TITLE 8 SOCIAL SERVICES
CHAPTER 243 MEDICAID ELIGIBILITY - WORKING DISABLED
INDIVIDUALS (WDI) (CATEGORY 043)
PART 500 INCOME AND RESOURCE STANDARDS
8.243.500.1 ISSUING AGENCY: Human Services
Department
[8.243.500.1 NMAC - N,
1-1-01]
8.243.500.2 SCOPE: This rule
applies to the general public.
[8.243.500.2 NMAC - N,
1-1-01]
8.243.500.3 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 by the state human
services department pursuant to state statute.
See NMSA 1978 27-2-12 et.
seq. (Repl. Pamp. 1991).
[8.243.500.3 NMAC - N,
1-1-01]
8.243.500.4 DURATION: Permanent
[8.243.500.4 NMAC - N, 1-1-01]
8.243.500.5 EFFECTIVE DATE: January 1,
2001, unless a later date is cited at the end of a section.
[8.243.500.5 NMAC - N,
1-1-01]
8.243.500.6 OBJECTIVE: The objective
of these regulations is to provide eligibility policy and procedures for the medicaid program.
[8.243.500.6 NMAC - N,
1-1-01]
8.243.500.7 DEFINITIONS: [RESERVED]
8.243.500.8 [RESERVED]
8.243.500.9 WORKING DISABLED INDIVIDUALS: Income and
resources are determined based on SSI methodology, except when deeming income
from an ineligible spouse. See 8.215.500 NMAC.
Individuals must meet all financial and non-financial eligibility
criteria in the month(s) for which a determination of eligibility is made.
[8.243.500.9 NMAC - N,
1-1-01; A, 6-1-04]
8.243.500.10 RESOURCE STANDARDS: A “resource”
is defined as cash or liquid assets and real or personal property which is
owned and can be used either directly, or by sale or conversion, for the
applicant’s/recipient’s support and maintenance. Resources may be liquid or non-liquid and may
be excluded from the eligibility determination process under certain
conditions.
A. A
liquid resource is an asset, which can readily be converted to cash.
B. A
non-liquid resource is an asset or property, which cannot readily be converted
to cash.
[8.243.500.10 NMAC - N,
1-1-01]
8.243.500.11 APPLICABLE RESOURCE STANDARDS: The resource
determination is made as of the first moment of the first day of the
month. For determination of continued
eligibility, see Section 8.243.600.12 NMAC.
[8.243.500.11 NMAC - N,
1-1-01]
8.243.500.12 COUNTABLE RESOURCES:
A. An
individual’s countable resources must be less than $10,000.
B. Married
individuals’ countable resources must be less than $15,000.
[8.243.500.12 NMAC - N,
1-1-01]
8.243.500.13 RESOURCE EXCLUSIONS: Specified
types of resources are excluded from the calculation of countable resources as
described in 8.215.500.14 NMAC as follows:
A. Retirement
funds: Internal revenue
service-recognized retirement fund accounts are excludable resources in the
eligibility determination so long as funds are not withdrawn from the account.
B. Examples
of such retirement fund accounts include: PERA, ERA, an employer’s qualifying
pension plan, 401(k) plan, civil service annuity, IRA, Roth IRA, KEOUGH plan, etc.
[8.243.500.13 NMAC - N,
1-1-01]
8.243.500.14 RESOURCES TRANSFERS: See
8.215.500.15 NMAC.
[8.243.500.14 NMAC - N,
1-1-01]
8.243.500.15 TRUSTS: See
8.281.510 NMAC and following subsections.
[8.243.500.15
NMAC - N, 1-1-01; A, 10-1-12]
8.243.500.16 DEEMING RESOURCES: If an eligible
noninstitutionalized applicant/recipient lives in the
same household with an ineligible spouse, resources are considered to belong to
the applicant/recipient. The resource standard for a couple applies.
[8.243.500.16 NMAC - N,
1-1-01]
8.243.500.17 INCOME:
A. Earned
income consists of the total gross income received by an
applicant/recipient for services performed as an employee or net income as a
result of self-employment.
(1) Royalties earned in connection with
the publication of the applicant’s/recipient’s work and any honoraria/fees
received for services rendered are considered earned income.
(2) In any given calendar quarter, an
applicant/recipient must have earnings equal to social security
administration’s definition of a covered quarter. See 8.200.520.20 NMAC.
B. Unearned
income consists of all other income (minus exclusions and disregards) that
is not earned in the course of employment or self employment.
C. Deemed
income is income which must be considered available to the
applicant/recipient from the ineligible spouse when both live in the same
household. Deemed income is counted in
determining eligibility for the applicant/recipient.
[8.243.500.17 NMAC - N,
1-1-01; A, 1-1-02; A, 6-1-04]
8.243.500.18 INCOME STANDARDS: The applicable
income standard of countable earned income for this category is less than 250%
of the federal poverty level for a household size of one. See Subsection H of 8.200.520.11 NMAC. The applicant/recipient must meet two income
tests to qualify for working disabled individuals. These are as follows:
A. TEST
1
(1) Determine applicant’s/recipient’s
gross monthly earnings.
(2) Apply a $20.00 general disregard.
(3) Apply a $65.00 earned income disregard.
(4) Disregard ½ of the remainder of income.
(5) Disregard work-related expenses for the
blind or disabled.
(6) If the countable earned income is less
than 250% of the applicable federal poverty level (FPL) for a household of one,
the individual is eligible.
(7) If the countable earned income is less
than 250% of the applicable FPL for a household size of one, determine if there
is an ineligible spouse and/or children in the household.
B. If
applicant/recipient lives with an ineligible spouse, see 8.215.500.21 NMAC to
determine if deeming income is applicable.
C. TEST
2
(1) Determine applicant’s/recipient’s
gross unearned income.
(2) Add ineligible spouse’s deemable income, if applicable.
(3) Apply a $20.00 disregard.
(4) Subtract an
amount equal to the current SSI federal benefit rate (FBR)
for an individual. See
8.200.520.13 NMAC.
(5) Compare the total countable income to the
SSI FBR for an individual or couple, as applicable.
(6) If the total countable income is less than
the applicable SSI FBR, the individual is eligible.
D. Income
exclusions: Income exclusions for
the applicant/recipient are applied before income disregards. Exclusions are not applied to the income of
the ineligible spouse from whom income may be deemed.
[8.243.500.18 NMAC - N,
1-1-01; A, 6-1-04; A, 3-14-08]
8.243.500.19 UNEARNED INCOME
A. Standards
for unearned income and exclusions: See
8.215.500.20.C. & D. NMAC.
B. Unearned
income is computed on a monthly basis.
If there are no expenses incurred with the receipt of unearned income,
such as annuities, pensions, retirement payments or disability benefits, the
gross amount is considered countable unearned income.
[8.243.500.19 NMAC - N,
1-1-01]
8.243.500.20 DEEMED INCOME: RESERVED
[8.243.500.20 NMAC - N,
1-1-01; Repealed, 6-1-04]
8.243.500.21 DISREGARDS: Income
disregards are allowed as described below when applicable.
A. Twenty
dollar disregard: The first $20 of
unearned or earned income received in a month is disregarded. This disregard is not applicable to payments
made to an applicant/recipient through a state or other government assistance
program, or by a private charitable organization, where such payments are based
on the applicant’s/recipient's need.
B. Additional
earned income disregard: If
appropriate, earned income of $65 per month, plus one-half of the remainder is
disregarded.
C. Work-related
expenses defined: Work-related
expenses of an employed applicant/recipient who is blind or disabled are
disregarded. This disregard is applied
to earned income only. Disregarded
expenses must be for items or services directly related to enabling a person to
work, and which are necessarily incurred by that individual because of a physical
or mental disability or blindness. Such
expenses are disregarded if not covered by other third party payers, including medicaid.
(1) Types of work-related expenses which may
be disregarded include:
(a) federal, state,
and local income taxes;
(b) social security
contributions;
(c) union dues;
(d) transportation
costs, including actual cost of bus or taxi cab fare, or fifteen (15) cents per
mile for private automobile;
(e) lunches;
(f) child care costs,
if not otherwise provided;
(g) uniforms, tools,
and other necessary equipment;
(h) special vehicle
modifications to enable transportation to and from work, but not the cost of
the vehicle itself;
(i) attendants who may be hired for the purpose of taking
applicant/recipient to and from work, and getting ready for work;
(j) durable medical
equipment that is medically related and generally not useful in absence of the
blindness or disability yet, are necessary to attend and perform tasks in the
work place;
(k) expenses for work
related equipment, which is impairment related and necessary for the individual
to perform his/her tasks;
(l) prostheses
necessary to perform work related tasks.
(m) design modifications related to blindness
or disability that enable the applicant/recipient to leave home in order to
attend work, or design modifications made to the work area of the home in the
case where the applicant/recipient engages in a home-based business;
(n) special expenses necessary to enable an
applicant/recipient who is blind or disabled to engage in employment, such as a
seeing-eye dog, braille instructions, or instructions
on using special equipment and,
(o) health insurance
premiums.
(2) If items or services above are purchased
through an installment contract, the payments are disregarded. Should the item or service be a one-time
purchase, the purchase may be pro-rated over a 12-month period, or over the
life of the contract.
(3) If items are leased, the monthly payment
would be disregarded.
D. NONDEDUCTIBLE
ITEMS: The following items cannot be deducted from earned income:
(1) in-kind payments;
(2) expenses deducted
under other provisions;
(3) expenses which
will be reimbursed;
(4) life maintenance
expenses; although not all-inclusive, life maintenance items include the
following:
(a) meals consumed
outside of work hours;
(b) self-care items
(including items of cosmetic rather than work related nature);
(c) general
educational development;
(d) deposits into
retirement accounts intended as an IRA, Keogh, 401K, PERA or voluntary
pensions;
(e) life insurance
premiums;
(f) items furnished
by others that are needed in order to work (the value of such items is not
income), and
(g) expenses claimed
on a self-employment tax return.
[8.243.500.21 NMAC - N,
1-1-01]
HISTORY OF 8.243.500 NMAC: [RESERVED]
History of Repealed
Material: [RESERVED]