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: New Mexico
Health Care Authority (HCA).
[8.243.500.1 NMAC - N,
1/1/2001; A, 7/1/2024]
8.243.500.2 SCOPE: This rule
applies to the general public.
[8.243.500.2 NMAC - N, 1/1/2001]
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 health care
authority pursuant to state statute. See
Section 27-2-12 et. seq. NMSA 1978 (Repl. Pamp. 1991). Section 9-8-1 et seq. NMSA 1978 establishes
the health care authority (HCA) as a single, unified department to administer
laws and exercise functions relating to health care facility licensure and
health care purchasing and regulation.
[8.243.500.3 NMAC - N,
1/1/2001; A, 7/1/2024]
8.243.500.4 DURATION: Permanent
[8.243.500.4 NMAC - N, 1/1/2001]
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, 1/1/2001]
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, 1/1/2001]
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, 1/1/2001;
A, 6/1/2004]
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, 1/1/2001]
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, 1/1/2001]
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, 1/1/2001]
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, 1/1/2001]
8.243.500.14 RESOURCES TRANSFERS: See
8.215.500.15 NMAC.
[8.243.500.14 NMAC - N, 1/1/2001]
8.243.500.15 TRUSTS: See 8.281.510 NMAC and following subsections.
[8.243.500.15
NMAC - N, 1/1/2001; A, 10/1/2012]
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, 1/1/2001]
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, 1/1/2001;
A, 1/1/2002; A, 6/1/2004]
8.243.500.18 INCOME STANDARDS: The applicable
income standard of countable earned income for this category is less than two
hundred-fifty percent 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 two hundred-fifty percent 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 two
hundred-fifty percent 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, 1/1/2001;
A, 6/1/2004; A, 3/14/2008]
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, 1/1/2001]
8.243.500.20 DEEMED INCOME: [RESERVED]
[8.243.500.20 NMAC - N, 1/1/2001;
Repealed, 6/1/2004]
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 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, 1/1/2001]
HISTORY OF 8.243.500 NMAC: [RESERVED]
History of Repealed
Material: [RESERVED]