10- 144 C.M.R. ch. 332, § 7-6

Current through 2024-51, December 18, 2024

Section 144-332-7-6 - BUDGETING FOR WORKING DISABLED

There is a two step test of income that must be met.

I. Countable unearned income must be equal to or less than 100% of the Federal Poverty Level.

II. Countable unearned and earned income subject to federal tax withholding must be less than 250% of the FPL.

Section 6.1: Earnings

The individual must have earnings subject of federal tax withholding but there is no minimum work requirement and no SGA earnings test.

Section 6.2: Disability

The individual must meet the SSI criteria for disability. This criteria is met if there is currently in effect a decision by the Social Security Administration that this disability criteria is met.

Section 6.3: Changes

If the individual becomes eligible for Medicaid without a premium because of a change in income and that change is expected to last for a full calendar month, the individual will be moved to Medicaid coverage without a premium. This change is made effective the month the change occurred as long as this change is reported within ten days of its occurrence; otherwise, it is effective the month the change is reported. "Occurrence" is the date the change takes place.

The individual will be given a refund for any prepaid months in which s/he is subsequently moved to coverage without a premium.

Section 6.4: Premiums

I.Due Date/Amount of Premium

A premium payment is due for each month the individual is open for Medicaid under this coverage group unless s/he is exempt from a premium as identified below.

If a couple is eligible under this coverage group, there is one premium for the couple based on the couple's countable income.

Premiums are due on the first day of each month of coverage.

The premium amount is based on countable monthly income projected for the twelve month eligibility period and does not change. A premium is effective the month an individual is added for coverage under this coverage group. Any decrease in premium is effective the month the individual's coverage under this group ends.

If countable monthly income is over 150% and equal to or less than 200% of the FPL, the monthly premium is $10.00. If countable monthly income is over 200% and less than 250% of FPL the monthly premium is $20.00.

II.Exemptions from Premium Payment

An individual is exempt from a premium:

A. if countable income is less than or equal to 150% of the Federal Poverty Level;

B. if s/he is responsible for paying for their Medicare Part B premium; or

C. if there is good cause for premiums not paid or not paid when due because of one of the following reasons:

1. mail delay;

2. illness of the individual or their responsible relative; or 3. an anticipated emergency beyond the control of the individual or their responsible relative.

D. For periods of retroactive coverage or temporary coverage.

III.Payment of Premiums

A. Premiums can be paid monthly, for more than one month at a time, or they can be paid in advance for the twelve month eligibility period. Payments will be credited to the earliest months of coverage first, during the current 12 month eligibility period.

Example

A monthly premium of $10.00 is due during a twelve month eligibility period from January to December and the first payment of $50 is received on June 1st. Months one through five will be credited with a premium paid. The June payment is overdue.

B. When a premium is not paid by the first of the month in which it is due the Department will give notice of nonpayment.

C. There is a grace period for nonpayment of premiums. The grace period extends through the last day of the twelve month eligibility period.

Example

If the eligibility period is January through December, the individual has until December 31st to pay his or her premiums for the period January to December. If the last day of the month falls on a weekend or holiday the premium is then due on the next workday.

D. When eligibility under this coverage group ends prior to the end of the twelve month eligibility period, the grace period for premium payment extends to the last day of the month in which coverage under the Working Disabled group ends.

Example

An individual granted 10/07 has a review date of 9/08 but his coverage is changed to Medicaid without a premium for 12/07. The grace period for payment of premiums for October and November is November 30th.

E. When eligibility under this coverage group is continued pending a hearing and a premium is due, the grace period is the last day of the month for which coverage is provided.

Example

The premium for the month of July is due July 1st. The grace period extends to July 31st.

IV.Non Payment of Premiums

A. At the beginning of month twelve of the eligibility period, notification will be given if any premiums for the eligibility period have not been paid when due. The individual will be notified of the penalty to be imposed because of the nonpayment.

B. At the twelve month review a determination will be made as to whether there are any overdue premiums. If so, coverage under the Working Disabled group will end unless there is "good cause" for nonpayment. Coverage as Working Disabled cannot begin again until any unpaid premiums are paid.

V.Administrative Hearings

A. Coverage as Working Disabled continues pending a hearing decision if a hearing is timely requested even if the individual is not paying premiums that are due. If the individual was responsible for paying a premium prior to the proposed negative action, this premium will continue to be due.

B. If the individual is upheld at the hearing and they have overpaid any premiums s/he will be issued a refund.

10- 144 C.M.R. ch. 332, § 7-6