Non-Grant Medical Assistance (NGMA) examples
To provide examples of the decision-making process for non-grant medical assistance (Apple Health).
Example: Individual is resource eligible for SSI-related Medicaid, but income exceeds the Substantial Gainful Activity (SGA) test.
Robert (53) is working and earns $1885 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 $900 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 he could be eligible for 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 who will review for a disability and request a NGMA if appropriate.
Example: Earned income gives an individual the choice between SSI-related Medicaid and HWD if program requirements are met.
Katie (45) receives L&I payments of $950 per month and she has a small self-employment business and earns approximately $100 per week. Her total gross income is $1350 per month. Also, she has recently become eligible for Medicare. If she were not eligible for Medicare, then she should first be screened for MAGI coverage under the new adult group (N05), using the Healthplanfinder.
Since Katie's earnings are below the current SGA limit, she is eligible for regular SSI-related Medicaid with a spenddown OR she can choose HWD coverage with a premium. Explain the options available to her. If she chooses HWD, the NGMA referral is initiated by the HWD worker.
Example: An individual on a DDA waiver 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 applies 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. Although Miranda's income is below the Special Income Level for the Basic Waiver program, her earnings are over the SGA amount. Refer Miranda's application to the HWD unit to complete the NGMA referral and premium determination. Miranda is not eligible for SSI-related medical under the L22 coverage group because of the SGA test.