Page 13

Official source

1. Sherlock Premium – To calculate a premium, the earned income of the Sherlock beneficiary and their spouse, if applicable, are added together and then all SSI-related disregards are applied. The remaining earned income is added to the unearned income of the beneficiary or couple (after unearned income disregards are applied) and are assigned a premium as follows: a.

Income Monthly Premium Less than 150% FPL No premium At least 150% and less than 185% FPL $ 61.00 At least 185% and less than 200% FPL $ 77.00 At least 200% and up to 250% FPL $ 92.00 b. Premiums must be paid in full before retroactive coverage for allowable health care expenses is made available by the State. 2. LTSS Sherlock Cost of Care – The State bases its calculation of a LTSS Sherlock beneficiary’s cost of care in accordance with the post-eligibility treatment of income rules set forth in Part 50-00-8 of this Title. A LTSS Sherlock beneficiary is entitled to all the allowances set forth therein when determining the amount of income available to pay toward the cost of care. 3. Sherlock LTSS beneficiary choice – The State calculates both the monthly premium and the LTSS cost of care for Sherlock LTSS beneficiaries. An LTSS eligibility specialist is responsible for informing the beneficiary of the premium versus the LTSS cost of care and assisting the beneficiary in making an appropriate choice. The State does not impose or collect a cost share until a Sherlock LTSS beneficiary has been so informed and made a choice. Coverage may not be delayed or denied pending the beneficiary’s decision. 1.9.2 Non-Payment Sherlock Cost Share A. Absent a hardship exemption, EOHHS will terminate eligibility after a beneficiary fails to pay their premium for ninety (90) days.

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Page 13

Official source

1. Sherlock Premium – To calculate a premium, the earned income of the Sherlock beneficiary and their spouse, if applicable, are added together and then all SSI-related disregards are applied. The remaining earned income is added to the unearned income of the beneficiary or couple (after unearned income disregards are applied) and are assigned a premium as follows: a.

Income Monthly Premium Less than 150% FPL No premium At least 150% and less than 185% FPL $ 61.00 At least 185% and less than 200% FPL $ 77.00 At least 200% and up to 250% FPL $ 92.00 b. Premiums must be paid in full before retroactive coverage for allowable health care expenses is made available by the State. 2. LTSS Sherlock Cost of Care – The State bases its calculation of a LTSS Sherlock beneficiary’s cost of care in accordance with the post-eligibility treatment of income rules set forth in Part 50-00-8 of this Title. A LTSS Sherlock beneficiary is entitled to all the allowances set forth therein when determining the amount of income available to pay toward the cost of care. 3. Sherlock LTSS beneficiary choice – The State calculates both the monthly premium and the LTSS cost of care for Sherlock LTSS beneficiaries. An LTSS eligibility specialist is responsible for informing the beneficiary of the premium versus the LTSS cost of care and assisting the beneficiary in making an appropriate choice. The State does not impose or collect a cost share until a Sherlock LTSS beneficiary has been so informed and made a choice. Coverage may not be delayed or denied pending the beneficiary’s decision. 1.9.2 Non-Payment Sherlock Cost Share A. Absent a hardship exemption, EOHHS will terminate eligibility after a beneficiary fails to pay their premium for ninety (90) days.