping all necessary records.

Verification: (not all inclusive)

- Copy of ledger sheets receipts and/or income tax records SENIOR COMPANION PROGRAM

1. Unearned

2. Excluded in Financial

3. Excluded in Patient Liability

4. Non-Taxable Stipends received for services rendered. (See also Action Programs)

Verification (not all inclusive)

- Copy of check - Documents from source of payment

(e-300)(page-36)Page 36#

MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL

INCOME TYPE DESCRIPTION

E-30036 Division of Welfare and Supportive Services TYPES OF EARNED AND UNEARNED INCOME Medical Assistance Manual

14 Mar 01 MTL 14/01 SEVERANCE PAY

1. Earned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable Final payment to employees laid off or terminated.

Verification: (not all inclusive)

- Copy of check stubs - Statement from employer, Form 2074 SICK PAY

1. Earned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable Employer paid sick leave.

Verification: (not all inclusive)

- Statement from employer, Form 2074 - Copy of paystub SPINA BIFIDA ALLOWANCES

1. Unearned

2. Excluded in Financial

3. Counted in Patient Liability

4. Non-Taxable Children of Vietnam veterans who are born with Spina Bifida are eligible to receive a monthly allowance ranging from $200 to $1,200 per month, effective October 1, 1997.

These payments are excluded from income and resources.

Verification: (not all inclusive)

- Documents from source of payment - Documents from the Veterans Administration or Department of Veterans Affairs

SPONSOR INCOME

1. Unearned

2. Excluded in Financial

3. Excluded in Patient Liability

4. Non-Taxable

The income of a non-citizen’s sponsor is not deemed in the Medicaid and NCU eligibility determination.

If the sponsor is providing a cash contribution to the household evaluate this amount under cash contribution.

(e-300)(page-37)Page 37#

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INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-30037 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 16 Nov 01 MTL 05/16 STUDENT/CHILD EARNED INCOME

1. Earned

2. Conditional Exclusion in

Financial

3. Counted in Patient Liability

4. Taxable- MAGI conditional exclusion MAABD Exclusion: If a child is under 22, not the head of a household, regularly attending school, and has never been married, exclude $1,730 per month not to exceed $6,960 per calendar year.

MAGI Exclusion: Child/tax dependent income is not counted in the tax payers assistance unit unless the child/tax dependent is required to file a tax return.

Earnings of a child/tax dependent are included in their own assistance unit when the child/tax dependent is not included in the same assistance unit as the parent/tax filer claiming them.

Verification: (not all inclusive)

- Copy of check, Form 2074 - School statement STRIKE BENEFITS

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable Income received from a union as strike or lockout benefits.

Verification:

- Copy of check - Statement from agency paying benefit SUPPLEMENTAL SECURITY INCOME (SSI)

1. Unearned

2. Excluded in Financial

3. Excluded in Patient Liability

4. Non-Taxable Benefits based on need for aged, blind and disabled individuals.

Verification: (not all inclusive)

- SOLQ - SSA Benefit Record - SDX - Copy of award or denial letter

See “Cost of Living Adjustments” (COLAs) for evaluating increases to SSI.

(e-300)(page-38)Page 38#

MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL

INCOME TYPE DESCRIPTION

E-30038 Division of Welfare and Supportive Services TYPES OF EARNED AND UNEARNED INCOME Medical Assistance Manual

14 Mar 01 MTL 14/01 SUPPORTED LIVING ARRANGEMENT (SLA)

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Non-Taxable Supported Living Arrangement (SLA) payments are funds authorized by state legislation to assist individuals with disabilities or mentally disabled SSI applicants/recipients so they can live in the community.

- exempt payments to or received on behalf of an SSI recipient, and - exempt payments for medical needs that are not paid by Medicaid.

Note: SLA vendor payments and reimbursements for receipted expenditures are not considered income. MH/MR may also refer to SLA as Supplemental Living Assistance; however, this is the same as Supported Living Arrangement. TANF/TRIBAL TANF

1.. Unearned

2. Excluded in Financial

3. Excluded in Patient Liability

4. Non-Taxable

Any cash and/or in-kind assistance provided by a governmental medical or social services program is not counted as income. TRIBAL GAMING INCOME

1. Count as unearned income

Conditional exclusion

2. Count in financial

3. Count in Patient Liability

4. Taxable

5. Exclude first $60 per calendar quarter

6. Exclude if does not exceed

$20 per month

Funds paid in a lump sum to an eligible tribal individual from tribal casino revenues. In month received, credited to individual’s account, or set aside for the individual’s use.

Between July 1, 2004 and September 7, 2006, infrequent income defined as income received no more than once in a calendar quarter from a single source.

(e-300)(page-39)Page 39#

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INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-30039 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 16 Nov 01 MTL 05/16 TRIBAL GAMING INCOME (Cont'd)

Prior to July 1, 2004, infrequent or irregular income is excluded provided the total does not exceed.

Verification: (not all inclusive)

- Type, amount, frequency, or predictability of income - Copy of check - Document from source of payment

(e-300)(page-40)Page 40#

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INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-30039 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 16 Nov 01 MTL 05/16 TRUST FUNDS

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable For the MAABD program, all trusts (other than minor blocked trusts) are referred to the Chief of Eligibility and Payments (E&P) for a legal evaluation. The case manager must obtain the trust document with all attachments to send with the request, using Form 6009.

For clients applying for or receiving Medicaid in a MAGI category, do not send trusts for evaluation. Verify if the client is receiving income from the trust, and count the income per the instructions in this section. This includes institutionalized individuals receiving Medicaid as a Childless Adult (CA).

Always refer trusts to the Chief of E&P when an individual receiving Medicaid in a MAGI category is to be converted to MAABD under the Institutional or Home-Based Waiver programs.

Trusts established prior to August 11, 1993 by an individual or the individual’s spouse, under which the individual is the recipient of all or part of any payments from the trust, are called Medicaid Qualifying Trusts (MQTs). MQT assets (income/ resources) are “deemed” available to the client

The following are types of payments from a trust fund: 1. Interest income as it becomes available, if the client has a right to the interest on the principal, whether or not the client is currently receiving it.

2. Payments from the trust which are being made to:

• The client; or • The representative/legal guardian of the client; or • A vendor on behalf of the client.

(e-300)(page-41)Page 41#

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INCOME TYPE DESCRIPTION

E-30040 Division of Welfare and Supportive Services TYPES OF EARNED AND UNEARNED INCOME Medical Assistance Manual

17 Mar 01 MTL 02/17

TRUST FUNDS (Cont’d)

3. Payments which are being or could be made to the client from a Medicaid Qualifying Trust.

The maximum payment which could be made

to the client will be counted whether it is being

paid or not.

Verification: (not all inclusive)

- Copy of trust document with all attachments - Copy of trust account ledgers - Statement from guardian - Memorandum from Chief of E&P

UBER/LYFT DRIVER WAGES - Wages - Business Income

1. Earned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable Uber/Lyft Drivers are required to keep detailed records of any mileage or expenses related to their business. Drivers are able to claim their actual costs, a percentage of their actual costs, or use a standard rate per business mile. Actual costs include car/lease payments, vehicular improvements, vehicle registration, etc. as it relates to the business usage of the Uber/Lyft vehicle. Verification must be provided. Drivers who use their vehicle for both business and personal transportation, may claim only a percentage of the actual costs as a deduction. This percentage is calculated as (business mileage/total mileage) used on the vehicle. Multiply this percentage to all verified actual costs to determine the allowable deduction. (Ex. Client provides proof they drove 1000 miles for Uber out of a total 2000 miles on their car. This calculates to 50% (1000/2000), allowing only 50% of the actual costs as a deduction). Non-car related expenses such as parking fees, tolls, meals, lodging, water, snacks, etc. that are attributable as business usage are an allowable deduction for Uber/Lyft drivers regardless of which expense option they claim.

(e-300)(page-42)Page 42#

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INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-30041 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 17 Mar 01 MTL 02/17 UBER/LYFT DRIVER WAGES (Cont’d)

Verification: (not all inclusive) - Copy of ledger sheets, receipts and /or income tax records - Uber/Lyft printouts on mileage usage UNIFORM GIFTS TO MINORS

1. Real/Personal Property

2. Conditional Exclusions Uniform Gifts to Minors Act permits gifts to minors which are free of tax burdens.

An individual (donor) makes an irrevocable gift of money or other property to a minor (the donee). The gift, plus any earnings it generates, is under the control of a custodian until the donee reaches the age of majority by state law (18 years for Nevada). The custodian has discretion to provide to the minor or spend for the minor’s support, maintenance, benefit or education, as much of the assets as he/she deems equitable. The donee automatically receives control of the assets upon reaching the age of majority.

The gift, including any additions or earnings, is not income to the donee.

The custodian’s disbursements to the donee are income to the minor. All property becomes available to the donee and subject to income rules in the month the donee reaches the age of majority. The month following the month of majority, the property is subject to resource evaluation.

Verification: (not all inclusive)

- Copy of the document of ownership, e.g., deed, CD, savings passbook, etc. UNEMPLOYMENT BENEFITS

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable Any unemployment benefits being received from Nevada or any other state.

Verification: (not all inclusive)

- ESD printout - Copy of check stub - Form 2339

(e-300)(page-43)Page 43#

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INCOME TYPE DESCRIPTION

E-30042 Division of Welfare and Supportive Services TYPES OF EARNED AND UNEARNED INCOME Medical Assistance Manual

14 Mar 01 MTL 14/01 VACATION PAY

1. Earned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable Income from employer for vacation time off.

Verification: (not all inclusive)

- Copy of check - Statement from employer, Form 2074 VENDOR PAYMENTS

1. Unearned

2. Excluded in Financial

3. Excluded in Patient Liability

4. Non-Taxable Payments made to business/organization on behalf of the client.

Verification: (not all inclusive)

- Statement from person making payment VETERAN’S BENEFITS

1. Unearned

Veteran’s benefits include the following types: (Benefit increases usually occur effective December, reflected on January checks.)

a. Counted in Financial & Patient Liability

b. Non-Taxable

VA Compensation for Service Connected Disability, DIC or VA Survivor benefits

a. Exclude UME first then count in Financial & Patient Liability

b. Taxable-excluding UME allowance

VA Pension – Pension to wartime veterans, a non- service-connected disability benefit, or a benefit to survivors of wartime veterans. Evaluate for UME using Form 2039 and the VA award letter which indicates medical expenses were used to determine benefit amounts.

a. Exclude in Financial & Patient Liability

b. Non-Taxable

Aid and Attendance or Housebound benefits are paid to certain veterans and/or widows(ers) of veterans when these persons are unable to fully care for themselves physically. The $90 reduced pension is considered Aid and Attendance benefits.

A reimbursement of Unusual Medical Expenses (UME) is paid to veterans and/or widow(ers) of veterans when they show their medical expenses exceeded 5% of the maximum annual VA payment rate. This payment could be made as a lump sum payment or be prorated over the next year and be a part of the regular monthly VA check.

(e-300)(page-44)Page 44#

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INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-30043 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 16 Nov 01 MTL 05/16 VETERAN’S BENEFITS (Cont’d)

a. Exclude in Financial & Patient Liability

b. Non-Taxable Verification: (not all inclusive)

- Copy of award letter or amended award letter - Copy of disallowance letter - SSA Benefit Record - Written statement from Veteran’s Administra- tion Regional Office - Form 2339 or 2038 “Benefit” Certification” - Form 2339 “VA UME Budget”

Exception: Veterans residing in a State Veteran’s Home do not have their pension reduced to $90. However, their Veteran’s benefits are excluded from financial eligibility.

Their pension is used for patient liability, including any portions designated as UME or Aid and Attendance.

VICTIMS OF CRIME

1. Unearned

2. Excluded in Financial

3. Counted in Patient Liability

4. Non-Taxable

Payments received from a fund established by a state to aid victims of crime.

Verification: (not all inclusive)

- Copy of check or award letter - Statement from the agency making payment VOLUNTEERS IN SERVICE TO AMERICA (VISTA)

1. Unearned

2. Excluded in Financial

3. Excluded in Patient Liability

4. Taxable (Conditional) A federal domestic volunteer agency service program:

Verification: (not all inclusive)

- Copy of check - Statement from VISTA

MAGI: Only meal and lodging allowances paid are taxable

(e-300)(page-45)Page 45#

MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL

INCOME TYPE DESCRIPTION

E-30044 Division of Welfare and Supportive Services TYPES OF EARNED AND UNEARNED INCOME Medical Assistance Manual

14 Mar 01 MTL 14/01 WAGES

1. Earned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable

Salary and/or tips from employment.

Verification: (not all inclusive)

- Copy of check - Statement from employer, Form 2074 WITNESS PROTECTION PROGRAM PAYMENTS

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable

Payments received by informants while living under a witness protection program. Also known as Informant or Whistleblower Awards. Payments are subject to all current federal tax reporting and withholding requirements.

Verification: (not all inclusive)

- Copy of check - Copy of Form 1099 WORK STUDY PROGRAMS

1. Earned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable

Income from Work Study Programs.

Verification: (not all inclusive)

- Copy of check - Statement from employer, Form 2074 WORK TRAINING PROGRAMS

1. Earned

2. Counted in Financial

3. Counted in Patient Liability

4. Taxable

Income from a Work Training Program.

Verification: (not all inclusive)

- Copy of check - Statement from source of payment

(e-300)(page-46)Page 46#

MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL

INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-30045 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 18 May 01 MTL 03/18 WORKERS COMPENSATION

Income received by employee unable to perform from employer

1. Unearned

2. Counted in Financial

3. Counted in Patient Liability

4. Non-Taxable

Income received by employee temporarily unable to perform work duties, due to injury or disability.

Verification: - Copy of check - Statement from employer WORKFORCE INNOVATION AND OPPORTUNITY ACT (WIOA) PAYMENTS

1. Earned / Unearned 2. Counted in Financial 3. Counted in Patient Liability 4. Taxable

Income received by employee unable to perform from employer

WIOA supersedes the Workforce Investment Act (WIA) of 1998 and amends the Adult Education and Family Literacy Act, the Wagner-Peyser Act, and the Rehabilitation Act of 1973. WIOA went into effect on July 1, 2015.

Consider the gross amount of stipends received from WIOA-funded programs as either earned or unearned income as described below. Stipends may be received in lieu of or in addition to wages from the participating employer.

WIOA income for children under the age of 18 is exempt except for minor parent caretakers on their own case. This includes income that is funded by both WIOA and an employer. Payments received for the Summer Youth Employment and Training Program (SYETP) or any comparable AmeriCorps program for summer youth employment is also excluded.

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INCOME TYPE DESCRIPTION

Division of Welfare and Supportive Services E-30045 Medical Assistance Manual TYPES OF EARNED AND UNEARNED INCOME 18 May 01 MTL 03/18

WORKFORCE INNOVATION AND OPPORTUNITY ACT (WIOA) PAYMENTS (cont’d)

WIOA payments received by adults are countable unless specifically identified by the provider or employer as:

- a needs-based payment - payment for supportive/post-program services - payment for participation in: 1. Summer Youth Program; or 2. Work Experience Program; or 3. Limited Work Experience Program (work study for college, vocational courses, enrolled in WNCC Single Parent Program); or - reimbursement for training-related expense such as transportation, meals away from home, and similar expenses. Earned income: 1. Any Title I program for Adults, Dislocated Workers and Youth. 2. Any Title III program administered by an Employment Service Office (Wagner-Peyser or other one-stop-centers); 3. Any Title IV program such as Vocational Rehabilitation; 4. Any other Occupational or On-the-job Training (OJT), or Workforce Development Program such as Limited Work Experience (LWE) or Job Corps participation.

Unearned income: 1. Incentive payment from a WIOA-funded program as a reward for completing specific activity (even if based on hourly participation); 2. Title II payment from Adult Education and Family Literacy Act (AEFLA), Adult Basic Education (ABE), or Literacy and English Language (ESL) acquisition.

Verification: (not all inclusive)

- Statement from provider - Copy of check or award letter

(e-400)Nevada Medical Assistance Manual (MAM): E-400 Resources#

(e-400)(page-1)Page 1#

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD E-400 Division of Welfare and Supportive Services RESOURCES Medical Assistance Manual OVERVIEW – RESOURCE LIMITS 24 Sept MTL 04/24

RESOURCES

E-400 OVERVIEW

Resources are excluded in the Medical assistance eligibility determination for MAGI based eligibility groups.

Resources must be evaluated and verified for MAABD medical assistance determinations.

Resources are defined as those assets, both real and personal, which an individual owns and can apply, either directly or by sale, to meet basic needs of food, clothing, shelter, and medical costs.

Real property is land, including buildings or immovable objects attached permanently to the land.

Personal property is any property that is not real property. The term encompasses such things as cash, tools, life insurance policies, mobile homes, automobiles, etc.

Any income which is retained the month following the month of receipt and later, is subject to resource evaluation.

Resources are evaluated at market value less encumbrances. When the combined value of all countable resources does not exceed the resource limit, verification of encumbrances is not necessary.

When the value of countable resources is under the resource limit on any day of the month, the customer is eligible for that month.

The Asset verification System (AVS) is used to verify resources and is considered verified upon receipt, unless questionable. If questionable, or if the AVS fails to return information*, follow regular procedures to obtain verification. AVS is not used for MAABD programs in which resources are not countable (e.g., individuals who are receiving SSI).

*Not all financial institutions participate in the AVS. If a customer reports a financial account and it does not return through AVS, follow regular procedures to obtain verification.

E-405 RESOURCE LIMITS

• Resource limits for home-based waivers and institutional groups are $2,000 for individuals and $3,000 for couples.

• Resource limits for QMB, SLMB and QI are $9,430 for an individual and $14,130 for a couple when one OR both spouses are applying. When countable resources exceed the limit, the customer is ineligible.

• Resource limits for QDWI are $4,000 for an individual and $6,000 for a couple when one OR both spouses are applying.

• See MAABD Income chart for the spousal impoverishment maximum resource share that can be transferred to the community spouse of an institutionalized individual or home and community- based waiver recipient.

(e-400)(page-2)Page 2#

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD Division of Welfare and Supportive Services E-410 Medical Assistance Manual RESOURCES 24 Sept MTL 04/24 TYPES OF RESOURCES (not all inclusive) ABLE ACCOUNTS – ANNUITIES

E-410 TYPES OF RESOURCES (not all inclusive)

RESOURCE TYPE DESCRIPTION

ABLE ACCOUNTS (Achieving a Better Life Experience)

1. Personal Property

2. Conditional Exclusion

ABLE Accounts are savings programs which allow individuals with disabilities that began prior to age 26 an opportunity to save and invest money without losing eligibility for certain benefits programs, such as Medicaid, SSI and RSDI. Money in ABLE accounts may be spent for education, housing, transportation, employment, health care, personal support services, legal fees, funeral and burial expenses, and other approved expenses.

Currently, the maximum amount an individual can deposit into an ABLE account annually is $18,000.00. Contributions to an individual’s ABLE account may be made by anybody. The first $100,000.00 does not count against the asset limit for Medicaid. Anything over $100,000.00 is countable.

ANNUITIES

1. Personal Property

2. Conditional Exclusion

Annuities are usually purchased to provide a source of income for retirement. A lump sum of money is paid to a bank or insurance company and in return, the individual is promised regular payments of income. These payments continue for a fixed period or for as long as the individual lives, thus creating an ongoing income stream.

The value of an annuity is the amount of money an individual can currently withdraw from the fund after the penalty deduction. This amount, if any, is a countable resource.

Verification: (not all inclusive)

- Documents from the source of payment - Copy of the annuity agreement

(e-400)(page-3)Page 3#

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD E-410 Division of Welfare and Supportive Services RESOURCES Medical Assistance Manual TYPES OF RESOURCES (not all inclusive) 24 Sept MTL 04/24 BANK ACCOUNTS RESOURCE TYPE DESCRIPTION

BANK ACCOUNTS Checking, Savings, Time Certificates, Money Markets, Certificates of Deposit (CD)

1. Personal Property

2. Counted

Refer to Individual Development Account (IDA) section for consideration of funds deposited and interest earned on funds in an IDA savings account.

To determine the countable resource amount, consider the low balance of the account on any given day of the calendar month. Any income/interest deposits in a calendar month are not a resource until the month following the month it is posted to the account. Rebutting ownership does not apply for spousal resource determinations.

A. Ownership

The person designated as owner of the account owns all the funds in the account.

Exception: If the owner is acting as an agent for another individual, monies deposited and disbursed on behalf of that individual are not countable.

B. Shared Ownership (joint account)

Account holders are: - married couples - parent and minor child

When deeming applies in determining eligibility for the coverage group (e.g., Public Laws, institutionalized less than 30 days, etc.), rebutting ownership is NOT REQUIRED because deeming resources takes precedence.

When deeming does not apply (e.g., home based waivers, institutionalized at least 30 days, etc.), the account resource balance will be presumed available to the customer unless the customer can successfully prove all or part of the funds are not his/hers. Exception: cases where spousal impoverishment applies, equal division of resources applies or when the customer is acting as an agent for the other account holder(s); rebutting ownership is NOT REQUIRED.

Account holders ARE NOT: - married couples - parent and minor child

(e-400)(page-4)Page 4#

BANK ACCOUNTS (Cont'd)

The customer has successfully disproved ownership for all months of requested coverage when proof from the financial institution shows: 1) the customer’s name has been removed from the joint account; OR 2) access to the account has been restricted and the funds are not available to the customer; OR 3) the account has been changed so only the customer’s money is in the account.

If the customer can show they are in the process of removing their name from the account, but the action cannot be completed for a time due to a specified reason, the customer has successfully disproved ownership. The case manager should set a future action alert to verify the account was closed/name removed.

Example: Customer and daughter are joint account owners. The customer’s SSA is directly deposited into the account. Customer disproves ownership of the account and provides a statement from Social Security she has requested her check go directly to another account in her name and a statement from the bank requesting the removal of her name from the account. The statement from the bank indicates they will not remove her name until Social Security gets the direct deposit transferred to the other account, which will take approximately two months. If all other criteria are met, the account is successfully disproved. The case would be processed, and the case manager should set a future action alert to verify the removal of her name from the account.

In cases where the customer did not successfully disprove ownership, notify the customer in writing that ownership was not disproved and explain how income and resources are being evaluated.

F. Customer Does Not Disprove Ownership

The account will be considered the customer’s resource.

Verification: (not all inclusive)

- For public guardianship cases only, the ledger card (aka PA Transaction Journal, PA Journal Report or PA Transaction Report) is the primary source for verifying liquid resources. - Copy of bank statement - Copy of deposits and withdrawals - Copy of canceled checks

(e-400)(page-5)Page 5#

BURIAL FUNDS

1. Personal Property

2. Conditional Exclusion DESCRIPTION

Funds set aside for burial include burial insurance, revocable burial contracts, burial trusts, and any separately identifiable assets which are clearly designated for expenses connected with burial, cremation, or other funeral arrangements. ("Separately identifiable" means the funds must be kept separate from the individual's other assets.)

Only financial instruments can be claimed by the customer/representative to be funds set aside for burial and must be clearly designated as such. Financial instruments include cash, burial contracts, financial institution accounts, stocks, bonds, life insurance policies, etc.

Burial funds cannot be co-mingled with any non-burial related assets. Note: If money is withdrawn from funds designated as set aside for burial, these funds are no longer considered "designated" and cannot meet the burial exclusion.

Designation is either by legend on an account or by declaration. Declaration is a signed statement under penalty stating the purpose for which the funds were set aside and the date on which the funds were set aside. Within the statement is the value and the owner of the assets, for whose burial, the form in which the funds are held and the date on which the person first considered the funds set aside for burial. The funds can be excluded effective with the latest of:

a. The date of application (if the funds were considered set aside before the month of application); OR

b. The month following the month in which the funds were considered set aside, unless there is evidence the funds were used and replaced after that date.

Dedicated-cumulative burial fund accounts permit monies from different individuals to be placed into one account as long as all the money in the account is for a dedicated purpose. The money deposited into this account must consist of burial funds only. These accounts, their use, establishment and protocol must be approved by the Chief of Eligibility & Payments. The dedicated-cumulative burial fund utilized by the Clark County and the Washoe County Public Guardian’s office has been approved for use.

(e-400)(page-6)Page 6#

BURIAL FUNDS (Cont'd)

THE FOLLOWING EXCLUSIONS APPLY TO BURIAL FUNDS:

a. Any interest accrued in burial accounts which is not paid but left to accumulate as part of the funds;

b. Up to the maximum of $1,500 each for the customer and/or customer’s spouse.

Only the cash surrender value (CSV), less interest, of the policy, contract or insurance OWNED by the customer/ customer’s spouse is applied towards the $1,500 exclusion. Obtain verification from the mortuary/insurance company of the CSV. Burial funds in excess of $1,500 will be a countable resource.

THE $1,500 MAXIMUM MUST BE REDUCED BY:

a. The amount of funds held in an irrevocable burial trust, irrevocable burial contract or other irrevocable arrangement available to meet burial expenses.

Note: Any burial trusts, contracts or other arrangements issued in Nevada are not considered irrevocable by state law. These are available resources.

Other burial arrangements issued outside of Nevada may be considered irrevocable. Verify with the state where they were issued to determine availability.

b. The FACE value of any life insurance policy owned by the customer/ customer’s spouse if the CSV was excluded in determining countable resources. Note: Life insurance with no provision for a CSV will not affect the burial exclusion.

Example: Customer has a life insurance policy with a FACE value of $1,200 and a CSV of $500. Because the FACE value was less than $1,500, the $500 was excluded as a resource.

The customer also has funds set aside for burial in the amount of $2,000 (i.e., CSV of a burial policy). To determine the amount of burial which can be excluded:

(e-400)(page-7)Page 7#

BURIAL FUNDS (Cont'd)

a) Subtract the $1,200 FACE value of the excluded life insurance policy from the $1500 leaving $300 left of the exclusion.

b) Subtract the remaining $300 exclusion from the $2,000 burial funds, leaving a balance of $1,700. The $1,700 is counted toward the resource limit.

Verification: (not all inclusive)

– Copy of policy, contract, trust, financial instrument, etc. – Form 2006 designating burial funds – Form 2605 Insurance Policy Information

BURIAL SPACES AND RELATED ITEMS

1. Personal Property

2. Excluded

A burial space or item held for the burial of the customer, customer’s spouse, or any other member of the customer’s immediate family is an excluded resource, regardless of value.

The burial space exclusion is in addition to and has no effect on the burial funds exclusion.

a. Burial spaces are defined as burial plots, gravesites, crypts, mausoleums, caskets, urns, niche or other repositories customarily used for the remains of deceased persons.

Burial items may include, but are not limited to vaults, headstones, markers, or plaques, burial containers (e.g., for caskets) and arrangements for the opening and closing of the gravesite and endowment care.

b. Immediate family includes a customer’s minor and adult children, stepchildren, and adopted children, brothers, sisters, parents, adoptive parents and spouses of those persons.

Verification: (not all inclusive)

– Copy of policy, contract or other document

itemizing items

CASH ON HAND

1. Personal Property

2. Counted

Currency held by customer at home, on their person, etc.

Verification: (not all inclusive)

– Customer’s statement

(e-400)(page-8)Page 8#

DEATH BENEFITS

1. Personal Property

2. Conditional Exclusion

Death benefits, including gifts and inheritances, to the extent they are not income because they are to be spent on costs resulting from the last illness and burial expenses of the deceased, are not resources for the calendar month following the month of receipt. If retained until the second calendar month following receipt, they become a resource.

Verification: (not all inclusive)

– Documents from source of payment

DIRECT EXPRESS PRE-PAID MASTERCARD DEBIT ACCOUNTS

1. Personal Property

2. Counted

The Direct Express MasterCard is issued to recipients of Social Security benefits when they do not have a regular bank account, or they choose to use this type of account. Note: Customers are charged a fee to receive a monthly statement.

If a customer receives Social Security benefits and claims to not have a bank account, they will have a Direct Express pre- paid MasterCard debit account.

Verification: (not all inclusive)

– Copy of statement – ATM transaction receipts

(e-400)(page-9)Page 9#

ENTRANCE FEES

1. Personal Property

2. Conditional

Fees paid to continuing care retirement communities (CCRCs), or life care communities (LCCs) where a range of living arrangements from independent living through skilled nursing facility care is provided.

These facilities require potential residents to provide information about their finances, resources and income, before being accepted for admission.

The value is determined taking into account spousal impoverishment rules, where appropriate.

Effective February 8, 2006, considered an available resource if all three conditions are met:

– Individual can use them to pay for care when other income and assets are insufficient; Refundable upon death of the resident or termination of residency in the facility; and

– Fees do not confer (give) any ownership interest in the CCRC or LCC

Verification: (not all inclusive)

– Customer’s statement – Copy of signed contract – Receipt of funds paid

FEDERAL TAX REFUNDS

1. Personal Property

2. Conditional Exclusion

An unspent federal tax refund or payment is excluded from resources for a period of 12 months following the month of receipt of the payment.

Verification: (not all inclusive)

– Copy of check – Copy of IRS filing form

(e-400)(page-10)Page 10#

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD Division of Welfare and Supportive Services E-410 Medical Assistance Manual RESOURCES 24 Sept MTL 04/24 TYPES OF RESOURCES (not all inclusive)

HOME EQUITY RESOURCE TYPE DESCRIPTION

HOME EQUITY

1. Personal Property

2. Conditional Exclusion

Individuals whose equity interest in their home exceeds $713,000 are ineligible for long-term care and HCBW services, unless:

– The individual’s spouse, dependent child under age 21, or blind/disabled child resides in the home; or – Equity is reduced below $636,000 due to a home equity loan or reverse mortgage.

Effective with applications filed on or after January 1, 2006.

The value is the current market price of the home, or the amount for which it can reasonably be expected to sell on the open market.

An encumbrance is a legally binding debt against the resource, like a mortgage, reverse mortgage, home equity loan, or other debt secured by the home. Refer to F-415.2 for potential transfer of assets.

Verification: (not all inclusive)

– Written statement from county assessor’s office – Tax lists – Copy of mortgage papers/escrow documents – Copy of deed – Real estate appraisal

(e-400)(page-11)Page 11#

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD E-410 Division of Welfare and Supportive Services RESOURCES Medical Assistance Manual TYPES OF RESOURCES 24 Sept MTL 04/24 HOUSEHOLD GOODS AND PERSONAL EFFECTS – INDIAN LAND RESOURCE TYPE DESCRIPTION

HOUSEHOLD GOODS AND PERSONAL EFFECTS

1. Personal Property

2. Excluded

Household goods are items of personal property customarily found in the home and used in connection with the maintenance, use, and occupancy of the premises as a home. They include, but are not too: furniture, appliances, televisions, carpets, cooking and eating utensils, dishes, etc.

Personal effects are items of personal property that are worn or carried by an individual or that have an intimate relation to him or her. They include, but are not limited to: clothing, jewelry, personal care items, prosthetic devices, and educational or recreational items such as books, musical instruments, or hobby materials.

Prosthetic devices, wheelchairs, hospital beds, dialysis machines and other items required by a person's physical condition are excluded.

Verification: (not all inclusive)

– Customer’s statement

INCOME PLACED IN AN ACCOUNT IDENTIFIED AS EXCLUDED INCOME

1. Personal Property

2. Conditional Exclusion

Any excluded income placed in a financial institution when clearly identified as excluded income.

Verification: (not all inclusive)

– Source of income – Copy of account statement – Source of deposits

INDIAN LAND

1. Real Property

2. Conditional Exclusion

ALL INDIAN PROPERTY under authority of the Bureau of Indian Affairs has a restricted title.

A. ASSIGNED LAND – An assignment allows the use of tribal land by a member of the tribe. Assigned land will not be considered a resource.

B. ALLOTTED LAND – This type of land can be sold by the individual upon approval by the Bureau of Indian Affairs. Allotted land is not a resource until the property is sold or transferred.

C. UNRESTRICTED LAND – Land owned by the individual and not controlled by the Bureau of Indian Affairs. This land is an available resource.

(e-400)(page-12)Page 12#

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD Division of Welfare and Supportive Services E-410 Medical Assistance Manual RESOURCES 24 Sept MTL 04/24 TYPES OF RESOURCES INDIAN LAND (Cont’d) – INDIVIDUAL DEVELOPMENT ACCCOUNT (IDA)

INDIAN LAND (Cont'd)

Verification: (not all inclusive)

– Tax rolls – Copy of deed – Bureau of Indian Affairs – Customer’s statement

INDIAN MONEY

1. Personal Property

2. Conditional Exclusion

Per capita share payments granted to Western Shoshone Indians pursuant to Public Law 108-270 are an exempt resource.

INDIVIDUAL DEVELOPMENT ACCOUNT (IDA)

1. Earned/Unearned

2. Excluded in Financial

3. Excluded in Patient Liability

Intended to improve the economic independence and stability of individuals and families and to promote and support the transition to economic self-sufficiency. An IDA participant can only deposit earned income into an IDA. Federal funds match the amount of earnings low-income working individuals and families deposit into an IDA. IDA savings are to be used for a first home purchase, post- secondary educational expenses, or business capitalization.

The Social Security Act provides for state family assistance grant funds (i.e., TANF, WtW) to be used to establish IDAs. The Assets for Independence Act (AFIA) provides for IDAs to be established under Head Start, Low Income Home Energy Assistance (LIHEA), and Community Services.

Income in an IDA includes:

- Participant contribution (earned income); - Interest earned on participant earned income contributions; - Matching funds; and - Interest accrued on matching funds.

An individual whose participation in the IDA program has terminated, voluntarily or otherwise, is no longer covered by the resource exclusion.

(e-400)(page-13)Page 13#

LIFE ESTATES

1. Personal Property

2. Conditional Exclusion

A life estate gives an individual for his/her lifetime certain rights in property. These rights are the right of possession, the right to use the property, the right to obtain profits from the property (i.e., collection of rents) and the right to sell his or her life estate interest. A contract establishing a life estate may restrain one or more of these rights. The owner(s) of a life estate do not have title to the property and do not have the right to sell the property.

The value of a customer’s life estate is determined by:

1) the age of the customer, 2) the number of owners, and 3) the fair market value of the property.

The above information must be verified and then sent to the Chief of E&P requesting a determination of the life estate value.

Exception: A life estate in the principal place of residence is an excluded resource and determining its value is not necessary.

Evaluate for potential transfer of assets.

Verification: (not all inclusive)

– Signed and dated statement from a licensed real estate broker – Written statement from county assessor's office – Tax lists – Copy of mortgage papers – Copy of deed – Copy of life estate contract

(e-400)(page-14)Page 14#

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD Division of Welfare and Supportive Services E-410 Medical Assistance Manual RESOURCES 24 Sept MTL 04/24 TYPES OF RESOURCES (not all inclusive)

LIFE INSURANCE POLICIES RESOURCE TYPE DESCRIPTION

LIFE INSURANCE POLICIES

1. Personal Property

2. Conditional Exclusion

A life insurance policy is a contract. Its purchaser (the owner) pays premiums to the company that provides the insurance (the insurer). In return, the insurer agrees to pay a specified sum to a designated beneficiary upon the death of the insured (the person on whom, or on whose life, the policy exists).

Face Value (FV) is the amount of basic death benefit contracted for at the time the policy is purchased.

A policy's cash surrender value (CSV) is a form of equity value that it acquires over time. The owner of a policy can obtain its CSV only by turning the policy in for cancellation before it matures or the insured dies. A loan against a policy reduces its CSV.

A life insurance policy is a resource if it has a CSV. Its value as a resource is the amount of the CSV. Life insurance which does not have a cash surrender value (e.g., term life insurance) is excluded from all computations.

Any life insurance policy with a CSV must be evaluated for the FV. If the total FV of the policy or combined FV of multiple policies the individual owns total $1,500 or less, exclude them as a resource. If the total FV of the policy or policies exceeds $1,500, the total CSV for each policy is counted.

Accelerated life insurance payments are proceeds paid to a policyholder PRIOR to death. Because an individual receives proceeds from the policy (not the policy's resource value, which is its cash surrender value), the receipt of an accelerated payment is not treated as a conversion of a resource. Since accelerated payments can be used to meet the individual's needs, the payments are income in the month received and a resource if retained into the following month.

Most accelerated payment plans fall into three basic types, depending on the circumstances which cause or "trigger" the payments to be accelerated. These are the:

● Long–term care model, which allows policy- holders to access their death benefits should they require extended confinement in a care facility or, in some instances, health care services at home;

(e-400)(page-15)Page 15#

LIFE INSURANCE POLICIES (Cont’d)

● Dread disease or catastrophic illness model, which allows policy holders to access their death benefits if they contract or acquire one of several specified covered conditions; and

● Terminal illness model, which allows policy holders to access their death benefits following a diagnosis of terminal illness where death is likely to occur within a specified number of months.

Some companies refer to these types of payments as "living needs" or "accelerated death" payments.

Depending on the type of accelerated payment plan, receipt of accelerated payments may reduce the policy's FV by the amount of the payments and may reduce CSV in a manner proportionate to the reduction in FV. In some cases, a lien may be attached to the policy in the amount of the accelerated payments and a proportionate reduction in CSV results.

Verification: (not all inclusive)

– Insurance policy/rider – Form 2015 from insurance company – Written statement from insurance company

Note: If the CSV is excluded in determining countable resources the FACE value of the life insurance policy may reduce an applicant’s burial exclusion. See Burial Funds.

(e-400)(page-16)Page 16#

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD Division of Welfare and Supportive Services E-410 Medical Assistance Manual RESOURCES 24 Sept MTL 04/24 TYPES OF RESOURCES (not all inclusive)

LIQUIDATED RESOURCE – MACHINERY AND EQUIPMENT

RESOURCE TYPE DESCRIPTION

LIQUIDATED RESOURCE

1. Real/Personal Property

2. Counted/Excluded

If a resource is liquidated, the money received is not budgeted as income; it is still considered a resource. Apply the countable/exclusion rules governing the new form the liquidated resource has taken, i.e., cash on hand, bank account, vehicle, stocks, etc.

Verification: (not all inclusive)

– Sales receipt – Proof of purchase documents – Financial statements

MACHINERY AND EQUIPMENT

1. Personal Property

2. Counted

Machinery and equipment not established as property essential for self–employment/self–support is counted at market value less encumbrances.

Verification: (not all inclusive)

– Customer’s statement is accepted unless the case manager has reason to question the customer's statement. Verification is required ONLY when the case manager has reason to question the customer's statement. – Written statement from county assessor's office – Written dealer's estimate – Written estimate from agricultural agent

(e-400)(page-17)Page 17#

MEDICAL SAVINGS ACCOUNTS (employee)

1. Personal Property

2. Conditional Exclusion An employer may elect to provide health care benefits for an employee through a medical savings account program.

The account is available and therefore countable to the employee after the last business day of the year in an amount equal to the amount contributed during that year.

The account is also available and therefore countable when the individual is no longer employed by the employer.

Disbursements may be made during a given year by the administrator of the account to pay medical expenses of the employee or his/her dependent, or to reimburse the employee for paid medical expenses.

Verification: (not all inclusive)

- Written statement from the employer

MINERAL RIGHTS

1. Real/Personal Property

2. Counted

Mineral rights represent ownership interest in natural resources such as coal, oil, or natural gas, which are normally extracted from the ground.

If the individual owns the land to which the mineral rights pertain, the market value of the land should include the value of any mineral rights too. If the individual does not own the land to which the mineral rights pertain, obtain the market value from a knowledgeable source.

Verification: (not all inclusive)

– The Bureau of Land Management – U.S. Geological Survey – Mining companies holding leases

(e-400)(page-18)Page 18#

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD Division of Welfare and Supportive Services E-410 Medical Assistance Manual RESOURCES 24 Sept MTL 04/24 TYPES OF RESOURCES (not all inclusive)

MONEY FROM SALE OF EXCLUDED HOME – PATIENT TRUST ACCOUNTS RESOURCE TYPE DESCRIPTION

MONEY FROM SALE OF EXCLUDED HOME

Money received from the sale of an excluded home is disregarded if used to purchase another excludable home within 3 months after the money is received.

When the money is received in increments over a period of time, amounts applied to principal are considered a resource and amounts applied to interest are unearned income.

Verification: (not all inclusive)

– Escrow documents – Copy of check – Bill of sale

PATIENT TRUST ACCOUNTS

To determine the countable resource amount, consider the low balance of the account on any given day of the calendar month.

Any income deposits in a calendar month are not a resource.

If the facility rebuts the trust account balance due to a delay in posting patient liability or other expenses, they must provide a statement which includes the following:

a. The total balance of the patient trust account; and

b. What portion of the balance is not available and why. The unavailable portion must be itemized showing the amounts which are encumbered and the source of the encumbrance; and

c. It must be clear the encumbered portion would not be released to the customer if a request were made by the customer.

If a statement is provided with all of the above, the portion the facility states is unavailable will not be counted as a resource in determining eligibility.

Verification: (not all inclusive)

- Patient Trust Account Ledgers - Medical Facility Information Form 2547-EE

(e-400)(page-19)Page 19#

PENSION FUNDS

1. Personal Property

2. Conditional Exclusion

Pension funds are funds held in individual retirement accounts (IRA) (as described by the IRS), or in work–related pension plans (including Keogh plans). A vested retirement account is an account to which an employee makes contributions for a specified period of time, as defined by the employer. The money contributed by the employee is not matched by the employer until the defined period of time ends.

Count money in an IRA or Keogh as a resource, even if there is a penalty for early withdrawal. Deduct the early withdrawal penalty and count the remainder as a resource.

Do not count Keogh plans as a resource if there is a contractual withdrawal agreement with other people who are not household members but share the same fund. Consider this resource inaccessible.

Count money in a vested retirement account as a resource, unless early withdrawal is prohibited.

If a vested retirement account is attached and distribution or availability of funds is blocked by a court order due to divorce or child support, consider this resource inaccessible.

Count money in a 401K plan as a resource.

Any retirement fund is not a resource if an individual must terminate employment to obtain any payment.

Pension funds of the customer’s ineligible spouse are excluded, unless spousal impoverishment rules apply.

Verification: (not all inclusive)

– Financial statements – Tax return documents

(e-400)(page-20)Page 20#

DESCRIPTION

PERSONAL CARE AND HOME CARE CONTRACT AGREEMENTS

1. Personal Property

3. Conditional Exclusion

When assistance and/or services are provided to the applicant/recipient, regardless of whether it is by a relative or non-relative, compensation for past assistance and/or services will be considered a transfer for less than fair market value. If the transfer of assets is rebutted, the fair market value of the assistance and/or services may be determined by consulting with area businesses that provide such services.

A contract that provides advance payment for expenses, including but not limited to, repairs, maintenance, property taxes, homeowner’s insurance, heat and utilities for real property/homestead, or for services like health care monitoring, hospitalization, medical treatment, visitation, entertainment, travel and/or transportation, financial management or shopping, etc., will be considered a transfer of assets. All payments for care and services which were made during the look-back period are considered transfer of assets. Contracts/agreements that involve the provision of companionship are prohibited.

All contracts/agreements and payments related to Personal Care and Home Care, whether between an applicant/recipient and a relative or a non-relative, must be evaluated for transfer of assets.

Personal Care and Home Care contracts/agreements are considered transfers for less than fair market value unless the agreement meets all of the following criteria:

• The services must be performed after a written legal contract/agreement has been executed between the applicant/recipient and the provider. The contract/agreement must be dated, and the signatures must be notarized. Payment for the services must not be made until the services have been provided (there can be no advance payment for future expenses or services); and

(e-400)(page-21)Page 21#

PERSONAL CARE AND HOME CARE CONTRACT AGREEMENTS (Cont’d.)

• At the time the services are received, the applicant/recipient cannot be residing in a nursing facility, adult foster care home (licensed or unlicensed), institution for mental diseases, inpatient hospital, intermediate care facility for individuals with intellectual disabilities or be eligible for home and community-based waiver,

home health or home help; and

• At the time the services are received, the services must have been recommended in writing and signed by the applicant/recipient’s physician as necessary to prevent the transfer of the applicant/recipient to a residential care or nursing facility. Such services cannot include the provision of companionship; and

• The contract/agreement must be signed by the applicant/recipient or legally authorized representative, such as an agent under a power of attorney, guardian, or conservator. If the agreement is signed by a representative, that representative cannot be the provider or beneficiary of the contract/agreement.

Assets transferred to another person in exchange for a contract/agreement related to personal services/assistance and/or payment for real property/homestead expenses after the date of application are considered available and countable assets until they are actually disposed of.

Verification (not all inclusive).

- Financial Statements - Bank Statements - Copy of signed contract - Itemized statements or bills - Verification of fair market value of services rendered.

(e-400)(page-22)Page 22#

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD Division of Welfare and Supportive Services E-410 Medical Assistance Manual RESOURCES 24 Sept MTL 04/24 TYPES OF RESOURCES (not all inclusive)

PROMISSORY NOTES, FORMAL WRITTEN LOAN AGREEMENTS AND PROPERTY AGREEMENTS RESOURCE TYPE DESCRIPTION

PROMISSORY NOTES, FORMAL WRITTEN LOAN AGREEMENTS AND PROPERTY AGREEMENTS

1. Personal Property

2. Conditional Exclusion

Generally, promissory notes, property agreements and loan agreements may be sold or discounted. If the customer’s statement of value, either alone or combined with other resources, exceeds the resource limit, there is no need to verify current market value. Presume the value is its outstanding principal balance unless reliable evidence shows current market value (CMV) is less.

Evaluate for potential transfer of assets.

If the individual alleges the item is for sale, promissory notes, formal written loan agreements and property agreements are excluded when the customer verifies the item is for sale at market value and no offers to purchase have been received. The item must remain for sale while the customer receives assistance.

"Good Faith" efforts must be made by or on behalf of the customer to qualify under this exclusion. These efforts must continue for the exclusion to remain in effect.

Federal regulations state "good faith efforts" to sell resources consist of taking all necessary and reasonable steps to sell it in the geographic area covered by media (radio, television, and newspaper, etc.) serving the area where the property is located.

"Necessary and reasonable" steps to sell this resource will be to utilize a licensed realtor to list the resource for sale OR advertise the resource is for sale through at least one media source covering the area where the resource is located and posting a 'for sale' sign on the property if applicable. The frequency in advertising property for sale will be at least twice a month.

Example: Newspaper advertisements should appear twice in a month with each length of time the decision of the customer/ representative.

A bona fide negotiable agreement is a resource. The portion of any payment received representing payment on the principal is also a resource. The portion of any payment which represents interest on the principal is unearned income.

(e-400)(page-23)Page 23#

PROMISSORY NOTES, FORMAL WRITTEN LOAN AGREEMENTS AND PROPERTY AGREEMENTS (Cont'd)

An agreement which is not bona fide or negotiable is not a resource. The total payments received, whether principal and/or interest, are unearned income.

Verification: (not all inclusive)

– Bank or other financial institution – Title company – Private investor – Real estate broker

RADIATION EXPOSURE PAYMENTS

1. Personal Property

2. Excluded

Payments made under the Radiation Exposure Compensation Act.

Verification: (not all inclusive)

– Documents from source of payment – Verify how the resources are held

(e-400)(page-24)Page 24#

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD Division of Welfare and Supportive Services E-410 Medical Assistance Manual RESOURCES 24 Sept MTL 04/24 TYPES OF RESOURCES (not all inclusive)

REAL PROPERTY RESOURCE TYPE DESCRIPTION

REAL PROPERTY

1. Real Property

2. Conditional Exclusion

Real property is land, including buildings or immovable objects attached permanently to the land.

OWNERSHIP/AVAILABILITY

a. Sole Ownership:

Sole ownership of real or personal property mean only one person may sell, transfer or otherwise dispose of the property. All of the resource evaluated at market value, less encumbrances, is available to the customer.

b. Shared Ownership:

Shared ownership of real or personal property means two or more people own it simultaneously. The following are common types of shared ownership:

1) Tenancy-In-Common:

Two or more persons each have an undivided fractional interest in the whole property for the duration of the tenancy. These interests are not necessarily equal. One owner may sell, transfer or otherwise dispose of his/her share of the property Without permission of the other owner(s); but cannot take these actions with the entire property. If a tenant-in- common dies, the deceased’s interest passes to his/her estate of heirs. Count the fair market value, less encumbrances, of the customer’s property share.

2) Joint Tenancy:

Each of two or more persons have one and the same undivided ownership interest and possession of the whole property for the duration of the tenancy. This means each owner owns ALL the property. If a joint tenant dies, the survivor becomes the sole owner. If more than one joint tenant survives, the survivors become joint tenants of the entire property interest. Count the total fair market value, less encumbrances, of the entire property.

(e-400)(page-25)Page 25#

REAL PROPERTY (Cont'd)

3) Tenancy By The Entirety (Married Couples only):

This type of ownership can only exist between married couples. The spouses as a unit own the entire property and can be sold only with the consent of both parties. However, if a legal divorce occurs, the former spouses become tenants-in-common and one can sell his/her share without the consent of the other. If one spouse dies, the survivor becomes the sole owner. Verify whether the customer’s spouse will give permission to sell the property. If permission cannot be obtained, DO NOT count the customer’s one-half share of the property.

Real property is land, including buildings or immovable objects attached permanently to the land.

Real property is excluded:

a. When the property is the customer’s principal place of residence. A principal place of residence is defined as a home (including a mobile home or contiguous land) in which a customer is residing or has resided in the past. Land is contiguous to the home when not separated by property owned by another person. The home exclusion applies to all buildings on the land.

A principal place of residence is/was a permanent living arrangement of at least one full calendar month prior to his/her absence.

When a customer has ownership interest in more than one residence, determine which is primary by obtaining evidence such as, but not limited to:

1. How much time is spent at each residence; 2. Where he/she is registered to vote; 3. Which address he/she uses as a mailing address or for tax purposes.

(e-400)(page-26)Page 26#

REAL PROPERTY (Cont'd)

Determine the primary residence accordingly and document in the permanent section of the case file.

The exemption continues to apply when the customer is absent from the home but:

1) Intends to return. If the customer or his authorized representative states in writing the customer intends to return to the home, regardless of whether there is medical evidence showing this is a probability, the home will be exempt; OR representative states in writing the customer intends to return to the home, regardless of whether there is medical evidence showing this is a probability, the home will be exempt; OR

2) The home is occupied by a spouse or dependent

(e.g., financially, medically dependent) relative; OR

3) The home ownership is transferred to a revocable trust.

The transfer of a primary residence by an institutionalized individual, including SSI recipients, must be evaluated for potential transfer of resource penalty.

b. For all non-business property up to $6,000 of the customer’s equity if the property is producing a net annual income of at least 6 percent of the excluded equity. The amount of equity exceeding $6,000 is counted as a resource. Income from this property is counted; OR

c. When the customer verifies the property is for sale at market value AND no offers to purchase have been received (the property must remain for sale while the customer receives assistance), or the property has been sold and escrow has not been completed.

"Good Faith" efforts must be made by or on behalf of the customer in order for property to qualify under this exclusion. These efforts must continue for the exclusion to remain in effect.

(e-400)(page-27)Page 27#

REAL PROPERTY (Cont'd)

Federal regulations state "good faith efforts" to sell property consist of taking all necessary and reasonable steps to sell it in the geographic area covered by media (radio, television, and newspaper, etc.) serving the area where the property is located.

"Necessary and reasonable" steps to sell this resource will be to utilize a licensed realtor to list the property for sale OR advertise the property is for sale through at least one media source covering the area where the property is located and posting a 'for sale' sign on the property. The frequency in advertising property for sale will be at least twice a month.

Example: Newspaper advertisements should appear twice in a month with each length of time the decision of the customer/representative.

Verification: (not all inclusive)

– Signed and dated statement from a licensed real estate broker – Written statement from county assessor's office – Tax lists – Copy of mortgage papers – Copy of deed – Letter from mobile home dealer

(e-400)(page-28)Page 28#

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD Division of Welfare and Supportive Services E-410 Medical Assistance Manual RESOURCES 24 Sept MTL 04/24 TYPES OF RESOURCES (not all inclusive)

REIMBURSABLE MEDICAL EXPENSES – REPLACEMENT/REPAIR FUNDS

RESOURCE TYPE DESCRIPTION

REIMBURSABLE MEDICAL EXPENSES

1. Personal Property

2. Conditional Exclusion

Reimbursement for expenses already paid for by the individual (pre-paid institutional care) is not countable as income, but IS countable as a resource following the month of receipt. Other types of cash received for medical expenses (reimbursed prescription expenses) are not countable as income, and are not countable as resources until the second month following receipt.

Verification: (not all inclusive)

- Documents from the source of payment

RELOCATION ASSISTANCE PAYMENTS

1. Personal Property

2. Conditional Exclusion

Unspent relocation assistance payments from a state or local government are excluded from resources for 9 months beginning the month after the month in which they received these funds.

Example: If an individual receives relocation assistance in January, the assistance can be excluded beginning February through October.

Verification: (not all inclusive)

– Documents from Source of Payment

REPLACEMENT/REPAIR FUNDS

1. Personal Property

2. Conditional Exclusion

When monies are received for replacement or repair of destroyed, damaged, or stolen excluded resources, the amount of money received is disregarded from resources for 9 months.

When monies are received for replacement or repair of destroyed, damaged or stolen resources, the amount of money received is considered a change in type of resource and remains a resource, not income.

Verification: (not all inclusive)

– Documents from source of payment – Receipts and canceled check copies

(e-400)(page-29)Page 29#

REVERSE MORTGAGE

1. Personal Property

2. Counted

Payments received from a reverse mortgage are exempt income in the month received. Any portion of the payments retained the month following the month of receipt is considered a countable resource.

Evaluate for potential transfer of assets.

SAFE DEPOSIT BOXES

Safe deposit boxes may contain copies of deeds, insurance policies, money and other countable resources. The customer’s statement on the application as to the contents may be taken unless questionable. If the contents are questionable, they must be verified.

Exception: If the contents are questionable or unknown, and there is no way to verify the contents because the customer is incapable of opening the box and there is no other way to verify the contents, the contents will be considered inaccessible.

Verification: (not all inclusive)

– The case manager viewing the contents – A written statement verifying the contents

SELF-SUPPORT RESOURCES

1. Real/Personal Property

2. Conditional Exclusion

Resources necessary to fulfill a Plan for Achieving Self– Support (PASS) for the blind and disabled as long as the plan remains in effect. The plan must be an individual plan, in writing, approved by the Social Security Administration.

Verification: (not all inclusive)

– Written documents from the Social Security

Administration

(e-400)(page-30)Page 30#

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD Division of Welfare and Supportive Services E-410 Medical Assistance Manual RESOURCES 24 Sept MTL 04/24 TYPES OF RESOURCES (not all inclusive)

SELF-EMPLOYMENT RESOURCES – STOCKS AND BONDS RESOURCE TYPE DESCRIPTION

SELF-EMPLOYMENT RESOURCES

1. Real/Personal Property

2. Conditional Exclusion

Property essential for self–employment/self-support. All property used in a trade or business and all property used by an employee in connection with employment, regardless of the amount of equity an individual has in the property or whether the property is producing a reasonable rate of return (e.g., real property, buildings, inventory, equipment, tools, machinery, vehicles, etc.). The property must be in current use or returned to use (or in the case of a deceased person, was expected to have been returned to use) within one year.

Verification: (not all inclusive)

– Income Tax Records – Business Records – Customer’s statement

SSI/RSDI RETRO PAYMENTS

1. Personal Property

2. Conditional Exclusion

The unspent portion of SSI and RSDI Retroactive payments received on or after 03/02/2004 are excluded from resources for 9 months following the month of receipt. The unspent portion of SSI and RSDI Retroactive payments received before 03/02/2004 are excluded from resources for 6 calendar months following the month of receipt.

Example: A retroactive RSDI payment received in January 2018 is unearned income for January when determining financial eligibility and patient liability. The RSDI retroactive payment is excluded from resources effective February through October.

These payments are no longer excluded when converted to another resource such as stocks, bonds, etc.

Verification: (not all inclusive)

– SSA Award Letter – Verify how the resources are held

STOCKS AND BONDS

1. Personal Property

2. Conditional Exclusion (Stocks Only) Shares of stock represent ownership in a business corporation. Their value shifts with demand and may fluctuate widely. Exclude shares of stock which cannot be sold.

(e-400)(page-31)Page 31#

STOCKS AND BONDS (Cont'd)

U.S. Savings Bonds are obligations of the federal government. Unlike other government bonds, they are not transferable; they can only be sold back to the federal government.

U.S. Saving Bonds cannot be redeemed for six months after the issue date specified on the face of the bond.

A municipal bond is the obligation of a state or a locality (county, city, town, village or special purpose authority such as a school district).

A corporate bond is the obligation of a private corporation.

Verification: (not all inclusive) – Newspaper reporting stock closing prices – Local securities firm – Written statement from firm's accountants – Table of redemption values for U.S. Savings Bonds – Telephone call to local bank

(e-400)(page-32)Page 32#

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD Division of Welfare and Supportive Services E-410 Medical Assistance Manual RESOURCES 24 Sept MTL 04/24 TYPES OF RESOURCES (not all inclusive)

TRUST FUNDS RESOURCE TYPE DESCRIPTION

TRUST FUNDS

1. Personal Property

2. E & P Chief Evaluation Required

Most trusts are referred to the Chief of Eligibility and Payments for an evaluation and decision on availability. Obtain the complete trust document with all attachments to send with the request. Use form 6009 and ensure it is signed by both the case worker and supervisor. Send via inter-office mail.

Exception: MAGI Medicaid groups do not require a resource evaluation. If a customer is applying for or receiving Medicaid in a MAGI category and the customer has a trust, do not refer the trust to the Chief of E&P for legal evaluation. Refer to MAM E-300 (Trust Funds) for instructions on counting trust income. Trusts should always be referred to E&P when a MAGI Medicaid case is to be converted to a MAABD program.

Trusts established prior to August 11, 1993 by an individual or the individual's spouse, under which the individual is the recipient of all or part of any payments from the trust are called Medicaid Qualifying Trusts (MQTs). MQT assets (income/resources) are "deemed" available to the customer.

When the evaluation determines that the principal of the trust is not available to meet the needs of the customer, it is an excludable resource.

Verification: (not all inclusive)

– Trust documents/agreements – Memorandum from Chief of E&P

(e-400)(page-33)Page 33#

UNIFORM GIFTS TO MINORS

1. Real/Personal Property

2. Conditional Exclusion

Uniform Gifts to Minors Act permits gifts to minors which are free of tax burdens.

An individual (donor) makes an irrevocable gift of money or other property to a minor (the donee). The gift, plus any earnings it generates, is under the control of a custodian until the donee reaches the age of majority by state law (18 years for Nevada). The custodian has discretion to provide to the minor or spend for the minor's support, maintenance, benefit or education, as much of the assets as he/she deems equitable. The donee automatically receives control of the assets upon reaching the age of majority.

The gift, including any additions or earnings, is not income to the donee. The custodian's disbursements to the donee are income to the minor. All property becomes available to the donee and subject to income rules in the month the donee reaches the age of majority. The month following the month of majority, the property is subject to resource evaluation.

Verification: (not all inclusive)

– Copy of the document of ownership, e.g., deed, CD, savings passbook, etc.

VEHICLES

1. Personal Property

2. Conditional Exclusion

Vehicles include passenger cars, trucks, boats, snowmobiles, trailers, recreational vehicles, etc.

The fair market value (FMV) less encumbrances of all types of vehicles for which the total or partial value has not been excluded. The FMV is determined by the "average trade–in" value or the current "wholesale blue book" value of the vehicle excluding optional equipment and mileage.

If the vehicle is no longer listed in the blue book or the vehicle is inoperable or extensively damaged, the customer’s statement of value is acceptable.

ALWAYS obtain FMV of vehicles which are collectible or antique.

For vehicles used to provide transportation such as passenger cars, trucks, boats, snowmobiles, animal drawn vehicles, etc., apply the following exclusions in the following order.

(e-400)(page-34)Page 34#

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD Division of Welfare and Supportive Services E-410 Medical Assistance Manual RESOURCES 24 Sept MTL 04/24 VEHICLES (Cont’d)

VEHICLES (Cont'd)

This does not include recreational vehicles or vehicles not used for transportation.

a. Exclude the TOTAL value of ONE vehicle for the customer or member of the customer's household if:

1) It is necessary for employment; 2) It is necessary for transportation to or from medical treatment of a specific or regular medical problem; 3) The vehicle has been modified for operation by or transportation of the handicapped customer/household member; 4) It is necessary because of climate, terrain, or distance to provide transportation to perform essential daily activities (such as going to the grocery store, going to the post office, etc.).

b. When NO vehicle has been excluded under 1, 2, 3 or 4 above, the current market value (CMV), NOT allowing any encumbrances, of ONE vehicle up to $4,500 will be excluded. When the market value exceeds $4,500, the excess amount is divided equally among all owners and the customer’s share is applied toward the resource limit.

c. The market value of any OTHER vehicles less encumbrances is divided equally among all owners and the customer’s share is applied toward the resource limit.

d. Exclude the TOTAL value of the customer’s vehicle(s) essential for producing income including vehicles used in a trade or business.

Verification: (not all inclusive)

– Customer’s statement regarding the number of vehicles owned, ownership status and availability is acceptable unless the case manager has reason to question the statement. Possible sources of verification are: – Kelley Blue Book – Copy of bill of sale – Copy of vehicle registration – Written statement from county tax assessor – Estimate from auto dealer

(e-400)(page-35)Page 35#

MAABD MAABD MAABD MAABD MAABD MAABD MAABD MAABD E-410 Division of Welfare and Supportive Services RESOURCES Medical Assistance Manual VICTIMS OF CRIME – HIWA-RESOURCE EXCLUSIONS 24 Sept MTL 04/24 RESOURCE TYPE DESCRIPTION

VICTIMS OF CRIME

1. Personal Property 2. Conditional Exclusion

Payments received from a fund established by a state to aid victims of crime are excluded for a 9–month period beginning the month after the payments are received.

Verification: (not all inclusive)

– Documents from source of payment

HIWA RESOURCE EXCLUSIONS:

Under the HIWA program the following resources are excluded:

● One vehicle ● Approved accounts of $15,000 or less ● Special needs trusts ● IRS recognized retirement accounts ● SSA death benefit payment ● Medical savings account ● Tax refunds ● Life insurance policies with cash surrender values of less than $50,000. ● Funeral/burial policies

(f-100)Nevada Medical Assistance Manual (MAM): F-100 Long Term Care Services#

(f-100)(page-1)Page 1#

LONG TERM CARE SERVICES F-100 PERSONS INSTITUTIONALIZED AT LEAST 30 CONSECUTIVE DAYS The term “institutionalized” refers to a person who is receiving long-term care services in a medical or nursing facility or has been screened and approved to receive Medicaid-covered Long-Term Care (LTC) services in the person’s home or community setting. The individual must be in the institution at least 30 consecutive days. In determining the number of days in a medical institution for eligibility purposes, include the date of admission, but not the date of discharge/death. Applications can be processed under this category prior to the 30th day based on a licensed physician’s statement the customer is likely to be in the institution at least 30 consecutive days. The customer must be an inpatient in a skilled nursing facility (SNF), intermediate care facility (ICF) or intermediate care facility for individuals with intellectual disabilities (ICF/IID), or hospital. Time spent in an institution for mental disease (IMD) is considered when determining institutionalization for 30 consecutive days when going to or from the IMD. If, when going from the IMD to a SNF, ICF or hospital, the customer was only temporarily transferred and not actually discharged, the time in the IMD cannot be counted toward length of time institutionalized. An "outpatient" stay is less than a 24–hour period regardless of the hour of admission, whether or not a bed is used or whether or not the patient remains in the facility past midnight. Before determining a person’s financial eligibility for a long-term care coverage category, first determine that the person resides in an institution and that all non-financial requirements have been met. Institutionalized persons must meet the same non-financial requirements as non-institutionalized persons. Special Medicaid eligibility rules, including a higher income limit, apply to institutionalized individuals. Specific provisions, known as spousal impoverishment, are used to evaluate the income and resources of institutionalized persons who are married. Eligibility begins the first day of the month in which the customer entered the medical facility, provided an application is received, and all other eligibility requirements met. F-100.1 Eligibility Exceptions • Individuals under age 65 who are inpatients in an institution for mental diseases (IMD) i.e., freestanding psychiatric hospital, are not eligible for Institutional Medicaid. • An IMD is a hospital, nursing facility or other institution of more than 16 beds primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services. Individuals are considered severely psychotic, emotionally ill, suicidal and a danger to themselves, others or property. In Nevada, IMDs are commonly referred to as "psychiatric hospitals." An institution for persons with intellectual disabilities IS NOT an institution for mental diseases F-100 LONG TERM CARE SERVICES Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25 PERSONS INSTITUTIONALIZED AT LEAST 30 CONSECUTIVE DAYS

(f-100)(page-2)Page 2#

• An inmate of a public institution is ineligible for Medicaid UNLESS the institution is a medical institution. An inmate of a penal institution is NEVER eligible for Medicaid while in the custody of law enforcement officials, UNLESS admitted as an inpatient to a hospital, nursing facility, juvenile psychiatric facility, or ICF. If determined Medicaid eligible, this individual is eligible for any Medicaid-covered services provided to them while an inpatient in these facilities. If this individual becomes an inpatient of a long-term care facility, they must meet level of care and plan of care assessments to become eligible. • Individuals under age 22 receiving inpatient psychiatric services in a Residential Treatment Center (RTC) are considered to be in an acceptable living arrangement. • RTCs specialize in treating children with conduct disorders, personality disorders, depression, hyperactivity, academic failure, and/or mild learning disabilities. Medicaid will pay for services provided in the RTC if the admission was prior authorized/certified by Medicaid’s Peer Review Organization (PRO). F-105 DEFINITIONS Institutionalized Spouse – a married person residing in a medical facility at least 30 consecutive days who has a spouse in an independent living situation. Community Spouse – a married person who is not in a medical facility whose spouse has been residing in a medical facility at least 30 consecutive days. Spouse – a person legally married to another under state law. In Nevada, a person is married until divorced. Medical Facility – a facility for skilled nursing or intermediate care, or a hospital. Spousal Share – an amount equal to one-half of the total resources (separately and jointly held) at the time of the spouse’s institutionalization. Community Spouse Maintenance Allowance – an amount of income and/or resources allocated to the community spouse to allow them to maintain residence in the community. Personal Needs Allowance – an amount of income institutionalized Medicaid recipients are allowed to keep to meet their own needs. Continuous Period of Institutionalization – institutionalized at least 30 consecutive days. To determine whether Spousal impoverishment resource provisions apply, a continuous period ends when the customer is absent from an institution for 30 consecutive days. Designation of Resources through a Court Order – resources and/or portions of resources ordered to the community spouse by a court of competent jurisdiction. Liquid Resources - cash and other items that can reasonably be converted to cash within 20 workdays. Non–Liquid Resources - items that are not cash and cannot be converted to cash within 20 workdays. F-100.1 LONG TERM CARE SERVICES Eligibility Exceptions Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25

(f-100)(page-3)Page 3#

Monthly Maintenance Needs Allowance – Nevada allows the Federal Maximum Maintenance Need Standard for all Spousal Impoverishment cases. No Court Order is required. Housing Costs (principal place of residence) - the community spouse's expenses for rent or mortgage payment (including principal and interest), property taxes and mortgage/rental insurance. In situations where a maintenance charge is required, allow only that portion which does not include personal or individual utility expenses. Standard Utility Allowance (SUA) – an amount established under SNAP which is the statewide average of total monthly utility costs. o Do not allow SUA if utilities are included with the rent and cannot be separately identified. o If the telephone service is the only utility, allow the telephone allowance instead of the full SUA. Excess Shelter Allowance - An amount (if any) determined by subtracting the Federal Excess Shelter Deduction (30% of 150% poverty for two persons) from the community spouse's housing costs, plus the SUA. F-110 BUDGETING PROCEDURES FOR FINANCIAL ELIGIBILITY-FORM 2203-EM Perform the gross income test to determine if an individual is eligible as an institutional case. Perform the net income test to determine which aid code is applicable. F-110.1 Gross Countable Income Test (Form 2203-EM: Side 1, Column 1) – Unearned Income, Earned Income and Division of Income. a. Enter the countable amount of all unearned income of the institutionalized individual. b. Enter the gross earned income of the institutionalized individual. c. Determine the total gross countable income by adding items A. and B. d. Compare the total gross countable income to the income limit. If the gross countable income is less than or equal to the income limit, the customer is eligible as a state institutional case. If gross countable income exceeds the income limit and the customer is married, apply the equal division of income rules using column 1, item C. If one-half of the countable gross marital income exceeds the income limit, the customer is ineligible for Medicaid. Example 1: Mary is a single individual living in a skilled nursing facility and her only income is $950 gross RSDI. Her total countable income (Side 1, Column 1, total of A and B) is $950. The institutional income limit is $2,313. Mary is income eligible. Example 2: Mary is a married individual living in a skilled nursing facility. Her income is $2150 gross RSDI. Her spouse’s income is $750 gross RSDI. Using Side 1, Column 1, C - the gross community income is $2900 ($2150 + $750= $2900/2=$1450). The institutional income limit is $2,313. Mary is income eligible. F-105 LONG TERM CARE SERVICES Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25 DEFINITIONS

(f-100)(page-4)Page 4#

F-110.2 Net Income Determination (Form 2203-EM: Side 1, Column 2) a. Enter the countable amount of all unearned income (or one-half of marital unearned income) from Column 1. b. Subtract the $20 general income exclusion from countable unearned income. c. Enter the gross amount of all earned income or one-half of the marital earned income (from Column 1) and subtract the following: 1. Any remaining general exclusion amount not offset by unearned income (example: unearned income is $16, leaving $4 left of the general exclusion); and 2. The earnings exclusion of $65; and 3. Impairment–related work expenses (IRWE). This exclusion only applies to earned income of disabled (but not blind) individuals under age 65. o The expense must be reasonable for items and/or services directly related to enabling an impaired individual to work and are necessarily incurred by the individual because of a physical or mental impairment. o IRWE’s are excludable if the cost is paid by the disabled individual and is not reimbursable from another source. 4. One-half of the remaining earned income. d. Determine total countable net income by adding Column 2, A-2 and B-2. e. Aid Code Determination – See appendix D for current benefit levels. SSI Institutional (SS) – These individuals are receiving the institutional $30.00 SSI payment. Would be SSI Eligible (WB) – These individuals have countable net income greater than $30.00 but less than the SSI payment level and would be receiving SSI or a state supplement if not residing in long-term care. Special Income (SI) – These individuals have countable net income between the SSI payment level and 142% of the SSI payment level. County Match (CM) – These individuals have countable net income exceeding the county match income limit (142% of the SSI payment level). The County pays the non-federal amount of assistance. F-115 RESOURCES FOR PERSONS INSTITUTIONALIZED AT LEAST 30 CONSECUTIVE DAYS Resources are assets, both real and personal, which an individual owns and can apply, either directly or by sale, to meet basic needs of food, clothing, shelter, and medical costs. Real property is land, including buildings or immovable objects attached permanently to the land. F-110.2 LONG TERM CARE SERVICES Net Income Determination Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25

(f-100)(page-5)Page 5#

Personal property is any property that is not real property. The term encompasses such things as cash, tools, life insurance policies, mobile homes, automobiles, bank accounts, etc. Any income retained the month following the month of receipt and later, is subject to resource evaluation. Evaluate resources at market value, less encumbrances. When the combined value of all countable resources does not exceed the resource limit, verification of encumbrances is not necessary. When the value of countable resources is under the resource limit on any day of the month, the customer is eligible for that month. All resources must be reported at the time of application, any time there is a change, and at redetermination. F-115.1 Ownership/Availability (Non-Spousal Impoverishment) If institutionalized prior to 09/30/1989, contact the Eligibility and Payments Unit for non-spousal impoverishment rules. F-115.2 Resource Provisions for Spousal Impoverishment Cases This section applies to ALL persons who begin a "continuous period of institutionalization" (medical/mental institution or a combination of both) on or after September 30, 1989 and who have a spouse in an independent living situation. These rules apply regardless of state laws relating to community property or to the division of marital property. If the community spouse dies prior to an eligibility decision, spousal impoverishment rules do not apply. Treat the case as a non-spousal case and apply the treatment of resource rules accordingly for all requested months of coverage. If the institutional spouse dies prior to an eligibility decision, spousal impoverishment rules apply. Treat the case as a spousal case from the date of application through the date of death of the institutional spouse. F-115.2.1 Ownership/Availability Sole Ownership - All of the resource evaluated at market value less encumbrances is available to the applicant/recipient or community spouse. Shared Ownership - Shared ownership of real or personal property means two or more people own it simultaneously. • Resource Jointly Owned Between Spouses a Liquid resources (bank accounts, certificates of deposit, stocks, bonds, etc.) Consider all liquid resources held jointly between spouses as available, in their entirety, to the institutionalized spouse only. Do not consider them as an "available resource" to the community spouse when determining the community spouse resource allowance. b Non–liquid resources (real property, vehicles, etc.) F-115 LONG TERM CARE SERVICES Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25 RESOURCES FOR PERSONS INSTITUTIONALIZED AT LEASE 30 CONSECUTIVE DAYS

(f-100)(page-6)Page 6#

When non–liquid resources are held jointly between spouses, consider only one–half as available to each spouse when determining the community spouse resource allowance. • Resources Jointly Held with Someone Other Than a Spouse a If the customer or community spouse is able to sell or dispose of a resource without another person's signature of approval, evaluate all of the resource at market value less encumbrances and considered available to the customer or community spouse. b If the customer or community spouse is able to sell or dispose of his/her share of a resource without another person's signature of approval, consider that portion evaluated at market value, less encumbrances as available to the customer or community spouse. • Exceptions a. When a resource is owned jointly by more than one TANF/Medicaid applicant/recipient (other than a community spouse), divide the resource equally among those applicants/recipients to whom available. b. When the customer is a representative payee or legal guardian for managing someone else's funds, these funds are not considered the customer’s resource when they are kept in an account separate and apart from the customer’s monies and can be identified as being received and designated for someone other than the customer. c. If the customer has a court order dividing resources, send a copy of the order to the Chief of Eligibility and Payments for a decision on whether DSS can recognize the order. F-115.2.2 Spousal Impoverishment Resource Determination An assessment of a couple’s total resources completed at the time of institutionalization. Nevada automatically allows the community spouse the maximum federal spousal resource standard. This amount does not change from year to year; it is based upon the year the institutionalized spouse applies for Medicaid, or at the time a request is received by the Division, to determine the total value of a couple’s resources. Complete this determination only once at the beginning of the first continuous period of institutionalization (beginning on or after 9/30/89). An institutionalized spouse, community spouse or their representative(s) may submit a written and signed request to the division at any time, to determine the total value of their resources. Make the determination whether or not the institutionalized spouse is applying for Medicaid. (See Task Guide - Case Initiation 03 for more information.) Determine and verify the total value of all countable resources owned separately or jointly by the institutionalized spouse and the community spouse as of the beginning of a "continuous period of institutionalization. F-1115.2.1 LONG TERM CARE SERVICES Ownership/ Availability Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25

(f-100)(page-7)Page 7#

If the request is not part of an application, make a determination within 45 days from the date of request unless delays are due to non–receipt of documentation/verification from the requesting party or third party. Ensure all documents for each assessment are imaged to the Virtual Case File in the Document Imaging System (DIS). Assessment documents retained in DIS are to include: the written request, the signed statement of resources owned by both spouses (Form 2794–EM), documentation and verification of the market value less encumbrances of all countable resources and Form 2793–EM "Assessment and Documentation of Resources." When an applicant applies for assistance and provides a spousal resource assessment completed from another state, review the assessment. If the assessment is correct, use the assessment as provided; however, if there is an error on the assessment, re-determine the resource assessment based on the error only. Once the error is corrected, the assessment is accepted. If more than one resource assessment is provided, review all assessments to determine acceptability. Form-2793 must notify the customer/spouse/authorized representative of hearing rights. If this form is printed, ensure that the right to a hearing is included with the form prior to mailing. F-115.2.3 Spousal Share of Resources at the Time of Institutionalization (Section I of Form 2797– EM) Complete this determination only once at the beginning of the first continuous period of institutionalization (beginning on or after 9/30/89). 1. Enter the community spouse's separate resources. 2. Enter the institutionalized spouse's separate resources. 3. Enter joint resources between spouses. 4. Divide TOTAL resources equally. This one–half portion of total resources is the "spousal share." F-115.2.4 Community Spouse Resource Allowance (Section II of Form 2797-EM) Nevada automatically allows the community spouse the maximum federal spousal resource standard. This amount does not change from year to year; it is based upon the year the institutionalized spouse applies for Medicaid, or at the time a request is received by the Division, to determine the total value of a couple’s resources. 1. Enter the state Medicaid maximum. 2. Enter the spousal share (one–half of resources at the time of the first continuous period of institutionalization) up to the federal maximum. 3. Enter the administrative hearing decision amount (if applicable). 4. Enter the court ordered amount (if applicable). 5. Enter the greatest of a, b, c, or d above. The state Medicaid and spousal share maximums change annually. Use the annual amounts applicable to the year associated with the months of requested coverage. The amount of resources (if any) determined from this computation is the community spouse resource allowance. F-115.2.2 LONG TERM CARE SERVICES Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25 Spousal Impoverishment Resource Determination

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F-115.2.5 Assignment of Resources at the Time of Application for Medicaid (Section III Form 2797–EM) Complete Section III for each month of requested Medicaid coverage. 1. Enter the community spouse's separate resources. 2. Enter the institutionalized spouse's separate resources. 3. Enter joint resources between spouses. 4. Total all resources. Subtract the total amount of Section II, item "f" from the total countable resources of both spouses. The difference (if any) will be the amount of resources applied toward the institutionalized spouse's resource limit. If the value exceeds the resource limit, the customer is ineligible. If the value is within the resource limit, the customer is resource eligible. CAUTION: There are situations in which the customer has separate resources and/or joint resources with their spouse (Section III b & c) which exceed the $2,000 resource limit (ineligible). This situation occurs even though the protected resource amount puts the countable resources for the customer’s eligibility (Section III f) within the $2,000 resource limit. A notice is sent to the community spouse which must advise them to place an amount of resources into their name, which will leave the customer’s resources under the $2,000 resource limit. This notice is generated when the spousal resource assessment is completed in the system. F-115.2.6 Permitting Transfer of Resources to the Community Spouse The applicant must transfer an amount up to the community spouse resource allowance to the community spouse's name only within 30 days from the date of the approval notice. In situations in which transferring the resource(s) cannot reasonably occur within the 30–day period, the customer, spouse and/or their representative(s) must substantiate the circumstances and provide an expected date the transfer will take place. The case manager must monitor, document and verify the situation until the transfer occurs. The customer, spouse and/or their representative(s) must continue to make every effort and take all possible steps to transfer the resource(s) to the community spouse. Failure to comply will cause the resources to count towards the institutionalized spouse's resource limit. State law regarding court orders giving state courts guidelines when protecting income and resources for the community spouse was amended effective October 1, 1993. The guidelines provide for an equal division of income and resources OR a protection of income not to exceed the federal maximum monthly maintenance needs allowance and a protection of resources which does not exceed the federal maximum spousal share. The court may order a greater amount of income for the support of the community spouse upon finding exceptional circumstances resulting in significant financial duress. The court may also transfer a greater amount of resources, in relation to the amount of income generated by the resource, if resources up to the federal maximum are not enough to fund the amount of income ordered. The transfer of resources policies DO NOT apply to transfers made under the provisions above. F-1115.2.5 LONG TERM CARE SERVICES Assignment of Resources at the Time of Application for Medicaid Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25

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F-115.2.7 Separate Treatment of Resources After Eligibility is Established During the "continuous period" of institutionalization and after the customer has been determined eligible, no resources of the community spouse are available to the customer, unless actually made available to the customer. If the community spouse in an ongoing case passed away, the only assets available to the institutionalized spouse are items received by a will after an order of the probate court, or anything held in joint tenancy. F-115.2.8 Undue Hardship An undue hardship determination may be requested at any time when applying spousal impoverishment rules, transfer of asset provisions, or when applying the home equity interest provision. If undue hardship is claimed as a result of a denial of eligibility for excess resources under spousal impoverishment rules, the applicant may be determined eligible, despite having excess resources, if all of the following conditions exist: 1. The institutionalized spouse is otherwise eligible for Medicaid without applying spousal impoverishment rules; and 2. The community spouse is the sole owner of liquid resources or non–liquid joint resources valued in excess of the federal maximum; and 3. The community spouse has refused to make the resources available to the institutionalized spouse; and 4. The institutional spouse has insufficient funds to cover the cost of institutionalized care; and 5. Without Medicaid, the institutionalized spouse would go without life sustaining medical care as determined by an individual licensed to practice medicine in the State of Nevada. NOTE: Undue hardship requests must address each point above. Send undue hardship requests to the Chief of Eligibility and Payments for evaluation and decision. F-115.2.9 Additional Resources Following Initial Eligibility If the institutionalized spouse acquires a new countable resource following the initial eligibility determination, his/her resource eligibility must be re–evaluated. Determine how much of the spousal protected resources (Line II "e") was used to transfer resources in the community spouse's name only. If there is a balance remaining, more resources countable to the institutionalized spouse can be protected for the community spouse so the institutionalized spouse remains resource eligible. Determine if the spousal protected resources have an unused balance in an amount equal to or more than the new resource. If not, and the excess of resources is over the resource limit, terminate Medicaid coverage allowing for adverse notice. If the balance of the spousal protected resources is enough to cover the new resource, apply the transfer to community spouse provisions as outlined in this section. F-115.2.7 LONG TERM CARE SERVICES Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25 Separate Treatment of Resources After Eligibility is Established

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Example #1: Liquid Resources The community spousal protected resources were determined to be $12,000. After approval, the community spouse transferred $8,600 of resources to his/her name only. This leaves a balance of $3,400 in spousal protected resources. Later, the institutionalized spouse receives a retroactive VA benefit check for $13,000; $10,000 remains the month after receipt and is a countable resource. Since the balance of the spousal protected resources is $3,400, this is the maximum that can be protected. The difference of $6,600 ($10,000 – $3,400) remains a countable resource to the institutionalized spouse and renders him/her ineligible for Medicaid. Example #2: Non-Liquid Resources The institutionalized and community spouse receives an inheritance of vacant land valued at $5,000. One–half is available to each spouse ($2,500). The spousal protected resources were determined to be $12,000. Of this $12,000, the community spouse used $6,000 to transfer resources to his/her name after approval. Therefore, the community spouse has a $6,000 balance in resource protection. One–half of the vacant land ($2,500) is available to the community spouse. Since there is a balance of $6,000 in protected resources, the institutionalized spouse remains resource eligible by protecting his/her share of the vacant land. Transfer his/her share of the vacant land ($2,500) to the community spouse. In this example, the new balance of the spousal protected resources would then be $3,500. F-115.3 Resource Exemptions Exclude one vehicle without regard to use or value. An individual who has received benefits under a qualified long-term care partnership insurance policy is eligible for a resource disregard equal to the amount of insurance benefits paid to or on behalf of the individual at the time of Medicaid application. Allow the resource disregard even if additional benefits remain available under the terms of the policy. Only qualified long-term care partnership policies purchased after January 1, 2007, meet the resource exemption rules. Beneficiaries must provide a certificate indicating the amount of benefits issued and certifying the policy as a qualified partnership policy. The state will not seek adjustment or recovery from the individual’s estate for assets or resources disregarded. Note: LTC resource exclusion does apply to home equity in excess of $713,000. F-115.4 Resource Limits The value of all countable resources of the customer cannot be more than $2,000. When the resource limit is exceeded, the case is ineligible. Individuals with home equity interest exceeding $713,000 are ineligible for long-term care services. F-120 PATIENT LIABILITY Patient liability is a post-eligibility calculation to determine the total amount of the institutionalized individual’s income applied to the cost of institutional care. There is no patient liability for any portion of institutionalization (full or partial month stays) in a VA hospital, AGCF, FCH, freestanding psychiatric hospital or RTC F-1115.2.9 LONG TERM CARE SERVICES Additional Resources Following Initial Eligibility Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25

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If the community spouse dies prior to an eligibility decision, spousal impoverishment rules do not apply. Treat the case as a non-spousal case and apply patient liability rules accordingly for all requested months of coverage. If the institutional spouse dies prior to an eligibility decision, spousal impoverishment rules do apply. Treat the case as a spousal case from the date of application through the date of death of the institutional spouse. Obtain verification of the community spouse's gross income and housing costs. • If income verifications are not received by the required date, the case will be completed without allowing a maintenance allowance. • If verification of housing costs and/or utility expense is not received, compute the spousal income allowance without it. • Notify the customer on the Notice of Decision, that patient liability was determined without a maintenance allowance deduction. If verifications are received after the patient liability has been determined, the maintenance allowance deduction will be allowed beginning the month the verification was received. The community spouse monthly income allowance deduction will be discontinued if the agency receives information that the community spouse is not receiving the maintenance allowance. F-120.1 Treatment of Income, Deductions and Expenses The division of income policy DOES NOT APPLY when determining patient liability. Consider all income the payor designates as the institutionalized spouse’s income when determining patient liability, unless otherwise excluded. When determining patient liability for initial and ongoing cases, budget income for the month received and deductions/expenses for the month they are paid and/or incurred. With receipt of unanticipated income, adjust patient liability for the month it is received, not to exceed the actual cost of care for the month. If the payor designates payment to both the institutionalized and community spouse, consider one-half of the income available to each of them. If the payor designated payment in the names of the institutionalized and community spouse, or both, and to another person(s), consider the income available to each person in proportion to the person’s interest. If payment is made with respect to both spouses and no such interest is specified, one-half of the joint interest shall be considered available to each spouse. If the customer has a court order granting a spousal maintenance allowance, a copy of the order must be sent to the Chief of Eligibility and Payments for a decision on whether the Division of Social Services (DSS) can recognize the order. The response from the Chief takes precedence. F-120 LONG TERM CARE SERVICES Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25 PATIENT LIABILITY

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F-120.2 Partial Month Proration Prorate the amount of patient liability according to the number of days the customer was in a facility when the person is institutionalized less than a full calendar month due to: a. Date of admission. b. Discharge to independent living, VA hospital, AGCF, FCH, freestanding psychiatric hospital or RTC. c. Partial month of eligibility due to transfer of asset penalty. d. Death. Determine what the patient liability would be for a full month. Divide that full month amount by the number of days in the month of partial institutionalization to determine the daily amount of patient liability. Multiply this daily amount by the number of days the customer was institutionalized in that month (include the day of admission but not the day of discharge/death). The result is the amount of patient liability due for the partially institutionalized month. F-120.3 Effective Date of Patient Liability a. State Institutional o Patient liability is effective the first month of eligibility (this includes requested months prior to the application month). b. State Institutional/QMB o Hospital Stay: Establish patient liability effective the first day of institutionalization and send the appropriate notice(s). The Fiscal Intermediary will make the decision when patient liability will be collected and will advise the facility when they can begin collecting it. c. Income Changes (ongoing cases) o Applicants/recipients are required to report changes in circumstances by the 5th of the following month. o When a change is reported timely, the agency is required to update the next administratively possible month, allowing 13 days advance notice if the action adversely impacts the customer. o If the change/information was not reported timely and results in a difference of $25 or more, retroactively update the case back to the first month which should have been affected. Example #1: The customer or authorized representative fails to disclose at application that the customer receives a pension each month. The case manager discovers the income at the regularly scheduled redetermination. The difference in monthly patient liability is greater than $25. Because the customer failed to disclose the income, patient liability is adjusted retroactively to the month that should have been affected. See FAME Task Guide Eligibility-04 for instructions on modifying P/L for a previously posted version. F-120.2 LONG TERM CARE SERVICES Partial Month Proration Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25

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Example #2: The case manager incorrectly allows a garnishment for back taxes as an income deduction and calculates the patient liability using net income after the garnishment. The mistake is discovered during a supervisory case review. Because the agency incorrectly calculated patient liability by allowing the deduction, do not adjust patient liability retroactively; adjust patient liability the next administratively possible month, allowing for adverse notice. d. Deceased customer o Notify the facility of the patient liability amount due for the month of death. The facility will collect only for charges actually incurred. Deposit any unused patient liability in the patient trust fund account. F-120.4 Notification of Patient Liability/Case Status Upon approval or when patient liability changes, the customer, authorized representative(s) and facility are notified on a Notice of Decision of the amount and effective date. When the customer moves from one facility to another, notify the facilities of the current case status and monthly patient liability if this information has not already been provided to them in or for that month. F-120.5 Patient Liability Budgeting Procedures – Form 2220–EM/A a. Determine the customer’s total gross countable monthly income. 1. Subtract income excluded in patient liability b. Subtract the following items from total monthly income in the following order: 1. Personal Needs Allowance a Deduct a $154 personal needs allowance (PNA) for each month of institutionalization. b Additional personal needs – Institutionalized individuals with no community spouse living in the home but with other dependent family members in the home are allowed an additional personal needs allowance based on household size. The additional personal needs amount is determined by subtracting the 1996 needs standard of $459 from the current TANF need standard for the household size. Note: this requires a NOMADS work around. 2. Community Spouse Monthly Income Allowance Income allocated to the community spouse for maintenance. This amount (if any) is determined by subtracting any of the community spouse’s income which is considered available (including need-based assistance like TANF, SSI, etc.), from the monthly maintenance allowance. DO NOT count VA UME as income considered available to the community spouse. F-120.3 LONG TERM CARE SERVICES Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25 Effictive Date of Patient Liability

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-- Customer do not have to request the maintenance allowance for their spouse/dependents. The case manager will automatically request the information necessary to determine the maintenance allowance when there is a spouse or dependents at home. 3. Family Allowance (Spousal Impoverishment) Family members must be a dependent child, dependent parent(s) or dependent sibling(s). The child, parent or sibling must be residing in the home of the community spouse and claimed by the community spouse or institutionalized spouse as dependent(s) for federal income tax purposes. The amount determined to be the family allowance is deducted from the institutionalized spouse's countable income effective with the first month in which the continuous period of institutionalization is met, or if this deduction was not previously allowed, the deduction will be allowed effective the first month following the month in which the change is reported. The family allowance deduction need not be determined if the $154 personal needs allowance, in combination with the community spouse monthly income allowance, makes the patient liability zero. Obtain verification of each family member's gross income. a Subtract the family member's gross income from minimum needs allowance (150% of poverty). b Divide the amount from above by three. This is one family member's allowance. Repeat this calculation for each family member. If there is more than one family member, add each family member's allowance to determine the total family allowance deduction. 4. Dependent Allowance (Non-Spousal Impoverishment) The dependent allowance is a monthly income allowance for each dependent family member living in the institutionalized individual’s home with no community spouse living in the home. Determine the dependent allowance by subtracting the dependent's total income from the Need Standard (100% Need Standard) for the household size. 5. Expenses Incurred For Health Insurance Premiums, Deductibles and Co– Insurance Charges Deduct health insurance premiums, deductibles and co–insurance expenses incurred by the customer. Customers/Representatives must advise the agency of medical insurance and provide proof of expenses. These expenses must not be paid or subject to payment by a third party. F-120.5 LONG TERM CARE SERVICES Patient Liability Budgeting Procedures – Form2220 EM/A Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25

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NOTE: Medicare premiums are subject to payment by a third party. For an institutional case in which the customer is not an SSI recipient and will not receive a reimbursement for Medicare cost from any source, deduct the Medicare premium as an expense for months immediately preceding the second month after the month of approval. Example #1 (Medicaid Only): Customer applied June 2nd and requested 3 months prior medical. Case is approved July 10th. Deduct Medicare premiums from March through August. Beginning September do not deduct the Medicare premium, as it is then subject to third–party payments. Example #2 (Medicaid/QMB): Customer applied for Medicaid/QMB on June 2nd and requested 3 months prior medical. In June, QMB eligibility is established, and benefits begin effective July 1st. Then, on July 20th Medicaid eligibility is established back to March. Deduct Medicare premiums for March, April, May and June only. Effective July and ongoing, the premiums are subject to third–party payments as QMB coverage began in July. 6. Expenses Incurred For Medical Care Deduct expenses incurred by the customer for necessary medical care recognized under the state law but not covered under the Medicaid Program. This includes medical expenses incurred more than three months prior to the date of application. Customer/Representatives must advise the agency and submit proof of the expenses. The case manager must attach a copy of the medical bill plus all related medical records to Form-2536 and submit it to DHCFP for approval. These expenses must not be paid or subject to payment by a third party. DHCFP approval is required to assure the deduction is for necessary care payable to reasonable limits. c. The deficit, if any, is the customer’s share of facility cost (PATIENT LIABILITY). F-120.5 LONG TERM CARE SERVICES Division of Social Services Medical Assistance Manual 08 Aug MTL 08/25 Patient Liability Budgeting Procedures – Form2220 EM/A

(f-200)Nevada Medical Assistance Manual (MAM): F-200 Home and Community Based Waivers#

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Division of Welfare and Supportive Services F-200 Medical Assistance Manual HOME AND COMMUNITY BASED SERVICES 24 Jan 25 MTL 02/24 HOME AND COMMUNITY BASED SERVICES

HOME AND COMMUNITY BASED SERVICES

F-200 HOME AND COMMUNITY BASED SERVICES

F-200.1 Eligible Groups

Eligibility under each waiver is determined in combination with the agency administering the waiver.

a. Aged Individuals - Living in the Community

Waiver for the Frail Elderly (aka Community Home Based Initiatives Program (CHIP))

1. Administration – Aging and Disability Services Division (ADSD).

2. Aid Code – HC

b. Aged Individuals – Living in an Adult Group Care Facility

Waiver for Elderly Adult in Residential Care (WEARC)

1. Administration – Aging and Disability Services Division (ADSD).

2. Aid Code – HG

c. Aged Individuals – Living in Assisted Living Facility

Assisted Living Waiver

1. Administration – Aging and Disability Services Division (ADSD).

2. Aid Code – AL

3. Eligibility for this waiver is limited to Clark County.

d. Blind/Disabled Individuals

Waiver for Persons with Physical Disabilities (aka Waiver for Independent Nevadans (WIN))

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F-200.1 Division of Welfare and Supportive Services HOME AND COMMUNITY BASED SERVICES Medical Assistance Manual Eligible Groups 24 Jan 25 MTL 02/24

1. Administration – Division of Health Care Financing and Policy District Offices (DHCFP).

2. Aid Code – HD

e. Persons with Intellectual Disabilities

Waiver for Persons with Intellectual Disabilities and Related Conditions.

1. Administration – Aging and Disability Services Division (ADSD).

2. Aid Code – HR

F-200.2 Identification of Applicants/Recipients Who May Be Eligible

Individuals eligible for this category of assistance will be identified in the following ways:

a. Individuals referred to the administering division will be pre-screened for nursing home level of care. The screening is completed by the administering division staff.

b. Medicaid applications or inquiries which do not appear eligible in any other category but have indicated a need for home based services, will be referred by the case manager to the appropriate division for pre-screening.

Note: The case manager should submit a referral if they see a need even if it is not indicated on the application.

F-205 DEFINITIONS

Institutionalized Spouse - a married person residing in a medical facility at least 30 consecutive days (including Home and Community Based Services Waiver - HCBW customers) with a spouse in an independent living situation.

Community Spouse - a married person who is not in a medical facility or receiving HCBW services whose spouse has been residing in a medical facility or receiving HCBW services at least 30 consecutive days.

Medical Facility - a facility for skilled nursing or intermediate care, or a hospital.

Spousal Share – an amount equal to one-half of the total resources (separately and jointly held) at the time of the customer’s institutionalization/application for HCBW services.

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Division of Welfare and Supportive Services F-205 Medical Assistance Manual HOME AND COMMUNITY BASED SERVICES 24 Jan 25 MTL 02/24 Definitions Community Spouse Resource Allowance – an amount of resources allocated to the community spouse for his/her maintenance.

Continuous Period of Institutionalization – institutionalized for 30 days or determined to meet the level of care for home based services.

Designation of Resources through a Court Order – resources and/or portions of resources ordered to the community spouse by a court of competent jurisdiction.

Liquid Resources - cash and other items which can reasonably be converted to cash within 20 work days.

Non-Liquid Resources - items which are not cash and cannot be converted to cash within 20 work days.

F-210 ELIGIBILITY REQUIREMENTS

Individuals applying under this category must meet each of the following:

a. CHIP Waiver – Aged Individuals – Living in the Community

1. Be age 65 or over;

2. Be living at home;

3. Require a level of care provided in a nursing facility (determined by ADSD);

4. Have medical costs for home care which are less than if the customer were institutionalized (determined by ADSD); 5. Meet all financial and non-financial eligibility criteria of an institutional case except for residing in an institution; and 6. Be approved, post eligibility, for and receiving home-based services (determined by DHCFP).

b. WEARC Waiver – Aged Individuals – Living in an Adult Group Care Facility

1. Be age 65 or over;

2. Currently residing in a hospital, nursing facility, the community at large, or receiving waiver services in their home;

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F-210 Division of Welfare and Supportive Services HOME AND COMMUNITY BASED SERVICES Medical Assistance Manual ELIGIBILITY REQUIREMENTS 24 Jan 25 MTL 02/24

3. Meet all financial and non-financial eligibility criteria of an institutional case except they reside in a group home rather than an acute care or skilled nursing facility;

4. Require a level of care provided in a nursing facility (determined by ADSD); and

5. Demonstrate he/she would be safe in a group care environment (determined by ADSD). c. AL Waiver – Aged Individuals – Living in Assisted Living Facility – Clark County only

1. Be age 65 or over;

2. Meet the criteria for placement in an assisted living facility;

3. Meet all financial and non-financial eligibility criteria of an institutional case except they reside in an assisted living facility;

4. Require a level of care provided in a nursing facility (determined by ADSD); and

5. Demonstrate he/she would be safe in an assisted living environment.

d. WIN Waiver – Blind/Disabled Individuals

1. Be living at home;

2. Meet blindness/physical disability criteria;

Blindness/disability criteria are the same as the Social Security Administration's.

If the customer is currently receiving disability benefits through SSA, use disability onset date as verification of disability.

If the customer is not receiving Social Security Disability, or if the customer is pending a disability decision through the SSA, the DHCFP case manager will initiate Form NMO-3004 and send with medical records to the DHCFP waiver team. DHCFP will determine if the applicant meets the criteria for the physically disabled. The DWSS case manager will receive the original NMO-3004 form and a copy of Form NMO-3010 approving or denying waiver admission.

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Division of Welfare and Supportive Services F-210 Medical Assistance Manual HOME AND COMMUNITY BASED SERVICES 24 Jan 25 MTL 02/24 ELIGIBILITY REQUIREMENTS 3. Require a level of care provided in a nursing facility (determined by DHCFP District Office staff);

4. Be approved, eligible for and receiving home based services (determined by DHCFP); and

5. Meet all financial and non-financial eligibility criteria of an institutional case except for residing in an institution.

e. MR Waiver - Persons with Intellectual Disabilities

1. Be diagnosed as having an intellectual disability or related condition, or evaluated and certified to need placement in an intermediate care facility for individual with intellectual disabilities (ICF/IID) within 30 to 60 days if waiver services were not available (determination made by ADSD);

2. Be living at home, in a foster home, group care home or a supported living arrangement (SLA) which is overseen by ADSD; and

3. Meet all financial and non-financial eligibility criteria of an institutional case except for residing in an institution.

F-215 ELIGIBILITY DETERMINATION PROCESS

Two separate eligibility determinations must be made on these cases:

a. Administering division - will have the individual complete an application packet and send with Form NMO-3010 to DWSS when the applicant/recipient is pending approval for waiver admission to their program.

The administering division is responsible for completing an assessment to determine if the recipient meets the need for an appropriate level of care.

b. DWSS - is responsible for determining if the applicant meets all financial and non-financial Medicaid eligibility criteria.

c. DHCFP Central Office - The DHCFP waiver team will review the application/packet with the NMO-3010 and complete a post approval waiver admission, notifying the administering division by sending Form NMO-3010.

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F-215 Division of Welfare and Supportive Services HOME AND COMMUNITY BASED SERVICES Medical Assistance Manual ELIGIBILITY DETERMINATION PROCESS 24 Jan 25 MTL 02/24 Note: Medicaid cannot be approved/continued under this category unless the customer is found eligible in both areas.

To make the Medicaid eligibility determination, the following steps must then be taken:

a. If the applicant is not eligible for Medicaid, the case manager will deny the case. A copy of the Notice of Decision with Form NMO-3010 will be sent to the administering division and notifying them of the denial.

b. If the HCBW services are denied, the administering division will send the denial information via Form NMO-3010. The Medicaid application will then be denied if the applicant does not qualify under another category of eligibility.

c. If the waiver team denies waiver admission, the Medicaid application will be denied for the reason given on Form NMO-3010, unless the applicant qualifies for another category of eligibility.

d. If the administering division determines the individual meets the criteria for home based services, they will send Form NMO-3010 to DWSS and the administering division’s case managers with the decision.

e. The DWSS case manager will approve Medicaid eligibility and apply the appropriate aid code, using the effective date provided on Form NMO-3010, if all other eligibility criteria are met.

The DWSS case worker will send Form NMO-3010 verifying approval back to the administering division and notify the DHCFP waiver unit in Central Office via email within two (2) days of approval.

If the application was previously denied for non-cooperation and the customer reapplies and/or cooperates with verifications, contact the administering agency prior to approval to determine if the waiver slot is still available.

f. If Form NMO-3010 indicates the individual is eligible but is on a waiting list, and the individual meets financial eligibility, the case will remain pending up to the 45 day processing timeframe. Contact the administering division case manager at 45 days to determine if the waiver slot has become available. If no slot is available, deny eligibility.

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Division of Welfare and Supportive Services F-215 Medical Assistance Manual HOME AND COMMUNITY BASED SERVICES 24 Jan 25 MTL 02/24 ELIGIBILITY DETERMINATION PROCESS

Note: 45 days for aged and 90 days for disabled unless extenuating circumstances exist.

g. The DHCFP waiver unit will enter the individual’s benefit plan into the MMIS database when notification of approval is received. The plan will start on the date listed on Form NMO-3010 or the date Medicaid eligibility is established, whichever date is later.

h. The waiver benefit will remain in MMIS until/unless the DHCFP waiver team in DHCFP central office is notified by the case manager to terminate the benefit, or until the individual loses Medicaid eligibility. DWSS case manager should notify DHCFP waiver unit of all waiver approval, termination and reinstatements via email within two (2) business days.

i. If a case terminates and is subsequently reinstated prior to the end of the month (effective date of closure), the customer’s approved waiver admission will continue in MMIS.

j. If a case is reinstated after the end of the month, email the DHCFP waiver team, who will determine the status of the prior approved waiver. If the waiver team finds the waiver admission open, Form NMO-3010 will be sent and Medicaid eligibility will be reinstated, and the prior approved waiver continues. If the waiver team finds the prior approved waiver admission ended, the individual must complete and submit another application packet with Form NMO-3010 through the administering division case manager to the waiver team for waiver admission.

k. Copies of all notices, such as approvals, denials, and P/L, which are usually sent to the institution, will be sent to the administering division by entering them as the secondary representative in the Authorized Representative screen.

Note: If the applicant falls into another eligible category, such as SSI, QMB or SLMB, approve the case under that category and do not wait for the HCBW services decision. Notify the administering division the case has been approved under another category of Medicaid. Eligibility can be updated once it is determined the customer is eligible for HCBW services. If it appears the person may be eligible for SSI, refer them to apply, but do not hold the case if they can be approved sooner under this category.

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F-220 Division of Welfare and Supportive Services HOME AND COMMUNITY BASED SERVICES Medical Assistance Manual INCOME 23 Oct 01 MTL 04/23 F-220 INCOME

Income means the receipt of money in the month for which an eligibility determination is being made. All income or changes in income must be reported. All income must be evaluated for financial eligibility.

F-220.1 Ownership/Availability

F-220.1.1 Sole Ownership

All income which a payer designates as the customer’s will be considered in determining eligibility.

When a benefit or income is received for more than one person or family member, only the customer’s portion of the income is considered.

F-220.1.2 Shared Ownership

a. Deeming: Does not apply.

b. Dividing:

If it is in the applicant's best interests for financial eligibility, the case manager will divide the total income of spouses who are living separate and apart (due to institutional status of Waiver program) equally between them. Only the applicant's share of the income will be considered when determining eligibility; however, if a portion of the spouse's income is made available to the applicant, that portion is counted as income to the customer in determining eligibility.

Married persons are considered to be living separate and apart when both spouses are residing in a medical facility and when qualifying under the HCBW category.

Dividing income takes precedence over the joint bank account procedures. Income deposited in a joint bank account held by both spouses will NOT be considered as "being made available."

c. Court Orders:

If the customer has a court order designating spousal income and/or customer income trust document, a copy of the court order and/or trust must be sent to the Chief of Eligibility and Payments for a decision on whether DWSS can recognize the court order or trust.

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Division of Welfare and Supportive Services F-220.1.2 Medical Assistance Manual HOME AND COMMUNITY BASED SERVICES 23 Oct 01 MTL 04/23 Shared Ownership d. Exceptions:

Monies received by the customer in his/her capacity as an agent are not income to him/her. An "agent" is a person acting on behalf of someone, such as a representative payee, guardian, conservator, etc.

F-220.2 Treatment of Income

When determining financial eligibility, budget income for the month it is received.

Regular unearned income deposited directly into a financial institution is considered received in the month for which it is intended to be received.

Section 1917 of the Social Security Act established that a Qualified Income Trust (QIT), also known as Miller Trust*, may be used by individuals applying for or receiving Home and Community Based Waiver (HCBW) services to reduce the amount of countable income when determining eligibility for the HCBW program.

*Note: A QIT, or Miller Trust, helps an individual living in a long-term care setting to potentially qualify for Medicaid if his or her income exceeds the allowable income limit.

When a one-time lump sum payment is received, evaluate as a resource in future months.

a. Intake Cases

Individually determine financial eligibility for each month of requested coverage.

b. Ongoing Cases

Financial eligibility is always determined prospectively (future month). When information becomes known which causes ineligibility prospectively terminate benefits allowing adverse action.

F-220.3 Income Limits

See income chart in Appendix C.

F-220.4 Budgeting Procedures for Financial Eligibility - Form 2203-EM

a. Gross Countable Income Test

1. Enter the countable amount of all unearned income.

2. Enter the gross earned income.

3. Determine total gross countable income by adding items I- A and I-B.

4. Compare the total gross countable income to the income limit. If gross countable income is less than or equal to the income limit, the

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F-220.4 Division of Welfare and Supportive Services HOME AND COMMUNITY BASED SERVICES Medical Assistance Manual Budgeting Procedures For Financial Eligibility-Form 2203-EM 23 Oct 01 MTL 04/23 customer is eligible under the HCBW category.

If gross countable income exceeds the income limit, the customer is not eligible for the HCBW category.

If gross countable income exceeds the income limit and the customer is married, apply the equal division of income rules. If one-half of countable gross marital income exceeds the income limit, the customer is ineligible for Medicaid.

F-225 RESOURCES

Resources are defined as those assets, both real and personal, which an individual owns and can apply, either directly or by sale, to meet basic needs of food, clothing, shelter and medical costs.

Real property is land, including buildings or immovable objects attached permanently to the land.

Personal property is any property that is not real property. The term encompasses, but is not limited to, such things as cash, tools, life insurance policies, mobile home, automobiles, bank accounts, etc.

Any income retained the month following the month of receipt and later, is subject to resource evaluation.

Resources are evaluated at market value less encumbrances. When the combined value of all countable resources does not exceed the resource limit, verification of encumbrances is not necessary.

When the value of countable resources is under the resource limit on any day of the month, the customer is eligible for that month.

All resources must be reported.

F-225.1 Ownership/Availability

F-225.1.1 Sole Ownership

Sole ownership of real or personal property means only one person may sell, transfer or otherwise dispose of the property. All of the resource evaluated at market value less encumbrances is available to the customer.

F-225.1.2 Shared Ownership

Shared ownership of real or personal property means two or more people own it simultaneously. The following are common types of shared ownership:

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Division of Welfare and Supportive Services F-225.1.2 Medical Assistance Manual HOME AND COMMUNITY BASED SERVICES 23 Oct 01 MTL 04/23 Shared Ownership a. Tenancy-In-Common

Two or more persons each have an undivided fractional interest in the whole property for the duration of the tenancy. These interests are not necessarily equal. One owner may sell, transfer or otherwise dispose of his/her share of the property without permission of the other owner(s); but cannot take these actions with the entire property. If a tenant-in-common dies, the deceased’s interest passes to his/her estate or heirs. Count the fair market value less encumbrances of the customer’s property share.

b. Joint Tenancy

Each of two or more persons has one and the same undivided ownership interest and possession of the whole property for the duration of the tenancy. This means each owner owns ALL the property. If a joint tenant dies, the survivor becomes the sole owner. If more than one joint tenant survives, the survivors become joint tenants of the entire property interest. Count the total fair market value less encumbrances of the entire property.

c. Tenancy by the Entirety (Married Couples only)

This type of ownership can only exist between married couples. The wife and husband as a unit own the entire property and can be sold only with the consent of both parties. However, if a legal divorce occurs, the former spouses become tenants-in-common and one can sell his/her share without the consent of the other. If one spouse dies, the survivor becomes the sole owner. Verify whether the customer’s spouse will give permission to sell the property. If permission cannot be obtained, DO NOT count the customer’s one-half share of the property.

d. Exceptions

When a resource is owned jointly by more than one TANF/Medicaid applicant/recipient (other than a community spouse), divide the resource equally among those applicants/ recipients to whom available.

When a customer is representative payee or legal guardian managing someone else's funds, these funds are not considered the customer’s resource when they are kept in an account separate and apart from the customer’s monies AND can be identified as being received and designated for someone other than the customer.

F-225.1.3 Treatment of Resources

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F-225.1.3 Division of Welfare and Supportive Services HOME AND COMMUNITY BASED SERVICES Medical Assistance Manual Treatment of Resources 23 Oct 01 MTL 04/23 a. Deeming: Does not apply.

b. Dividing:

The agreement is effective the month it is signed as long as the spouses were living separate and apart at least part of the month. An agreement cannot be effective for months prior to the date the arrangement was signed.

Married persons are considered to be living separate and apart when both spouses qualify under the HCBW category.

The written agreement must include the following:

1. A specific listing of all resources being divided.

2. A statement specifying which resources are being given to whom.

Example: A couple has resources totaling $2,000. These resources consist of $1,000 cash in savings, $500 in a CD and $500 in stocks. The agreement must specify exactly which resources the agreement is designating as the customer’s and which are the spouse's. They cannot simply state $1,000 of the total resources belong to the customer and $1,000 belong to the spouse.

In this example, an acceptable written agreement would:

- designate to the customer $500 of the savings account and the $500 CD.

- designate to the spouse $500 of the savings account and $500 in stocks.

Do not require couples to liquidate resources when considering an equal division, as long as the written agreement specifically designates which resources or a portion of resources belongs to the customer and spouse.

3. The signature of the customer and the customer’s spouse or the signature of a legal representative of the customer and the customer’s spouse. A legal re is defined as a person who has legal authority

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Division of Welfare and Supportive Services F-225.1.3 Medical Assistance Manual HOME AND COMMUNITY BASED SERVICES 23 Oct 01 MTL 04/23 Treatment of Resources

such as a legal guardian, power of attorney, etc. Being an authorized representative does not give that person legal authority.

If the spouse of the customer makes a portion of his/her resources available to the customer, that portion is counted as a resource to the customer.

c. Court Order

When a court order equally divides resources between spouses, only the portion the court order specifies as the customer’s is counted when determining eligibility, UNLESS the spouse makes a portion of his/her resources available to the customer. The portion made available to the customer is counted as a resource in determining eligibility.

If the customer has a court order dividing resources unequally a copy of the court order must be sent to the Chief of Eligibility & Payments for a decision on whether DWSS can recognize the court order.

d. Inaccessible Resources

The cash values of resources which are not legally available to the household are exempt. If the Medicaid applicant/recipient or authorized representative is able to verify a resource is unavailable due to the customer’s inability to access the resource due to incapacity, and no one else has the ability to access the resource on their behalf, exempt the value of the resource as long as reasonable and timely steps are being taken to access the account on the customer’s behalf, such as a referral to the public guardian’s office. Once the resource becomes accessible, the resource becomes countable and eligibility must be reevaluated for future months.

F-225.2 Resource Provisions for Spousal Impoverishment Cases

This section applies to all persons who are likely to begin a "continuous period of services" under a HCBW on or after September 30, 1989 and who have a spouse in an independent living situation (e.g., the spouse is not receiving HCBW services or is not residing in a nursing facility).

If the community spouse dies prior to an eligibility decision, spousal impoverishment rules do not apply. Treat the case as a non-spousal case and apply the treatment of resource rules accordingly for all requested months of coverage.

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F-225.2 Division of Welfare and Supportive Services HOME AND COMMUNITY BASED SERVICES Medical Assistance Manual Resource Provisions for Spousal Impoverishment Cases 23 Oct 01 MTL 04/23 If the institutional spouse dies prior to an eligibility decision, spousal impoverishment rules do apply. Treat the case as a spousal case from the date of application through the date of death of the institutional spouse.

F-225.2.1 Ownership/Availability

a. Sole Ownership

All of the resource evaluated at market value less encumbrances is available to the applicant/ recipient or community spouse.

b. Shared Ownership

1) Resources Jointly Owned Between Spouses

a) Liquid Resources (bank accounts, certificates of deposit, stocks, bonds, etc.).

All liquid resources held jointly between spouses are considered available in their entirety to the institutionalized/HCBW customer only. They are not considered an "available resource" to the community spouse when determining the community spouse resource allowance.

b) Non-liquid Resources (real property, vehicles, etc.)

When non-liquid resources are held jointly between spouses, consider only one-half as available to each spouse when determining the community spouse resource allowance.

2) Resources Jointly Held With Someone Other Than a Spouse

a) When the customer or community spouse is able to sell or dispose of a resource without another person's signature of approval, all of the resource is evaluated at market value less encumbrances and considered available to the customer or community spouse.

b) When the customer or community spouse is able to sell or dispose of his/her share of a resource without another person's signature of approval, that portion evaluated at market value less encumbrances is available to the customer or community spouse.

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Division of Welfare and Supportive Services F-225.2.1 Medical Assistance Manual HOME AND COMMUNITY BASED SERVICES 23 Oct 01 MTL 04/23

Ownership/Availability c. Exceptions

When a resource is owned jointly by more than one TANF/Medicaid applicant/recipient (other than a community spouse), divide the resource equally among those applicants/recipients to whom available.

When a customer is representative payee or legal guardian managing someone else's funds, these funds are not considered the customer’s resource when they are kept in an account separate and apart from the customer’s monies and can be identified as being received and designated for someone other than the customer.

If the customer has a court order dividing resources, a copy of the order must be sent to the Chief of Eligibility and Payments for a decision on whether DWSS can recognize the order.

F-225.2.2 Resource Determination

a. Spousal Impoverishment/Resource Determination – An assessment of a couple's total resources completed at the time of institutionalization/application for HCBW Services.

This determination is only completed once at the beginning of the first application for HCBW services (beginning on or after 9/30/89).

The HCBW customer, community spouse or their representatives may submit a written and signed request to DWSS to determine the total value of their resources. The determination shall be made whether or not the HCBW customer is applying for Medicaid.

Determine and verify the total value of all countable resources owned separately or jointly by the HCBW customer and the community spouse as of the beginning of a continuous period of institutionalization or as of the date the customer is eligible for home based waiver services.

If the request is not part of an application, the determination must be completed within 45 days from the date of request unless delays are due to non-receipt of documentation/verification from the requesting party or third party. Make up a case file for each assessment. The case file shall contain the written request, the signed statement of resources owned by both spouses (Form 2794-EM), documentation and verification of the market value less encumbrances of all countable resources and Form 2793-EM "Assessment and Documentation of Resources." These files will be kept alphabetically and retained indefinitely.

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F-225.2.2 Division of Welfare and Supportive Services HOME AND COMMUNITY BASED SERVICES Medical Assistance Manual Resource Determination 23 Oct 01 MTL 04/23 When an applicant applies for assistance and provides a spousal resource assessment completed from another state, the assessment must be reviewed. If the assessment is done correctly, use the assessment as provided.

However, if an error(s) is found on the assessment, redetermine the resource assessment based on the error(s) only. Once the information in error is corrected, the assessment can be accepted. If more than one resource assessment is provided, review all assessments to determine acceptability.

b. Spousal Share of Resources at the Time of Application for HCBW Services (Section I of Form 2797-EM)

This determination is only completed once at the beginning of the first application for HCBW services (beginning on or after September 30, 1989), unless additional resources are received after the determination.

1. Enter the community spouse's separate resources.

2. Enter the HCBW customer’s separate resources.

3. Enter joint resources between spouses.

4. Divide total resources equally.

This one-half portion of total resources is the "Spousal Share."

c. Community Spouse Resource Allowance (Section II of Form 2797-EM)

1. Enter the state Medicaid maximum.

2. Enter the spousal share (one-half of resources at the time of the first continuous period of institutionalization or the first application for HCBW services) up to the federal maximum.

3. Enter the administrative hearing decision amount (if applicable).

4. Enter the court ordered amount (if applicable).

5. Enter the greatest of 1, 2, 3, or 4 above.

The state Medicaid and spousal share maximums change annually. Use the annual amounts applicable to the year associated with the months of requested coverage.

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Division of Welfare and Supportive Services F-225.2.2 Medical Assistance Manual HOME AND COMMUNITY BASED SERVICES 23 Oct 01 MTL 04/23 Resource Determination The amount of resources (if any) determined from this computation is the community spouse resource allowance.

d. Assignment of Resources at the Time of Application for Medicaid (Section III of Form 2797-EM)

Complete Section III for each month of requested Medicaid coverage.

1. Enter the community spouse's separate resources.

2. Enter the HCBW customer’s separate resources.

3. Enter joint resources between spouses.

4. Total all resources.

Subtract the total amount of Section II item "e" from the total countable resources of both spouses. The difference (if any) will be the amount of resources applied toward the HCBW customer’s resource limit.

If the value exceeds the resource limit, the customer is ineligible. If the value is within the resource limit, the customer is resource eligible.

CAUTION: There are situations where the customer has separate resources and/or joint resources with their spouse (Section III, b, & c) which exceed the $2,000 resource limit (ineligible). This situation occurs even though the protected resource amount puts the countable resources for the customer’s eligibility (Section III, f) within the $2,000 resource limit.

The notice to the community spouse must advise them to place an amount of resources into their name which will leave the customer’s resources under the $2,000 resource limit.

e. Permitting Transfer of Resources to the Community Spouse

An amount up to the community spouse resource allowance must be transferred to the community spouse's name only within 30 days from the date of the approval notice.

In situations where transferring the resource(s) cannot reasonably occur within the 30-day period, the customer, spouse and/or their representatives must substantiate the circumstances and provide an expected date the transfer will take place. The case manager must monitor, document and verify the situation until the transfer occurs.

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F-225.2.2 Division of Welfare and Supportive Services HOME AND COMMUNITY BASED SERVICES Medical Assistance Manual Resource Determination 23 Oct 01 MTL 04/23 The customer, spouse and/or their representatives must continue to make every effort and take all possible steps to successfully transfer the resource(s) to the community spouse. Failure to comply will cause the resources to be counted towards the HCBW customer’s resource limit.

Effective October 1, 1993, state law is amended regarding court orders giving state court's guidelines when protecting income and resources for the community spouse.

The guidelines provide for an equal division of income and resources OR a protection of income not to exceed the federal maximum monthly maintenance needs allowance and a protection of resources which does not exceed the federal maximum spousal share.

The court may order a greater amount of income for the support of the community spouse upon finding exceptional circumstances resulting in significant financial duress. The court may also transfer a greater amount of resources, in relation to the amount of income generated by the resource, if resources up to the federal maximum are not enough to fund the amount of income ordered.

The Transfer of Resources policies DO NOT apply to transfers made under these provisions.

f. Separate Treatment of Resources after Eligibility is Established

During the "continuous period" of institutionalization and after the customer has been determined eligible, no resources of the community spouse are available to the customer, unless actually made available to the customer.

g. Undue Hardship

If undue hardship is claimed as a result of a denial of eligibility for excess resources under spousal impoverishment rules, the applicant may be determined eligible in spite of having excess resources if all of the following conditions exist:

1. The HCBW customer is otherwise eligible for Medicaid without applying spousal impoverishment rules; and

2. The community spouse is the sole owner of liquid resources or non- liquid joint resources valued in excess of the Federal maximum; and

3. The community spouse has refused to make the resources available to the HCBW customer; and

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Division of Welfare and Supportive Services F-225.2.2 Medical Assistance Manual HOME AND COMMUNITY BASED SERVICES 23 Oct 01 MTL 04/23 Resource Determination

4. The HCBW customer has insufficient funds to cover the cost of Home Care; and

5. Without Medicaid, the HCBW customer would be forced to go without life sustaining medical care as determined by an individual licensed to practice medicine in the State of Nevada.

Send Undue Hardship requests to the Chief of Eligibility and Payments for evaluation and decision.

h. Additional Resources Following Initial Eligibility

If the HCBW customer acquires a new countable resource following the initial eligibility determination, his/her resource eligibility must be re- evaluated.

Apply the ownership/availability rules to newly acquired resources.

Determine how much, if any, of the spousal protected resources (Line II, "e") was used to transfer resources in the community spouse's name only. If there is a balance remaining, more resources countable to the HCBW customer can be protected for the community spouse so the HCBW customer remains resource eligible.

Determine if the spousal protected resources has an unused balance in an amount equal to or more than the new resource. If not, and the excess of resources is over the resource limit, terminate Medicaid coverage allowing the appropriate adverse action time. If the balance of the spousal protected resources is enough to protect the new resource from being counted toward the resource limit, apply the transfer to community spouse provisions as outlined.

Example #1: Liquid Resources

The community spousal protected resources was determined to be $12,000. After approval, the community spouse transferred $8,600 of resources to his/her name only. This leaves a balance of $3,400 in spousal protected resources. Later, the HCBW customer receives a retroactive VA benefit check in the amount of $13,000; $10,000 remains the month after receipt and must be considered a countable resource. Since the balance of the spousal protected resources is $3,400, this is the maximum that can be protected. The difference of $6,600 ($10,000 - $3,400) remains a countable resource to the HCBW customer and renders him/her ineligible for Medicaid.

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F-225.2.2 Division of Welfare and Supportive Services HOME AND COMMUNITY BASED SERVICES Medical Assistance Manual Resource Determination 23 Oct 01 MTL 04/23

Example #2: Non-Liquid Resources

The HCBW customer and community spouse receive an inheritance of vacant land valued at $5,000. One-half is considered available to each spouse ($2,500). The community spousal protected resources was determined to be $12,000. Of this $12,000, the community spouse used $6,000 to transfer resources in his/her name after approval. Therefore, the community spouse has a $6,000 balance in resource protection.

One-half of the vacant land ($2,500) must be considered available to the community spouse. Since the community spouse has a balance of $6,000 in spousal protected resources, the HCBW customer remains resource eligible by protecting his share of the vacant land.

His/her share of the vacant land ($2,500) must now be transferred to the community spouse. In this example, the new balance of the spousal protected resources would then be $3,500.

F-225.3 Resource Exemptions

One vehicle must be excluded without regard to use or value.

An individual who has received benefits under a qualified long-term care insurance policy is eligible for a resource disregard equal to the amount of insurance benefits paid to or on behalf of the individual. The resource disregard is allowed, even if additional benefits remain available under the terms of the policy.

Only qualified long-term care policies purchased after January 1, 2007 will meet the resource exemption rules. Beneficiaries will need to provide a certificate indicating the amount of benefits issued and certifying the policy as a qualified “partnership policy”. The state will not seek adjustment or recovery from the individual’s estate for the amount of assets or resources disregarded.

F-225.4 Resource Limits

The value of all countable resources of the customer cannot be more than $2,000. When the resource limit is exceeded, the case is ineligible.

Home equity limits are applicable.

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Division of Welfare and Supportive Services F-230 Medical Assistance Manual HOME AND COMMUNITY BASED SERVICES 23 Oct 01 MTL 04/23 PATIENT LIABILITY F-230 PATIENT LIABILITY

Individuals who are approved under the HCBW category are entitled to a maintenance allowance to take care of their needs, such as rent, utilities, etc. The needs allowance is currently set at 300% of SSI (Appendix C), which is equal to the income limit, resulting in zero patient liability.

If the customer is admitted to a hospital or nursing facility for “long-term care,” adjust the patient liability deduction to the $35 personal needs allowance beginning with the month following the month of institutionalization.

If an applicant leaves a medical facility to enter the HCBW Program, adjust the patient liability deduction to the home based maintenance allowance effective the month following the month of discharge.

(f-300)Nevada Medical Assistance Manual (MAM): F-300 Persons Institutionalized Less Than 30 Consecutive Days#

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MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID LONG TERM CARE SERVICES F-300 PERSONS INSTITUTIONALIZED LESS THAN 30 CONSECUTIVE DAYS A client in this group must have countable income below SSI payment levels and must be an inpatient in a skilled nursing facility (SNF), intermediate care facility (ICF or ICF/MR), or hospital and meet all eligibility requirements. In determining the number of days in a medical institution for eligibility purposes, include the day of admission, but not the day of discharge/death. An "outpatient" stay is less than a 24–hour period regardless of the hour of admission, whether or not a bed is used or whether or not the patient remains in the facility past midnight. F-305 ELIGIBILITY EXCEPTIONS a. All individuals under age 65 who are inpatients in an institution for mental disease (IMD), i.e., freestanding psychiatric hospital, are not eligible for Medicaid in this category. An IMD is defined as a hospital, nursing facility or other institution of more than 16 beds which is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services. Individuals are severely psychotic, emotionally ill, suicidal and a danger to themselves, others or property. In Nevada IMDs are commonly referred to as "psychiatric hospitals." An institution for the mentally retarded IS NOT an institution for mental disease. b. An inmate of a public institution is ineligible for Medicaid UNLESS the institution is a medical institution. An inmate of a penal institution is NEVER eligible for Medicaid while in the custody of law enforcement officials, UNLESS admitted as an inpatient to a hospital, nursing facility, juvenile psychiatric facility, or intermediate care facility. This individual is eligible for any Medicaid covered services provided to them while an inpatient in these facilities and they are Medicaid- eligible. If this individual becomes an inpatient of a long-term care facility, they must meet level of care and plan of care assessments to become eligible. c. Individuals under 22 receiving inpatient psychiatric services in a residential treatment center (RTC) are eligible for Medicaid in this category. RTCs specialize in treating children with conduct, personality and emotional disorders, depression, hyperactivity, academic failure, and/or mild learning disabilities. Medicaid will pay for services provided in a RTC if the referral resulted from a "Healthy Kids" screening and the admission was prior authorized/certified by Medicaid's Peer Review Organization (PRO). These cases must also be evaluated for QMB eligibility.

Division of Welfare and Supportive Services LONG TERM CARE SERVICES Medical Assistance Manual PERSONS INSTITUTIONALIZED LESS THAN 30 CONSECUTIVE DAYS – 24 Sept MTL 05/24 ELIGIBILITY EXCEPTIONS F-300

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MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID F-310 DEFINITIONS SSI Eligible Spouse - The client's spouse who meets the requirements in both a. and b. below: a. Is pending SSI, received SSI or would have been eligible for SSI; To determine if the spouse would have been eligible for SSI, the spouse: 1. must have been aged, blind or disabled. Blindness and disability is established when the spouse has been determined eligible for any type of permanent disability/blind benefits (e.g., SSA, VA, or retirement disability benefits); and 2. must be determined financially eligible. b. Is living with the client or has not been separated longer than the specified time frames: 1. Consider the client a member of a couple with an eligible spouse only for the month they ceased living together. SSI Ineligible Spouse - The client's spouse who is not pending SSI, not receiving SSI and would not have been eligible for SSI. When the spouse is not aged or has not been determined eligible for some type of permanent disability/blindness benefits consider the spouse an SSI ineligible spouse. The ineligible spouse's income must always be considered when the client is living with the spouse. When the client and ineligible spouse are separated, the ineligible spouse's income is only considered the month of separation. Individual - Consider clients as individuals when they are: a. NOT married; b. Married but have been separated from their SSI ELIGIBLE spouse for a specified time frame: The client will be considered an individual beginning the month after the month they cease living together. c. Married but have been separated from their SSI INELIGIBLE spouse for a specified time frame: Consider the client an individual the month FOLLOWING the month they ceased living together; Division of Welfare and Supportive Services F-310 Medical Assistance Manual LONG TERM CARE SERVICES 24 Sept MTL 05/24 DEFINITIONS

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MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID d. Had an SSI INELIGIBLE spouse who received TANF, VA pension or other assistance based on need for the month Medicaid is requested. Monthly Maintenance Needs Allowance - An amount determined by adding together the federal minimum maintenance need standard (150% of poverty for 2 persons) and an excess shelter allowance. This amount cannot exceed the federal maximum maintenance needs standard except when authorized by findings of an administrative review/hearing. Housing Costs (principal place of residence) - The community spouse's expenses for rent or mortgage payment (including principal and interest), property taxes and mortgage/rental insurance. In situations where a maintenance charge is required, allow only that portion which does not include personal or individual utility expenses. Standard Utility Allowance (SUA) - An amount established under SNAP which is the statewide average of total monthly utility costs. Do not allow SUA if utilities are included with the rent and cannot be separately identified. If the telephone service is the only utility, allow the telephone allowance instead of the full SUA. Excess Shelter Allowance - An amount (if any) determined by subtracting the federal excess shelter deduction (30% of 150% poverty for two persons) from the community spouse's housing costs plus the SUA. Verification of the community spouse's gross income and housing costs must be obtained. If income verifications are not returned by the required date, the case will be completed without allowing a maintenance allowance. If verification of housing costs and/or utility expense is not provided, compute the spousal income allowance without it. The client will be notified on the Notice of Decision, the patient liability was determined without a maintenance allowance deduction. If, however, the verifications are received after the required date, the maintenance allowance deduction will be allowed beginning the month the verification was received. The community spouse monthly income allowance deduction will be discontinued if information is received the spouse is not receiving the maintenance allowance. F-315 BUDGETING PROCEDURES FOR SSI FINANCIAL ELIGIBILITY SSI BUDGET FORM 2646-EE (Spouse to Spouse Deeming) F-315.1 Income Consideration Determine whether the client is considered an individual or a member of a couple with an SSI eligible or ineligible spouse by applying the definitions in this section. Division of Welfare and Supportive Services LONG TERM CARE SERVICES Medical Assistance Manual DEFINITIONS – INCOME CONSIDERATION 24 Sept MTL 05/24 F-310

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Division of Welfare and Supportive Services F-315.1 Medical Assistance Manual LONG TERM CARE SERVICES 24 Sep MTL 05/24 INCOME CONSIDERATION - INDIVIDUAL MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID When the client is considered an individual, only the client's income is counted. Additionally, when the client is considered a member of a couple, the spouse's income is counted for a specified time period. Spouses separated temporarily, for economic (employment) or emergency reasons (hospitalization), vacations or visits are NOT considered "separated" (ceased living together) for purposes of income consideration. The separation must be expected to continue. A temporary absence is one where the individual leaves and returns to the household in the same month or the following month. When income of the spouse must be considered, the income will be verified. If impossible to verify the spouse's income, document the circumstances and accept the client's statement. F-315.2 SSI Budget Form 2646–EE – General Instructions

F-315.2.1 Member of Couple with Eligible Spouse Any time the spouse appears potentially SSI eligible, treat as an eligible spouse until determined ineligible. Use the member of a couple, with eligible spouse column. a. If ineligibility results, consider the spouse ineligible and go through the deeming computation by using the member of a couple, with ineligible spouse column, to determine if deeming applies. b. If deeming doesn't apply, proceed to Part B using the individual column. c. If deeming does apply, proceed with the budget under the member of a couple with ineligible spouse column. If this process also results in ineligibility, the client is ineligible for Medicaid. F-315.2.2 Member of Couple with Ineligible Spouse Use the member of a couple, with ineligible spouse column, items A–1 through 3 to determine if deeming applies. a. If deeming doesn't apply, proceed to the individual column of the budget. b. Deeming never applies when the SSI ineligible spouse receives Medicaid, TANF, VA pension or other federal or state assistance based on need. F-315.2.3 Individual Use the individual column, when the person meets the definition of an individual.

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MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID F-315.3 SSI Budget Form 2646-EE - Specific Instructions

F-315.3.1 Deeming Computation Deeming never applies when the SSI ineligible spouse receives Medicaid, TANF, VA pension or other federal or state assistance based on need. a. Determine the ineligible spouse's total unearned income. b. Determine if an SSI ineligible child(ren) allocation is applicable. The allocation is applicable if there are any dependent children who are: 1. Under age 18 OR under age 22 and are students regularly attending a school, college or university or a course of vocational or technical training to prepare for gainful employment; and 2. The child(ren) are not receiving Medicaid, TANF, VA pension or other federal or state assistance based on need. c. If the allocation deduction is applicable, for each ineligible child, subtract the child's income from the child allocation amount. Subtract the remainder from the ineligible spouse's unearned income. d. Determine the ineligible spouse's gross earned income. e. Subtract the balance of any allocation for ineligible children not offset by unearned income. f. Add the remaining unearned income to the remaining earned income, after the allocation deductions. g. Compare the total income after allocations to the deeming indicator amount. If less than the deeming indicator amount, deeming does not apply, proceed to Part B, individual column of the SSI budget using only the client's income. If equal to or more than the deeming indicator amount, deeming DOES APPLY. Proceed to Part B member of a couple with an ineligible spouse column adding the unearned income after allocations to the client's unearned income and the remaining earned income to the client's earned income. F-315.3.2 SSI Eligibility Determination

In this section of the budget, use only the client's income when using the individual column. Use combined incomes of the client and eligible or ineligible spouse when using the member of a couple with an eligible or ineligible spouse column. a. Determine unearned income. b. Subtract the general income exclusion of $20 to arrive at the remaining unearned income. F-315.3 Division of Welfare and Supportive Services LONG TERM CARE SERVICES Medical Assistance Manual SSI BUDGET FORM 2646-EE – SSI ELIGIBILITY DETERMINATION 24 Sept MTL 05/24

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MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID c. Determine total gross earned income. d. Subtract any balance of the general exclusion not offset by unearned income. e. Subtract the work expense exclusion of $65. f. Impairment–Related Work Expenses (IRWE). This exclusion is applied to earned income of disabled (but not blind) individuals under age 65. The expense must be reasonable; for items/services which are directly related to enabling an impaired individual to work, and which are necessarily incurred by the individual because of a physical or mental impairment. IRWEs are excludable when the cost is paid by the disabled individual and is not reimbursable from another source. g. Subtract 1/2 of the remaining earned income after the above deductions. h. Determine the total countable income by adding Items B–1–b and B–2–e. i. Compare the total countable income (Item B–3) to the appropriate SSI payment amount (SPA). If the amount is equal to or greater than the SPA in the member of a couple with ineligible spouse or individual columns, the client is ineligible for Medicaid. If ineligible in the member of a couple with eligible spouse column, proceed to the member of a couple with ineligible spouse column to complete the eligibility determination. F-320 BUDGETING PROCEDURES FOR SSI FINANCIAL ELIGIBILITY OF CHILDREN – PARENT TO CHILD DEEMING BUDGET – FORM 2646–EE/A F-320.1 General Deeming Provisions

If the child is under age 18 or under age 21 and regularly attending school, college, university or technical training designed to prepare him/her for gainful employment and living in the same household with the natural/adoptive parent(s) or natural/adoptive parent and a stepparent; all income of the ineligible parent(s) will be considered in determining eligibility for the child. a. Deeming applies from a parent to a child when they live together in the same household. b. Deeming stops the month following the month of institutionalization in a medical facility. c. Deeming begins the month following the month the child returns home from a medical facility. Division of Welfare and Supportive Services F-315.3.2 Medical Assistance Manual LONG TERM CARE SERVICES 24 Sept MTL 05/24 SSI ELIGIBILITY DETERMINATION – GENERAL DEEMING PROVISIONS

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MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID d. Deeming applies even when the child is temporarily absent from the home. A temporary absence exists when: 1. The child leaves the household but intends to, and does, return in the same month or the following month; or 2. The child is away at school but returns home on some weekends, holidays, or vacations and is subject to parental control. Consider the parent(s) or stepparent an ineligible parent when they are not pending SSI, receiving SSI or would not have been eligible for SSI. To determine if the parent would have been eligible for SSI, the parent must be aged, blind or disabled. Blindness and disability is established when the parent has been determined eligible for any type of permanent disability/blind benefits, such as SSA, VA, or Retirement Disability Benefits, and is determined financially eligible. When the parent is not aged or has not been determined eligible for some type of permanent disability/blindness benefits, consider the parent an SSI ineligible parent. If the child is only living with a stepparent (natural/adoptive parent is not in the home) deeming does not apply. If the child is living with a natural/adoptive parent and a stepparent, deeming will apply. F-320.2 Parent to Child Deeming Budget – General Instructions

The following types of parental income are excluded when determining the amount of deemed income: a. Any portion of a grant, scholarship or fellowship used to pay tuition or fees; b. Money received for providing foster care to an ineligible child; c. Any income used to comply with the terms of court–ordered support or support payments enforced under Title IV–D; d. Disaster Assistance. Deeming never applies when the parent(s) or stepparent receives TANF, VA pension or other federal or state assistance based on need. F-320.3 Deeming Computation a. Determine the ineligible parent/stepparent's total unearned income. b. Determine if an SSI ineligible child(ren) allocation is applicable. The allocation is applicable if there are a dependent (natural or adoptive) child(ren) who are: 1. Under age 18 OR under age 21 and are students regularly attending a school, college or university or a course of vocational or technical training to prepare for gainful employment; and F-320.1 Division of Welfare and Supportive Services LONG TERM CARE SERVICES Medical Assistance Manual GENERAL DEEMING PROVISIONS – DEEMING COMPUTATION 24 Sept MTL 05/24

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MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID 2. The child(ren) are not receiving TANF, VA pension or assistance based on need. other federal or state c. If the allocation deduction is applicable, for each ineligible child, subtract the ineligible child's income (includes the total child support for the ineligible child) from the child allocation amount. Subtract the remainder from the ineligible parent/stepparent's unearned income. d. Determine the ineligible parent/stepparent's gross earned income. e. Subtract the balance of any allocation for ineligible children not offset by unearned income. f. Subtract $20 (general income exclusion) from the remaining unearned income. g. Subtract any balance of the general income exclusion not offset by unearned income from earned income. h. Subtract the work expense exclusion of $65. i. Impairment–Related Work Expenses (IRWE). This exclusion is applied to earned income of disabled (but not blind) individuals under age 65. The expense must be reasonable; for items/services which are directly related to enabling an impaired individual to work, and which are necessarily incurred by the individual because of a physical or mental impairment. IRWEs are excludable when the cost reimbursable from another source. is paid by the disabled individual and is not j. Subtract 1/2 of the remaining earned income after the above deductions. k. Add the countable unearned and earned income to arrive at total countable income. l. Then subtract the parent allocation amount. m. The net amount (if any) is the deemed income to the child. F-320.4 Eligibility Determination a. Add the child's own parent/stepparent. unearned income to the deemed income from the ineligible b. Subtract $20 (general income exclusion). c. If the child has earnings subtract any balance of the general income exclusion not offset by the child's unearned income from the child's earned income. d. Subtract the work expense exclusion of $65. Division of Welfare and Supportive Services F-320.3 Medical Assistance Manual LONG TERM CARE SERVICES 24 Sept MTL 05/24 DEEMING COMPUTATION – ELIGIBILITY DETERMINATION

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MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID e. Impairment–Related Work Expenses (IRWE). This exclusion is applied to earned income of disabled (but not blind) individuals under age 65. The expense must be reasonable; for items/services which are directly related to enabling an impaired individual to work, and which are necessarily incurred by the individual because of a physical or mental impairment. IRWEs are excludable when the cost is paid by the disabled individual and is not reimbursable from another source. f. Subtract 1/2 of the remaining earned income after the above deductions. g. Add countable unearned and earned income to arrive at total countable income. h. Compare the total countable income to the individual SSI Payment Amount (SPA). If the amount is equal to or greater than the SPA, the child is ineligible for Medicaid. F-325 PATIENT LIABILITY

Patient liability is determined for eligible persons in a medical facility. There is no patient liability for any portion of institutionalization in a VA hospital, AGCF, FCH, freestanding psychiatric hospital or RTC. F-325.1 Treatment of Income, Deductions and Expenses When determining patient liability for initial and ongoing cases, budget income for the month it is received and deductions/expenses for the month in which they are paid/incurred. When unanticipated income is received, patient liability will be adjusted for the month in which it was received. Regular unearned income deposited directly into a financial institution is considered received in the month for which it is intended to be received. F-325.2 Partial Month Proration

The amount of patient liability is prorated according to the number of days the client was in a facility when the person is institutionalized less than a full calendar month due to: a. Date of admission b. Discharge to independent living, VA hospital, AGCF, FCH, freestanding psychiatric hospital or RTC. c. Death F-320.4 Division of Welfare and Supportive Services LONG TERM CARE SERVICES Medical Assistance Manual ELIGIBILITY DETERMINATION – PARTIAL MONTH PRORATION 24 Sept MTL 05/24

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Division of Welfare and Supportive Services F-325.2 Medical Assistance Manual LONG TERM CARE SERVICES 24 Sept MTL 05/24 PARTIAL MONTH PRORATION – PATIENT LIABILITY BUDGETING PROCEDURES

MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID Determine what the patient liability would be for a full month. Divide that full month amount by the number of days in the month of partial institutionalization to determine the daily amount of patient liability. Multiply this daily amount by the number of days the client was institutionalized in that month (include the day of admission but not the day of discharge/ death). The result is the amount of patient liability due for the partially institutionalized month. F-325.3 Effective Date of Patient Liability a. State Institutional Patient liability is effective the first month of eligibility (this includes requested months prior to the application month). b. State Institutional/QMB (SLMB) Hospital Stay Only: For inpatient hospital stays under 90 consecutive days, do not calculate or send notice of patient liability. This is because Medicare will cover up to 90 days in a hospital and Medicaid must pay the hospital deductible and co–pay charges. If hospitalized beyond the 90 day time period, begin patient liability the first of the month following the 90 days. c. Deceased Clients The facility is notified of the patient liability amount due for the month of death. The facility will collect only for charges actually incurred. Any unused patient liability will be deposited in the patient trust fund account. F-325.4 Notification of Patient Liability/Case Status When a case is approved or patient liability changes, the client, facility and authorized representative (if applicable) are notified on a Notice of Decision of the amount and effective date. When the client moves from one facility to another, notify the facilities of the current case status and MONTHLY patient liability when this information has not already been provided them in or for that month. F-325.5 Patient Liability Budgeting Procedures – Form 2220–EM a. Determine the client's total gross countable monthly income 1. Subtract income excluded in patient liability b. Subtract the following items from total monthly income in the following order:

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MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID 1. Personal Needs Allowance a) Deduct $154 personal needs allowance (PNA) for each month of institutionalization. b) Additional personal needs – Institutionalized individuals with no community spouse living in the home but with other dependent family members in the home are allowed an additional personal needs allowance based on household size. The additional personal needs amount is determined by subtracting the 1996 needs standard of $459 from the current TANF need standard for the household size. Note: this requires a NOMADS work around. 2. Community Spouse Monthly Income Allowance Income allocated to the community spouse for maintenance. This amount (if any) is determined by subtracting the community spouse’s income which is considered available (including need based assistance like TANF, SSI, etc.) from the monthly maintenance allowance. DO NOT count VA UME as income considered available to the community spouse. Clients do not have to request the maintenance allowance for their spouse/dependents. The case manager will automatically request the information necessary to determine the maintenance allowance when there is a spouse or dependents at home. 3. Family Allowance (Spousal Impoverishment) Family members must be a dependent child, dependent parent(s) or dependent sibling(s). The child, parent or sibling must be residing in the home of the community spouse AND claimed by the community spouse or institutionalized spouse as dependents for federal income tax purposes. The amount determined to be the family allowance is deducted from the institutionalized spouse's countable income effective with the first month in which the continuous period of institutionalization is met OR if this deduction was not previously allowed the deduction will be allowed effective the first month following the month in which the change is reported. The family allowance deduction need not be determined IF the $154 personal needs allowance in combination with the community spouse monthly income allowance zero's out the patient liability. F-325.5 Division of Welfare and Supportive Services LONG TERM CARE SERVICES Medical Assistance Manual PATIENT LIABILITY BUDGETING PROCEDURES 24 Sept MTL 05/24

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MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID Verification of each family member's gross income must be obtained. a) Subtract the family member's gross income from minimum needs allowance (150% of poverty). b) Divide the amount from (a) above by three. This is one family member's allowance. Repeat this calculation for each family member. If there is only one family member, the amount from (b) will be the family allowance deduction. If there is more than one family member, add each family member's allow ance to determine the family allowance deduction. 4. Dependent Allowance (Non-Spousal Impoverishment) A monthly income allowance for each dependent family member living in the Institutionalized individual’s home with no community spouse living in the home. Calculated by subtracting the dependents total income from the need standard (100% Need Standard) for the household size. 5. Expenses Incurred For Health Insurance Premiums, Deductibles and Co– Insurance Charges Deduct health insurance premiums, deductibles and co–insurance expenses incurred by the client. Clients/Representatives must advise the agency of medical insurance and provide proof of expenses. These expenses must not be paid or subject to payment by a third party. Medicare premiums are subject to payment by a third party. Any institutional case where the client is not a SSI recipient and will not receive a reimbursement for Medicare cost from any source, may have the Medicare premium deducted as an expense for months immediately preceding the second month after the month of approval. Example #1 (Medicaid Only): Client applied June 2nd and requests 3 months prior medical. Case is approved July 10th. Medicare premiums may be deducted from March through August. Beginning September, we cannot deduct the Medicare premium as it is then subject to third–party payments. Division of Welfare and Supportive Services F-325.5 Medical Assistance Manual LONG TERM CARE SERVICES 24 Sept MTL 05/24 PATIENT LIABILITY BUDGETING PROCEDURES

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MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID Example #2 (Medicaid/QMB): Client applied for Medicaid/QMB on June 2nd and requests 3 months prior medical. In June, QMB eligibility is established and benefits begin effective July 1st. Then Medicaid eligibility is established July 20th back to March. Medicare premiums may be deducted for March, April, May and June only. Effective July and ongoing, the premiums are subject to third–party payments as QMB coverage began in July. 6. Expenses Incurred For Medical Care Deduct expenses incurred by the client for necessary medical care recognized under the state law but not covered under the Medicaid Program. This includes medical expenses incurred more than three months prior to the date of application. Client/Representatives must advise the agency and submit proof of the expenses. The case manager will attach a copy of the medical bill plus all related medical records to Form 2536 and submit to DHCFP for approval. These expenses must not be paid or subject to payment by a third party. DHCFP approval is required to assure the deduction is for necessary care payable to reasonable limits. c. The deficit, if any, is the client’s share of facility cost (PATIENT LIABILITY). F-325.5 LONG TERM CARE SERVICES PATIENT LIABILITY BUDGETING PROCEDURES Division of Welfare and Supportive Services Medical Assistance Manual 24 Sept MTL 05/24

(f-400)Nevada Medical Assistance Manual (MAM): F-400 Transfer of Assets#

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Division of Welfare and Supportive Services F-400 Medical Assistance Manual TRANSFER OF ASSETS 23 Oct 01 MTL 04/23 OVERVIEW

TRANSFER OF ASSETS

F-400 OVERVIEW

For purposes of this section, assets include all income and resources of the individual and the individual’s spouse. This includes income or resources which the individual or the individual's spouse is entitled to but does not receive because of any action by:

a. the individual or the individual's spouse;

b. a person, including a court or administrative body with legal authority to act in place of, or on behalf of the individual or the individual's spouse; or

c. any person, including a court or administrative body, acting at the direction or upon the request of the individual or the individual's spouse.

For purposes of this section, the term "assets to which an individual or spouse is entitled" includes assets to which the individual is entitled or would be entitled if action had not been taken to avoid receiving the asset.

The following are examples of actions which would cause income or resources not to be received:

a. irrevocably waiving pension income;

b. waiving the right to receive an inheritance;

c. not accepting or accessing injury settlements;

d. tort settlements which are diverted by the defendant into a trust or similar device to be held for the benefit of an individual who is a plaintiff; and

e. refusal to take legal action to obtain a court ordered payment that is not being paid, such as child support or alimony.

Failure to cause assets to be received does not constitute a transfer of assets for less than fair market value in all instances. Example: the individual may not be able to afford to take the necessary action to obtain the asset, or the cost of obtaining the asset may be greater than the asset is worth, thus effectively rendering the asset worthless to the individual. Examine the specific circumstances of each case before making a decision whether an uncompensated asset transfer occurred.

Note: Not applicable to Medicare beneficiaries, public law and prior medical categories.

F-405 DEFINITIONS

Transfer of Assets – Assets (income/resources) which are given away, sold or disposed of for less than fair market value to obtain or retain Medicaid eligibility. This includes all income and resources to which the customer or spouse is entitled or would

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F-405 Division of Welfare and Supportive Services TRANSFER OF ASSETS Medical Assistance Manual DEFINITIONS 23 Oct 01 MTL 04/23 be entitled if action had not been taken to avoid receiving the asset. Note: The home of an applicant/recipient (principal place of residence) can only be transferred in the specific instances outlined in 440.5 whether the home is excludable or not.

Institutionalized Individual - Any person who is residing in a medical facility, including SSI recipients, or persons who fall into any category considered institutionalized recipients, such as Home and Community Based Services Waiver (HCBW) customers.

Fair Market Value - The current market value of the asset at the time of transfer.

Compensation - All money, real or personal property, food, shelter, or services received by the applicant/recipient at or after the time of transfer in exchange for the asset. Items received prior to the transfer will be considered compensation only if they were provided pursuant to a binding contract (verbal or written) to provide such items in exchange for payment.

Personal Care Contract – a contract/agreement that provides health care monitoring, medical treatment, securing hospitalization, visitation, entertainment, travel/transportation, financial management, shopping, home help or other assistance with activities or daily living.

Home Care Contract – a contract/agreement which pays in advance for the applicant/recipient’s expenses for their home or other real property, including but not limited to repairs, property maintenance, property taxes, homeowner’s insurance, heat and utilities.

NOTE: Home Care and/or personal Care contracts/agreements may be between relatives or non-relatives. A relative is anyone related to the applicant/recipient by blood, marriage, or adoption.

Uncompensated Value - The Fair Market Value of the asset at the time of transfer, minus the amount of compensation received by the applicant/recipient or spouse in exchange for the asset.

Legal Representative - Parent of a minor child, power of attorney, legal guardian, or anyone legally authorized to execute a contract for the customer/spouse. Note: Assets transferred by anyone acting in place of, or on behalf of, or at the request or direction of the customer or spouse, are considered to be transferred by the customer or spouse.

Spouse – Person legally married to another under state law. In Nevada, a person is married until divorced.

Community Spouse – A spouse who is not living in a medical institution, nursing facility, or receiving HCBW services.

Penalty – Individuals who receive Home and Community Based Waiver (HCBW) services, or institutionalized individuals are denied coverage of certain Medicaid services during the transfer of asset penalty period. The individual remains eligible for Medicaid and can receive certain services not subject to the penalty. Eligibility codes C and D are used to indicate a penalty period.

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Division of Welfare and Supportive Services F-410 Medical Assistance Manual TRANSFER OF ASSETS 23 Oct 01 MTL 04/23 GENERAL RULE

F-410 GENERAL RULE

If an institutionalized individual, his/her spouse, or their legal representative has given away, sold or disposed of assets for less than fair market value, it is presumed the asset was disposed of for the purpose of becoming eligible for or to remain eligible for Medicaid.

F-410.1 Look-Back Period

a. Asset Transfers Prior to February 8, 2006

Asset transfers must be evaluated during the 36-month 'look-back' period beginning the month of application; OR if the individual is/was Medicaid eligible at the time he/she began receiving HCBW or long term care (LTC) services, the 36-month 'look-back' period begins with the month the HCBW or LTC Services began.

Asset transfers must also be evaluated any time after the individual begins receiving HCBW or LTC services or any time after the individual applies for Medicaid.

The 'look-back' period is extended to 60 months when there is a transfer of assets involving a trust. If, in the case of a revocable trust, a portion is disbursed to someone other than the grantor or for the benefit of the grantor, that portion is treated as a transfer of assets. If, in the case of an irrevocable trust, all or a portion of the trust cannot be disbursed to or on behalf of the individual, that portion is treated as a transfer of assets.

b. Asset Transfers On or After February 8, 2006

The Deficit Reduction Act (DRA) provides that for any transfer of assets made on or after February 8, 2006, the look-back period is 60 months from the date the individual applied for Medicaid and was institutionalized or began receiving HCBW services.

Asset transfers must also be evaluated at any time after the individual begins receiving HCBW or LTC services.

F-415 TREATMENT OF INCOME AS ASSETS

When an individual's income is given or assigned in some manner to another person, such a gift or assignment can be considered a transfer of assets for less than fair market value.

If income or the right to receive income has been transferred, a penalty period must be imposed. If the income is a single lump sum, the penalty period is calculated on the basis of the amount of the payment. If a stream of income or the right to such income is transferred, a determination of value will be made by the Chief of Eligibility and Payments and based on an actuarial projection of the individual's life expectancy.

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F-415.1 Division of Welfare and Supportive Services TRANSFER OF ASSETS Medical Assistance Manual TREATMENT OF JOINTLY OWNED ASSETS 23 Oct 01 MTL 04/23 F-415.1 Treatment of Jointly Owned Assets

When an asset is held by an individual in common with another person or persons via joint tenancy, tenancy in common, joint ownership or a similar arrangement, the asset (or affected portion of the asset) is considered to be transferred by the individual when any action is taken, either by the individual or any other person, that reduces or eliminates the individual's ownership or control of the asset.

When a transfer of assets situation is identified, individuals must be allowed an opportunity to rebut the presumption of ownership. Either individual can provide convincing evidence the assets transferred were the sole property of the other person.

The account resource balance will be presumed available to the individual unless the individual can successfully prove the funds are not his/hers. This portion will be considered a transfer of assets if withdrawn by the other individual or given away by the individual.

In the event of a divorce of an institutionalized applicant or recipient of Medicaid, a copy of the divorce decree and property settlement agreement must be provided to the case manager.

In the event that the court made an unequal disposition of the community property and failed to find a compelling reason set forth in writing for making such unequal disposition as required in state statute, this will be deemed to be a transfer of assets for less than fair market value to the extent of the unequal division. (NRS 125.150)

F-415.2 Treatment of Certain Kinds of Asset Transfers

Life Estates, Promissory Notes, Loans or Mortgages

a. Treatment of Life Estates Prior to April 1, 2006:

In a transaction involving a life estate, a transfer of assets has occurred:

1. Whenever the value of the transferred asset is greater than the value of the rights conferred (given) by the life estate.

b. Treatment of Life Estates and Promissory Notes, Loans or Mortgage Purchases on or after April 1, 2006:

In a transaction involving a life estate, a transfer of assets has occurred:

1. When the individual purchasing a life estate in another individual’s home has not actually resided in the home for a period of at least one year after the date of purchase.

2. When payment exceeds the fair market value of the life estate.

3. When an individual makes a gift or transfers interest in a life estate.

Note: The amount of the transfer is the entire amount used to purchase the life estate. This amount is not reduced or prorated to reflect an individual’s residency for any time less than a year.

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Division of Welfare and Supportive Services F-415.2 Medical Assistance Manual TRANSFER OF ASSETS 23 Oct 01 MTL 04/23 TREATMENT OF CERTAIN KINDS OF ASSET TRANSFERS In a transaction involving a promissory note, loan, or mortgage, a transfer of assets has occurred unless all of the following criteria are met:

a. The repayment term is actuarially sound;

b. Payments are made in equal amounts during the term of the loan with no deferral of payments and no balloon payments; and

c. The cancellation of the balance of the note, loan, or mortgage upon the death of the lender is prohibited.

Note: If the above criteria are not met, the amount of the transfer is the value of the outstanding balance due as of the date of the individual’s application for Medicaid coverage of LTC or HCBW services.

F-415.23 Personal Care and Home Care Contract Agreements

When assistance and/or services are provided to the applicant/recipient, regardless of whether it is by a relative or non-relative, compensation for past assistance and/or services will be considered a transfer for less than fair market value. If the transfer of assets decision is appealed or rebutted by the applicant/recipient or care provider, the fair market value of the assistance and/or services may be determined by consultation with area businesses which provide such services.

A contract that provides advanced payment for expenses, including, but not limited to, repairs, maintenance, property taxes, homeowner’s insurance, heat and utilities for real property/homestead, or that provide for monitoring health care, securing hospitalization, medical treatment, visitation, entertainment, travel and/or transportation, financial management or shopping, etc., is considered a transfer of assets. Consider all payments for care and services which were made during the look-back period as transfer of assets. Contracts/agreements that include the provision of companionship are prohibited.

All Personal Care and Home Care contracts/agreements and payments made therein, regardless of whether between an applicant/recipient and a relative or an applicant/recipient and a non-relative, must be evaluated for transfer of assets.

Personal Care and Home Care contracts/agreements shall be considered a transfer for less than fair market value unless the agreement meets all of the following:

a. The services must be performed after a written legal contract/agreement has been executed between the applicant/recipient and the provider. The contract/agreement must be dated, and the signatures must be notarized. The services are not paid for until the services have been provided (there can be no advance payment for future expenses or services); and

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F-415.3 Division of Welfare and Supportive Services

TRANSFER OF ASSETS Medical Assistance Manual

PERSONAL CARE AND HOME CARE AGREEMENTS 23 Oct 01 MTL 04/23

b. At the time the services are received, the applicant/recipient cannot be residing in a nursing facility, adult foster care home (licensed or unlicensed), institution for mental diseases, inpatient hospital, intermediate care facility for individuals with intellectual disabilities, or be eligible for home and community-based waiver, home health or home help; and

c. At the time services are received, the services must have been recommended in writing and signed by the applicant/recipient’s physician as necessary to prevent the transfer of the applicant/recipient to a residential care or nursing facility. Such services cannot include the provision of companionship; and

d. The contract/agreement must be signed by the applicant/recipient or legally authorized representative, such as an agent under a power of attorney, guardian, or conservator. If the agreement is signed by a representative, that representative cannot be the provider or beneficiary of the contract/agreement.

Field staff will forward the Personal Care or Home Care Agreement/Contract and itemized billing to the chief of Eligibility & Payments at Carson City Administrative Office, where DWSS will verify the contract/agreement by reviewing the written contract/agreement between the applicant/recipient and the provider which must show the type, frequency, and duration of such services being provided to the applicant/recipient and the amount of consideration (money or property) being received by the provider. Itemized billing for services not paid for in advance must accompany the contract/agreement verifying the type, frequency and duration of services provided and the type and amount of assets(s) being exchanged, including when such assets were exchanged. Once evaluated, a memo will be sent from the Chief of Eligibility & Payments to the field staff who will then determine the amount of penalty prior to processing the application.

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Division of Welfare and Supportive Services F-420 Medical Assistance Manual TRANSFER OF ASSETS 23 Oct 01 MTL 04/23 ANNUITIES F-420 ANNUITIES

An annuity is a contract between an individual and a commercial company in which the individual invests funds and, in return, is guaranteed fixed substantially equal installments for life or a specified number of years.

A determination must be made regarding the purpose of the annuity. The annuity must have an expected return commensurate (equal) with the life expectancy of the beneficiary to be deemed actuarially sound.

If the individual is not expected to live longer than the guarantee period of the annuity, the individual will not receive fair market value and is subject to a transfer of assets penalty.

a. Treatment of Annuities Purchased Prior to October 1, 2000.

An annuity purchased prior to October 1, 2000 is not an available resource if it is annuitized (yields monthly fixed, equal installments for a specified number of years, not to exceed the life expectancy of the customer, or for the life of the customer) and regular returns are being received by the annuitant. The funds received are income in the month received.

If the annuity purchased by the applicant/customer or his/her spouse has not been annuitized it shall be considered an available resource regardless of the irrevocable status.

b. Treatment of Annuities Purchased On or After October 1, 2000.

The purchase of an annuity shall be considered as a transfer of assets without fair consideration unless the following criteria are met:

1. The annuity is purchased from a life insurance company or other commercial company that sells annuities as part of its normal course of business; and

2. The annuity is annuitized for the applicant/customer or his/her spouse; and

3. The annuity is purchased on the life of the applicant/customer or his/her spouse; and

4. The annuity provides payments for a period not exceeding the annuitant’s projected life.

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F-420 Division of Welfare and Supportive Services TRANSFER OF ASSETS Medical Assistance Manual ANNUITIES 23 Oct 01 MTL 04/23 Staff shall determine the maximum spousal need allowance of the community spouse, if applicable. If the monthly payment amount provided by the annuity to the community spouse exceeds the maximum spousal need allowance, the amount of the annuity which causes the monthly annuity payment to exceed the maximum spousal need allowance shall be considered a transfer without fair consideration in determining the institutionalized spouse’s eligibility. This subsection applies only to the extent the transferred amount causes the community spouse resource allowance to exceed the maximum.

Staff shall determine if the applicant/customer is receiving substantially equal installments from the annuity for the period of the annuity. If the annuity is not paid in substantially equal installments, the original purchase price of the annuity shall be considered as a transfer without fair consideration.

If an annuity was purchased more than 36 months prior to the date of application, the penalty period for a transfer without fair consideration has expired. Any income received from the annuity shall be considered as income in the month received.

If an irrevocable annuity is purchased by a Medicaid applicant/customer, or their spouse, and the return or benefit from the annuity is transferred to a third party, a transfer of assets without fair consideration exists for the total amount of the annuity.

If a revocable annuity is purchased by a Medicaid applicant/customer, or their spouse, the total amount invested in the annuity is considered as a countable resource. Once it has been determined a transfer of assets without fair consideration exists, the penalty period shall be calculated as shown below.

An annuity purchased by the applicant/customer must name their spouse as the beneficiary, and if unmarried, Medicaid is the beneficiary, otherwise a transfer of assets without fair consideration exists for the total amount of the annuity.

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Division of Welfare and Supportive Services F-420 Medical Assistance Manual TRANSFER OF ASSETS 23 Oct 01 MTL 04/23 ANNUITIES

c. Treatment of Annuities Purchased On or After February 8, 2006.

Application Requirements

Disclosure of interest in an annuity is required for Medicaid coverage for HCBW and long-term care services at application or redetermination. The individual is required to disclose any interest they, or their community spouse, may have in an annuity regardless if it is irrevocable or is treated as an asset.

If the individual, spouse, or representative refuses to disclose information related to any annuity, the case manager will deny or terminate eligibility for long-term care services or Home and Community Based Waiver (HCBW) services, as applicable.

Information regarding the income and/or resources related to an annuity must be collected and verified to establish Medicaid eligibility.

1. There is no option to withhold information about annuities.

2. If the individual fails to provide enough information about an annuity to allow a determination of Medicaid eligibility, the case manager will deny the application based on the individual’s failure to cooperate.

3. When an unreported annuity is discovered after eligibility has been established and after payment for long-term care services has been made, terminate eligibility for long-term care services based on the applicant’s failure to cooperate.

The state must be named as a remainder beneficiary in annuities in which the applicant or spouse is the annuitant.

The case manager will notify the issuer of any annuity disclosed of the state’s right as a preferred remainder beneficiary.

The issuer is required to notify the state of any changes in disbursement of income or principal from the annuity.

The issuer may disclose information about the state’s position as remainder beneficiary to others who have a remainder interest in the annuity.

d. Evaluation and Treatment of Certain Transactions Related to Annuities On or After February 8, 2006

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F-420 Division of Welfare and Supportive Services TRANSFER OF ASSETS Medical Assistance Manual ANNUITIES 23 Oct 01 MTL 04/23

Annuity-Related Transactions Other Than Purchases

Transactions that occur on or after February 8, 2006 may make an annuity, including one purchased before that date, subject to the DRA transfer of assets, if the transaction includes:

1. Any action taken by the individual that changes the course of payments, or

2. Any action taken by the individual that changes the treatment of the income, or principal.

For annuities purchased prior to February 8, 2006, routine changes and automatic events that do not require any action or decision after February 8, 2006 are not considered transactions that would subject the annuity to the DRA transfer of asset provisions include:

1. Notice of address change; or

2. Death or divorce of a remainder beneficiary, and other similar circumstance; or

3. Changes that occur based on the terms of the annuity which existed prior to February 8, 2006, and which do not require a decision election or action to take effect. Example: if an annuity purchased in June 2001 included terms that require distribution to begin five years from the date of purchase, and payouts consequently begin, as scheduled, in June 2006, it would not be considered a transaction subject to the DRA transfer provision, since no action was required to initiate the change; or

4. Changes that are beyond the control of the individual, such as a change in law, change in the policies of the issuer, or a change in the terms based on other factors such as the issuer’s economic conditions.

Requirement to Name the State as a Remainder Beneficiary on Annuities

The annuity shall be treated as a transfer of assets for less than fair market value unless the state is named as remainder beneficiary in the first position.

This applies unless there is:

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Division of Welfare and Supportive Services F-420 Medical Assistance Manual TRANSFER OF ASSETS 23 Oct 01 MTL 04/23 ANNUITIES

1. A community spouse; and/or

2. A minor child or disabled child (the disabled child could be a minor or an adult); and

3. There is a community spouse or minor or disabled child and the state is named in the next position after (1) or (2); but

4. If a community spouse or minor or disabled child, or their representative disposed of any of the remainder of the annuity for less than fair market value, the state is named in the first position.

As a remainder beneficiary the state may receive up to the total medical assistance, LTC, or HCBW services paid on behalf of an individual.

The case manager notifies the issuer of the annuity of the state’s right as the preferred remainder beneficiary, and requests verification the state is named as a remainder beneficiary in the correct position.

The issuer is required to notify the state if and when there is a change in the amount of income or principal being withdrawn.

If the state is not named as a remainder beneficiary in the correct position, the full purchase value of the annuity is considered a transfer for less than fair market value.

Annuities Purchased By or On Behalf of an Annuitant Who Applies for Medical Assistance

The purchase shall be treated as a transfer of assets for less than fair market value unless the annuity meets the following criteria:

1. The community spouse is the annuitant, and

2. The state is named in the proper position as a remainder beneficiary.

The purchase shall be treated as a countable resource if it meets one or both of the following:

1. The annuity can be cancelled or revoked; or

2. The annuity is assignable.

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F-420 Division of Welfare and Supportive Services TRANSFER OF ASSETS Medical Assistance Manual ANNUITIES 23 Oct 01 MTL 04/23 The purchase will not be treated as a transfer of assets if the annuity meets any of the following conditions:

Is either:

1. An individual retirement annuity (according to Section 408(b) of the Internal Revenue Code of 1986 (IRC)); or

2. A deemed Individual Retirement Account (IRA) under a qualified employer plan (according to Section 408(q) of the IRC).

Is purchased with proceeds from one of the following:

1. A traditional IRA (IRC Section 408a); or

2. Accounts or trusts that are treated as traditional IRAs (IRC Section 408 §(c)); or

3. A simplified retirement account (IRC Section 408 §(p)); or

4. A simplified employee pension (IRC Section 408 §(k)); or

5. A Roth IRA (IRC Section 408A).

Meets all the following requirements:

1. Is irrevocable and non-assignable;

2. Is actuarially sound;

3. Provides payments in equal amounts, with no deferred or balloon payments.

The burden of proof is upon the individual or their representative to verify if the annuity meets the provisions above. Absent proof, the full purchase value of the annuity is considered a transfer of assets.

Refer annuities which are irrevocable and non-assignable to the Chief of Eligibility and Payments to determine actuarial soundness.

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Division of Welfare and Supportive Services F-420 Medical Assistance Manual TRANSFER OF ASSETS 23 Oct 01 MTL 04/23 ANNUITIES Note: Even if an annuity is determined to meet the conditions above and the purchase is not treated as a transfer, if the annuity or the income stream from the annuity is transferred, except to a spouse or to another individual for the sole benefit of the spouse, child, or trust, that transfer may be subject to penalty.

Send all documents of the life estate, promissory note, loan, mortgage, and/or annuity to the Chief of Eligibility and Payments for review.

F-425 HOME AND COMMUNITY BASED WAIVER (HCBW) AND MILLER TRUST (QIT)

Section 1917 of the Social Security Act established that a Qualified Income Trust (QIT), also known as a Miller Trust*, may be used by individuals applying for or receiving Home and Community Based Waiver (HCBW) services to reduce the amount of countable income when determining eligibility for the HCBW program. Because a HCBW customer is not assessed a patient liability, the HCBW customer may not be able to spend all income deposited in the QIT monthly. No patient liability expense may cause income to accumulate in a QIT for a HCBW customer. HCBW customer with a QIT require regular accounting to verify proper payments of allowable expenses as outlined in 42 CFR 435.725 (i.e., personal needs allowance, spousal/family allowance and certain unreimbursed medical expenses) and income deposited into the QIT. If any accumulation occurs in the QIT, the HCBW customer must be evaluated for transfer of asset penalty.

*Note: A QIT, or Miller Trust, helps an individual living in a long-term care or HCBW setting to potentially qualify for Medicaid if his or her income exceeds the allowable income limit.

F-430 RESOURCES

For the purposes of this section, the definition of resources is the same definition used by the (SSI) program, except that the home is not excluded for any institutionalized individuals.

F-435 PURSUING A POSSIBLE TRANSFER

If the individual follows the appropriate steps and provides a rebuttal to the presumption of transfer, but is unsuccessful in rebutting the presumption of transfer, the individual may request an undue hardship waiver if the request is made within twenty (20) days after the adverse decision of the Chief of Eligibility and Payments or the Hearing Officer on the presumption of transfer issue.

F-435.1 Transfer/Disposal of Asset Notification (Form 2601)

Send Form 2601-EE to applicant to inform the individual the Division presumes the asset was transferred to become/remain eligible for Medicaid LTC or HCBW Services. The amount of the uncompensated value is the amount of the transfer. Allow 20 days

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F-435.1 Division of Welfare and Supportive Services TRANSFER OF ASSETS Medical Assistance Manual TRANSFER/DISPOSAL OF ASSET NOTIFICATION (FORM 2601) 23 Oct 01 MTL 04/23 for the individual to:

a. Rebut the presumption of transfer; or

b. Request an undue hardship.

The notice to the individual advises them of the undue hardship exceptions.

If the customer does not respond within the 20-day time limit, the case manager will assume he/she does not want to rebut the presumption of transfer or request an undue hardship waiver. The penalty period will remain imposed and HCBW benefits or long- term care benefits, as applicable, will not be paid by Medicaid during the penalty period.

If a rebuttal or undue hardship request is submitted, follow the appropriate steps.

F-435.2 Rebuttal

If the individual rebuts the presumption of the transfer, it is their responsibility to present convincing evidence responding specifically to each of the following listed points that the asset was transferred exclusively for some reason other than to become eligible or retain eligibility for Medicaid, LTC or HCBW services. The rebuttal must include:

a. A written statement from the customer/authorized representative and the other individual(s) involved in the transfer, stating the reason for the transfer;

b. Verification of the attempts to dispose of the asset at fair market value, if applicable;

c. Documentation fair market value was received if that is the contention or the reasons for accepting less than fair market value;

d. The customer's relationship, if any, to the person(s) to whom the resource was transferred;

e. The customer's plans for self-support after the transfer;

f. Any relevant documentation regarding the transfer such as legal documents, correspondence, statements from other individuals, receipts, etc.

Once a rebuttal and all the necessary information to substantiate the claim are received, the case manager must determine if the information specifically addresses points (a)

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Division of Welfare and Supportive Services F-435.2 Medical Assistance Manual TRANSFER OF ASSETS 23 Oct 01 MTL 04/23 REBUTTAL through (f) and as described on Form 2601. If the customer fails to address a point or points, advise the customer which point(s) must be addressed before a decision can be made.

Upon receipt of the information, send the rebuttal to the Chief of Eligibility and Payments requesting a decision on whether a transfer of assets occurred and include a Form 6009 with the following information:

a. The name and case number of the applicant/recipient;

b. The application date;

c. The date the customer began receiving HCBW of LTC Services;

d. A brief description of the circumstances of the transfer; and

e. Verification of the Fair Market Value of the asset at the time of transfer.

F-435.3 Undue Hardship

If undue hardship is claimed, the individual will be responsible for providing convincing evidence the penalty period would cause an undue hardship. The evidence must include:

a. A written statement from the customer/authorized representative, or facility staff person (upon consent of the individual or the individual’s authorized representative) stating the reason they feel undue hardship applies;

b. Verification, if possible, there is no means, legal or otherwise, by which the customer is able to have the asset transferred back to his/her ownership or receive further compensation; and

c. The customer’s relationship, if any, to the person(s) to whom the asset was transferred.

Denial of eligibility would cause an undue hardship against the individual when all of the following conditions exist:

a. The customer is otherwise eligible for Medicaid; and

b. The customer has insufficient funds to cover the cost of institutionalized care; and

c. The person(s) who has/have the asset(s) has refused to make the asset(s) available to the customer; and

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F-435.3 Division of Welfare and Supportive Services TRANSFER OF ASSETS Medical Assistance Manual UNDUE HARDSHIP 23 Oct 01 MTL 04/23 d. The customer has exercised all reasonable efforts and all possible avenues to recover and/or access the assets by returning the assets to his/her ownership or to receive further compensation; and

e. Without Medicaid, the customer would be forced to go without life sustaining medical care as determined by an individual licensed to practice medicine in the State of Nevada.

Upon receipt of the information, send the hardship request to the Chief of Eligibility and Payments requesting a decision on whether undue hardship exists and include a Form 6009 with the following information:

a. The name and case number of the applicant/recipient;

b. The application date;

c. The date the customer began receiving LTC or HCBW Services; and

d. A brief description of the circumstances of the transfer and why it would be an undue hardship if the penalty were imposed.

A decision whether a transfer of assets occurred or an undue hardship waiver is granted will be made within 45 days from the date the Form 6009 and all pertinent information is received by the Chief of Eligibility and Payments, unless extenuating circumstances exist. An adverse determination may be appealed if received by the hearing officer within 90 days from the date of the transfer of assets or undue hardship decision.

If the individual’s request for an undue hardship waiver is received timely, continue through to the decision-making process by the Chief of Eligibility and Payments.

F-435.4 Return of Assets

If all assets transferred for less than fair market value are returned to the individual, no penalty for transferring assets can be assessed. Full Medicaid eligibility must be restored for any months a penalty was assessed if the return of assets does not cause ineligibility for other reasons.

If counting the returned income/assets results in the individual being ineligible for some or all of the months of the penalty period (because of excess income/resources), do not restore full Medicaid for months that would now be ineligible due to the excess income/resource.

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Division of Welfare and Supportive Services F-440.1 Medical Assistance Manual TRANSFER OF ASSETS 23 Oct 01 MTL 04/23 APPLICATION OF PENALTIES FOR TRANFERS MADE F-440 PENALTY PERIOD

F-440.1 Application of Penalties for Transfers Made Prior to February 8, 2006

The penalty begins the first day of the month in which the asset was transferred, provided that date does not occur during an existing penalty period.

For HCBW applicants/recipients:

a. The length of the penalty period is based solely on the value of the assets transferred and the average cost of private nursing care.

b. The length of the penalty period is calculated by dividing the value of the transferred asset (at the time of transfer) by the average cost of care (at the time of application).

For institutional applicants/recipients:

a. The length of the penalty period is based solely on the value of the assets transferred and the average cost of private nursing care.

b. The length of the penalty period is calculated by dividing the value of the transferred asset (at the time of transfer) by the average cost of care (at the time of application).

A new penalty period cannot begin until an existing penalty period has expired.

A penalty period runs continuously regardless of whether the individual remains eligible for HCBW services or if the institutionalized individual remains in or leaves the institution.

The penalty period can be shortened if:

a. Verification is received the asset has been returned to the customer.

b. The applicant/recipient receives additional compensation for the transferred asset. Verification of the additional compensation must be obtained by the case manager. The uncompensated value will be reduced by the amount of the additional compensation paid.

If the uncompensated value is reduced to a point that when dividing the remaining amount by the average cost of private nursing care only a partial month remains, the case may be eligible beginning with that partial month if all other eligibility criteria is met.

A penalty is not imposed when one amount or many amounts of transfer(s) in one month is less than the monthly cost of the nursing facility care.

A penalty is not imposed when a series of transfers, each less than the private nursing facility rate for a month, is made by an individual.

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F-440.1 Division of Welfare and Supportive Services TRANSFER OF ASSETS Medical Assistance Manual APPLICATION OF PENALTIES FOR TRANFERS MADE 23 Oct 01 MTL 04/23 When a single asset is transferred or a number of assets are transferred during the same month, the penalty period is calculated using the total value of the asset(s) divided by the average monthly cost of nursing facility care.

When multiple transfers in separate months occur, use the following methods for calculating the penalty periods.

a. Penalty Periods Overlap – calculate the individual penalty periods and impose them sequentially.

Example: An individual transfers $20,000 in January, $20,000 in February and $20,000 in March, all of which are uncompensated. Calculate the individual penalty periods and impose them sequentially: $20,000/$4,583 (2004) equals a 4-month penalty. The penalty for the first transfer extends from January through April, the second extends May through August, and the third extends from September through December.

b. Penalty Periods Do not Overlap – when multiple transfers in multiple months occur where the penalty periods for each do not overlap, treat each transfer as a separate event with its own penalty period.

Example: An individual transfers $12,000 in January, $12,000 in May and $12,000 in October, all of which are uncompensated.

Using the current nursing facility cost of $4,583, calculate each transfer $10,000/$4,583 (2004) to determine each penalty period. In this example, the penalty periods for transfers are a 2-month period, respectively, the months of January through February, the months of May through June, and the months of October through November.

F-440.2 Application of Penalties for Transfers Made On or After February 8, 2006

The length of the penalty period is calculated by dividing the value of the transferred asset (at the time of transfer) by the average cost of care (at the time of application).

The period of ineligibility will not always be the first day of the month following the month in which the transfer occurred but:

a. The first day of the month following the month which assets have been transferred for less than fair market value; or

b. The date the individual would otherwise be eligible for HCBW or LTC services whichever is later.

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Division of Welfare and Supportive Services F-440.2 Medical Assistance Manual TRANSFER OF ASSETS 23 Oct 01 MTL 04/23 APPLICATION OF PENALTY FOR TRANFERS MADE

Asset transfers are also evaluated anytime after the individual begins receiving nursing facility or HCBW services. Apply the transfer of assets penalty to the first month administratively possible allowing for adverse.

“Rounding down” or “disregarding” any fractional period of ineligibility is prohibited; therefore, calculate the percentage to continue the penalty into the next month.

Example: An applicant/recipient is eligible to receive Medicaid coverage for long-term care effective July, 2013. This individual made a transfer for less than market value of $20,000 in May, 2013. The penalty is calculated by dividing the $20,000 by $7,139 (state’s average cost of care in 2013). The result is 2.80. The penalty would be imposed for July, 2013 through September, 2013, plus 25 days of October, 2013 (31 days times .80 equals 25 days.)

Any transfer of assets for less than market value must have a penalty imposed even if only for a “partial month.” To determine the penalty period, case managers will divide the monthly cost of care by the number of days in the month the penalty is to be imposed, to establish a daily rate of care. The amount of the transfer is then divided by the daily rate to determine the total days for a fractional penalty period.

Example: An applicant/recipient is eligible to receive Medicaid coverage for long-term care effective July, 2013. In May, 2013, the individual made a transfer for less than fair market value of $2,000. The month of July has 31 days with a daily rate of cost of care at $230.29. This results in a penalty of 9 (8.68) days for July, 2013.

If an individual or the individual’s spouse has made “multiple transfers” within the look- back period, regardless of whether the value exceeds the state’s average cost of care, combine the values for a cumulative total and impose a penalty as if it were one transfer.

The penalty period cannot begin until the expiration of any existing penalty period.

Once a penalty period is imposed, it cannot be interrupted or temporarily suspended regardless if the individual remains in or leaves long-term care.

F-440.3 Exceptions

The Transfer of Assets policies shall not apply:

a. To medical assistance provided for services furnished prior to February 8, 2006;

b. To assets disposed of on or before February 8, 2006;

c. To trusts established prior to February 8, 2006; or

d. To transactions involving a partial month, multiple transfers, a life estate, or promissory note, loan or mortgage prior to April 1, 2006.

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F-440.4 Division of Welfare and Supportive Services TRANSFER OF ASSETS Medical Assistance Manual PENALTY PERIOD – SPOUSE INVOLVEMENT 23 Oct 01 MTL 04/23

F-440.4 Penalty Period - Spouse Involvement

When a spouse transfers an asset resulting in a penalty period for the customer, in the following circumstances the penalty period must be apportioned between spouses:

a. The spouse is eligible for Medicaid as an institutionalized individual; and

b. Some portion of the penalty against the customer remains at the time the above condition is met.

The remaining penalty period existing for the customer will be divided in one-half and that one-half period of time will apply to the customer and the spouse.

If for some reason one spouse is no longer subject to a penalty, the remaining penalty period applicable to both spouses must be served by the remaining spouse.

F-440.5 Situations Under Which Transfer of Asset provisions DO NOT Apply (not all inclusive)

a. Assets which are excluded at the time of the transfer. Exception: The home of an institutionalized applicant/recipient (principal place of residence) can only be transferred in the specific instances outlined in section (e) below.

b. When the customer’s name is removed from a joint bank account in accordance with joint banking policy.

c. Assets which have been divided equally, or by the legal portions owned, between legal owners.

d. When the customer provides verification they made a purchase(s) for themselves. If someone else made the purchase(s) for the customer, the Chief of Eligibility and Payments must make the final decision in accordance with the transfer procedures.

e. When the customer’s home is transferred to:

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Division of Welfare and Supportive Services F-440.5 Medical Assistance Manual TRANSFER OF ASSETS 23 Oct 01 MTL 04/23 SITUATIONS UNDER WHICH TRANSFER OF ASSET PROVISIONS

1. The spouse of the applicant/recipient.

2. A child of the customer who is under 21, or over 21 and is blind or disabled.

3. A sibling of the applicant/recipient who has equity interest in the home and was residing in the home for at least one year immediately preceding the customer becoming institutionalized or receiving HCBW Services.

4. A son or daughter who does not meet "2" above, who resided in the home for at least two years immediately preceding the customer becoming institutionalized (including HCBW Services) and who (as determined by the state) provided care to the customer which permitted the customer to reside at home rather than in an institution or facility.

f. When the asset is transferred to the customer’s spouse or to their child who is blind or disabled.

g. Assets placed in an exempt trust for a disabled individual or assets placed in a trust which are used to benefit the disabled individual and the trust purchases items and services for the disabled individual at fair market value. An exempt trust is a "special needs" or a "pooled" trust as described in subsection Treatment of Trusts.

If 3 or 4 above applies, the case manager supervisor must sign off on the case prior to the case being approved.

F-445 DECISION

Forward Form 6009 with all attached documents to the Chief of Eligibility and Payments for cases requiring a decision from the Chief of Eligibility and Payments. A memo will be issued to the district office notifying them of the decision. If the decision is that no transfer occurred, the case can be approved/continued if all other eligibility factors are met. If the decision is that a transfer took place, the memo will identify the penalty period to be applied.

(f-500)Nevada Medical Assistance Manual (MAM): F-500 Treatment of Trusts#

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL TREATMENT OF TRUSTS F-500 DEFINITIONS Trust - Any arrangement in which a grantor transfers assets to a trustee(s) with the intention it be held, managed, or administered by the trustee(s) for the benefit of the grantor or certain designated individuals (beneficiaries). Legal Instrument or Device Similar to a Trust - Any legal instrument, device or arrangement which is similar to a trust. That is, it involves a grantor who transfers assets to an individual or entity with fiduciary obligations (trustee) with the intention that it be held, managed, or administered by the trustee(s) for the benefit of the grantor or others. This can include but is not limited to, escrow accounts, investment accounts, pension funds, and other similar devices managed by an individual or entity with fiduciary obligations. Trustee - Any individual(s) or entity (such as an insurance company or bank) that manages a trust or similar device and has fiduciary responsibilities (held or found in trust or confidence). Grantor - Any individual who creates a trust. This includes: a. The individual; b. The individual's spouse; c. A person, including a court or administrative body, with legal authority to act in place of or on behalf of the individual or the individual's spouse; d. A person, including a court or administrative body, acting at the direction or upon the request of the individual or the individual's spouse. Revocable Trust - A trust which can be revoked (recalled) by the grantor. This includes trusts which can only be modified or terminated by a court, and irrevocable trusts that will terminate if some action is taken by the grantor. Irrevocable Trust - A trust which cannot, in any way, be revoked by the grantor. Beneficiary - Any individual(s) listed in the trust benefiting in some way from the trust. The beneficiary can be the grantor, another individual(s), or a combination of any of these parties, excluding the trustee or any other individual whose benefit consists only of reasonable fees or payments for managing or administering the trust. Payment - A payment from a trust is any disbursement from the corpus (principal) of the trust or from income generated by the trust. A payment may include actual cash, as well as non-cash or property disbursements, such as the right to use and occupy real property. Annuity - This is a right to receive fixed, periodic payments, either for the life of the annuitant or for a term of years. F-500 TREATMENT OF TRUSTS Division of Welfare and Supportive Services Medical Assistance Manual 25 Mar MTL 03/25 DEFINITIONS

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Assets - Assets are all income and resources of the individual including assets to which the individual is entitled or would be entitled if action had not been taken to avoid receiving the assets. F-505 EFFECTIVE DATE Trusts established prior to October 1, 1993, are "deemed" available to the customer and therefore countable, without regard to normal program exclusions, when determining income or resource eligibility. Exception: Medicaid Qualifying Trusts established prior to April 7, 1986, SOLELY for the benefit of a person with an Intellectual Disabilities (ID) who resides in an Intermediate Care Facility (ICF)/ID. Trusts established October 1, 1993, and later may be considered unavailable when determining resource eligibility. F-515 APPLICATION OF TRUST PROVISIONS For trusts established October 1, 1993, and later, the following rules apply without regard to: a. The purpose for which the trust is established; b. Whether the trustee(s) can exercise any discretion under the trust; c. Any restrictions on when or whether distributions can be made from the trust; d. Any restrictions on the use of the distributions from the trust. This means any trust can be counted in determining Medicaid eligibility no matter how specifically a clause or requirement in the trust precludes a trust from being considered under Medicaid rules. Placement of the home of an institutionalized individual in a trust does not result in the home becoming a countable resource. The home continues to be an excluded resource. F-520 TYPES OF TRUSTS How trusts are treated depend on the terms and conditions of the trust. The following are rules for counting various types of trusts. F-520.1 Revocable Trust a. The entire corpus (principal) of the trust is counted as an available resource; b. Any payments from the trust made to or for the benefit of the individual are counted as income; c. Any payments from the trust which are not made to or for the benefit of the individual are considered assets disposed of for less than fair market value and a "look-back" period of 60 months applies. F-520.2 Irrevocable Trust - Payment Can Be Made to Individual If there is any circumstance under which payment can be made to or for the benefit of the individual from all or a portion of the trust, the following rules apply: F-505 TREATMENT OF TRUSTS EFFECTIVE DATE Division of Welfare and Supportive Services Medical Assistance Manual 25 Mar MTL 03/25

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL a. Payments from income or from the corpus (principal) made to or for the benefit of the individual are treated as income; b. Income from the corpus (principal) of the trust which could be paid to or for the benefit of the individual are treated as an available resource; c. The portion of the corpus (principal) that could be paid to or for the benefit of the individual is treated as an available resource; d. Payments from income or the corpus (principal) not paid to or for the benefit of the individual are treated as a transfer of assets for less than fair market value and a "look back" period of 60 months applies. F-520.3 Irrevocable Trust - Payment Cannot Be Made to Individual When all or a portion of the corpus (principle) or income of the trust cannot be paid to or for the benefit of the individual, treat all or any such portion or income as a transfer of assets for less than fair market value and a "look-back" period of 60 months applies. F-520.4 Special Needs Trust The trust must be irrevocable and must contain the assets of an individual under age 65 who is disabled and which trust is established for the sole benefit of the disabled individual by the disabled individual, a parent, grandparent, legal guardian of the disabled individual, or a court (effective with special needs trusts established on or after 12/13/2016), or prior to 12/13/2016 by a parent, grandparent, legal guardian of the disabled individual, or a court. In addition to the assets of the individual, the trust may also contain the assets of individuals other than the disabled individual. The trust must specify that upon the death of the disabled individual, the state receive all amounts remaining in the trust up to an amount equal to the total amount of medical assistance paid on behalf of the disabled individual. If the trust meets all the above requirements, the corpus (principle) of the trust is not considered available when determining resource eligibility. However, any liquid funds, e.g., cash paid out of the trust that are used for items other than the supplemental or special needs of the individual, are considered income in the month paid out for financial eligibility and patient liability. Exception: Administrative and trust fees are allowed as deductions without counting as income or a transfer in the month paid out. Any non-liquid resource, e.g., re-title of home from the trust to an individual, removed from the trust may convert an exempt resource to a countable resource in the month it is removed from the trust. Any non- liquid resource removed from the trust not for the supplemental or special needs of the individual are considered assets disposed of for less than fair market value and a transfer of assets penalty will apply. If the trust is used to purchase a residence for a beneficiary, the fair market rental value for others living in the home will be considered income each month that others live in the home, unless the trust is paid fair market rental value for such other persons. The trustee must immediately inform the Division of Welfare and Supportive Services (DWSS) of any F-520.2 TREATMENT OF TRUSTS Irrivocable Trust-Payment Can be Made to Individual Division of Welfare and Supportive Services Medical Assistance Manual 25 Mar MTL 03/25

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL expenditure of the trust that exceeds $5,000. It must be for the sole benefit of the individual. The trustee is also required to provide a reconciled financial accounting of the expenditures made from the trust on an annual basis or as otherwise requested by the DWSS. A justification of the expenditures must accompany the financial record to ensure the expenditures were used to or for the sole benefit of the individual. A transfer of assets penalty may apply. The trustee must immediately notify the DWSS when the disabled individual passes away and must, no later than three (3) months after the individual passes away or if the trust exemption is terminated, repay the state up to the amount of the individual’s cost of care. Any additions to, or augmentations of any funds to the trust after age 65, are considered assets which are not subject to the resource exemption. F-520.5 Pooled Trusts The trust must be irrevocable, must contain the assets of a disabled individual, and be established and managed by a non-profit association as defined in section 501(c) of the Internal Revenue Code (IRC) and which has tax-exempt status under section 501(a) of the IRC. Separate accounts are maintained for each beneficiary of the trust (like a bank that holds the assets of individual accountholders) but assets are “pooled” for investing and management purposes. An account may be established for the sole benefit of the disabled individual by the individual, or by the parent(s), grandparent(s), legal guardian(s) or a court. If the account provides a benefit to any other individual, this exception does not apply. The trust must also specify that upon the death of the disabled individual, the state receive all amounts remaining in the trust up to an amount equal to the total amount of medical assistance paid on behalf of the disabled individual. If the trust meets all the above requirements, the corpus (principle) of the trust is not considered available when determining resource eligibility. However, transfer of assets provisions may apply. For example, funds added to the trust after the disabled individual is aged 65 or funds used to pay for family vacations will be considered a transfer of assets. Any non-liquid resources, e.g., re-title of home from the trust to an individual removed from the trust may convert an exempt resource to a countable resource in the month it is removed from the trust. Resources removed from the trust not for the supplemental or special needs of the individual are considered assets disposed of for less than fair market value and a transfer of assets penalty will apply. Administrative and trust fees are allowed as deductions without counting as income in the month paid out. F-520.6 Miller Type or Qualified Income Trusts - QITs A trust established to enable individuals with income that exceeds the income limit, to become eligible for Institutional Medicaid or Home and Community Based Waiver (HCBW) programs by placing their income into the Trust. F-520.4 TREATMENT OF TRUSTS Special Needs Trust Division of Welfare and Supportive Services Medical Assistance Manual 25 Mar MTL 03/25

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL a. Miller Type or QIT Requirements: 1. The trust must be irrevocable. 2. The trust must be established from income of the recipient, composed only of the individual’s pensions, Social Security, and any other unearned income which the individual receives, from whatever source, including accumulated interest in the trust. 3. No resources may be used to establish or augment the trust. Inclusion of resources voids the exemption. 4. The trust must specify that the only payments allowed from the trust are those permitted in 42 CFR 435.725 which includes patient liability, personal needs allowance (PNA), spousal/family allowance and certain unreimbursed medical expenses. Accumulation of income is NOT allowed. Any income deposited in the trust must be spent by the month following the month in which the income was deposited. 5. The trust must not provide for the payment of guardianship fees, attorney fees or trustee fees as a deduction from the trust or from the patient liability owed by the individual. 6. The trust must specify that upon the death of the individual, the state receive all amounts remaining in the trust up to an amount equal to the total amount of medical assistance paid on behalf of the individual. F-525 RESOURCES If the trust meets all the above requirements, the corpus (principle) of the trust is not considered available to the recipient when determining resource eligibility. F-530 INCOME Income deposited into a QIT is excluded in the financial eligibility determination. • Any income not deposited into the QIT is counted in the financial eligibility determination. • Any withdrawals from the QIT are counted in financial eligibility determination unless used for: o PNA; or o spousal and family allowance; or o medical expenses not covered by Medicaid; or o patient liability. Case managers must enter unearned income deposited to a QIT as income type 61-Miller Trust and make the income non-countable to ensure financial eligibility is properly determined. F-535 PATIENT LIABILITY The customer’s total available income regardless of whether or not deposited into the QIT is used to determine the customer’s share of the cost of care. See Income Types for income types excluded in the patient liability calculation. F-520.6 TREATMENT OF TRUSTS Miller Type or QITs Division of Welfare and Supportive Services Medical Assistance Manual 25 Mar MTL 03/25

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL F-540 TRANSFER OF ASSETS Income deposited into a QIT is considered a transfer of assets, unless used to or for the benefit of the applicant/recipient. Payment towards the cost of care is considered to or for the benefit of the customer/applicant, thus avoiding a transfer of assets penalty. When income placed in a QIT exceeds the amount paid out of the trust for the individual’s monthly cost of care, the excess income is subject to a transfer of assets penalty. F-540.1 Transfer of Asset Penalty Medicaid applicants/recipients seeking or receiving HCBW Services must be assessed a penalty period using the same rules as those receiving Medicaid under Long Term Care (LTC) eligibility. Use the amount of the transfer divided by the average cost of LTC to determine the number of months the individual is ineligible for waiver eligibility. The TRAN record will calculate the penalty. The penalty can only be assessed if there is a slot available and the individual is otherwise eligible for services. F-545 ELIGIBILITY & PAYMENTS REVIEW When an individual has an income trust or court document, a copy of the trust or document must be sent to the Chief of Eligibility & Payments (E&P) to determine if it meets the requirements for an exempt trust. NOTE: MAGI Medicaid groups do not require a resource evaluation. If a customer is applying for or receiving Medicaid in a MAGI category and the customer has a trust, do not refer the trust to the Chief of E&P for legal evaluation. Refer to MAM E-300 (Trust Funds) for instructions on counting trust income. Trusts should always be referred to E&P when a MAGI Medicaid case is to be converted to a MAABD program. If the trust document fails to meet the requirements of a Miller Trust (QIT), the individual will be served a timely denial/termination notice. The individual will be allowed ninety days from the date of the notice to apply for undue hardship. F-550 UNDUE HARDSHIP The trust provisions may not apply when it is determined such application would work an undue hardship. If undue hardship is claimed, the individual will be responsible for providing convincing evidence that application of the trust provisions would cause an undue hardship. The evidence must include: a. A written statement from the individual/authorized representative stating the reason they feel undue hardship applies. b. Verification there is no means, legal or otherwise, by which the individual is able to recover and/or access assets held in the trust. c. The individual's relationship, if any to the person(s) who are trustees of the trust. Denial of eligibility would cause an undue hardship against the individual when all of the following conditions exist: a. The individual is otherwise eligible for Medicaid; and F-540 TREATMENT OF TRUSTS TRANSFER OF ASSETS Division of Welfare and Supportive Services Medical Assistance Manual 25 Mar MTL 03/25

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL b. The trustee has refused to make such income/resources available to the individual; and c. The individual has sufficient funds to cover the cost of institutionalized care; and d. Without Medicaid, the individual would be forced to go without life sustaining medical care; and e. Where the individual has the ability to amend the trust so it contains the provision, upon death of the individual the State receives an amount equal to the total amount of medical assistance paid on behalf of the individual; and f. The customer has exercised all reasonable efforts and all possible avenues to recover and/or access the assets held in the trust. Once the undue hardship request and all the necessary information to substantiate the claim are received, send all the information along with Form 6009 with the information below to the Chief of E&P requesting a decision on whether an undue hardship exists. a. The name and case number of the applicant/recipient; b. The applicant date; c. The date the customer began receiving LTC or HCBW Services; and d. A brief description of the circumstances why it would be an undue hardship if the trust provisions were applied. A decision whether an undue hardship waiver will be granted should be made within forty-five days from the date the Form 6009 and all pertinent information is received by the Chief of E&P, unless extenuating circumstances exist. An adverse determination may be appealed if received by the hearing officer within ninety days from the date of the undue hardship decision. F-550 TREATMENT OF TRUSTS Division of Welfare and Supportive Services Medical Assistance Manual 25 Mar MTL 03/25 UNDUE HARDSHIP

(g-100)Nevada Medical Assistance Manual (MAM): G-100 Non-Discrimination of Hearings and Claims#

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NON DISCRIMINATION/HEARINGS/CLAIMS G-100 NON DISCRIMINATION OVERVIEW The Division of Welfare and Supportive Services (DWSS) does not discriminate against any applicant or participant in any aspect of program administration. Benefits are extended to all eligible households without regard to age, race, color, sex, handicap, religious creed, national origin, or political beliefs.

The Division must inform the public of this nondiscrimination policy and the applicable complaint procedures, and must provide access to nondiscrimination information within 10 days of a request. All Division district offices must post nondiscrimination and civil rights policy in lobby areas. Workers are also given publications to post in individual interviewing areas. G-105 DISCRIMINATION COMPLAINTS Explain the following procedures to clients who feel they have been discriminated against and want to file a claim.

Encourage the client to complete Form 2174-EG. Once the complaint is received, submit it to the social welfare manager (SWM) for investigation. Clients may submit the complaint directly to the appropriate federal office, any Division district office, Central Office or all of the above. Below is the contact information for the Federal Civil Rights Office for each program.

U.S. Office of Civil Rights (OCR) Dept. of Health & Human Services 50 United Nations Plaza San Francisco, CA 94102

(415) 437-8310, Toll free 800-368-1019 or TDD (415 437-8311

Clients must file their complaints in writing within 180 calendar days of the incident that caused the complaint.

In the event a complainant refuses to put the allegation in writing, the person to whom the allegation is made must put the elements of the complaint in writing. Note: The complaint may be made anonymously.

Division of Welfare and Supportive Services G-100 Medical Assistance Manual NON DISCRIMINATION/HEARINGS/CLAIMS 13 Oct 01 MTL 01/13 NON DISCRIMINATION OVERVIEW

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G-110 RACIAL AND ETHNIC DATA COLLECTION The Division obtains racial and ethnic information about all clients. The ethnic categories include Hispanic or non-Hispanic. The racial categories are: American Indian or Alaskan Native, Black or African American, Asian, Native Hawaiian or Other Pacific Islander and White. Clients are asked to voluntarily identify their race and/or ethnicity on the Form 2905, Application for Assistance. If this information is not voluntarily provided on the application form, the case worker will determine the category by observation and record it on each individual’s MEMB screen in NOMADS. G-115 INTERPRETIVE SERVICE REQUESTS The Division provides interpretive services for both foreign and sign languages. If you recognize or have any reason to believe that a person or companion is deaf or hard of hearing, you must advise the person that appropriate auxiliary aids and services, such as sign language and oral interpreters, TTYs, note takers, written materials, assistive listening devices and systems, and telephones compatible with hearing aids, will be provided free of charge. If you are the case manager, you must ensure that such aids and services are provided when appropriate.

G-115.1 Sign Language Interpreter Requests To request a sign language interpreter, for a scheduled appointment, the case manager must e- mail the request to Welfare – Interpretive Services under Welfare Groups in the Outlook Address Book at least two working days prior to the date of the interview/appointment. The request must include the type of interpretive services needed, the date and time of the interview/appointment, the name of the client, the office the interview/appointment will be held at, the type of interview/appointment to be conducted, estimated length of interview/appointment, name of employee who will be conducting the interview/appointment and the direct telephone number of the employee.

The E&P unit clerk will contact the appropriate interpreter and confirm the appointment with the case manager. Once the request is received and processed, the case manager will receive a confirmation. If the case manager does not receive a confirmation within one working day, a second request should be sent.

Once the in-person interview has been conducted, the case manager must complete Section I of form 2034-WG and have the interpreter complete Section II. Once Sections I and II are completed, both the case manager and the interpreter must acknowledge the information provided by signing the bottom of the form. A photocopy of this form must be given to the interpreter for submission with their invoice for payment AND the ORIGINAL mailed to Eligibility and Payments in Central Office to verify the services of the interpreter. If a confirmed interpreter does not show for the appointment, notify Welfare-Interpretive Services the same day via email.

G-110 Division of Welfare and Supportive Services NON DISCRIMINATION/HEARINGS/CLAIMS Medical Assistance Manual RACIAL AND ETHNIC DATA COLLECTION MTL 01/13 01 Oct 13

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If the applicant cancels the appointment, notify the Eligibility and Payments unit clerk at (775) 684-0615 of the cancellation, as soon as possible. NON-DWSS EMPLOYEES PROVIDING INTERPRETIVE SERVICES – All non-DWSS employees who provide in-person interpretive services must attest to their status as an employee of the State of Nevada. At each interview, the case manager must inquire if the non- DWSS employee is currently an employee of the State of Nevada. Any interpreter providing in- person interpretive services for the first time must complete page 2 of form 2034-WG verifying current State of Nevada employment status. Failure to complete and submit page 2 of form 2034-WB will result in non-payment for the services provided. G-115.2 Non-English Speaking Interpretive Requests CTS LanguageLink Interpretive Services is a secondary option for Spanish interpretive services and is the primary resource for all other languages. This applies to all pre-scheduled appointments as well as those circumstances where immediate interpretive services are needed. CTS LanguageLink will assist in setting up conference calls for interviews conducted on the telephone.

To access CTS LanguageLink services, follow the procedures located at G:\WILLCALL\Interpretive Services\CTSLanguageLink Procedures.

Once the call is completed with CTS LanguageLink, all areas of Section 1 of form 2034-WG must be completed and the employee/case manager must sign the form. Section II and page 2 do not need to be completed when CTS LanguageLink is used. Once the form is completed, it must be forwarded to Eligibility and Payments in Central Office the same business day the service is used.

It is imperative that any employee/case manager of DWSS accessing the CTS LanguageLink services complete the Confirmation of Interpretive Services form including the program being interpreted for. It is also imperative that staff become familiar with the procedures for CTS LanguageLink including the use of DWSS’s account number and the appropriate access code for each office and any associated units. G-200 HEARINGS Hearing requests must be RECEIVED in writing within 90 days from the date of the Notice of Decision. The day after the notice date is the 1st day of the 90-day period.

Clients may request a hearing because:

a. of agency action to deny, reduce or terminate benefits; or

b. of agency action to make payments to a protective payee; or

c. they are aggrieved about an application was not acted on with reasonable promptness; or

Division of Welfare and Supportive Services G-115.1 Medical Assistance Manual NON DISCRIMINATION/HEARINGS/CLAIMS 20 Jan 05 MTL 01/20 Sign Language Interpreter Requests

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d. due to exceptional circumstances resulting in significant financial duress, a higher minimum monthly maintenance needs allowance is needed to provide additional income to the community spouse; or

e. the community spouse resource allowance is inadequate to raise the community spouse's income level to the minimum monthly maintenance needs allowance without adding more resources which are income producing.

Continued benefits will be provided if a hearing request is RECEIVED in writing no later than the 10th day after the effective date of the proposed action. Assistance will continue unchanged until the hearing decision is made unless the client provides a written request asking benefits not be continued or the hearing officer makes a preliminary finding the sole issue is one of state or federal law requiring automatic benefit adjustments. See Welfare Administrative Manual Section 3100 for more detailed information regarding the hearing process.

G-300 MEDICAID PROGRAM CLAIMS

G-300.1 Definition of a Claim A Medicaid claim is the calculated value of any service, good or other item of value paid by the Medicaid Program which exceeds the amount of benefits the individual(s) was eligible for. G-300.2 Medicaid Claims When information exists that a Medicaid claim exits the case manager will:

• Ensure the household’s current budget reflects correct, up-to-date information to avoid further incorrect payment of benefits.

• Obtain written verification of the questionable issue.

• Refer the claim to I&R via the Investigations and Recovery Information System (IRIS) for review, calculation and claim establishment. G-300.3 Claim Packet Immediately at claim referral, case manager shall compile a “claim packet.” The claim packet must include: • a copy or original of all pertinent documents (applications, picture ID, etc.) contained within the case file; • a copy or original of substantiating documentation relative to the claim;

G-200 Division of Welfare and Supportive Services NON DISCRIMINATION/HEARINGS/CLAIMS Medical Assistance Manual HEARINGS MTL 01/13 01 Oct 13

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• a case narrative containing at a minimum how the claim occurred; and • a copy of the claim referral. The claim packet must be sent to the I & R Unit responsible for their program office as soon as possible to begin the collection process.

Claims are addressed in detail in the I & R Manual, section 300–500, respectively. Reference should be made to these manual sections for issues/events not addressed in this chapter.

Division of Welfare and Supportive Services G-300.3 Medical Assistance Manual NON DISCRIMINATION/HEARINGS/CLAIMS 13 Oct 01 MTL 01/13 Claim Packet

(h-100)Nevada Medical Assistance Manual (MAM): H-100 Hospital Presumptive Eligibility Provider Guidance#

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H-100 Division of Welfare and Supportive Services PRESUMPTIVE ELIGIBILITY Medical Assistance Manual OVERVIEW 23 Oct 01 MTL 04/23 PRESUMPTIVE ELIGIBILITY PROVIDER GUIDANCE

H-100 OVERVIEW

Presumptive Eligibility (PE) allows qualified providers and hospitals to determine certain individuals “presumptively eligible” for Medicaid based on preliminary information obtained from the applicant. Individuals determined eligible for PE receive Medicaid benefits for a temporary period of time, provided all eligibility criteria is met.

The purpose of PE is to provide a streamlined process for individuals to obtain access to immediate coverage and to promote ongoing Medicaid enrollment by encouraging individuals to complete a full application for health insurance with DWSS.

Questions regarding all PE or Medicaid policy listed in this Medicaid Assistance Manual (MAM) should be directed to the DWSS Chief of Eligibility and Payments or the DWSS Medicaid Program Specialist.

H-101 QUALIFIED PROVIDERS / QUALIFIED HOSPITALS

A qualified provider or hospital participates as a provider under the State Medicaid Program and must agree that they will make PE determinations consistent with state policies and procedures outlined in both the Division of Health Care Financing and Policy (DHCFP) Medicaid Services Manual (MSM) and the Division of Welfare and Supportive Services (DWSS) Medicaid Assistance Manual (MAM).

Each provider or hospital electing to participate in the PE program must have a signed Presumptive Eligibility Medicaid provider contract amendment in place with DHCFP. Hospital staff making the PE determination must be trained and certified by the DWSS Learning and Development unit to obtain system access to the DWSS PE Portal.

Qualified Provider or Qualified Hospital Requirements

DHCFP and DWSS will determine the appropriate Medicaid provider types for each PE program. Selected providers must be publicly available and must allow any individual or family to request a PE application and determination be made for them regardless of whether the individual or family is a current patient of the provider or hospital.

There are differences in the PE program that a qualified Provider or a qualified Hospital may approve:

• qualified providers may approve Prenatal Pregnancy PE only. • qualified hospitals may approve full Health Care Services (Hospital PE)

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Division of Welfare and Supportive Services H-100 Medical Assistance Manual PRESUMPTIVE ELIGIBILITY 23 Oct 01 MTL 04/23 PRENATAL PREGNANCY PE

H-102 PRENATAL PREGNANCY PE

Prenatal Pregnancy PE can only be approved by a certified employee of a qualified provider. Pregnant individuals approved under this program are eligible to receive prenatal pregnancy care at outpatient clinics or other places in the community. PE for prenatal care provides limited services and will not cover the cost if you are admitted to a hospital. Questions on what specific services are or aren’t covered under this program should be directed to the DHCFP Provider Services unit.

H-103 HOSPITAL PE

Hospital PE can only be approved by a certified employee of a qualified hospital. Individuals and families approved under this program are eligible to receive immediate Medicaid services such as doctor visits, hospital care, and prescription drugs. They can go to any health care provider who accepts Medicaid starting the day you are approved. Questions on what specific services are or aren’t covered under this program should be directed to the DHCFP Provider Services unit.

H-105 ELIGIBLE GROUPS

Eligibility for medical assistance is categorized in groups based on the associated budget methodology used to determine eligibility.

An application for PE must contain the applicant’s name, address, and signature. See MAM D-100 for more information on acceptable applications and signatures.

Individuals applying for PE may designate anyone to act on their behalf by providing a signed written statement. If circumstances exist that render the individual incapacitated and unable to make that designation, a responsible adult family member or facility staff completing the application may designate themselves. See MAM A-120 for more information and restrictions on designating an Authorized Representative.

Individuals are eligible for 1 presumptive eligibility period in a 24- month period. Pregnant individuals are eligible for 1 presumptive eligibility period for each separate pregnancy.

a. Children o Under the age of 19; and o Children with household income that is at or below the FPL for the child’s age and applicable assistance unit.

1. Children 0 through 5 up to 165% (CH aid code) 2. Children 6 through 18 up to 122% (CH aid code) 3. Children 6 through 18 above CH up to 138% (CH1 aid code)

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H-105 Division of Welfare and Supportive Services PRESUMPTIVE ELIGIBILITY Medical Assistance Manual ELIGIBLE GROUPS

23 Oct 01 MTL 04/23 • Children on CH1 aid code can have dental and vision insurance but cannot have other major medical insurance.

Note: This group only covers children approved for CH and/or CH1 categories. Pregnant children are evaluated under the Pregnant Women group for CHP or CHO. Qualified providers or hospitals do not make determinations for Nevada Check Up.

b. Parents and caretaker relatives o A relative of a dependent child by blood, adoption, or marriage with whom the child is living, who assumes primary responsibility for the child's care, and who is one of the following:

1. the child's father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece;

2. the spouse of such parent or relative, including same-sex marriage, even after the marriage is terminated by death or divorce; or

3. another relative of the child based on blood (including those of half- blood), adoption, or marriage;

4. the domestic partner of the parent or other caretaker relative; (domestic partnerships must be registered in Nevada.)

o Parents and caretakers with household income that is at or below 138% FPL for the applicable assistance unit. (AM aid code).

o Parents and caretakers with income between the AM income limit and 138% of FPL (AM1 aid code);

• Are not eligible if they are entitled to or enrolled in Medicare.

Note: See MAM Appendix A, MAGI Income chart

c. Pregnant women o Pregnant women with household income that is at or below 165% FPL for the applicable family size. (CHP aid code) o Pregnant women approved for prenatal PE service only. (CHO aid code).

Note: Each unborn is counted as an additional member when determining assistance unit size for the pregnant woman’s assistance unit.

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Division of Welfare and Supportive Services H-105 Medical Assistance Manual PRESUMPTIVE ELIGIBILITY 23 Oct 01 MTL 04/23 ELIGIBLE GROUPS d. Childless adults age 19-64 o age 19 and under age 65; and o not pregnant; and o not entitled to or enrolled in Medicare benefits under Part A or B; and o not otherwise eligible for medical coverage in any other group; and o member of a household that has income that is at or below 138% FPL for the applicable family size. (CA aid code)

e. Aged Out of Foster Care o under 26 years of age; and o were in foster care in Nevada, under the responsibility of the state at the time they turned 18 years of age; and o were enrolled in Medicaid while in foster care; o were in foster care under the responsibility of any state and turned 18 years of age on or after January 1, 2023. OR o under 21 years of age; and o were in foster care under the responsibility of a state at the time they turned 18 years of age.

Note: Aged out of foster care is aid code AO regardless of which category. Individuals who qualify as AO should be referred to the Division of Child & Family Services (DCFS) website for more information at http://dcfs.nv.gov/Programs/CWS/IL/ where they can obtain a copy of the full Medicaid application for AO individuals.

MAGI Exception: Individuals who receive Supplemental Security Income (SSI) from social security may qualify for PE under any eligibility group identified above. SSI individuals must meet all other factors of eligibility to qualify. SSI income is not countable under the PE program.

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H-110 Division of Welfare and Supportive Services PRESUMPTIVE ELIGIBILITY Medical Assistance Manual FACTORS OF ELIGIBILITY 17 Jul 01 MTL 04/17 H-110 FACTORS OF ELIGIBILITY

To be eligible for PE, potential recipients must meet certain citizenship, residency, and income criteria.

Citizenship – Individuals must attest to U.S. Citizenship or indicate they are a Lawful Permanent Resident and have been continuously residing in the U.S. for 5 years.

Residency – Individuals must be living in Nevada with the intention of making Nevada their home permanently OR must be living in Nevada with a job commitment or seeking employment. Individuals are not required to have a fixed place of residence to meet this requirement.

Income – Individuals must meet income eligibility criteria for the appropriate eligibility group. MAGI specific Federal Poverty Levels (FPL) and their effective dates are listed in MAM Appendix A.

Budget the current taxable gross income received, or anticipated to be received, for every individual included in the assistance unit, with the following exceptions:

a. Income of a child in the parent’s assistance unit determination unless the child is required to file a tax return.

b. Income deemed non-taxable.

c. Allowable pre-tax deductions.

Note: See MAM E-300 for types of earned and unearned income, E-110.1 for who must file a tax return and E135.1 for allowable deductions.

Assistance Unit – Must apply non-filer rules to all cases.

The non-filer household consists of the individual and, if living with the individual;

a. the individual’s spouse/domestic partner; and

b. the individual’s natural, adopted and step children under age 19; and

c. in the case of children under age 19:

1. the child’s natural, adopted and step parents; and 2. natural, adoptive and step siblings under age 19

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Division of Welfare and Supportive Services H-115 Medical Assistance Manual PRESUMPTIVE ELIGIBILITY 23 Oct 01 MTL 04/23 VERIFICATION H-115 VERIFICATION

Qualified providers and hospitals are prohibited from requiring individuals to provide verification of any eligibility factors used in a PE determination. Hospitals must accept client attestation.

Note: If the individual provides any type of verification, a copy of the verification needs to be retained with the application.

H-120 PE COVERAGE PERIOD

The PE period begins the day of application and ends the last day of the month following the first month of the eligibility determination, if a full application for health insurance is not received by DWSS for the individual. If a full application for health insurance is received during the PE period, PE ends the day DWSS approves or denies the full application.

Example: A PE determination is made on January 10th and no health insurance application is received. Medicaid eligibility begins January 10th and ends February 28th. The system will automatically terminate eligibility, requiring no action by DWSS staff.

Example: A PE determination is made on February 10th and a full DWSS application for health insurance application is received on March 2nd. DWSS processes the application on April 10th. PE ends April 10th.

Individuals approved for Hospital PE are eligible for one (1) PE period every 24 months.

Pregnant individuals and individuals approved under the Prenatal Pregnancy PE program may receive one (1) PE period for each separate pregnancy.

Both PE programs, Prenatal and Hospital, will count against the other program’s restricted time limit.

Note: Adverse action notification is not required when ending a PE period after the denial of the DWSS application for full health insurance.

H-125 NOTIFICATION OF PE DETERMINATION

Qualified providers and hospitals are required to provide a written notification of the PE eligibility determination through a Notice of Decision (NOD) to individuals and families applying for PE. The NOD must advise the applicant of the eligibility determination, the appropriate PE period and the option for individuals or families to submit a complete health insurance application to DWSS. The PE Notice of Decision (Form 2991) will be provided to the qualified providers and hospitals by DWSS.

The requirement to provide a notice and fair hearing regulations and appeal rights does not apply to the PE determination.

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H-130 Division of Welfare and Supportive Services PRESUMPTIVE ELIGIBILITY Medical Assistance Manual TIME FRAMES

23 Oct 01 MTL 04/23 H-130 TIME FRAMES

The hospital must enter the presumptive eligibility determination into the DWSS PE system within five (5) days of the application date. This process serves as notification of the eligibility decision.

Note: The PE system will update the DHCFP Medicaid Eligibility Verification System (EVS). This process takes a minimum of two business days after case entry.

H-135 “PRUDENT PERSON” PRINCIPLE

The policies included in the manual are rules for determining eligibility. It is impossible to foresee and give examples for all situations; therefore, the qualified provider and hospital staff certified to make PE determinations are encouraged to use reason and apply good judgment in making eligibility decisions when rare and unusual situations are encountered.

Reasonable decisions made by PE certified staff based on the best information available, using good judgment, program knowledge, experience and expertise in a particular situation is referred to as the Prudent Person Principle. The “Prudent Person Principle” may be applied when rare and unusual situations are encountered, and guidance is not clearly stated in this Medicaid Assistance Manual (MAM). Any decision made that is determined to be incompatible with current DWSS or DHCFP policy will be cited in accordance with the established DWSS PRE PE Review Guide.

H-140 WITHDRAWAL OF APPLICATION

An individual may voluntarily withdraw an application any time before PE determination is made. The qualified provider or hospital must allow the request to be made electronically, telephonically recorded, or handwritten.

H-145 CASE DOCUMENTATION

All PE decisions are reviewed by the DWSS Program, Review, and Evaluation (PRE) unit. The PE certified staff must include in an individual’s case record any facts used to support the decision on the application. A case narrative is required, and documentation must be clear and concise to allow the DWSS PRE unit reviewing the case to determine the reason, logic and accuracy of the PE certified staff’s decision and actions.

Any decision made that is determined to be incompatible with current DWSS or DHCFP policy will be cited in accordance with the established DWSS PRE PE Review Guide.

Supporting documentation, voluntarily provided by the individual, must be maintained in the case record.

The PE application must be complete and signed by the individual or the individual’s authorized representative.

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Division of Welfare and Supportive Services H-145 Medical Assistance Manual PRESUMPTIVE ELIGIBILITY 23 Oct 01 MTL 04/23 CASE DOCUMENTATION The PE certified staff completing the eligibility determination is required to sign and issue the PE Notice of Decision (Form 2991).

H-150 PRESUMPTIVE ELIGIBILITY STANDARDS

All qualified providers and hospitals must maintain the following eligibility standards in order to remain a certified PE facility provider.

1. Ninety-four percent (94%) of all PE decisions must be correctly determined based on the State’s PE policies and must be entered into the PE system correctly from the information gathered at application.

2. Ninety percent (90%) of individuals determined presumptively eligible by a hospital must submit a full health insurance application to DWSS prior to the end of the presumptive eligibility period.

3. Qualified providers processing Prenatal pregnancy PE are encouraged to stress the importance of applying for full health insurance from DWSS to continue to receive Medicaid services beyond the PE period.

When entering information into the PE system, PE certified staff must ensure the accuracy of the information being entered. The use of slang or nicknames is not permitted. Individual names, dates of birth, and social security numbers must be accurate upon entry into the PE system to ensure a proper data match can occur and identity confirmed.

H-151 DWSS PROGRAM, REVIEW, AND EVALUATION (PRE) AUDIT

DWSS Program, Review, and Evaluation (PRE) staff will monitor monthly reports as well as conduct audits to ensure policy, procedures and standards are being met. All qualified providers and hospitals are required to cooperate with PRE by providing case records and any supporting documentation as requested to complete a PRE audit.

When a qualified provider or hospital is determined to have fallen below standards based on the PRE audit review period, a corrective action plan (CAP) will be developed for the qualified provider or hospital by the DWSS PRE staff. If PRE staff determine, after implementation of the CAP, the qualified provider or hospital remains below the standards, the hospital will:

o be disqualified by DWSS; and

o no longer be authorized to conduct PE determinations; and

o be required to serve a 1 year sit out period from making PE determinations.

Note: Non-cooperation with a PRE audit request without good cause (as determined by PRE) may result in the immediate assessment of the qualified provider or hospital being placed in a CAP.

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H-151 Division of Welfare and Supportive Services DWSS PROGRAM, REVIEW, AND EVALUATION (PRE) AUDIT Medical Assistance Manual CASE RECORDS AND RETENTION 23 Oct 01 MTL 04/23 Qualified providers and hospitals may not delegate the authority to determine PE to another entity. Trained and certified staff must make the PE eligibility determinations. Third parties may assist in gathering information from applicants and assist in completion of the application paperwork, but they may not make the PE determination. Only PE certified staff will have access to the DWSS PE portal system.

H-155 CONDITIONS OF PARTICIPATION

Participating qualified providers and hospitals must meet all conditions of participation as set forth in the Division of Health Care Financing and Policy (DHCFP), Medicaid Services Manual, Chapter 100 all inclusive.

H-160 CASE RECORDS AND RETENTION (NRS 239.080, NRS 230.125)

The qualified provider or hospital must maintain case files in accordance with the State’s record retention schedule. Records must be maintained for 37 months after the PE period end date.

Note: The qualified provider or hospital is required to maintain documentation regarding the PE eligibility determination and can be maintained as paper or electronic files.

H-165 AUTHORITY

42 CFR 435.1110, 42 CFR 435.907, 42 CFR 435.1102, 42 CFR 435.1103, NRS 422.306, SSA 1915(f)(2), SSA 1915(f).

(h-200)Nevada Medical Assistance Manual (MAM): H-200 Hospital Presumptive Eligibility DWSS Case Manager Guidance#

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services H-200 Medical Assistance Manual HOSPITAL PRESUMPTIVE ELIGIBILITY 23 Oct 01 MTL 04/23 OVERVIEW

PRESUMPTIVE ELIGIBILITY DWSS CASE MANAGER GUIDANCE

H-200 OVERVIEW

The purpose of PE is to provide a streamlined process for individuals to get access to immediate coverage and to promote ongoing Medicaid enrollment, by encouraging individuals to complete a full application for health insurance with DWSS.

H-201 QUALIFIED PROVIDERS/QUALIFIED HOSPITALS

A qualified provider or hospital participates as a provider under the State Medicaid program and must agree that they will make PE determinations consistent with state policies and procedures outlined in both the Division of Health Care Finance & Policy (DHCFP) Medicaid Services Manual (MSM), and the Division of Welfare and Supportive Services (DWSS) Medicaid Assistance Manual (MAM).

Each provider or hospital electing to participate in the PE program must have a signed Presumptive Eligibility (PE) Medicaid provider contract amendment in place with DHCFP. Provider of hospital staff making the PE determination must be trained and certified by the DWSS Learning and Development unit to obtain PE system access to the DWSS Portal.

H-205 ELIGIBLE GROUPS

Qualified providers and hospitals participating in the PE program may make presumptive eligibility determinations for the following eligibility groups. Eligibility for medical assistance is categorized in groups based on the budgeting methodology associated with the eligibility determination.

a. Children (This group only covers children approved for the CH and/or CH1 categories. Hospitals do not make determinations for Nevada Check Up.)

b. Parents and caretaker relatives

c. Pregnant women (Providers can approve prenatal services, hospitals can approve full PE).

d. Childless adults age 19-64

e. Aged Out of Foster Care

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL H-210 Division of Welfare and Supportive Services HOSPITAL PRESUMPTIVE ELIGIBILITY Medical Assistance Manual FACTORS OF ELIGIBILITY 23 Oct 01 MTL 04/23

Qualified providers and hospitals are not limited to registered patients; they may assist with presumptive determinations for family members and other non-patients.

Participants are eligible for one (1) presumptive eligibility period in a 24-month period.

Exception: Pregnant individual may receive one (1) presumptive eligibility (prenatal or hospital) period per pregnancy.

H-210 FACTORS OF ELIGIBILITY

To be eligible for PE, potential recipients must meet certain citizenship, residency and income criteria.

Citizenship – Individuals must attest to U.S. Citizenship or indicate they are a Lawful Permanent Resident and have been continuously residing in the U.S. for 5 years.

Income – Individuals must meet income eligibility criteria for the appropriate eligibility group.

Assistance Unit – Must apply non-filer rules to all cases. The household consists of the individual and, if living with the individual;

a. the individual’s spouse/domestic partner; and

b. the individual’s natural, adopted and step children under age 19; and

c. in the case of children under age 19:

1. the child’s natural, adopted and step parents; and 2. natural, adoptive and step siblings under age 19

H-215 VERIFICATION

Hospitals are prohibited from requiring individuals to provide verification of any of the eligibility factors used in a Medicaid determination. Hospitals must accept client attestation for all factors of eligibility.

H-220 HPE COVERAGE PERIOD

The PE period begins the day the HPE determination is made by the hospital and ends the last day of the month following the month of the eligibility determination, if an

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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services H-220 Medical Assistance Manual HOSPITAL PRESUMPTIVE ELIGIBILITY 23 Oct 01 MTL 04/23 HPE COVERAGE PERIOD

application for medical assistance is not received by DWSS for the individual. If a full application for medical assistance is received during the HPE period, HPE ends the day DWSS approves or denies the application.

Example: HPE determination is made on January 10th and no medical assistance application is received. Medicaid eligibility begins January 10th and ends February 28th. The system will automatically terminate eligibility, requiring no action by DWSS staff.

Example: PE determination is made on February 10th and a full medical assistance application is received on March 2nd. DWSS processes the application on April 10th. Presumptive eligibility ends April 10th.

Note: Adverse action is not required when ending a presumptive eligibility period by denying the medical assistance application.

DWSS case managers are not required to update the HPE determination in the system. When the full application for medical assistance is processed, using all current eligibility policies, the system will update the PE determination automatically.

Example: PE determination was made in January and the full medical assistance application was received in January, but not processed until March. Case manager would post application month of January and ongoing regardless of the PE determination. This will allow DHCFP and their MMIS system to adjust the eligibility status and retroactively claim the appropriate federal match rates for newly eligible individuals.

H-225 NOTIFICATION

Qualified providers and hospitals are required to provide written notification of the eligibility determination (Notice of Decision) to individuals applying for PE.

The notice must:

a. advise the applicant of the eligibility determination; and b. the PE period; and c. the importance of submitting a complete medical assistance application

Notice and fair hearing regulations do not apply to the PE determination. The PE Notice of Decision (form 2991) will be provided to qualified providers and hospitals by DWSS.

(table-of-contents)Nevada Medical Assistance Manual (MAM): Table of Contents#

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A-100 TABLE OF CONTENTS

MEDICAL ASSISTANCE PROGRAM MANUAL PART A – GENERAL PROVISIONS AND DEFINITIONS MEDICAL ASSISTANCE OVERVIEW 100 Purpose and Applicability 105 Medical Assistance Overview 110 Cooperation 115 Prior Medical 115.1 Applying For Prior Medical Coverage 115.2 Verification of Prior Medical Assistance 120 Authorized Representative 120.1 Spousal Authorization 125 Medicaid Card 130 Managed Care Enrollment 135 Services Provided by Nevada Medicaid 140 Medicaid Estate Recovery Program 140.1 Legal Authority 140.2 Program Overview 140.3 Affected Individuals 140.4 Notification to Affected Individual 145 Referral of Cases to MER Unit 145.1 Initiation of MER Activities A-200 DEFINITIONS AND ACRONYMS 200 Definitions and Use of Terms 210 Acronyms PART B – MEDICAID CATEGORIES B-100 MAGI MEDICAL CATEGORIES 100 Overview 105 Family Medical Coverage Groups 110 Parents and Other Caretaker Relatives (42 CFR 435.4, 42 CFR 435.110, 42 CFR 435.911) 110.1 Shared Custody 115 Pregnant Women and Postpartum (42 CFR 435.4, 42 CFR 435.116, 42 CFR 435.911) 120 Infants and Children Under Age 19 (42 CFR 435.118, 42 CFR 435.911) 120.1 Deemed Newborn Children (also known as OBRA) (42 CFR 435.117) 120.2 Nevada Check Up (NCU)-Children with Income Above Medicalid Limits and Below 205% FPL (42 CFR 457) 125 Childless Adults/Individuals Age 19 Thru 64 (42 CFR 435.119, 42 CFR 435.911) 130 Transitional Medicaid Coverage (1925, 42 CFR 435.112) 135 Post medical (42 CFR 435.115) 140 Emergency Medicaid MAGI (42 CFR 435.139, 42 CFR 435.406) Division of Social Services Medical Assistance Manual 13 Aug 25 MTL 10/25

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B-200 SPECIALIZED MEDICAL CATEGORIES 200 Overview 205 Specialized Medicaid Eligibility Groups 210 Medicaid For Children For Whom A Public Agency Has Assumed Financial Responsibility 215 Medicaid Eligibility for Title IV-E Eligible Foster Children at Rite of Passage 220 Aged Out of Foster Care Program (42 CFR 435.150, 42 CFR 435.226) 225 Breast/Cervical Cancer Medicaid (Public Law 106-354) 225.1 MCB Presumptive Eligibility B-300 MAABD MEDICAL CATEGORIES 300 Overview 305 Aged, Blind and Disabled 310 Medicare Beneficiaries 310.1 Low Income Subsidy (LIS) Referrals 310.2 Qualified Medicare Beneficiaries (QMB) 310.3 Special Low-Income Medicare Beneficiaries (SLMB) 310.4 Qualified Individuals (QI) 310.5 Qualified Disabled Working Individuals (QDWI) 315 Supplemental Security Income (SSI) 315.1 Eligibility Exceptions 315.2 SSI Resources 320 Public Law Cases 320.1 Pickle Amendment-Public Law 94-566 Section 503 320.2 Adult Disabled Child-Public Law 99-643 320.3 Widow/Widowers-Public Law 100-203 320.4 Widows, Widowers and Surviving Divorced Spouses Public Law 101-508 320.5 Suspension of SSI Due to Income-Public Law 96-265 320.6 Persons Ineligible for SSI Due to Alien Sponsor Deeming (42 CFR 416.1160) 325 Institutionalized Individuals 325.1 Persons Institutionalized Less than 30 Consecutive Days 325.2 Persons Institutionalized at Least 30 Consecutive Days 330 Home and Community Based Services 335 Katie Beckett 340 Prior Medical 345 Health Insurance for Work Advancement (HIWA) 350 Aged, Blind and Disabled Specialized Medical Groups 350.1 Continuation of ‘Pregnancy Related’ Medical Coverage 350.2 Emergency Medical for Ineligible Non-Citizens (Public Law 99-509 Section 9406) Division of Social Services Medical Assistance Manual 13 Aug 25 MTL 10/25

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C-100 PART C – GENERAL ELIGIBILITY REQUIREMENTS RESIDENCE REQUIREMENTS 100 Residence Requirements (42 CFR 435.403) 100.1 SSI Recipients Receiving a State Supplementary Payment (SSP) from Another State 100.2 Verification 105 Exception to Residency Rules 105.1 Individuals Placed in an Out-of-State Institution 105.2 Individuals Under the Age 21 105.3 Individuals Age 21 and Over 110 Disputed Residency 115 Temporary Absence 120 CAP Program (NRS 217) C-200 FURNISHING SOCIAL SECURITY NUMBERS 200 Social Security Numbers (42 CFR 435.910) 200.1 Verification 200.2 Worker Action at Application 200.3 Failure to Comply C-300 CHILD SUPPORT ENFORCEMENT 300 Child Support Enforcement (42 CFR 433.138, 42 CFR 433.145, 42 CFR 433.147, 42 CFR 433.148, 42 CFR 433.152 and 42 CFR 435.610) 305 Child Support Non-Cooperation C-400 CITIZENSHIP REQUIREMENTS 400 Citizenship and Identification Requirements (42 CFR 435.406, 42 CFR 435.407, 42 CFR 435.940, 42 CFR 435.956) 405 Eligibility Requirements 405.1 Verification and Documentation 405.2 Reasonable Opportunity (42 CFR 435.956(b)) 405.3 Stand-Alone Evidence of U.S. Citizenship or Nationality 405.4 Evidence of U.S. Citizenship or Nationality 410 Acceptable Verification of Identity 415 Verification of Collective Naturalization 415.1 Puerto Rico 415.2 U.S. Virgin Islands 415.3 Northern Mariana Islands (NMI) 420 Non-Citizen Medical Assistance Eligibility Chart 420.1 Verification of Non-Citizen Status 420.2 Verifying Non-Citizen Status Using the Systematic Alien Verification to Entitlements (SAVE) System 420.3 Paroled as Refugees and Cuban/Haitian Entrants 425 Non-Citizen Status 430 Re-Verification of Immigration Status Due to an INS Document’s Expiration Date 435 Documentation of Veteran Status 435.1 Verification of Veteran Status 435.1.1 Discharged Members Division of Social Services Medical Assistance Manual 13 Aug 25 MTL 10/25

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435.1.2 Active Duty Members 435.1.3 Reserve Members (Not On Active Duty for Training) 440 Definition of Battered Non-Citizen 445 Iraqi and Afghani Special Immigrants 450 Victims of Human Trafficking C-500 C-505 SSI Application and Determination 505 SSI Application and Determination 505.1 Required 505.1.1 Aged, Blind and Disabled Persons Not in an Institution with Total Countable Income Less than SSI Payment Levels 505.1.2 Persons in an Institution with Total Countable Income Less Than $30 505.2 Not Required C-600 THIRD-PARTY LIABILITY 600 Third-Party Liability (TPL) (42 CFR 435.610) 605 Medicare as TPL 605.1 Persons Eligible for Medicare 610 Notification of Third-Party Liability (TPL) to the Fiscal Agent 610.1 Verification 615 TPL and Accidents 620 Health Insurance Premium Payment (HIPP) Program for Cost Effective Employer Group Health Insurance C-700 BUY-IN 700 Medicare Buy-In 705 Effective Dates for Buy-In 720 Case Manager Responsibilities in the Buy-In Process C-800 INCARCERATION 800 Incarceration PART D – APPLICATION PROCESSING D-100 MAGI APPLICATION PROCESSING (42 CFR 435.906, 42 CFR 435.907) 100 Overview 105 Requests for an Application 110 Application Assistance (42 CFR 435.908) 115 Filing the Application 120 Withdrawal of Application 125 Registration of the Application 130 Duplicate Assistance Screening 135 Time Frames (42 CFR 435.912) 140 Pre-Eligibility Verification 140.1 Non-Financial 140.2 Financial 145 Post Eligibility Verification Division of Social Services Medical Assistance Manual 13 Aug 25 MTL 10/25

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D-200 150 Verification Sources 150.1 Reasonable Compatibility (42 CFR 435.952) 150.2 MAGI Discrepancy with Supported State-Based Marketplace Applications (42 CFR 435.603(h)(3)(i)) 155 Pending Information 155.1 Future Actions 160 Certification Period 160.1 Nevada Check Up 160.2 Newborns (AKA OBRA) 160.3 Transitional Medicaid 165 Nevada Check Up Premiums 170 Case Documentation (42 CFR 435.913) 170.1 Case records (NRS 239.080, NRS 230.125) 175 Prior Medical Coverage 180 Reinstatements 185 “Prudent Person” Principle SPECIALIZED GROUPS-APPLICATION PROCESSING 200 Overview 200.1 Income 200.2 Resources 205 Aged Out of Foster Care 205.1 Aged Out of Foster Care in Another State 205.2 Reporting Requirements 205.3 Denial/Termination 210 Breast/Cervical Cancer Medicaid 210.1 Verification 210.2 MCB Presumptive Eligibility 210.3 Eligibility Requirements 210.4 Do Not Apply the Following Eligibility Requirements 210.5 Termination 215 Children for Whom a Public Agency has Assumed Financial Responsibility 215.1 Application 215.2 Verifications 215.3 Denial/Termination 215.4 Reporting Requirements 220 Medicaid Eligibility for Title IV-E Eligible Foster Children at Rite of Passage 220.1 Application 220.2 Verifications 220.3 Denial/Termination 220.4 Reporting Requirements 220.5 Case Management 225 Request for Information 230 Withdrawal of Application 235 Duplicate Assistance Screening 240 “Prudent Person” Principle 245 Prior Medical Coverage 245.1 How To Apply for Prior Coverage 245.2 Eligibility for Prior Coverage 245.3 Prior Medical Determinations Division of Social Services Medical Assistance Manual 13 Aug 25 MTL 10/25

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D-300 MAABD APPLICATION PROCESSING 300 Overview 305 Requests for an Application 305.1 Forms Given to the Customer with Application 310 Application Assistance 315 Filing the Application 320 Withdrawal of the Application 325 Registration of the Application 325.1 Application From a Facility 330 Duplicate Assistance Screening 335 Time Frames 340 Pre-Eligibility Verification 340.1 Non-Financial Verification 340.2 Division of Health Care Finance and Policy (DHCFP) Disability Determination 340.3 Pending SSI Determination 340.4 Financial Verification 340.4.1 Income 340.4.2 Resources 340.5 Post Eligibility Verification 340.6 Verification Sources 345 Pending Information – Intake Cases 345.1 Future Actions 350 Disposition of Application 350.1 Certification Period 355 Medicaid, Special Low-Income Medicare Beneficiary (SLMB) & Qualified Individuals (QI) 355.1 Medicaid, Qualified Medicare Beneficiary (QMB) 360 Case Documentation 360.1 Case Records (NRS 293.080, NRS 239.125) 365 Prior Medical Coverage 365.1 How To Apply for Prior Coverage 365.2 Eligibility for Prior Coverage 365.3 Prior Medical Income Computation 370 Reinstatements 375 “Prudent Person” Principle 380 Katie Beckett 380.1 Division of Health Care Finance and Policy (DHCFP) Determination 385 Parental Financial Responsibility for Services Provided to Disabled Children 385.1 Definitions 385.2 Calculating Monthly Parental Reimbursements 385.3 Redetermination of Eligibility 385.4 Undue Hardship 385.5 Responsibilities of Eligibility Staff 385.6 Investigations and Recovery (I&R) Staff Responsibilities D-400 REDETERMINATIONS 400 MAGI Redeterminations (42 CFR 435.916) 400.1 Reserved Division of Social Services Medical Assistance Manual 13 Aug 25 MTL 10/25

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400.2 Verification at Redetermination 410 MAABD Redeterminations 410.1 Verification at Redetermination 410.2 Public Laws 420 Title IV-E Eligible Foster Children at Rite of Passage 420.1 Verification at Redetermination 420.2 Termination of Foster Children at Rite of Passage 425 Aged Out of Foster Care 425.1 Verification at Redetermination 425.2 Termination of Aged Out of Foster Care 430 Treatment for Breast and Cervical Cancer 430.1 Termination of Breast and Cervical 435 Transitional Medicaid 440 Redetermination Based on Changes 445 Other Insurance Affordability Programs 450 Terminations D-500 CHANGES 500 Overview 505 Reporting Requirements 510 When To Report 515 How To Report 520 Questionable Information and/or Unreported Changes 525 Processing Requirements 525.1 Returned Mail 525.1.2 General Delivery 525.2 Actions On Changes 525.3 Mass Changes 525.4 Additions To the Household 525.4.1 Exceptions for Adding Newborns To NCU Cases 525.4.2 NCU Enrollment 530 Terminations for Medicaid 530.1 Non-Payment of Nevada Check Up Premiums 530.2 Adverse Action 530.3 Adverse Action NOT Required 530.4 Cut-Off 535 Re-Evaluations – Nevada Check Up 540 Conversions 540.1 Converting To Institutional Eligibility 540.2 Converting To Home Based Waiver Eligibility 540.3 Other MAGI Groups To SSI Case 540.4 SSI Eligibility Terminating 540.5 QMB/SLMB/QI1 Only To Medicaid With QMB/SLMB 540.6 Medicaid Only To Medicaid with QMB/SLMB 540.7 Medicaid-QMB/SLMB to QMB/SLMB/QI1 Only 540.8 Medicaid-QMB/SLMB To Medicaid Only 540.9 Katie Beckett To SSI 540.10 QMB and < 30 Day Hospital Stay 540.11 Forms Used for Conversion Division of Social Services Medical Assistance Manual 13 Aug 25 MTL 10/25

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PART E – INCOME AND BUDGETING E-100 MAGI BUDGETING 105 Assistance Unit Determination (42 CFR 435.603(f)) 105.1 Tax Filing Status 105.2 Tax-Filer Not Claimed As a Tax Dependent 105.3 Individuals Claimed As Tax Dependents 105.4 Married Couples 105.4.1 Divorced Couples 105.4.2 Domestic Couples (NRS 122A) 105.5 Non-Filer Rules 110 Assistance Unit Budgeting 110.1 Annual Income Guidelines for Children and Tax Dependents 115 Budget Period 120 Earned Income 120.1 Self-Employment 120.2 Verification of Self-Employment 125 Unearned Income 128 Zero Income 130 Best Estimate of Income 130.1 Converting Income to Monthly Amounts 130.2 Unpredictable Income 130.3 Irregular Income 130.4 Converting New Income 135 Application of Modified Adjusted Gross Income 135.1 Allowable Deductions 140 Step-By-Step Assistance Unit and Income Determination 140.1 Construct a Medicaid/NCU Assistance Unit for Each Applicant 140.2 Determine the Medicaid/NCU Income for Each Assistance Unit 145 MAGI Exemptions E-200 MAABD INCOME AND BUDGETING 200 Application of Social Security Income (SSI) Budget Methodology 205 Household Determination 205.1 Definition Related to Household Determination 205.2 Income Consideration 210 SSI – MAABD – Income Budgeting 210.1 Ownership/Availability of Income 210.2 Income Deeming 210.3 Dividing Income 210.4 Court Order/Trust Income 220 Budgeting Procedures for SSI Financial Eligibility – Spouse To Spouse Deeming – (SSI Budget Form 2646-EE) 220.1 SSI Budget Form 2646-EE 220.1.1 Member of Couple With Eligible Spouse 220.1.2 Member of Couple With Ineligible Spouse 220.1.3 Individual 220.1.4 Deeming Computation 220.1.5 SSI Eligibility Determination 225 Income Disregards By Public Law Division of Social Services Medical Assistance Manual 13 Aug 25 MTL 10/25

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225.1 Pickle Amendment – Public Law 94-566 225.2 Adult Disabled Child – Public Law 99-643 225.3 Widow/Widowers – Public Law 100-203 225.4 Widows, Widowers and Surviving Divorced Spouses Public Law 101-508 230 Medicare Beneficiaries (QMBs, SLMBs and QDWIs) 235 Medicare Beneficiaries Budget Method 235.1 Medicare Beneficiary Budget Form 2203-EM 235.1.1 Determine Whether the Customer is Considered An Individual or a Member of a Couple with a QMB/SLMB/QI/QDWI Eligible Spouse By Applying the Definitions In This Section 235.1.2 Medicare Beneficiaries Budget Form 2203-EM 235.2 Budgeting – Specific Instructions 240 Health Insurance for Work Advancement (HIWA) 240.1 HIWA Employment Related Work Disregards 240.2 Computing Monthly Employment-Related Work Disregards 240.3 HIWA Income Determination 240.4 HIWA Premiums 245 Resources 245.1 Ownership/Availability of Resources 245.2 Treatment of Resources 245.2.1 Resource Deeming 245.2.2 Dividing Resources 245.2.3 Court Order 245.3 Transfer of Resources 245.4 Inaccessible Resource 245.5 Resource Limits E-300 TYPES OF EARNED AND UNEARNED INCOME E-400 RESOURCES 400 Overview 405 Resource Limits 410 Types of Resources (Not All Inclusive) PART F – LONG TERM CARE SERVICES F-100 LONG TERM CARE SERVICES 100 Persons Institutionalized At Least 30 Consecutive Days 100.1 Eligibility Exceptions 105 Definitions 110 Budgeting Procedures for Financial Eligibility-Form 2203-EM 110.1 Gross Countable Income Test (Side 1, Column 1)-Unearned Income, Earned Income and Division of Income 110.2 Net Income Determination (Side 1, Column 2) 115 Resources for Persons Institutionalized At Least 30 Consecutive Days 115.1 Ownership/Availability (Non-Spousal Impoverishment) 115.2 Resource Provisions for Spousal Impoverishment Cases 115.2.1 Ownership/Availability Division of Social Services Medical Assistance Manual 13 Aug 25 MTL 10/25

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120 F-200 200 205 210 215 220 225 230 F-300 300 Division of Social Services Medical Assistance Manual 13 Aug 25 MTL 10/25 115.2.2 Spousal Impoverishment Resource Determination 115.2.3 Spousal Share of Resources at the Time of Institutionalization (Section I of Form 2797-EM) 115.2.4 Community Spouse Resource Allowance (Section II of Form 2797-EM) 115.2.5 Assignment of Resources at the Time of Application for Medicaid (Section III of Form 2797-EM) 115.2.6 Permitting Transfer of Resources to the Community Spouse 115.2.7 Separate Treatment of Resources After Eligibility is Established 115.2.8 Undue Hardship 115.2.9 Additional Resources Following Initial Eligibility 115.3 Resource Exemptions 115.4 Resource Limits Patient Liability 120.1 Treatment of Income, Deductions and Expenses 120.2 Partial Month Proration 120.3 Effective Date of Patient Liability 120.4 Notification of Patient Liability/Case Status 120.5 Patient Liability Budgeting Procedures-Form 2220-EM/A HOME AND COMMUNITY BASED SERVICES Home and Community Based Services 200.1 Eligible Groups 200.2 Identification of Applicants/Recipients Who May Be Eligible Definitions Eligibility Requirements Eligibility Determination Process Income 220.1 Ownership/Availability 220.1.1 Sole Ownership 220.1.2 Shared Ownership 220.2 Treatment of Income 220.3 Income Limits 220.4 Budgeting Procedures for Financial Eligibility-Form 2203-EM Resources 225.1 Ownership/Availability 225.1.1 Sole Ownership 225.1.2 Shared Ownership 225.1.3 Treatment of Resources 225.2 Resource Provisions for Spousal Impoverishment Cases 225.2.1 Ownership/Availability 225.2.2 Resource Determination 225.3 Resource Exemptions 225.4 Resource Limits Patient Liability PERSONS INSTITUTIONALIZED LESS THAN 30 CONSECUTIVE DAYS Persons Institutionalized Less Than 30 Consecutive Days

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F-400 305 310 315 320 325 400 405 410 415 420 425 430 435 440 Division of Social Services Medical Assistance Manual 13 Aug 25 MTL 10/25 Eligibility Exemptions Definitions Budgeting Procedures for SSI Financial Eligibility-SSI Budget Form 2646-EE (Spouse-To-Spouse Deeming) 315.1 Income Consideration 315.2 SSI Budget Form 2646-EE – General Instructions 315.2.1 Member of a Couple With Eligible Spouse 315.2.2 Member of a Couple With Ineligible Spouse 315.2.3 Individual 315.3 SSI Budget Form 2646-EE – Specific Instructions 315.3.1 Deeming Computation 315.3.2 SSI Eligibility Determination Budgeting procedures for SSI Financial Eligibility of Children –Parent To Child Deeming Budget – Form 2646-EE/A 320.1 General Deeming Provisions 320.2 Parent to Child Deeming Budget – General Instructions 320.3 Deeming Computation 320.4 Eligibility Determination Patient Liability 325.1 Treatment of Income, Deductions and Expenses 325.2 Partial Month Proration 325.3 Effective Date of Patient Liability 325.4 Notification of Patient Liability/Case Status 325.5 Patient Liability Budgeting Procedures-Form 2220-EM TRANSFER OF ASSETS Overview Definitions General Rule 410.1 Look-Back Period Treatment of Income as Assets 415.1 Treatment of Jointly Owned Assets 415.2 Treatment of Certain Kinds of Asset Transfers 415.23 Personal Care and Home Care Contract Agreements Annuities Home and Community Based Waiver (HCBW) and Miller Trust (QIT) Resources Pursuing a Possible Transfer 435.1 Transfer/Disposal of Asset Notification (Form 2601) 435.2 Rebuttal 435.3 Undue Hardship 435.4 Return of Assets Penalty Period 440.1 Application of Penalties for Transfers Made Prior to February 8, 2006 440.2 Application of Penalties for Transfers Made On or After February 8, 2006 440.3 Exceptions 440.4 Penalty Period-Spouse Involvement 440.5 Situations Under Which Transfer of Asset Provisions Do Not Apply (Not

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F-500 All Inclusive) 445 Decision TREATMENT OF TRUSTS 500 Definitions 505 Effective Date 515 Application of Trust Provisions 520 Types of Trusts 520.1 Revocable Trust 520.2 Irrevocable Trust-Payment Can Be Made to Individual 520.3 Irrevocable Trust-Payment Cannot Be Made to Individual 520.4 Special Needs Trust 520.5 Pooled Trusts 520.6 Miller Type or Qualified Income Reduction Trusts-QIT 525 Resources 530 Income 535 Patient Liability 540 Transfer of Assets 545 Central Office Review 550 Undue Hardship PART G – NON-DISCRIMINATION/HEARINGS/CLAIMS G-100 100 Non-Discrimination Overview 105 Discrimination Complaints 110 Racial and Ethnic Data Collection 115 Interpretive Service Requests 115.1 Sign Language Interpreter Requests 115.2 Non-English Speaking Interpretive Requests G-200 200 Hearings G-300 300 Medicaid Program Claims 300.1 Definition of a Claim 300.2 Medicaid Claims 300.3 Claim Packet PART H – PRESUMPTIVE ELIGIBILITY Presumptive Eligibility – Provider Guidance 100 Overview 101 Qualified Providers/Qualified Hospitals 102 Prenatal Pregnancy PE 103 Hospital PE 105 Eligible Groups 110 Factors of Eligibility 115 Verification 120 PE Coverage Period 125 Notification of PE Determination Division of Social Services Medical Assistance Manual 13 Aug 25 MTL 10/25 H-100

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H-200 130 Time Frames 135 “Prudent Person” Principle 140 Withdrawal of Application 145 Case Documentation 150 Presumptive Eligibility Standards 151 DSS Program, Review and Evaluation (PRE) Audit 155 Conditions of Participation 160 Case Records and Retention (NRS 239.080, NRS 239.125) 165 Authority Hospital Presumptive Eligibility – DSS Case Manager Guidance 200 Overview 201 Qualified Providers/Qualified Hospitals 205 Eligible Groups 210 Factors of Eligibility 215 Verification 220 HPE Coverage Period 225 Notification APPENDICES Appendix A MAGI Income Charts, Verification Plan, Aid Code Charts Appendix B Possible Benefits Available to Division Social Services Customers Appendix C MAABD Income Standard Chart Appendix D Benefit Level Chart (SSI, VA, QMB, SLMB, QI1, QI2, QDWI, County Match, Spousal Impoverishment) Appendix E BIC Code Values Appendix F MAABD Budgets Appendix G PRUCOL Verification Appendix H Determining Countable RSDI Payments for MAGI Budgeting Appendix I Non-Citizen Matrix Division of Social Services Medical Assistance Manual 13 Aug 25 MTL 10/25

(a-100)Nevada Medical Assistance Manual (MAM): A-100 Medical Assistance Overview#

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(a-100)Nevada Medical Assistance Manual (MAM): A-100 Medical Assistance Overview#

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(a-200)Nevada Medical Assistance Manual (MAM): A-200 Definitions and Acronyms#

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(appendix-a)Nevada Medical Assistance Manual (MAM): Appendix A MAGI Income Charts Verification Plan AID Code Charts#

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(appendix-b)Nevada Medical Assistance Manual (MAM): Appendix B Possible Benefits Available to Division of Welfare and Supportive Services Clients#

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(appendix-c)Nevada Medical Assistance Manual (MAM): Appendix C MAABD Income Standard Chart#

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(appendix-d)Nevada Medical Assistance Manual (MAM): Appendix D Benefit Level Chart#

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(appendix-e)Nevada Medical Assistance Manual (MAM): Appendix E BIC Code Values#

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(appendix-f)Nevada Medical Assistance Manual (MAM): Appendix F MAABD Budgets#

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