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VA MEDICAID WORKS - Financial Eligibility

Individuals who choose to participate in Virginia's MEDICAID WORKS program must meet Assistance Unit, Resource, and Income requirements to determine eligibility. These eligibility requirements are different for initial eligibility determination and ongoing eligibility after enrollment, as explained below.

Assistance Unit

Initial Eligibility Determination

In order to qualify for MEDICAID WORKS, the individual must meet the normal assistance unit policy and procedures that apply to other Aged, Blind, and Disabled individuals with income that does not exceed 80% FPL. Resources and income from the individual's spouse with whom he lives or, if under age 21, the individual's parents with whom he lives, must be deemed available.

Ongoing Eligibility

Once the individual is enrolled in MEDICAID WORKS, the individual is treated as an assistance unit of one. Spousal and parental resources and income are disregarded for ongoing enrollee eligibility.

Resources

Initial Eligibility Determination

For the initial eligibility determination, the resource limit is $2,000 for an individual and $3,000 for a couple. Resources must be evaluated for all individuals, including SSI recipients, who wish to qualify for MEDICAID WORKS. The individual's countable, nonexempt resources must be verified. All countable resources must be added together to determine if the individual's countable resources are within the limit.

Ongoing Eligibility

Once the individual is enrolled in MEDICAID WORKS, the following resource policies apply:

i. For earnings accumulated after enrollment in MEDICAID WORKS, up to the current 1619(b) income threshold amount will be disregarded if deposited and retained in the WIN Account.

ii. Resources accumulated while in MEDICAID WORKS and held in Internal Revenue Service (IRS)-approved retirement accounts, medical savings accounts, medical reimbursement accounts, education accounts, independence accounts, and other similar State approved accounts are excluded. Examples of these accounts include Archer Medical Savings Accounts, 401(k) accounts, traditional Individual Retirement Accounts (IRAs), Roth IRAs, SEP-IRAs, SIMPLE IRAs, Thrift Savings Plans, and 503(b) plans. The account must be designated as a Work Incentive (WIN) Account in order to be excluded. Resources accumulated while in MEDICAID WORKS and held in IRS-approved accounts that have been designated as WIN Accounts are also excluded in all future Medicaid determinations for former MEDICAID WORKS enrollees. The account must be exclusively used to hold resources accumulated while in MEDICAID WORKS (including interest) in order for the exclusion to continue.

iii. For all other resources, the resource requirements of initial eligibility determination apply. All of the individual's countable, nonexempt resources must be verified and evaluated.

All nonexempt resources must be added together to determine if the individual meets the Medicaid resource requirements. The resource limit for resources not excluded in paragraphs i or ii above is $2,000 for an individual.

NOTE: Current Supplemental Security Income (SSI) recipients who have Medicaid coverage under the SSI 1619(b) work incentive for higher allowable earned income are still subject to the same resource limits as SSI. The ongoing resource limits for MEDICAID WORKS are significantly higher. If you receive SSI and meet the criteria for Medicaid coverage as a Qualified Severely Impaired Individual (1619(b)), you may choose to participate in MEDICAID WORKS because of the substantially higher resource limit. After enrollment, all MEDICAID WORKS participants are subject to the same higher resource limits.

Income

Initial Eligibility Determination

For the initial eligibility determination, the countable income limit is no more than 80% of the Federal Poverty Level (FPL).

Spenddown does not apply to the Medicaid Works covered group. Therefore, admission into MEDICAID WORKS is not available to individuals whose income exceeds 80% of the FPL.

NOTE: Current Supplemental Security Income (SSI) recipients, including recipients who have Medicaid coverage under the SSI 1619(b) work incentive, do not have to meet the normal requirement that their countable income not exceed 80% FPL for initial eligibility determination. These individuals are considered to meet the income requirements and no evaluation of income is necessary for the initial eligibility determination. After enrollment, all MEDICAID WORKS participants are subject to the same higher income limits.

Ongoing Eligibility

Once the individual is enrolled in MEDICAID WORKS, the following income policies apply:

i. The countable income limit for earned income is 200% of the FPL for one person as long as the funds are deposited in a WIN Account. If the individual is self-employed, net earnings from self-employment (NESE) must be demonstrated through documentation of Internal Revenue Service (IRS) filings, quarterly estimated taxes, business records, and/or business plans. The individual's signed allegation of self-employment is acceptable if no other evidence of NESE can be obtained.

ii. The countable income limit for unearned income remains less than or equal to 80% of the FPL.

NOTE: Current MEDICAID WORKS regulations may potentially impact an enrollee's continuing eligibility for MEDICIAD WORKS in certain scenarios that effect unearned income. These may be changed in the future, but remain in effect as of January 2012.

1. If automatic COLA increases to SSDI cause an enrollee's total unearned income to exceed 80% of the Federal Poverty Level, the person will no longer be eligible for MEDICIAD WORKS.

2. Enrollees must, under the regulations, apply for Unemployment Insurance, which is considered unearned income. If the UI causes total unearned income to exceed 80% of the Federal Poverty Level, the person will no longer be eligible for MEDICIAD WORKS.

NOTE: In the case of a person with no unearned income, the annual earnings limit for ongoing eligibility may be determined by calculating the sum of twice the 200% FPL countable earned income limit and adding 12 months worth of the monthly $65 earned income exclusion to it. For example, in 2012, this would be twice the $22,340 200% FPL amount ($44,680) plus 12 times the $65 monthly earned income exclusion ($780) for at total of $45,460.

Also See:

Virginia MEDICAID WORKS - Overview

Virginia MEDICAID WORKS - Agreement

Virginia MEDICAID WORKS - Blindness and Disability

Virginia MEDICAID WORKS - Cost Sharing and Premium Payment

Virginia MEDICAID WORKS - Employment Considerations

Virginia MEDICAID WORKS - Entitlement and Enrollment

Virginia MEDICAID WORKS - Good Cause Exceptions

Virginia MEDICAID WORKS - Non-Financial Eligibility

Virginia MEDICAID WORKS - Safety Net

VA MEDICAID WORKS - Work Incentive (WIN) Account

Source

Some information for this topic was drawn from the DMAS website at:
http://www.dmas.virginia.gov/downloads/pdfs/mb-FactSheet_Medicaid.pdf
http://www.dmas.virginia.gov/downloads/pdfs/rcp-medicaid_applicant_handbook.pdf

Additional information was drawn from Section M0320.211 of the Department of Social Services (DSS) Medicaid Manual.

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