D.C. Mun. Regs. tit. 29, r. 29-9506

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 29-9506 - MODIFIED ADJUSTED GROSS INCOME (MAGI) ELIGIBILITY

9506.1

This section shall establish the factors of District Medicaid eligibility for modified adjusted gross income (MAGI) eligibility groups, as identified in Section 9500.

9506.2

To be determined eligible for Medicaid as a parent or other caretaker relative, an individual shall:

(a) Be a parent or other caretaker relative of a dependent child;

(b) Have a household income that does not exceed two hundred sixteen percent (216%) of the Federal Poverty Level (FPL) as determined in accordance with this section; and

(c) Meet all other applicable non-financial eligibility factors identified at Subsection 9506.9.

9506.3

To be determined eligible for Medicaid as a pregnant woman, an individual shall:

(a) Be pregnant or in the post-partum period;

(b) Have household income that does not exceed three hundred nineteen percent (319%) of the FPL as determined in accordance with this Section;

(c) Not otherwise eligible or enrolled under the following mandatory groups:

(1) Supplemental Security Income (SSI) and related groups,

(2) Parent or Other Caretaker Relatives,

(3) Infants and Children, or

(4) Title IV-E Foster Children;

(d) Not entitled to or enrolled in Medicare; and

(e) Meet all other applicable non-financial eligibility factors identified at Subsection 9506.9.

9506.4

The Department shall not require a pregnant woman to cooperate in establishing paternity in order to receive Medicaid.

9506.5

A pregnant woman who is determined eligible for Medicaid shall retain eligibility throughout the pregnancy and the post-partum period regardless of changes in household income.

9506.6

To be determined eligible for Medicaid as an infant and child under age nineteen (19), an individual shall:

(a) Be age zero (0) through eighteen (18);

(b) Have a household income that does not exceed three hundred nineteen percent (319%) of the FPL as determined in accordance with this section; and

(c) Meet all other applicable non-financial eligibility factors identified at Subsection 9506.9.

9506.7

To be determined eligible for Medicaid as a child age nineteen (19) or twenty (20), an individual shall:

(a) Be age nineteen (19) or twenty (20);

(b) Have household income that does not exceed two hundred sixteen percent (216%) of the FPL as determined in accordance with this section; and

(c) Meet all other applicable non-financial eligibility factors identified at Subsection 9506.9.

9506.8

To be eligible as an individual without a dependent child (childless adult), an individual shall:

(a) Be age twenty-one (21) through sixty-four (64);

(b) Have a household income that does not exceed hundred thirty-three percent (133%) of the FPL as determined in accordance with this section;

(c) Without dependent children;

(d) Not otherwise eligible or enrolled under the following mandatory groups:

(1) SSI and related groups,

(2) Parent or Caretaker Relative,

(3) Pregnant Woman,

(4) Former Foster Child, or

(e) Not entitled to or enrolled in Medicare Part A or Part B; and

(f) Meets all other applicable non-financial eligibility requirements identified at Subsection 9506.9.

9506.9

All individuals applying for Medicaid, regardless of eligibility group, shall meet the following non-financial eligibility factors:

(a) Be a District resident pursuant to 42 C.F.R. Section 435.403;

(b) Provide an SSN or be exempt pursuant to 42 C.F.R. Section 435.910 and Subsection 9504.7; and

(c) Be a U.S. citizen or national, or be in a satisfactory immigration status.

9506.10

The Department shall employ MAGI methodologies (based on federal income tax rules) to determine household composition, family size, and how income is counted during eligibility determinations for MAGI eligibility groups.

9506.11

For individuals who expect to file a federal income tax return or who expect to be claimed as a tax dependent by another tax filer for the taxable year in which an eligibility determination is made, household composition shall be determined as follows:

(a) The household of an individual who expects to be a tax filer consists of the tax filer and all of the tax dependents the tax filer expects to claim;

(b) The household of a tax dependent, except individuals identified in Subsection 9506.14, consists of the tax filer claiming the tax dependent and all other tax dependents expected to be claimed by that tax filer;

(c) The household of a married individual who lives with their spouse consists of both spouses regardless of whether they expect to file a joint federal tax return or whether one or both spouses expect to be claimed as a tax dependent by another tax filer;

(d) The household of a married individual who does not live with their spouse and files a joint federal tax return includes the married individual plus their spouse;

(e) The household of a married individual who does not live with their spouse and is filing a federal tax return separately does not include the spouse; and

(f) The household of a pregnant woman includes the pregnant woman plus the number of children she is expected to deliver. In determining the family size of the household of an individual that includes a pregnant woman, the pregnant woman is counted herself plus the number of children she is expected to deliver.

9506.12

The Department shall consider an individual who expects to be both a tax filer and a tax dependent to be a tax dependent.

9506.13

For individuals who do not expect to file a federal income tax return or be claimed as a tax dependent for the taxable year in which an eligibility determination is made, household composition shall be determined as follows:

(a) The household of an individual who expects to be a non-filer consists of the non-filer and, if living with the non-filer:

(1) The non-filer's spouse;

(2) The non-filer's children under age nineteen (19); and

(3) If the non-filer is under age nineteen (19), the non-filer's parents and any siblings who are also under age nineteen (19).

9506.14

Household composition shall be determined under Subsection 9506.13 for the following:

(a) Individuals who expect to be claimed as a tax dependent by a tax filer who is not their spouse or biological, adoptive, or step parent, regardless of the individual's age;

(b) Individuals who are under age nineteen (19) living with both parents who do not expect to file a joint federal tax return, and who expect to be claimed as a tax dependent by one of their parents; or

(c) Individuals who are under age nineteen (19) and expect to be claimed by a non-custodial parent.

9506.15

MAGI-based income shall be determined using federal income tax rules for determining adjusted gross income except as otherwise provided in this Section. Countable income shall include the following:

(a) Wages, salaries, tips, and other forms of earned income;

(b) Taxable and tax-exempt interest;

(c) Ordinary dividends;

(d) Qualified dividends;

(e) Taxable refunds, credits, or offsets of state and local income taxes;

(f) Alimony received;

(g) Business income or losses;

(h) Capital gains or losses;

(i) Other taxable gains or losses;

(j) Taxable Individual Retirement Account (IRA) distributions;

(k) Taxable pensions and annuities - taxable amount;

(l) Rental real estate, royalties, income from partnerships, S corporations, trusts, etc.;

(m) Farm income or losses;

(n) Unemployment compensation;

(o) Taxable and tax-exempt Social Security benefits except as provided in Subsection 9506.16(q) below;

(p) Lump sum payments, which shall be counted as follows:

(1) Qualified lottery winnings as defined under 42 U.S.C. § 1396a(e) (14)(K)(v), and qualified lump sum income as defined under § 1396a(e)(14)(K)(vi) (i.e., gambling winnings), shall be counted using the following formula (lottery winnings paid out in installments shall not be considered "qualified lottery winnings" and shall be considered unearned, recurring income that is counted in the month they are received):

(A) Single payment winnings less than eighty thousand dollars ($80,000.00) shall be counted in the month received in their entirety;

(B) Single payment winnings of eighty thousand dollars ($80,000.00) but less than ninety thousand dollars ($90,000.00) shall be counted as income over two (2) months, with an equal amount counted in each month only for the individual who received the winnings. For other household members, the winnings should be counted under subsection 9506.15(p)(2); and

(C) For every additional ten thousand dollars ($10,000.00) of single payment winnings, one (1) month is added to the period over which total winnings are divided, in equal installments, and counted as income up to a maximum of one hundred twenty (120) months only for the individual who received the winnings (a table showing the amount of monthly income attributed to increasing amounts of winnings and the number of months over which the winnings are counted can also be found in the Centers for Medicare and Medicaid Services (CMS) State Health Official Letter # 19-003, Attachment B, pages 12 - 13, at https://www.medicaid.gov/federal-policy-guidance/downloads/sho19003.pdf (last visited on September 23, 2021)). For other household members, the winnings should be counted under subsection 9506.15(p)(2);

(2) Other lump sum payments that are not qualified lottery winnings or qualified lump sum income described in Subsection 9506.15(p)(1) (including but not limited to backpay, a retroactive benefit payment, State tax refund, or an insurance settlement) shall be counted in the month(s) during which they are received; and

(q) Any other income reported on Internal Revenue Service (IRS) Form 1040.

9506.16

Countable income shall exclude the following:

(a) Income scholarships, awards, or fellowship grants used for education purposes and not for living expenses;

(b) American Indian/Alaska Native income as defined in 42 C.F.R Section 435.603(e);

(c) Educator expenses;

(d) Certain business expenses of reservists, performing artists, and fee-based government officials;

(e) Health savings account deductions;

(f) Moving expenses for active duty members of the military who are ordered to move or change duty stations. For individuals who are not active duty members of the military, moving expenses shall not be excluded from income through tax year 2025;

(g) Deductible part of self-employment tax;

(h) Self-employed Simplified Employee Pension (SEP), Savings Incentive Match Plan for Employees (SIMPLE), and qualified plans;

(i) Self-employed health insurance deductions;

(j) Penalty(ies) on early withdrawal of savings;

(k) Alimony paid pursuant to separation or divorce agreements finalized on or before December 31, 2018, that has not been modified after December 31, 2018;

(l) Alimony received pursuant to a separation or divorce agreement finalized on or after January 1, 2019, or pursuant to a pre-existing agreement modified on or after January 1, 2019;

(m) Individual Retirement Account (IRA) deductions;

(n) Student loan interest deductions;

(o) Discharged student loan debt of a borrower if the debt is discharged due to the death or the permanent and total disability of the student, as described under section 11031 of the Tax Cuts and Jobs Act of 2017, approved on December 22, 2017 ( Pub. L. No. 115-97, 131 Stat. 2054) (TCJA);

(p) Public assistance benefits;

(q) Domestic production activities deductions;

(r) Supplemental Security Income (SSI) benefits under Title XVI of the Social Security Act; and

(s) Compensation of a parent mentor, as defined under 42 U.S.C. § 1397mm(f)(5), that assists families with children that are eligible, but not enrolled, in Medicaid, in accordance with section 3004 of the Helping Ensure Access for Little Ones, Toddlers, and Hopeful Youth by Keeping Insurance Delivery Stable Act of 2017, approved on January 22, 2018 ( Pub. L. No. 115-120, 132 Stat. 28) (HEALTHY KIDS Act).

9506.17

Household income shall include the MAGI-based income of all individuals in a household except that:

(a) The MAGI-based income of an individual who is included in the household of his or her natural, adopted, or step parent and is not expected to be required to file a federal tax return for the taxable year of an eligibility determination, shall not be included in household income, whether or not the individual files a federal tax return; and

(b) The MAGI-based income of a tax dependent, other than a spouse or child under age nineteen (19), who is not expected to be required to file a separate federal tax return for the taxable year of an eligibility determination, is not included in the household income of the tax filer who expects to claim the tax dependent, whether or not such tax dependent files a federal tax return.

9506.18

An amount equivalent to five percent (5%) of the Federal Poverty Level (FPL) for the applicable family size shall be deducted from household income only when determining the financial eligibility of an individual under the highest income standard available for an individual.

9506.19

The Department shall base current financial eligibility for Medicaid on current monthly income.

9506.20

Current monthly income shall be calculated as follows:

(a) Income received on a yearly basis or less often than monthly, that is predictable in both amount and frequency, shall be converted to a monthly amount or prorated;

(b) If the amount or frequency of regularly received income is known, the Department shall average the income over the period between payments; or

(c) If neither the amount nor the frequency is predictable, the Department shall not average the income but count income only for the month in which it is received.

9506.21

The Department shall verify financial eligibility for Medicaid at the time of application, at each renewal of eligibility, and at each redetermination of eligibility in accordance with the District Verification Plan, submitted to CMS pursuant to 42 C.F.R. Sections 435.940 - 435.965 and Section 457.380.

9506.22

An applicant adult who is in a minor applicant's household or family, or an authorized representative of an applicant, as identified in 42 C.F.R. Section 435.923, shall attest to household income.

9506.23

The Department shall verify financial eligibility through one (1) or more federal or state electronic data sources, except for qualified lottery winnings and lump sum payments, for which the Department shall accept self-attestation, subject to post-eligibility verification using available electronic data sources.

9506.24

The Department shall use a reasonable compatibility standard to match financial information obtained from federal and State electronic data sources with attested application information.

9506.25

The reasonable compatibility standard for financial information shall be met when:

(a) The attestation and data sources are both above the District Medicaid program's applicable income standard;

(b) The attestation and data sources are both below the District Medicaid program's applicable income standard.

(c) The attestation is below the District Medicaid program's applicable income standard and the data sources are above the applicable income standard, when the difference between them is less than twenty percent (20%) of the amount given by data sources; and

(d) The attestation is zero (0) income and no income data is available from electronic data sources.

9506.26

The Department may require supplemental information where electronic data is unavailable or application information is not reasonably compatible with information obtained from an electronic data source.

9506.27

The Department may accept supplemental information reflecting current monthly income in the following forms:

(a) Paystubs;

(b) Completed employer verification form;

(c) Statement showing retirement income, disability income, Workers Compensation income, or a pension statement;

(d) Bank and checking account statement;

(e) Paper, electronic, or telephonic documentation; or

(f) If other documentation is not available, a statement which explains the discrepancy.

9506.28

The Department shall provide written notice to the applicant or beneficiary to provide supplementary information to verify financial eligibility and the date by which an applicant or beneficiary shall provide the required information, consistent with §9501.3.

9506.29

The Department may waive the verification required under this section for exceptional circumstances.

9506.30

In accordance with the District Verification Plan, exceptional circumstances shall include:

(a) Homelessness;

(b) Domestic violence;

(c) Employer moved to another state or country;

(d) Business closed;

(e) Employer will not release information;

(f) Self-employed individuals who cannot produce documentation of income; or

(g) Other circumstances as identified on a case-by-case basis and approved by the Department.

9506.31

An individual whose income exceeds the applicable limit due to the application of the formula for qualified lottery winnings and qualified lump sum income, as described in subsection 9506.15(p)(1), may continue to be eligible to the extent the Department determines that the denial of eligibility of the individual would cause an undue medical or financial hardship as determined on the basis of criteria as may be established by the Secretary of the U.S. Department of Health and Human Services.

D.C. Mun. Regs. tit. 29, r. 29-9506

Final Rulemaking published at 62 DCR 11142 (8/14/2015); amended by Final Rulemaking published at 69 DCR 11768 (9/30/2022); amended by Final Rulemaking published at 69 DCR 12065 (10/7/2022); amended by Final Rulemaking published at 70 DCR 15109 (11/17/2023)