TITLE 8 SOCIAL SERVICES

CHAPTER 240 MEDICAID ELIGIBILITY - QUALIFIED MEDICARE BENEFICIARIES (QMB)

(CATEGORY 040)

PART 500 INCOME AND RESOURCE STANDARDS

8.240.500.1 ISSUING AGENCY: New Mexico Human Services Department.

[2/1/1995; 8.240.500.1 NMAC - Rn, 8 NMAC 4.QMB.000.1, 7/15/2010]

8.240.500.2 SCOPE: The rule applies to the general public.

[2/1/1995; 8.240.500.2 NMAC - Rn, 8 NMAC 4.QMB.000.2, 7/15/2010]

8.240.500.3 STATUTORY AUTHORITY: The New Mexico medicaid program is administered pursuant to regulations promulgated by the federal department of health and human services under Title XIX of the Social Security Act, as amended and by the state human services department pursuant to state statute. See Section 27-2-12 et seq. NMSA 1978 (Repl. Pamp. 1991).

[2/1/1995; 8.240.500.3 NMAC - Rn, 8 NMAC 4.QMB.000.3, 7/15/2010]

8.240.500.4 DURATION: Permanent.

[2/1/1995; 8.240.500.4 NMAC - Rn, 8 NMAC 4.QMB.000.4, 7/15/2010]

8.240.500.5 EFFECTIVE DATE: February 1, 1995, unless a later date is cited at the end of the section.

[2/1/1995; 8.240.500.5 NMAC - Rn, 8 NMAC 4.QMB.000.5 & A, 7/15/2010]

8.240.500.6 OBJECTIVE: The objective of this rule is to provide eligibility policy and procedures for the medicaid program.

[2/1/1995; 8.240.500.6 NMAC - Rn, 8 NMAC 4.QMB.000.6 & A, 7/15/2010]

8.240.500.7 DEFINITIONS: [RESERVED]

8.240.500.8 [RESERVED]

8.240.500.9 GENERAL NEED DETERMINATION: Applicants for, or recipients of, the qualified medicare beneficiaries (QMB) program must apply for and take all necessary steps to obtain any income or resources to which they may be entitled. Recipients of supplemental security income (SSI) or aid to families with dependent children (AFDC) who apply for QMB are excluded from this requirement. A victim of crime is not required to accept victim compensation payments from a state-administered fund established to aid crime victims as a condition of eligibility.

[2/1/1995; 9/15/1995; 8.240.500.9 NMAC - Rn, 8 NMAC 4.QMB.500 & A, 7/15/2010]

8.240.500.10 RESOURCE STANDARDS: The value of an applicant/recipient’s individual countable resources must not exceed the amount set forth in Section 8.200.510.14 NMAC, resource amounts for supplemental security income (SSI) related medicare savings programs (QMB and SLIMB/QI). The resource limit for an applicant couple is the amount set forth in Section 8.200.510.14 NMAC. An applicant/recipient with an ineligible spouse is eligible if the couple’s countable resources do not exceed the amount set forth in Section 8.200.510.14 NMAC, when resources are deemed. The resource determination is always made as of the first moment of the first day of the month. The applicant/recipient is ineligible for any month in which the countable resources exceed the current resource standard as of the first moment of the first day of the month. Changes in the amount of resources during a month do not affect eligibility for that month. See Section 8.215.500.13 NMAC, countable resources, and Section 8.215.500.14 NMAC, resource exclusions, for specific information on exclusions, disregards, and calculation of countable resources.

[2/1/1995; 9/15/1995; 8.240.500.10 NMAC - Rn, 8 NMAC 4.QMB.510 & A, 7/15/2010]

8.240.500.11 RESOURCE TRANSFERS: The social security administration excluded transfer of resources as a factor of eligibility for non-institutionalized SSI recipients. Transfer of resources is not a factor for consideration in categories that use SSI methodology in the eligibility determination.

[2/1/1995; 9/15/1995; 8.240.500.11 NMAC - Rn, 8 NMAC 4.QMB.515, 7/15/2010]

8.240.500.12 TRUSTS: See Section 8.281.510 NMAC and following subsections.

[2/1/1995; 9/15/1995; 8.240.500.12 NMAC - Rn, 8 NMAC 4.QMB.520 & A, 7/15/2010; 8.240.500.12 NMAC - N, 10/1/12]

8.240.500.13 INCOME STANDARDS: The income ceiling for QMB eligibility is one hundred percent of the federal income poverty guidelines. These guidelines are updated annually effective April 1st. See Section 8.200.520 NMAC, Income Standards. If the applicant is a minor child, income must be deemed from the parent(s). Income must be verified and documented in the case record. See Section 8.215.500.13 NMAC, countable resources, and Section 8.215.500.14 NMAC, resource exclusions, for specific information on exclusions, disregards, and calculation of countable income.

[2/1/1995; 9/15/1995; 8.240.500.13 NMAC - Rn, 8 NMAC 4.QMB.522 & A, 7/15/2010; 8.240.500.13 NMAC - Rn, 8.240.500.12 NMAC, 10/1/12]

8.240.500.14 UNEARNED INCOME:

A. Unearned income exclusions: All social security and railroad retirement beneficiaries receive cost of living adjustments (COLAs) in January of each year. The ISD caseworker must disregard the COLA from January through March when (re)determining QMB eligibility. For redeterminations made in January, February and March and for new QMB applications registered in January, February or March, the ISD caseworker uses the December social security and railroad retirement benefit amounts. For QMB applications registered from April through December, total gross income including the new COLA figures are used to determine income and compared to the new April federal poverty levels. This exclusion does not apply to other types of income.

B. Evaluation of applicant/recipient’s income: The ISD caseworker determines the amount of income available to the applicant/recipient using only the applicant/recipient’s own income. A standard $20 disregard is allowed in accordance with Section 8.215.500.22 NMAC. The federal poverty level standard disregard is only given if the applicant/recipient lives with an ineligible spouse. See Section 8.240.500.15 NMAC for deemed income.

[2/1/1995; 9/15/1995; 8.240.500.14 NMAC - Rn, 8 NMAC 4.QMB.523 & A, 7/15/2010; 8.240.500.14 NMAC - Rn, 8.240.500.13 NMAC, 10/1/12; A, 3/1/2018]

8.240.500.15 DEEMED INCOME:

A. Minor applicant/recipient living with parent(s): If the applicant/recipient is a minor who lives with a parent(s), deemed income from the parent(s) must be considered in accordance with Section 8.215.500.21 NMAC, deemed income, and applicable subsections.

B. Applicant/recipient living with an ineligible spouse: If an applicant/recipient is living in the same household with an ineligible spouse, the income of the applicant/recipient and the income of the ineligible spouse must be considered in accordance with the following paragraphs.

(1) Evaluation of applicant/recipient’s Income: The ISD caseworker determines the amount of income available to the applicant/recipient using only the applicant/recipient’s own income. Allow the standard $20 disregard in accordance with instructions in Subsection B of Section 8.215.500.22 NMAC of the medical assistance division policy manual. If the applicant/recipient has earned income, allow the earned income disregard as specified in Subsection C of Section 8.215.500.22 NMAC. From the combined total of the applicant/recipient’s remaining earned and unearned income, subtract up to the difference between one hundred percent of the federal income poverty level for two persons and one hundred percent of the federal income poverty level for one person. This is referred to as the FPL disregard. Compare the remaining countable income of the applicant/recipient to the individual income standard for the QMB program. If the applicant/recipient’s remaining countable income is greater than the individual standard, s/he is ineligible for the QMB program. If the applicant/recipient’s remaining countable income is less than the individual income standard, proceed to the following section.

(2) Evaluation of the ineligible spouse’s gross income: The ISD caseworker determines the total gross earned and unearned income of the ineligible spouse. From this combined amount, subtract a living allowance for any ineligible minor dependent child(ren) of either member of the couple who live(s) in the home. The deductible amount of the ineligible child(ren)’s living allowance cannot exceed the ineligible spouse’s total gross income. The amount of the living allowance for an ineligible child is determined by subtracting the child’s gross income from the figure which represents the difference between one hundred percent of the federal income poverty level for two persons and one hundred percent of the federal income poverty level for one person. A “child” must be under 18 years of age or under 21 years of age if a full-time student at an institution of learning.

(3) Determination of countable income for eligibility purposes: The ISD caseworker adds the gross unearned income of the applicant/recipient (without applying any disregards) to the gross unearned income of the ineligible spouse. The ISD caseworker then adds the total gross earned income of the applicant/recipient to the total gross earned income of the ineligible spouse. From the combined total gross earnings of the couple, the ISD caseworker subtracts one earned income disregard (the first $65 of the total earnings plus 1/2 of the remainder). The resulting figure is the total combined countable earnings of the couple. Add the couple’s total combined countable earned income to their total gross unearned income. From this figure subtract the standard twenty dollars ($20) disregard determined in accordance with Subsection B of Section 8.215.500.22 NMAC. Next, subtract the amount of the FPL disregard which the applicant/recipient was allowed. Finally, subtract the amount of the ineligible child(ren)’s living allowance which was calculated in Paragraph (2) of Subsection B of Section 8.240.500.14 NMAC. The resulting figure is the countable income of the couple. Compare it to the couple standard for QMB. If the countable income of the couple exceeds the couple standard, the applicant/recipient is ineligible for the QMB program. If the countable income of the couple is less than the couple standard, the applicant/recipient is eligible for the QMB program of the factor of income.

[8.240.500.15 NMAC - Rn, 8.240.500.14 NMAC, 10/1/12]

HISTORY OF 8.240.500 NMAC:

Pre-NMAC History: The material in this part was derived from that previously filed with the Commission of Public Records - State Records Center and Archives:

MAD Rule 840, Qualified Medicare Beneficiaries, filed 3/7/89.

MAD Rule 840, Qualified Medicare Beneficiaries, filed 3/31/89.

MAD Rule 840, Qualified Medicare Beneficiaries, filed 12/29/89.

MAD Rule 840, Qualified Medicare Beneficiaries, filed 6/22/90.

MAD Rule 840, Qualified Medicare Beneficiaries, filed 12/4/90.

MAD Rule 840, Qualified Medicare Beneficiaries, filed 5/3/91.

MAD Rule 840, Qualified Medicare Beneficiaries, filed 6/30/92.

MAD Rule 840, Qualified Medicare Beneficiaries, filed 9/26/94.

History of Repealed Material: MAD Rule 840, Qualified Medicare Beneficiaries, filed 9/26/94 - Repealed effective 2/1/1995.