Non-Grant Medical Assistance (NGMA) examples
Purpose: To provide examples of the decision making process for non-grant Apple Health and to ensure that applications for medical assistance are considered for the correct program.
Example: Individual 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 appears Robert's net countable income of $557.50 would make him eligible under the S02 program (based on the Categorically Needy Income Level (CNIL)). However, since S02 medical does not waive the SGA test, and Robert has earned income over the current SGA limit, 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 Apple Health for Workers with Disabilities (HWD) program. Since Robert has gross earned income over SGA, send his application to the HWD unit for processing.
Example: Earned income gives individual the choice between SSI-related medical and HWD if she meets other program requirements.
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 current SGA limit, 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 individual with earnings over SGA.
Miranda (34) has been receiving state-funded employment supports through the Developmental Disabilities Administration (DDA) but has not had medical coverage. Miranda submits an application for Apple Health, because DDA wants to transition her to the 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 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 L22 coverage group because of the SGA test.