Section 467-2-003 - MEDICAL AND FINANCIAL ELIGIBILITYEligibility for the Medically Handicapped Children's Program and Genetically Handicapped Persons Program is based on medical eligibility and financial qualifications. Current medical and financial information must be provided.
003.01MEDICAL ELIGIBILITY DETERMINATION. Medical eligibility is determined by either the Department or Department designated medical reviewer. If an applicant is seen by a Department designated clinic team, medical eligibility can be determined without going through the medical reviewer. Eligibility is specific to one or more diagnosis and each diagnosis must meet the qualifications in Chapter 3. To determine eligibility, the medical records must include the diagnosis and a current individual medical treatment plan developed by a physician, physician assistant, or nurse practitioner. Medical records submitted must have a date of service less than six months prior to the determination request date.003.02MEDICAL ELIGIBILITY REVIEWS. Current medical specialty reports must be received for the eligible diagnosis at the time of review annually. Department designated clinic team reports may take the place of a specialty report. Medical eligibility for reviews are not determined by a medical consultant.003.03FINANCIAL ELIGIBILITY DETERMINATION. Financial eligibility is determined based on the probable cost of specialized medical care and the income and resources available to the applicant, parents, or legal guardians. The recipient's income must be at or below 185 percent of the federal poverty level for the appropriate family size after countable income is figured minus deductions. If the family's income minus deductions exceeds the requirement, a financial margin must be calculated. Countable income includes all income not listed as exclusions in the Title. 003.03(A)INCOME EXCLUSIONS. The following are excluded as sources of income: (i) Withdrawals of bank deposits;(iv) Cash gifts under $500;(v) Earnings of all children age 18 years and younger;(vi) Child or spousal support;(vii) Subsidized adoption or subsidized guardianship payments from Title IV-E or child welfare funds;(viii) Value of United States Department of Agriculture donated foods;(ix) Any payment received under the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970;(x) Loans, grants, and scholarships obtained and used under conditions that prohibit the use for current living costs;(xi) Alaska Native Claims Settlement Act payments to the extent the payments are exempt from taxation under section 21(a) of the Act;(xii) Value of Supplemental Nutrition Assistance Program and the special food service program for children under the National School Lunch Program Child Nutrition Act of 1966, as amended;(xiii) Money awarded by the Indian Claims Commission or the Court of Claims;(xiv) Reimbursement of expenses or payments for services from the Senior Companion Program, AmeriCorps, Senior Corps, Foster Grandparents, Service Corps of Retired Executives, Experience Works, and any other programs under Title II and III of Public Law 93-113;(xv) Payments to an individual participating in training or school attendance subsidized Vocational Rehabilitation within the Nebraska Department of Education; and(xvi) Low Income Energy Assistance funds;003.03(B)FINANCIAL DEDUCTIONS. The following are deducted from the countable income: (2) Spousal support or alimony paid;(3) Child care necessary for employment or education if both parents are employed or receiving education or if one parent is unavailable to care for the child due to absence or incapacity. This excludes students pursuing second undergraduate degrees and certificates or any post-graduate schooling;(4) Tuition and books for family members attending school. This excludes students pursuing second undergraduate degrees and certificates or any post-graduate schooling; and(5) Medical expenses for the entire family, including medical insurance premiums, paid within the 12 months preceding the date of application.003.03(B)(i)MEDICAL EXPENSE DEDUCTION REDETERMINATION. Medical expenses allowed for the previous year's financial margin are not counted for the current year's medical expenses. The medical expenses deducted and allowed on the previous year's application must be deducted at the time of redetermination.003.03(C)RESOURCE LIMITS. There are no resource limits for these programs.003.03(D)FINANCIAL MARGIN. The financial margin is the recipient's responsibility that must be paid annually, after any third party, on the recipient's specialized health care prior to the Department making any payments. If the family's income minus deductions exceeds the income requirement, a financial margin must be calculated. The financial margin is 25 percent of the amount which exceeds the income requirements minus the financial margin deductions. 003.03(D)(i)FINANCIAL MARGIN DEDUCTIONS. The following are deducted from the financial margin: (1) Unpaid medical bills for the applicant or recipient, not included in previous year's medical allowance;(2) Projected travel and lodging costs using state employee rates for specialized medical care; and(3) Projected costs of child care for siblings while the client is hospitalized or receiving medical services.003.04FINANCIAL ELIGIBILITY REVIEWS. Financial eligibility redetermination must be completed annually or at the time of any changes in income or family size.003.05MEDICAID ELIGIBLE WITH SHARE OF COST. Applicants and recipients must apply for Medicaid if a referral is appropriate. If the applicant or recipient is eligible or denied Medicaid with a high share of cost, the Department may request Medicaid be open with the share of cost based on the cost savings for the program and benefit to the applicant or recipient. Funds may be used towards medical care not to exceed the Medicaid share of cost. The applicant or recipient is considered Medicaid eligible once the share of cost is met.467 Neb. Admin. Code, ch. 2, § 003
Amended effective 5/17/2022