La. Admin. Code tit. 48 § V-5101

Current through Register Vol. 50, No. 11, November 20, 2024

Section V-5101 - Eligibility Criteria

A. Eligibility shall be based on two factors, medical eligibility and financial eligibility. This determination shall be made by the designated statewide CSHS Regional Staff . To be eligible to receive direct medical services, the applicant:

1. must reside in the State of Louisiana;

2. must not have reached his/her 21st birthday;

3. must have a condition for which the Program provides treatment services and must be reasonably expected to benefit from the services;

4. must be a member of a family who meets the financial eligibility criteria to receive services. Financial eligibility is based upon three (3) criteria; family size, income(s) and resource(s). All three criteria must be met in order for an applicant to be financially eligible.

a. Family Size. Family size shall be defined as the number of persons living together and related to the applicant by blood, marriage and/or legal adoption and supported by reported income. Foster parents are not to be counted as family members. If a child is in a foster placement and is in the custody of the Department of Health and Hospitals, or Department of Social Services, he shall be considered a family of one.

i. In situations of divorce, blended families, etc., the legal custody decree shall be considered as the rule in determining family size and income.

ii. A parent or step-parent required by a legal custody decree to pay child support to a child/children residing outside the family home is allowed to subtract the amount of the annual child support payment from the applicant's family gross income.

iii. Unusual family situations will be forwarded in writing to the CSHS Administrative Unit for consideration.

b. Family Income. Family income shall be defined as the total annual cash receipts from all sources before taxes. (Income data for a part of a year may be annualized in order to determine eligibility -for example, multiply by four the amount of income received during the most recent three months). Income includes money, wages, and salaries before any deductions, but does not include food or rent received in lieu of wages. Income also includes regular payments from Social Security, Railroad Retirement, unemployment compensation, strike benefits from union funds, veterans benefits, public assistance (including Aid to Families with Dependent Children and Supplement Security Income), alimony, child support, and military family allotments or other regular support from an absent family member or someone not living with the family, private pension, government employee pensions, cash gifts, regular insurance or annuity payments, and income from dividends, interest, rent, royalties, or periodic receipts from estates or trusts.

i. Excluded from family income are non-cash benefits, such as employer or union paid health insurance or other fringe benefits, food or rent received in lieu of wages, the value of food produced and consumed on farms, and state entitlement programs such as Family Subsidy,(Cash Subsidy, Family Support).

ii. Accumulated family medical payment for bills not paid by insurance for the previous 12 months will be deducted from the annual income before eligibility is determined. The annual medical insurance premium paid by the family will also be subtracted from the gross income.

iii. All income must be verified by check stubs, previous year federal income tax form, statement from employer, and/or, upon request, other appropriate documents.

c. Family Resource. Family resources shall be defined as assets or possessions which a family can apply (directly or by sale or conversion) to meet needs. Resources for consideration in determining resource eligibility are as follows:

i. bank accounts (checking and savings; joint and individual);

ii. promissory notes;

iii. time deposits;

iv. mortgages held by applicant and/or family( only those from which income is derived);

v. mutual fund shares;

vi. municipal, corporate and government bonds/stocks;

vii. excess property (other than primary home);

viii. undivided estate ( if the disposing of property is not within the control of the family, then it will not be considered);

ix. trust;

x. mineral rights;

xi. power-driven conveyances (not used in business, farming or other income producing activity. If the vehicle is not used for necessary transportation, it is considered personal property countable at equity value. Examples are motor homes, trailers, campers and boats.) The family is allowed two vehicles per family unit;

xii. lump sum settlements (structured or lump), awards or winnings;

xiii. crops in storage;

xiv. IRA and Keogh Plans (when another retirement option is also available). Resources include assets held individually or in joint names to which the family has unrestricted access.

d. Resource exclusions are as follows:

i. burial insurance and/or funds set aside for burial

ii. term life insurance;

iii. home and contiguous property;

iv. vehicle(s) used for necessary transportation;

v. Resources to which a person rather than the family holds the usufruct, i.e. designated trust.

e. The maximum allowable resource limits for CSHS are as follows:

i. $4,000 for individual;

ii. $5,000 for two;

iii. $6,000 for three;

iv. add $1,000 for each additional family member.

B. Medical Category Number. Medical category number is defined as the value of 1,5, or 10 used in the determination of financial eligibility to reflect the relative costliness of the medical condition of the child. A Medical Category Number is assigned only after the child is determined to have a condition which can be treated by CSHS. This number enables children who have conditions with the highest medical costs to be considered the highest priority for treatment. The CSHS medical category numbers are defined in Table I.

C. CSHS Regional Staff will determine the total gross income (resource and family income) of the applicant's family by completing a Family Income and Resource Worksheet with responses and documentation supplied by the applicant, parent(s) and/or guardian(s). The completed worksheet will be reviewed for correctness of documentation and signed as indicated.

D.

1. The CSHS Family Income and Resource Worksheet Form is included as Exhibit I. A formula is used to calculate the Eligibility Determination Value. The three components of the formula are:

a. Family Income

b. Family Size

c. Medical Category Number

2. The formula is as follows:

Family Income

-Family size

+ Medical Category Number

Eligibility Determination Value

Establish Baseline Number as follows:

Family income in thousands--less:

a. child support payments;

b. annual medical insurance premium;

c. out of pocket medical payments for previous 12 months

Example: If the family income is $15,000, use 15 as baseline number.

If the family income is $15,500, use 16. ($500 or more, use the next higher number)

Subtract: Family Size

Example: Family of six with income of $15,500 whose child has Cystic Fibrosis with no countable resources.

Add: Medical Category Number (See Table I) Calculation Example:

Baseline Number 16

Less Family Size -6

Medical Category Number +1

Eligibility Determination Value 11

d. Any family that has an Eligibility Determination Value of less than 25 and meets the resource eligibility criteria will be financially eligible for CSHS. Applicants possessing a valid Medicaid card are automatically financially eligible for CSHS.

e. Insurance Coverage. CSHS will seek financial reimbursement for services rendered to families with medical insurance. A family failing to sign an Assignment of Insurance Benefits form (Exhibit II) and/or failing to complete application for other funding sources and Medicaid will be denied services or discharged from the program.

La. Admin. Code tit. 48, § V-5101

Promulgated by the Department of Health and Human Resources, Office of Preventive and Public Health Services, LR 13:246 (April 1987), amended by the Department of Health and Hospitals, Office of Public Health, LR 15:10 (October 1989, amended by the Department of Health and Hospitals, Office of Public Health, LR 22:362 (May 1996).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:31.2, R.S. 40:1299. 111-120, and Title XIX, Public Health Service Act, §1905