Lorie Mayorga
Deputy Director, Eligibility Policy
Department of Health and Mental Hygiene

• Medicaid expansion: new eligibility for non-disabled, non-elderly, childless adults up to 138% of the Federal Poverty Level
• Certain populations transition to simplified eligibility rules based on income only
• Primary Adult Care population automatically transitioning to full
Medicaid effective January 1 st
• Former foster youth eligible for Medical Assistance up to age 26, regardless of income effective January 1 st

• Medical Assistance Fair Hearing Appeals, COMAR 10.01.04
• Approved effective October 1, 2013 by the Joint Committee on
Administrative, Executive & Legislative Review Committee (AELR)
• Emergency Regulations same as proposed
• Proposed regulations published October 18, 2013
• Medical Assistance Eligibility, COMAR 10.09.24
• MCHP, COMAR 10.09.11
• MCHP Premium, COMAR 10.09.43

• Individuals must still meet Medicaid/MCHP Premium’s non-financial eligibility criteria
• Citizenship/immigration status
• Residency
• MHBE will make determinations on income-based Medicaid only for the following groups:
• children
• pregnant women
• parents and caretaker relatives of dependent children
• non-elderly, non-disabled childless adults
• Generally, the tax definitions of household size and MAGI-based income apply

• Household size must be calculated for each household member, as it can vary even within the household
• Example:
• Lee and Amanda are married. Amanda is pregnant with twins.
• Amanda’s household size: 4 (Amanda + the twins + Lee)
• Lee’s household size: 2 (Lee and Amanda; the twins are not included in
Lee’s household)

• The tax rules for household size do not apply for Medicaid/MCHP Premium when:
• the applicant is not planning to file taxes (i.e., income below filing threshold)
• the individual (child or adult) lives with a grandparent or other caretaker relative, regardless of who claims the individual as a tax dependent
• a child under age 21 lives with both parents, but only one parent will claim the child as a tax dependent
• a child, under age 21, lives with a custodial parent but will be claimed as a tax dependent by the non-custodial parent

In those situations, the (traditional) relationship-based household rules apply:
• For adults, a household consists of:
• adult applying for coverage
• applicant’s spouse, if living with the applicant
• applicant’s natural, adopted, and stepchildren under age 21, if living with the applicant
• For children under age 21, a household consists of:
• the child applying for coverage
• any of the child’s parents, stepparents, or adoptive parents living with the child
• for households headed by a non-parent caretaker adult, the caretaker adult
• any of the child’s siblings, step-siblings, or adoptive siblings under age 21 living with the child

• Medicaid looks at monthly income
• A pro-rated portion of reasonably predictable changes in income may be considered if there is a basis for anticipating the changes
• e.g., such as a signed contract for employment, a clear history of predictable fluctuations in income, or other indications of future changes in income
• For Medicaid eligibility, MHBE uses the most recently published FPL level in effect for the month when an applicant applies

(DC + all states except for Alaska and Hawaii)

• Household Income
• To be eligible for MAGI Medicaid, applicant’s current monthly household income must meet specified standards
Coverage Groups
Adults
Medicaid for children under age 1
Medicaid for children ages 1-21
MCHP
MCHP Premium
Parents and Caretaker Relatives
Pregnant Women
FPL
138%
199%
138%
211%
322%
138%
264%

• Whose income is counted?
• In general, MAGI income of all individuals in an applicant’s household is counted toward household income, with two exceptions:
• Income of children (even over age 21) in household with parent if they are dependents and not expected to be required to file a tax return
• Income of most other dependents (not children or spouses) if not expected
to be required to file a tax return
• A spouse’s MAGI income is always counted even if claimed as a tax dependent

• Special rules for Medicaid/MCHP Premium MAGI
• Lump sum payments are counted only in month received
• Taxable educational scholarships, awards—continue to be excluded from
Medicaid income
• Certain types of income for American Indian/Alaska Natives are excluded

• No exclusionary period for voluntarily dropping employment-based health coverage
• Maximum 90 day “lockout” for nonpayment of premium
• Enrollment still requires payment of first month’s premium, but now children will receive a period of fee-for-service coverage during the
MCO processing period

• Maryland Health Connection determines eligibility only on the basis of MAGI income
• If application shows that applicant may be eligible for Medicaid on a different basis, or if the applicant requests a determination for non-
MAGI groups, application will be referred to DHMH
• Some individuals who would otherwise have required a disability evaluation may now qualify for Medicaid in the adult expansion group

• Retroactive coverage rules remain the same: Medicaid will pay providers for services during any of the 3 months before application for individuals who are found eligible for such months
• Maryland Health Connection cannot determine eligibility for services furnished before 1/1/14
• The single streamlined application allows Medicaid-eligible individuals to indicate that they have bills from the last 3 months
• Current eligibility is determined first—no application will be referred for “retro” processing unless applicant is eligible in application month

Former foster care individuals may be determined eligible under MAGI coverage rules if they are:
(a) Are younger than 26 years old;
(b) Are not eligible and enrolled for coverage under a mandatory
Medicaid group other than childless adult; and
(c) Were in a Maryland out-of-home placement, including categorical
Medicaid:
(i) On attaining age 18 and leaving out-of-home placement, or
(ii) On attaining age 19-21 during extended out-of-home placement under
COMAR 07.02.11.04B.

Definition of MAGIbased income
Data sources used
APTC/Cost Sharing Reduction
IRS definition
FTI is checked first; if the FTI is not reasonably compatible, then State data sources are checked automatically
Medicaid/MCHP Premium
IRS definition, except that the following is excluded: income of dependents as long as they are not expected to be required to file a tax return; certain
American Indian/Alaska Native income; and educational scholarships and grants. Also, lump sum payments are counted only in the month received.
State data sources

APTC/CSR
Applicable FPL
Percentage of FPL
FPL in effect as of the first day of Open
Enrollment (always in October)
Determined using annual income
Definition of household IRS definition
Medicaid/MCHP Premium
FPL in effect for the month that coverage is sought
Determined using monthly income
IRS definition except when: an applicant does not plan to file taxes; an individual lives with a grandparent or other caretaker relative; a child who lives with both parents is claimed by only one parent; or a child is claimed by non-custodial parent

• Lauren is a divorced mother who lives with her two children, Mitchell and Patrick. Her ex-husband, Chris, claims Mitchell on his taxes while
Lauren claims Patrick. Lauren makes $38,000 per year.
• What coverage is each member of the household eligible for?

Lauren is a divorced mother who lives with her two children, Mitchell and Patrick. Her exhusband, Chris, claims Mitchell on his taxes while Lauren claims Patrick. Lauren is a salaried employee making $38,000 per year.
STEP 1: Determine Medicaid/MCHP Premium eligibility
There are 3 people in the household; the fact that Lauren does not claim Mitchell as a dependent does not affect the Medicaid household size. The applicable monthly FPL is
$1,627.50, so the monthly household income of $3,166.67 is at 195% of the poverty line, making both Mitchell and Patrick eligible for
MCHP. Lauren, is not eligible for Medicaid because the income is higher than 138%

• Kurt worked at an ice cream stand on the boardwalk in Ocean City from April through September. Before that he was unemployed for over a year and did not file taxes during that time. In December, Kurt applies online through Maryland Health Connection and attests to an annual income of $14,000. HIX checks the federal hub but there is no
FTI available. HIX then checks the State data sources, and MABS shows that Kurt earned $7,000 in each of the last two quarters. HIX calculates that Kurt’s annual income is $28,000 per year. Given that the difference between Kurt’s attested income and the annualized income from MABS is greater than 10%, Kurt is asked to explain the discrepancy. He indicates that he is a seasonal employee.
• What coverage is Kurt eligible for?

• Kurt worked at an ice cream stand on the boardwalk in Ocean City from April through
September. Before that he was unemployed for over a year and did not file taxes during that time. In December, Kurt applies online through Maryland Health Connection and attests to an annual income of $14,000. HIX checks the federal hub but there is no FTI available. HIX then checks the State data sources, and MABS shows that Kurt earned
$7,000 in each of the last two quarters. HIX calculates that Kurt’s annual income is
$28,000 per year. Given that the difference between Kurt’s attested income and the annualized income from MABS is greater than 10%, Kurt is asked to explain the discrepancy. He indicates that he is a seasonal employee.
• STEP 1: Determine Medicaid eligibility
• Because Kurt’s employment is seasonal, HIX’s calculations were not correct.
The income is corrected during the Inconsistency Period and Kurt is determined eligible for Medicaid.

Lorie Mayorga lorie.mayorga@maryland.gov
410-767-1464
Maryland Health Connection: marylandhealthconnection.gov
Customer Service Center: 1-855-642-8572