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 Human Services Department.
[8.248.500.1 NMAC - N, 2-1-06]
8.248.500.2 SCOPE: The
rule applies to the general public.
[8.248.500.2 NMAC - N, 2-1-06]
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 human services department pursuant to state
statute. See NMSA 1978, 27-2-12 et. seq.
( 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.
[8.248.500.3 NMAC - N, 2-1-06]
8.248.500.4 DURATION:
Permanent.
[8.248.500.4 NMAC - N, 2-1-06]
8.248.500.5 EFFECTIVE
DATE: February 1, 2006, unless a later date is
cited at the end of a section.
[8.248.500.5 NMAC - N, 2-1-06]
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 - N, 2-1-06]
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 - N, 2-1-06]
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 - N, 2-1-06]
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 his 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 - N, 2-1-06]
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 - N, 2-1-06]
8.248.500.13 COUNTABLE RESOURCES:
Before a resource can be considered countable, the three (3) 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 his resource. If he has 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, he 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 him.
[8.248.500.13 NMAC - N, 2-1-06]
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 his spouse have an ownership interest and which serves as his
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 twenty-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, his 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 - N, 2-1-06]
8.248.500.15 INCOME STANDARDS: Income
is anything the applicant/spouse receives in cash or in-kind that can be used
to meet his needs for food or shelter. The
gross income of the applicant and his spouse if living with him, but not
dependent family members, will be considered.
However, dependent family members will be counted in the family size.
[8.248.500.15 NMAC - N, 2-1-06]
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 his 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 he is 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,
16.3% 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, 25% of gross earnings for blind work expenses (BWE).
[8.248.500.16 NMAC - N, 2-1-06]
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 - N, 2-1-06]
8.248.500.18 DEEMED INCOME: Deeming
income from a spouse to his minor child(ren) or from one spouse to his spouse
when living in the same household, does not apply.
[8.248.500.18 NMAC - N, 2-1-06]
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 or0 exclusions.
Only one earned income exclusion ($65 plus 1/2 the remainder) is applied
and one $20 disregard is applied if using income from both spouses.
[8.248.500.19 NMAC - N, 2-1-06]
HISTORY OF 8.248.500
NMAC: [RESERVED]