TITLE 8 SOCIAL
SERVICES
CHAPTER 248 MEDICAID
ELIGIBILITY - MEDICARE DRUG COVERAGE (CATEGORY 048)
PART 500 INCOME
AND RESOURCE STANDARDS
8.248.500.1 ISSUING
AGENCY: New Mexico Health Care Authority.
[8.248.500.1 NMAC - Rp 8.248.500.1 NMAC, 7/1/2024]
8.248.500.2 SCOPE: The
rule applies to the general public.
[8.248.500.2 NMAC - Rp 8.248.500.2 NMAC, 7/1/2024]
8.248.500.3 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 health care authority pursuant to state statute. See 27-2-12 et. seq. NMSA 1978 (Repl. Pamp. 1991). The legal basis for the low-income subsidy (LIS) program is the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), Public Law 108-173. 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.
[8.248.500.3 NMAC - Rp 07/01/2024]
8.248.500.4 DURATION:
Permanent.
[8.248.500.4 NMAC - Rp 8.248.500.4 NMAC, 7/1/2024]
8.248.500.5 EFFECTIVE
DATE: July 1, 2024, unless a later date is cited at
the end of a section.
[8.248.500.5 NMAC - Rp 8.248.500.5 NMAC, 7/1/2024]
8.248.500.6 OBJECTIVE: The
objective of these regulations is to provide eligibility policy and procedures
for the medicare part D (drug benefit) - low income
subsidy program.
[8.248.500.6 NMAC - Rp 8.248.500.6 NMAC, 7/1/2024]
8.248.500.7 DEFINITIONS: [RESERVED]
8.248.500.8 [RESERVED]
8.248.500.9 NEED DETERMINATION: This
section describes the methodology to be used in determining countable resources
and income for the low-income subsidy (LIS) program which is based in part on
supplemental security income (SSI) methodology.
These guidelines are used for initial and on-going eligibility for medicare beneficiaries enrolled in part A or part B medicare. LIS
eligibility is determined prospectively.
Applicants/recipients must meet, or expect to meet, all financial and
non-financial eligibility criteria in the month for which a determination of
eligibility is made.
[8.248.500.9 NMAC - Rp 8.248.500.9 NMAC, 7/1/2024]
8.248.500.10 APPLICATION PROCESS: The
income support division (ISD) office is responsible for taking LIS applications
from those individuals who do not want to submit their application to the
social security administration either directly or through the ISD office.
A. Who does not have to apply: Certain groups of medicare beneficiaries who are also receiving medicaid do not have to apply for the LIS. These individuals are called "deemed
eligible" and will automatically be put on the LIS:
(1) full-benefit dual eligibles, who are
persons eligible for both medicare and have full medicaid benefits (including drug benefits);
(2) SSI recipients;
(3) medicare
beneficiaries, who are participants in the medicare
saving programs, which are: QMB, SLIMB,
and QI-1;
(4) working disabled individuals (WDI) who
are receiving medicare;
(5) HCBW recipients who are receiving medicare; and
(6) individuals screened for QMB, SLIMB,
or QI-1 and determined eligible before the application for LIS is processed.
B. Who can apply: medicare
beneficiaries who are not deemed eligible (See Paragraphs (1) through (6)
above) and who insist on filing their application with the state rather than
with social security administration (SSA).
[8.248.500.10 NMAC - Rp 8.248.500.10 NMAC, 7/1/2024]
8.248.500.11 RESOURCE STANDARDS: A
"resource" is defined as cash and other assets that can be converted
to cash within 20 days.
A. Resource
determination: The resource determination is made as
of the first moment of the first day of the month. An applicant/recipient is ineligible for any
month in which their countable resources exceed the allowable resource standard
as of the first moment of the first day of the month. Changes in the amount
of countable resources during a month do not affect eligibility or
ineligibility for that month.
B. Distinguishing
between resources and income: Resources
must be distinguished from income to avoid counting a single asset twice. As a general rule,
ownership of a resource precedes the current month while income is received in
the current month. Income held by an
applicant/recipient until the following month becomes a resource.
[8.248.500.11 NMAC - Rp 8.248.500.11 NMAC, 7/1/2024]
8.248.500.12 APPLICABLE RESOURCE STANDARDS: The
resource standard for the LIS is $10,000 for an individual and $20,000 for a
couple. Resources belonging to other
dependent family members are not considered.
A. Cash
resources: The face value of cash,
savings or checking accounts is considered in determining LIS eligibility.
(1) An applicant/recipient must provide
verification of the value of all cash resources. The resource value of a bank account is
customarily verified by a statement from the bank showing the account balance
as of the first moment of the first day of the month in question. If an applicant/recipient cannot provide this
verification, the ISD worker sends a bank or postal savings clearance to the
appropriate institution(s).
(2) If the applicant/recipient can
demonstrate that a check was written and delivered to a payee but not cashed by
the payee prior to the first moment of the first day of the month, the amount
of that check is subtracted from the applicant/recipient's checking account
balance to arrive at the amount to be considered a countable resource.
B. Other
resources: The value of other resources
is evaluated according to the applicant/spouse's equity in the
resource(s). The equity value of an item
is defined as the price for which that item, minus any encumbrances, can
reasonably be expected to sell on the open market in the particular
geographic area. Other resources
which can be converted to cash within 20 days include, but are not limited to:
stocks, bonds, mutual fund shares, promissory notes, mortgages, whole life
insurance policies, financial institution accounts (savings, checking, CDs,
IRAs, 401(K) accounts, and annuities), and real property not contiguous with
home property.
[8.248.500.12 NMAC - Rp 8.248.500.12 NMAC, 7/1/2024]
8.248.500.13 COUNTABLE RESOURCES:
Before a resource can be considered countable, the three criteria listed
below must be met.
A. Ownership interest:
An applicant/recipient must have an ownership interest in a resource for
it to be countable. The fact that an
applicant/recipient has access to a resource, or has a legal right to use it,
does not make it countable unless the applicant/recipient also has an ownership
interest in it.
B. Legal
right to convert resource to cash: An
applicant/recipient must have the legal ability to spend the funds or to
convert non-cash resources into cash.
(1) Physical possession of resource: The fact that an applicant/recipient does not
have physical possession of a resource does not mean it is not their
resource. If they have the legal ability
to spend the funds or convert the resource to cash, the resource is considered
countable. Physical possession of
savings bonds is a legal requirement for cashing them.
(2) Unrestricted use of resource: An applicant/recipient is considered to have
free access to the unrestricted use of a resource even if he can take those
actions only through an agent, such as a representative payee or guardian.
(3) If there is a legal bar to the sale of
a resource, such as a co-owner legally blocking the sale of jointly owned
property, the resource is not countable.
The applicant/recipient is not required to undertake litigation in order to accomplish the sale.
C. Legal ability to use a resource: If a legal restriction exists which prevents
the use of a resource for the applicant/recipient's own support and
maintenance, the resource is not countable.
D. Jointly-held account: If the applicant/spouse is
the only subsidy claimant or subsidy recipient who is an account holder on a
jointly held account, the state will presume that all of
the funds in the account belong to the applicant/spouse. If more than one subsidy claimant or subsidy
recipient are account holders, the state will presume that the funds in the
account belong to those individuals in equal shares. If the applicant/spouse disagrees with the
ownership presumption described in this subsection, they may rebut the presumption. Rebuttal is a procedure that permits an
individual to furnish evidence and establish that some or all
of the funds in the jointly-held account do not belong to them.
[8.248.500.13 NMAC - Rp 8.248.500.13 NMAC, 7/1/2024]
8.248.500.14 RESOURCE EXCLUSIONS: The
following resources are not to be considered for purposes of determining LIS
eligibility:
A. Applicant's
home: A home is any property in which
the applicant and spouse have an ownership interest
and which serves as the applicant’s principal place of residence. There is no restriction on acreage of home
property. This property includes the
shelter in which an individual resides, the land on which the shelter is
located, and any outbuildings.
B. Non-liquid resources, other than real property: These include, but are not limited to:
(1) household goods and personal effects;
(2) automobiles, trucks, tractors and
other vehicles;
(3) machinery and livestock; and
(4) non-cash business property.
C. Property of a trade or business: Property of a trade or business that is
essential to the applicant/spouse's means of self-support.
D. Non-business property:
Non-business property that is essential to the applicant/spouse's means
of self-support.
E. Stock in regional or village corporations: Stock in regional or village corporations
held by natives of Alaska during the 20-year period in which the stock is
inalienable pursuant to the Alaska Native Claims Settlement Act.
F. Whole life insurance:
Whole life insurance owned by an individual (and spouse, if any) if the
total face value of all the life insurance policies on any person does not
exceed $1,500. When the total face value
of all policies exceeds $1,500, the cash surrender value of all policies is
countable.
G. Term life insurance:
Term life insurance that has no cash surrender value.
H. Restricted, allotted Indian lands: Restricted, allotted Indian lands, if the
Indian/owner cannot dispose of the land without the permission of other
individuals, their tribe, or an agency of the federal government.
I. Payments or benefits:
Payments or benefits provided under a federal statute other than title
XVI of the act where exclusion is required by such statute.
J. Federal disaster relief:
Federal disaster relief assistance received on account of a
presidentially declared major disaster, including accumulated interest, or
comparable state or local assistance.
K. Funds of $1,500:
Funds of $1,500 for the individual and $1,500 for the spouse who lives
with the individual if these funds are intended to be used for funeral or
burial expenses of the individual and spouse.
L. Burial spaces:
Burial spaces, including burial plots, gravesites, crypts, mausoleums,
urns, niches, vaults, headstones, markers, plaques, burial containers, opening
and closing of the gravesite, and other customary and tradition repositories
for the deceased's bodily remains, for the applicant/spouse.
M. Retained retroactive SSI or social security: Retained retroactive SSI or social security
benefits for nine months after the month they are received.
N. Certain housing assistance:
O. Refunds: Refunds of
federal income taxes and advances made by an employer relating to an earned
income tax credit for the month following the month of receipt, and refunds of
child tax credits for nine months after the month they are received.
P. Payments: Payments
received as compensation incurred or losses suffered as a
result of a crime (victims' compensation payments), for nine months
beginning with the month following the month of receipt.
Q. Relocation assistance:
Relocation assistance for a state or local government, for nine months,
beginning with the month following the month of receipt.
R. Dedicated financial institution accounts: Dedicated financial institution accounts
consisting of past-due benefits for an SSI-eligible individual under age 18.
S. Gifts: A gift to,
or for the benefit of, an individual who has not attained 18 years of age and
who has a life-threatening condition, from an organization described in section
501(c)(3) of the internal revenue code of 1986 which is exempt from taxation
under Section 501(a) of such code. The
resource exclusion applies to any in-kind gift that is not converted to cash,
or to a cash gift that does not exceed $2,000.
T. Funds received:
Funds received from a government or nongovernmental agency, program, or
health insurance policy whose purpose is to provide medical care or medical
services or social services and conserved to pay for medical or social
services.
[8.248.500.14 NMAC - Rp 8.248.500.14 NMAC, 7/1/2024]
8.248.500.15 INCOME STANDARDS: Income
is anything the applicant/spouse receives in cash or in-kind that can be used
to meet their needs for food or shelter.
The gross income of the applicant, and their spouse if living together,
but not dependent family members, will be considered. However, dependent family members will be
counted in the family size.
[8.248.500.15 NMAC - Rp 8.248.500.15 NMAC, 7/1/2024]
8.248.500.16 EARNED
INCOME:
A. Earned income: Earned
income consists of the following types of payments:
(1) wages counted at the earliest of: when received, when credited to the person
employed, or when set aside for the employee's use;
(2) net earnings from self-employment
counted on a taxable year basis; net losses, if any, are deducted from other
earned income, but not from unearned income;
(3) payments for services performed in a
sheltered workshop or work activities center counted when received or set aside
for the employee’s use;
(4) royalties earned by an individual in
connection with any publication of their work and any honoraria received for
services rendered; and
(5) in-kind earned income is counted based
on current market value. If the
applicant/spouse receives an item that is not fully paid for and they are
responsible for the balance, only the paid up value is income to the applicant.
B. Period under consideration: The period for which earned income is counted
is, in 2006, the remainder of the calendar year, starting with the month of
application for the subsidy. Adjust
prospective earned income based on the number of months remaining in the
calendar year. The income standard
against which the income is measured should be adjusted to reflect the same
number of months. For subsidy
applications filed in 2005, eligibility cannot begin prior to January 1, 2006.
C. Earned income exclusions:
Earned income exclusions apply in the order listed below:
(1) refund of federal income taxes and
payments under the earned income tax credit;
(2) the first $30 of earned income per
calendar quarter that is received too irregularly or infrequently to be counted
as income;
(3) any portion of the $20 per month
exclusion that has not been excluded from combined unearned income;
(4) $65 per month of the
applicant/spouse’s earned income;
(5) for applicants who are under age 65
and receive a social security disability insurance benefit based on disability,
sixteen and three-tenths percent of gross earnings for impairment related work
expenses (IRWE);
(6) one half of the applicant/spouse’s
remaining earned income; and
(7) for applicants who are under age 65
and receive a social security disability insurance benefit that is based on
blindness, twenty-five percent of gross earnings for blind work expenses (BWE).
[8.248.500.16 NMAC - Rp 8.248.500.16 NMAC, 7/1/2024]
8.248.500.17 UNEARNED INCOME:
Unearned income is all income that is not earned income. Unearned income is counted at the earliest of
the following points: when received,
when credited to the recipient, or when set aside for the recipient’s use.
A. Unearned income includes, but is not limited to:
(1) social security;
(2) railroad retirement;
(3) veterans benefits;
(4) temporary assistance for needy families
(TANF);
(5) pensions;
(6) annuities;
(7) alimony and support payments;
(8) rents;
(9) workmen’s compensation;
(10) in-kind support and maintenance;
(11) death benefits;
(12) royalties not counted as earned income;
and
(13) dividends and interest not otherwise
excluded under SSI rules.
B. Unearned income disregards:
(1) In-kind support and maintenance is any food and shelter that is given to the
applicant/spouse or received because someone else pays for it. This includes room, rent, mortgage payments,
real property taxes, heating fuel, gas, electricity, water, sewage, and garbage
collection services. The maximum amount
of income countable for in-kind support and maintenance is limited to one third
of the monthly SSI benefit rate for an individual or a couple, if the applicant’s
spouse is counted, or the current market value of the support, whichever is
lower.
(2) When benefits are reduced for
overpayments or garnishments, count the gross benefit before deductions.
(3) If part of a payment reflects expenses
the applicant/spouse incurred in getting the payment, such as legal fees,
damages, or medical expenses, incurred because of an accident, reduce the
payment by the amount of the expenses.
Do not reduce the payment by the amount of personal income taxes owed on
the payment.
(4) Subtract from veterans benefits any
amount included in the payment for a dependent.
If the applicant/spouse is the dependent, count the portion of the
benefit attributable to the dependent if they reside with the veteran or
receive their own separate payment from the department of veteran affairs.
(5) Subtract from death benefits the
expenses of the deceased person’s last illness and death paid by the recipient.
C. Unearned income exclusions: The following types of unearned income are
not considered for purposes of determining LIS eligibility:
(1) SSI benefits;
(2) any public agency’s refund of taxes on
real property or food;
(3) need-based assistance wholly funded by
a state or one of its subdivisions, including state supplementation of SSI
benefits but not a federal/state grant program such as TANF;
(4) any portion of a grant, scholarship,
fellowship, or gift used for paying tuition, fees, or other educational
expenses; any portion set aside or used
for food, clothing or shelter is countable;
(5) food which the applicant or their
spouse raise if it is consumed by them or their household;
(6) assistance received under the Disaster
Relief and Emergency Assistance Act and assistance provided under any federal
statute because of a catastrophe which the president of the United States
declares to be a major disaster;
(7) Alaska longevity bonus payments made
to an individual who is a resident of Alaska and who, prior to October 1, 1985,
met the 25-year residency requirement for receipt of such payments in effect
prior to January 1, 1983, and was eligible for SSI;
(8) payments for providing foster care to
a child who was placed in the applicant’s home by a public or private nonprofit
child placement or child care agency;
(9) any interest earned on excluded burial
funds and any appreciation in the value of an excluded burial arrangement which
are left to accumulate and become part of the separate burial fund;
(10) home energy assistance (any assistance
related to meeting the costs of heating or cooling a home);
(11) one-third of support payments made to or
for the applicant by an absent parent if the applicant is a child;
(12) the first $20 of any unearned income in
a month other than income in the form of in-kind support and maintenance
received in the household of another and income based on need;
(13) housing assistance-any assistance paid
with respect to a dwelling unit under:
(a) the United States Housing Act of 1937;
(b) the National Housing Act;
(c) Section 101 of the Housing and Urban
Development Act of 1965;
(d) Title V of the Housing Act of 1949; or
(e) Section 202(h) of the Housing Act of
1959;
(14) any interest accrued on and left to
accumulate as part of the value of an excluded burial space purchase agreement;
(15) gift of a domestic travel ticket
received by the applicant or their spouse and not converted to cash;
(16) payments made to the applicant or their
spouse from a fund established by the state to aid victims of crime;
(17) relocation assistance provided to the
applicant or their spouse by the state or local government that is comparable
to relocation assistance provided under title II of the Uniform Relocation
Assistance and Real Property Acquisition Policies Act of 1970;
(18) hostile fire pay received from one of
the uniformed services;
(19) the first $60 of unearned income
received per calendar quarter that is received too irregularly or infrequently
to be counted as income; or
(20) any dividends or interest earned on
countable resources, any dividends or interest earned on resources excluded
under a federal statute other than the Social Security Act, and any dividends
or interest excluded under the Social Security Protection Act of 2004.
[8.248.500.17 NMAC - Rp 8.248.500.17 NMAC, 7/1/2024]
8.248.500.18 DEEMED INCOME: Deeming
income from a spouse to their minor child(ren) or from one spouse to the other
spouse when living in the same household, does not apply.
[8.248.500.18 NMAC - Rp 8.248.500.18 NMAC, 7/1/2024]
8.248.500.19 TOTAL COUNTABLE INCOME: Countable
income is the sum of unearned income or earned income for the individual or
spouse less disregards or exclusions.
Only one earned income exclusion ($65 plus one half of the remainder) is
applied and one $20 disregard is applied if using
income from both spouses.
[8.248.500.19 NMAC - Rp 8.248.500.19 NMAC, 7/1/2024]
HISTORY OF
8.248.500 NMAC: [RESERVED]
History of Repealed Material: 8.248.500
NMAC - Income And Resource Standards (filed 1/13/2006) Repealed effective
7/1/2024.
Other:
8.248.500 NMAC - Income And Resource Standards (filed 1/13/2006)
Replaced by 8.248.500 NMAC - Income And Resource Standards effective 7/1/2024.