Revision 19-1; Effective March 1, 2019

 

An eligibility budget is used to determine a person's financial eligibility for Medicaid. Base the type of eligibility budget on:

  • where the person lives and whether a person is married or not married at the beginning of each month;
  • whether a person is considered a child; and
  • whether a person is considered another person's parent.

The setting where a person lives, in part, determines whether an eligibility budget will be:

  • noninstitutional; or
  • institutional.

Examples of an institutional setting are a nursing facility or a waiver. Even though the person receiving services though a waiver is living in the community, eligibility factors are based on that person living in an institution.

This chapter will focus on the financial income eligibility budget. However, the person must meet all other requirements to be eligible for Medicaid. The financial resource budget is discussed under Chapter F, Resources.

 

G-1100 Texas Administrative Code Rules

Revision 09-4; Effective December 1, 2009

 

Subchapter C, Division 6, Budgeting for Eligibility and Co-payment

§358.431. Definitions.

In this division, the following words and terms have the following meanings, unless the context clearly indicates otherwise.

(1) Child--Has the meaning given in 20 CFR §416.1856.

(2) Couple--Two persons who live together and:

(A) present themselves to the community as husband and wife, intend to be married, and are considered to be married under state law;

(B) are determined to be husband and wife for purposes of receiving Social Security benefits; or

(C) are recognized as husband and wife under state law.

(3) Dependent relative--A relative who was living in the home of an applicant or recipient before the applicant's or recipient's absence and who is unable to support himself or herself outside of the person's home due to medical, social, or other reasons.

(4) Parent--Has the meaning given in 20 CFR §416.1881.

§358.432. Eligibility Budgets.

The Texas Health and Human Services Commission (HHSC) prepares an eligibility budget to determine a person's financial eligibility for Medicaid. The type of eligibility budget HHSC prepares depends on:

(1) where the person lives and whether a person is married or not married at the beginning of each month;

(2) whether a person is considered a child; and

(3) whether a person is considered another person's parent.

§358.433. Special Income Limit.

The Texas Health and Human Services Commission uses a special income limit to determine income eligibility under circumstances established in this section. The special income limit for a person is equal to or less than 300 percent of the full individual Supplemental Security Income (SSI) federal benefit rate. The special income limit for a couple is twice the special income limit for an individual.

(1) To qualify for the special income limit, a person or couple must have countable income that exceeds the reduced SSI federal benefit rate; and:

(A) must:

(i) reside in:

(I) a Medicaid-certified long-term care facility for 30 consecutive days; or

(II) a Medicaid-certified institution for mental diseases for 30 consecutive days, if the person is 65 years of age or older; and

(ii) receive a level of care or medical necessity determination that qualifies the person or couple for Medicaid; or

(B) must be approved by a Texas health and human services agency to receive services under a §1915(c) waiver program and receive the services within one month after approval.

(2) The 30 consecutive days described in paragraph (1)(A) of this section are not disrupted if the person:

(A) makes a three-day therapeutic home visit with a planned return to the facility;

(B) is admitted to a hospital with a planned return to the facility; or

(C) moves from a facility described in paragraph (1)(A)(i) of this section:

(i) to a §1915(c) waiver program; or

(ii) to another Medicaid-certified facility.

(3) If a person dies before meeting the 30-consecutive-day requirement without moving to a noninstitutional setting, the person is considered to have met the requirement for application of the special income limit.

§358.434. Budget Types for a Noninstitutional Setting.

(a) Individual budget. The Texas Health and Human Services Commission (HHSC) prepares an individual budget for a person in a noninstitutional setting if the person is:

(1) single;

(2) widowed;

(3) divorced; or

(4) married and is:

(A) an applicant separated from his or her spouse at the time of application; or

(B) a recipient separated from his or her spouse during the previous month.

(b) Couple budget. HHSC prepares a couple budget for a couple in a noninstitutional setting if:

(1) the couple meets the definition of a couple in §358.431 of this division (relating to Definitions);

(2) each spouse is an applicant or a recipient; and

(3) both spouses are in the same coverage group.

(c) Companion budget. HHSC prepares a companion budget for a person in a noninstitutional setting who has an ineligible spouse if:

(1) the couple meets the definition of a couple in §358.431 of this division; and

(2) the person lives with the ineligible spouse during any part of a calendar month.

§358.435. Noninstitutional Eligibility Budgets.

(a) Scope. The Texas Health and Human Services Commission (HHSC) prepares a noninstitutional eligibility budget to determine financial eligibility for a person or couple in a noninstitutional setting, if the person or couple:

(1) applies for retroactive coverage;

(2) applies for or has eligibility redetermined under a federally mandated Medicaid-funded program for the elderly and people with disabilities as described in §358.107 of this chapter (relating to Coverage Groups); or

(3) applies for or has eligibility redetermined under §1929(b)(2)(B) of the Social Security Act.

(b) Individual budget. In preparing an eligibility budget for a person who meets the criteria in §358.434(a) of this division (relating to Budget Types for a Noninstitutional Setting), HHSC:

(1) counts the person's income in accordance with §1612 of the Social Security Act (42 U.S.C. §1382a);

(2) counts the person's resources in accordance with §1613 of the Social Security Act (42 U.S.C. §1382b);

(3) applies the individual resource limit in accordance with 20 CFR §416.1205; and

(4) applies the appropriate income limit, effective the month of eligibility determination, as follows:

(A) for a person who meets the criterion in subsection (a)(1) or (2) of this section, the income limit is the full individual Supplemental Security Income (SSI) federal benefit rate; and

(B) for a person who meets the criterion in subsection (a)(3) of this section, the income limit is the special income limit based on 300 percent of the full individual SSI federal benefit rate.

(c) Couple budget. In preparing an eligibility budget for a couple who meets the criteria in §358.434(b) of this division, HHSC:

(1) counts the income of both spouses in accordance with §1612 of the Social Security Act;

(2) counts the resources of both spouses in accordance with §1613 of the Social Security Act;

(3) applies the couple resource limit in accordance with 20 CFR §416.1205; and

(4) applies the appropriate income limit, effective the month of eligibility determination, as follows:

(A) for a couple who meets the criterion in subsection (a)(1) or (2) of this section, the income limit is the full couple SSI federal benefit rate; and

(B) for a couple who meets the criterion in subsection (a)(3) of this section, the income limit is twice the special income limit based on 300 percent of the full individual SSI federal benefit rate.

(d) Companion budget. In preparing an eligibility budget for a person who meets the criteria in §358.434(c) of this division, HHSC:

(1) counts the income of both spouses in accordance with §1612 of the Social Security Act;

(2) counts the resources of both spouses in accordance with §1613 of the Social Security Act;

(3) deems the ineligible spouse's income and resources;

(4) applies the couple resource limit in accordance with 20 CFR §416.1205; and

(5) applies the appropriate income limit, effective the month of eligibility determination, as follows:

(A) for a person who meets the criterion in subsection (a)(1) or (2) of this section, the income limit is the full individual SSI federal benefit rate; and

(B) for a person who meets the criterion in subsection (a)(3) of this section, the income limit is the special income limit based on 300 percent of the full individual SSI federal benefit rate.

§358.436. Budget Types for an Institutional Setting.

(a) Individual budget. The Texas Health and Human Services Commission (HHSC) prepares an individual budget for a person in an institutional setting if the person is:

(1) single;

(2) widowed;

(3) divorced; or

(4) married and meets the criteria in subsection (c) of this section, but the community spouse refuses to cooperate in providing information and circumstances indicate possible abuse or neglect by the community spouse.

(b) Couple budget. HHSC prepares a couple budget for a couple in an institutional setting if:

(1) the couple meets the definition of a couple in §358.431 of this division (relating to Definitions);

(2) each spouse is an applicant or a recipient; and

(3) both spouses are in the same coverage group.

(c) Institutional companion budget. HHSC prepares an institutional companion budget for a person in an institutional setting if:

(1) the person has a community spouse; and

(2) the couple meets the definition of a couple in §358.431 of this division, except the criterion that the couple live together does not apply.

§358.437. Institutional Eligibility Budgets.

(a) Scope. The Texas Health and Human Services Commission (HHSC) prepares an institutional eligibility budget to determine financial eligibility for a person or couple in an institutional setting, if the person or couple:

(1) applies for retroactive coverage; or

(2) applies for or has eligibility redetermined under a federally optional Medicaid-funded program for the elderly and people with disabilities as described in §358.107 of this chapter (relating to Coverage Groups).

(b) Individual budget. In preparing an eligibility budget for a person who meets the criteria in §358.433 of this division (relating to Special Income Limit) and §358.436(a) of this division (relating to Budget Types for an Institutional Setting), HHSC:

(1) counts the person's income in accordance with §1612 of the Social Security Act (42 U.S.C. §1382a);

(2) counts the person's resources in accordance with §1613 of the Social Security Act (42 U.S.C. §1382b);

(3) applies the individual resource limit in accordance with 20 CFR §416.1205; and

(4) applies the special income limit effective the month of eligibility determination.

(c) Couple budget. In preparing an eligibility budget for a couple who meets the criteria in §358.433 of this division and §358.436(b) of this division, HHSC:

(1) counts the income of both spouses in accordance with §1612 of the Social Security Act;

(2) counts the resources of both spouses in accordance with §1613 of the Social Security Act;

(3) applies the couple resource limit in accordance with 20 CFR §416.1205; and

(4) applies the special income limit, effective the month of eligibility determination.

(d) Institutional companion budget. In preparing an eligibility budget for a person who meets the criteria in §358.433 of this division and §358.436(c) of this division, HHSC:

(1) applies spousal impoverishment treatment of income and resources under 42 U.S.C. §1936r-5, counting income of both spouses in accordance with §1612 of the Social Security Act and resources of both spouses in accordance with §1613 of the Social Security Act;

(2) follows resource eligibility in accordance with 42 U.S.C. §1396r-5;

(3) bases income eligibility on the income of the person in the institutional setting; and

(4) applies the special income limit effective the month of determination.

(e) Less than 30 consecutive days. In preparing an eligibility budget for a person or couple in an institutional setting who does not meet the criteria in §358.433 of this division, HHSC applies the criteria in §358.435 of this division (relating to Noninstitutional Eligibility Budgets).

 

G-1200 Definitions

Revision 15-4; Effective December 1, 2015

 

A child is neither married nor a head of a household and is either:

  • under age 18; or
  • under age 22 and a student regularly attending school, college or training that is designed to prepare him/her for a paying job.

See Section D-1210, Definition of a Child, for more information.

A couple is two people who live together and:

  • present themselves to the community as a married couple, intend to be married and are considered to be married under state law;
  • are determined to be married for purposes of receiving Social Security benefits; or
  • are recognized as married under state law.

A dependent relative is a relative who was living in the home of an applicant or recipient before the applicant's or recipient's absence and who is unable to support himself or herself outside of the person's home due to medical, social or other reasons.

A parent is:

  • a natural or adoptive parent of the child, or
  • the spouse of the natural or adoptive parent ("stepparent").

The stepparent must be the present spouse of the natural or adoptive parent. A person is not a stepparent if the natural or adoptive parent to whom the stepparent was married has died, or if the parent and stepparent have been divorced or their marriage has been annulled. See Section D-4213, Parent, for more information on the definition of a parent.

 

G-1300 Income Limits

Revision 12-4; Effective December 1, 2012

 

The MEPD programs use income limits based on the Supplementary Security Income (SSI) limit up to the 300% of the federal poverty level. For a detailed list of the various income limits for the different programs, see Appendix XXXI, Budget Reference Chart.

 

G-1310 Community-Based Programs Using SSI Limits

Revision 19-1; Effective March 1, 2019

 

For those programs being tested using the SSI federal benefit rate (FBR), use the following figures.

Income Limits

The monthly income limits for initial certification are:

Date Range Individual Couple
Jan 1, 2019 to present $771 $1,157
Jan 1, 2018 to Dec 31, 2018 $750 $1,125
Jan 1, 2017 to Dec 31, 2017 $735 $1,103
Jan 1, 2016 to Dec 31, 2016 $733 $1,100
Jan 1, 2015 to Dec 31, 2015 $733 $1,100
Jan 1, 2014 to Dec 31, 2014 $721 $1,082
Jan 1, 2013 to Dec 31, 2013 $710 $1,066
Jan 1, 2012 to Dec 31, 2012 $698 $1,048
Jan 1, 2011 to Dec 31, 2011 $674 $1,011
Jan 1, 2010 to Dec 31, 2010 $674 $1,011

For additional prior year income limits, see Appendix XLI, Historical Income Limits Chart for Institutional, SSI and MBI.

 

G-1320 Special Income Limits

Revision 19-1; Effective March 1, 2019

 

For those programs being tested using the special income limit of 300 percent of the SSI-FBR, use the following figures.

Income Limits

The monthly income limits for initial certification are:

Date Range Individual Couple
Jan 1, 2019 to present $2,313 $4,626
Jan 1, 2018 to Dec 31, 2018 $2,250 $4,500
Jan 1, 2017 to Dec 31, 2017 $2,205 $4,410
Jan 1, 2016 to Dec 31, 2016 $2,199 $4,398
Jan 1, 2015 to Dec 31, 2015 $2,199 $4,398
Jan 1, 2014 to Dec 31, 2014 $2,163 $4,326
Jan 1, 2013 to Dec 31, 2013 $2,130 $4,260
Jan 1, 2012 to Dec 31, 2012 $2,094 $4,188
Jan 1, 2011 to Dec 31, 2011 $2,022 $4,044
Jan 1, 2010 to Dec 31, 2010 $2,022 $4,044

 

For additional prior year income limits, see Appendix XLI, Historical Income Limits Chart for Institutional, SSI and MBI.