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Documents
Instructions
Updated: 7/2006
Purpose
- To document changes in income and/or incurred medical expenses occurring between annual reviews.
- To calculate the projected amount of variable income and/or incurred medical expenses for start-up budgeting, for mandated semi-annual reviews or whenever there is a change occurring between annual reviews.
- To rebudget applied income between annual reviews.
- To retroactively reconcile variable income and/or incurred medical expenses at the end of any projection period.
Procedure
When to Prepare
Form H1202-A is completed whenever there is a change in income or incurred medical expenses occurring between annual reviews, or any time variable income and/or incurred medical expenses are rebudgeted and/or retroactively reconciled.
Note: Form H1202-A, page 2, may be used in conjunction with Form H1201 at application or annual review for purposes of calculating projected variable income and/or retroactively reconciling variable income and/or incurred medical expenses.
Number of Copies
The eligibility specialist completes an original Form H1202-A in legible handwriting. For special reviews, the eligibility specialist files the form in the case record on top of the last complete review.
If Form H1202-A is used at application or annual review in conjunction with Form H1201, Form H1202-A is filed in the case record just beneath the corresponding Form H1201.
Form Retention
Form H1202-A is kept in the case record for three years after the case is denied.
Detailed Instructions
Page One
Identifying Information — Enter the client name, application/client number, category and type program. Enter the same information for the client's spouse, if any.
Check the appropriate box to indicate the type case (individual, companion or couple). Enter the source of the information and the date the information is obtained.
Title XIX Budget
Federal Maximum – Type Program 14
Enter under "Deemed Income" any income deemed from an ineligible parent(s).
Enter under "Other Unearned Income" the amount of the individual's or eligible couple's gross unearned income.
Enter under "Earned Income" the amount of the individual's or eligible couple's gross earned income.
Enter under "Total Income" the total of deemed, unearned and earned income of the individual or eligible couple.
Enter under "Exclusions (VA-A&A/HB)" any VA aid and attendance or VA housebound allowance benefits received by the individual or eligible couple.
Enter under "Balance" the difference between the entry under "Total Income" and the entry under "Exclusions."
Enter under "Federal Maximum" the current institutional or special income limit. For individual and companion (including spousal impoverishment) cases, this is three times the SSI Federal Benefit Rate (FBR). The couple income limit is twice the individual income limit.
Eligibility Test – All Type Programs
Enter under "Deemed Income" any income deemed from an ineligible parent(s).
Enter under "Other Unearned Income" the gross amount of the individual's or eligible couple's unearned income.
Enter under "Earned Income" the gross earned income of the individual or eligible couple.
Enter under "Total Income" the total of the amounts entered under "Deemed Income," "Other Unearned Income" and "Earned Income."
Enter under "RSDI COLA Exclusions (TP 03, 18, 22, 51)" the amount of the appropriate RSDI exclusion in TP 03, 18 and 22 cases, or the cost-of-living adjustment exclusion in any pension or retirement benefit in TP 51 (non-S-I-G code "J") cases.
Enter under "Other Exclusions" any other appropriate exclusions. Example: Earned income exclusions in cases for which the SSI Federal Benefit Rate (FBR) or the QMB/SLMB income limit is used in testing eligibility.
Enter under "Balance" the difference between the entry under "Total Income" and the total of the entries under "RSDI COLA Exclusions (TP 03, 18, 22, 51)" and "Other Exclusions."
Enter under "Income Limit" the appropriate individual or couple income limit.
Applied Income - Type Programs 02, 13, 14, 51
A. — Enter the client's monthly countable income (excluding any mandatory payroll deductions from earned income and income taxes withheld from pension or benefit checks).
B. — Enter the eligible spouse's monthly countable income (excluding mandatory payroll deductions from earned income and income taxes withheld from pension or benefit checks).
C. — Enter the total of items A + B.
D. — Enter the $60 personal needs allowance ($60 for each spouse in couple cases). In ICF-MR cases (including state supported living centers), include the protected earned income allowance.
E. — Subtract item D from item C and enter the difference here.
F. — In spousal impoverishment cases, enter the community spouse's total income (less mandatory payroll deductions from earned income and income taxes withheld from pension or benefit checks).
G. — Enter the sum of items E and F.
H. — If the community spouse's total monthly income (as entered in item F) is equal to or less than the current spousal monthly maintenance allowance, enter the current spousal monthly maintenance allowance. If the community spouse's total monthly income (as entered in item F) is more than the current spousal monthly maintenance allowance, enter the community spouse's total income (as entered in item F).
I. — In spousal impoverishment cases, enter the deduction for dependents.
J. — Enter the amount of the client's and eligible spouse's Medicare Part B premium, if not MQMB-eligible.
K. — Enter the monthly amount of premiums on assignable general health insurance policies being paid by the client and eligible spouse.
L. — Enter the amount of any other allowable incurred medical expenses. Example: Payments for oxygen or dentures.
M. — Enter the applied income amount for the client and spouse (if couple case). This is obtained by subtracting the sum of items H through L from item G. In couple cases, the difference is divided by two.
Budget Change/No Budget Change — Check the appropriate box to indicate whether there is or is not a budget change. Also, indicate the date that Form H1259 and/or Form H4808 were sent, if appropriate.
PAGE TWO
Step 1 — Enter the actual and projected variable income and incurred medical expense (IME) amounts for each of the months in the reconciliation period. Total each of the actual and projected variable income/IME columns.
Divide the totals of each amount in the actual/projected columns by the number of months in the reconciliation period to obtain the monthly average. If the projected average monthly income and the actual average monthly income are each less than $2, or if the difference between the two is less than $1, then reconciliation is not required. Also, if the projected average monthly IME and the actual average monthly IME are each less than $2, or if the difference between the two is less than $1, then reconciliation is not required. (Although reconciliation is optional for these small amounts, reconcile whenever the client requests it.)
Step 2 — Using the totals from Step #1, subtract the total amount of projected variable income from the total amount of actual variable income. The difference (+ or - ) is the income adjustment.
Step 3 — Using the totals from Step #1, subtract the total amount of actual IMEs from the total amount of projected IMEs. The difference (+ or - ) is the IME adjustment.
Step 4 — If the IME adjustment (from Step #3) is a positive number (+), add it to the income adjustment (from Step #2).
If the IME adjustment (from Step #3) is a negative number (–), subtract it from the income adjustment (from Step #2).
The result is the overall adjustment, which may be a positive (+) number or a negative (-) number.
Step 5 — Complete this step only if the overall adjustment (from Step #4) is a positive number (+). If the overall adjustment (from Step #4) is a negative number (–), proceed to Step #6.
Divide the overall adjustment (from Step #4) by the number of months in the reconciliation period. The quotient is the average monthly adjustment.
If the average monthly adjustment is +$4.99 or less, stop. Do not reconcile.
If the average adjustment is +$5.00 or more, proceed to Step #6.
Step 6 — If the overall adjustment is a positive number (+), add this adjustment to the applied income for the most recent month in the reconciliation period. The result is reconciled applied income for that month.
If the overall adjustment is a negative number (–), subtract this adjustment from the applied income for the most recent month in the reconciliation period. The result is reconciled applied income for that month.
"Excess Adjustment" — If the negative (–) overall adjustment exceeds the amount of applied income for the most recent month in the reconciliation period, the difference is the "excess adjustment." If there is an "excess adjustment," proceed to Step #7.
Step 7 — Subtract the "excess adjustment" from Step #6 from applied income for the next-to-most-recent month in the reconciliation period. The result is reconciled applied income for that month.