Neb. Admin. Code tit. 477 — Medicaid Eligibility

Chapter 1 General Definitions

Neb. Admin. Code tit. 477, ch. 1 General Definitions {#sec-477-nac-1 omnilex-key=us-ne-regs-official--title-477--477 NAC 1}

TITLE 477 MEDICAID ELIGIBILITY

CHAPTER 1 GENERAL DEFINITIONS

001. SCOPE AND AUTHORITY. These regulations govern the services provided under Nebraska’s Medicaid program as defined by the Medical Assistance Act, Nebraska Revised Statute § 68-901 et seq.

002. DEFINITIONS.

002.01 ABSENT PARENT. A parent who is not living with his or her child(ren).

002.02 ADEQUATE NOTICE. Notice of case action, which includes a statement of what action(s) are intended, the reason(s) for the intended action(s), and the specific manual reference(s) that supports or the change in federal or state law that requires the action(s).

002.03 AFFORDABLE CARE ACT (ACA). The Patient Protection and Affordable Care Act of 2010, as amended by the Health Care and Education Reconciliation Act of 2010, as amended by the Three Percent Withholding Repeal and Job Creation Act.

002.04 A-NUMBER. Alien registration number, which is assigned to a noncitizen when he or she enters the United States.

002.05 APPLICANT. An individual who is seeking an eligibility determination through submission of an application or a transfer from another agency or insurance affordability program.

002.06 APPLICATION. A request for Medicaid benefits submitted by an applicant or his or her authorized representative via a Department-approved format.

002.07 APPLICATION DATE. For new and reopened cases, the date a properly signed application is received.

002.08 APPLICATION SIGNATURE. Applications may be signed in writing, by telephonic signature, or by electronic signature.

002.09 APPLICATION SUBMISSION. Applications may be submitted in person, by mail, by telephone, by fax, or by electronic transmission.

002.10 APPROVAL OR DENIAL DATE. The date that a new or reopened case is determined eligible or denied by the Department.

002.11 ASSIGNMENT. The transfer of a client’s right to third-party resources to the Department, which is accomplished by the submission and approval of an application.

002.12 AUTHORIZED REPRESENTATIVE. A person or organization authorized by an applicant, client, or court of competent jurisdiction to represent the applicant or client in any matter(s) with the Department.

002.13 BUDGET MONTH(S). The calendar month(s) for which verification of eligibility factors is used to compute eligibility.

002.14 CASUALTY. The legal obligation of a third party to indemnify an injured person for damages caused by the third party or for which the third party is otherwise responsible.

002.15 CHILD SUPPORT. Money that is ordered by a court of competent jurisdiction to be paid by a noncustodial parent of behalf of a minor child or money that is paid by a noncustodial parent on behalf of a minor child without a court order.

002.16 CLIENT. An individual who has been determined eligible for and is currently receiving Medicaid.

002.17 COURT OR TRIBAL WARD. A child whose custody is committed to a court or other public agency. In order to receive payment from the Department that is otherwise permitted or required, the court or other public agency must be authorized under state law for the placement and supervision of children, and the court or other public agency must have a written agreement with the Department to ensure that Title IV-E requirements are met.

002.18 COURT ORDER. A document signed by a judge and entered into the court record in a court of competent jurisdiction.

002.19 CREDITABLE HEALTH INSURANCE COVERAGE. Any current health insurance coverage, except a plan that is limited to a single condition, such as cancer insurance, dental insurance, or long-term care insurance. Insurance to which an individual does not have reasonable geographic access is not creditable coverage.

002.20 CURRENT SUPPORT. The monthly amount of child support or spousal support ordered by a court of competent jurisdiction.

002.21 DEEMING. The process of determining the amount of income and resources of a parent or sponsor that must be considered available to meet the client's needs. Deeming does not apply to pregnant women or children.

002.22 DENIAL. A case in which an application was completed, signed, and submitted, but the applicant did not meet eligibility requirements.

002.23 DEPARTMENT. The Nebraska Department of Health and Human Services (DHHS), Division of Medicaid and Long-Term Care (MLTC). The Department is the single state agency designated to administer and supervise the administration of the Medicaid program under Title XIX of the federal Social Security Act, as amended.

002.24 DEPENDENT CHILD. A child from birth through 17 years old; or who is 18 years old and a full-time student in secondary school or equivalent vocational or technical training, if before attaining 19 years of age the child may reasonably be expected to complete school or training.

002.25 DIRECTOR. The director of Medicaid and Long-Term Care.

002.26 DISCHARGED WARD. An individual who has been discharged as a ward of a court or tribe.

002.27 EDUCATIONAL INSTITUTION. A properly licensed or credentialed school, college, university, or vocational or technical training facility.

002.28 EFFECTIVE INCOME LEVEL. The income standard applicable under the State Plan for an eligibility group, after taking into consideration any income disregards applied in determining financial eligibility for the group.

002.29 ELECTRONIC ACCOUNT. An electronic file consisting of information collected or generated by the Department regarding client Medicaid or Children’s Health Insurance Program (CHIP) eligibility and enrollment.

002.30 ELIGIBILITY DETERMINATION. An approval or denial of eligibility, as well as any renewal or termination of eligibility.

002.31 EMANCIPATED MINOR. A child 18 years old or younger who is considered an adult because he or she has:

(A) Married;

(B) Moved away from his or her parent’s(s’) home and is not receiving support from his or her parent(s); or

(C) If a pregnant child, 18 years old or younger, is denied financial support by her parents, guardians, or custodians due to her refusal to obtain an abortion, the pregnant child shall be deemed emancipated for purposes of eligibility, except that benefits may not be used to obtain an abortion.

002.32 FEDERAL POVERTY LEVEL (FPL). The current federal poverty level in effect for the applicable budget period used to determine an applicant’s eligibility or a client’s continued eligibility.

002.33 GUARDIAN OR CONSERVATOR. A person appointed by a court of competent jurisdiction to be in charge of the affairs of another person who cannot effectively manage his or her own affairs because of his or her age or incapacity.

002.34 GUARDIAN AD LITEM (GAL). A person appointed by a court of competent jurisdiction to protect the best interests of a minor or vulnerable adult in a specific legal action.

002.35 HEARING. An administrative proceeding before the Director or his or her designee. During a hearing, a client, applicant, or his or her authorized representative may present evidence with or without the help of witnesses to show why the action as indicated on the relevant Notice of Action or inaction of the Department should be corrected by the Department.

002.36 INCAPACITY (PHYSICAL OR MENTAL). As determined by the Social Security Administration (SSA) or the State Review Team (SRT), any physical or mental illness, impairment, or defect, which is expected to last at least 30 days, that is so severe as to reduce substantially or eliminate a parent's ability to provide support or care for a child(ren). Age itself is not considered incapacity.

002.37 INQUIRY. Any question received by phone, letter, electronically, or personal contact without any indication that the individual wishes to apply. This may or may not be followed by an application for Medicaid.

002.38 IRREGULAR INCOME. Income, earned or unearned, that varies in amount from month to month or that is received at irregular intervals.

002.39 LAWFULLY RESIDING. Qualified alien pregnant women and children who are lawfully present in the United States and who are residents of Nebraska.

002.40 MEDICAID. A joint federal and state program under Title XIX of the federal Social Security Act, as amended, that provides medical assistance to eligible low-income individuals.

002.41 MEDICAL NEED. A condition of eligibility referring to a medical need.

002.42 MEDICAL PAYMENT. Payment from any health insurance plan, individual, or group or entity for medical expenses, whether for a client or any other member of his or her household.

002.43 MEDICAL SUPPORT. The obligation of a noncustodial parent to provide health insurance or pay medical costs.

002.44 MINIMUM ESSENTIAL COVERAGE. Coverage under a specified government-sponsored program, an eligible employer-sponsored plan, a health plan offered in the individual market, a grandfathered health plan, or other health benefits coverage that is recognized by the federal government.

002.45 MINOR PARENT. An individual 18 years old or younger, with a child.

002.46 NON-APPLICANT. An individual who is not seeking an eligibility determination for himself or herself and is included in an applicant’s or client’s household to determine eligibility for the applicant or client.

002.47 NOTICE OF ACTION (NOA). A statement sent by the Department to an applicant, client, or his or her Authorized Representative that includes a reasonably short, plain statement of the action(s) taken by the Department, the factual reason(s) for the action, and reference to the applicable regulatory law(s) or otherwise that authorizes the action(s).

002.48 PARENT OR CARETAKER RELATIVE (PCR). A relative of a dependent child by blood, adoption, or marriage, with whom the child is living, who assumes primary responsibility for the child’s care, and who is one of the following:

(A) The child’s father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece;

(B) The spouse of the parent or relative, even if the marriage is terminated by death or divorce; or

(C) Another relative of the child based on blood, adoption, or marriage, or an adult with whom the child is living and who has provided sufficient documentation of a court-ordered guardianship or conservatorship of the child.

002.49 PENDING. A case in which a complete and signed application has been received and eligibility has not yet been determined by the Department.

002.50 POSTPARTUM PERIOD. The period following the end of a pregnancy, which begins on the last day of pregnancy, then extends 60 days, and ends on the last day of the month in which the 60-day period ends.

002.51 POSTPARTUM PERIOD (EFFECTIVE JANUARY 1, 2024). A continuous 12-month period directly following the end of a pregnancy, which begins on the last day of pregnancy, regardless of the reason the pregnancy ends and extends through the end of the month in which the 12-month period ends.

002.52 POWER OF ATTORNEY (POA). A written and notarized authorization allowing one person to act for another person. The powers granted may be general or may be limited to specific circumstances. A power of attorney (POA) may be durable, in which case the powers continue to exist even if the appointing individual becomes legally incompetent. A power of attorney (POA) ceases to be effective upon the death of the appointing individual.

002.53 PREGNANT WOMAN. A woman during pregnancy and the post-partum period.

002.54 PROSPECTIVE ELIGIBILITY FOR MEDICAL ASSISTANCE. The date of eligibility beginning the first day of the month of the date of application if the client was eligible for Medicaid in that same month.

002.55 REASONABLY COMPATIBLE. For each eligibility factor, except social security number, citizenship, and immigration status, reasonable compatibility shall be applied. Electronic data matches shall be used when applicable and compared to an applicant’s or client’s self-attestation of information.

002.56 RETROACTIVE ELIGIBILITY. The date of eligibility beginning no earlier than the first day of the third month before the month of application.

002.57 SECURE ELECTRONIC INTERFACE. An interface which allows for the exchange of data between Medicaid and insurance affordability programs.

002.58 SPONSOR. A citizen or national of the United States, or an alien who is lawfully admitted to the United States for permanent residence, living in any state or the District of Columbia, who is 18 years of age or older and is petitioning or has petitioned for the admission of a noncitizen(s) under Section 204 of the Immigration and Nationality Act. An organization cannot be a sponsor.

002.59 SPOUSAL SUPPORT. Alimony or maintenance support for a spouse or former spouse.

002.60 STANDARD OF NEED. The maximum standard according to eligible unit size and living arrangement.

002.61 STATE PLAN. The written plan between the Department and the federal government that authorizes and describes how the Department administers Medicaid.

002.62 STUDENT. An individual who is 18 years old or younger and attending a secondary school or the equivalent level of vocational or technical training.

002.63 THIRD-PARTY RESOURCES. The legal obligation of a third party, including certain individuals, entities, insurers, and programs, to pay for or provide monies or benefits. Third-Party Resources include Casualty, Child Support, Medical Payment, Medical Support, and Spousal Support. Medicaid is the payer of last resort.

002.64 TIMELY NOTICE. A notice of case action dated and mailed at least 10 calendar days before the date the action becomes effective.

002.65 UNIT. The number of individuals in a household.

002.66 WITHDRAWAL. A voluntary written or verbal retraction of an application.

History

Effective 2024-09-17

Chapter 2 Overview of Eligibility Requirements

Neb. Admin. Code tit. 477, ch. 2 Overview of Eligibility Requirements {#sec-477-nac-2 omnilex-key=us-ne-regs-official--title-477--477 NAC 2}

2-001 PRIMARY ELIGIBILITY REQUIREMENTS : To be eligible for Medicaid, an individual must satisfy the requirements of the following eligibility criteria, as applicable:

Application;
U.S. citizenship or alien status (see Appendix 477-000-003 and 477-000-004);
Nebraska residence;
Social Security number;
Age (limited to ABD, Former Foster Care, Children, 599 CHIP, Former Ward, Women’s Cancer Program);
Dependent Child;
Relative responsibility;
Assignment of Third-Party Resources;
Cooperation with the Child Support Enforcement Office (see Appendix 477-000-005);
Living arrangement;
Resources (for exceptions see 477 NAC 17-001);
Income (see Appendix 477-000-012); and
Categorical Eligibility Factors.

History

Effective 2018-03-13

Chapter 3 Application Process

Neb. Admin. Code tit. 477, ch. 3 Application Process {#sec-477-nac-3 omnilex-key=us-ne-regs-official--title-477--477 NAC 3}

TITLE 477 MEDICAID ELIGIBILITY

CHAPTER 3 APPLICATION PROCESS

001. SCOPE AND AUTHORITY. These regulations govern the services provided under Nebraska’s Medicaid program as defined by the Medical Assistance Act, Nebraska Revised Statute § 68-901 et seq.

002. INTERVIEW. An interview is not required for a Medicaid application or renewal.

003. APPLICANT AND CLIENT RIGHTS. All applicants and clients have the following rights:

(A) The right to have the Medicaid application process and the Medicaid requirements, responsibilities, and benefits reasonably explained by the Department, including by written translations, oral interpretation, and taglines for individuals with disabilities or limited English proficiency;

(B) The right to have other potential sources of assistance explained by the Department, including, as applicable: income that may be currently or potentially available such as Retirement, Survivors, and Disability Insurance (RSDI), Supplemental Security Income (SSI), or Veterans Affairs (VA) benefits; social and other financial services available through the Department, such as social services, Early Periodic Screening, Diagnosis, and Treatment (EPSDT), and family planning; and receive a referral to other agencies, if appropriate;

(C) The right to have his or her civil rights upheld. No applicant or client may be subjected to discrimination on the grounds of race, color, national origin, sex, age, disability, religion, political belief, or any other classification protected by law;

(D) The right to be offered the opportunity to register to vote;

(E) The right to submit an application or have an application submitted by an authorized representative;

(F) The right to have his or her application and any personal information treated confidentially according to the applicable privacy laws;

(G) The right to receive reasonably prompt action on his or her application which is pending. A determination of eligibility must be made by the Department about an application within 45 days of the date the complete and signed application has been received by the Department; except for applications under the disability category, for which a determination of eligibility must be made within 90 days;

(H) The right to receive adequate notice of any action affecting his or her application or benefit; and

(I) The right to appeal to the Director for a hearing about any action or inaction regarding his or her application, or failure to act with reasonable promptness. Any appeal must be filed with the Department in writing within 90 days of the decision date.

004. APPLICANT AND CLIENT RESPONSIBILITIES. Each applicant or client is required to:

(A) Provide complete and accurate information. State and federal law provides penalties that may include a fine, imprisonment, or both, for persons found guilty of making false

statements or failing to report promptly any changes in their circumstances to obtain assistance or services for which they are not eligible;

(B) Report a change in circumstances no later than 10 days following the change. This includes information regarding:

(i) Change or receipt of a resource including cash, stocks, bonds, or a motor vehicle.

Changes in resources do not apply to clients whose eligibility is determined using

modified adjusted gross income (MAGI)-based methodology;

(ii) Change in unit composition, such as the addition, loss of, or temporary absence of a

unit member;

(iii) Change in residence;

(iv) Living arrangement;

(v) Disability status;

(vi) New employment;

(vii) Termination of employment; or

(viii) Change in the amount of monthly income, including:

(1) All changes in unearned income; and

(2) Changes in the source of employment, in the wage rate, or in employment status, such as part-time to full-time or full-time to part-time.

(a) For reporting purposes, full-time employment is considered at least 30 hours per week. The client must report new employment within 10 days of receipt of the first paycheck, and a change in wage rate or hours within 10 days of the change. To avoid adverse action, a client must prove good cause for any failure to report a change to the Department within 10 days. Unconfirmed statements do not constitute good cause;

(D) Inform the medical provider and the Department of any third-party resources which may be liable for his or her medical expenses, in whole or in part, and cooperate in obtaining these third-party resources;

(E) Enroll in a health plan and maintain enrollment if:

(i) One is available to the client;

(ii) The client is able to enroll on his or her own behalf; and

(iii) The Department has determined enrollment in the plan to be cost effective;

(F) Reimburse to the Department or pay to the provider any third-party resources received directly for services payable by Medicaid;

(G) Pay any unauthorized medical expenses;

(H) Pay any required medical copayment;

(I) Meet the requirements of Managed Care, if applicable; and

(J) Cooperate with state and federal quality control.

005. APPLICATION.

005.01 APPLICATION SUBMITTAL. An application may be submitted by an applicant, an adult member of the applicant’s immediate family, an adult member of the applicant’s tax household, an authorized representative, or if the applicant is a minor or incapacitated, someone acting responsibly for the applicant. A medical provider may submit an application on behalf of an individual whom the provider is treating if the individual is unconscious or otherwise unable to apply and does not have an existing power of attorney or court-appointed individual to apply on his or her behalf. An application may be signed in writing, by telephonic acknowledgment, or by electronic signature. An application may be submitted in person, by mail, by telephone, by fax, or by electronic submission. An application may be taken on behalf of a deceased person, including a miscarriage or a stillborn. If there is no one to represent a deceased person, the administrator of the estate may sign the application.

005.02 APPLICATION DATE. An application is considered valid the date it is received by the Department if it contains the applicant’s name, address, and proper signature of the applicant or authorized representative.

005.03 APPLICATION WITH A DESIGNATED PROVIDER. An applicant or authorized representative may apply for Medicaid with a designated outreach provider or entity which has contracted with the Department to accept Medicaid applications at its location.

005.04 ALTERATIONS. The application, when completed and signed by the applicant or authorized representative, constitutes the applicant’s own statement regarding eligibility. Information may be added to an application up to the decision date.

005.05 WITHDRAWALS. An applicant may voluntarily withdraw an application verbally or in writing, which will be confirmed by the Department sending a Notice of Action to the applicant or authorized representative documenting this voluntary withdrawal.

005.06 NEW APPLICATION. A new application is required after 90 days of ineligibility.

006. AUTHORIZATION FOR INVESTIGATION. The Department may request a release of information from the applicant or authorized representative when it appears information is incorrect or inconsistent, when the client is unable to furnish the necessary information, or for sample quality control verification.

007. RENEWALS. A redetermination of eligibility for continued Medicaid benefits must be completed every 12 months.

007.01 RENEWAL OF ELIGIBILITY FOR MODIFIED ADJUSTED GROSS INCOME (MAGI) PROGRAMS. A renewal of modified adjusted gross income (MAGI)-based eligibility shall be completed on the basis of information available to the Department without requiring information from the individual. Information will only be required from the individual when not available through other sources. If information is not available to complete a renewal, a prepopulated renewal form shall be sent by the Department to the applicant or authorized representative. The completed renewal form and necessary verifications shall be returned within 30 days of the date the renewal form was sent.

007.02 RENEWAL OF ELIGIBILITY FOR NON-MODIFIED ADJUSTED GROSS INCOME (non-MAGI) PROGRAMS. A prepopulated renewal form shall be required every 12 months for non-modified adjusted gross income (non-MAGI) based eligibility renewals.

007.03 RENEWAL FOR SUPPLEMENTAL SECURITY INCOME (SSI) RECIPIENTS. A renewal form is not required at the time of renewal for clients who are receiving Supplemental Security Income (SSI).

007.03(A) RENEWAL DURING NON-PAY SUPPLEMENTAL SECURITY INCOME (SSI) STATUS. A renewal is not required for periodic non-pay status due to an extra pay period in a month.

007.03(B) SUPPLEMENTAL SECURITY INCOME (SSI) CLIENTS ELIGIBLE UNDER 1619(b). Supplemental Security Income (SSI) clients who are determined eligible for Medicaid by the Social Security Administration (SSA) under the provisions of 1619(b) are not required to complete a renewal form, and resources do not need to be verified.

007.04 INCOME REVIEW FOR AGED, BLIND, AND DISABLED (ABD) CLIENTS. For eligibility purposes, a review of income must be completed every 12 months. An income review is completed by the Social Security Administration (SSA) for Supplemental Security Income (SSI) clients, including those placed in 1619(b) status.

007.05 DISABILITY REVIEW FOR AGED, BLIND, AND DISABLED (ABD) CLIENTS. For clients whose disability status is approved by the State Review Team (SRT), a periodic review of the disability determination is required. Reviews of the disability determination are conducted consistent with the relevant portions of the Supplemental Security Income program and 20 Code of Federal Regulations (CFR) Part 416 Subpart I.

007.05(A) REQUIRED DISABILITY REVIEWS. A review of a beneficiary’s disability status will occur in the following circumstances:

(i) The previous determination period has ended;

(ii) The beneficiary was determined disabled as a child, and is now turning age 18;

(iii) The beneficiary begins, or returns, to work, and the income earned is greater than the Substantial Gainful Activity (SGA) amount published by the Social Security Administration (SSA);

(iv) The Department receives credible evidence or reports that the beneficiary is no longer disabled; or

(v) The beneficiary reports that the disability has ended.

007.05(B) REQUIRED DOCUMENTATION. The State Review Team (SRT) requires contemporaneous documentation of a beneficiary’s health condition in order to determine whether the beneficiary meets the disability criteria. The medical documentation must be dated no more than 12 months prior to the date for which a disability determination is requested. The medical documentation must include an examination by a physician or another appropriate provider for the condition or conditions related to the disability determination dated no more than 12 months prior to the date for which a disability determination is requested. A failure to provide all necessary documentation will result in a denial of disability status.

007.05(C) DURATION OF DISABILITY DETERMINATION. The length of time during which a beneficiary is considered to be disabled is dependent on the beneficiary’s medical condition. A shorter time period is assigned if the medical evidence indicates that the beneficiary’s medical condition may improve in order to ensure that the beneficiary continues to meet the disability criteria. The beneficiary’s condition, and length of the disability review period, is re-determined at each review. The review schedule is determined as follows:

(i) A disability review will be conducted every 12 months when the disability may reasonably be expected to improve;

(ii) A disability review will be conducted every three years if the disability is not permanent, but the possibility for medical improvement cannot be accurately predicted; or

(iii) A disability review will be conducted every five years if it is unlikely that the medical condition will improve.

008. CONTINUOUS ELIGIBILITY.

008.01 CONTINUOUS ELIGIBILITY FOR PREGNANT WOMEN. Once a pregnant woman is determined Medicaid eligible, she remains continuously eligible through the post-partum period, regardless of her category of eligibility at the time the pregnancy began. Continuous eligibility does not apply to pregnant women covered during a period of presumptive eligibility.

008.02 CONTINUOUS ELIGIBILITY FOR A NEWBORN. Children born to Medicaid-eligible mothers are deemed eligible for Medicaid and remain Medicaid eligible for one year after birth. For 599 Children’s Health Insurance Program (CHIP), see 477 Nebraska Administrative Code (NAC) 19.

008.03 CONTINUOUS ELIGIBILITY FOR CHILDREN. Children from birth through age 18 are eligible for six months of continuous Medicaid from the date of initial eligibility. Retroactive months do not count in the six months of continuous eligibility unless there is no prospective eligibility. For 599 Children’s Health Insurance Program (CHIP), see 477 NAC 19.

008.03(A) CONTINUOUS ELIGIBILITY FOR CHILDREN (EFFECTIVE JANUARY 1, 2024). Children from birth through age 18 are eligible for one year of continuous Medicaid from the date of initial eligibility. Retroactive months do not count in the one year of continuous eligibility unless there is no prospective eligibility. For 599 Children’s Health Insurance Program (CHIP), see 477 NAC 19.

008.04 CONTINUOUS ELIGIBILITY FOR HOSPITALIZED CHILDREN. Children who are eligible and enrolled in Medicaid and are receiving inpatient services covered by Medicaid on the date they lose eligibility due to age are continuously eligible until the end of their inpatient stay if the child would remain eligible but for attaining such age.

008.05 EXCEPTIONS TO CONTINUOUS ELIGIBILITY. Exceptions to continuous eligibility are:

(A) A child attaining age 19 who does not meet another level of continuous eligibility, such as pregnancy or hospitalization;

(B) The individual requests voluntary termination;

(D) The agency determines that eligibility was determined incorrectly at the most recent determination or redetermination of eligibility because of agency error or fraud, abuse, or perjury attributed to the individual; or

(E) The individual dies.

History

Effective 2024-09-17

Chapter 4 Effective Date of Medicaid Eligibility

Neb. Admin. Code tit. 477, ch. 4 Effective Date of Medicaid Eligibility {#sec-477-nac-4 omnilex-key=us-ne-regs-official--title-477--477 NAC 4}

001. SCOPE AND AUTHORITY . These regulations govern the services provided under Nebraska’s Medicaid program as defined by the Medical Assistance Act, Nebraska Revised Statute § 68-901 et seq.

002. EFFECTIVE DATE OF MEDICAID ELIGIBILITY . If an individual is eligible one day of the month, he or she is eligible the entire month.

002.01 EFFECTIVE DATE EXCEPTIONS. This provision does not apply to the following groups:

(A) Emergency Medical Services Assistance (EMSA). Individuals eligible under this category are eligible only for the dates of the determined emergency medical condition;

(B) Presumptive eligibility begins on the date the provider completes a presumptive eligibility determination; and

(C) Individuals who are inmates of a public institution and meet inpatient status in a medical institution as defined by 42 Code of Federal Regulations (CFR) 435.1010 are only eligible for the dates of a qualifying inpatient stay.

003. RETROACTIVE ELIGIBILITY . The effective date of Medicaid can be determined up to three months prior to the month of application when the following conditions are met:

(A) Eligibility is determined and a budget computed separately for each of the three months;

(i) An applicant may be eligible for any or all months of the retroactive period even though ineligible for the prospective period. Continuous eligibility may begin in a retroactive month.

(B) A medical need exists; and

History

Effective 2020-07-29

Chapter 5 Citizenship/Alien Status and Identity

Neb. Admin. Code tit. 477, ch. 5 Citizenship/Alien Status and Identity {#sec-477-nac-5 omnilex-key=us-ne-regs-official--title-477--477 NAC 5}

001. SCOPE AND AUTHORITY . These regulations govern the services provided under Nebraska’s Medicaid program as defined by the Medical Assistance Act, Nebraska Revised Statute § 68 901 et seq.

002. CITIZENSHIP AND ELIGIBLE NON-CITIZENS . In order to be eligible for Medicaid, an applicant or client must be a citizen of the United States or an eligible non-citizen. Citizenship or non-citizen status must be verified through acceptable documentation, as defined by federal regulations. The following individuals meet the criteria for citizenship or eligible non-citizen status:

(A) Citizens or nationals of the United States. A child born in the United States is a United States citizen. A newborn who was determined to be eligible for Medicaid in the month of birth meets citizenship and identity requirements without further verification, including newborns whose birth expenses were paid for Emergency Medical Services Assistance (EMSA) for non-citizens;

(B) Qualified non-citizens as defined in Section 431 of the Immigration and Nationality Act (INA):

(i) A non-citizen who was admitted as a lawful permanent resident (LPR) and has resided in the United States for at least five calendar years from the date of entry, or who has worked or can be credited with 40 qualifying quarters of work. Medicaid-eligible pregnant women and children are exempt from the five year bar;

(ii) A refugee admitted to the United States under Section 207 of the Immigration and Nationality Act (INA);

(iii) An asylee under Section 208 of the Immigration and Nationality Act (INA);

(iv) Victims of a severe form of trafficking, as indicated in the Victims of Trafficking and Violence Protection Act of 2000);

(v) A non-citizen whose deportation is withheld under Section 243(h) of the Immigration and Nationality Act (INA);

(vi) A non-citizen from Cuba or Haiti who was admitted under Section 501(e) of the Refugee Education Assistance Act of 1980;

(vii) A refugee who entered the U.S. before April 1, 1980, and was granted conditional entry;

(viii) A non-citizen who has been battered or subjected to extreme cruelty in the United States by a spouse or a parent, or by a member of the spouse’s or parent’s family who is residing in the same household as the non-citizen, but only after having resided in the United States for at least five calendar years from the date of entry or who has worked or can be credited with 40 qualifying quarters of work. The child of a battered non-citizen meeting these requirements is also eligible. Medicaid-eligible pregnant women and children are exempt from the five year bar;

(D) An Amerasian immigrant under Section 584 of the Foreign Operations, Export Financing, and Related Programs Appropriations Act, 1988, as amended;

(E) A non-citizen with past or current military involvement, defined as a non-citizen veteran who is on active duty, other than active duty for training, with any of the United States Armed Forces units or who has been honorably discharged and who has fulfilled minimum active-duty service requirements. Minimum active duty is defined as at least 24 months or the period for which the person was called to active duty. The spouse or unmarried dependent child of a non-citizen veteran as described in this paragraph is also eligible;

(F) Certain American Indian tribe members born in Canada or outside the United States, or who are a member of an Indian tribe; or

(G) A non-citizen who is paroled into the United States under Section 212(d)(5) of the Immigration and Nationality Act (INA), but only after having resided in the United States for at least five calendar years from the date of entry or who has worked or can be credited with 40 qualifying quarters of work.

003. MEDICAID FOR CERTAIN CHILDREN AND PREGNANT WOMEN . A child or pregnant woman may be eligible if he or she is a Nebraska resident and is lawfully present in the United States. A child or pregnant woman is considered lawfully present if he or she is:

(A) A qualified non-citizen as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (8 U.S.C. § 1641);

(B) A non-citizen in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission;

(C) A non-citizen who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and Nationality Act (INA) (8 U.S.C. §1182(d)(5)) for less than one year, except for a non-citizen paroled for prosecution, deferred inspection, or pending removal proceedings;

(D) A non-citizen who belongs to one of the following classes:

(i) Non-citizens currently in temporary resident status, pursuant to section 210 or 245A of the Immigration and Nationality Act (INA) (8 U.S.C. §§1160 or 1255a, respectively);

(ii) Non-citizens currently under temporary protected status, pursuant to section 244 of the Immigration and Nationality Act (INA) (8 U.S.C. §1254a), and pending applicants for temporary protected status who have been granted employment authorization;

(iii) Non-citizens who have been granted employment authorization under 8 CFR 274 a.12(c)(9), (10), (16), (18), (20), (22), or (24);

(iv) Family Unity beneficiaries pursuant to section 301 of Pub.L. 101-649, as amended;

(v) Non-citizens currently under Deferred Enforced Departure (DED), pursuant to a decision made by the President;

(vi) Non-citizens currently in deferred action status, not including Deferred Action for Childhood Arrival (DACA); or

(vii) Non-citizens whose visa petition has been approved and who have a pending application for adjustment of status;

(E) A non-citizen who has a pending application for asylum under section 208(a) of the Immigration and Nationality Act (INA) (8 U.S.C. § 1158) or for withholding of removal under section 241(b)(3) of the Immigration and Nationality Act (INA) (8 U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 who has had an application pending for at least 180 days;

(F) A non-citizen who has been granted withholding of removal under the Convention Against Torture;

(G) A child who has a pending application for Special Immigrant Juvenile status, as escribed in section 101(a)(27)(J) of the Immigration and Nationality Act (INA) (8 U.S.C. §1101(a)(27)(J));

(H) A non-citizen who is lawfully present in the Commonwealth of the Northern Mariana Islands, under 48 U.S.C. § 1806(e); or

(I) A non-citizen who is lawfully present in American Samoa, under the immigration laws of American Samoa.

004. INELIGIBLE NON-CITIZENS . Non-citizens who do not meet these requirements may be eligible for emergency medical services only.

005. VERIFICATION OF CITIZENSHIP AND NON-CITIZEN STATUS . When an applicant or clients states one or more of the unit members is a non-citizen, the applicant or client is required to present verification for each non-citizen member. The non-citizen status must be verified using the Federal Data Services hub. If the hub is not available to verify citizenship and non-citizen status, the Systematic Alien Verification for Entitlements Program System of Records (SAVE), or receipt of Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), or Medicare is sufficient proof of citizenship or lawfully admitted non-citizen status.

005.01 FAILURE TO COOPERATE. If the applicant or client fails to cooperate in providing documentation, the applicant or client is ineligible.

006. REASONABLE OPPORTUNITY PERIOD . Applicants or clients who attest to being United States citizens or eligible non-citizens, and meet all other eligibility requirements must be given a reasonable opportunity to present satisfactory documentation of citizenship or non-citizen status. Medical benefits must not be denied, delayed, reduced, or terminated during the reasonable opportunity period. If the Department has requested verification, such as an out-of-state birth certificate, benefits will not be denied or terminated while awaiting receipt. Once an individual has declared himself or herself a United States citizen or eligible non-citizen and has provided all other information to determine eligibility, benefits must be provided.

006.01 DURATION OF REASONABLE OPPORTUNITY. A 90-day timeframe is given to verify an individual’s attested citizenship or satisfactory non-citizen status if the Department or applicant or client cannot provide verification. A notice will be sent to inform the applicant or client of the reasonable opportunity period. The reasonable opportunity period extends 90 days from the date on which the notice is received by the applicant or client, which means five days after the date of the notice unless the applicant or client shows he or she did not receive the notice within the five-day period. If citizenship or immigration status has not been verified by the end of the reasonable opportunity period, Medicaid benefits will be terminated. If the individual appeals the case closure, the Medicaid case is not subject to reinstatement pending the outcome of a fair hearing. The reasonable opportunity period encompasses all aspects of the process to verify citizenship or immigration status, including not only time for an individual to provide documentation but also time for the Department to resolve inconsistencies or conclude the electronic verification process.

007. REPATRIATION PROGRAM . The Repatriation Program provides temporary assistance, care, and treatment for up to 90 days for United States citizens or dependents of United States citizens who have returned from foreign countries. To qualify for repatriation assistance, the individual must be returned from a foreign country because he or she is destitute or ill or because of war, threat of war, or a similar crisis. A request must be made by the State Department to the United States Department of Health and Human Services to receive the individual in the United States and to provide the necessary care, treatment, and assistance. The assistance may include reception service, food, shelter, clothing, and transportation. It may also include payment for special services such as medical and psychiatric care. Any assistance provided through General Assistance or Emergency Assistance may be reimbursed through federal funds. Central Office will contact the appropriate local office on all arriving cases. If it appears the individual is eligible for another form of assistance, a referral must be made or an application for categorical assistance must be completed.

007.01 ELIGIBILITY PERIOD. Assistance may be provided for up to 90 days from the date the individual arrives in the United States. If the individual needs assistance beyond 90 days and is not eligible for Retirement, Survivors, and Disability Insurance (RSDI), Supplemental Security Income (SSI), or categorical assistance, the local office shall contact Central Office.

007.02 MEDICAL PAYMENTS. All payments for medical care must be made at rates no higher than those paid by Medicaid.

007.03 REPAYMENT. The individual is required to sign an agreement to repay the cost of the assistance provided.

History

Effective 2020-07-29

Chapter 6 State Residency

Neb. Admin. Code tit. 477, ch. 6 State Residency {#sec-477-nac-6 omnilex-key=us-ne-regs-official--title-477--477 NAC 6}

6-001 RESIDENCE : To be eligible for assistance, an applicant/client must be a Nebraska resident. A resident is an individual living in the state voluntarily with the intent of making Nebraska his/her home. Residence starts with the month the applicant/client moves into the state, even if the applicant/client received categorical assistance in another state.

6-002 RESIDENCE OF APPLICANTS ENTERING THE STATE INTO A LICENSED HOME : The intent of an applicant to establish Nebraska residence must be investigated if the applicant comes into the state and immediately enters a home licensed by the Nebraska Department of Health and Human Services, Division of Public Health (nursing home or alternate care facility).

To determine the applicant’s intent to establish residence in Nebraska, the applicant’s purpose for entering the state must be considered.

The applicant is a Nebraska resident if his/her purpose for entering the state was because s/he

Desired to be near to close friends or relatives in the state;
Previously resided in the state; or
Has other contacts in the state.

If none of these conditions exist, the applicant’s intent to establish residence shall be evaluated by the Department. If the applicant states that s/he plans to establish residence, but the situation seems to indicate otherwise, other factors are reviewed, including when the applicant entered the state, whether the applicant maintains a residence or owns property (including real and/or personal property) in another state, and the place of residence of the applicant’s spouse and other immediate family members, if any.

Relevant factors to take into consideration include if the applicant was eligible for Medicaid in the state in which s/he previously resided, how the applicant was referred to the facility in Nebraska, and where the applicant would reside if s/he moved out of the facility in Nebraska, and any other related factors.

6-003 NON-INSTITUTIONALIZED APPLICANTS/CLIENTS

6-003.01 Age 21 and Over: For applicants/clients who are not residing in an institution and who are not capable of indicating intent, the state of residence is the state where the applicant/client is living.

6-003.02 If an applicant/client is under age twenty-one (21), not emancipated or married, and not Title IV-E eligible, the state of residence is the state where the individual resides, including

With or without a fixed address; or
The state of residency of the parent or caretaker.

6-003.03 Any Age

6-003.03A For an individual who is capable of indicating intent and who is emancipated or married, the state of residence is the state where the individual is living, and

Intends to reside, including without a fixed address; or
Has entered with a job commitment or seeking employment, whether or not currently employed.

6-003.04 Incapable of Indicating Intent: An applicant/client who is not institutionalized and is incapable of indicating intent is considered a resident of the state in which the individual is living if one of the following is met:

His/her I.Q. is 49 or less or s/he has a mental age of seven (7) or less, based on tests acceptable to the developmental disability agency in the state;
S/he is judged legally incompetent; or
Medical documentation obtained from a physician, psychologist, or other person licensed by the state in the field of developmental disability, or other documentation acceptable to the state, supports a finding that s/he is incapable of indicating intent.

6-003.05 Applicants/Clients Receiving a State Supplementary Payment (SSP): For any applicant/client who is receiving an SSP, the state paying the SSP is the state of residence.

6-003.06 Applicants/Clients Receiving Title IV-E Payments: For applicants/clients of any age who are receiving federal payments for foster care and/or adoption assistance under Title IV-E of the Social Security Act, as amended, the state of residence is the state where the applicant/client lives.

6-004 INSTITUTIONALIZED APPLICANTS/CLIENTS

6-004.01 Institutionalized Applicants/Clients: The state where the institution is located is an institutionalized applicant/client’s state of residence unless it is determined that the applicant/client is a resident of another state, according to the following: For any institutionalized applicant/client who is twenty (20) years old or younger, or who is twenty-one (21) years old or older and became incapable of indicating intent before reaching twenty-one (21) years old, the state of residence is

That of his/her parent(s) or his/her legal guardian at the time of placement, or
That of his/her parent(s) or his/her legal guardian if the applicant/client is institutionalized in that state.

For any institutionalized applicant/client who became incapable of indicating intent at or after reaching twenty-one (21) years old, the state of residence is the state in which the applicant/client is physically present except where another state makes a placement.

6-004.02 Placement in an Out-of-State Institution: If a state arranges for an applicant/client to be placed in an institution located in another state, the state making the placement is the applicant/client’s state of residence, regardless of the applicant/client’s indicated intent or ability to indicate intent.

6-004.03 Discharge from an Out-of-State Institution: When an applicant/client leaves the facility in which the applicant/client is placed by a state, that applicant/client’s state of residence is the state where the applicant/client is physically located.

6-005 ABSENCE

6-005.01 Absence From the State: The Department may not deny assistance because an individual has not resided in the state for a specified period.

6-005.02 Temporary Absence: The Department may not deny or terminate eligibility due to an applicant/client’s temporary absence from the state, if the applicant/client intends to return. A temporary absence is ninety (90) days or less, except in extraordinary circumstances.

6-006 LOSS OF STATE RESIDENCE : Eligibility is terminated if the family unit leaves Nebraska with the intent of establishing its home in another state.

History

Effective 2018-03-13

Chapter 7 Age and Date of Birth

Neb. Admin. Code tit. 477, ch. 7 Age and Date of Birth {#sec-477-nac-7 omnilex-key=us-ne-regs-official--title-477--477 NAC 7}

7-001 AGE REQUIREMENT/AGE LIMIT : To be eligible for Medicaid or 599 CHIP, an applicant/client must meet the age requirements for the applicable Medicaid category.

For age requirements for Children’s Medicaid, see 477 NAC 19-003.01 and 477 NAC;
For 599 CHIP, see 477 NAC 19-004.04;
For Former Ward, see 477 NAC 19-005.02;
For Former Foster Care, see 477 NAC 27-007;
For Aged, Blind, and Disabled (ABD), see 477 NAC 27-001.01 and 477 NAC 24-001.07A;
For Women’s Cancer Program, see 477 NAC 27-004.02; and
For Medically Needy see 477 NAC 27-005.02 and 477 NAC 27-005.02A.

7-002 EFFECTIVE BIRTH DATE IF INFORMATION IS INCOMPLETE : When birth information is incomplete, see Appendix 477-000-004 for the Verification Plan.

7-003 VERIFICATION OF AGE : If age is a factor for eligibility, an applicant’s/client’s age must be verified, see Appendix 477-000-004 for the Verification Plan.

History

Effective 2018-03-13

8-001 REQUIREMENT OF A SOCIAL SECURITY NUMBER : Each applicant for or recipient of Medicaid is required, as a condition of eligibility, to

Furnish his/her Social Security number (SSN); or
Apply for an SSN with the Social Security Administration (SSA), if one has not been issued or is not known.

The SSN, in conjunction with other information, provides evidence of identity of the individual.

8-002 EXCEPTION TO REQUIREMENT OF AN SSN : If an applicant/client refuses to obtain an SSN for a well-established religious objection, the Department may assign the individual a unique Medicaid identification number as an alternative.

8-002.01 Well-Established Religious Objection: An individual

Is a member of a recognized religious group or division of the group; and
Adheres to the tenets or teachings of the group or division of the group, and for that reason is conscientiously opposed to applying for or using a national identification number.

8-003 APPLICATION FOR AN SSN : An applicant who has not previously applied for an SSN shall be given ninety (90) days from the date of application to verify that he/she has submitted an application with the SSA. An applicant shall not be eligible after the ninety (90)-day period unless verification of the application is received.

8-004 ASSISTANCE PENDING VERIFICATION : After the applicant/client has been referred to SSA, if s/he is otherwise eligible, assistance shall not be delayed, denied, or discontinued pending the verification or assignment of an SSN.

8-005 APPLICATION FOR A NEWBORN : An SSN is not an eligibility requirement through the month a child turns one (1) if Nebraska Medicaid paid for the birth.

8-006 INDIVIDUALS NOT SEEKING MEDICAID : An individual not seeking Medicaid assistance shall not be required to provide or apply for an SSN.

History

Effective 2018-03-13

Chapter 9 Notification

Neb. Admin. Code tit. 477, ch. 9 Notification {#sec-477-nac-9 omnilex-key=us-ne-regs-official--title-477--477 NAC 9}

001. SCOPE AND AUTHORITY . These regulations govern the services provided under Nebraska’s Medicaid program as defined by the Medical Assistance Act, Nebraska Revised Statute § 68-901 et seq.

002. TYPES OF NOTICES .

002.01 ADEQUATE NOTICE. An adequate notice must include a statement of what action is intended, the reason for the intended action, and the specific supporting manual reference or the change in federal or state law that requires the action. An adequate notice must be sent no later than the effective date of the action.

002.02 TIMELY NOTICE. A timely notice must be sent by the Department to the applicant, client, or his or her authorized representative at least ten calendar days before the date the action becomes effective, which is always the first day of the month.

002.03 ADEQUATE AND TIMELY NOTICE. In cases of intended adverse action the client must be given both adequate and timely notice. Adverse action includes action to discontinue, terminate, suspend, or reduce assistance; to change the manner or form of assistance; or to change service provision to a more restrictive method.

003. SITUATIONS REQUIRING ADEQUATE NOTICE ONLY . In the following situations, timely notice does not apply, however, adequate notice must be sent no later than the effective date of action:

(A) The Department has factual information confirming the death of the client;

(B) The Department receives a written and signed statement from the client:

(i) Stating that assistance is no longer required; or

(ii) Giving information that requires termination or reduction of assistance, and indicating, in writing, that the client understands the consequence of supplying the information;

(C) The client has been admitted or committed to an institution and no longer qualifies for Medicaid. This does not apply to individuals who remain eligible in suspended status;

(D) The client has been placed in skilled nursing care, intermediate care, long-term hospitalization, or Assisted Living Waiver;

(E) The client's whereabouts are unknown, and mail directed to the client has been returned by the post office indicating no known forwarding address;

(F) It has been established the client has been accepted for assistance in another state; or

(G) A change in the level of medical care.

004. WAIVER OF NOTICE . If a client agrees to waive his or her right to a timely notice in situations requiring timely notice, a statement signed by the client must be obtained and filed in the case record.

005. FRAUD CASES . At least five days’ advance written notice must be given if:

(A) The Department has facts indicating that action should be taken to discontinue, terminate, or reduce assistance because of probable fraud by the client; and

(B) The facts have been verified when possible through collateral sources.

History

Effective 2020-07-29

Chapter 10 Fair Hearing Processes

Neb. Admin. Code tit. 477, ch. 10 Fair Hearing Processes {#sec-477-nac-10 omnilex-key=us-ne-regs-official--title-477--477 NAC 10}

001. SCOPE AND AUTHORITY . These regulations govern the services provided under Nebraska’s Medicaid program as defined by the Medical Assistance Act, Nebraska Revised Statute § 68-901 et seq.

002. RIGHT TO FAIR HEARING . Every applicant or client has the right to appeal any action, inaction, or failure to act with reasonable promptness by requesting a fair hearing.

002.01 REASONS FOR APPEAL. The applicant or client may appeal because:

(A) His or her application is denied;

(B) His or her application is not acted on with reasonable promptness;

(D) His or her services are reduced;

(E) His or her Medicaid case is closed;

(F) His or her services are changed to be more restrictive; or

(G) He or she thinks the Department’s action was erroneous.

002.02 CHANGES IN STATE OR FEDERAL LAW. The client is not entitled to a fair hearing when either state or federal law requires automatic case adjustments for classes of clients unless the reason for an individual appeal is an incorrect eligibility determination.

003. REQUEST DATE . The applicant or client must request a fair hearing within 90 days following the date the Notice of Action is mailed.

004. MAINTAINING SERVICES . If an applicant or client submits a request for a fair hearing before the effective date on the Notice of Action, the applicant or client is presumed to have requested the continued receipt of any ongoing assistance pending the appeal decision, unless the applicant or client otherwise indicates.

005. REINSTATING SERVICES . The agency allows for the reinstatement and the receipt of any ongoing assistance pending the appeal decision when timely notice is not given and a fair hearing is requested within 10 days from the date the individual receives the Notice of Action, which is considered to be five days after the date on the notice.

006. FILING AN APPEAL . See 465 NAC 6.

History

Effective 2020-07-29

Chapter 11 Living Arrangements

Neb. Admin. Code tit. 477, ch. 11 Living Arrangements {#sec-477-nac-11 omnilex-key=us-ne-regs-official--title-477--477 NAC 11}

001. SCOPE AND AUTHORITY . The regulations govern the services provided under the Medical Assistance Act, Nebraska Revised Statutes (Neb. Rev. Stat.) §§ 68 901 et seq.

002. DEFINITIONS . The following definitions are used in the administration of Medicaid:

002.01 INPATIENT. A patient who has been admitted to a medical institution on the recommendation of a physician or dentist and is receiving room, board, and professional services in the institution on a continuous 24 hour-a-day basis.

002.02 INSTITUTION. An establishment which furnishes, in single or multiple facilities, food and shelter to four or more persons unrelated to the proprietor and, in addition, provides some treatment or services which meet some need beyond the basic provision of food and shelter.

002.03 INSTITUTION FOR MENTAL DISEASE (IMD). An institution of more than 16 beds which is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases. Such care includes medical attention, nursing care, and related services. Whether an institution is an institution for mental diseases is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such.

002.04 LEVEL OF CARE. A category of living arrangement. Levels of care funded by Medicaid include nursing facility (NF), intermediate care facility for individuals with developmental disabilities (ICF/DD), acute hospital, and institution for mental disease (IMD).

002.05 MEDICAL INSTITUTION. An institution which is organized to provide medical care, including nursing and convalescent care, and has the necessary professional personnel, equipment, and facilities to manage the medical, nursing, and other health needs of patients on a continuing basis in accordance with accepted standards. The institution must be authorized under state law to provide medical care.

002.06 PUBLIC INSTITUTION. An institution which is the responsibility of a governmental unit, or over which a governmental unit exercises administrative control.

002.07 PUBLICLY OPERATED COMMUNITY RESIDENCE. A publicly operated residence to serve no more than 16 residents and provide some services beyond food and shelter, such as social services, help with personal living activities, or training in socialization or life skills. Occasional or incidental medical or remedial care may also be provided.

002.07(A) EXCEPTIONS. The following facilities are not considered publicly operated community residences, even if their accommodations are for 16 or fewer residents:

(i) Residential facilities adjacent to any large institution or multi-purposes complex;

(ii) Education or vocational training institutions;

(iii) Correctional or holding facilities for individuals whose personal freedom is restricted because of a court sentence, holding, or pending disposition; and

(iv) Medical treatment facilities such as hospitals and skilled nursing facilities.

003. LIVING ARRANGEMENTS .

003.01 ELIGIBLE LIVING ARRANGEMENTS. An applicant or client is eligible regardless of his or her living arrangement.

003.01(A) INSTITUTIONALIZED INDIVIDUALS. An inmate of a public institution, as defined by 42 Code of Federal Regulations (CFR) 435.1009, who meets inpatient status in a medical institution, as defined by 42 CFR 435.1010, and who is otherwise eligible may only receive payment for services received during his or her inpatient stay over 24 hours.

003.01(A)(i) EXCEPTION. This does not apply to infants or young children who reside with their mother at the Nebraska Correctional Center for Women.

003.01(B) INSTITUTES OF MENTAL DISEASE (IMD). Psychiatric care is only covered by Medicaid to individuals in an institute for mental disease who are age 21 or younger or age 65 or older. If an individual is receiving treatment in a facility on the individual’s twenty-first birthday, eligibility continues until either release or the month of the twenty-second birthday, whichever is sooner.

003.02 DETERMINING THE NATURE OF AN INSTITUTION. The Department is responsible for determining the public or private nature of an institution, and whether a public institution is one in which otherwise eligible individuals may receive Medicaid.

003.03 CRITERIA FOR DETERMINING PUBLIC NATURE OF INSTITUTIONS. Governmental participation in financial support of an institution, in policy formulation, or in the application of policy to specific situations, is evidence of the public nature control which makes it a public institution. Payment from public funds to, or in support of, individuals in a private institution is not considered governmental participation in support of the institution.

003.04 PRIVATE INSTITUTION AND HOME. The private institution in which a Medicaid applicant or recipient chooses to reside may be a fraternal, benevolent, or charitable institution, or an individual may make plans for living in a home which is privately owned and operated which furnishes shelter, board, and care according to the person’s needs.

003.04(A) ELIGIBILITY IN A PRIVATE INSTITUTION OR HOME. In determining the Medicaid eligibility of a person living in a private institution or home, it is necessary to determine if the person has entered into any agreement with the institution to receive shelter and care in return for a transfer of property, insurance, or other assets. It is also necessary to determine what the institution is able to furnish its residents from its own resources. The individual may be eligible to receive Medicaid if residing in a facility if the terms of the individual’s stay do not in any way restrict the use of personal assets or income and if the individual has a medical need.

003.05 PATIENTS IN A MEDICAL INSTITUTION. Medicaid may be provided for a person who is a patient in a medical institution if all other eligibility factors are met. Psychiatric wards of medical hospitals are considered part of the medical institution and are not subject to the restriction on psychiatric care for individuals in an institute for mental disease (IMD).

003.06 MEDICAID APPROVED PROVIDERS. In order to receive Medicaid payment, an institution, whether public or private, must be a Medicaid approved provider and have signed a Medicaid provider agreement in accordance with 471 of the Nebraska Administrative Code (NAC).

004. ABSENCE .

004.01 ABSENCE BECAUSE OF SCHOOLING. The child's absence from home for the purpose of attending school does not affect eligibility.

004.02 TEMPORARY ABSENCE FROM THE HOME. A child is still considered part of the household while he or she is out of the home for a visit not to exceed three months. A child is still considered part of the original household while he or she is on summer visitation.

004.03 TEMPORARY ABSENCE DUE TO EMERGENCY SITUATIONS. In emergency situations which deprive a child of the care of a parent relative, guardian, or conservator, temporary plans may be made to care for the child in the home of an individual or institution acting in the place of the caretaker. The unit may continue to receive assistance for the period of the emergency or the time actually required to make new arrangements for care, but the assistance must not continue beyond three months.

004.04 CONVALESCENT LEAVE. Eligibility for individuals on convalescent leave or visit from public medical institutions is determined in accordance with the applicable program standards. Eligibility is based on an individual’s living situation and needs while on leave.

History

Effective 2020-07-29

Chapter 12 Third-Party Resources and Child Support Enforcement

Neb. Admin. Code tit. 477, ch. 12 Third-Party Resources and Child Support Enforcement {#sec-477-nac-12 omnilex-key=us-ne-regs-official--title-477--477 NAC 12}

12-001 ASSIGNMENT OF THIRD PARTY RESOURCES : See 471 NAC 3-004.

The assignment of third-party resources gives the Department the right to pursue and receive payments from any third party liable to pay for the cost of medical care and services for the client or for any other household member, and which otherwise would be covered by Medicaid. The assignment of the rights to third party medical payments is effective with the date of Medicaid eligibility.

For Medicaid cases with a share of cost, the assignment becomes effective the first day of the month when the case status changes to "Share of Cost Met."

For third party payments received directly see Appendix 477-000-015.

12-001.01 Third-Party Payments Not Assigned: The following third-party payments are not subject to the automatic assignment provision:

Medicare benefits; and
Payments from income-producing policies that subsidize the client’s income while s/he is hospitalized or receiving care, regardless of the type of medical service being provided.

12-002 CLIENT COOPERATION

12-002.01 Client Cooperation Required: As a condition of eligibility, a client must cooperate in obtaining third-party resources unless s/he has good cause for noncooperation. Cooperation includes any or all of the following:

Providing complete information regarding the extent of third-party resources that s/he or any other household member has or may have. This includes coverage provided by a person not in the household or by an agency;
Providing any additional information or signing claim forms that may be necessary for identification and collection of potential third-party payments;
Appearing as a witness in a court or another proceeding, if necessary;
Notifying the Department of any action s/he is initiating to recover money from a liable third-party for medical care or services. This includes the identity of the third-party, as well as the entire amount of any settlement, court award, or judgment;
Reimbursing the Department or paying to the provider any payments received directly from a third-party for any services payable by Medicaid; and
Taking any other reasonable steps to secure payments

Noncooperation by the client is failure or refusal by the client to fulfill these requirements. Pregnant women are not exempt from these requirements.

12-003 OPPORTUNITY TO CLAIM GOOD CAUSE

12-003.01 Notification of Right: The client must be notified of the right to claim good cause for noncooperation at the time of application, renewal, and whenever cooperation becomes an issue.

12-003.02 Good Cause Exemption: See 466 NAC 3-003.

12-003.03 Delay Pending Determination: The Department must not deny, delay, or discontinue Medicaid pending a determination of good cause if the client has complied with the requirements of providing acceptable evidence or other necessary information.

12-003.04 Review of Good Cause: At the time of each eligibility renewal, a good cause claim must be reviewed based on a circumstance that is subject to change. If circumstances remain the same, no action is required. A new determination is necessary if circumstances have changed. If good cause no longer exists, the requirement to cooperate must be enforced.

12-004 SANCTION FOR REFUSAL TO COOPERATE : If the client fails or refuses to cooperate and there is no good cause shown, the appropriate sanction must be applied. If the reason for noncooperation is the client's failure or refusal to provide information about or obtain third-party resources, the client is ineligible. Eligibility of dependent child(ren) is not affected. Ineligibility continues for the client until s/he cooperates or cooperation is no longer an issue.

12-004.01 Pregnant Women and Noncooperation: If a pregnant woman refuses to cooperate in obtaining third-party resources and there is no good cause claim or determination, the appropriate sanction is applied.

12-005 THIRD-PARTY RESOURCES RECEIVED DIRECTLY : If a client receives a third-party resource directly and the medical expense for which the third-party resource is intended is payable by Medicaid, the payment is considered unearned income for Non-MAGI based categories unless reimbursed by the client. If the third-party resource exceeds Medicaid rates, the excess is considered unearned income for Non-MAGI based categories unless paid out on other medical services or supplies. Regardless of the existence of a good cause claim, any third-party resource received directly by the client must be reimbursed. See Appendix 477-000-01

12-006 RECOUPMENT OF THIRD-PARTY RESOURCES :

In order to claim reimbursement for benefits paid by Medicaid that should have been paid by a third-party resource, the Department must send a letter informing the client that s/he must reimburse the Department or the provider. The client is allowed ten (10) days from the date of notification to reimburse the medical payment. For an applicant, the Department must not delay determination of eligibility pending the applicant's reimbursement. At the time the application is approved, the client must be notified of the number of days left in which to reimburse the payment;
If the client tenders the third-Party Resource within the ten (10) days, no further action is taken; or
If the client fails or refuses to refund the third-party resource within the ten (10) days, the entire amount is considered unearned income in the first month possible, taking into account adequate and timely notice. Any balance remaining is considered a resource in the following month.

12-007 WILLFULLY WITHHELD INFORMATION : When evidence reasonably establishes a client willfully withheld information regarding a third-party resource that resulted in an overpayment of Medicaid expenditures, the case must be referred to the Special Investigation Unit (SIU).

Once a case has been referred to SIU, no further action shall be taken with regard to the prosecution of the suspected fraud, except in accordance with instructions or approval by SIU. However, normal case actions must be completed, which include applying the appropriate sanction.

12-008 TERMINATION OF ASSIGNMENT : When a client is removed from the household, the assignment provision is terminated. The client’s rights to any further third-party resources are automatically restored effective with the date of ineligibility. However, the assignment remains in effect for the time period during which the client was receiving Medicaid.

12-009 HEALTH INSURANCE

12-009.01 Cooperation in Obtaining Health Insurance: A client shall enroll in an available health plan if the Department has determined that it is cost effective and the client is able to enroll on his/her own behalf. In those circumstances, the Department pays the premiums, deductibles, coinsurance, and other cost-sharing obligations for this insurance. See Appendix 477-000-016.

12-010 COOPERATION WITH CHILD SUPPORT ENFORCEMENT (CSE) UNIT : Child Support Enforcement Services are provided to a child eighteen (18) years old or younger who has a noncustodial parent(s). See Appendix 477-000-005.

CSE services are not provided for

An unborn child;
A child who is receiving Home and Community-Based Services in the home of both parents; or
An emancipated minor.

12-011 DUTIES OF THE CLIENT : The parent/needy caretaker relative, relative payee, guardian, conservator, or the minor parent of the child for whom aid is claimed is required to cooperate with CSE (unless good cause for refusing to do so is shown).

12-012 OPPORTUNITY TO CLAIM GOOD CAUSE

12-012.01 Notification of Right: The client must be notified at the time of application and whenever cooperation becomes an issue of the right to claim good cause as an exception to the cooperation requirement. The client must be given

A verbal explanation of good cause, and
The opportunity to ask questions.

12-012.02 Good Cause Claimed: If the client claims good cause is present, the Department must

Have the client provide the name and address of the noncustodial parent and forward this information to the CSE Unit;
Have the client provide child/spousal support information and forward this information to the CSE Unit; and
Notify the Title IV-D unit that a good cause claim is pending when the CSE referral is made.

12-012.03 Delay Pending Determination: The Department may not deny, delay, or discontinue Medicaid pending a determination of good cause as an exception to the cooperation requirement if the client has complied with the requirements of providing acceptable evidence or other necessary information.

12-013 SANCTIONS FOR REFUSAL TO COOPERATE : Upon receiving notification from the CSE Unit that an individual refused to cooperate, the individual is no longer eligible for Medicaid. The sanctioned individual remains in the household as financially responsible.

12-013.01 Exceptions for Sanctions for Refusal to Cooperate:

If an individual is age 18 or younger, Medicaid cannot be closed until the end of his/her initial six months of continuous eligibility.
If a minor parent is in the household of his/her active Medicaid parent(s), the minor's parent is responsible for cooperating in obtaining support for the minor's child. The minor’s active Medicaid parent(s) is sanctioned if s/he or the minor does not cooperate.
No sanction is imposed for non-cooperation of a pregnant woman.
No sanction is imposed if at the time non-cooperation began, a child was not in the household of the active Medicaid parent(s).

12-014 OTHER RELATED ELIGIBILITY REQUIREMENTS

12-014.01 Receipt of Other Assistance: An individual who receives Medicaid may not at the same time receive a payment of another type of categorical assistance administered by the Department. This does not preclude a Medicaid client from being the payee for a grant made on behalf of a child in the individual’s care. Assistance from a source other than the Department may be used to supplement but not duplicate assistance for a particular need.

History

Effective 2018-03-13

Chapter 13 Medicaid Benefits Provided in Error

Neb. Admin. Code tit. 477, ch. 13 Medicaid Benefits Provided in Error {#sec-477-nac-13 omnilex-key=us-ne-regs-official--title-477--477 NAC 13}

13-001 MEDICAID BENEFITS PROVIDED IN ERROR : If a client has received Medicaid benefits through misrepresentation or fraud, including because of erroneously reported income, changes in income, or changes in private health insurance premiums, the client is required to repay those benefits.

13-001.01 Fraud or Abuse: If there is reason to believe that a client has defrauded or abused the Medicaid program, the Department shall refer the case to the Special Investigation Unit (SIU) to conduct a full investigation of the claim. Once a case has been referred to SIU, no additional action shall be taken with regard to the prosecution of the suspected fraud, except in accordance with instructions or approval by SIU.

13-001.02 Repayment of Medicaid Benefits Provided in Error: A client who has received Medicaid benefits for which s/he was not eligible due to an error by the Department may choose to make restitution to the Department.

History

Effective 2018-03-13

Chapter 14 Definitions Pertaining to Magi-Based Programs

Neb. Admin. Code tit. 477, ch. 14 Definitions Pertaining to Magi-Based Programs {#sec-477-nac-14 omnilex-key=us-ne-regs-official--title-477--477 NAC 14}

Chapters 477 NAC 14 through 19 apply to the following: Parents/Caretaker Relatives, Children/Children in an IMD/Children and Young Adults Eligible for Non-IV-E Assistance, Pregnant Women, 599 CHIP, Former Wards, and Hospital Presumptive.

599 CHIP: Health care coverage for eligible unborn children of pregnant women who are without pregnancy-related coverage and are otherwise ineligible for Medicaid.

Advanced Payments of the Premium Tax Credits (APTC): A payment of the tax credits that are provided on an advance basis to an eligible individual enrolled in a qualified health plan (QHP) through an Exchange.

Children’s Health Insurance Program (CHIP): Health care coverage for eligible children eighteen (18) years old and younger who are without other health insurance and who do not otherwise qualify for Medicaid.

Family Size Using Modified Adjusted Gross Income (MAGI)-Based Methodology: The number of persons counted as members of an applicant’s/client’s household. When determining the family size of other individuals who have a pregnant woman in their household, the family size is counted as the pregnant woman plus the number of children she is expected to deliver.

Household Size Using MAGI-Based Methodology: The group of individuals who will be included to determine family size for a particular applicant and whose income may be counted toward the applicant’s total household income for purposes of determining his/her eligibility for Medicaid or CHIP.

Household Income Using MAGI-Based Methodology: The sum of an applicant’s/client’s MAGI and the MAGI of tax dependents in the family, if required to file a tax return.

Insurance Affordability Program: A program that is one of the following:

Medicaid, including CHIP or a state basic health program;
Coverage in a qualified health plan (QHP) through the Exchange; or
Advanced Payments of the Premium Tax Credit (APTC) and Cost Sharing Reductions (CSR).

Modified Adjusted Gross Income (MAGI): The methodology used to determine financial eligibility.

Non-Filer: Individuals who do not expect to file a tax return and do not expect to be claimed as a tax dependent for the taxable year.

Tax Dependent: An individual for whom another individual claims a deduction for a personal exemption for a taxable year.

Tax Filer: An individual who intends to file a federal tax return for the coverage year and who is not claimed as a tax dependent by another taxpayer for that tax year.

History

Effective 2018-03-13

Chapter 15 Household or Unit Size for Magi-Based Programs

Neb. Admin. Code tit. 477, ch. 15 Household or Unit Size for Magi-Based Programs {#sec-477-nac-15 omnilex-key=us-ne-regs-official--title-477--477 NAC 15}

15-001 HOUSEHOLD SIZE FOR A TAX FILER : The individual who expects to file a tax return plus all persons whom the individual expects to claim as a tax dependent. See Appendix 477-000-006 on how to construct a Medicaid household.

If an individual does not intend to file an income tax return and do not expect to be claimed as a dependent for the tax year, non-filer rules apply. If the tax filer cannot reasonably establish that another individual is a tax dependent of the tax filer for the tax year in which Medicaid is sought, the inclusion of the individual in the household of the tax filer is determined by using non-filer rules.

15-002 MARRIED COUPLES : In the case of married couples living together or filing jointly, each spouse will be included in the household of the other spouse, regardless of whether they expect to file a joint tax return or whether one spouse expects to be claimed as a tax dependent by the other spouse.

15-003 INDIVIDUAL CLAIMED AS A TAX DEPENDENT : In the case of an individual who expects to be claimed as a tax dependent by a tax filer for the taxable year of an eligibility determination, the household is the household of the tax filer claiming the individual as a tax dependent, except when

The individual expects to be claimed as a tax dependent of someone other than a spouse or a biological, adopted, or step parent;
The individual is under nineteen (19) years old, expects to be claimed by one (1) parent as a tax dependent, and is living with both parents, but the parents are not expected to file a joint return.
The individual is under nineteen (19) years old and expects to be claimed as a tax dependent by a non-custodial parent.

a. To be considered a non-custodial parent, a court order, binding separation, divorce, or custody agreement establishing custody must exist.

b. If no court order exists, or in the event of a shared custody agreement, the custodial parent is the parent with whom the child spends most nights.

c. In the event of a joint custody arrangement, the child’s household includes the individuals listed at 477 NAC 15-005 that reside in either household.

If a tax dependent meets an exception, see Household Size for a Non-Tax Filer at 477 NAC 15-005.

15-004 CHILDREN WHO EXPECT TO FILE BUT DO NOT EXPECT TO BE CLAIMED : When a child under nineteen (19) years old resides with his/her parent(s) and expects to file a tax return, but does not expect to be claimed as a tax dependent by his/her parents(s), non-filer rules shall be applied when constructing the child’s household size.

15-005 HOUSEHOLD SIZE FOR A NON-TAX FILER : The individual and, if living with the individual,

The individual’s spouse;
The individual’s natural, adopted, and step children under nineteen (19) years old; and
In the case of individuals under nineteen (19) years old, the individual’s natural, adopted, and step parents, and natural, adoptive, and step siblings under nineteen (19) years.

15-006 FAMILY SIZE USING MODIFIED ADJUSTED GROSS INCOME METHODOLOGY (MAGI) : The number of persons counted as members of an applicant’s/client’s household. When determining the family size of other individuals who have a pregnant woman in their household, the family size is counted as the pregnant woman plus the number of children she is expected to deliver.

15-007 REASONABLY PREDICTABLE CHANGE IN FAMILY SIZE : See 477 NAC 16-001.03.

History

Effective 2018-03-13

Chapter 16 Income for Magi-Based Programs

Neb. Admin. Code tit. 477, ch. 16 Income for Magi-Based Programs {#sec-477-nac-16 omnilex-key=us-ne-regs-official--title-477--477 NAC 16}

16-001.01 MAGI Income: The sum of MAGI-based income for each member of the applicant’s/client’s household, with the following exceptions (for examples, see Appendix 477-000-006 and 477-000-011):

Income of an individual who is included in the household of his/her natural, adopted, or step parent and is not expected to file a tax return for the taxable year in which eligibility for Medicaid is being determined is not included in household income whether or not the individual files a tax return.
Income of a tax dependent, other than a spouse or biological, adopted, or step-child, who expects to be claimed as a tax dependent by another taxpayer included in the household and is not expected to file a tax return is not included.
Cash support provided by a tax filer to a claimed tax dependent, other than a spouse or biological/adopted/step-child, is not included.

16-001.01A Income Counted for Children Who Expect to File but Who Do Not Expect to Be Claimed: When a child under nineteen (19) years old resides with his/her parent(s) and expects to file a tax return but does not expect to be claimed as a tax dependent by his/her parents(s), non-filer rules shall be applied when constructing the child’s household size. The income of the child’s parents and siblings living with him/her counts in the child’s budget.

16-001.01B Excluded Income for MAGI:

Income exclusions that are allowed under the Internal Revenue Code (see Appendix 477-000-008 for allowable deductions);
An amount received as a lump sum is counted only in the month received;
Scholarships, awards, or fellowship grants used for education, but not living expenses;
Child support;
Veterans benefits (this does not include military retirement);
Workers’ Compensation; and
Other excluded income, see Appendix 477-000-007.

16-001.01C Excluded Income for Native American/Alaskan Native applicant/client:

Distributions from Alaska Native Corporations and Settlement Trusts;
Distributions from any property held in trust, subject to Federal restrictions, located within the most recent boundaries of a prior Federal reservation, or otherwise under the supervision of the Secretary of the Interior;
Distributions and payments from rents, leases, rights of way, royalties, usage rights, or natural resource extraction and harvest from

a. Rights of ownership or possession in any lands from any property held in trust, subject to Federal restrictions, located within the most recent boundaries of a prior Federal reservation, or otherwise under the supervision of the Secretary of the Interior; or

b. Federally protected rights regarding off-reservation hunting, fishing, gathering, or usage of natural resources;

Distributions resulting from real property ownership interests and related to natural resources and improvements

a. Located on or near a reservation or within the most recent boundaries of a prior Federal reservation; or

b. Resulting from the exercise of federally-protected rights relating to such real property ownership interests;

Payments resulting from ownership interests in or usage rights to items that have unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or a traditional lifestyle according to applicable Tribal Law or custom; and
Student financial assistance provided under the Bureau of Indian Affairs education programs.

16-001.02 Monthly Income: Current monthly household income and family size shall be used for individuals who have been determined financially eligible for Medicaid. For family size see 477 NAC 15-000.

16-001.03 Reasonably Predictable Change in Future Income and Family Size: In determining current monthly or projected annual household income and family size, the Department shall include a prorated portion of reasonably predictable future income, to account for a reasonably predictable increase or decrease in future income, or both, as evidenced by a signed contract for employment, a clear history of predictable fluctuations in income, or other clear indicia of such future changes in income or family size.

16-001.04 Five Percent Federal Poverty Level Disregard: A disregard of five percent (5%) of the Federal Poverty Level (FPL) shall be applied when determining eligibility of an individual for medical assistance under the eligibility group with the highest income standard under which the individual may be determined eligible using MAGI-based methodologies.

16-001.05 Reasonably Compatible Regarding Income: Information obtained through an electronic data match must be considered reasonably compatible with income information provided by or on behalf of an individual if both are either above, at, or below the applicable income standard. See Verification Plan at Appendix 477-000-004 for the applicable income standard.

16-001.06 Reasonable Explanation: If information obtained from an electronic data source is not reasonably compatible with an applicant’s/client’s self-attestation, the applicant/client shall be asked for a reasonable explanation. See Verification Plan at Appendix 477-000-004.

16-001.07 Earned Income: Earned income is money received from wages, tips, salary, commissions, and profits from activities in which an individual is engaged as a self-employed person or as an employee. See Appendix 477-000-007 for income chart regarding taxable income.

16-001.07A Contractual Income:

Income paid on a contractual basis is prorated over the number of months covered under the contract, even if the client is paid in fewer months than the contract covers.
Income received intermittently is prorated over the period it is intended to cover if the income is expected to continue.

16-001.07B Disregards for Self-Employment: All operating expenses related to producing goods or services and without which such goods or services could not be produced are deducted from gross income.

16-001.07C Operating Expenses - Farm Income: All expenses related to farm income are considered operating expenses and are allowable deductions.

16-001.08 Unearned Income: Unearned income is any cash benefit that is not the direct result of labor or services performed by the individual as an employee or a self-employed person. See income chart at Appendix 477-000-007.

16-001.08A Spousal Support: Spousal support (alimony) received is considered unearned income. See Appendix 477-000-006 for budgeting.

16-001.08B Delay in Counting RSDI Increase: After the annual Retirement, Survivors, and Disability Insurance (RSDI) cost of living adjustment (COLA), if a client would go from Medicaid only status to Medicaid excess because his/her income exceeds the Federal Poverty Level, the current RSDI amount shall be used. The month after the month that the new FPL figures are published, the client's eligibility shall be determined by comparing the increased RSDI benefit to the new FPL guidelines. The delayed COLA provision applies only if the RSDI increase would cause the client to have excess income. If there is an increase in other unearned income or the client begins receiving other unearned income in the same month as the COLA in RSDI benefits, the delayed COLA provisions do not apply.

16-001.08C Intercepted, Withheld or Garnished Income: If a client’s wages or unearned income is being garnished or intercepted, the gross amount of income before garnishment shall be counted.

16-001.09 Deeming Income for Sponsors of Aliens

16-001.09A Sponsors for Aliens: One hundred percent (100%) of the income of a sponsor (and sponsor’s spouse, if living with the sponsor) shall be considered when determining the eligibility of an alien who applies for Medicaid if the sponsor has signed an affidavit of support under Section 213A of the Immigration and Nationality Act. The sponsor’s income will be considered available to the alien until one or more of the following circumstances apply:

The individual becomes a U.S. citizen;
The individuals has worked forty (40) qualifying quarters of coverage as defined under Title II of the Social Security Act, or can be credited with the qualifying quarters as provided under Section 435 and the alien did not receive any federal means tested public benefit during that time period. This provision does not apply to restricted medical assistance;
The individual is pregnant (including 60 days post-partum); or
The individual is under age 19.

16-001.09B Sponsor of More than One Alien: When an individual is a sponsor for two or more aliens who are living in the same home, the amount of deemed income of the sponsor (and the sponsor’s spouse, if living with the sponsor) is divided equally among the aliens. When an individual sponsors several aliens but not all apply for Medicaid, the sponsor's total deemable income is applied to the needs of the aliens who apply for Medicaid.

16-001.09C Deeming Exception: If a sponsored immigrant demonstrates that s/he or his/her child(ren) have been battered or subjected to extreme cruelty by a spouse, a parent, or by a member of the spouse's or parent's family who is residing in the same household as the alien, deeming may be waived if a judge, an administrative law judge, or the U.S. Citizenship and Immigration Services (USCIS) recognizes the battery or cruelty.

16-001.09D Alien Duties: As an eligibility requirement, an alien is responsible for

Providing income information from the sponsor; and
Obtaining the necessary cooperation from the sponsor.

If an alien does not provide the necessary information, s/he is not eligible for Medicaid.

16-001.10 Potential Income: As a condition of Medicaid eligibility, the Department shall require clients to take all necessary steps to obtain any annuities, pensions, retirement, and disability benefits to which they are entitled.

Annuities, pensions, retirement, and disability benefits include, but are not limited to, veterans’ compensation and pensions, Social Security benefits, railroad retirement benefits, and unemployment compensation.

A client and/or any responsible relative, such as a spouse or parent, is required to apply for any non-Medicaid benefits for which s/he appears to be entitled within 60 days of the date the client is notified of the requirement.

A responsible relative shall be referred for any potential benefit, but there is no sanction applied to the child(ren)’s Medicaid case if the responsible relative fails or refuses to apply.

Determination of eligibility shall not be delayed pending determination of entitlement for potential benefits, so long as the client/responsible relative has applied for such benefits within the 60-day timeframe.

16-001.10A Refusal to Apply for Potential Income: A client is expected to apply for and accept non-Medicaid benefits promptly after the client’s apparent entitlement to such benefits have been discussed.

If a client’s non-Medicaid benefit is terminated for noncompliance, s/he shall be given ten days to make contact to reestablish the benefit. If no contact is made within ten days, Medicaid eligibility cannot be determined.

Income of responsible relatives is still considered in determining the Medicaid eligibility of the client.

16-001.11 Verification of Income: For verification of income see the Verification Plan listed at Appendix 477-00-004. If paper documentation is required, verification of income consists of at least the following:

The source of the income,
The date paid or received,
The period covered by the payment or benefit, and
The gross amount of payment or benefit.

16-001.12 If Paper Documentation is Required for Income Verification

16-001.12A Income Verification

16-001.12A1 At Initial Application: One month of current income is used to determine initial eligibility. Income is converted for weekly and bi-weekly income.

Note: Once eligibility has been determined, no verification is required during the continuous eligibility period.

16-001.12A2 At Renewal: Income must be verified every 12 months.

Regular income must be verified using one month’s income at a minimum.
Irregular income must be verified using the three most recent months, if available.

16-001.12B Income Conversion: Income is converted for weekly and bi-weekly income. This figure is used to project Medicaid eligibility unless

There was a significant change in the income of the previous three months; or
A significant change is anticipated during the projected 12-month period.

16-001.12C Self-Employment and Farming Income: If electronic data sources are not available, the most recent 1040 or bookkeeping records shall be used. See Verification Plan at Appendix 477-000-004 to determine when paper documentation is required.

16-001.13 Terminated Income: When an individual engages in different types of self-employment, it is not considered a termination of income if the individual stops one type of work. See Appendix 477-000-004.

16-001.14 Retroactive Medical Eligibility: To determine retroactive medical eligibility, each month's actual income shall be used unless an electronic data source is available and is reasonably compatible with the individual’s attested income.

History

Effective 2018-03-13

Chapter 17 Resources for Magi-Based Programs

Neb. Admin. Code tit. 477, ch. 17 Resources for Magi-Based Programs {#sec-477-nac-17 omnilex-key=us-ne-regs-official--title-477--477 NAC 17}

17-001 RESOURCES USING MAGI-BASED METHODOLOGY : In the case of applicants/clients whose financial eligibility for Medicaid is determined using MAGI-based methodologies, the Department shall not apply any asset or resource test.

History

Effective 2018-03-13

Chapter 18 Relative Responsibility for Magi-Based Programs

Neb. Admin. Code tit. 477, ch. 18 Relative Responsibility for Magi-Based Programs {#sec-477-nac-18 omnilex-key=us-ne-regs-official--title-477--477 NAC 18}

18-001 RELATIVE RESPONSIBILITY :

Spouse for spouse; and
Parent (biological, adoptive, or step) for child if the child is eighteen (18) years old or younger and still considered part of the household.

18-001.01 Child Considered Part of Household

If a child is living in the same household with his/her parent(s), the parent(s)' income must be included.
If a child is temporarily absent from the home (generally ninety (90) days or fewer) but is still considered part of the household, the parent(s)' income must be included. Temporary absence includes, but is not limited to:

a. School attendance where the child returns to the home on a regular basis (weekends, vacations, or summers); or

b. Residence in an institution for a developmental disability or mental illness for 90 days or fewer may be considered temporary absence if the child was living in the parent(s)' household before institutionalization and will return to the parent(s)' household upon discharge.

18-001.02 If a child is permanently out of the home and no longer considered part of the household, the parent(s)' income must not be included. If income is deemed from a parent to a child in an IMD, see 477 NAC 19-003.02A.

18-002 FINANCIAL RESPONSIBILITY

18-002.01 Unmarried Parents: When unmarried parents are living together, the alleged father is not financially responsible unless he has acknowledged paternity or a court has determined that he is the father of the child after the birth.

18-002.02 Children of a Marriage: Married individuals are considered the parents of any children who are conceived or born during a marriage, even if the couple is separated, has filed for divorce or annulment, or states that one individual is not the parent of the child, unless there is a court order that states otherwise.

18-003 DETERMINATION OF PATERNITY : Paternity cannot be established unless an alleged father has signed a written and notarized paternity acknowledgment form or a court has determined him to be the father. Note: Paternity cannot be established for an unborn.

18-004 MILITARY SERVICE

18-004.01 If a parent is absent due to active duty in the uniformed services of the United States, that parent is still considered part of the assistance unit and his/her income is considered available to the unit. Uniformed service is defined as the Army, Navy, Air Force, Marine Corps, Coast Guard, Environmental Sciences Services Administration, and Public Health Service of the United States. If a client states that separation is due to reasons other than performance in military service, the client must provide proof of bona fide separation.

18-004.02 If a parent in the military is incarcerated, s/he is no longer considered part of the assistance unit.

18-005 SPECIAL PROVISIONS PERTAINING TO MINOR PARENTS

18-005.01 Minor Parent: If a minor parent has a legal guardian, according to Nebraska law, the guardian has no financial responsibility for the minor.

18-005.02 Minor's Parent(s) Receiving Medicaid: If a minor parent is living with his/her parent(s) who is receiving Medicaid for another child, the minor parent must be in his/her parent(s)’ unit.

History

Effective 2018-03-13

Chapter 19 Modified Adjusted Gross Income (magi)-Based Programs

Neb. Admin. Code tit. 477, ch. 19 Modified Adjusted Gross Income (magi)-Based Programs {#sec-477-nac-19 omnilex-key=us-ne-regs-official--title-477--477 NAC 19}

Chapters 477 Nebraska Administrative Code (NAC) 14 through 19 apply to the following: Parents and Caretaker Relatives, Children, Pregnant Women, 599 CHIP, Former Wards, Hospital Presumptive

001. SCOPE AND AUTHORITY . These regulations govern the services provided under Nebraska’s Medicaid program as defined by the Medical Assistance Act, Nebraska Revised Statute § 68-901 et seq.

002. PREGNANT WOMEN .

002.01 PREGNANT WOMEN. In order to be eligible as a pregnant woman, an individual must be pregnant and have income equal to or less than 194% of the Federal Poverty Level (FPL).

002.01(A) POST-PARTUM ELIGIBILITY. In order for a pregnant woman to be eligible for the post-partum period, she must have been eligible for and enrolled in Medicaid on the date her pregnancy ends. If a pregnant woman is found to be retroactively eligible for the date her pregnancy ends, she is eligible for the post-partum period.

002.02 PREGNANCY VERIFICATION. Verification of pregnancy is not required unless information is not reasonably compatible with an applicant or client’s attestation.

003. PARENTS AND CARETAKER RELATIVES .

003.01 PARENTS AND CARETAKER RELATIVES. In order to be eligible as a Parent or Caretaker Relative, an individual must:

(A) Have a dependent child, see 477 NAC 1; and

(B) Have household income equal to or less than 58% of the Federal Poverty Level (FPL).

004. CHILDREN .

004.01 MEDICAID FOR CHILDREN UNDER AGE 19. Children may receive Medicaid if they meet one of the following the eligibility requirements:

(A) Newborn children: Newborn children born to Medicaid eligible pregnant women are eligible at the time of birth for one year;

(B) Infants under age one: Children under age one are eligible if their household income is equal to or less than 162% of the Federal Poverty Level (FPL);

(C) Children age one through age five: Children age one through age five are eligible if their household income is equal to or less than 145% of the Federal Poverty Level (FPL);

(D) Children age six through age 18: Children age six through age 18 are eligible if their household income is equal to or less than 133% of the Federal Poverty Level (FPL);

(E) Children’s Health Insurance Program (CHIP): Children age 18 or younger who do not meet income limits for Medicaid are eligible for Children’s Health Insurance Program (CHIP) if their household income is equal to or less than 213% of the Federal Poverty Level (FPL) and the children are not covered by creditable health insurance; or

(F) Minor pregnant women: Minor pregnant women who do not meet the income limits for children’s Medicaid are eligible under the Pregnant Women’s category if their household income is at or below the applicable Federal Poverty Level (FPL). Ongoing Medicaid eligibility must be reviewed prior to the end of the 60-day postpartum period.

004.02 CHILDREN IN AN INSTITUTION FOR MENTAL DISEASE (IMD).

004.02(A) INDIVIDUALS AGE 19 AND 20. Individuals age 19 and 20 may be found eligible for services under this category if they are receiving inpatient care in an institution for mental disease. If an individual is an inpatient in an institution for mental disease when he or she reaches age 21, he or she may remain eligible for services either until discharge or until he or she reaches age 22, whichever comes first.

004.03 CHILDREN WHO ARE STATE WARDS NOT ELIGIBLE FOR IV-E ASSISTANCE. Children who are state wards not eligible for IV-E assistance must complete an application for Medicaid. Eligibility will be determined using modified adjusted gross income (MAGI)-based methodologies.

004.04 CHILDREN ELIGIBLE FOR IV-E ASSISTANCE. See 477 NAC 28.

005. 599 CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) .

005.01 ELIGIBILITY REQUIREMENTS. A pregnant woman who is not otherwise eligible for Medicaid or Children’s Health Insurance Program (CHIP) may have her unborn child’s eligibility reviewed under the 599 Children’s Health Insurance Program (CHIP) program. Eligibility for Medicaid must first be determined before 599 Children’s Health Insurance Program (CHIP) eligibility can be reviewed. Eligibility is determined for unborn children from conception through birth, if the household income is equal to or less than 197% of the Federal Poverty Level (FPL).

005.01(A) CITIZENSHIP AND NON-CITIZEN STATUS. 599 Children’s Health Insurance Program (CHIP) has no requirement for citizenship or alien status, as the unborn child’s status is independent of that of the pregnant woman.

005.01(B) CREDITABLE HEALTH INSURANCE. There is no eligibility for the unborn child if the pregnant woman has creditable health insurance. Health insurance which does not provide prenatal or maternity care is not considered creditable coverage. For a definition of creditable health insurance, see 477 NAC 1.

005.01(C) NEBRASKA RESIDENCE. The residency of the unborn child will follow the residency of the pregnant woman.

005.01(D) RELATIVE RESPONSIBILITY. Relative responsibility in the 599 Children’s Health Insurance Program (CHIP) is determined using relative responsibility regulations for modified adjusted gross income (MAGI) programs. For a pregnant minor, the income of her financially responsible parent shall not be used to determine eligibility for the unborn child.

005.01(E) AGE REQUIREMENT. For receipt of 599 Children’s Health Insurance Program (CHIP) benefits, an individual is considered an unborn child from conception until birth.

005.01(F) THIRD PARTY LIABILITY. If an ineligible pregnant woman or her spouse fails or refuses to cooperate with third party liability, the unborn child is ineligible for 599 Children’s Health Insurance Program (CHIP).

005.02 EFFECTIVE DATE OF ELIGIBILITY. The effective date of eligibility for 599 Children’s Health Insurance Program (CHIP) is no earlier than the first day of the application month. There is no retroactive eligibility for 599 Children’s Health Insurance Program (CHIP).

005.03 CONTINUOUS ELIGIBILITY. Unborn children are continuously eligible for up to six months or through their month of birth, whichever comes first. After six months of continuous eligibility, a full eligibility review is not required. However, information reported or known to the Department must be acted upon. An unborn child must have at least a thirty-day period of ineligibility before he or she would qualify for another six-month period of continuous eligibility.

005.03(A) ELIGIBILITY FOR THE CHILD UPON BIRTH. Following the birth of the child, eligibility will be determined for medical assistance based on any changes reported or known to the Department. If the newborn is determined eligible for medical assistance, the newborn is eligible for six months of continuous Medicaid eligibility.

005.03(B) POST-PARTUM SERVICES. The pregnant woman will not be eligible for post-partum services under 599 Children’s Health Insurance Program (CHIP). If post-partum care is needed for complications following labor and delivery, the woman may apply for Emergency Medical Services Assistance (EMSA).

006. FORMER WARDS .

006.01 ELIGIBILITY REQUIREMENTS. In order for an individual to be eligible in the former ward program, he or she must:

(A) Meet non-financial eligibility requirements for Medicaid;

(B) Be age 18 through age 20;

(D) Be a former ward of the Department; and

(E) Be regularly attending a school, college, or a course of vocational or technical training designed to prepare the individual for gainful employment.

007. NON-IV-E SUBSIDIZED ADOPTIONS AND GUARDIANSHIPS FOR YOUNG ADULTS .

007.01 ELIGIBILITY REQUIREMENTS. In order for an individual to be eligible for Medicaid in this program, he or she must:

(A) Be 19 through age 20;

(B) Have entered into a subsidized guardianship agreement or a subsidized adoption agreement after reaching age 16;

(i) The individual is completing secondary education or in an educational program leading to an equivalent credential;

(ii) The individual is enrolled in an institution that provides postsecondary or vocational education;

(iii) The individual is employed for at least 80 hours per month;

(iv) The individual is participating in a program or activity designed to promote employment or remove barriers to employment; or

(v) The individual is incapable of doing any part of these activities due to a medical condition. Incapacity must be supported by regularly updated information in the case plan of the individual; and

(D) Have income equal to or less than 23% of the Federal Poverty Level (FPL).

008. PRESUMPTIVE ELIGIBILITY .

008.01 ELIGIBILITY REQUIREMENTS. To be presumptively eligible in accordance with the policies and procedures established by the Department, a presumptive eligibility determination must be made by a qualified provider on the basis of preliminary information indicating the individual has gross income at or below the income standard established for the applicable group, has attested to being a citizen or national of the United States or is in satisfactory non-citizen status, and is a resident of Nebraska.

008.02 EFFECTIVE DATE. Presumptive eligibility begins on the date the provider completes a presumptive eligibility determination.

008.03 ELIGIBILITY PERIOD. If the individual files an application for Medicaid by the last day of the month following the month in which the qualified provider made the determination of presumptive eligibility, the presumptive eligibility ends on the day the Department makes the determination of Medicaid eligibility based on that application. If the individual does not file an application for Medicaid by the last day of the month following the month in which the qualified provider made the determination, the presumptive eligibility ends on that day. A presumptive application approved in error will be closed by the Department upon discovery of the error.

008.04 NOTICES. Notice and fair hearing regulations do not apply to determinations and closures of presumptive eligibility.

008.05 RESPONSIBILITIES OF QUALIFIED ENTITIES. An entity qualified to make presumptive eligibility determinations must:

(A) Notify the appropriate individual at the time a determination regarding presumptive eligibility is made, in writing or orally if appropriate, of such determination, and of the presumptive eligibility period, and

(i) If a Medicaid application on behalf of the eligible individual is not filed by the last day of the following month, the individual’s presumptive eligibility will end on that last day;

(ii) If a Medicaid application on behalf of the eligible individual is filed by the last day of the following month, the individual’s presumptive eligibility will end on the day that a decision is made on the Medicaid application;

(iii) If the individual is not determined presumptively eligible, the qualified entity must notify the appropriate individual of the reason for the determination and he or she may file an application for Medicaid with the Department;

(B) Provide the individual with a Department approved application for Nebraska Medicaid;

(C) Notify the Department the individual is presumptively eligible within five working days from the date the determination is made; and

(D) Refrain from delegating the authority to determine presumptive eligibility to another entity.

008.06 FAILURE TO MEET CATEGORICAL ELIGIBILITY. If a client fails to satisfy any of the eligibility criteria for a presumptive eligibility Medicaid category, other than income, at any time during the client’s presumptive eligibility period, presumptive eligibility must be discontinued regardless of the client’s submission of an application.

008.07 PRESUMPTIVE ELIGIBILITY FOR PREGNANT WOMEN. Medicaid covers ambulatory prenatal care for pregnant women on the basis of presumptive eligibility. The qualified provider may authorize a period of presumptive eligibility once per pregnancy. There is no presumptive eligibility under the 599 Children’s Health Insurance Program (CHIP).

008.07(A) AMBULATORY PRENATAL CARE. See 471 NAC 28.

010.07(B) QUALIFIED PROVIDER. Only a qualified provider may make presumptive eligibility determinations. See 471 NAC 28 for requirements of a qualified provider.

008.08 HOSPITAL PRESUMPTIVE ELIGIBILITY. The Department will provide Medicaid during a presumptive eligibility period to individuals who are determined eligible by a qualified hospital.

008.08(A) ELIGIBLE GROUPS. Determinations are limited to:

(i) Children, see 477 NAC 19;

(ii) Pregnant women, see 477 NAC 19. A pregnant woman is eligible for ambulatory care only;

(iii) Parents and caretaker relatives, see 477 NAC 19;

(iv) Effective October 1, 2020, the Heritage Health Adult Program, see 477 NAC 29;

(v) Former foster care children, see 477 NAC 28; and

(vi) Breast and cervical cancer patients, see Women’s Cancer Program at 477 NAC 27. Hospitals which may determine presumptive eligibility for such patients are limited to those participating in the National Breast and Cervical Cancer Early Detection Program under authority of the Centers of Disease Control and Prevention.

008.08(B) FREQUENCY. Presumptive eligibility determination is limited to no more than one period within two calendar years per person. A qualified provider may authorize a period of presumptive eligibility once per pregnancy.

008.08(C) QUALIFIED HOSPITAL CRITERIA. A hospital qualified to make presumptive eligibility determinations must:

(i) Participate as a Medicaid provider;

(ii) Notify the Department of its decision to make presumptive determinations;

(iii) Agree to make determinations consistent with state policy and procedures;

(iv) Assist individuals in completing and submitting full Medicaid applications;

(v) Assist individuals in understanding required documentation requirements; and

(vi) Not be disqualified by the Department.

History

Effective 2020-07-29

Chapter 20 Definitions Pertaining to Non-Modified Adjusted Gross Income (magi) Programs

Neb. Admin. Code tit. 477, ch. 20 Definitions Pertaining to Non-Modified Adjusted Gross Income (magi) Programs {#sec-477-nac-20 omnilex-key=us-ne-regs-official--title-477--477 NAC 20}

001. APPLICABILITY . Chapters 477 Nebraska Administrative Code (NAC) 20 through 28 apply to the following: Aged, Blind, and Disabled (ABD); Medically Needy (MN); Medicaid Insurance for Workers with Disabilities (MIWD); Women’s Cancer Program; Transitional Medical Assistance (TMA); Former Foster Care; Emergency Medical Services Assistance (EMSA); and Children and Young Adults Eligible for IV-E Assistance.

002. SCOPE AND AUTHORITY . The regulations govern the services provided under Nebraska’s Medicaid program as defined by the Medical Assistance Act (Nebraska Revised Statute § 68-901 et seq).

003. DEFINITIONS . The following definitions apply to 477 NAC 20 through 28:

003.01 ACHIEVING A BETTER LIFE EXPERIENCE (ABLE) ACCOUNT. An Achieving a Better Life Experience (ABLE) Account is a special type of investment account under Section 529A of the Internal Revenue Code. These accounts are for individuals who have a medically determinable physical or mental impairment, which results in marked and severe functional limitation, and which can be expected to result in death or which has lasted, or can be expected to last for a continuous period of not less than 12 months. The accounts must be held at designated institutions and can only be used for qualified disability expenses, as defined by the Internal Revenue Code. All amounts remaining in an Achieving a Better Life Experience (ABLE) account are transferred to the state at the time the account holder dies.

003.02 AGED, BLIND, AND DISABLED (ABD). A category of medical assistance for aged, blind, and disabled (ABD) persons who meet the appropriate criteria for assistance.

003.03 AGED. A client who is 65 years old or older.

003.04 ANNUITY. A prepaid investment which pays periodic, usually monthly, payments for a set period of time. Payments may begin immediately or at a future date.

003.05 ANNUITY TRANSACTION. The purchase of an annuity, changing the annuity beneficiary, or annuitizing, which is authorizing the commencement of the pay-out period.

003.06 ASSETS. Assets are all income and resources of an applicant or client and the spouse of an applicant or client, including income or resources to which the applicant or client or the spouse of the applicant or client is entitled but does not receive because of action or inaction by the applicant or client; the spouse of the applicant or client; a person or entity, including a court or administrative body with legal authority to act in place of, or on behalf of, the applicant or client or the spouse of the applicant or client; or, a person or entity, including a court or administrative body, acting at the direction or upon the request of the applicant or client or the spouse of the applicant or client.

003.07 AVAILABLE RESOURCES. For the determination of eligibility, available resources include cash or other liquid assets, or any type of real or personal property or interest in property which the client owns and may convert into cash to be used for support and maintenance.

003.08 BLIND. A category of eligibility for clients who are 64 years old and younger and who are blind in accordance with program standards.

003.09 BURIAL INSURANCE. Insurance policies in which the terms specifically provide proceeds can be used only to pay the burial expenses of the insured.

003.10 CASH SURRENDER VALUE. Amount which the insurer will pay, usually to the owner, upon cancellation of the policy before death of the insured or before maturity of the policy.

003.11 CHILD. For aged, blind, and disabled programs, a child is an individual aged 17 years or younger. For medically needy children, a child is an individual aged 18 or younger.

003.12 CLIENT. An applicant or recipient of Medicaid. For the purposes of these regulations, a reference to a client may also refer to the person’s guardian, legal representative, or authorized representative.

003.13 CONTRIBUTIONS OR CASH SUPPORT. Verified payments paid to or for a Medicaid unit.

003.14 COUNTABLE INCOME. The amount of income, after all appropriate disregards are applied, used to determine eligibility for medical assistance.

003.15 DISABLED. A category of eligibility for clients who are 64 years old and younger and who are disabled as determined by the Social Security Administration or the State Review Team. An individual is disabled if he or she is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. See Titles II and XVI of the federal Social Security Act, as amended, for further disability criteria.

003.16 EQUITY. The fair market value of property minus the total amount owed on it.

003.17 ESSENTIAL PROPERTY. Property or equipment owned solely by the client or the client’s spouse in his or her name, or held in a partnership or corporation interest.

003.18 FACE VALUE. Basic death benefit of the policy exclusive of dividend additions or additional amounts payable because of accidental death or under other special provisions. In determining the face value of a policy, the original face value of the policy is used.

003.19 FAIR MARKET VALUE. The price an item of a particular make, model, size, material, or condition will sell for on the open market in the geographic area involved.

003.20 FORMER FOSTER CARE. A client less than 26 years old who was in foster care under Nebraska or the tribe’s responsibility and receiving Medicaid when he or she became eighteen (18) or nineteen (19) years old, or such higher age at which federal foster care assistance ends.

003.21 FORMER WARD. An individual between the ages of 18 and 21 who has been discharged as a ward by the Department and who is in a continuing educational program.

003.22 GRANTOR OF A TRUST. Any individual who creates a trust is the grantor of the trust. A grantor may be:

(A) An applicant or client;

(B) The spouse of an applicant or client;

(C) A person or entity, including a court or administrative body, with legal authority to act in place of, or on behalf of, the applicant or client or the spouse of the applicant or client; or

(D) A person or entity, including a court or administrative body, acting at the direction or on the request of the applicant or client or the spouse of the applicant or client.

003.23 HOME. Any shelter which the individual owns and uses as his or her principal place of residence. The home includes any land on which the house is located and any related outbuildings necessary to the operation of the home.

003.24 HOUSEHOLD SIZE. The total number of individuals living together on the basis of relative responsibility.

003.25 INCOME. Gain or recurrent benefit received in money or in-kind from employment, business, property, investments, gifts, benefits, annuities, or trusts at regular or irregular intervals of time.

003.26 IN-KIND INCOME. The value of food, clothing, shelter, or other items received in lieu of wages.

003.27 IRREVOCABLE TRUST. A trust which cannot in any way be revoked by the grantor of the trust.

003.28 MEDICAID-QUALIFYING TRUST. An irrevocable trust or similar legal device which was established prior to August 11, 1993, by an applicant or client or the spouse of an applicant or client under which:

(A) The applicant or client is the beneficiary of all or part of the distributions from the trust; and

(B) The amount of the distribution is determined by a trustee who is permitted to exercise any discretion with respect to the amount to be distributed to the individual and the distributable amount from a Medicaid-qualifying trust has no use limitation.

003.29 MEDICALLY NEEDY. A program which extends Medicaid coverage to eligible individuals with high medical expenses whose income exceeds the maximum threshold, but who would otherwise be eligible.

003.30 POOLED TRUST. An irrevocable trust containing the assets of a disabled individual established and managed by a nonprofit association in a separate account solely for the benefit of a disabled individual.

003.31 QUALIFIED LONG-TERM CARE (LTC) PARTNERSHIP POLICY. A qualified long-term care (LTC) partnership policy is a long-term care insurance policy which has been approved by the Nebraska Department of Insurance. The Department of Health and Human Services accepts the Department of Insurance’s certification of the policy. If an individual has a long term care insurance policy which does not meet the requirements for a qualified long-term care partnership policy because it was issued before July 1, 2006, the individual may exchange the policy for another.

003.32 REAL PROPERTY. Land, houses, or buildings.

003.33 REVOCABLE TRUST. A trust which can be revoked by the grantor of the trust. A trust which allows a court to modify, terminate, or revoke the trust and allow the grantor to receive the trust’s assets is a revocable trust. A trust claiming to be irrevocable and indicates the trust would terminate if certain action is taken by the grantor is a revocable trust.

003.34 SHARE OF COST. A client’s monthly financial out-of-pocket obligation for medical services when the client’s income exceeds the program limits.

003.35 SPECIAL NEEDS TRUST. An irrevocable trust containing the assets of a disabled individual and established solely for his or her benefit by the individual (if established on or after December 12, 2016) or the individual’s, parent, grandparent, legal guardian, or a court, if the state will receive all amounts remaining in the trust upon the death of the individual or on termination of the trust up to the amount of total medical assistance paid on behalf of the individual.

003.36 SUPPLEMENTAL SECURITY INCOME (SSI) FEDERAL BENEFIT RATE. The maximum Supplemental Security Income benefit payable based on an individual's living arrangement.

003.37 TESTAMENTARY TRUST. A trust created and funded by a grantor’s will.

003.38 TRUST. A trust is any written legal instrument, arrangement, or device which is otherwise valid under applicable law and by which an individual, the grantor, transfers property to another person, the trustee, with the intention it be held, managed, or administered under a fiduciary duty by the trustee for the benefit of a designated beneficiary. Trusts can include escrow accounts, investment accounts, pension funds, irrevocable burial trusts, and annuities.

003.39 TRUST BENEFICIARY. An individual, designated by a trust to receive any distribution from the income or principal for the benefit of the individual is a beneficiary of the trust. A distribution from a trust may include cash, non-cash, or property disbursements, including the right to use or occupy real property.

003.40 WOMEN’S CANCER PROGRAM. Health care coverage for eligible women who need treatment for breast and cervical cancer. This program was established by the Breast and Cervical Cancer Prevention and Treatment Act of 2000.

History

Effective 2020-10-04

Chapter 21 Household or Unit Size for Non-Magi Programs

Neb. Admin. Code tit. 477, ch. 21 Household or Unit Size for Non-Magi Programs {#sec-477-nac-21 omnilex-key=us-ne-regs-official--title-477--477 NAC 21}

Chapters 477 NAC 20 through 28 apply to the following: Aged, Blind, and Disabled (ABD); Medically Needy (MN); Medicaid Insurance for Workers with Disabilities (MIWD); Women’s Cancer Program; Transitional Medical Assistance (TMA); Former Foster Care; Emergency Medical Services Assistance (EMSA); Children and Young Adults Eligible for IV-E Assistance

21-001.01 Determination of Unit Size: The unit size shall be based on the number of family members. Except for ABD programs, this number shall include unborn(s). The principles of relative responsibility apply, see 477 NAC 24-001.

History

Effective 2018-03-13

Chapter 22 Income for Non-Modified Adjusted Gross Income (non-Magi) Programs

Neb. Admin. Code tit. 477, ch. 22 Income for Non-Modified Adjusted Gross Income (non-Magi) Programs {#sec-477-nac-22 omnilex-key=us-ne-regs-official--title-477--477 NAC 22}

001. APPLICABILITY . This chapter applies to the following Non-Modified Adjusted Gross Income (Non-MAGI) programs: Aged, blind, and disabled (ABD); medically needy (MN); medical insurance for workers with disabilities (MIWD); women’s cancer program; transitional medical assistance (TMA); former foster care (FFC); emergency medical services assistance (EMSA); and children and young adults eligible for IV-E assistance.

002. INCOME .

002.01 DEFINITION. Income is a gain or recurrent benefit received in money or in-kind from employment, business, property, investments, gifts, benefits, or annuities, at regular or irregular intervals of time. Unless otherwise stated in this chapter, income is defined and counted according to 20 Code of Federal Regulations (CFR) Part 416 Subpart K.

002.02 VERIFICATION. Income must be verified at least every 12 months. Verification of income consists of at least the following:

(i) The source of the payment or benefit;

(ii) The date the payment or benefit was received;

(iii) The person entitled to receive the payment or benefit;

(iv) The period covered by the payment or benefit; and

(v) The gross amount of payment or benefit.

002.02(A) VERIFICATION SOURCES. Electronic data sources will be used to verify income, if available. Paper documentation is required when electronic data sources are either unavailable or are not reasonably compatible with a client’s attestation.

002.02(A)(i) STABLE INCOME. One month’s income is verified when a client’s income is stable.

002.02(A)(ii) FLUCTUATING INCOME. When a client’s income fluctuates, the most recent three months income is verified, when available.

002.03 PROSPECTIVE BUDGETING. Non-Modified Adjusted Gross Income (Non-MAGI) is computed on a monthly budgeting basis. Income is converted into a monthly amount. The amount used to determine monthly eligibility is the amount which is expected or can reasonably be anticipated consistent with the regulations in this chapter.

002.03(A) RETROACTIVE EXCEPTION. To determine retroactive eligibility, the amount of income actually received by the assistance unit in the requested retroactive months is verified and used.

002.04 AVAILABILITY. All sources of income, whether earned or unearned, available to the client are used to determine initial and ongoing eligibility. Relative responsibility provisions determine what income is used to determine eligibility for each member of the assistance unit.

002.04(A) PAYMENT RECEIVED FOR ANOTHER PERSON. Any benefit or payment received by the client for a person not in the assistance unit is countable for the client if the benefit or payment is not forwarded to the person for whom such payment is due.

002.05 INTERCEPTED, WITHHELD, OR GARNISHED INCOME. Income which is being intercepted, withheld, or garnished, even if done pursuant to a court order, is counted in determining eligibility.

002.06 TERMINATED INCOME. It is necessary to verify when a source of income ends. The income is not used in determining eligibility beginning in the month after the month in which the final payment is received or the benefit or contract ends.

003. EARNED INCOME .

003.01 DEFINITION. Earned income is money received from wages, tips, salary, commissions, bonuses, holiday pay, or profits from activities in which an individual is engaged as a self-employed person or as an employee. Earned income does not include reimbursement for employment-related expenses such as fuel, mileage, lodging, or meals.

003.02 IN-KIND INCOME. For programs in which age, blindness, or disability is an eligibility requirement, earned income includes any food, clothing, shelter, or other items provided in lieu of wages.

003.03 SELF-EMPLOYMENT. Self-employment is an activity or work effort performed by the individual for the purpose of generating income. Passive receipt of income from a resource does not constitute self-employment. For self-employed individuals, the net amount of income, after payment of expenses, is used to determine eligibility. Gross income and expenses must be verified. If the self-employed individual files taxes on this source of income, then the taxable amount of income from the self-employment may be used.

003.03(A) OFFSET OF INCOME. Losses from self-employment may be used to offset other earned income of the individual or a financially responsible spouse or relative. Self-employment losses cannot be used to offset unearned income.

003.04 CONTRACTUAL INCOME. Income paid on a contractual basis is prorated over the number of months covered under the contract, even if the client is paid in fewer months than the contract covers.

004. UNEARNED INCOME .

004.01 DEFINITION. Unearned income is any cash benefit that is not the direct result of labor or services performed by the individual as an employee or a self-employed person. Unearned income includes, but is not limited to:

(A) Retirement, Survivors, and Disability Insurance (RSDI) benefits;

(B) Railroad retirement benefits;

(D) Military service benefits;

(E) Veteran’s Affairs (VA) benefits;

(F) Civil service benefits;

(G) Unemployment compensation;

(H) Gifts or inheritance;

(I) Disability insurance benefits;

(J) Workers’ compensation payments;

(K) Disability benefits, other than sick leave, paid by an employer;

(L) Returns from certain investments;

(M) Payments from an annuitized annuity; or

(N) Income from a life estate in real property.

004.02 PRORATION OF PERIODIC INCOME. When income is received annually, semi-annually, quarterly, or bi-monthly, the amount is prorated on a monthly basis.

004.02(A) PERIODIC INCOME PRIOR TO APPLICATION. If the most recent periodic payment has been received and spent before the initial application, then the income may be considered unavailable and is not counted. If the application is approved, the client must report the receipt of the next payment within ten days. All payments received after the application is approved are prorated on a monthly basis and used for eligibility.

004.03 POTENTIAL BENEFITS. Applicants and recipients of Medicaid must take all necessary steps to obtain any annuities, pensions, retirement, and disability benefits to which they are entitled, unless there is good cause shown for not doing so. Annuities, pensions, retirement, and disability benefits include, but are not limited to, veterans’ compensation and pensions; retirement, survivors, and disability insurance (RSDI) benefits; railroad retirement benefits; unemployment compensation; and employer sponsored retirement benefits.

004.03(A) ELIGIBILITY DETERMINATION. If a client is otherwise eligible for Medicaid, then eligibility may be determined. The client will be notified that continued eligibility for Medicaid depends on their application for the potential benefit. A client has 60 days from the date of the notice to apply for a potential benefit.

004.03(B) REINSTATEMENT OF BENEFITS. If a Medicaid client loses eligibility for a pre-existing benefit, then continued eligibility is dependent upon taking all necessary steps to reinstate the benefit. A client has 30 days to apply to reinstate the benefit.

004.04 SPECIFIC TYPES OF UNEARNED INCOME. Certain types of unearned income have specific rules which apply. These may be an exception to the general rule, a result from the application of other program rules, or may apply to only certain eligibility groups governed by this chapter.

004.04(A) CHILD OR SPOUSAL SUPPORT. Child, spousal, and cash medical support received by the individual is considered unearned income. If payment has been irregular or is less than the court ordered amount, then a three month average is used. If a portion of the payment has been retained by the Department to satisfy a debt to the state, then no more than the court-ordered amount will be used. When child support is paid to a child who is not in the home of the assistance unit, the payment is considered income of the child only when it is provided to the child.

004.04(B) CONTRIBUTIONS. Contributions are verified gifts, payments, or in-kind assistance given to members of the assistance unit by a third party. Contributions are considered unearned income subject to the exceptions below:

(i) A self-supporting individual who resides with the client pays the client for a portion of the shelter expenses or shares expenses with the client. This includes situations where more than one assistance unit resides at the same address;

(ii) An individual makes payments directly to a vendor on behalf of a client for items which are not food or shelter;

(iii) A client who has no income receives shelter from another individual due to a crisis situation and has made arrangement to pay the individual providing shelter when the client has income;

(iv) Contributions made directly to an alternate living arrangement for a Medicaid client in order for the client to have a private room in the facility; or

(v) Payment directly to a medical provider for services which are not covered by Medicaid.

004.04(C) INHERITANCE AND GIFTS. Gifts or inheritance received by a client are considered unearned income in the month of receipt or report and are counted in the first possible month considering adequate and timely notice. Any unspent remainder is considered a resource in the month after it is countable as income.

004.04(D) INSURANCE BENEFITS. Insurance settlements, benefits, and payments are countable as income depending on the type of payment made according to the rules below.

004.04(D)(i) INCOME PRODUCING. Payments from an income producing or income replacement policy are countable as unearned income. An income producing policy pays the beneficiary based upon the triggering of a specific event without regard to costs incurred or medical procedures which may be necessary.

004.04D(ii) REPLACEMENT. Payments made to replace or restore damaged property are not counted as income.

004.04(D)(iii) LIFE INSURANCE. Life insurance benefits paid are countable as unearned income. Any verified payments of debts or obligations of the deceased are subtracted from the countable amount.

004.04(D)(iv) SETTLEMENTS. Insurance payments received from a legal settlement are counted as unearned income. Any costs related to the cause of the settlement, including attorney fees, that the client is obligated to pay is deducted from the settlement amount.

004.04(E) CONTRACT PAYMENTS. If the client has sold property on contract and the contract is not a countable resource, then the full amount of the payment received is countable as unearned income. If the contract is a countable resource, and the client remains eligible, then only the interest portion of the payment is countable as unearned income.

004.04(F) LIFE ESTATE INCOME. Net income from property retained as a life estate when a client is the life tenant is countable as unearned income. The net income is determined by deducting payments for the cost of maintaining, repairing, or restoring property; and taxes due on the property from the gross amount received. Examples are available in the appendix to this chapter.

004.04(G) LUMP SUM PAYMENTS. Lump sum payments are considered income in the first possible month considering adequate and timely notice requirements. Any unspent remainder is considered a resource in the month after the lump sum is counted as income.

004.04(G)(i) BENEFIT EXCEPTION. Any lump sum received as the result of a retroactive determination of eligibility for retirement, survivors, and disability insurance (RSDI); supplemental security income (SSI); veterans’ assistance (VA) benefits; or other entitlement benefit programs are not considered income when received.

004.04(H) MEDICAL PAYMENTS. Income received from a liable third party that pays the client directly is disregarded if it is refunded to the provider or the Department as reimbursement for a specific service. If the client fails or refuses to refund a payment due, then the payment is counted as unearned income in the first possible month, considering adequate and timely notice requirements.

005. INCOME DISREGARDS .

005.01 EARNED INCOME DISREGARDS. Specific portions of earned income are disregarded in determining eligibility. The amounts below are only disregarded from the earned income received by the client or a financially responsible relative and do not apply to unearned income.

005.01(A) AMERICORPS INCOME. Income earned by participants in the AmeriCorps program is disregarded.

005.01(B) INCOME FROM EMPLOYMENT. Earned income from employment is disregarded according to the category of eligibility.

005.01(B)(i) AGED, BLIND, AND DISABLED (ABD) CLIENTS. For categories of eligibility where age, blindness, or disability are an eligibility factor, earned income receives the following disregards:

(1) Aged or disabled clients deduct $65 from the gross amount of earned income. The remainder is divided by two to arrive at the countable amount used to determine eligibility; or

(2) Blind or blind-aged clients deduct $85 from the gross amount of earned income. The remainder is divided by two to arrive at the countable amount used to determine eligibility.

005.01(B)(ii) MEDICALLY NEEDY FAMILIES AND CHILDREN. Medically needy families and children categories of eligibility are allowed the following disregards from earned income to determine the countable amount used to determine eligibility:

(1) One-hundred dollars ($100) is deducted from the gross amount of earned income of each employed individual whose income is used to determine eligibility;

(2) Child care expenses as billed or paid are deducted if the parent whose income is used to determine eligibility requires child care in order to participate in education, training, or employment; and

(3) Any earned income of a child is disregarded.

005.01(C) EARNED INCOME TAX CREDITS (EIC). The amount of an individual’s earned income tax credits (EIC) are not counted as income. This includes any advanced earned income tax credits (AEIC).

005.01(D) JURY PAY. Income received from serving on a jury is disregarded.

005.01(E) INCOME FROM THE NATIONAL COMMUNITY SERVICE TRUST ACT. Income earned from programs funded by the National Community Service Trust Act of 1993 are not counted as income for eligibility. This includes the following programs:

(i) Volunteers in Service to America (VISTA or AmeriCorps VISTA);

(ii) University Year for Action;

(iii) Special and Demonstration Volunteer Programs;

(iv) Retired Senior Volunteer Program (RSVP);

(v) Foster Grandparent Program; and

(vi) Senior Companion Program.

005.02 UNEARNED INCOME DISREGARDS. The following amounts are deducted from unearned income in determining eligibility. When a source of income is only disregarded for a specific category of eligibility, it is noted. These disregards do not apply to earned income.

005.02(A) ACHIEVING A BETTER LIFE EXPERIENCE (ABLE) ACCOUNT DISTRIBUTION. A distribution from a qualified Achieving a Better Live Experience (ABLE) account is not counted as income if the distribution is for a qualified disability expense. It is presumed that any distribution is for a qualified disability expense unless the client reports otherwise or other information becomes known to the agency.

005.02(B) BONA FIDE LOANS. A bona fide, enforceable loan is treated as follows:

005.02(B)(i) CLIENT AS BORROWER. When a client has borrowed money which must be repaid, the money received by the client is not counted as income.

005.02(B)(ii) CLIENT AS LENDER. When a client has loaned money to another party, and the loan is countable as a resource, then the principal portion of the payment is not considered income. If the loan made to another party would not be considered a countable resource, then the full amount of the payment is countable as unearned income. A loan made to a third party where the purpose of the loan is to make the client eligible for Medicaid is not considered a bona fide loan, and is countable as a resource. It is the client’s responsibility to show that a loan was not made for the purpose of becoming eligible for Medicaid.

005.02(C) CHILD SUPPORT PAYMENTS. One-third of the amount of a child support payment received on behalf of a child eligible due to blindness or disability is disregarded from the income of the blind or disabled child.

005.02(D) COMPENSATION PAYMENTS. Payments that a client receives as compensation due to various circumstances are treated according to the provisions below.

005.02(D)(i) AGENT ORANGE. Payments made from the fund created by manufacturers of Agent Orange due to product liability are disregarded as income.

005.02(D)(ii) CERTAIN CHILDREN OF VETERANS. Veterans’ Affairs (VA) payments made to the children of veterans who served in Vietnam and Korea who were born with spina bifida and children born to women veterans who served in Vietnam who have certain birth defects are disregarded as unearned income.

005.02(D)(iii) CERTAIN HEMOPHILIA PATIENTS. Payments made to hemophilia patients from any fund established by the Susan Walker v. Bayer Corporation et al. who are infected with human immunodeficiency virus (HIV) are disregarded as unearned income.

005.02(D)(iv) RADIATION EXPOSURE COMPENSATION FUND. Payments made to victims under the Radiation Exposure Compensation Fund are disregarded as unearned income.

005.02(D)(v) VICTIMS OF CRIME. Payments made by a state or local government to compensate crime victims are disregarded as unearned income.

005.02(D)(vi) VICTIMS OF NAZI PERSECUTION. Payments made to victims of Nazi persecution made by any country are disregarded as unearned income.

005.02(E) EDUCATIONAL ASSISTANCE. Assistance paid to clients for higher education is treated according to the provisions below.

005.02(E)(i) GRANTS, SCHOLARSHIPS, FELLOWSHIPS, AND GIFTS. Any portion of a grant, scholarship, fellowship, or gift used to pay for tuition, fees, or other necessary educational expenses is disregarded from income. Any portion used to pay for other expenses is counted as unearned income.

005.02(E)(ii) ASSISTANCE UNDER THE HIGHER EDUCATION ACT OR BUREAU OF INDIAN AFFAIRS. All assistance received from the Bureau of Indian Affairs (BIA) or paid under the Higher Education Act of 1965 is disregarded as unearned income. Programs under the Higher Education Act of 1965 include:

(1) Pell grants;

(2) State student incentives;

(3) Academic achievement incentive scholarships;

(4) Byrd Scholars;

(5) Federal supplemental educational opportunities grants;

(6) Federal educational loans;

(7) Upward Bound;

(8) Gaining early awareness and readiness for undergraduate programs (GEARUP);

(9) Leveraging educational assistance partnership (LEAP);

(10) Special leveraging educational assistance partnership (SLEAP); or

(11) Work-study programs.

005.02(E)(iii) VETERANS AFFAIRS EDUCATION BENEFITS. The Department of Veterans’ Affairs (VA) has several types of education assistance programs available for veterans, spouses, or the children of veterans. Regardless of the type of educational program paying benefits, any portion of a payment which is used to pay for tuition, fees, or other necessary educational expenses is disregarded as unearned income. Any portion of the payment not used for such expenses is countable as unearned income.

005.02(E)(iv) MEDICALLY NEEDY FAMILIES AND CHILDREN. For medically needy family and children programs, the full amount of any grant, scholarship, or fellowship is disregarded as income.

005.02(F) INTEREST INCOME. Interest earned on excluded accounts, investments, and burial funds is not counted as income. Any countable interest earned has $10 per month per source disregarded in determining eligibility.

005.02(G) MEDICAL SERVICES. Medical services received at no cost to the client are not considered income. Medical services include diagnostic, preventative, therapeutic, or palliative care proved at no cost; prescription drugs; eyeglasses; prosthetics; durable medical equipment; service animals and supplies; or vehicle modifications.

005.02(H) NEEDS BASED ASSISTANCE. Assistance received by a client which is wholly funded by a state or local government or provides basic food and shelter and is determined by financial need is not counted in determining eligibility. This includes the following:

(i) General assistance;

(ii) Supplemental Nutritional Assistance Program (SNAP) benefits;

(iii) Housing assistance;

(iv) Energy assistance including Low Income Home Energy Assistance Program (LIHEAP);

(v) Crisis assistance payments; or

(vi) Home modification or weatherization.

005.02(I) OLDER AMERICANS ACT PAYMENTS. Payments or services received pursuant to the Older Americans Act are not considered income. These may include nutrition services, legal assistance, or health services. Income paid as wages or salaries for a program under the Older Americans Act is considered earned income and counted.

005.02(J) RELOCATION ASSISTANCE. Relocation costs paid by an employer as an inducement to an employee are countable as income. Relocation costs paid by a local, state, or federal government as assistance are not counted as income. These costs may include:

(i) Moving expenses;

(ii) Reimbursement for losses of property;

(iii) Displacement allowances;

(iv) Rental expenses due to displacement;

(v) Direct provision of housing; or

(vi) Expenses for closing costs on a replacement dwelling.

005.02(K) SOCIAL SECURITY BENEFITS. In certain instances, all, or a portion of, a client’s Social Security income is not used in determining eligibility.

005.02(K)(i) SUPPLEMENTAL SECURITY INCOME (SSI). Supplemental Security Income (SSI) benefits are not used in determining eligibility. A recipient of Supplemental Security Income (SSI) benefits is considered categorically eligible to receive Medicaid.

005.02(K)(ii) FORMER SUPPLEMENTAL SECURITY INCOME (SSI) RECIPIENTS. Certain former recipients of Supplemental Security Income benefits continue to be considered receiving the Supplemental Security Income benefit for the purposes of receiving Medicaid. An individual must meet all of the specific criteria in order to receive the corresponding income disregard.

005.02(K)(ii)(1) DISABLED EARLY WIDOWS OR WIDOWERS. These individuals are also referred to as additional reduction factor (ARF) widows or widowers. The amount or increase in Title II benefits are not counted if all of the following are met:

(a) Have been determined disabled;

(b) Were receiving Supplemental Security Income (SSI) in December, 1983 and lost Supplemental Security Income (SSI) benefits in January, 1984 due to the elimination of a benefit reduction factor for widows or widowers before the attainment of age 60;

(d) Applied for benefits under this group prior to July 1, 1988 or a later date established under the court order in Darling v. Bowen; and

(e) Would continue to be eligible for Supplemental Security Income (SSI) benefits, including the resource standard, if the client had not received the increase in Title II benefits.

005.02(K)(ii)(2) DISABLED ADULT CHILDREN (DAC). This population is also known as childhood disability beneficiaries (CDB). The amount or increase in Title II benefits received from a parent’s claim is not counted if all of the following are met:

(a) Lost Supplemental Security Income (SSI) status after November 10, 1986 due to the mandatory receipt or increase in Title II benefits on a parent’s record due to the retirement, death, or disability of the parent;

(b) Are age 18 or older;

(d) Would continue to be eligible for a Supplemental Security Income (SSI) payment, including the resource standard, if they were not receiving the Title II disabled adult child benefit.

005.02(K)(ii)(3) SECTION 503 GROUP. This population is commonly referred to as the Pickle Amendment Group. Title II cost-of-living increases beginning the month before the month in which Supplemental Security Income (SSI) benefits ended if all of the following factors are met:

(a) Is currently receiving Title II income;

(b) Was eligible for and receiving Supplemental Security Income (SSI) benefits concurrently with Title II income for at least one month after April 1, 1977; and

(c) Lost Supplemental Security Income (SSI) benefits, but would continue to receive it, including the resource standard, if the amount of cost-of-living increases received from Title II income after the month in which Supplemental Security Income (SSI) benefits were lost were deducted from the current Title II benefit. The cost-of-living increases include the increases received by the individual, the individual’s spouse, or a financially responsible family member.

005.02(K)(ii)(4) EARLY WIDOWS OR WIDOWERS. This population is also known as COBRA widows or widowers. The amount received from Title II benefits is deducted in determining eligibility if all of the following factors are met:

(a) Lost Supplemental Security Income (SSI) benefits due to the mandatory receipt of Title II benefits;

(b) Is not yet eligible for Medicare Part A;

(d) Would continue to be eligible for Supplemental Security Income (SSI) if not receiving Title II benefits.

005.02(K)(iii) DELAYED COST-OF-LIVING ADJUSTMENT (COLA). In determining countable income for aged, blind, or disabled recipients whose eligibility is determined by a comparison to the federal poverty line (FPL), the amount of Retirement, Survivors, or Disability Insurance (RSDI) increase received from the annual cost-of-living adjustment is not counted until the month after the month in which the annual revision to the federal poverty line (FPL) is published. This applies only to the Retirement, Survivors, or Disability Insurance (RSDI) benefits. A cost-of-living adjustment to another source of income continues to be counted in the first month it is received.

005.02(L) VETERANS’ PAYMENTS. The amount received by a veteran or their spouse as an Aid and Attendance benefit while in a nursing facility is not counted as income or used when determining the share of cost due to the facility.

005.02(M) WINNINGS AND DIVIDENDS. Gambling and gaming winnings and countable dividends have $10 per month per source of the income disregarded in determining eligibility. The winnings or dividends are considered income in the month of receipt or report subject to adequate and timely notice requirements.

005.03 GENERAL INCOME DISREGARDS. General income disregards are not specific to earned or unearned income. Such disregards may apply to either earned, unearned, or both, as appropriate.

005.03(A) $20 GENERAL DISREGARD. The first $20 of income is not counted in determining eligibility. The disregard is applied first to any unearned income. Any remaining amount is applied to earned income. This disregard is only used once in the assistance unit, regardless of the number of individuals in the unit.

005.03(B) MEDICAL INSURANCE PREMIUMS. The amount paid for private health insurance premiums is deducted from countable income in determining eligibility. The client or a financially responsible relative must be responsible for payment of the premium. The insurance policy must be a health insurance policy which pays for medical services or treatments, and the amount of income producing policies does not receive this income deduction. This deduction is not used for Medicare premiums. This disregard does not apply to individuals eligible as medically needy. For medically needy individuals, the amount of health insurance premiums is deducted from any share of cost due.

005.03(C) NATIVE AMERICAN INCOME. Certain types of income received by Native Americans are disregarded, in whole or in part, when determining Medicaid eligibility. Multiple statutes exclude this income from Medicaid eligibility. In some cases, an income type may be specific to a certain tribe or activity. If an income source is identified or alleged which is not listed below, then submit the income for review to determine whether an exclusion exists.

005.03(C)(i) INDIAN JUDGMENT FUNDS DISTRIBUTION ACT. Per capita distribution payments made to tribal members who are due judgment funds after October 19, 1973 according to a plan of the Secretary of the Interior are excluded.

005.03(C)(ii) DISTRIBUTION OF JUDGMENT FUNDS. Distributions after January 12, 1983 of judgment funds held in trust or distributed per capita are excluded from income. This includes any interest or investment income accrued while the funds were held in trust.

005.03(C)(iii) PER CAPITA ACT. Any funds held in trust distributed after August 2, 1983 by the Secretary of the Interior to tribal members are excluded from income.

005.03(C)(iv) ALASKA NATIVE CLAIMS SETTLEMENT ACT. Stock, a partnership interest, an interest in land, or an interest in a settlement trust for Alaskan Natives are excluded. Up to $2,000 received in income from a native corporation is excluded.

005.03(C)(v) INCOME FROM RESTRICTED LANDS. Up to $2,000 per year is excluded from income from individual interests or trust interests if the income is derived from restricted lands.

005.03(D) PLAN TO ACHIEVE SELF-SUPPORT (PASS). Income used to meet a goal for the Plan to Achieve Self-Support (PASS) program is disregarded in determining Medicaid eligibility. This may be earned or unearned income. The Plan to Achieve Self-Support (PASS) program is administered by the Social Security Administration (SSA). The amount of income to be disregarded due to participation in this program will need to be verified with the Social Security Administration (SSA) when determining Medicaid eligibility.

005.03(E) TAX RETURNS. The amount received by an individual as a tax return is not counted as income.

005.04 LONG-TERM CARE EXCEPTION. When a client resides in a medical facility, any income disregarded in determining eligibility is used in determining the amount of the share of cost due. Medical facilities include nursing facilities, skilled nursing facilities, intermediate care facilities for the developmentally disabled, or hospitals.

History

Effective 2020-11-04

Chapter 23 Resources for Non-Modified Adjusted Gross Income (magi) Programs

Neb. Admin. Code tit. 477, ch. 23 Resources for Non-Modified Adjusted Gross Income (magi) Programs {#sec-477-nac-23 omnilex-key=us-ne-regs-official--title-477--477 NAC 23}

002. SCOPE AND AUTHORITY . The regulations govern the services provided under Nebraska’s Medicaid program as defined by the Medical Assistance Act (Nebraska Revised Statute [Neb. Rev. Stat.] § 68-901 et seq).

003. RESOURCES

003.01 RESOURCES. The total equity value of available non-excluded resources of the client or client and responsible relative is determined and compared with the established maximum for available resources the client may own and still be considered eligible. If the total equity value of available non-excluded resources exceeds the established maximum, the client is ineligible.

003.02 VERIFICATION OF RESOURCES. As a condition of both retroactive and prospective eligibility, all countable resources must be verified and documented in the case record. See the Medicaid Resource Verification Plan for verification sources.

003.02(A) EXCEPTIONS.

(i) For Aged, Blind, and Disabled clients who receive Supplemental Security Income, including individuals in 1619(b) status, verification of resources is not required.

(ii) If it is unknown whether or not a resource is countable, verification will be required.

003.02(B) RESOURCE REVIEW. If there is reason to believe at any time there has been an increase in resources which may affect eligibility, all resources must be verified immediately. A resource review is not required for Supplemental Security Income recipients.

003.03 AVAILABILITY OF RESOURCES. For the determination of Medicaid eligibility, available resources include cash or other liquid assets or any type of real or personal property or interest in property which the client owns and may convert into cash to be used for support and maintenance.

003.03(A) UNAVAILABILITY OF RESOURCES. Regardless of the terms of ownership, if it can be documented in the case record a resource is unavailable to the client, the value of the resource is not used in determining eligibility. The feasibility of the client's taking legal action to make the resource available must be taken into consideration. If it is determined legal action can be taken, the client is allowed 60 days to initiate legal action. After 60 days, if the client has not filed legal action, the case is closed for failure to comply.

003.03(B) BENEFIT FUNDS. If the applicant or recipient has benefit funds, such as funds raised by a benefit dance or auction, the Department must determine whether those funds are available as a resource. If the client or a financially responsible relative can access the benefit funds to pay for shelter costs, maintenance needs, or medical costs otherwise covered by Medicaid, then the funds are considered available.

003.03(C) AUGMENTED ESTATE. An applicant or client must file in county court for the maximum elective share of a deceased spouse's augmented estate as specified in Neb. Rev. Stat. §§ 30-2313 and 30-2314. The status of the resource must be monitored.

003.03(D) VALUE AND EQUITY. Equity is the actual value of property, the price at which it could be sold, less the total of encumbrances against it. If encumbrances against the property equal or exceed the price for which the property could be sold, the client has no equity and the property is not an available resource.

003.03(D)(i) SECURED DEBTS. The total value of unpaid personal taxes and other personal debts secured by mortgages, liens, promissory notes, and judgments, other than those on which the statute of limitations applies, is subtracted from the gross value of the encumbered property to find the equity. The case record includes documentation of the type of debt and plan under which payment was made. A service or payment made for free at the time for the benefit of the client, without a written agreement for repayment later, is not a debt.

003.03(D)(ii) DETERMINATION OF VALUE. Public tax records or county assessor records may be used to determine the sale value of a resource. If there is a question as to the accuracy of the sale value determined by these records, verification may be obtained from a real estate agent, car dealer, or other appropriate individual.

003.04 DEPRIVATION OF RESOURCES.

003.04(A) DEPRIVATION OF RESOURCES. Any action taken by the applicant or client, or any other person or entity, which reduces or eliminates the applicant’s, client’s, or spouse’s recorded ownership or control of the asset for less than fair market value is a deprivation of resources. The fair market value of a resource at the time the resource was disposed of must be verified and the equity value of the resource must be determined by taking into consideration any encumbrances against the resource. A deprivation of resources includes:

(i) Recorded transfer of ownership of real property;

(ii) Not receiving the spousal share of an augmented estate;

(iii) Purchase of a life estate in another individual’s home without meeting the 12-month requirement to reside there;

(iv) Promissory notes, loans, mortgages, and contract sales for less than fair market value or which are for at least fair market value and are not enforced;

(v) Purchase of an irrevocable, non-assignable annuity, if Medicaid is not the preferred beneficiary and the annuity is issued on or after February 8, 2006;

(vi) Any transfer above the protected spousal reserved amount to a community spouse;

(vii) Purchase of any contract or financial instrument, including an endowment or insurance, where the criteria for fair market value are not met;

(viii) Resources transferred to a pooled trust established for the benefit of a person 65 years old or greater at the time of transfer; and

(ix) Transfer or gift of any resource to a third party for less than fair market value.

003.04(B) FAIR MARKET CRITERIA. The criteria for fair market value are not met when

(1) The term of the instrument exceeds the life expectancy of the applicable client;

(2) The instrument does not provide for equal monthly or annual payments commencing immediately during the term of the contract;

(3) The instrument does not provide for the recovery of assets in the event of default;

(4) The instrument contains exculpatory or cancellation terms of balance due; or

(5) The purpose of a transaction is solely to become eligible.

(6) The value received for the transfer of any resource is less than the expected value which would have been received on an open market for a similar resource of the same type.

003.04(B)(i) EXCULPATORY PROVISION. If a client living in a nursing home lends money to an individual with a promissory note stating the obligation to pay any remaining balance ceases upon the client’s death, the exculpatory provision forgives or clears the debt and is therefore not a permissible transaction which would avoid a deprivation.

003.04(B)(ii) REPAYMENT AGREEMENT. Any service agreement must be in writing and reasonably describe the services to be rendered prior to the rendering of services.

003.04(C) ASSET PLACED IN ANNUITY. When an asset is placed in an annuity on February 8, 2006 or later, annuity regulations in this chapter apply.

003.04(D) ASSET PLACED IN TRUST. Trust regulations in this chapter take precedence over deprivation when an asset is placed in a trust.

003.04(E) SALE OF REAL PROPERTY IN LIFE ESTATE. When real property in which the individual has a life estate is sold, the individual or spouse must receive as a lump sum his or her life estate interest from the net proceeds, or the entire net proceeds invested and the individual who has the life estate receives all the income.

003.04(F) DEPRIVATION OF RESOURCE REVIEW. Deprivation of a resource must be reviewed only if an individual or an individual’s spouse resides in a specified living arrangement, which is defined as

(i) A nursing home;

(ii) Receiving skilled level of care in a hospital;

(iii) Receiving Home and Community-Based Services, including an assisted living waiver, Program of All-Inclusive Care for the Elderly, or requesting and meeting the criteria for such services; or

(iv) An intermediate care facility for persons with a developmental disability.

003.04(G) LOOK-BACK PERIOD FOR DISPOSAL OR TRANSFER OF RESOURCES ON OR AFTER FEBRUARY 8, 2006. To determine if a client or his or her spouse deprived himself or herself of a resource to qualify for Medicaid, the Department must look back 60 months before the month of application. The look-back is triggered when the applicant first applies for Medicaid and is in a specified living arrangement or is on Medicaid and enters a specified living arrangement. When an applicant applies for Medicaid more than once, the look-back period is based on the first date the individual meets both of these requirements. The look-back period may include the three months prior to the month of application if retroactive Medicaid benefits are requested for those months.

003.04(G)(i) COUNTABLE VALUE OF DISPOSED RESOURCES. To determine any countable value disposed of, the Department will:

(1) Take the equity the client had in the resource at the time of disposition; equity equals fair market value minus encumbrances, and

(2) Subtract any compensation received by the client.

003.04(H) PERIOD OF INELIGIBILITY. If it is determined an applicant or client disposed of a resource, the applicant or client is ineligible. To determine the length of the period of ineligibility the countable value of the resource will be divided by the actual monthly cost of care in the specified living arrangement at the current private pay rate. If both spouses are applying and eligible for Medicaid, the period of ineligibility is divided equally between the spouses. The period of ineligibility begins:

(i) If the client is receiving Medicaid, with the month of entry into a specified living arrangement, following notice requirements; or

(ii) If an applicant, the first month of requested benefits if in a specified living arrangement.

003.04(I) IMPOSING A PERIOD OF INELIGIBILITY. The applicant or client must be Medicaid eligible, except for the deprivation of resources, in the month benefits are requested for a deprivation penalty to be imposed. If the division results in a fraction, the fraction is converted to a dollar amount and this amount is included as unearned income for the applicable month. In determining the period of ineligibility, the fair market value of the transferred resource is used. The value of other resources and income are not included in the calculation. For periodic disposals within the look-back period, each is determined separately; the periods of ineligibility run consecutively. Multiple fractional month transfers are cumulative and treated as a single transfer.

003.04(I)(i) SPOUSE FOR SPOUSE INELIGIBILITY. If a community spouse enters a specified living arrangement and is Medicaid eligible except for the deprivation, divide the full or any remaining period of ineligibility between the spouses.

003.04(J) DEPRIVATION HARDSHIP WAIVER. An exception may be made if it is determined a transfer was made for less than fair market value, but the individual can verify he or she intended to dispose of the resource for fair market value or for other valuable consideration, the transfer was not made to qualify for assistance, or denial of assistance would cause undue hardship.

003.04(J)(i) REQUESTING A HARDSHIP WAIVER. All requests for deprivation hardship waiver must be submitted in writing to the Department. On receipt of the written request, the Department will follow the Deprivation of Resources Hardship Waiver Procedure. The facility in which the institutionalized individual resides may file the undue hardship waiver request on behalf of the individual with the written consent of the individual or his or her legal representative. The guardian, conservator, or anyone acting on behalf of the applicant or client must attempt to recover transferred assets. Up to 30 days of nursing home services may be provided if the applicant or client is cooperating to the fullest extent in attempting to recover transferred assets. If cooperation ceases, undue hardship no longer exists and eligibility is terminated. A hardship waiver will be denied if the applicant or client, or his or her spouse participated in the transfer. A denial of hardship waiver request may be appealed.

003.04(K) TRANSFERS NOT CONSIDERED DEPRIVATION. It is not considered a deprivation of a resource if:

(i) An applicant or client transferred a resource to his or her spouse, to an individual with power of attorney, or to a guardian or conservator for the sole benefit of the applicant’s or client’s spouse;

(ii) An applicant’s or client’s spouse transferred a resource to an individual with power of attorney, or to a guardian or conservator, for the sole benefit of the applicant’s or client’s spouse;

(iii) A resource was transferred to a trust established solely for the benefit of the applicant’s or client’s son or daughter who is blind or disabled;

(iv) A resource was transferred to the applicant’s or client’s son or daughter who is blind or disabled; or

(v) A resource was transferred to a special needs trust established solely for the benefit of an individual 64 years old or younger who is disabled.

003.04(L) TRANSFER OF A HOME. It is not considered a deprivation of a resource if an applicant or client transfers title to his or her home to his or her:

(i) Spouse;

(ii) Son or daughter who

(1) Is age 20 or younger;

(2) Is blind or disabled; or

Was residing in the home for at least two years before his or her parent applied for Medicaid or entered long-term care and provided care to his or her parent which permitted the parent to reside at home rather than be institutionalized or receive Home and Community Based Services Waiver; or

(iii) Sibling who has an equity interest in the home and who was residing in the home for at least one year immediately before his or her sibling applied for Medicaid or entered a specified living arrangement as defined in this chapter.

003.05 TYPES OF RESOURCES. Resources are divided into two categories, liquid and non-liquid.

003.05(A) LIQUID RESOURCES. Liquid resources are assets which are in cash or financial instruments which are convertible to cash.

003.05(A)(i) CASH, SAVINGS, INVESTMENTS, AND MONEY DUE. Available resources include cash on hand, cash in checking and savings accounts, salable stocks or bonds, certificates of deposit, promissory notes and other collectible unpaid notes or loans, cash in investment accounts, and accessible retirement accounts.

003.05(A)(ii) LAND CONTRACTS. A land contract, or real estate contract of sale, is considered a resource to the seller of the property if the contract can be sold. In determining the value of the contract, the salability of the contract and the resulting value will be determined. The contract is not considered salable unless there is a known buyer. If the contract is determined to be salable, the net value of the contract becomes the value at which it could be sold, minus encumbrances, against the property. If it is determined and documented the contract is not salable, the contract is not considered an available resource to the client. A review of the salability will be completed at all renewals or more often as deemed necessary. Any income received from a land contract is considered unearned income to the client. The contract may be considered a deprivation of resources.

003.05(A)(iii) FUNDS SET ASIDE FOR BURIAL. A specified maximum may be disregarded if it is set aside for the purpose of paying burial expenses.

003.05(A)(iii)(1) BURIAL FUNDS. The individual may choose to put the money in:

(a) A pre-need burial trust. If the client has an irrevocable burial trust for more than the specified maximum, the excess is considered an available resource;

(b) A policy of burial insurance. If the client has irrevocably assigned more than the specified maximum in burial insurance, the excess is not an available resource but may be a deprivation of resources; or

(c) A maximum of $1,500 may be designated for burial. These funds may be in an account or in an insurance policy. This provision is applicable to Aged, Blind, and Disabled Medicaid eligible individuals only.

003.05(A)(iii)(2) TRANSFER OF FUNDS TO AN INSURANCE POLICY. An individual may transfer funds from an irrevocable burial trust fund into an insurance policy if there is no lapse of time between the withdrawal and the transfer.

003.05(A)(iii)(3) IRREVOCABLE BURIAL TRUSTS. If money was placed in an irrevocable burial trust on July 16, 1982, or later, it is not considered an available resource. The value of the irrevocable burial trust is limited by the specified maximum amount identified at Neb. Rev. Stat. Section 68-129. The trust must be created for the purpose of paying prearranged burial expenses. The value up to the specified maximum of an irrevocable burial trust and any accrued interest or dividends on this amount, if irrevocable, are considered unavailable and are disregarded. The mortuary may retain an additional amount not to exceed 15 percent, but this amount must not be included in the burial trust. An irrevocable burial trust must be deposited by a mortuary with a financial institution. A written copy of the contract may be retained by the client or the funeral home. In determining whether the value of a burial fund contracted in Nebraska is considered available, the terms of the contract must be verified with the financial institution. If a burial trust is drawn up in another state, the contract terms must be verified and determined whether the state allows irrevocable burial funds or whether the value of the trust is available to the client regardless of the contract terms.

003.05(A)(iii)(4) INTEREST AND DIVIDENDS ON BURIAL TRUSTS. For irrevocable burial trusts all accrued interest or dividends are also irrevocable.

003.05(A)(iii)(5) BURIAL INSURANCE. Burial insurance is defined as insurance in which the policy’s terms specifically provide the proceeds can be used only to pay the burial expenses of the insured, or a life insurance policy which is irrevocably assigned for the specific purpose of burial. When the proceeds of a life insurance policy are irrevocably assigned for the purpose of burial, the cash value is not available and is disregarded as a resource. If the burial insurance has been irrevocably assigned, it is treated according to this rule and the specified maximum applies. If a total of more than the specified maximum in burial insurance is irrevocably assigned for services, the amount above the specified maximum may be considered deprivation of a resource.

003.05(A)(iii)(6) MONEY DESIGNATED FOR BURIAL. Up to $1,500 may be disregarded for each individual if it is set aside for the purpose of paying burial arrangements for the individual or the individual's spouse. This exclusion is in addition to the burial space exclusion. To qualify for this exclusion, funds must be separated into a designated account. The $1500 is reduced by:

(a) The face value of any policy of life or burial insurance, and

(b) The amount of any irrevocably assigned burial trust, contract, or arrangement

003.05(A)(iii)(7) BURIAL SPACES. The value of burial spaces, held for the purpose of providing a place for the burial of the client, his or her spouse, and members of the client's immediate family, are not counted as an available resource. Immediate family includes minor and adult children, including adopted children and stepchildren, brothers, sisters, parents, adoptive parents, and the spouses of these individuals. A burial space includes a crypt, mausoleum, urn, casket, marker, vault, or other repository for the remains of a deceased person. This exemption also applies to markers, vaults, applicable sales tax, charges for opening and closing the grave, but does not include services, burial fees, etc. These items are exempt only if they are actually purchased.

003.05(A)(iii)(8) BURIAL SPACE ITEMS HELD IN A CONTRACT. Burial space items may be disregarded when they are held for an individual by way of a contract. To meet the requirement the item is actually purchased, the contract must state the individual has purchased a particular item for a specified price. The contract may be revocable or irrevocable as long as the agreement itself represents the individual’s ownership. The contract may be funded by money set aside in a bank account or in a burial insurance policy. Any interest accrued and left to accumulate is not counted as income. If a client transfers ownership of a life insurance policy to someone else, and there is a contract with a mortuary for purchase of burial space items which the insurance policy will be used to fund, the cash value of the policy is not considered a resource because the client does not own it. Additionally, this is not considered deprivation of a resource.

003.05(A)(iv) LIFE INSURANCE.

003.05(A)(iv)(1) INSURED. The person whose life is insured.

003.05(A)(iv)(2) OWNER. The person who has the right to change the policy.

003.05(A)(iv)(3) TERM INSURANCE. A form of life insurance which generally furnishes insurance protection for only a specified or limited period of time.

003.05(A)(iv)(4) FACE VALUE. The basic death benefit of a life insurance policy exclusive of dividend additions or additional amounts payable because of accidental death, or under other special provisions. In determining the face value of a policy, the original face value of the policy is used.

003.05(A)(iv)(5) CASH SURRENDER VALUE. Amount an insurer will pay, usually to the owner, upon cancellation of a life insurance policy before death of the insured or before maturity of the policy.

003.05(A)(iv)(5)(a) AMOUNT COUNTED AS A RESOURCE. Each person in the unit is allowed a $1,500 exemption for the face value of his or her life insurance policies. If the combined original face value of all the life insurance policies owned by the client exceeds $1,500, the actual cash surrender value of all the policies is considered a countable resource. If the cash surrender value is to be counted toward the resource total of a client, consideration is given to any outstanding loans against the policy in determining net cash surrender value. The following must be disregarded in determining the combined original face value of all life insurance policies:

(i) Burial insurance, and

(ii) Life insurance policies where the proceeds are irrevocably assigned for the purpose of burial.

003.05(A)(v) LONG-TERM CARE PARTNERSHIP PROGRAM. Resources equal to the amount of benefits paid out by a qualified Long-Term Care Partnership policy are disregarded for an individual applying for Medicaid if the policy was issued on July 1, 2006, or later, and the individual is otherwise Medicaid-eligible. The benefits may be paid as direct reimbursement of long-term care expenses, or paid on a per diem or other periodic basis, for periods during which the individual received long-term care services. The disregard is applied to the amount of benefits paid to or for the individual as of the month of application, even if additional benefits remain available under the terms of the policy. The amount of the resource disregard is also excluded from estate recovery.

003.05(A)(v)(1) QUALIFIED LONG-TERM CARE PARTNERSHIP POLICY. A long-term care insurance policy which has been approved by the Nebraska Department of Insurance. The Department accepts the Department of Insurance’s certification of the policy. If an individual has a long-term care insurance policy which does not meet the requirements for a Qualified Long-Term Care Partnership policy because it was issued before July 1, 2006, the individual may exchange the policy for another.

003.05(A)(v)(2) EXCHANGE OF A NON-PARTNERSHIP POLICY FOR A QUALIFIED LONG-TERM CARE PARTNERSHIP POLICY. An applicant or client may exchange a policy which does not meet the requirements of a qualified Long-Term Care Partnership Policy for one which does meet the requirements. The date of exchange is considered the issue date for the qualified Long-Term Care Partnership Policy.

003.05(A)(v)(2)(a) RECIPROCITY WITH OTHER STATES. The Department will accept qualified Long-Term Care Partnership Policies issued in other states with Long-Term Care Partnership Programs.

003.05(A)(vi) ANNUITY, TRUST, GUARDIANSHIP AND CONSERVATORSHIP FUNDS. When an annuity, trust, guardianship, or conservatorship has been established on behalf of an applicant or client, it must be verified if the annuity, trust, guardianship, or conservatorship is available to the applicant or client.

003.05(A)(vi)(1) ANNUITIES.

003.05(A)(vi)(1)(a) ANNUITY. A prepaid investment which pays periodic payments for a set period of time. Payments may begin immediately or at a future date.

003.05(A)(vi)(1)(b) ANNUITY TRANSACTION. The purchase of an annuity, changing the annuity beneficiary, or authorizing the commencement of the pay-out period.

003.05(A)(vi)(1)(c) PURCHASED OR ANNUITIZED BEFORE FEBRUARY 8, 2006. When an applicant or client cannot assign or change the ownership or payee of an annuity, the annuity is unavailable. A determination must then be made if a deprivation has occurred. If the expected return on the annuity is commensurate with the life expectancy of the applicant or client, the annuity can be deemed actuarially sound and no deprivation has occurred. If the average number of years of expected life remaining for the applicant or client does not coincide with the life of the annuity, a deprivation has occurred. The look-back period is the same as for trusts. See the Life Expectancy Tables available in the appendix to this title.

003.05(A)(vi)(1)(d) ANNUITY TRANSACTION ON OR AFTER FEBRUARY 8, 2006.

003.05(A)(vi)(1)(d)(i) COUNTABLE RESOURCES. Revocable and assignable annuities are countable resources. A saleable annuity which has not been sold is a countable resource for the amount annuitized, less the payment amount already received. A saleable annuity which has been sold for a value consistent with the secondary market is a countable resource in the amount of the proceeds. If a saleable annuity is sold for less than a value consistent with the secondary market, it will be valued at the current secondary market amount and the difference will be subject to the deprivation of resources regulation.

003.05(A)(vi)(1)(d)(ii) DEPRIVATION OF RESOURCES FOR ANNUITY TRANSACTIONS. For long-term care services, an annuity transaction after February 8, 2006, is treated as a disposal of an asset for less than fair market value unless the State of Nebraska is named as the remainder beneficiary in the first position for at least the total amount of Medicaid expenditures paid, or is named as the remainder beneficiary in the second position after a community spouse or minor or disabled child. An annuity is also treated as a disposal of assets for less than fair market value unless it is irrevocable and non-assignable, actuarially sound, and provides for payments in equal amounts during the term of the annuity, with no deferral and no balloon payments. This provision also applies to a community spouse. The issuer of an annuity must notify the Department when there is a change in the amount of income or principal withdrawn from the annuity.

003.05(A)(vi)(1)(e) ANNUITIES EXCLUDED FROM RESOURCES. An annuity which has been annuitized will be excluded from countable resources if it meets the following conditions:

(i) The annuity is considered either an individual retirement annuity according to the Internal Revenue Code or a deemed Individual Retirement Account under a qualified employer plan by the Internal Revenue Code; or

(ii) The annuity is purchased with the proceeds from a simplified employee pension; and

(iii) The annuity is irrevocable and non-assignable, the individual who owned the retirement account or plan is receiving equal monthly payments with no deferral or balloon payments, and the scheduled payout period is actuarially sound. The applicant or recipient must verify the annuity meets these requirements.

003.05(A)(vi)(2) TRUSTS.

003.05(A)(vi)(2)(a) TRUST. A trust is any written legal instrument, arrangement, or device which is otherwise valid under applicable law and by which an individual, the grantor, transfers property to another person or entity, the trustee, with the intention it be held, managed, or administered under a fiduciary duty by the trustee for the benefit of a designated beneficiary. Trusts can include escrow accounts, investment accounts, pension funds, irrevocable burial trusts, and annuities.

003.05(A)(vi)(2)(b) GRANTOR OF A TRUST. Any individual who creates a trust is the grantor of the trust. A grantor may be:

(i) An applicant or client;

(ii) The spouse of an applicant or client;

(iii) A person or entity, including a court or administrative body, with legal authority to act in place of, or on behalf of, the applicant or client or the spouse of the applicant or client; or

(iv) A person or entity, including a court or administrative body, acting at the direction or upon the request of the applicant or client or the spouse of the applicant or client.

(v) Exception: This subsection does not apply to Third-Party Irrevocable Trusts or Testamentary Trusts.

003.05(A)(vi)(2)(c) TRUST BENEFICIARY. An individual designated by a trust to receive any distribution from the income or principal for the benefit of the individual is a beneficiary of the trust. A distribution from a trust may include cash, non-cash, or property disbursements, including the right to use or occupy real property.

003.05(A)(vi)(2)(d) DISCLOSURE OF TRUST INTEREST. An applicant for or client of medical assistance or the spouse of an applicant for or client of medical assistance who is a grantor or a beneficiary of a trust must report the existence of and provide documentation regarding the trust and any distributions made from the trust to the Department at the time of application for medical assistance and within ten days of the creation of or distributions from a trust after applying for medical assistance.

003.05(A)(vi)(2)(e) AVAILABILITY. Consistent with this chapter and Section 1917(d) of the Social Security Act, and supplementing and not impairing the applicability of any additional requirement contained within this subsection, a trust, or any relevant portion, is considered an available resource if:

(i) The trust was funded with the assets of the applicant or client or the spouse of the applicant or client and there is any circumstance, no matter how remote, in which distribution can be made from the trust to the applicant or client, unless and to the extent an exception contained within this chapter applies;

(ii) The applicant or client or the spouse of the applicant or client is both a trustee and a beneficiary of the trust;

(iii) The terms of the trust require a distribution to the applicant or client or the spouse of the applicant or client;

(iv) The applicant or client or the spouse of the applicant or client, as a matter of general trust administration or interpretation, can compel distribution from the trust;

(v) The applicant or client or the spouse of the applicant or client has the ability to receive loans or payments from the trust based on a current or future right to trust distributions;

(vi) The applicant or client or the spouse of the applicant or client can modify, terminate, or revoke the trust and receive trust assets;

(vii) Regardless of the terms of the trust, the trustee has made trust assets available to the applicant or client or the spouse of the applicant or client; or,

(viii) The Supplemental Security Income program has determined the trust is an available resource for the applicant or client or the spouse of the applicant or client.

003.05(A)(vi)(2)(f) REVOCABLE TRUST. A trust which can be revoked by the grantor of the trust. A trust which allows a court to modify, terminate, or revoke the trust and allow the grantor to receive the trust’s assets is a revocable trust. A trust which claims to be irrevocable and also indicates the trust would terminate if certain action is taken by the grantor is a revocable trust. For a revocable trust:

(i) A distribution from income or from principal made to or for the benefit of the applicant or client or the spouse of the applicant or client is income to the applicant or client;

(ii) Income on the principal of the trust which could be distributed to or for the benefit of the applicant or client or the spouse of the applicant or client is an available resource to the applicant or client;

(iii) The entire principal is an available resource to the applicant or client or the spouse of the applicant or client; and,

(iv) A distribution from income or principal which is not made to or for the benefit of the applicant or client or the spouse of the applicant or client is subject to the provisions regarding transfers of assets for less than fair market value, except, to the extent a trust also contains the assets of someone other than the applicant or client or the spouse of the applicant or client, this provision only applies to those assets attributable to the applicant or client or the spouse of the applicant or client.

003.05(A)(vi)(2)(g) IRREVOCABLE TRUSTS. A trust which cannot in any way be revoked by the grantor of the trust.

003.05(A)(vi)(2)(g)(i) TRUSTS ESTABLISHED BEFORE AUGUST 11, 1993. A Medicaid-qualifying trust is a trust or similar legal device established prior to August 11, 1993 by or legally on behalf of an applicant or client or the spouse of the applicant or client from the assets of the applicant or client or the spouse of the applicant or client under which the applicant or client or the spouse of the applicant or client is the beneficiary of all or some of the distributions from the trust and the trustee is permitted to exercise any discretion with respect to the amount to be distributed, with no use limitation, to the applicant or client or the spouse of the applicant or client. For a Medicaid qualifying trust, the maximum amount which could have been distributed from either the income or principal if the trustee had exercised full discretion under the terms of the trust is considered an available resource.

003.05(A)(vi)(2)(g)(ii) TRUSTS ESTABLISHED ON OR AFTER AUGUST 11, 1993. An Omnibus Budget Reconciliation Act of 1993 trust is a trust or similar legal device which was established other than by will on or after August 11, 1993 by or on behalf of an applicant or client or the spouse of the applicant or client from at least in part the assets of the applicant or client or the spouse of the applicant or client, under which the applicant or client or the spouse of the applicant or client, is a beneficiary of all or some of the distributions from the trust and there is any circumstance under which the trustee can make a distribution to or for the benefit of the applicant or client or the spouse of the applicant or client from all or a portion of the trust. For an Omnibus Budget Reconciliation trust:

(1) A distribution from income or principal made to or for the benefit of the applicant or client or the spouse of the applicant or client is income to the applicant or client;

(2) Income on the principal of the trust which could be distributed to or for the benefit of the applicant or client or the spouse of the applicant or client is an available resource to the applicant or client;

(3) The portion of the principal which could be distributed to or for the benefit of the applicant or client or the spouse of the applicant or client is an available resource to the applicant or client;

(4) A distribution from income or principal which is not made or cannot under any circumstance be made to or for the benefit of the applicant or client or the spouse of the applicant or client is subject to the provisions regarding transfers of assets for less than fair market value, except, to the extent a trust also contains the assets of someone other than the applicant or client or the spouse of the applicant or client, this provision only applies to those assets attributable to the applicant or client or the spouse of the applicant or client; and

(5) To the extent the trust contains discretionary or support terms, or both, regarding the trustee’s authority to distribute trust assets from all or a portion of the trust to or for the benefit of the applicant or client or the spouse of the applicant or client, those assets are an available resource.

003.05(A)(vi)(2)(g)(iv) EXCEPTIONS.

(1) The assets of an irrevocable trust are not available if the trust is established for a disabled applicant or client 64 years old or younger who is receiving or eligible to receive Supplemental Security Income, Retirement, Survivors, and Disability Insurance, or Medicaid in the Aged, Blind, or Disabled category and is a:

(a) Special needs trust: A trust which meets all of the following requirements:

(i) Contains the assets of the applicant or client;

(ii) Established solely for the benefit of the applicant or client;

(iii) Established by the applicant or client (if established on or after December 13, 2016); a parent, grandparent, or legal guardian of the applicant or client; or, a court; and

(iv) The state will receive all amounts remaining in the trust upon the death of the applicant or client or on termination of the trust up to the amount of total medical assistance paid on behalf of the applicant or client; or

(b) Pooled trust: A trust containing the assets of the applicant or client which meets all of the following requirements:

(i) Established and managed by a non-profit association;

(ii) A separate account is maintained for each beneficiary of the trust, but, for purposes of investment and management of assets, the trust pools these accounts;

(iii) Accounts in the trust are established solely for the benefit of individuals who are blind or disabled; and

(iv) The trust provides to the extent any amounts remaining in the applicant’s or client’s account on his or her death are not retained by the trust, the trust will pay to the state the amount remaining up to the amount of total Medicaid paid on behalf of the applicant or client.

003.05(A)(vi)(2)(g)(v) THIRD PARTY IRREVOCABLE TRUSTS. A trust which cannot in any way be revoked by the grantor of the trust and is created and funded during life by a grantor who is neither the applicant or client nor the spouse of the applicant or client. For purposes of eligibility for medical assistance, a distribution from income or principal made to or for the benefit of the applicant or client or the spouse of the applicant or client is income, and income or principal which could be distributed to or for the benefit of the applicant or client or spouse of the applicant or client is an available resource. If the trust contains both discretionary and support terms regarding the trustee’s authority to distribute trust assets from all or a portion of the trust to or for the benefit of the applicant or client or the spouse of the applicant or client, those assets are an available resource to the extent the applicant or client or spouse of the applicant or client can compel distribution as a matter of general trust administration or interpretation. To the extent any relevant essential term of the trust is modified or negated by amendment, agreement, or judicial action after becoming irrevocable, any distribution from income or principal which could have been made to or for the benefit of the applicant or client or the spouse of the applicant or client absent such amendment, agreement, or judicial action is subject to provisions regarding transfers of assets for less than fair market value. A relevant essential term includes but is not limited to terms which delineate the respective interest of beneficiaries or set forth the relative ability to compel distribution.

003.05(A)(vi)(2)(g)(vi) TESTAMENTARY TRUSTS. A testamentary trust is a trust created and funded by a grantor’s will. For purposes of eligibility for medical assistance, a distribution from income or principal made to or for the benefit of the applicant or client or the spouse of the applicant or client is income, and income or principal which could be distributed to or for the benefit of the applicant or client or the spouse of the applicant or client is an available resource. If the trust contains both discretionary and support terms regarding the trustee’s authority to distribute trust assets from all or a portion of the trust to or for the benefit of the applicant or client or the spouse of the applicant or client, those assets are an available resource to the extent the applicant or client or spouse of the applicant or client can compel distribution as a matter of general trust administration or interpretation. To the extent any relevant essential term of the trust is modified or negated by amendment, agreement, or judicial action after becoming irrevocable, any distribution from income or principal which could have been made to or for the benefit of the applicant or client or the spouse of the applicant or client absent such amendment, agreement, or judicial action is subject to provisions regarding transfers of assets for less than fair market value. A relevant essential term includes but is not limited to terms which delineate the respective interests of beneficiaries or set forth the relative ability to compel distribution.

003.05(A)(vi)(2)(g)(vii) GUARDIANSHIPS AND CONSERVATORSHIPS. Neb. Rev. Stat. 30-2654 and 30-2628 require funds in conservatorships or “blocked” accounts be made available for the care and maintenance of the individual whose funds are in the account.

003.05(A)(vi)(2)(g)(viii) ACHIEVING A BETTER LIFE EXPERIENCE (ABLE) ACCOUNTS. The balance of an Achieving a Better Life Experience Account is disregarded as a countable resource. A contribution to an Achieving a Better Life Experience Account is not counted as income for an applicant or client. A distribution from an Achieving a Better Life Experience Account is not considered income, but conversion of a resource. A distribution from an Achieving a Better Life Experience Account for a non-housing Qualified Disability Expense to an applicant or client or his or her financial account is disregarded. A distribution from an Achieving a Better Life Experience Account for a housing Qualified Disability Expense is not counted in the month of receipt. The distribution is counted only if retained in a later month. A distribution from an Achieving a Better Life Experience Account is counted as a resource if it is not spent on a Qualified Disability Expense.

003.05(B) NON-LIQUID RESOURCES. Non-liquid resources are tangible properties which must be sold if they are to be used for the maintenance of an applicant or client. They include all properties not classified as liquid resources.

003.05(B)(i) REAL PROPERTY OTHER THAN THE PRINCIPAL HOME. In computing the amount of a unit's total available resources, the potential sales value of all real property, other than the allowed exemption for the home, must be determined and used.

003.05(B)(ii) JOINT OWNERSHIP OF REAL PROPERTY. Real property jointly owned is excluded if sale of the property would cause the other owner undue hardship. However, if undue hardship does not apply or ceases to exist, the property is included in countable resources and handled according to the following regulations.

003.05(B)(ii)(1) ALL OWNERS AGREE TO LIQUIDATE. If an applicant or client owns a property with other persons who are not on Medicaid and the real property is not the principal place of residence for the other owner, the other owners must be contacted to determine if they are willing to liquidate their interest in the property. If all parties are willing to liquidate, the liquidation proceeds.

003.05(B)(ii)(2) ONE OR MORE OWNERS DO NOT AGREE TO LIQUIDATE. If one or more of the parties do not wish to liquidate, the process for unavailability of a resource is applied, which requires the applicant or client to take legal action to force a sale of the property. A written statement may be obtained from the other parties and filed in the case record. After a legal determination is made regarding the availability of the applicant’s or client’s interest in the property, appropriate action must be taken.

003.05(B)(iii) EXEMPTION OF THE HOME. The applicant’s or client’s home is exempt from consideration as an available resource, subject to the limitations below.

003.05(B)(iii)(1) DEFINITION OF HOME. Home is defined as any shelter which an individual owns and uses as his or her principal place of residence. The home includes any land on which the house is located and any related outbuildings necessary to the operation of the home.

003.05(B)(iii)(2) HOME EQUITY VALUE. For applications on or after January 1, 2006, an applicant or client is not eligible for any long-term care services if the equity value interest in the home exceeds the specified amount as listed in the appendix to this title.

003.05(B)(iii)(3) ADJACENT LOTS. A lot adjacent to the home is considered available if it can be sold separately from the home. If it is determined and documented in the case record a lot adjacent to the home cannot be sold or is not salable due to the location or condition of the property, the adjacent lot is also exempt.

003.05(B)(iii)(4) REMOVAL FROM HOME. If an applicant or client moves away from the home and does not plan or is unable to return, it must be determined when the home becomes an available resource in accordance with the following provisions. The home continues to be exempt as a resource while it is actually occupied by the applicant’s or client’s spouse or dependent relative. A dependent relative includes the client's:

(a) Child, stepchild, or grandchild 17 years old or younger;

(b) Child, stepchild, or grandchild 18 years old or older if aged, blind, or disabled; or

(c) Brother, sister, stepbrother, stepsister, half-brother, half-sister, parent, stepparent, grandparent, aunt, uncle, niece, nephew, or the spouse of any persons previously named, even after the marriage has been terminated by death or divorce, who is receiving or who would be eligible for categorical assistance except for income and resources and who lived in the home at any time one year before the client moved away from the home.

003.05(B)(iii)(5) ABILITY TO RETURN HOME. When it is not possible to determine immediately whether an applicant or client who moves to a nursing home or assisted living facility and is receiving Aged and Disabled Waiver services will be able to return to the home, a maximum of six months must be allowed to make this determination. Unless the applicant, client, or his or her authorized representative signs a statement which the applicant or client will not return to the home, or the home is already listed for sale, it is not possible to determine immediately if he or she will return home.

003.05(B)(iii)(6) CLIENT OUT OF THE HOME FOR SIX MONTHS. After an applicant or client lives out of the home for a maximum of six months, the home is no longer considered the applicant’s or client’s principal place of residence and must be considered an available resource. However, the applicant or client is allowed a reasonable amount of time commensurate with then existing conditions to liquidate the property before it affects eligibility. The six months begin with the first full month following the month of admission to a nursing home or assisted living facility, if receiving Home and Community Based Services or Programs of All-Inclusive Care for the Elderly services. After the applicant or client is admitted, if the home is exempt because it is occupied by one or more of the relatives identified previously, the six months begin with the first full month following the month the home is no longer allowed the exemption for occupation.

003.05(B)(iii)(6)(a) LIQUIDATION OF HOME. As soon as the determination is made the applicant or client will not be able to return home, the applicant or client must be allowed time to liquidate the property. The applicant or client is also allowed time for liquidation if he or she leaves the home for a reason other than entering a medical institution.

003.05(B)(iii)(7) SALE OF HOME. If an applicant or client sells his or her home, the net proceeds become an available resource unless reinvested immediately in another home. In order to be allowed time to reinvest the proceeds, an applicant or client must be residing in the home at the time of the sale and move directly to his or her new home. Net proceeds are the remainder after payment of the mortgage, realtor's fees, legal fees, etc. Any deductions must be verified.

003.05(B)(iv) LIQUIDATION OF REAL PROPERTY. When an applicant or client has excess resources because of real property, he or she may receive Medicaid pending liquidation of the resource, according to the following regulations. An applicant or client is not entitled to a liquidation period if disregarding the value of the property would allow the applicant or client to begin a sanction period for a deprivation of resources. This reference does not apply if the community spouse under spousal impoverishment regulations will retain any of the proceeds of the sale. If an applicant or client has excess resources because of real property other than his or her home during a retroactive period, he or she is ineligible for Medicaid. The applicant or client may be prospectively eligible with excess resources because of real property if an Agreement to Sell Real Property Form is signed.

003.05(B)(iv)(1) TIME LIMIT FOR LIQUIDATION. Real property which an applicant or client is making a good faith effort to sell must be excluded. First, it must be determined if the applicant or client has the legal authority to liquidate the property. The applicant or client is allowed 60 days to initiate legal action to obtain liquidation. If the applicant or client owns the property with other persons, the applicant or client must obtain the legal authority to liquidate the property. Once the applicant or client has the legal authority to liquidate the property, the client's signature on the Agreement to Sell Real Property Form must be obtained. The applicant or client is allowed six calendar months to liquidate the real property. If the applicant or client refuses to sign the Agreement to Sell Real Property Form, he or she is immediately ineligible due to excess resources. The six-month period begins with the month following the month in which the Agreement to Sell Real Property Form is signed. Once the Agreement to Sell Real Property Form is signed, the six calendar months are counted whether or not the applicant or client is receiving Medicaid. If, after the Agreement to Sell Real Property Form is signed, the applicant or client goes into current pay status for Supplemental Security Income, the Agreement to Sell Real Property Form is void.

003.05(B)(iv)(1)(a) SUPPLEMENTAL SECURITY INCOME NON-PAY STATUS DURING LIQUIDATION PERIOD. If the applicant or client later goes into non-pay status for Supplemental Security Income, a new Agreement to Sell Real Property Form is signed and a new six-month liquidation period is established. If the applicant or client moves back to the home and subsequently moves out again during the six-month period, he or she is only allowed the months remaining in the original six-calendar-month period. One liquidation period is allowed for each piece of real property which is determined to cause excess resources, even if the case is closed and subsequently reopened.

003.05(B)(iv)(2) EXTENSION OF TIME LIMIT. If an applicant or client is unable to liquidate a property in six calendar months, the Department may authorize one additional three-calendar-month extension. The three calendar months are counted whether or not the applicant or client is receiving Medicaid. If the applicant or client moves back to the home during the three-month period and subsequently moves out again, he or she is allowed the months remaining in the initial three-month extension. In determining whether to allow a three-calendar-month extension, the Department will consider:

(a) If the property has been placed on the market with a real estate licensee;

(b) If the applicant or client is asking a fair price for the property;

(d) If the applicant or client understands the requirement for liquidation of the property;

(e) If the applicant or client has refused a reasonable offer to purchase, defined as at least 2/3 of either the estimated current market value or the proven actual value, if there is no better offer; and

(f) The economic conditions in the area and if real estate is selling.

003.05(B)(v) MOTOR VEHICLES. One motor vehicle regardless of its value, as long as it is necessary for an applicant or client or a member of his or her household for employment or medical treatment, is disregarded. If an applicant or client has more than one motor vehicle, the vehicle with the greatest equity must be excluded. Any other motor vehicles are treated as non-liquid resources and the equity is counted toward the resource limit. An applicant’s or client’s verbal statement the motor vehicle is used for employment or medical treatment is sufficient for verification purposes.

003.05(B)(v)(1) EXCEPTIONS. Exceptions include:

(a) The disregard of any motor vehicle is not allowed when it has been determined a client residing in a nursing home or an assisted living facility and receiving services through Home and Community Based Services or Programs or All-Inclusive Care for the Elderly does not intend, or will not be able to return home if medical transportation is included in the payment to the facility; or

(b) The applicant or client designates the disregarded vehicle for Assessment of Resources.

003.05(B)(v)(2) DETERMINATION OF FAIR MARKET VALUE. For motor vehicles which are counted toward the resource total, fair market value is used. Cars, trucks, SUVs, vans, motorcycles, recreational vehicles, motorboats, watercraft, and planes are included in the category of motor vehicles.

003.05(B)(vi) LIFE ESTATES. The owner of a life estate in real property is generally unable to sell the property. The net income from the life estate must be included in the budget rather than considering the life estate as an available resource. If the owner of a life estate transfers it to another individual, it must be determined whether or not it is deprivation of a resource. If the life estate is sold, the proceeds are counted as resources. Examples of treatment of life estate income are available in the appendix to this title. It is a disposal of assets to purchase a life estate interest in another individual’s home unless the purchaser resides in the home for at least 12 months after the date of purchase. The Life Estate Interest Table is available in the appendix to this chapter.

003.05(B)(vii) ESSENTIAL PROPERTY. Resources which are used in an applicant, client, or responsible relative’s trade or business are disregarded, regardless of value. Land which is leased or rented out to another person or entity or land enrolled in an agricultural development program is not disregarded. Disregarded property includes:

(1) Real property such as land, houses, buildings, business equipment and fixtures, farm machinery, tools, safety equipment, livestock, and crops used for a client’s trade or business; and

(2) Business bank accounts, as long as the funds are separated from other liquid resources.

003.05(B)(viii) HOUSEHOLD GOOD AND PERSONAL EFFECTS. Household goods and personal effects are exempt. Household goods include:

(1) Household furniture;

(2) Furnishings and equipment used in the operation, maintenance, and occupancy of the home or in the functions and activities of the home and family life;

(3) Those items which are for comfort and accommodation; and

(4) Personal effects.

003.05(B)(ix) NON-BUSINESS PROPERTY FOR MEDICAID IN THE AGED, BLIND, AND DISABLED CATEGORY. A maximum of $6,000 in equity value of nonbusiness property which is used to produce goods or services essential to daily activities is excluded from resources. Any equity in excess of $6,000 is counted as a resource. Examples are available in the appendix to this title.

003.05(C) INHERITANCE. When an applicant or client receives an inheritance, verified payment of debts or obligations of the deceased are subtracted from the settlement, and the remainder is considered unearned income.

003.06 EXCLUDED RESOURCES. The worth of resources, both available and excluded, is determined on the basis of their equity. Disregarded income is also disregarded as a resource, unless there is a specific regulation stating otherwise. In addition, the following resources are excluded in making a determination of eligibility:

(1) Real property the individual owns and occupies as a home;

(2) Household goods and personal effects;

(3) Cash surrender value of life insurance policies with combined face values of $1,500 or less per individual;

(4) A specified maximum in proceeds from an insurance policy irrevocably assigned for the purpose of burial of the client;

(5) Irrevocable burial trusts up to the specified amount per individual and the interest if irrevocable;

(6) Burial space items or a contract for the purchase of burial space items owned by a client or designated family member;

(7) Burial spaces;

(8) Up to $1,500 set aside for burial arrangements;

(9) One motor vehicle;

(10) Certain life estates in real property;

(11) Income received annually, semi-annually, or quarterly which is prorated on a monthly basis and included in the budget. This income is excluded as a resource over the period of time it is being considered as income;

(12) The unspent portion of any Retirement, Survivors, and Disability Insurance (RSDI) or Supplemental Security Income (SSI) retroactive payments (excluded for six months following the month of receipt);

(13) U.S. savings bonds, which are excluded for the initial 12 month mandatory retention period;

(14) A resource used in the client's trade or business;

(15) A maximum of $6,000 equity value of nonbusiness property, real or personal, used to produce goods or services essential to daily activities for the Aged, Blind, and Disabled categories;

(16) The unspent portion of an Aid to the Aged, Blind, and Disabled (AABD) payment or State Disability Program retroactive payment, which is excluded for six months following the month of receipt;

(17) Victims compensation payments, which are excluded for nine months beginning with the first month after receipt;

(18) Payments received from a state or local government to assist in relocation, which are excluded for nine months beginning with the first month after receipt;

(19) An unavailable job-related retirement account held by the employer;

(20) An Individual Development Account;

(21) Medicare set-aside accounts which may be used only for payment of medical bills of Medicare beneficiaries;

(22) Funds held in an Achieving a Better Life Experience (ABLE) account; and

(23) An account excluded under the Social Security Program to Achieve Self-Support (PASS).

003.06(A) MONETARY FUNDS TO BE EXCLUDED. For any of these resources in the form of monetary funds to be excluded, they must be segregated in a separate account so they can be identified. If the funds are not in a separate account, an applicant or client is allowed 30 days from notification of the requirement to set up a new account. After 30 days, the resource is included in the resource limit if the applicant or client fails to segregate the funds. Several excludable resources may be combined in a single account.

003.06(B) EXCLUDED RESOURCES FOR AMERICAN INDIANS AND ALASKA NATIVES.

003.06(B)(i) LEGAL BASIS. As established under the American Recovery and Reinvestment Act of 2009, states are required to exclude certain types of property specific to American Indians and Alaska Natives as resources when determining Medicaid eligibility for an individual who is an American Indian or an Alaska Native.

003.06(B)(i)(1) DEFINITION OF AMERICAN INDIAN OR ALASKA NATIVE. Anyone who, pursuant to 25 U.S.C. § 1603(c) & (f) and 25 U.S.C §1679(b), or 42 C.F.R. 136.12 or Title V of the Indian Health Care Improvement Act, is eligible to receive health care services from Indian health care providers or through referral under Contract Health Services. The following resources are excluded in making a determination of Medicaid eligibility for an individual who is an American Indian or Alaska Native:

(a) Property, including real property and improvements, which is held in trust, subject to federal restrictions, or otherwise under the supervision of the Secretary of the Interior, located on a reservation, including any federally recognized Indian Tribe’s reservation, pueblo, or colony, including former reservations in Oklahoma, Alaska Native regions established by the Alaska Native Claims Settlement Act, and Indian allotments on or near a reservation as designated and approved by the Bureau of Indian Affairs of the Department of the Interior;

(b) For any federally recognized Tribe not described in paragraph 1, property located within the most recent boundaries of a prior federal reservation; Ownership interests in rents, leases, royalties, or usage rights related to natural resources, including extraction of natural resources or harvesting of timber, other plants, and plant products, animals, fish, and shellfish, resulting from the exercise of federally protected rights;

(c) Ownership interests in or usage rights to items not covered by paragraphs one through three which have unique religious, spiritual, traditional, or cultural significance, or rights supporting subsistence or a traditional lifestyle according to applicable tribal law or custom; and,

(d) Historical Accounting Class and Trust Administration Class payments made under the Claims Resolution Act of 2010 are excluded as a resource for one year from the date of receipt.

003.07 DETERMINATION OF OWNERSHIP OF RESOURCES. A resource appearing on record in the name of an applicant or client or responsible relative as defined in Chapter 24 or this title must be considered to belong to the applicant or client. Ownership of real estate must be verified through records in the offices of the register of deeds or county clerk. If it is substantiated the applicant or client is not the true owner of a resource, it is permissible to allow the applicant or client to remove his or her name from the title of ownership in order to reflect true ownership. The applicant or client is allowed 60 days to make this change without affecting eligibility. After the applicant or client removes his or her name from the resource, eligibility may be determined retroactively or prospectively, as applicable. If the applicant or client does not remove his or her name within 60 days, the resource is counted.

003.07(A) REAL ESTATE. Ownership of real estate is verified through records in the offices of the register of deeds or county clerk. The terms on which property is held in cases of joint ownership must be verified. Transfer on Death Deed must be revoked for initial and continued eligibility. This includes real property owned by a community spouse. Procedures are available in the appendix to this title.

003.07(B) JOINTLY OWNED RESOURCES.

003.07(B)(i) RESOURCES OWNED WITH OTHER CLIENTS. If an applicant or client owns a resource with another applicant or client, the value of the resource is divided by the number of owners, regardless of the terms of ownership. The appropriate value is counted for each unit. This reference also applies to resources owned with a spouse or child.

003.07(B)(ii) RESOURCES OWNED WITH NON-CLIENTS. If an applicant or client owns a resource with an individual who is not receiving Medicaid, the following regulations apply:

003.07(B)(ii)(1) MOTOR VEHICLES. Ownership of a motor vehicle is verified by the title. The number of individuals on the title legally determines the percentage of ownership.

003.07(B)(ii)(2) BANK ACCOUNTS. The terms of the account are verified with the bank. If any person on the account is able to withdraw the total amount, the full amount of the account belongs to the applicant or client. If all signatures are required to withdraw funds, the proportionate share must be counted toward the applicant or client. If the applicant or client verifies none of the funds belong to him or her, the applicant or client must be allowed 60 days to remove his or her name from the account. The applicant or client must provide proof of the change. After the applicant or client removes his or her name from the bank account, eligibility may be determined retrospectively or prospectively, as applicable. If the applicant or client does not remove his or her name within 60 days, the funds are counted as a resource. If a portion of the funds belongs to the applicant or client, the applicant or client must be notified of the requirement to place the funds in a separate account. Verified contributions to the account determine ownership if ownership is disputed.

003.08 RESOURCES OF OTHER INDIVIDUALS COUNTABLE IN A CLIENT’S BUDGET.

003.08(A) RESOURCES OF AN INELIGIBLE OR SANCTIONED PARENT FOR MEDICALLY NEEDY. The resources of an ineligible or sanctioned individual or parent are included in the resource total for the eligible unit members. The ineligible or sanctioned individual or parent is allowed Medicaid resource exclusions. After resource exclusions, the remaining resource amount is counted in the resource total of the eligible unit members.

003.08(B) INDIVIDUAL ADDED TO AN EXISTING UNIT. The resources of the total unit, the previous unit plus the added individual, are compared to the resource maximums based on the total unit size.

003.08(C) DEEMING RESOURCES OF A PARENT. Resource exclusions listed in this chapter apply to the parent's resources. The resources of the eligible child's siblings are not counted toward the child’s resource total. If income of a parent is not deemed according to chapter 24 of this title, resources are also not deemed. In considering the resources of a parent counted toward the resource total of a child 17 years old or younger who is eligible for Medicaid in the Aged, Blind, or Disabled category or a medically needy child 18 years old or younger who is eligible and living in the parent's household, the following resources are counted for the child whether or not they are actually made available:

(i) All resources exceeding $4,000 in the case of one parent; or

(ii) All resources exceeding $6,000 in the case of:

(1) Two parents;

(2) One parent and the spouse of the parent; or

(3) One parent and one minor sibling; and

(iii) $25 for each additional minor sibling in the parent's household.

003.09 DETERMINATION OF VALUE OF TOTAL AVAILABLE RESOURCES. The total value of all available resources is the total value of real and personal property determined according to the preceding guidelines.

003.10 MAXIMUM AVAILABLE RESOURCE LEVELS. The established maximums for available resources which an applicant or client may own and still be eligible are as follows:

(1) One member unit: $4,000;

(2) Two member unit or family: $6,000;

(3) Three member unit or family: $6,025; or

(4) Each additional individual: + $25.

003.10(A) CLIENTS RESIDING IN THE SAME HOUSEHOLD. If two or more related Aged, Blind, or Disabled clients, other than a married couple, reside in the same household, each client is entitled to a resource maximum of $4,000. The treatment of resources of a spouse or a parent is the same as for an applicant or client. If the total equity value of available non-excluded resources exceeds the maximums specified in this chapter, the applicant or client is ineligible. Resources must be below the maximum resource level for one day in the month in order for the applicant or client to be eligible for the month.

003.11 REDUCTION OF RESOURCES. The applicant or client may reduce available resources to the allowable limit if the case record contains documentation the resources have been reduced and the unit is within the allowable resource limits. An applicant who has excess resources other than real property may have his or her application held pending until the resources are reduced. An applicant or client may reduce his or her resources by paying any secured or unsecured debts, purchasing personal property, establishing burial funds, or expending the resources in any manner the applicant or client deems appropriate. If the applicant or client is in a medical institution or receiving waiver services, he or she cannot give away resources in order to establish eligibility. If the applicant or client is not in a medical institution or receiving waiver services, giving away the excess resources is not considered a deprivation of a resource. If the applicant or client reduces resources in any way except paying on outstanding medical bills, eligibility is effective the first day of the month in which the resources are actually expended, if all other eligibility factors are met. The applicant or client’s statement of expenditures is acceptable as verification.

003.11(A) REDUCTION OF RESOURCES TO ESTABLISH EARLIER MEDICAID EFFECTIVE DATE. An applicant or client may do a reduction of resources to establish an earlier Medicaid effective date if he or she has outstanding medical bills. However, eligibility may not begin earlier than the third month before the month of application. In order for an applicant or client with excess resources to establish an earlier effective date, he or she must pay all of the excess resources on medical bills incurred no earlier than the third month before the month of application. The medical expense does not have to be a Medicaid-covered service. The applicant or client should pay on the oldest medical bills incurred within the retroactive period and continue paying bills until the amount of the excess resources has been expended. Once it has been determined there are medical expenses in the retroactive period, the applicant or client is given 90 days to complete the reduction of resources on medical expenses. Medicaid eligibility may begin with the first day of the month in which the last medical bill was paid, which reduced the resources to the allowable limit. Expenditures for medical bills must be verified. If an applicant has excess resources in the month of application, it is not necessary to verify resources in any of the retroactive months. The spend-down of the excess resources from the month of application is all which is necessary. If the applicant does not have excess resources in the month of application, resources must be verified in the oldest retroactive month in which the applicant has outstanding medical bills. If there are excess resources during this retroactive month, only this amount of excess resources must be used to complete the resource spend-down. Procedures related to documenting a resource spend-down are available in the appendix to this title.

003.12 RESOURCE REQUIREMENTS FOR MEDICARE SAVINGS PLAN (MSP) CLIENTS.

003.12(A) WORKING DISABLED PART A MEDICARE BENEFICIARIES. Resources are treated according to the Maximum Available Resource Levels in this chapter.

003.12(B) SPECIFIED LOW-INCOME MEDICARE BENEFICIARIES (SLMB) AND QUALIFIED INDIVIDUALS-1 (QI-1). Resource limits are adjusted annually by the Centers for Medicare and Medicaid Services, and are available in the appendix to this title.

003.12(C) MEDICARE SAVINGS PLAN AND QUALIFIED MEDICARE BENEFICIARIES (QMB). Resource limits are adjusted annually by the Centers for Medicare and Medicaid Services, and are available in the appendix to this title.

History

Effective 2020-10-04

24-001 RELATIVE RESPONSIBILITY : In determining eligibility, the Department must consider as available to a client the income and resources of

A parent (biological, adoptive, or step) for a child if the child is eighteen (18) years old or younger and is still considered part of the household; and
One spouse for another spouse.

24-001.01 Parent for Child Relative Responsibility

24-001.01A Child Considered Part of Household: If a child is living in the same household with his/her parent(s), the parent(s)'s income and resources must be considered available to the child.

24-001.01A1 Exceptions: A parent(s)’s income and resources are not considered available to

i. A pregnant minor who, pursuant to Neb. Rev. Stat. section 71-6903, is denied financial support by her parents, guardians, or custodians due to her refusal to obtain an abortion, and is therefore considered emancipated for purposes of public assistance;

ii. A child receiving Home and Community-Based Waiver;

iii. A child receiving Developmental Disability Waiver; or

iv. A child approved for Katie Beckett Medicaid. See 477 NAC 24-001G2b(1) and 477 NAC 27-009.

24-001.01A2 Temporary Absence: If a child is temporarily absent from the home (ninety (90) days or fewer) but is still considered part of the household, the parent(s)'s income and resources must be considered available to the child. Temporary absence includes, but is not limited to

School attendance where the child returns to the home on a regular basis (weekends, vacations, or summers).
Residence in an institution for a developmental disability or mental illness for 90 days or fewer may be considered temporary absence if the child was living in his/her parent(s)'s household before institutionalization and will return to the parent(s)'s household upon discharge.

24-001.01B Child No Longer Considered Part of Household: If a child is permanently out of the home and no longer considered part of the household, his/her parent(s)'s income and resources shall not be considered available to the child.

24-001.01C Determination of Paternity: Paternity cannot be established unless an alleged father has signed a birth certificate, written and notarized paternity acknowledgment form or a court has determined him to be the father.

Note: Paternity cannot be established for an unborn.

24-001.01C1 Unmarried Parents: When unmarried parents are living together, the alleged father is not financially responsible unless he has acknowledged paternity or a court has determined that he is the father of the child after the birth.

24-001.01C2 Children of a Marriage: Married individuals are considered the parents of any children who are conceived or born during a marriage, even if the couple is separated, has filed for divorce or annulment, or states that one individual is not the parent of the child, unless there is a court order that states otherwise.

24-001.01D Military Service: If a parent is absent due to active duty in the uniformed services of the United States, that parent is still considered part of the assistance unit and his/her income is considered available to the unit. Uniformed service is defined as the Army, Navy, Air Force, Marine Corps, Coast Guard, Environmental Sciences Services Administration, and Public Health Service of the United States. If the client states that separation is due to reasons other than performance in military service, the client must provide proof of bona fide separation.

If the parent in the military is incarcerated, s/he is no longer considered part of the assistance unit.

24-001.01E Joint Physical Custody: In a household where both parents are present, though not necessarily continuously, income and resources of each must be used in a child’s eligibility determination and the needs of both parents included in the unit. This includes situations in which the non-custodial parent has sufficiently frequent contact with the child(ren) so that the normal parental roles of providing guidance, physical care, and maintenance have not been interrupted.

This policy applies when there is joint physical (shared) custody in which the physical custody of the child(ren) is split between both parents. This can be either on a scheduled basis as included in a divorce decree or on an informal basis as agreed to by both parents. The percentage of time spent with each parent is irrelevant in a joint custody arrangement for Non-MAGI cases.

24-001.01F Special Provisions Pertaining to Minor Parents

24-001.01F1 Minor Parent: If a minor parent has a legal guardian, according to Nebraska law, the guardian has no financial responsibility for the minor.

24-001.01F2 Medically Needy Minor's Parent(s): If a minor parent is living with his/her medically needy parent(s) who is receiving Medicaid for another child, the minor parent must be in his/her parent(s)’s unit.

If assistance is received for the minor’s child, that child must also be in the parent(s)’s unit.

When a minor parent becomes emancipated, graduates from secondary school at age 18, or reaches age 19, s/he and his/her child become a separate unit.

Note: The family is not required to receive Medicaid for the minor’s child.

24-001.01F3 Minor Living in Parent(s)’ Home: If a minor is living in his/her parent(s)’ home, s/he is considered emancipated if s/he has married. If the minor has married, s/he may be a separate unit with his/her child. If the marriage is annulled, the minor is not considered emancipated.

24-001.01F4 Minor Not Living with Parent(s): If the parent(s) has been contributing to the support of the minor, written verification from the parent(s) of his/her plans to continue or not continue to support is required.

24-001.01F5 Minor Parent Living with Specified Relative, Guardian, or Conservator: A minor parent who is living with a specified relative, guardian, or conservator is considered emancipated unless the minor parent is being supported from his/her parent(s), guardian, or conservator.

Note: See 477 NAC 1-001 for a list of specified relatives.

24-001.01G Deeming Provisions for ABD Children

24-001.01G1 Parent for Child: If an ABD child age 17 or younger is living in the household of his/her parent(s), the income and resources of the parent(s) shall be deemed (i.e., determined available).

See 477 NAC 24-002.03 for exceptions to this deeming requirement.

24-001.01G2 Disabled Child Not Receiving SSI

24-001.01G2a Deeming Income and Resources of Responsible Persons: A parent(s)’s income and resources are considered in determining the eligibility of a child age 17 or younger who is part of the household when the disabled child does not receive SSI.

When there is a self-supporting parent(s) for children in two different program cases, the procedures for deeming found below are followed and the resulting deemed income and resources are divided between the program cases containing the children on ABD. A portion of the income and resources of these individuals is deemed to the child using the following procedures.

24-001.01G2b Neither Parent nor Child is Receiving SSI: If neither a disabled child nor his/her disabled parent(s) is receiving SSI, and the child is living in the same household with his/her parent(s), the parent(s)'s income and resources must be deemed, with the following exceptions.

24-001.01G2b(1) Exceptions:

Home and Community-Based Waiver: If a child living in his/her parent(s)'s home is receiving Medicaid services through a Home and Community-Based Service waiver, the parent(s)'s income and resources are not deemed when determining eligibility for Medicaid.
Katie Beckett: If a child is not receiving waiver services, the income and resources of a parent are not deemed for Medicaid if the child is severely disabled and would require the level of care provided in a medical institution as well as certain medical services for special needs (a Katie Beckett child; see 477 NAC 27-009).

24-001.01G3 Child Receiving SSI: If a child age 17 or younger leaves a nursing facility or hospital where s/he was receiving an institutional personal needs amount SSI payment and goes home under a waiver, SSI must be notified of the waiver eligibility. Even though income and resources of the parent(s) may make the child ineligible for SSI, if the child is waiver-eligible, SSI continues the institutional personal needs amount payment without deeming income and resources of the parent(s).

Note: If the parent(s) is receiving SSI, none of the parent(s)’s income shall be deemed.

24-001.01G4 Child in an IMD: If a child under age 19 is placed in an IMD and is a ward of the Department or another public agency, or if the placement is court-ordered, see 477 NAC 25-001. If the child who is placed in an IMD is still considered part of the household, the parent(s)’ income is deemed. See Appendix 477-000-009 for calculation procedures.

24-001.02 Special Provisions Pertaining to Spouse-for-Spouse Relative Responsibility for ABD

24-001.02A Divorce and Separation: A divorce dissolves the marriage of a couple and there is no longer spouse-for-spouse responsibility. A legal separation does not dissolve the marriage.

24-001.02B Determining Financial Responsibility for a Married Couple:

24-001.02B1 Living Together without Medicaid Waiver or Program of All-Inclusive Care for the Elderly (PACE) Services: The income and resources of spouses living together in the same household shall be considered available to each other. The resource standard for two shall be used to determine eligibility whether one spouse or both are eligible.

Exception: If one spouse is receiving VA benefits, and is eligible for ABD Medicaid, then eligibility shall be determined separately. This only applies if the couple would be ineligible for SSI as a couple. If they would both be eligible for SSI, the non-SSI spouse must apply.

24-001.02B2 Living Together with Medicaid Waiver or PACE Services: If only one spouse is eligible for ABD Medicaid, then use the spousal impoverishment treatment of resources and income. An assessment and designation of resources must be completed. See 477 NAC 26-003.01B and 477 NAC 26-003.01F. If both spouses are eligible for ABD Medicaid, then eligibility shall be determined separately. The resource standard for one shall be used for each spouse. The combined resources must be $8,000 or less.

24-001.02B3 Living Apart and Neither in a Specified Living Arrangement: Eligibility shall be determined separately beginning the first full month the couple ceases to live together. Consider only the income and resources in the applicant spouse’s name. The spouse shall be allowed a resource standard for one, and eligibility shall be determined separately. Total countable resources for each spouse must not exceed $4,000. This guideline shall be followed whether one spouse or both are eligible.

24-001.02B4 Living Apart and Both in a Specified Living Arrangement: If both spouses are in a specified living arrangement (see 477 NAC 26-001), eligibility is determined as follows: Consider the income of each spouse separately.

Consider the resources that each spouse has in their own name. Combined resources must be below $8,000. Each spouse shall be allowed a resource standard for one. This guideline shall be followed whether one spouse or both are eligible.

24-001.02B5 Living Apart with One in a Specified Living Arrangement: If only one spouse is eligible for ABD Medicaid, spousal impoverishment rules apply for treatment of income and resources (see 477 NAC 26-004 and 477 NAC 26-003). An assessment and designation of resources must be completed (see 477 NAC 26-003.01B and 477 NAC 26-003.01F). The spouse shall be allowed the resource standard for one. If both spouses are eligible and one enters a specified living arrangement, income and resources shall be considered separately beginning the first full month the couple ceases to live together. Each spouse shall be allowed a resource standard for one. Combined resources must be $8,000 or less.

Note: If one spouse is temporarily absent from the home, the couple's income and resources shall continue to be considered together. An absence of fewer than 90 days is considered temporary. If the spouse will be absent more than 90 days, the spouse’s plans or ability to return home shall be evaluated.

24-001.02C Spouse for Spouse Hardship Exemption: A hardship exemption may be granted to enable an eligibility determination using only the applicant’s resources in cases where it is noy possible to verify the resources of the non-institutionalized spouse due to inability to obtain complete information. This exemption can only be granted by Central Office.

Note: If the community spouse is assisting the applicant with the application process or was living with the institutionalized spouse just prior to institutionalization, spouse for spouse financial responsibility applies.

24-002 SPONSOR DEEMING FOR ALIENS

24-002.01 Sponsors for Aliens: One hundred (100) percent of the income and resources of a sponsor (and sponsor’s spouse, if they are living together) shall be considered when determining the eligibility of an alien who applies for Medicaid if the sponsor has signed an affidavit of support under Section 213A of the Immigration and Nationality Act. Alien status must be verified by electronic data sources. The sponsor’s income and resources will be considered available to the alien until one or more of the following circumstances apply:

The individual becomes a U.S. citizen;
The individual has worked 40 qualifying quarters of coverage as defined under Title II of the Social Security Act or can be credited with the qualifying quarters as provided under Section 435, and the alien did not receive any federal means tested public benefit during that time period. This provision does not apply to restricted Medicaid;
The individual is pregnant (including 60 days post-partum); and/or The individual is under age 19.

24-002.02 Sponsor of More than One Alien: When an individual is a sponsor for two or more aliens who are living in the same home, the amount of deemed income and resources of the sponsor (and the sponsor’s spouse, if living with the sponsor) is divided equally among the aliens. When an individual sponsors several aliens but not all apply for Medicaid, the sponsor's total deemable income and resources is applied to the needs of the aliens who apply for Medicaid.

24-002.03 Deeming Exceptions

24-002.03a Battery or Extreme Cruelty: If a sponsored immigrant demonstrates that s/he or his/her child(ren) have been battered or subjected to extreme cruelty by a spouse, a parent, or by a member of the spouse’s or parent’s family who is residing in the same household as the alien, deeming may be waived if a judge, an administrative judge, or the U.S. Citizenship and Immigration Services (USCIS) recognize the battery or cruelty.

24-002.03b Categorically Ineligible Spouse: The sponsor’s deemed income and resources for a categorically ineligible spouse (e.g., not aged, blind, or disabled) are not deemed to the non-sponsored eligible spouse.

24-002.04 Alien Duties: As an eligibility requirement, the alien is responsible for:

Providing income and resource information from the sponsor; and
Obtaining the necessary cooperation from the sponsor.

If the alien does not provide the necessary information, s/he is not eligible.

History

Effective 2018-03-13

Chapter 25 Budgeting for the Medically Needy

Neb. Admin. Code tit. 477, ch. 25 Budgeting for the Medically Needy {#sec-477-nac-25 omnilex-key=us-ne-regs-official--title-477--477 NAC 25}

TITLE 477 MEDICAID ELIGIBILITY

CHAPTER 25 BUDGETING FOR THE MEDICALLY NEEDY

Chapters 477 Nebraska Administrative Code (NAC) 20 through 28 apply to the following: Aged, Blind, and Disabled (ABD); Medically Needy (MN); Medicaid Insurance for Workers with Disabilities (MIWD); Women’s Cancer Program; Transitional Medical Assistance (TMA); Former Foster Care; Emergency Medical Services Assistance (EMSA); Children and Young Adults Eligible for IV-E Assistance

001. SCOPE AND AUTHORITY . These regulations govern services provided by the Nebraska Medicaid program as defined by the Medical Assistance Act, Nebraska Revised Statutes (Neb. Rev. Stat.) §§ 68-901 et seq.

002. ELIGIBILITY FOR THE MEDICALLY NEEDY.

002.01 WHEN APPLICABLE. Children, parents or caretaker relatives, pregnant women, and the aged, blind, and disabled who have income above the limit for categorical eligibility may be eligible for Medicaid with a share of cost if a medical need exists or can be reasonably expected to exist. A medical need exists if medical costs for the financial unit exceed the Medically Needy Income Limit (MNIL) for the unit size.

002.02 BUDGET. A budget or system must be used to determine eligibility for medically needy individuals. Each month is determined separately. If an individual is eligible for one day of the month, then that person is considered to be eligible for the entire month. If at any time factors change that affect eligibility, then eligibility must be re-determined.

002.03 METHODOLOGY USED. The methodology used for the medically needy is based upon the most closely related cash assistance methodology. Income is counted in accordance with 477 Nebraska Administrative Code (NAC) 22. Resources are counted in accordance with 477 NAC 23.

002.03(A) MEDICALLY NEEDY CHILDREN, FAMILIES, AND PREGNANT WOMEN. The treatment of income and resources for medically needy children, parents or caretaker relatives, and pregnant women is based on § 1931 of the Social Security Act.

002.03(B) MEDICALLY NEEDY AGED, BLIND, AND DISABLED. The treatment of income and resources for individuals who are aged, blind, or disabled is based on the methodology of the Supplemental Security Income (SSI) program.

002.04 STANDARD LEVELS. When computing a budget for medically needy individuals, the unit or family size is determined according to 477 NAC 24.

003. CALCULATING THE SHARE OF COST.

003.01 MEDICALLY NEEDY NOT RECEIVING LONG-TERM CARE SERVICES AND SUPPORTS. Medically needy individuals who are not residing in a medical institution or who do not receive Home and Community-Based Services (HCBS) have a share of cost (SOC)

calculated according to the factors below. When countable income is reduced to at or below the appropriate Medically Needy Income Limit (MNIL), the individual is eligible to receive Medicaid.

003.01(A) MEDICAL EXPENSES. The individual must obligate payment for medical and remedial care expenses incurred by the individual or another person in the individual’s financial unit. This may include medical costs not covered by Medicaid or medical premiums paid by the members of the unit. See 477-000-045 for the process by which these expenses are counted and recorded. Expenses are used to meet the share of cost (SOC) obligation in the order in which the expenses are received.

003.01(B) EFFECTIVE DATE. The individual is eligible for Medicaid on the first day of the month in which the share of cost (SOC) obligation is met, and remains eligible for the entire month.

003.01(C) COSTS NOT COVERED. Medical and remedial care costs used to meet the share of cost (SOC) obligation will not be covered by Medicaid.

003.02 MEDICALLY NEEDY WHO RECEIVE HOME AND COMMUNITY-BASED SERVICES (HCBS). A medical need is established for a medically needy individual using a hypothetical amount of services in order to begin receiving Home and Community-Based Services (HCBS). The share of cost (SOC) for medically needy individuals who receive Home and Community-Based Services (HCBS) is calculated according to the provisions below.

003.02(A) INCOME USED. The gross income is used to determine the share of cost for medically needy individuals. Income which is excluded or disregarded in determining eligibility is used to calculate the share of cost (SOC).

003.02(B) DEDUCTIONS. The following deductions are made to determine the share of cost (SOC) owed to the Home and Community-Based Services (HCBS) provider:

(i) The appropriate personal needs allowance is deducted from an individual’s income. The personal needs allowance will vary according to the living arrangement in which the individual resides, and the type of waiver used to provide the Home and Community-Based Services (HCBS);

(ii) The expense of a guardian or conservator of up to ten dollars ($10) per month, and an additional amount or as ordered by a court for accounting and bonding fees, is allowed as a deduction; and

(iii) Expenses for medical services not provided by the Home and Community-Based Services (HCBS) provider which are incurred by the individual may be deducted from the share of cost (SOC) owed to the provider. This may include medical expenses not covered by Medicaid or medical premiums paid by the individual.

003.02(C) EFFECTIVE DATE. These budgeting regulations are effective the first full month that an individual is both eligible as medically needy and receiving Home and Community-Based Services (HCBS).

003.02(D) COSTS NOT COVERED. Medical and remedial care costs used to meet the share of cost (SOC) obligation will not be covered by Medicaid.

003.03 MEDICALLY NEEDY RESIDING IN MEDICAL INSTITUTIONS. A medically needy individual who resides in a medical institution may establish a medical need using a reasonable projection of institutional expenses. The share of cost (SOC) for a medically needy individual who resides in a medical institution is calculated according to the provisions below.

003.03(A) INCOME USED. The gross income is used to determine the share of cost (SOC) for medically needy individuals. Income that is excluded or disregarded in determining eligibility is used to calculate the share of cost (SOC).

003.03(B) DEDUCTIONS. The following deductions are made in determining the share of cost (SOC) due to the provider of institutional services:

(i) A personal needs allowance appropriate to the type of facility in which the individual resides is deducted from income;

(ii) The expense of a guardian or conservator of up to ten dollars ($10) per month, and an additional amount or as ordered by a court for accounting and bonding fees, is allowed as a deduction;

(iii) An allowance for the cost of mortgage, rent, utilities, real estate taxes, or homeowner’s insurance may be allowed for up to six months if it is possible that

the individual will return home. This amount may not exceed the maximum shelter amount for a single individual listed in 477-000-012; and

(iv) Medical expenses not provided by the institutional service provider are deducted from the share of cost (SOC) amount owed to the provider. This may include expenses not covered by Medicaid or medical insurance premiums.

003.03(C) EFFECTIVE DATE. This budget procedure is used the first full month that a budget for a medical institution is used for the individual.

003.03(D) COSTS NOT COVERED. Medical and remedial care costs used to meet the share of cost obligation will not be covered by Medicaid.

History

Effective 2025-01-20

Chapter 26 Spousal Impoverishment Medicaid Program (simp)

Neb. Admin. Code tit. 477, ch. 26 Spousal Impoverishment Medicaid Program (simp) {#sec-477-nac-26 omnilex-key=us-ne-regs-official--title-477--477 NAC 26}

001. SCOPE AND AUTHORITY . These regulations establish the conditions for eligibility for the spousal impoverishment Medicaid program. These regulations are promulgated under the authority of the Medical Assistance Act, Nebraska Revised Statutes (Neb. Rev. Stat.) §§ 68-901 et seq. and §1924 of the Social Security Act 42 United States Code (U.S.C.) § 1396r-5.

002. DEFINITIONS . For the purposes of these rules and regulations, the following definitions apply.

002.01 COMMUNITY SPOUSE. The spouse of an institutionalized spouse, as defined below. A community spouse may not reside in a medical institution, nursing facility, receive Home and Community-Based Services (HCBS), or participate in Program for All-inclusive Care for the Elderly (PACE).

002.02 DEPENDENT FAMILY MEMBERS. Minor children residing with a community spouse, dependent parents, or siblings of the community spouse or institutionalized spouse who reside with the community spouse and could be claimed as dependents for tax purposes.

002.03 EXCESS SHELTER COSTS. The amount by which the combined rent or mortgage; property taxes; homeowner’s insurance; and condominium or cooperative fees, if applicable, exceed 30% of the minimum maintenance needs amount.

002.04 FAMILY MAINTENANCE ALLOWANCE. The amount deducted from an institutionalized spouse's income to meet the maintenance needs of the community spouse and family members.

002.05 INSTITUTIONAL LEVEL OF CARE. The level of care, based on medical and functional criteria, which is normally required by the Department to reside in a nursing facility, intermediate care facility for the developmentally disabled, or to receive Home and Community-Based Services (HCBS).

002.06 INSTITUTIONALIZED SPOUSE. An individual who is in a medical institution, nursing facility, intermediate care facility for the developmentally disabled, or meets the requirements to receive Home and Community-Based Services (HCBS) for at least 30 consecutive days and who is married to a spouse who does not reside in a medical institution, nursing facility, intermediate care facility for the developmentally disabled, or meet the requirements to receive Home and Community-Based Services.

002.07 MAINTENANCE NEED STANDARD. The income standard to which the community spouse's and other dependent family members' income is compared for the purpose of determining the amount of allowance that may be made from the institutionalized spouse's income. The maintenance need standard is determined by need and is subject to a minimum and maximum amount.

003. RESOURCES . The following provisions apply to resource determinations made for the spousal impoverishment Medicaid program. Unless otherwise stated, these provisions do not alter the methodology for determining and evaluating resources as found elsewhere in this title.

003.01 ASSESSMENT OF RESOURCES. An assessment of resources for the couple is completed in accordance with the regulations below.

003.01(A) FORM USED. The IM-73 form is used to catalog all resources owned and available to the couple for the spousal impoverishment Medicaid program.

003.01(B) TIMELINE FOR COMPLETION. A married couple is allowed one assessment. Either spouse may request the assessment of resources when one spouse has already received institutional level of care for at least 30 days, is likely to need an institutional level of care for more than 30 continuous days, or would have received such care except for death. The month that the institutional spouse was first able to request an assessment is the month used to complete the IM-73, regardless of when the form is completed. The couple does not need to apply for Medicaid in order to complete an assessment of resources.

003.01(C) RESOURCES INCLUDED ON THE ASSESSMENT. All countable resources owned or available to the couple must be verified and accounted for on the assessment of resources. This includes any resource owned individually, jointly, or owned with other parties. For the purposes of the spousal impoverishment Medicaid program (SIMP), prenuptial agreements or laws or principles of marital property do not apply.

003.01(D) RESOURCES NOT INCLUDED ON THE ASSESSMENT. Resources which are excluded in determining Medicaid eligibility are also excluded for the assessment of resources. An excluded resource owned by the couple at the time of the assessment which later loses its exclusion cannot be added to the assessment of resources when the exclusion is lost. Resources acquired after the assessment is completed, resources which were not disclosed, and resources which were discovered after completion of the IM-73 cannot be later added in order to increase the amount reserved for the community spouse.

003.01(E) RESOURCES RESERVED FOR THE COMMUNITY SPOUSE. After all resources have been accounted for on the assessment of resources form, the amount of resources to be reserved for the community spouse is calculated. The community spouse may reserve up to half of the couple’s combined resources, subject to a minimum and maximum reserved amount. The minimum and maximum amounts used on an assessment of resources are the minimum and maximum amounts in effect for the date used to assess the resources. The minimum amount may always be reserved, even if the combined resources are below the minimum. A community spouse may not reserve more than the maximum amount. The minimum and maximum amounts are adjusted annually according to the consumer price index. See 477-000-029.

003.01(F) APPLICABILITY OF THE ASSESSMENT. The amount of resources reserved for the community spouse that is calculated on the assessment of resources is used when Medicaid eligibility is determined for the institutionalized spouse. If the institutionalized spouse stops receiving services which require an institutional level of care, then eligibility for the spousal impoverishment program (SIMP) ends. If one spouse later needs an institutional level of care, then the original assessment of resources and reserved amount is used in determining Medicaid eligibility.

003.01(G) APPEAL OF THE ASSESSMENT. The assessment of resources notifies the couple that they may appeal the assessment. The couple may appeal the value assigned to the resources, the amount reserved for the community spouse, or both. In order to appeal, the institutionalized spouse must apply for Medicaid. If the community spouse alleges that it is necessary to reserve additional resources, the community spouse must first show that the need cannot be met by allocating additional income from the institutionalized spouse. If the community spouse prevails on appeal, then additional resources may be reserved.

003.02 DESIGNATION OF RESOURCES. The designation of resources is completed in accordance with the rules below.

003.02(A) FORM USED. The IM-74 form is used to account for all resources owned by the institutionalized and community spouses. The form is used to designate which resource will be considered available to each spouse.

003.02(B) TIMELINE FOR COMPLETION. A designation of resources must be completed when Medicaid eligibility for the spousal impoverishment Medicaid program (SIMP) is determined. The institutionalized spouse must have submitted a Medicaid application before the designation is completed and eligibility is determined.

003.02(C) RESOURCES INCLUDED ON THE DESIGNATION. All resources owned and available to the couple at the time that Medicaid eligibility is being requested are included on the designation of resources. The value of all resources on the designation must be verified before being included on the form. The institutionalized spouse must have countable resources below four thousand ($4,000) to be eligible. The community spouse cannot have countable resources above the amount reserved on the assessment of resources for the institutionalized spouse to be eligible.

003.02(C)(i) TRUST EXCEPTION. No resource owned by a trust is allowed on the IM-74. If either spouse is the beneficiary of a trust, and the trust is a countable resource, then the trust assets available must be distributed to the beneficiary before such assets can be included on the designation of resources.

003.02(D) INTERSPOUSAL TRANSFERS. The IM-74 may be completed, and Medicaid eligibility determined before all resources have changed title to reflect the arrangement on the form. The ownership of all resources is verified again at the time of the institutionalized spouse’s first Medicaid renewal. If any necessary transfers have not been completed at that time, and the institutionalized spouse retains ownership in more than four thousand ($4,000) in resources, Medicaid must be closed due to excess resources. Transfer of resources between spouses is an exception to the deprivation of resource provisions unless the resources transferred from the institutionalized spouse would result in the community spouse having countable resources above the reserved amount. The amount transferred in excess of the community spouse’s reserved amount is counted as a deprivation of resources.

003.02(E) RESOURCES NOT INCLUDED ON THE DESIGNATION. A resource which is acquired, omitted, or that loses its exclusion after the designation of resources has been completed is treated as follows:

(i) The value of a resource titled in the name of the institutionalized spouse is attributable to the institutionalized spouse;

(ii) The value of a resource titled in the name of the community spouse is attributable to the community spouse; and

(iii) The value of a resource titled jointly in the name of both spouses is divided in equal shares to each spouse.

003.02(F) APPLICABILITY OF THE DESIGNATION. The IM-74 is in effect while the institutionalized spouse remains eligible for the spousal impoverishment Medicaid program (SIMP). This is true even when the institutionalized spouse moves from one institutional living arrangement to another. If the institutionalized spouse resides in the home with the community spouse without receiving institutional services, then eligibility for spousal impoverishment ends and the designation of resources no longer applies. If the community spouse begins to receive institutional services, then eligibility for spousal impoverishment ends and the designation of resources does not apply.

003.03 MAXIMUM AVAILABLE RESOURCE LIMITS. The established maximum for available resources that a couple may own and still be considered eligible for Medicaid in the following circumstances are as follows:

003.03(A) INSTITUTIONALIZED SPOUSE. The institutionalized spouse in the spousal impoverishment Medicaid program must have four thousand ($4,000) or less in countable resources to be eligible. The institutionalized spouse may transfer resource to the community spouse without penalty up to the amount reserved for the community spouse on the IM-73.

003.03(B) COMMUNITY SPOUSE. The community spouse must reduce countable resources to the amount calculated on the IM-73 before the institutionalized spouse may become eligible.

003.03(C) RESIDING WITH COMMUNITY SPOUSE. If the institutionalized spouse resides with the community spouse without being eligible to receive Home and Community-Based Services (HCBS) or Program for All-inclusive Care for the Elderly (PACE), then eligibility for the spousal impoverishment Medicaid program ends. The couple would have a resource limit of six thousand ($6,000) in order to be eligible under other Medicaid programs for the aged, blind, or disabled.

003.03(D) COMMUNITY SPOUSE RECEIVES INSTITUTIONAL CARE. If the community spouse begins to receive institutional care, then eligibility for the spousal impoverishment Medicaid program ends. The couple would need to reduce resources such that each spouse had four thousand ($4,000) or less in countable resources before either would be eligible for other aged, blind, or disabled (ABD) Medicaid programs.

003.04. ASSIGNING SUPPORT RIGHTS. If the couple has resources that exceed the allowable amount and refuse to spend down, which prevents Medicaid eligibility for the institutionalized spouse, the Department has the legal right to bring support proceedings against the community spouse.

004. INCOME .

004.01 EFFECTIVE DATES. Spousal impoverishment Medicaid program (SIMP) budgeting procedures begin the first month, including a partial month, in which an eligible spouse enters an institutional living arrangement. The budgeting procedures end the first full month that an institutionalized spouse ceases to receive an institutional level of care or when the community spouse no longer meets the definition of a community spouse, whichever occurs first.

004.02 ALLOCATION OF INCOME. Only the income of the institutionalized spouse is used to determine whether any cost sharing amount is due to the provider. The income of a community spouse is not considered available to the institutionalized spouse. Some of the income of the institutionalized spouse may be allocated to the community spouse and dependent family members. The amount that may be allocated is determined in accordance with the procedures in this chapter.

004.03 DETERMINING OWNERSHIP OF INCOME. All income must be verified to determine the amount of the income and the individual to whom the income is due. Income is considered to be owned by the person legally entitled to receive it. Ownership of income may be appealed.

004.03(A) MULTIPLE OWNERS. When a source of income is payable to more than one party, the following rules apply:

(i) If payment is made payable to both spouses, one-half is considered available to each spouse;

(ii) Income must be divided by the number of payees if payment is made payable to one or both spouses and a third party;

(iii) Only the spouse's proportionate share is considered available to that spouse;

(iv) If income is paid to one spouse and a third party but the verification reveals that the income is intended for both spouses, both spouses must be included in the division to determine the proportionate share; and

(v) If income does not specify either spouse, one-half of the amount is considered available to each spouse.

004.04 BUDGETING THE INSTITUTIONALIZED SPOUSE. The budget of the institutionalized spouse is calculated using the procedure below. Only the income of the institutionalized spouse is used to determine whether any cost sharing applies. The institutionalized spouse must be allowed sufficient income to meet their personal needs before determining whether any income is allocated to the community spouse. If the income of the community spouse is not provided or verified then no allocation is allowed. If an allocation for the maintenance needs of the community spouse is calculated, but is not made available to the community spouse, then no deduction is allowed. A deduction for the maintenance of dependent family members is always allowed, even if the income is not made available to those family members. Any amount remaining after deductions are paid to the provider.

004.04(A) BUDGET CALCULATION. The following amounts are deducted from the gross, verified income of the institutionalized spouse in the following order:

(i) The income standard for the appropriate living arrangement. See 477-000-012;

(ii) A fee for a guardian or conservator;

(iii) The amount calculated for the maintenance needs of the community spouse;

(iv) The amount calculated for the maintenance needs of dependent family members; and

(v) Incurred medical expenses allowed under this title.

004.05 DETERMINING THE MAINTENANCE ALLOWANCE. The maintenance needs of a spouse or dependent family member are calculated. The calculation is subject to a minimum and maximum amount. See 477-000-012. In comparing income of a spouse or family member, all income is used, even if such income would normally be subject to a deduction or exclusion for Medicaid eligibility. The gross amount of income is used except for self-employment. Adjusted gross income is used for self-employment. The amount calculated for the maintenance needs of a spouse or dependent family member may be appealed.

004.05(A) DETERMINING THE COMMUNITY SPOUSE MAINTENANCE ALLOCATION. A portion of the income of the institutionalized spouse can be allocated to the community spouse when necessary to maintain the living standard of the community spouse. The allocation is subject to a minimum and maximum amount which is adjusted annually. If the community spouse has income in excess of the maximum amount, then no allocation is allowed. If the community spouse has income less than the maximum, then the calculation below is used. If the income of the community spouse is less than the calculated amount, then the institutionalized spouse may allocate income up to the calculated amount. The income of the community spouse is compared to a sum of the following factors:

(i) The minimum maintenance allowance;

(ii) Excess shelter costs, as defined; and

(iii) A standard utility amount.

004.05(B) DETERMINING A DEPENDENT FAMILY MEMBER’S MAINTENANCE ALLOCATION. A portion of the income of the institutionalized spouse will be allocated to assist in the maintenance of dependent family members. The maintenance amount is a sum of the needs of each dependent family member. For each dependent family member, the remaining income of the institutionalized spouse is compared to an amount calculated below. The sum of the needs of each dependent family member is used as the allocated amount. For each dependent family member, calculate the maintenance need amount as follows:

(i) The minimum spousal maintenance amount minus

(ii) The gross amount of income for the dependent family member, and then

(iii) Divide the result by three.

004.05(C) EXCEPTIONS. An allocation above the maximum amount is only allowed under the following circumstances:

(i) A court has ordered the institutionalized spouse to provide more financial support than the calculated maintenance amount. A court order takes precedence over the calculated amount; or

(ii) The family alleges that a need in excess of the calculated amount is needed due to exceptional circumstances resulting in significant financial duress and appeals the calculated amount. The family must show that there are insufficient resources reserved for the community spouse to meet the financial need. If the family prevails on appeal, then an additional amount may be allowed.

History

Effective 2020-07-29

001. SCOPE AND AUTHORITY . These regulations are promulgated under the authority of the Medical Assistance Act, Nebraska Revised Statutes (Neb. Rev. Stat.) §§ 68-901 et seq.

002. AGED, BLIND, AND DISABLED (ABD) . Medicaid for aged, blind, and disabled (ABD) provides medical coverage for individuals who meet the criteria specified below.

002.01 MANDATORY GROUPS. Certain individuals are eligible to receive Medicaid in the aged, blind, and disabled (ABD) category due to current or prior participation in the Supplemental Security Income (SSI) program. A separate application for Medicaid must be submitted before eligibility can be determined.

002.01(A) SUPPLEMENTAL SECURITY INCOME (SSI) RECIPIENTS. Nebraska residents who are currently receiving benefits from the Supplemental Security Income program are eligible to receive Medicaid in the aged, blind, and disabled (ABD) category. The Supplemental Security Income (SSI) program is responsible for verifying the individual’s income, resources, and the determination that an individual is disabled.

002.01(B) 1619B BENEFICIARIES. A blind or disabled individual is eligible if the individual received Medicaid and Supplemental Security Income (SSI) in the month before the month in which this reference applies and whose Supplemental Security Income (SSI) payment stopped due to the level of earnings and who is determined by the Social Security Administration (SSA) to have special Medicaid status under section 1619(b) of the Social Security Act, as amended. The Social Security Administration (SSA) is responsible for verifying the income, resources, disability status, and 1619(b) eligibility of the individual.

002.01(C) FORMER SUPPLEMENTAL SECURITY INCOME (SSI) RECIPIENTS. Certain former recipients of benefits from the Supplemental Security Income (SSI) program remain eligible for Medicaid benefits after losing the ability to receive Supplemental Security Income (SSI) program benefits. For each category below, all of the following requirements must be met in order to be considered a member of the category.

002.01(C)(i) DISABLED EARLY WIDOWS OR WIDOWERS. These individuals are also referred to as additional reduction factor (ARF) widows or widowers. All of the following must be met:

(1) Have been determined disabled;

(2) Were receiving Supplemental Security Income (SSI) in December, 1983 and lost Supplemental Security Income (SSI) benefits in January, 1984 due to the elimination of a benefit reduction factor for widows or widowers before the attainment of age 60;

(3) Have been continuously entitled to the Title II widow or widowers benefit based on disability since January, 1984;

(4) Applied for benefits under this group prior to July 1, 1988 or a later date established under the court order in Darling v. Bowen; and

(5) Would continue to be eligible for Supplemental Security Income (SSI) benefits, including the resource standard, if the client had not received the increase in Title II benefits.

002.01(C)(ii) DISABLED ADULT CHILDREN (DAC). This population is also known as childhood disability beneficiaries (CDB). All of the following must be met:

(1) Lost Supplemental Security Income status after November 10, 1986 due to the mandatory receipt or increase in Title II benefits on a parent’s record due to the retirement, death, or disability of the parent;

(2) Are age 18 or older;

(3) Blindness or disability began before age 22; and

(4) Would continue to be eligible for a Supplemental Security Income (SSI) payment, including the resource standard, if they were not receiving the Title II disabled adult child benefit.

002.01(C)(iii) SECTION 503 GROUP. This population is commonly referred to as the Pickle Amendment Group. All of the following factors must be met:

(1) Is currently receiving Title II income;

(2) Was eligible for and receiving Supplemental Security Income (SSI) benefits concurrently with Title II income for at least one month after April 1, 1977; and

(3) Lost Supplemental Security Income (SSI) benefits, but would continue to receive it, including the resource standard, if the amount of cost-of-living increases received from Title II income after the month in which Supplemental Security Income (SSI) benefits were lost were deducted from the current Title II benefit. The cost-of-living increases include the increases received by the individual, the individual’s spouse, or a financially responsible family member.

002.01(C)(iv) EARLY WIDOWS OR WIDOWERS. This population is also known as COBRA widows or widowers. All of the following factors must be met:

(1) Lost Supplemental Security Income (SSI) benefits due to the mandatory receipt of Title II benefits;

(2) Is not yet eligible for Medicare Part A;

(3) Has attained age 50, but is not yet age 65; and

(4) Would continue to be eligible for Supplemental Security Income (SSI) if not receiving Title II benefits.

002.02 AGED, BLIND, AND DISABLED (ABD) 100% GROUP. Aged, blind, and disabled individuals who are not eligible as a member of a mandatory group may be eligible for Medicaid if all of the criteria below are met. Members of this group are entitled to all benefits under the state plan. The eligibility factors below are in addition to the requirements in chapters three, five, six, and eight of this title.

002.02(A) INCOME. Countable income for the individual must be at or below 100% of the Federal Poverty Level (FPL). Countable income is determined according to the provisions of chapter 22 of this title.

002.02(B) RESOURCES. Countable resources must be at or below the limit specified in chapter 23 of this title. The provisions of chapter 23 will determine whether or not a resource is countable toward the specified limit.

002.02(C) CATEGORICAL FACTORS. An individual must meet the categorical factors of age, blindness, or disability, as defined below.

002.02(C)(i) AGE. An individual is considered a member of the aged category at age 65 or older. A blind or disabled individual becomes a member of the aged category the month that the individual turns age 65.

002.02(C)(ii) BLINDNESS OR DISABILITY. All applicants requesting eligibility in the blind or disabled category must meet the medical definitions of blindness or disability of the Retirement, Survivors, and Disability Insurance (RSDI) or the Supplemental Security Income (SSI) programs as administered by Social Security Administration (SSA). The determination by the Social Security Administration (SSA) that an individual is disabled or blind must be accepted for eligibility for the aged, blind, or disabled (ABD). In some cases, the State Review Team (SRT) may make the determination of blindness or disability.

002.02(C)(ii)(1) DISABILITY CRITERIA. Generally, an individual is disabled if the individual is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than 12 months. A child through 17 years old is considered disabled if the child suffers from any medically determinable physical or mental impairment of comparable severity. See Titles II and XVI of the federal Social Security Act, as amended, for further disability criteria. The Social Security Administration has the primary responsibility of determining whether an individual meets the disability criteria.

002.02(C)(ii)(1)(a) DETERMINATIONS UNDER APPEAL. An individual who is determined ineligible for Medicaid for the aged, blind, or disabled (ABD) because the individual does not meet the disability requirements of the Supplemental Security Income (SSI) program may appeal the decision to the Social Security Administration (SSA). Upon receiving an affirmative redetermination of disability from the Social Security Administration (SSA), the Department shall use the corresponding date of application in determining eligibility for Medicaid if the individual meets all of the following:

(i) Has been determined ineligible for the Supplemental Security Income (SSI) program because the individual is not considered disabled due to lack of severity;

(ii) Appeals the decision of the Supplemental Security Income (SSI) program; and

(iii) The individual wins the appeal.

002.02(C)(ii)(2) DIRECT REFERRAL TO THE STATE REVIEW TEAM. In the following situations a referral may be submitted directly to the state review team (SRT) for a determination of disability and its probable duration without waiting for a determination from the Supplemental Security Income (SSI) program if the individual is not eligible for another medical program, and during the initial intake it is apparent that:

(A) The individual has income and/or resources in excess of the limit for the Supplemental Security Income (SSI) program. The individual’s potential eligibility for the Supplemental Security Income (SSI) program must be monitored. If income or resources fall below the Supplemental Security Income (SSI) limit, an immediate referral for the Supplemental Security Income (SSI) program must be made to the Social Security Administration (SSA). The individual is allowed 60 days to apply for this potential benefit;

(B) The individual requires immediate long-term hospitalization or treatment for a severe impairment before the Social Security Administration (SSA) can make a determination for the Supplemental Security Income (SSI) program, or the individual would be required to extend a hospital stay solely because of a delay in processing the Supplemental Security Income (SSI) application. An immediate referral for the Supplemental Security Income (SSI) program must be made;

(C) The individual is residing in a medical facility or public institution and the Social Security Administration (SSA) will be unable to make a disability determination for the Supplemental Security Income (SSI) program. An individual is eligible for Supplemental Security Income (SSI) benefits while institutionalized only if Medicaid will pay 50 percent of the individual’s care. Therefore, the Social Security Administration (SSA) may, in some cases, wait for a determination of eligibility for Medicaid. An immediate referral for the Supplemental Security Income (SSI) program must be made;

(D) The individual is deceased and the Social Security Administration (SSA) will not make a disability determination for the Supplemental Security Income (SSI) program; or

(E) The individual is a non-citizen who the Social Security Administration (SSA) will not review for the Supplemental Security Income (SSI) program.

002.02(C)(ii)(2)(a) DOCUMENTATION STANDARD. The state review team (SRT) will review medical documentation dated no more than 12 months prior to the date for which a disability determination is requested. The individual whose disability status is being determined must have been examined by a physician, or appropriate provider, for the condition or conditions related to the disability determination within three months of the requested date.

002.02(C)(ii)(2)(b) REFERRALS TO THE SOCIAL SECURITY ADMINISTRATION. The Department must continue to monitor the individual’s potential eligibility for Retirement, Survivors, Disability Insurance (RSDI) and Supplemental Security Income (SSI) benefits even though the state review team (SRT) has made the determination of disability. A referral for the Supplemental Security Income (SSI) or Retirement, Survivors, Disability Insurance (RSDI) program, as appropriate, must be made at the time of the state review team (SRT) determination. If the individual is denied benefits under the Supplemental Security Income (SSI) or Retirement, Survivors, Disability Insurance (RSDI) programs initially for a non-disability related reason, but later appears to be eligible for such benefits, then a referral must be made. The individual’s referral will allow 60 days to apply for the potential benefits.

002.02(C)(ii)(2)(c) SOCIAL SECURITY DETERMINES THE INDIVIDUAL IS NOT DISABLED. If the state review team (SRT) has determined the individual is disabled but, the Social Security Administration (SSA) later determines that the individual is not disabled due to lack of severity or the ability to engage in substantial gainful activity, then the Department will abide by the decision of the Social Security Administration. If the individual has filed an appeal with the Social Security Administration (SSA), the individual must be considered disabled through the review period established by the state review team (SRT). If no appeal with the Social Security Administration (SSA) is filed, then the disability requirement cannot be considered to be met.

002.02(C)(iii) SUSPENSION OF BENEFITS. If Supplemental Security Income (SSI) benefits are suspended due to excess income or excess resources, the individual is still considered disabled for a period of 12 consecutive months, as long as all other eligibility factors are met. The 12 month period is effective the first day of the month in which the benefits are suspended. To continue Medicaid eligibility for the aged, blind, or disabled (ABD) category at the end of the 12 month period, a review of disability by the state review team (SRT) is necessary.

003. QUALIFIED DISABLED AND WORKING INDIVIDUALS . Individuals who were receiving Retirement, Survivors, Disability Insurance (RSDI) disability benefits and return to work, but remain disabled, may continue to be entitled to Medicare Part A at no cost for 48 months. The Omnibus Budget Reconciliation Act of 1989 allows these individuals, at the end of 48 months, to enroll in Medicare Part A and pay a premium. The act also requires state Medicaid programs to purchase Medicare Part A premiums for these individuals. To be eligible for this program, an individual must meet all of the following requirements.

003.01 AGE. To be eligible for the payment of the Medicare premium, an individual must be 64 years old or younger.

003.02 DISABILITY. To be eligible for the payment of the Medicare premium, an individual must continue to have a disabling impairment as determined by the Social Security Administration (SSA). The Social Security Administration (SSA) has the responsibility to verify periodically that the disability continues. If the Social Security Administration (SSA) determines through a continuing disability review that the individual is no longer disabled, the Department is notified and eligibility ceases. If the individual voluntarily withdraws from Medicare Part A premium coverage, then eligibility ceases.

003.03 INCOME. To be eligible for the Qualified Disabled and Working Individuals benefit, the unit must have income above 100%, but at or below 200% of the Federal Poverty Level (FPL). In determining countable income, the amount of medical insurance premiums is not allowed.

003.04 RESOURCES. The resource limit for the program is four thousand ($4,000) for an individual or six thousand ($6,000) for a couple.

003.05 NOT OTHERWISE ELIGIBLE. An individual eligible as a Qualified Disabled and Working Individual cannot be eligible for any other Medicaid program.

004. MEDICARE BUY-IN . The Medicare buy-in programs assist those eligible for both Medicare and Medicaid cover the costs of Medicare.

004.01 ELIGIBILITY REQUIREMENTS. The eligibility requirements of the Medicare buy-in programs are listed below. Specific requirements vary according to the program. An individual must:

(A) Be a resident of Nebraska;

(B) Be a United States citizen or qualified non-citizen;

(D) Meet the income and resource requirements of the program.

004.02 QUALIFIED MEDICARE BENEFICIARIES. Qualified Medicare Beneficiaries (QMBs) are Medicare recipients with low income. A Qualified Medicare Beneficiary (QMB) may be eligible to receive Medicaid benefits under another category.

004.02(A) BENEFITS. Qualified Medicare Beneficiaries (QMBs) receive a buy-in of the Medicare premium, as well as payment of any Medicare co-pays or deductibles.

004.02(B) EFFECTIVE DATE. Qualified Medicare Beneficiary (QMB) begins the month after the month in which eligibility is determined.

004.02 (C) INCOME AND RESOURCE LIMITS. Qualified Medicare Beneficiaries (QMBs) must have income at or below 100% of the Federal Poverty Level (FPL). The resource limit for a Qualified Medicare Beneficiary (QMB) is located at 477-000-012. The resource guideline is adjusted annually. Income is counted in accordance with 477 NAC 22. Resources are counted in accordance with 477 NAC 23.

004.02(C)(i) AGED, BLIND, AND DISABLED QUALIFIED MEDICARE BENEFICIARIES. Individuals who are eligible for Medicare and who are also eligible to receive Medicaid in the aged, blind, and disabled (ABD) category will automatically qualify as a Qualified Medicare Beneficiary. The joint benefit is referred to as the aged, blind, and disabled Qualified Medicare Beneficiary (ABD/QMB).

004.02(C)(ii) MEDICARE SAVINGS PROGRAM QUALIFIED MEDICARE BENEFICIARY. Individuals who have excess resources for the aged, blind, and disabled (ABD) category may still be eligible to receive the Qualified Medicare Beneficiary (QMB) benefit if within the resource limit for the Qualified Medicare Beneficiary (QMB) program. These individuals are only eligible for the Medicare buy-in, payment of co-pays, and deductibles. This benefit is referred to as the Medicare Savings Program Qualified Medicare Beneficiary (MSP/QMB).

004.03 SPECIFIED LOW INCOME MEDICARE BENEFICIARIES (SLMB). Specified Low Income Medicare Beneficiaries (SLMBs) are Medicare recipients who have income just above the level of a Qualified Medicare Beneficiary (QMB).

004.03(A) BENEFITS. Specified Low Income Medicare Beneficiaries (SLMBs) only receive payment of the Medicare Part B premium. An individual may be eligible as a Specified Low Income Medicare Beneficiary (SLMB) and as medically needy in the same month.

004.03(B) EFFECTIVE DATE. Eligibility for a Specified Low Income Medicare Beneficiary (SLMB) is determined from the date of the application. Eligibility may be determined for up to three months before the date of application, if the individual was eligible for those months and requests the benefit.

004.03(C) INCOME AND RESOURCES. A Specified Low Income Medicare Beneficiary must have income above 100% of the Federal Poverty Level (FPL) but at or below 120% of the Federal Poverty Level (FPL). Income and resources are determined for only a one or two person household. The resource limit for this eligibility group is located at 477-000-012, and is adjusted annually. Income is counted in accordance with 477 NAC 22. Resources are counted in accordance with 477 NAC 23.

004.04 QUALIFIED INDIVIDUALS (QI-1). A Qualified Individual (QI-1) has income just above the limit of an eligible Specified Low Income Medicare Beneficiary (SLMB).

004.04(A) BENEFITS. A Qualified Individual (QI-1) is only eligible for the payment of the Medicare Part B premium.

004.04(B) EFFECTIVE DATE. Eligibility for a Qualified Individual (QI-1) is determined from the date of application. Eligibility for up to three months before the month of application may be available if the individual was eligible and the month is within the current calendar year.

004.04(C) INCOME AND RESOURCES. A Qualified Individual (QI-1) must have income above 120% of the Federal Poverty Level (FPL) but at or below 135% of the Federal Poverty Level. Income and resources are determined for only a one or two person household. The resource limit for this eligibility group is located at 477-000-012, and is adjusted annually. Income is counted in accordance with 477 NAC 22. Resources are counted in accordance with 477 NAC 23.

004.04(D) PROHIBITION ON OTHER BENEFITS. A Qualified Individual (QI-1) cannot be eligible for Medicaid coverage under any other category in the same month that the individual is eligible as a Qualified Individual (QI-1). The individual must choose between either Medicaid coverage for medical costs or the Qualified Individual (QI-1) benefit, but cannot have both.

005. MEDICAID INSURANCE FOR WORKERS WITH DISABILITIES (MIWD) . Individuals who meet the necessary disability criteria, have income within income guidelines, and are working may be eligible for Medicaid Insurance for Workers with Disabilities (MIWD). An individual may be eligible for Medicaid Insurance for Workers with Disabilities (MIWD) in either the Basic Coverage Group or the Medical Improvement Group, as defined by The Ticket to Work and Work Incentives Improvement Act (TWWIIA) of 1999. After application of income disregards, individuals with income less than 200% of the Federal Poverty Level (FPL) are eligible for Medicaid with no premium; individuals with incomes of 200, but less than 250% of the Federal Poverty Level (FPL) are eligible for Medicaid with a monthly premium payment.

005.01 TICKET TO WORK AND WORK INCENTIVES IMPROVEMENT ACT (TWWIIA) BASIC COVERAGE GROUP ELIGIBILITY REQUIREMENTS. In order to receive Medicaid in the Basic Coverage Group, the individual must meet the requirements below:

005.01(A) AGE. An individual must be at least 16, but less than 65 years old.

005.01(B) DISABILITY. An individual must be determined disabled by the Social Security Administration (SSA) or state review team (SRT). This determination is made without regard to earnings.

005.01(C) EARNED INCOME. Participants must have earned income, which includes self-employment.

005.01(D) INCOME LIMIT. Combined countable earned and unearned income of the household is more than 100%, but less than 250% of the Federal Poverty Level (FPL).

0050.1(E) RESOURCE LIMIT. Countable resources are no more than $4,000 for an individual or $6,000 for a couple.

005.02 TICKET TO WORK AND WORK INCENTIVES IMPROVEMENT ACT (TWWIIA) MEDICAL IMPROVEMENT GROUP ELIGIBILITY REQUIREMENTS. In order to receive Medicaid in the Medical Improvement Group, the individual must meet the requirements below:

005.02(A) AGE. An individual must be at least 16, but less than 65 years old.

005.02(B) EARNED INCOME. Participants must have earned income, which includes self-employment.

005.02(B)(i) MINIMUM AMOUNT. Medical Improvement Group participants must earn at least the Federal minimum wage and be employed at least 40 hours per month.

005.02(C) INCOME LIMIT. Combined countable earned and unearned income of the household is more than 100%, but less than 250% of the Federal Poverty Limit (FPL).

005.02(D) RESOURCE LIMIT. Countable resources are no more than $4,000 for an individual and $6,000 for a couple.

005.02(E) BASIC COVERAGE GROUP. Medical Improvement Group participants must have been enrolled in the Basic Coverage Group, but lost eligibility due to a medically improved disability.

005.02(F) MEDICALLY IMPROVED DISABILITY. Medical Improvement Group participants no longer meet the medical criteria for disability as defined by the Social Security Administration (SSA) or state review team (SRT) under section 002.02(C)(ii)(1). Medical Improvement Group participants must continue to have a medically improved disability.

005.02(F)(i) DEFINITION. A medically improved disability is determined by the Department, and is defined as:

(1) A medically determinable severe impairment which continues to substantially limit the ability to work or conduct daily life activities;

(2) The mental or physical health condition has been stabilized by assistive technology, medication, treatment, monitoring by medical professionals, or a combination of these factors, and the loss of medical services may result in a deterioration of the condition; and

(3) The loss of medical assistance could result in the individual’s inability to continue in the workforce or health problems would regress to the point where the individual would meet the Social Security Administration (SSA) or state review team (SRT) definition of disabled.

005.02(F)(ii) DOCUMENTATION. The determination that an individual has a medically improved disability is reviewed by the Department every 12 months. During this review, the Department will analyze findings reported by a physician following a diagnostic examination of the individual. The report may be made from information in existing medical records from a physician, clinic, or hospital where the individual has been treated if the treatment was directly related to the impairment. The medical documentation must reflect examination or treatment received within the prior 12 months. There must be medical information from an examination which has occurred within three months of the time period for review.

005.03 DISABILITY DETERMINATION. Individuals who are not receiving a Social Security Disability payment must be determined disabled by the state review team (SRT). Receipt of a Social Security Disability Insurance (SSDI) payment meets the disability requirement

005.04 PREMIUM PAYMENT. Participants in either the Basic Coverage Group or the Medical Improvement Group who have income of 200% or more of the Federal Poverty Level (FPL) but less than 250% must pay a monthly premium in order to receive coverage. The amount of the monthly premium is calculated according to the chart at 477-000-012.

005.04(A) PREMIUM DUE. If the individual is determined eligible for Medicaid with a premium, the individual must pay the full premium no later than the 21st day of the month following the month for which the payment is designated. Failure to pay the required premium by the 21st of the following month will result in ineligibility for the month for which the premium was owed.

006. BREAST AND CERVICAL CANCER PROGRAM . Under the Breast and Cervical Cancer Prevention and Treatment Act of 2000, certain individuals who need treatment for breast or cervical cancer may be eligible for Medicaid. Neb. Rev. Stat. § 68-1020 authorizes this coverage in Nebraska.

006.01 ELIGIBILITY REQUIREMENTS. In order to receive Medicaid, the individual must:

(A) Be screened for breast and cervical cancer by Every Woman Matters;

(B) Be found to need treatment for breast or cervical cancer, including a precancerous condition or early stage cancer;

(D) Not be otherwise eligible for any category of Medicaid;

(E) Not be covered by creditable health insurance;

(F) Be a Nebraska resident; and

(G) Be a United States citizen or a qualified non-citizen.

006.02 CREDITABLE HEALTH INSURANCE. For purposes of this program, creditable health insurance includes any health insurance coverage except a plan that:

(A) Provides limited scope coverage such as plans that only cover dental, vision, or long-term care;

(B) Provides coverage for only a specified disease or illness;

(D) Has exhausted the individual’s lifetime limit on all benefits under the plan or coverage, including treatment for breast or cervical cancer.

006.03 ELIGIBILITY PERIOD. Eligibility begins the first of the month in which the individual signs the application for the Breast and Cervical Cancer Program. Eligibility continues as long as the treatment for breast or cervical cancer is required, as determined by a physician, unless the individual becomes ineligible for some other reason. Eligibility automatically ends the last day of the month of the client’s 65th birthday.

006.03(A) PRE-CANCEROUS CONDITIONS. For pre-cancerous cervical conditions, eligibility automatically ends the last day of the month following the month treatment begins unless the physician provides the Department with a monthly statement indicating continued treatment is required. Continued treatment does not include continued surveillance, testing, or screening.

006.03(B) BREAST AND CERVICAL CANCER. For breast and cervical cancer, a physician’s statement verifying the need for treatment must be provided to the Department every six months for the individual to remain eligible for Medicaid coverage.

006.03(C) PRESUMPTIVE ELIGIBILITY. Eligibility may be presumptively determined by a qualified Medicaid provider. See 477 NAC 19 for presumptive eligibility requirements.

007. MEDICALLY NEEDY . Parents or caretaker relatives, children, pregnant women, and aged, blind, or disabled (ABD) individuals with a medical need and high medical expenses whose income exceeds the guidelines for Medicaid eligibility in another eligibility category may be eligible as medically needy if all other eligibility requirements are met. A medically needy individual must incur and obligate a certain amount of medical expenses each month before Medicaid will provide coverage for the rest of the month. These medical expenses must be at least equal to the difference between the individual’s income and the applicable income standard. The share of cost obligation varies depending on the individual’s household size and income. Each month is determined separately and continuous eligibility does not apply. Individuals without a demonstrated medical need are not eligible under this category.

007.01 AGE. A medically needy child is eligible through age 18 years old if the child is a citizen or is a qualified non-citizen.

007.01(A) EXCEPTION. A medically needy child may be found eligible under this category if the child is receiving inpatient care in an institution for mental disease (IMD). If an individual is an inpatient in an institution for mental disease (IMD) when the individual reaches 21 years old, the individual may remain eligible either until discharge or until reaching 22 years old, whichever comes first.

007.02 TWO-PARENT FAMILIES. If unmarried parents are living together and the father has acknowledged paternity for their child, eligibility must be considered for the family as a unit.

007.03 SHARE OF COST OBLIGATION. The share of cost (SOC) obligation for medically needy individuals is calculated in accordance with the provisions of 477 NAC 25.

008. TRANSITIONAL MEDICAL ASSISTANCE (TMA)

008.01 TRANSITIONAL MEDICAL ASSISTANCE (TMA) ELIGIBILITY. A household may receive up to 12 months of Transitional Medical Assistance (TMA) if the parent or caretaker relative:

(1) Is in the household;

(2) Has earned income that results in ineligibility for Medicaid as a parent or caretaker relative using modified adjusted gross income (MAGI) methodology; and

(3) Is employed.

008.01(A) PRIOR ELIGIBILITY REQUIREMENT. The parent or caretaker relative must have received, or met income and resource eligibility to receive, a grant or Medicaid for which the individual was eligible in three of the last six months preceding ineligibility.

008.01(B) FRAUD EXCLUSION. The household is ineligible for Transitional Medical Assistance (TMA) if it received Medicaid as a parent or caretaker relative using modified adjusted gross income (MAGI) methodology in one or more of the three qualifying months as a result of convicted fraud during the last six months before the beginning of the transitional period.

008.01(C) EFFECTIVE DATE. Transitional medical assistance (TMA) begins with the month of ineligibility for Medicaid as a parent or caretaker relative.

008.02 RESOURCES. There is no resource test while the household is receiving Transitional Medical Assistance (TMA).

008.03 SANCTIONS. A parent who has been sanctioned for noncooperation with child support or third-party liability (TPL) provisions is not eligible for Transitional Medical Assistance (TMA) until cooperation is resolved.

008.04 CHANGES IN HOUSEHOLD COMPOSITION. When an individual is added, returns, or leaves a household, eligibility is impacted according to the provisions below.

008.04(A) INDIVIDUAL RETURNS OR IS ADDED TO THE HOUSEHOLD. When an individual returns or is added to the household, eligibility must be reassessed for the entire household.

(i) If the individual is a responsible relative, their income must be used when reassessing eligibility, regardless of whether this individual requests Medicaid coverage;

(ii) If the individual is a parent included in the tax household of the parent eligible for Transitional Medical Assistance (TMA), and the household remains ineligible for Medicaid as a parent or caretaker relative based on modified adjusted gross income (MAGI) methodology, this individual is added to the Transitional Medical Assistance (TMA) household; or

(iii) If the individual is a child included in the tax household of the parent eligible for Transitional Medical Assistance (TMA), the child is added to the Transitional Medical Assistance (TMA) cycle of that parent.

008.04(A)(1) APPLICATION REQUIREMENT. An individual who returns or is added to the household must submit an application for Medicaid if the individual has been ineligible for more than 90 days and requests Medicaid coverage.

008.04(B) FAMILY MEMBER LEAVES THE HOUSEHOLD. If a family member leaves the home, Medicaid eligibility for the remaining household members must be reassessed.

(i) If a parent or caretaker relative leaves the household, and the remaining parent or caretaker relative continues to be ineligible as a parent or caretaker relative using modified adjusted gross income (MAGI) methodology, the Transitional Medical Assistance cycle continues;

(ii) If the only dependent child leaves the household, the entire household loses eligibility for Transitional Medical Assistance (TMA); or

(iii) If the only dependent child no longer meets the age qualification, the entire household loses eligibility for Transitional Medical Assistance (TMA).

008.05 BREAKS IN THE TRANSITIONAL MEDICAL ASSISTANCE (TMA) CYCLE. A change in circumstances may or may not restart the Transitional Medical Assistance (TMA) eligibility cycle.

008.05(A) If a temporary reduction or loss of income results in eligibility as a parent or caretaker relative using modified adjusted gross income (MAGI) methodology, but eligibility in that category is lost within one or two months due to income, then the original Transitional Medical Assistance (TMA) cycle continues.

008.05(B) If the Transitional Medical Assistance (TMA) case is closed for any reason, then reopened within 90 days of closure, and eligibility for Transitional Medical Assistance (TMA) continues, the original Transitional Medical Assistance (TMA) cycle resumes.

008.05(C) A new Transitional Medical Assistance (TMA) cycle begins if an individual receives Medicaid as a parent or caretaker relative using modified adjusted gross income (MAGI) methodology for three or more months, then loses eligibility in that category because of income.

008.06 CLOSING TRANSITIONAL MEDICAL ASSISTANCE (TMA). Before closing a Transitional Medical Assistance (TMA) case for any reason, it must first be determined if the individuals in the household are eligible for another Medicaid program.

008.07 TRANSITIONAL MEDICAL ASSISTANCE (TMA) TIMELINE. The transitional medical assistance (TMA) program follows a defined timeline. Eligibility and cost sharing may change throughout the timeline in accordance with the provisions below.

008.07(A) MONTHS ONE THROUGH SIX. Eligibility for months one through six are subject to the following provisions.

008.07(A)(i) INCOME. Individuals in the first six months of Transitional Medical Assistance (TMA) coverage are exempt from income tests.

008.07(A)(ii) REPORT REQUIREMENT. The gross monthly earnings and child care costs for employment, as billed or paid, for each of the first three months of the transitional period must be verified. The first report or verification is due no later than the 21st of the fourth month.

008.07(A)(iii) CAUSES FOR CLOSURE. The household becomes ineligible for Transitional Medical Assistance (TMA) during the first six-month period if any of the following occur:

(1) The household becomes eligible for Medicaid as a parent or caretaker relative using modified adjusted gross income (MAGI) methodology;

(2) The household moves out of the state; or

(3) There is no longer an eligible dependent child in the household.

008.07(B) MONTHS SEVEN THROUGH TWELVE. If the household has earned income and child care deductions for employment that are equal to or less than 185% of the Federal Poverty Level (FPL), it is eligible for transitional medical assistance (TMA).

008.07(B)(i) REPORT REQUIREMENT. The gross monthly earnings and child care costs for employment, as billed or paid, for months seven through 12 must be verified. The second report or verifications of income and child care are due no later than the 21st of the seventh month. The third report or verifications of income or child care are due no later than the 21st of the tenth month.

008.07(B)(ii) INCOME ELIGIBILITY. The household’s earned income less any child care costs for employment, as billed or paid, for the three-month report period is averaged to determine income eligibility.

008.07(B)(iii) PREMIUM DUE. Beginning with month seven, the household is subject to payment of a monthly premium if its countable income is between 100% and 185% of the Federal Poverty Level (FPL). Failure to pay the required premium by the 21st of the following month will result in ineligibility for the month for which the premium was owed.

008.07(B)(iv) CAUSES FOR CLOSURE. The household is ineligible for the remaining months of Transitional Medical Assistance (TMA) if it:

(1) Fails, without good cause, to submit required verification of earnings and child care costs for employment;

(2) No longer includes a dependent child;

(3) Has gross monthly earnings and child care deductions for employment in excess of 185% of the Federal Poverty Level (FPL) during the preceding three-month period;

(4) The household moves out of the state; or

(5) An adult in the household regains eligible as a parent or caretaker relative using modified adjusted gross income methodology.

008.07(B)(iv)(a) GOOD CAUSE. Good cause for failing to submit the required program information exists when any of the following occur:

(i) Death of the parent or caretaker relative;

(ii) Verified hospitalization of a household member during the scheduled receipt period for required information; or

(iii) Natural disaster as determined by the Department.

008.07(C) AFTER MONTH 12. Eligibility for another Medicaid program will be determined at the end of the Transitional Medical Assistance (TMA) cycle.

009. EMERGENCY MEDICAL SERVICES ASSISTANCE (EMSA) . Emergency medical services may be provided to certain individuals who do not have a qualified non-citizen status for Medicaid. The individual must be eligible for a category of Medicaid assistance except for citizenship or a qualified non-citizen status. Only coverage for emergency services will be authorized.

009.01 EMERGENCY MEDICAL CONDITION. An emergency medical condition is defined as a medical condition, including emergency labor and delivery, manifesting itself by acute symptoms of sufficient severity, including severe pain, where the absence of immediate medical attention could reasonably result in:

(A) Serious jeopardy to the patient’s health;

(B) Serious impairment to bodily functions; or

009.02 EMERGENCY SERVICE AUTHORIZATION. To be considered eligible for emergency medical services for aliens (EMSA), the state review team (SRT) will determine that the individual has an emergency medical condition.

009.03 EFFECTIVE DATE. Emergency medical services for aliens (EMSA) is not subject to the provisions at 477 NAC 4 regarding the effective date of Medicaid eligibility. Eligibility for the program is limited to the time necessary to treat the emergency medical condition. The state review team (SRT) will determine the effective date of eligibility based upon the emergency medical condition.

010. KATIE BECKETT . The Katie Beckett program provides Medicaid coverage to children age 18 or younger with severe disabilities who live in their parent’s household, but who otherwise would require hospitalization or institutionalization due to their high level of health care needs.

010.01 ELIGIBILITY REQUIREMENTS. In order to receive Katie Beckett Medicaid, a child must meet all of the following:

(A) Not be eligible for the Supplemental Security Income (SSI) program or eligible for Medicaid based on parental income;

(B) Be age 18 or younger;

(D) Be certified by the Department’s Central Office designee as having hospital level of care needs; and

(E) Not incur in-home service costs to be funded by Medicaid that would exceed the costs Medicaid would pay if the child were in a hospital setting.

010.02 INCOME AND RESOURCES. Parental income and resources are not deemed for a child determined eligible for Katie Beckett Medicaid. Financial eligibility is based solely upon any income or resources belonging to the child.

010.03 REFERRALS. Medicaid accepts referrals for Katie Beckett eligibility determinations in the following situations:

(A) It is anticipated that a child will be discharged from a hospital to the child’s home and the child is not currently eligible for Medicaid;

(B) Notice has been received from SSI that a child’s benefits are being discontinued;

(C) The medical need of a child currently eligible for Home and Community-Based Waiver has been determined to have increased beyond the level applicable to the waiver program; or

(D) A child is not financially eligible for Medicaid based on family income.

010.04 HOSPITAL LEVEL OF CARE. Hospital level of care means that a child requires an extensive array of health care services throughout the day. This level of care may only be provided by highly skilled medical professionals in amounts normally available in a hospital but not in a skilled nursing facility. Lack of these services would be expected to result in hospitalization of the child.

010.04(A) CERTIFICATION OF HOSPITAL LEVEL OF CARE. Department certification for hospital level of care will be provided based upon the following criteria:

(i) A child needs frequent and complex medical care, as defined below, that requires the use of equipment to prevent life-threatening situations;

(ii) A child’s complex skilled medical interventions are expected to persist for a specific duration of time; and

(iii) A child’s overall health condition must require continuous assessment of a medical condition to prevent a life-threatening situation.

010.04(B) FREQUENT AND COMPLEX MEDICAL CARE. A child must need frequent and complex skilled medical interventions that require the use of medical equipment to prevent life-threatening situations. Tasks which are provided only when necessary and are not continuously required do not meet the criteria for frequent and complex medical care. SiteCare is not considered skilled medical task for the purpose of these requirements. The child’s health status must require both of the following:

(i) Provision of skilled medical assessment and interventions multiple times every 24-hour period; and

(ii) At least one of the following complex skilled medical interventions:

(a) Tracheostomy care requiring regular bronchial tree suctioning;

(b) Tracheostomy care with a dependency on a ventilator, for which the average use must be equal to or greater than 10 hours per day;

(c) Intravenous (IV) therapy involving central lines, including peripherally inserted central catheters (PICCs), for daily fluids or parenteral nutrition, for which the average use must be equal to or greater than ten hours per day; or

(d) Oxygen use that includes only skilled tasks requiring daily continuous oxygen, daily continuous assessments with titrations according to oxygen saturation levels, and daily bronchial tree suctioning.

010.04(C) DURATION. To meet hospital level of care, a child’s qualifying frequent and complex medical care need must be expected to be required for at least six months.

010.05 DISABILITY AND CARE LEVEL REVIEW. The Department will review a child’s Katie Beckett Medicaid eligibility on an annual basis.

History

Effective 2021-09-28

Chapter 28 Children Eligible for Iv-E Assistance; Non-Iv-E Adoption Subsidy; Former Foster Care Children

Neb. Admin. Code tit. 477, ch. 28 Children Eligible for Iv-E Assistance; Non-Iv-E Adoption Subsidy; Former Foster Care Children {#sec-477-nac-28 omnilex-key=us-ne-regs-official--title-477--477 NAC 28}

001. SCOPE AND AUTHORITY . These regulations govern the services provided under Nebraska’s Medicaid program as defined by the Medical Assistance Act, Nebraska Revised Statute § 68-901 et seq.

002. CHILDREN ELIGIBLE FOR IV-E ASSISTANCE . A child eligible for federally funded assistance through the Title IV-E program is Medicaid eligible. This includes subsidized adoption and subsidized guardianship.

002.01 ELIGIBLE CHILDREN. A child qualifying for IV-E assistance is eligible for Medicaid if:

(A) The child is IV-E eligible and is in the custody of the Department or a court of competent jurisdiction; (B) The child is in the custody of another state that made the IV-E determination, but the child lives in Nebraska; or (C) The child has been determined eligible for IV-E subsidized guardianship or adoption assistance by Nebraska, or another state but the child lives in Nebraska.

002.02 AGE. A child who is IV-E eligible and under 19 years old shall be eligible for Medicaid, with the following exceptions:

(A) A child who is in an institution for mental disease (IMD) is eligible until he or she turns 21 years old; and (B) A young adult who entered into an adoption or guardianship agreement after reaching 16 years old and is IV-E eligible may be eligible for Medicaid until he or she turns 21 years old.

002.03 INCOME AND RESOURCES. A child eligible for IV-E is exempt from income and resource tests.

002.04 EFFECTIVE DATE OF MEDICAID ELIGIBILITY. Medicaid eligibility is effective the first day of the month in which custody was first granted if the child was IV-E eligible in that same month.

002.05 CONTINUOUS ELIGIBILITY. Children who are eligible for Medicaid due to IV-E eligibility shall receive six months of continuous eligibility from the date of initial Medicaid eligibility. See 477 NAC 3.

002.06 CHILD PLACED IN A JAIL OR A DETENTION FACILITY. Medicaid cannot be used as a funding source for medical care during incarceration.

002.06(A) EXCEPTION. When a child placed in jail or detention leaves that setting and goes to an acute medical treatment setting for at least 24 hours, medical treatment in the acute setting may be billed to Medicaid if eligibility requirements are otherwise met.

003. CHILDREN ELIGIBLE FOR NON-IV-E ADOPTION . A special needs child eligible for non-IV-E subsidized adoption assistance may be Medicaid eligible if he or she meets special needs criteria.

003.01 ELIGIBLE CHILDREN. A child qualifying for non-IV-E subsidized adoption assistance is eligible for Medicaid if the following conditions are met:

(A) An adoption agreement, other than an agreement under Title IV-E, between the State of Nebraska and the adoptive parent(s) is in effect; (B) The Department has determined that the child cannot be placed for adoption without Medicaid coverage because of special needs for medical or rehabilitative care; (C) The child meets either of the following requirements:

(i) He or she would have been eligible for Medicaid before the adoption agreement was entered into; or (ii) He or she would have been eligible for Medicaid before the adoption agreement was entered into, if the eligibility standards and methodologies of the Title IV-E program were used without employing the threshold Aid to Dependent Children (ADC) eligibility determination; and

(D) The child is under 19 years old.

003.02 INCOME AND RESOURCES. A child who meets these criteria is exempt from income and resource tests.

004. FORMER FOSTER CARE CHILDREN .

004.01 FORMER FOSTER CARE CHILDREN. Individuals under 26 years old who were in foster care in any state and receiving Medicaid when the individual became 18 or 19 years old, or such higher age at which the state’s federal foster care assistance ends.

004.02 INCOME AND RESOURCES. former foster care children are exempt from income and resource tests.

004.03 ELIGIBILITY REQUIREMENTS. In order to receive Medicaid, the applicant or client must:

(A) Be under 26 years old; (B) Have been a client at 18 years old or such higher age at which the State’s foster care assistance ends under title IV-E of the Social Security Act; (C) Have been in foster care in any state at 18 or such higher age at which the state’s foster care assistance ends under title IV-E of the Social Security Act; and (D) Not be enrolled in mandatory Medicaid coverage through the Parent and Caretaker Relatives, Pregnant Women, Children, or Aged, Blind, and Disabled (ABD) eligibility groups.

History

Effective 2024-03-20

Chapter 29 Heritage Health Adult Program

Neb. Admin. Code tit. 477, ch. 29 Heritage Health Adult Program {#sec-477-nac-29 omnilex-key=us-ne-regs-official--title-477--477 NAC 29}

TITLE 477 MEDICAID ELIGIBILITY

CHAPTER 29 HERITAGE HEALTH ADULT PROGRAM

001. SCOPE AND AUTHORITY. These regulations govern the services provided under Nebraska’s Medicaid program as defined by the Medical Assistance Act, Nebraska Revised Statute (Neb Rev. Stat) §§ 68‑901 et seq.

002. DEFINITIONS. The following definitions apply to this chapter.

002.01 EDUCATIONAL PROGRAM. Educational program includes:

(A) An institution of higher education as defined by federal law; or

(B) A program of career and technical education as defined by federal law.

002.02 QUALIFYING MONTH. A month in which the applicant or beneficiary can demonstrate compliance with the work requirements. For applicants applying for benefits, the qualifying month must be the month prior to the month of application. For existing beneficiaries, the qualifying month must be one of the months during the time period between the beneficiary’s initial determination or most recent regularly scheduled redetermination of eligibility and the beneficiary’s next regularly scheduled redetermination of eligibility.

002.03 WORK PROGRAM. Work program has the meaning given to it under applicable federal law.

002.04 WORK REQUIREMENTS. A requirement that all applicants or beneficiaries within the Heritage Heath Adult (HHA) program demonstrate sufficient work, education, or community service activities, or an exception to such activities, in order to maintain coverage under Nebraska Medicaid.

003. HERITAGE HEALTH ADULT (HHA) PROGRAM. In order to be eligible for Nebraska Medicaid under the Heritage Health Adult (HHA) program, an individual must meet the following eligibility criteria.

003.01 METHODOLOGY AND INCOME LIMIT. Eligibility for the Heritage Health Adult (HHA) program is determined using the modified adjusted gross income (MAGI) methodology. In order to be eligible in the Heritage Health Adult (HHA) program, an individual must have household income equal to or less than 133% of the federal poverty level (FPL).

003.02 NON-FINANCIAL CRITERIA. In order to be eligible in the Heritage Health Adult (HHA) program, an individual must:

(A) Be age 19 or older and under age 65;

(B) Not be pregnant;

(D) Not be eligible for or enrolled in coverage in any of the following groups: parents and caretaker relatives, pregnant women, children under age 19, former foster care, individuals receiving IV-E assistance, transitional medical assistance (TMA) with or without a premium, and Nebraska Medicaid for the aged, blind, and disabled.

003.03 COVERAGE FOR DEPENDENT CHILDREN. Parents and caretaker relatives of dependent children are ineligible for coverage under the Heritage Health Adult (HHA) program unless all dependent children living in the household are enrolled in Nebraska Medicaid, the Children’s Health Insurance Program (CHIP), or are otherwise enrolled in minimum essential coverage as defined by state and federal law

003.04 INDIVIDUALS WHO BECOME PREGNANT WHILE ENROLLED IN THE HERITAGE HEALTH ADULT (HHA) PROGRAM. If an individual becomes pregnant during enrollment in the Heritage Health Adult (HHA) program, the individual will remain in the Heritage Health Adult (HHA) program until eligibility is redetermined at the end of the postpartum period.

003.05 WORK REQUIREMENTS. All applicants or beneficiaries through the Heritage Health Adult (HHA) program must demonstrate compliance with work requirements in order to be eligible for the program.

003.05(A) WORK REQUIREMENTS QUALIFYING ACTIVITIES. All applicants or beneficiaries must meet one or more of the following requirements in a qualifying month to comply with work requirements:

(i) Work not less than 80 hours;

(ii) Complete not less than 80 hours of community service;

(iii) Participate in a work program for not less than 80 hours;

(iv) Be enrolled in an educational program for at least half of the program’s full-time enrollment;

(v) Engage in any combination of work, community service, a work program, or educational program for a total of not less than 80 hours; or

(vi) Have income that is not less than the applicable federal minimum wage multiplied by 80 hours per month.

003.05(A)(1) SEASONAL WORK. For seasonal work, all applicants or beneficiaries must have an average income in the six months preceding the application or renewal date that is not less than the applicable minimum wage multiplied by 80 hours per month.

003.05(B) WORK REQUIREMENTS EXCEPTIONS. All applicants or beneficiaries shall be deemed to have complied with work requirements for a qualifying month if:

(i) For part or all of a qualifying month the applicant or beneficiary:

(1) Was a specified excluded individual;

(2) Was under the age of 19;

(3) Was entitled to or enrolled in Medicare Part A or B; or

(4) Was eligible for or enrolled in coverage in any of the following groups: parent and caretaker relatives, pregnant women, children under age 19, former foster care, individuals receiving IV-E assistance, transitional medical assistance (TMA) with or without a premium, and Nebraska Medicaid for the aged, blind, and disabled;

(ii) At any point during the three-month period preceding the application or renewal date, the applicant or beneficiary was an inmate of a public institution;

(iii) The applicant or beneficiary receives inpatient hospital services, nursing facility services, services in an intermediate care facility for individuals with developmental disabilities (ICF/DD), inpatient psychiatric hospital services, or such other services of similar acuity as determined by Nebraska Medicaid;

(iv) The applicant or beneficiary resides in a county with a federally declared emergency or disaster;

(v) The applicant or beneficiary resides in a county with an unemployment rate that is at or above the lesser of:

(1) Eight percent; or

(2) One and a half times the national unemployment rate; or

(vi) The applicant or beneficiary or their dependent must travel outside of their community for an extended period of time to receive medical services necessary to treat a serious or complex medical condition that are not available within their community of residence.

003.05(C) SPECIFIED EXCLUDED INDIVIDUALS. A specified excluded individual is an individual who is:

(i) Under 26 years of age and in foster care or eligible for the former foster care program:

(ii) An Indian or Urban Indian as such terms are described in federal law;

(iii) A California Indian as described in federal law;

(iv) Determined otherwise eligible as an Indian for the Indian Health Service (IHS) under regulations promulgated by the federal Secretary of Health and Human Services;

(v) The parent, guardian, caretaker relative, or family caregiver as defined by the Recognize, Asset, Include, Support, and Engage (RAISE) Family Caregiver Act of a dependent child 13 years of age or under or a disabled individual;

(vi) A veteran with a disability rated as total under federal law;

(vii) Medically frail or otherwise has special medical needs as defined by the federal Secretary of Health and Human Services or federal law;

(viii) In compliance with any requirements imposed pursuant to Temporary Assistance for Needy Families (TANF) under federal law;

(ix) A member of a household that receives Supplemental Nutrition Assistance Program (SNAP) under federal law and is not exempt from a work requirement under the same federal law;

(x) Participating in a drug addiction or alcoholic treatment and rehabilitation program as defined in federal law;

(xi) An inmate of a public institution as defined by this title;

(xii) Pregnant; or

(xiii) Entitled to postpartum medical assistance pursuant to this title.

003.06 WORK REQUIREMENTS PARTICPATION TIMEFRAMES. To be eligible for Nebraska Medicaid through the Heritage Health Adult (HHA) program, an applicant must demonstrate engagement in a qualifying activity or be subject to an exception in the calendar month preceding the month of application. To remain eligible, beneficiaries enrolled in the Heritage Health Adult (HHA) program must demonstrate compliance with work requirements in a qualifying activity or be subject to an exception for at least one month during the time period between the beneficiary’s initial determination or most recent regularly scheduled redetermination of eligibility and the beneficiary’s next regularly scheduled redetermination of eligibility.

003.07 DOCUMENTATION OF COMPLIANCE. Applicants or beneficiaries must provide documentation of compliance with work requirements which meet the requirements set forth in state and federal law and regulations.

003.08 NOTICE OF NONCOMPLIANCE. If Nebraska Medicaid is unable to verify compliance with work requirements at initial application, renewal, or change in circumstance, the applicant or beneficiary has 30 calendar days from receipt of the notice of noncompliance to provide verification to Nebraska Medicaid before their application or benefits may be denied or closed. If denied or closed, the applicant or beneficiary is still entitled to notice and fair hearing rights as laid out elsewhere in this title.

003.09 RENEWAL PERIOD. Beginning January 1, 2027, a redetermination of eligibility for continued benefits under the Heritage Health Adult (HHA) program must be completed every six months.

004. BINDING ON THE HERTIAGE HEALTH ADULT (HHA) PROGRAM. In the event of a conflict between the provisions of any section of this title and this chapter regarding Heritage Health Adult (HHA) program applications or renewals, the provisions of this chapter shall govern.

History

Effective 2026-04-26

Neb. Admin. Code tit. 477 — Medicaid Eligibility

Chapter 1 General Definitions

Neb. Admin. Code tit. 477, ch. 1 General Definitions {#sec-477-nac-1 omnilex-key=us-ne-regs-official--title-477--477 NAC 1}

Chapter 2 Overview of Eligibility Requirements

Neb. Admin. Code tit. 477, ch. 2 Overview of Eligibility Requirements {#sec-477-nac-2 omnilex-key=us-ne-regs-official--title-477--477 NAC 2}

Chapter 3 Application Process

Neb. Admin. Code tit. 477, ch. 3 Application Process {#sec-477-nac-3 omnilex-key=us-ne-regs-official--title-477--477 NAC 3}

Chapter 4 Effective Date of Medicaid Eligibility

Neb. Admin. Code tit. 477, ch. 4 Effective Date of Medicaid Eligibility {#sec-477-nac-4 omnilex-key=us-ne-regs-official--title-477--477 NAC 4}

Chapter 5 Citizenship/Alien Status and Identity

Neb. Admin. Code tit. 477, ch. 5 Citizenship/Alien Status and Identity {#sec-477-nac-5 omnilex-key=us-ne-regs-official--title-477--477 NAC 5}

Chapter 6 State Residency

Neb. Admin. Code tit. 477, ch. 6 State Residency {#sec-477-nac-6 omnilex-key=us-ne-regs-official--title-477--477 NAC 6}

Chapter 7 Age and Date of Birth

Neb. Admin. Code tit. 477, ch. 7 Age and Date of Birth {#sec-477-nac-7 omnilex-key=us-ne-regs-official--title-477--477 NAC 7}

Chapter 8 Social Security Number

Neb. Admin. Code tit. 477, ch. 8 Social Security Number {#sec-477-nac-8 omnilex-key=us-ne-regs-official--title-477--477 NAC 8}

Chapter 9 Notification

Neb. Admin. Code tit. 477, ch. 9 Notification {#sec-477-nac-9 omnilex-key=us-ne-regs-official--title-477--477 NAC 9}

Chapter 10 Fair Hearing Processes

Neb. Admin. Code tit. 477, ch. 10 Fair Hearing Processes {#sec-477-nac-10 omnilex-key=us-ne-regs-official--title-477--477 NAC 10}

Chapter 11 Living Arrangements

Neb. Admin. Code tit. 477, ch. 11 Living Arrangements {#sec-477-nac-11 omnilex-key=us-ne-regs-official--title-477--477 NAC 11}

Chapter 12 Third-Party Resources and Child Support Enforcement

Neb. Admin. Code tit. 477, ch. 12 Third-Party Resources and Child Support Enforcement {#sec-477-nac-12 omnilex-key=us-ne-regs-official--title-477--477 NAC 12}

Chapter 13 Medicaid Benefits Provided in Error

Neb. Admin. Code tit. 477, ch. 13 Medicaid Benefits Provided in Error {#sec-477-nac-13 omnilex-key=us-ne-regs-official--title-477--477 NAC 13}

Chapter 14 Definitions Pertaining to Magi-Based Programs

Neb. Admin. Code tit. 477, ch. 14 Definitions Pertaining to Magi-Based Programs {#sec-477-nac-14 omnilex-key=us-ne-regs-official--title-477--477 NAC 14}

Chapter 15 Household or Unit Size for Magi-Based Programs

Neb. Admin. Code tit. 477, ch. 15 Household or Unit Size for Magi-Based Programs {#sec-477-nac-15 omnilex-key=us-ne-regs-official--title-477--477 NAC 15}

Chapter 16 Income for Magi-Based Programs

Neb. Admin. Code tit. 477, ch. 16 Income for Magi-Based Programs {#sec-477-nac-16 omnilex-key=us-ne-regs-official--title-477--477 NAC 16}

Chapter 17 Resources for Magi-Based Programs

Neb. Admin. Code tit. 477, ch. 17 Resources for Magi-Based Programs {#sec-477-nac-17 omnilex-key=us-ne-regs-official--title-477--477 NAC 17}

Chapter 18 Relative Responsibility for Magi-Based Programs

Neb. Admin. Code tit. 477, ch. 18 Relative Responsibility for Magi-Based Programs {#sec-477-nac-18 omnilex-key=us-ne-regs-official--title-477--477 NAC 18}

Chapter 19 Modified Adjusted Gross Income (magi)-Based Programs

Neb. Admin. Code tit. 477, ch. 19 Modified Adjusted Gross Income (magi)-Based Programs {#sec-477-nac-19 omnilex-key=us-ne-regs-official--title-477--477 NAC 19}

Chapter 20 Definitions Pertaining to Non-Modified Adjusted Gross Income (magi) Programs

Neb. Admin. Code tit. 477, ch. 20 Definitions Pertaining to Non-Modified Adjusted Gross Income (magi) Programs {#sec-477-nac-20 omnilex-key=us-ne-regs-official--title-477--477 NAC 20}

Chapter 21 Household or Unit Size for Non-Magi Programs

Neb. Admin. Code tit. 477, ch. 21 Household or Unit Size for Non-Magi Programs {#sec-477-nac-21 omnilex-key=us-ne-regs-official--title-477--477 NAC 21}

Chapter 22 Income for Non-Modified Adjusted Gross Income (non-Magi) Programs

Neb. Admin. Code tit. 477, ch. 22 Income for Non-Modified Adjusted Gross Income (non-Magi) Programs {#sec-477-nac-22 omnilex-key=us-ne-regs-official--title-477--477 NAC 22}

Chapter 23 Resources for Non-Modified Adjusted Gross Income (magi) Programs

Neb. Admin. Code tit. 477, ch. 23 Resources for Non-Modified Adjusted Gross Income (magi) Programs {#sec-477-nac-23 omnilex-key=us-ne-regs-official--title-477--477 NAC 23}

Chapter 24 Relative Responsibility and Sponsor Deeming for Aliens for Non-Magi Programs

Neb. Admin. Code tit. 477, ch. 24 Relative Responsibility and Sponsor Deeming for Aliens for Non-Magi Programs {#sec-477-nac-24 omnilex-key=us-ne-regs-official--title-477--477 NAC 24}

Chapter 25 Budgeting for the Medically Needy

Neb. Admin. Code tit. 477, ch. 25 Budgeting for the Medically Needy {#sec-477-nac-25 omnilex-key=us-ne-regs-official--title-477--477 NAC 25}

Chapter 26 Spousal Impoverishment Medicaid Program (simp)

Neb. Admin. Code tit. 477, ch. 26 Spousal Impoverishment Medicaid Program (simp) {#sec-477-nac-26 omnilex-key=us-ne-regs-official--title-477--477 NAC 26}

Chapter 27 Eligibility for the Aged, Blind, and Disabled; Medically Needy; Qualified Disabled Working Individuals; Medicaid Insurance for the Workers with Disabilities; Breast and Cervical Cancer; Emergency Medical Services Assistance; and Katie Beckett

Chapter 28 Children Eligible for Iv-E Assistance; Non-Iv-E Adoption Subsidy; Former Foster Care Children

Neb. Admin. Code tit. 477, ch. 28 Children Eligible for Iv-E Assistance; Non-Iv-E Adoption Subsidy; Former Foster Care Children {#sec-477-nac-28 omnilex-key=us-ne-regs-official--title-477--477 NAC 28}

Chapter 29 Heritage Health Adult Program

Neb. Admin. Code tit. 477, ch. 29 Heritage Health Adult Program {#sec-477-nac-29 omnilex-key=us-ne-regs-official--title-477--477 NAC 29}

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