Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 477 - MEDICAID ELIGIBILITY
Chapter 24 - RELATIVE RESPONSIBILITY AND SPONSOR DEEMING FOR ALIENS FOR NON-MAGI PROGRAMS
Section 477-24-005 - MEDICALLY NEEDY

Universal Citation: 477 NE Admin Rules and Regs ch 24 ยง 005

Current through September 17, 2024

005.01 Individuals Ineligible for Medicaid Due to Income

Parents/caretaker relatives, children, pregnant women, and AABD/MA individuals with a medical need whose income exceeds the guidelines for Medicaid eligibility may be eligible for a share of cost if all other eligibility requirements are met. Once excess income is met for the month Medicaid eligibility is established for that month. Each month is determined separately and continuous eligibility does not apply. See Appendix 477-000-045 for examples.

005.02 Medical Insurance Disregards

The cost of medical insurance premiums is deducted if the client or responsible relative is responsible for payment. The Medicare Part B premium which the client or responsible relative is responsible for paying is included in this disregard. Exception: The cost of premiums for income-producing policies is not allowed as a medical deduction. See Appendix 477-000-026.

005.03 Age

Medically needy children are eligible through the month of his/her 19th birthday if s/he is a U.S. Citizen or is a qualified alien.

24-005.03A Exception: A Medically needy child may be found eligible under this category if they are receiving impatient care in an Institution for Mental Disease (IMD). If an individual is an inpatient in an IMD when s/he reaches 21 years of age, s/he may remain eligible either until discharge or until s/he reaches 22, whichever comes first.

005.04 Special Provisions for Two-Parent Families

24-005.04A Two-Parent Families: If unmarried parents are living together as a family and the father has acknowledged paternity for their child, eligibility must be considered for the family as a unit.

24-005.04B Deprivation Requirements for Two-Parent Families: Two-parent families must meet the following eligibility requirements:

24-005.04C Hundred-Hour Rule: Neither medically needy parent can be working more than 100 hours in a calendar month. The parent(s) must not have worked more than 100 hours in any of the three previous calendar months, or if the parent(s) is scheduled to work more than 100 hours for the month of application. Work study is considered employment when determining the 100 hours.

24-005.04D Physical or Mental Incapacity of a Parent: A needy child is considered deprived of parental support or care if either parent has a physical or mental incapacity. If the parent is receiving Aid to the Aged, s/he must be determined incapacitated according to provisions set forth below.
24-005.04D1 Determination of Incapacity: If a parent is receiving RSDI, SSI, AABD/MA, or SDP based on disability or blindness, s/he qualifies as incapacitated. For all others the determination of incapacity is made by the State Review Team (SRT).

24-005.04E Requirement to Cooperate: The incapacitated parent is required to cooperate in obtaining treatment or rehabilitative or vocational services that are recommended on Form DM-5R. If the incapacitated parent fails to obtain the treatment or services, the case is ineligible.

005.05 Transitional Medicaid Assistance (TMA)

A client may receive up to 12 months of Transitional Medicaid without a share of cost if:

1. The case has earned income which results in ineligibility for a grant and/or ADC related Medicaid.

Note: The parent or needy caretaker relative or guardian or conservator must be in the household.

2. The unit received, or met income and resource eligibility to receive, a grant and/or ADC related Medicaid for which they were eligible in three of the last six months preceding ineligibility;

3. The parent or needy caretaker relative or needy guardian or conservator is employed.

There is no resource test while the unit is in TMA.

TMA begins with the month of ineligibility for a grant and/or ADC related Medicaid.

If it was determined that the unit was ineligible for a grant, TMA shall be determined beginning with the first month in which the grant was erroneously paid.

The unit must submit the required reports in order to continue to receive TMA in the second six months. See Appendix 477-000-047 for the Transitional Timeline.

Note: The unit is ineligible for TMA if it received a grant and/or ADC related Medicaid in one or more of the three qualifying months as a result of convicted fraud during the last six months before the beginning of the transitional period.

If a family member, such as a parent or a child, returns to the home, grant or ADC related Medicaid eligibility for the whole family must be reviewed. If the returning family member is a responsible relative, the relative's income must be used to compare the family's income to the income guideline for the unit plus the responsible relative. If the family is ineligible for a grant or ADC related Medicaid, the returning family member is added to the TMA unit.

A child who is born or adopted while the family is receiving TMA is added to the TMA unit.

A parent who has been sanctioned while on grant for failure to cooperate with Employment First may be included in the TMA unit.

A parent who has been sanctioned for noncooperation with child support or TPL is not eligible until cooperation is resolved.

Note: Once a client is in TMA, s/he is not required to cooperate with program requirements such as Employment First, TPL, and child support.

24-005.05A If a unit member leaves the home, grant eligibility for the remaining unit members must be considered.
1. If the family is ineligible for a grant and/or ADC related Medicaid, the remaining unit members may continue to be eligible for TMA.

2. If it is the only dependent child who leaves, the whole unit loses eligibility for TMA.

3. If the only child no longer meets the age qualification, the unit loses eligibility for TMA.

Before closing the case, it must first be determined if the child is eligible for another Medicaid program.

005.06 TMA Months 1 Through 6

24-005.06A Report Requirement: The unit must report the gross monthly earnings and child care costs as billed or paid for each of the first three months of the transitional period. The first report is due by the 21st of the fourth month.

Note: The unit is not required to report unearned income.

24-005.06B Causes of Termination: The unit becomes ineligible for TMA if:
1. The unit becomes eligible for a grant or ADC related Medicaid;

2. The unit moves out of the state; or

3. There no longer is an eligible dependent child in the unit.

Note: If the only child is receiving AABD/MA or SSI, the parent(s) may be eligible for TMA.

005.07 Months 7 Through 12

If the unit has earned income (minus the cost of childcare) equal to or less than 185 percent of the Federal Poverty Level, they are eligible for TMA.

24-005.07A Premium Due: Beginning with month 7, the household is subject to payment of a monthly premium if their countable income is between 100 and 185 percent of the Federal Poverty Level. Failure to pay the required premium by the 21st of the following month will result in ineligibility for the month for which the premium was owed.

24-005.07B Report Requirement: The unit must provide a report of gross monthly earnings and child care costs as billed or paid for each three-month period of months 7 through 12.
1. The second report is due by the 21st of the seventh month.

2. The third report is due by the 21st of the tenth month.

Note: The unit is not required to report unearned income.

24-005.07C Causes for Termination: The unit is ineligible for the remaining months of TMA if it:
1. Fails without good cause to submit required verification of earnings and child care costs;

2. No longer includes a dependent child; or

3. Has gross monthly earnings (less child care costs) during the preceding three-month period in excess of 185 percent of the FPL.

24-005.07D Change in Unit
1. If a unit member leaves, income eligibility for the remaining unit members must be re-determined.

2. If a responsible relative returns to the home, the unit size is increased and the responsible relative's income is budgeted to the TMA unit.

24-005.07E Income Eligibility: The unit's earned income for the three-month report period is averaged to determine income eligibility.

005.08 Good Cause for Failing to Submit Information Required from the Quarterly Report Form (QRF)

1. Death of the parent or caretaker relative;

2. Hospitalization of a unit member during the due period for the QRF (the client is responsible for providing verification of hospitalization); or

3. Natural disaster (the Central Office will issue instructions when these situations occur).

Note: Eligibility for TMA shall not be terminated for failing to provide the QRF if the needed information from the QRF, for the applicable months, was received.

005.09 After Month 12

When a client has exhausted his/her months of TMA, a redetermination of eligibility for another Medicaid program must be completed.

If the unit regains grant or ADC related Medicaid eligibility for one or two months because of a temporary reduction or loss of income, then again loses grant or ADC related Medicaid eligibility because of earnings, the original TMA cycle resumes.

If the unit receives three or more ADC grants or months of ADC related Medicaid, then again loses grant or ADC related Medicaid eligibility because of earnings, a new TMA cycle begins.

If the unit becomes grant or ADC related Medicaid eligible again because of loss of income, the client may refuse the grant or ADC related Medicaid in order to continue receiving TMA.

Disclaimer: These regulations may not be the most recent version. Nebraska may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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