Title 16
15000 AFDC-TANF Related Programs
The Family Support Act of 1988, PL 100-485, mandated that effective April 1, 1990, states provide health care coverage known as Transitional Medical Assistance for up to twelve months for families who become ineligible for AFDC due to increased earnings, increased hours of employment, or loss of earned income disregards.
The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), P.L. 104-193, repealed the AFDC program and replaced it with a program of block grants to states for Temporary Assistance for Needy Families (TANF). Delaware implemented its TANF program, A Better Chance Welfare Reform Program (ABC), on March 10, 1997.
Prior to PRWORA, a family’s eligibility for Transitional Medicaid was linked to receipt of AFDC. Under PRWORA, a family’s eligibility for transitional Medicaid is linked to receipt of Medicaid under Section 15120, “Low Income Families with Children under Section 1931. (See DSSM 15120 )
The eligibility group described in “Low Income Families with Children under Section 1931, will be referred to as “receiving Medicaid under Section 1931 throughout this section.
Delaware's welfare reform waiver, "Temporary Assistance to Needy Families" (TANF) included a modification to the length of the Transitional Medicaid period. The TANF waiver extended Transitional Medicaid benefits for up to 24 months. This waiver expired on September 30, 2002. DSS will use the option under Section 1931(b)(2)(C) of the Social Security Act to disregard all earned income for 12 months after employment causes ineligibility for a family under Section 1931. (See DSSM 15120.2) Effective October 1, 2002, Transitional Medicaid coverage extends for up to one year. The year is divided into two periods of six months each. Families who establish eligibility for Transitional Medicaid prior to October 1, 2002, may be eligible for up to 24 months of Transitional Medicaid. These are families who establish eligibility for Transitional Medicaid under the DABC waiver authority. Families who establish eligibility for Transitional Medicaid on or after October 1, 2002, may be eligible for up to 12 months of Transitional Medicaid.
Families must meet the initial eligibility requirements described in this section to receive the first six (6) months of coverage. Families can be eligible when their income exceeds either 185% of the standard of need or the standard of need.
To continue to receive Medicaid for the second six (6) months, the family's gross earned income less dependent care costs must be at or below 185% FPL. Dependent care costs are for the care of dependent children or incapacitated persons living in the home. Family income will be budgeted prospectively.
15200.1 Initial Eligibility For First Six Months
At the time a family becomes ineligible for Medicaid under Section 1931 determine whether the family meets the following three requirements.
15200.1.1 Three Out of Six Months Requirement
The family must have received Medicaid under Section 1931 in three of the six months immediately preceding the month the family became ineligible for Medicaid under Section 1931.
A family is considered to have received Medicaid under Section 1931 in any month Medicaid assistance was correctly provided. This does not include Medicaid assistance provided in error; Medicaid assistance provided pending a hearing if the family loses the hearing and the Medicaid assistance provided is recoverable as an overpayment; or Medicaid assistance provided for a month of ineligibility because of administrative notice requirements. Recipients are obligated to report changes promptly. When a change is reported, the worker must review eligibility. If the change will result in ineligibility, the worker must take action to close the case. This can affect the month of ineligibility.
The family must have received Medicaid under Section 1931 in Delaware for three of the six months. Families who move into Delaware and who have not received three months of Medicaid under Section 1931 here are not eligible for transitional Medicaid. Transitional Medicaid benefits are not transferable from one state to another. If a family is entitled to and receives six months of transitional Medicaid benefits in another state and then moves into Delaware, they are not eligible for Transitional Medicaid here.
15200.1.2 Increased Earnings or Loss of Earned Income Disregards
The family must become ineligible for Medicaid under Section 1931 because of an increase in the hours of or increased income from the employment of the caretaker relative or because a member of the family loses the $30 and 1/3 earned income disregard or the $30 disregard.
This happens when:
a) an increase in earned income (or countable earned income because of loss of disregard) makes the family ineligible or
b) an increase in other income when combined with an increase in earned income (or countable earned income because of loss of disregard) makes the family ineligible. The caretaker relative whose earnings cause ineligibility must meet the three out of six months requirement in order for the family to receive Transitional Medicaid.
The increase in earned income (or hours of work or loss of the disregards) must have a causative effect on the loss of 1931 eligibility. Follow these steps to determine if an increase in income (or other factor) had a causative effect.
1. Determine if the increase in income (or hours of employment or loss of the disregards) would have resulted in loss of 1931 eligibility if all other factors in the case remained the same (i.e., there was no other change in income, no change in family composition, no change in 1931 standards, etc.).
If yes, the family is eligible to receive Transitional Medicaid.
If no, go to step 2.
2. Determine if events other than the increase in income (or hours of employment or loss of the disregards) would have resulted in loss of 1931 eligibility if the income (hours or disregards) had stayed the same.
If yes, the family is not eligible to receive Transitional Medicaid.
If no, go to step 3.
3. Determine if the family is ineligible for 1931 when all changes are considered.
If yes, the family is eligible for Transitional Medicaid. The increase in earnings (or hours of employment or loss of the disregards) was essential to the loss of 1931 eligibility. Without that increase, the family would not have lost 1931 eligibility.
If no, the family is still eligible for 1931.
15200.1.3 Child Living in the Home
The family must continue to have a child living in the home.
The family must continue to have a child living in the home that meets the age requirement for Medicaid under Section 1931; that is, an individual under age 18, or under age 19, and who is still a full-time student in high school, GED, or equivalent program and will graduate prior to his or her 19th birthday. Emancipated minors are considered adults. The earned income of a child is excluded. The child does not have to meet the former AFDC definition of dependent child. For AFDC purposes, a child must be both needy and deprived of parental care and support because of the absence, disability, unemployment, etc., of the parent. There is no deprivation requirement for Transitional Medicaid.
When the only child in the family no longer meets the age requirement, the family is no longer eligible for transitional Medicaid because there is no longer a child in the family. When one child turns age 18 or 19, but there is another child in the family, the child who turns age 18 or 19 is no longer considered a member of the transitional family unit. The rest of the family remains eligible for Transitional Medicaid.
15200.2 Composition of Family Unit
Transitional Medicaid provides eligibility for families rather than individual eligibility. Transitional Medicaid coverage is provided to all individuals who were included in the family unit at the time the family became ineligible for Medicaid under Section 1931. In addition, family members who enter the household or family members who were absent but return may be found eligible.
An individual who enters the family unit (including a child born to the family during the transitional period) may be eligible for transitional Medicaid if that individual would have been included in the caretaker relative's assistance unit if the family were now applying for Medicaid under Section 1931. The rules for the composition of the assistance unit for Medicaid under Section 1931 are the same as the rules for the composition of the assistance unit for TANF. These rules are found in the Financial Services Policy of the Division of Social Services Manual. The individual who enters the family must be one who could be found eligible for Medicaid under Section 1931 in their own right.
The transitional family includes:
• family members who were in the Medicaid under Section 1931 assistance unit when the Medicaid under Section 1931 was terminated, and
• family members who have since entered the household and who would be included in the assistance unit if the family were applying for Medicaid under Section 1931 in the current month.
The earned income of an individual who has entered or returned to the family unit is included in the gross earnings and that individual is counted when determining the family size. Follow the income rules of the TANF program. The earned income of a dependent child, regardless of student status, is not counted.
15200.2.1 Family Members Under TANF Sanction
Individuals who are under any TANF sanction are eligible for Medicaid under Section 1931. These individuals are included in the transitional family.
15200.3 Eligibility Determination
Families who lose Medicaid under Section 1931 because of earnings or loss of earned income disregards are eligible for transitional Medicaid when their income exceeds either 185% of the standard of need OR the standard of need.
15200.4 First Month Of Transitional Medicaid
Transitional Medicaid begins with the month of ineligibility for Medicaid under Section 1931 due to an increase in earned income or loss of earned income disregards. The month of ineligibility for Medicaid under Section 1931 is the month in which the family’s income exceeds either 185% of the standard of need or the standard of need.
Someone who is not timely in reporting the start of employment or increased wages could have their family's transitional benefits reduced so that they only receive the 24 months of transitional coverage from when they should have been closed. But, we will not totally disqualify a family.
15200.5 Eligibility During First Six-Month Period
The family will receive Transitional Medicaid without any reapplication for the first six months. The family must be notified when they lose eligibility for Medicaid under Section 1931 that they are eligible for Transitional Medicaid and the reasons why the benefits could be terminated. DCIS will automatically notify Transitional Medicaid families and issue cards for the family members. The notice will include information about termination of benefits.
15200.5.1 Child Living in the Home
To continue to receive Medicaid throughout the first six-month period the following conditions must be met in addition to the initial eligibility requirements:
there is a child living in the home.
The rules of Medicaid under Section 1931 are used to determine if a child is living in the home. When it is determined that a family no longer has a child living in the home, the family is no longer eligible under this program. The case must be reviewed to determine if the family members are eligible for Medicaid under another program.
15200.6 Eligibility During Second Six-Month Period
To continue to receive Medicaid during the second six-month period, the conditions listed in 15200.6.1, 15600.6.2 and 15600.6.3 must be met in addition to the initial eligibility requirements.
15200.6.1 Child Living in the Home
To continue to receive Medicaid throughout the second six-month period there must be a child living in the home.
The rules of Medicaid under Section 1931 are used to determine if a child is living in the home. When it is determined that a family no longer has a child living in the home, the family is no longer eligible under this program. The case must be reviewed to determine if the family members are eligible for Medicaid under another program.
15200.6.2 Employment of Caretaker Relative
To continue to receive Medicaid throughout the second six-month period a caretaker relative must be employed during each month unless good cause exists.
15200.6.2.1 Good Cause for Terminating Employment
Good cause for terminating employment is:
1. Circumstances beyond the individual's control such as but not limited to illness, illness of another family member requiring the wage earner's presence, a household emergency, the unavailability of transportation, and the lack of adequate dependent care.
2. Instances in which employment was unsuitable such as:
• wages offered less than the Federal minimum wage,
• employment on a piece-rate basis and the average hourly yield the employee receives is less than the Federal minimum wage,
• unreasonable degree of risk to one's health and safety,
• the individual is physically or mentally unfit to perform the employment as documented by medical evidence or reliable information from other sources,
• the distance from the individual's house to place of employment is unreasonable considering the expected wage and the time and cost of commuting,
• the working hours or nature of employment interferes with the members religious observance, convictions or beliefs.
3. Discrimination by an employer based on age, race, sex, disability, religious belief, national origin, or political belief.
4. Work demands or conditions that are unreasonable such as working without being paid on schedule.
5. Acceptance of other employment or enrollment at least half-time in a school, training program, or college.
6. Resignations by persons under the age of 60 that are recognized by the employer as retirement.
7. Leaving a job in connection with patterns of employment in which workers move from one employer to another as in migrant farm labor or construction work.
15200.6.3 Limit on Gross Monthly Earnings
The family's gross monthly earnings (less the monthly costs of necessary dependent care) are at or below 185% of the Federal Poverty Level (FPL) and continue to be at or below 185% FPL throughout the second six-month period. The FPL is effective each July for Transitional Medicaid.
There are no limits on necessary dependent care costs. Prospective budgeting is used to determine family income. Do not add unearned income to earned income. Count the earned income of all family members living in the home who were members of the family unit the month the family became ineligible for Medicaid under Section 1931 and any individual who would be included in the caretaker relative's assistance unit if the family were now applying for Medicaid under Section 1931.
Exception: Do not count the earned income of a dependent child, regardless of student status.
15200.7 12-Month Period of Eligibility
A family gets 24 months of transitional Medicaid from the month of ineligibility for Medicaid under Section 1931, even if they become eligible again for Medicaid under Section 1931. The clock on the 12-month period does not stop running when eligibility for Medicaid under Section 1931 is reestablished. The 12 months of transitional Medicaid run concurrently with months of eligibility for Medicaid under Section 1931.
If the family again loses eligibility for Medicaid under Section 1931 for non-work reasons, the transitional benefit period is unaffected. If the family is terminated again for earned income reasons, a new transitional period may begin.
15200.8 Termination of Eligibility
Eligibility for Transitional Medicaid may be terminated in either the first or second six-month period for the reasons described below.
15200.8.1 First Six-Month Period
Eligibility for Transitional Medicaid will be terminated during the first six-month period if the family no longer has a child living in the home. Use the definition for child as defined under Section 1931 Medicaid. A child is under age 18 or is under age 19 and who is still a full-time student in high school, GED, or equivalent program and will graduate prior to his or her 19th birthday. Emancipated minors are considered adults.
Eligibility will also be terminated if the family is found to have received Medicaid under Section 1931 "fraudulently" in the preceding six months. Fraud is defined at the end of this section. (See DSSM 15200.10 )
15200.8.2 Second Six-Month Period
Eligibility for Transitional Medicaid will be terminated if:
• the family no longer has a child living in the home
• the caretaker relative is no longer employed and good cause does not apply
• the family's monthly gross earned income minus dependent care costs exceeds 185% FPL.
We must explore eligibility for any other Medicaid program before Transitional Medicaid is terminated.
15200.9 Notices
Families who lose Medicaid under Section 1931 receive a notice that advises them of the eligibility requirements for continued coverage under Transitional Medicaid. The notice contains a statement advising families of the right to extended Medicaid benefits and an explanation of circumstances that could result in termination during the extended periods.
15200.10 Fraud
Section 1925(d) of the Social Security Act specifies that extended Medicaid must not be granted to any individual who has been legally determined by the Medicaid agency to be ineligible for Medicaid under Section 1931 because of fraud at any time during the last prior six months in which the family received Medicaid under Section 1931. The fraud determinations are subject to the fraud and program abuse provisions under Sections 1128, 1128A, and 1128B of the Social Security Act.
Under Medicaid, a conviction for fraud must be made by a court of competent jurisdiction.
