EXAMPLE

Client is resource eligible for SSI-related medical but income exceeds the Substantial Gainful Activity (SGA) test.

Robert (53) is working and earns $1200 per month managing an apartment complex.  He has no other income and his resources are below $2000.  After allowing the $20 income exclusion and the $65 plus one half earned income disregard, it would appear that Robert's net countable income of $557.50 would make him eligible under the S02 program (based on 2010 CN standard of $674).  However, since S02 medical does not waive the SGA test, and Robert has earned income over the 2010 SGA limit ($1000), Robert is not considered 'disabled' under S02 program rules and is not eligible for this program.

Since Robert is working and is under the age of 65, he would be eligible under the Healthcare for Workers with Disabilities (HWD) program. Since Robert has gross earned income over SGA, refer Robert's application to the HWD unit to process and advise Robert that he is required to pay the HWD premium to receive medical coverage.

EXAMPLE

Client is income eligible for SSI-related medical but resources exceed the standard.

Tom (62) receives $720 in Social Security retirement benefits.  He has recently cashed out a small IRA account from work and has $3200 in his savings account, plus $1500 set aside in a burial fund.  You receive his application on April 2nd, however when you call Tom on April 15th, he tells you he had to pay a medical bill of $1800 and he mailed them the check on April 8th.  Tom's resources are over the standard ($2000) as of April 1st therefore he is not eligible for medical coverage in April.  Refer Tom for a NGMA decision and be aware that even if Tom is found disabled as of April 1st, he will not be financially eligible for coverage until May 1st.

EXAMPLE

Earned income gives client the choice between SSI-related medical and HWD.

Katie (45) receives L&I payments of $950 per month and she has a small self employment business that brings in approximately $100 per week.  Her total gross income is $1350 per month.  Since Katie's earnings are below the SGA limit of $1000 (01/2010), Katie is eligible for regular SSI-related medicaid but would be subject to a spenddown OR she can choose HWD coverage with a premium.  Explain the options available to her and refer for a NGMA if she wants the spenddown.  If she chooses HWD, refer the application to the HWD unit to start the NGMA referral. 

EXAMPLE

DDD waiver client with earnings over SGA.

Miranda (34) has been receiving state-funded employment supports through the Division of Developmental Disabilities but has not had medical coverage.  Miranda submits a medicaid application because DDD wants to transition her to their Basic Waiver program.  She is working and earns $1800 per month.  Miranda has been working with a benefit analyst who has recommended that she apply for HWD - even with subsidies, Miranda is earning over the SGA amount.  Although Miranda's income is below the Special Income Level ($2022) for the Basic Waiver program, her earnings (net of subsidy) are over the SGA amount, refer Miranda's application to the HWD unit to process for the NGMA referral and premium determination.  Miranda is not eligible for SSI-related medical under the C01 coverage group because of the SGA test.