9. Budgeting
page 9-1
9.1 Accessing MAGI MC Budget
9. Budgeting
Medi-Cal (MC) budgeting is determined prospectively. When entering income into CalWIN it is
important to enter the income into the correct income specific windows. Entering income into CalWIN is
not dependent on a specific program; it is dependent on the type of income. CalWIN automatically
treats income differently depending on the rules for each program and program hierarchy. Cash-linked
programs and CalFresh (CF) income rules must be followed when entering the income into CalWIN
[Refer to “Fluctuating Income,” page 9-12].
For combo cases (i.e. CF/MC, General Assistance (GA)/MC, etc.), income must continue to be entered
as actually received (i.e weekly, biweekly, semi-monthly, etc.) in the appropriate income-related
windows. [Refer to other program handbooks for guidance].
Example:
Johnny Rocket is employed at Space Exploration Camp receiving $500.00 bi-weekly. His
16-year old son Neptune receives $200.00 monthly in direct child support. His 20-year old
daughter, Jupiter, has been disabled for more than 24 months; she is currently receiving
Medicare and receives $300.00 monthly from Retirement, Survivors, and Disability Insurance
(RSDI) Disability benefits. Johnny files taxes as Head of Household, Neptune and Jupiter are
his tax dependents. All 3 household members are receiving CF.
For income, the worker completes all windows under:
Collect Employment History Detail for Johnny’s income.
Collect Unearned Income Detail for Jupiter’s income.
Collect Child/Spousal Income Detail for Neptune’s income.
For Johnny, the income is entered bi-weekly, whereas Neptune’s and Jupiter’s incomes are
entered monthly into CalWIN.
9.1
Accessing MAGI MC Budget
The MAGI MC budget can be accessed in CalWIN or CalHEERS.
9.1.1
Accessing MAGI MC Budget in CalWIN
The MAGI MC budget can be accessed in CalWIN on the [MAGI] tab of the Display Health Care
Financial Eligibility Results window. The following is a description of the fields on this tab:
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Update #15-34
9. Budgeting
page 9-2
9.1 Accessing MAGI MC Budget
Table 9-1: CalWIN Fields on MAGI Budget Tab
CalWIN Fields
Description
Employment Monthly Income
Earned Income.
Other Monthly Income
Unearned Income.
Projected Monthly Income
Projected Annual Income divided into a monthly amount.
Countable Income Deduction
Income deductions that are counted for MAGI.
Total Income After Deduction
Total income less any deductions.
MAGI Income Limit
Income limit for the assigned aid code.
MAGI FPL
100% monthly FPL amount for given household size.
Status
MAGI eligibility status (i.e. Pass, Fail, Pending)
MAGI Eligible Type
When MAGI eligible, this field will display “MAGI Medi-Cal”. If not MAGI eligible,
it will display “N/A”
Start Date
Eligibility effective begin date.
Unmarried Pregnant Woman Disregard
Exception
Y/N indicates whether or not the individual is receiving the unmarried pregnant
woman disregard exception.
Meets 603F2
Non-tax filer household composition used for MAGI evaluation.
Meets 119C Exception
The value will be either Yes or No. Individual is not eligible for MAGI Adult
Coverage group because his/her dependent child under 19 years old does not
have Minimum Essential Coverage.
NOTE: The age limit is under 21 years old if the dependent child is attending
school full-time.
Meets 603I Exception
Bounce Back Rule. The value will be either Yes or No.
Self Employment Monthly Income
Self Employment Income.
Total Income
Total Earned, Unearned, and Self Employment income before deductions.
Non Countable Income Deduction
Income deductions that are not counted for MAGI.
Total Countable Income
Total countable income less any deductions.
FPL Percentage
The percentage of the FPL the income is.
MAGI Size
Tax filing household size.
MAGI Aid Code
Aid code the individual qualifies for.
End Date
When the eligibility to the MAGI aid code ends.
Renewal Date
Redetermination Date.
Soft Pause Reason
Reason case is on Soft Pause (i.e. Child, Parent, Aged, or N/A).
Contingent End Date
The date conditional eligibility ends if missing information is not provided.
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9. Budgeting
page 9-3
9.1 Accessing MAGI MC Budget
9.1.2
Accessing MAGI Budget Worksheet in CalHEERS
The CalHEERS Business Rules Engine (BRE) determines clients’ eligibility for MAGI MC. The MAGI
MC budget worksheet can be located in CalHEERS by following these steps:
1. Login to CalHEERS
2. Click on the Search Individual link
3. Select a Search option [Case ID, SSN, Combo (Name/Date of birth)]
4. Enter corresponding Search Value
5. Click on [Search] button
6. Click on a radio button to select an individual.
7. Click on [View Case] button.
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9. Budgeting
9.1 Accessing MAGI MC Budget
8. Click on the View Eligibility Results link. [Make sure to check the Date/Time Requested
column to select the most recent budget worksheet.
9. Scroll all the way down to the bottom of the page and click on the [View Budget Worksheets]
button.
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9. Budgeting
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9.1 Accessing MAGI MC Budget
9.1.3
MAGI Budget Worksheet
In CalHEERS, the budget worksheet will display an individual budget for MAGI MC and a household
budget for Advanced Premium Tax Credit (APTC) and Cost Sharing Reduction (CSR). The MAGI MC
individual budget is a monthly budget, APTC and CSR budgets are annual.
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9. Budgeting
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9.1 Accessing MAGI MC Budget
See the following chart for a description of each line item in the CalHEERS Budget Worksheet [Refer to
Table 9-1, page 9-6].
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9. Budgeting
9.1 Accessing MAGI MC Budget
Table 1: CalHEERS Budget Worksheet
CalHEERS MAGI Budget Worksheet Line
Description
Soft Paused Due To
This indicates whether or not the client has been placed on Soft Pause in
CalHEERS.
• Child (the member is a child)
• Parent (the member is a parent)
• Aged/Blind/Disabled (the member attests to being 65 or older, blind, or
disabled)
• Not Applicable (Soft Pause is not applied to this member)
NOTE: The 19 to 64 year old expansion group is not eligible for Soft Pause.
Parent/Caretaker Relatives over 109% FPL (114% FPL if receiving
Medicare) are no longer considered ‘Parent/Caretaker Relatives’ for the
purpose of Soft Pause.
Person Primary Tax Filer
The value will be either Yes or No. This line indicates if the client is the
primary tax filer in the tax filing household.
Person Included in Primary Tax Filer’s Tax
Household
The value will be either Yes or No. This line indicates if the client is a
member of the primary tax filer’s tax filing household.
Person Plans to File Taxes
The value will be either Yes or No. This line indicates if the client plans to
file taxes for the current tax year.
Person Expected to be Required to File Taxes
The value will be either Yes or No. This line indicates if the client is required
to file taxes for the current tax year.
Person Tax Filing Status
Individual’s tax filing status (i.e. Single, Married Filing Jointly, etc.)
Person Tax Dependent Status
The value will be either Yes or No. This line indicates if the client is a
dependent of the primary tax filer’s tax filing household.
a. Employment Income (Monthly)
This is the individual’s earned income, not the tax filing household’s
income.
b. Self-Employment Income (Monthly)
This is the individual’s earned income, not the tax filing household’s income
from self-employment.
c. Other Income (Monthly)
This is the individual’s unearned income, not the tax filing household’s
unearned income.
d. Total Income (Sum of a, b, c)
This is the individual’s total income, not the total tax filing household’s
income.
e. Allowable Deductions (Monthly)
This is the individual’s allowable deductions, not the tax filing household’s
deductions.
f. Total Income after Deductions
(Subtract e from d)
This is the individual’s total income after allowable deductions have been
subtracted.
g. Projected Monthly Income
This is how much income the individual projects as his/her monthly income
not the tax filing household monthly income.
h. Countable Income (Sum of f and g)
Monthly income after allowable deductions.
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Update #15-34
9. Budgeting
page 9-8
9.2 Treatment of Income for MAGI and Non-MAGI
Table 1: CalHEERS Budget Worksheet
CalHEERS MAGI Budget Worksheet Line
Description
i. Number of household members +
Number of expected babies
Total tax filing household members.
j. Federal Poverty Level for (i) (Monthly)
FPL dollar amount limit for individual.
k. FPL% for individual (Divide (h) by (j)
and round)
FPL percentage for individual.
MAGI Medi-Cal Eligible?
The value will be either Yes or No. This line indicates if the client is eligible
for MAGI MC.
Medi-Cal Access Program (MCAP) Eligible?
The value will be either Yes or No. This line indicates if the client is eligible
for MCAP.
MCAP is a program for Pregnant Women between 213% - 322% FPL,
previously known as (AIM). [Refer to Chapter 5, Section 5.21 "Medi-Cal
Access Program,” page-65]
County Children’s Health Initiative Program
(CCHIP) Eligible?
The value will be either Yes or No. This line indicates if the client is eligible
for CCHIP.
Meets 435.603(f)(2)(i-iii) to use a non tax filer
household composition for MAGI Medi-Cal
The value will be either Yes or No. This line indicates the individual is being
evaluated using non-tax filer rules.
Meets 435.603(i) exception to use APTC
income/deduction calculations for MAGI
Medi-Cal determination
Bounce Back Rule. The value will be either Yes or No.
Meets 435.119(c): Adults ineligible to the New
Adult Group due to dependent child under age
19 without Minimum Essential Coverage
The value will be either Yes or No. Individual is not eligible for MAGI Adult
Coverage group because his/her dependent child under 19 years old does
not have Minimum Essential Coverage.
NOTE: The age limit is under 21 years old if the dependent child is
attending school full-time.
9.2
9.2.1
Treatment of Income for MAGI and Non-MAGI
Actual Income
Income is considered available in the month received unless it is apportioned over a period of time (i.e.
teachers salary). [Refer to “Treatment of Apportioned Income,” page 9-10]
9.2.2
Treatment of Apportioned Income
Apportioned income is income that is earned and received in more than 8 but less than 12 months
under an annual contract of employment. It must be prorated over the period of the contract beginning
with the first month of the contract.
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Update #15-34
9. Budgeting
page 9-9
9.2 Treatment of Income for MAGI and Non-MAGI
Example:
Teacher's contracts are annual and income must be apportioned over the 12 months of the
contract, even though teachers may work only 9 or 10 months.
Income Received other than Monthly or Semi-Monthly
1. If income is received weekly, bi-weekly, quarterly or bi-monthly, AND
a. Client wants MC for three or more months, and
b. Client will receive the income for a full month, and
c. Income is not fluctuating, THEN
2. Convert to monthly income as follows:
a. Multiply weekly income by 4.33.
b. Multiply income received every two weeks by 2.167.
c. Divide quarterly income by 3.
d. Divide income received every two months by 2.
Example 1
Client receives DIB of $265 every two weeks. Calculate as follows to arrive at a
monthly amount:$265 x 2.167 = $574.26/mo.
Example 2
Client receives earnings of $350 gross every week. His/her gross amount does not
fluctuate. Calculate as follows to arrive at a monthly amount:$350 x 4.33 =
$1,515.50/monthly.
3. If client wants MC for one or two months only, use actual income.
Self-Employment Income
Income of self-employed persons is an estimation of the net profit of the annual net income for the
current year based on the federal tax return filed for the previous year. In the Display Self
Employment Detail window in CalWIN, the full gross self employment income must be entered in the
Collect Income Received Detail window and the expenses must be entered under the Collect
Income Expense Detail window. If there is no tax return or there is evidence that using the tax return
would give an inaccurate estimation of income, current business records must be used. [Refer to
“Self-Employment Income,” page 17-13, and [Refer to “Self-Employment Income,” page 25-50]
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9. Budgeting
page 9-10
9.2 Treatment of Income for MAGI and Non-MAGI
Note:
The Standard radio button can be selected in the Display Self Employment Detail window, in
addition to entering the actual expenses, to count the 40% standard deduction for other
programs.
Loans
A loan must be considered income and apportioned over the time period for which it is intended if:
• It does not require repayment, and
• It is not exempt, and
• It is specified in the loan statement the period of time it is intended to cover.
Interest Income
• Interest income received less frequently than monthly and not exempt must be apportioned by
dividing interest received by the number of months in the interest period. Consider the converted
monthly amount as income in each of the months of the next interest period.
• Interest income received from a deed of trust or contract of sale must be apportioned by
determining the annual interest and dividing by 12.
Note:
Be sure to evaluate whether interest income could be exempt as irregular or infrequent income.
[Refer to “Exempt Unearned Income [50542],” page 25-67]
9.2.3
Apportionment of Income Exemptions and Deductions
Any exemptions or deductions pertaining to apportioned income must be apportioned in the same
manner as the income.
Example:
Client receives $375 gross earnings every week and pays $30 every week for dependent care.
Income and deductions are:
$375 x 4.33 = $1,623.75 gross income; $30 x 4.33 = $129.90 dependent care.
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Update #15-34
page 9-11
9. Budgeting
9.2 Treatment of Income for MAGI and Non-MAGI
Reminder:
Dependent care deductions only apply to Non-MAGI MC budgeting. Dependent care
deductions are limited to maximum allowable amounts (i.e. $175 or $200 based on the age of
the child).
9.2.4
Fluctuating Income
For combo cases the income must follow the rules and regulations of that program (i.e. CF/MC,
GA/MC, etc.) methodology.
• Actual income must be used if known when computing the share of cost (SOC). Do not delay
computing the SOC determination in order to determine the actual income.
• If the actual income is unknown when computing the SOC, estimate the amount to be received in
a month, taking all of the following into consideration:
• The income pattern over the last year.
• The actual income received in the last month.
• The client's statement of anticipated income.
USE THE BEST ESTIMATE. BE SURE TO DOCUMENT THOROUGHLY HOW ESTIMATE WAS
ARRIVED AT.
• If the client provides at least 2 full months of income, the fluctuating income must be averaged
and entered into CalWIN as monthly income (regardless of the actual frequency of receipt of
income).
Example:
Client provides 8 pay stubs for January and February. Each stub shows different amounts and
he/she gets paid weekly. Do NOT enter each pay stub into CalWIN as CalWIN consider the
most current pay stub information and uses the frequency multiplier. The EW must manually add
the 8 pay stubs and divide it by 2 and enter the averaged income into CalWIN as Monthly.
• If the client only provides less than a month’s worth of pay stubs, the EW must clarify if the client
expects to earn the same exact (i.e., dollar-to-dollar) amount every pay period. If so, then the
income is not considered fluctuating. One pay stub information can be entered and CalWIN will
use the frequency multiplier.
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Update #15-34
9. Budgeting
page 9-12
9.2 Treatment of Income for MAGI and Non-MAGI
• If the pay stub provided includes overtime, the EW must clarify with the client if the overtime is
expected to continue. If not, explain to the client if he/she can provide additional pay stub if
averaging the income is more advantageous.
Reminder:
Per regulations, the client is only required to provide one pay stub, whether the income is stable
or fluctuating.
• When the client only provides one pay stub and client claims fluctuating income (i.e., gross
amount varies every pay period), enter the information from the pay stub provided, in CalWIN. In
this case, it is acceptable to use the frequency multiplier even if the income is fluctuating due to
“one pay stub” rule as noted in the above “Reminder.” The EW must thoroughly document in the
Search Case Comment window on how the income is calculated or determined.
9.2.5
CalWIN
Income information (earned or unearned) is entered into CalWIN as follows:
• Actual Income - Income that meets the definition of actual income is entered as monthly income.
• Apportioned IncomeIf the apportioned income is for a period of 12 months, enter the yearly
amount (if known) and select Annual as the frequency. CalWIN will automatically divide it by 12
months and uses the averaged amount as monthly income.
Example:
Teacher’s annual contract is $72,000. CalWIN will budget $6,000 as monthly income.
• Averaged incomeWhenever an income needs to be manually averaged by the EW, the
averaged income is entered as Monthly in CalWIN.
• Specific FrequencyIncome that are received weekly, bi-weekly, semimonthly, bi-monthly, etc. are
entered into CalWIN as such in order for CalWIN to use the appropriate multiplier (i.e., 2.167 for
bi-weekly, 4.33 for weekly, etc.).
• Fluctuating Income.
• If the verification provided can be averaged, the averaged amount is entered into CalWIN as
monthly.
• If the client can only provide one pay stub, enter the amount based on the frequency of receipt
(i.e., weekly, bi-weekly, etc.).
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Update #15-34
9. Budgeting
page 9-13
9.2 Treatment of Income for MAGI and Non-MAGI
9.2.6
Ending Income
CALWIN SYSTEM
If applicable, review the Collect Employment History Detail window in CalWIN for
ALL HOUSEHOLD MEMBERS WITH EMPLOYMENT.
Make sure that the income in CalWIN reflects the latest information provided by the client (i.e. from the
SAR 7, CSC 91, SCD 2350, MC 01-2014, application, pay stubs in IDM, etc.).
Collect Income Received Detail
• If employment has terminated, a Yes must be entered in the Income Terminated [Y/N] field of this
window.
Collect Earned Income Detail
• If employment has terminated, an Effective End Date must be entered on this window.
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Update #15-34
9. Budgeting
page 9-14
9.3 Bounce Back Rule
Collect Employment History Detail
• If employment has terminated, an End Date must be entered and the Employment Termination
group box must be completed on this window.
9.2.7
Documentation Requirements
It is very important to document the treatment of estimated, apportioned and fluctuating incomes.
Documentation must indicate how the non-exempt unearned/earned gross income figure was
calculated. Verification or proof that income was verified must be recorded in IDM.
[Refer to Chapter 10, Section 10.7.4 "Printed Verification for IDM,” page-58]
9.3
Bounce Back Rule
MC and APTC calculate income differently. MC income is based on Current Monthly Income (CMI) and
APTC income is based on Projected Annual Income (PAI).
MAGI MC eligibility is determined before APTC, but because of the difference in counting income, a
client could be found over income for MAGI MC (in a month) and under income for APTC (for the year).
To prevent such clients from being caught between MC and APTC, the Federal rules force those below
100% FPL using the APTC method (PAI) to be MAGI MC eligible and those at or above 100% FPL to
be APTC eligible. This prevents clients from being under PAI for APTC but over CMI for MAGI MC,
hence getting bounced between two programs but never qualifying for either. This is called the Bounce
Back Rule.
The Bounce Back Rule applies one year of eligibility at a time (at application or new employment in the
middle of the year). While a case is currently in the Bounce Back Rule period, any time after January 1st
of the following year, if eligibility is run (for any reason i.e. CIC), the income will count for the whole year.
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Update #15-34
9. Budgeting
page 9-15
9.3 Bounce Back Rule
Cases that are over 138% FPL monthly will likely go to APTC unless someone has potential Non-MAGI
MC eligibility, then he/she will be placed on Soft Pause.
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Update #15-34
9. Budgeting
page 9-16
9.3 Bounce Back Rule
INTAKE Bounce Back Rule Examples
Example:
Babar had no income for the first 6 months of the year and then he gets a job at the Elephant
Bar. His CMI determines him as over income for MAGI MC. When he is determined for APTC
financial eligibility, his PAI, which includes the 6 months of zero income, is below 100% FPL
using the APTC eligibility methodology. Babar is financially eligible for MAGI MC for the entire
year until MC RD or Change in Circumstance (CIC), whichever occurs first.
Example:
Juliette walks into an Intake office and applies for MC on July 10, 2016. Her application states
that she started work at Shake & Speare’s Bookstore on July 1, 2016 and she earns $1,400
monthly. After the EW completes all other Data Collection windows and runs EDBC to call the
BRE, CalHEERS will grant Juliette MAGI MC appropriately.
• Collect Employment History Detail
• Effective Begin Date: July 10, 2016
• Begin Date: July 1, 2016
• Complete all other applicable fields.
• Collect Earned Income Detail
• Effective Begin Date: July 10, 2016
• Frequency: Monthly
• Type: Earnings, Wages, Salaries, Bonuses, Commissions, Military Pay
• Collect Income Received Detail
•
•
•
•
•
Date Received/Expected to be Received: July 10, 2016
Pay Period Begin Date: July 1, 2016
Pay Period End Date: July 31, 2016
Gross Amount: $1400
Complete all other applicable fields.
Juliette’s monthly income is over 138% FPL; however, her annual income ($1,400 x 6
months = $8,400) is below 100% FPL for her first year of employment based on her
employment start date. Therefore, CalHEERS will appropriately grant her MAGI MC instead
of APTC/CSR; the Bounce Back Rule applies to her case.
Revised: 1/11/2017
Update #15-34
9. Budgeting
page 9-17
9.3 Bounce Back Rule
Note:
If Juliette’s income does not change at MC RD (June 2017) or at CIC any time after January 1,
2017, then she will be financially eligible for APTC/CSR. Her income will be calculated for 12
months ($1,400 x 12 = $16,800) which will be over 138% FPL monthly and over 100% FPL
annually.
Example:
During the Covered CA Open Enrollment, Jennifer Freebird applies for healthcare coverage on
January 28, 2016. She started working at Seeds Candy on January 18, 2016. She earns $347
weekly paid on Fridays. In CalWIN, the EW enters the job information as follows:
• Collect Employment History Detail
• Effective Begin Date: January 28, 2016
• Begin Date: January 18, 2016
• Complete all other applicable fields.
• Collect Earned Income Detail
• Effective Begin Date: January 28, 2016
• Frequency: Weekly
• Type: Earnings, Wages, Salaries, Bonuses, Commissions, Military Pay
• Collect Income Received Detail
•
•
•
•
•
Date Received/Expected to be Received: January 29, 2016
Pay Period Begin Date: January 18, 2016
Pay Period End Date: January 22, 2016
Gross Amount: $347
Complete all other applicable fields.
After the EW completes all other Data Collection windows and runs EDBC to call the BRE,
CalHEERS will grant Ms. Freebird APTC/CSR appropriately. Ms. Freebird’s monthly income
is over 138% FPL; ($347/weekly x 4.33 = $1,502.51/monthly), and over 100% for the year
($347/weekly x 4.33 = $1502.51/monthly x 12 months = $18,030.12/annually). Therefore,
CalHEERS will grant her APTC/CSR, not MAGI MC.
Since Ms. Freebird applied for healthcare coverage after the 15th of January, her coverage
will begin on March 1st, 2016.
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Update #15-34
9. Budgeting
page 9-18
9.3 Bounce Back Rule
Note:
Ms. Freebird’s income is over the monthly (138%FPL MAGI MC) and annual (100%FPL APTC)
income limit, therefore the Bounce Back Rule does not apply to his case.
Example:
Jack walks into an Intake office and applies for MC on January 23, 2016. His application states
that he started work at the Bean-Stock Coffee Shop on January 7, 2016 and he earns $1,400
monthly. After the EW completes all other Data Collection windows and runs EDBC to call the
BRE, CalHEERS will grant Jack APTC/CSR appropriately.
• Collect Employment History Detail
• Effective Begin Date: January 23, 2016
• Begin Date: January 7, 2016
• Complete all other applicable fields.
• Collect Earned Income Detail
• Effective Begin Date: January 23, 2016
• Frequency: Monthly
• Type: Earnings, Wages, Salaries, Bonuses, Commissions, Military Pay
• Collect Income Received Detail
•
•
•
•
•
Date Received/Expected to be Received: February 1, 2016
Pay Period Begin Date: January 1, 2016
Pay Period End Date: January 31, 2016
Gross Amount: $1,400
Complete all other applicable fields.
Jack’s monthly income is over 138% FPL ($1,400 x 12 months = $16,800) for the entire year.
Therefore, CalHEERS will grant him APTC/CSR, not MAGI MC. Since Jack applied for
healthcare coverage after the 15th of January, his coverage will begin on March 1st, 2016.
Note:
Jack’s income is over the monthly (138%FPL MAGI MC) and annual (100%FPL APTC) income
limit, therefore the Bounce Back Rule does not apply to his case.
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Update #15-34
9. Budgeting
page 9-19
9.3 Bounce Back Rule
Example:
Aurora walks into an Intake office and applies for MC on July 13, 2016. Her application states
that she started work at Beauty’s Mattresses on January 25, 2016 and she earns $1,400
monthly. After the EW completes all other Data Collection windows and runs EDBC to call the
BRE, CalHEERS will grant Aurora APTC/CSR appropriately.
• Collect Employment History Detail
• Effective Begin Date: July 13, 2016
• Begin Date: January 1, 2016
• Complete all other applicable fields.
• Collect Earned Income Detail
• Effective Begin Date: January 13, 2016
• Frequency: Monthly
• Type: Earnings, Wages, Salaries, Bonuses, Commissions, Military Pay
• Collect Income Received Detail
•
•
•
•
•
Date Received/Expected to be Received: February 1, 2016
Pay Period Begin Date: January 1, 2016
Pay Period End Date: January 31, 2016
Gross Amount: $1,400
Complete all other applicable fields.
Aurora’s monthly income is over 138% FPL ($1,400 x 12 months = $16,800) for the entire
year. Therefore, CalHEERS will grant her APTC/CSR, not MAGI MC.
Note:
Aurora’s income is over the monthly (138%FPL MAGI MC) and annual (100%FPL APTC)
income limit, therefore the Bounce Back Rule does not apply to her case.
CONTINUING Bounce Back Rule Examples
(All examples in this section refer specifically to the budgeting aspect of MC eligibility. There may be
examples that occur when the client will not immediately transition from MC to APTC or from APTC
directly to MC. [Refer to “Transitions (MAGI/Non-MAGI/APTC),” page 19-2 for more information on
Carry Forward and Soft Pause.]
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Update #15-34
9. Budgeting
page 9-20
9.3 Bounce Back Rule
Example:
Mr. Sanders reports a CIC on January 28, 2016. He started working at Kentucky Cluckies on
January 18, 2016. He earns $347 weekly paid on Fridays. In CalWIN, the EW enters the job
information as follows:
• Collect Employment History Detail
• Effective Begin Date: January 18, 2016
• Begin Date: January 18, 2016
• Complete all other applicable fields.
• Collect Earned Income Detail
• Effective Begin Date: January 18, 2016
• Frequency: Weekly
• Type: Earnings, Wages, Salaries, Bonuses, Commissions, Military Pay
• Collect Income Received Detail
•
•
•
•
•
Date Received/Expected to be Received: January 29, 2016
Pay Period Begin Date: January 18, 2016
Pay Period End Date: January 22, 2016
Gross Amount: $347
Complete all other applicable fields.
After the EW completes all other Data Collection windows, as necessary for CIC, and runs
EDBC to call the BRE, CalHEERS will grant Mr. Sanders APTC/CSR appropriately. Mr.
Sanders monthly income is over 138% FPL; ($347/weekly x 4.33 = $1,502.51/monthly), and
over 100% for the year ($347/weekly x 4.33 = $1502.51/monthly x 12 months =
$18,030.12/annually). Therefore, CalHEERS will grant him APTC/CSR, not MAGI MC.
Note:
Mr. Sanders income is over the monthly (138%FPL MAGI MC) and annual (100%FPL APTC)
income limit, therefore the Bounce Back Rule does not apply to his case.
Example:
Taylor is currently receiving MAGI MC. She submits the June 2016 MC RD on June 14, 2016;
however, it is processed July 7, 2016. She started working at Swift’s Karaoke on January 4,
2016. She earns $347 weekly paid on Fridays. In CalWIN, the EW enters the job information as
follows:
• Collect Employment History Detail
Revised: 1/11/2017
Update #15-34
page 9-21
9. Budgeting
9.3 Bounce Back Rule
• Effective Begin Date: January 4, 2016
• Begin Date: January 4, 2016
• Complete all other applicable fields.
• Collect Earned Income Detail
• Effective Begin Date: January 4, 2016
• Frequency: Weekly
• Type: Earnings, Wages, Salaries, Bonuses, Commissions, Military Pay
• Collect Income Received Detail
•
•
•
•
•
Date Received/Expected to be Received: January 15, 2016
Pay Period Begin Date: January 4, 2016
Pay Period End Date: January 8, 2016
Gross Amount: $347
Complete all other applicable fields.
After the EW completes all other Data Collection windows and runs EDBC to call the BRE,
CalHEERS will grant Taylor APTC/CSR appropriately (There is no potential eligibility for
Non-MAGI MC, therefore she is not entitled to Soft Pause). Taylor’s monthly income is over
138% FPL; ($347/weekly x 4.33 = $1,502.51/monthly), and over 100% for the year
($347/weekly x 4.33 = $1502.51/monthly x 12 months = $18,030.12/annually). Therefore,
CalHEERS will grant her APTC/CSR, not MAGI MC. Losing MAGI MC is considered a life
changing event and she is eligible for Special Enrollment. Her APTC Eligibility begins
August 2016.
Note:
Taylor’s income is over the monthly (138%FPL MAGI MC) and annual (100%FPL APTC)
income limit, therefore the Bounce Back Rule does not apply to her case.
Example:
Nala reports a Change in Circumstance (CIC) on September 9, 2016. She started working at
the Zoo on August 22, 2016. She earns $347 weekly paid on Fridays. In CalWIN, the EW enters
the job information as follows:
• Collect Employment History Detail
• Effective Begin Date: August 22, 2016
• Begin Date: August 22, 2016
• Complete all other applicable fields.
• Collect Earned Income Detail
Revised: 1/11/2017
Update #15-34
9. Budgeting
page 9-22
9.3 Bounce Back Rule
• Effective Begin Date: August 22, 2016
• Frequency: Weekly
• Type: Earnings, Wages, Salaries, Bonuses, Commissions, Military Pay
• Collect Income Received Detail
•
•
•
•
•
Date Received/Expected to be Received: September 2, 2016
Pay Period Begin Date: August 22, 2016
Pay Period End Date: August 29, 2016
Gross Amount: $347
Complete all other applicable fields.
After the EW completes all other Data Collection windows, as necessary for CIC, and runs
EDBC to call the BRE, CalHEERS will continue to grant Nala MAGI MC appropriately. Nala’s
monthly income is over 138% FPL; ($347/weekly x 4.33 = $1,502.51/monthly), but less than
100% for the year ($347/weekly x 4.33 = $1502.51/monthly x 4 months =
$6,010.04/annually). Therefore, CalHEERS will grant her MAGI MC initially, not APTC/CSR
because the Bounce Back Rule applies.
Note:
If Nala’s income does not change, after January 1, 2017 at MC RD or CIC she will be financially
eligible for APTC/CSR. Her income will be calculated for 12 months ($1502.51 x 12 =
$18,030.12) which will be over 138% FPL monthly and over 100% FPL annually.
Example:
Lawrence Hopper reports a CIC on September 9, 2016. He started working as a soccer referee
on August 22, 2016. He earns $347 weekly paid on Fridays. Lawrence also reported that he
ended his 2-year job as a piano teacher on July 27, 2016 where he earned $150 weekly. In
CalWIN, the EW end dates all windows related to the piano teacher job. In addition, the EW
makes new entries for the new job (soccer referee) information as follows:
• Collect Employment History Detail
• Effective Begin Date: August 22, 2016
• Begin Date: August 22, 2016
• Complete all other applicable fields.
• Collect Earned Income Detail
• Effective Begin Date: August 22, 2016
• Frequency: Weekly
• Type: Earnings, Wages, Salaries, Bonuses, Commissions, Military Pay
• Collect Income Received Detail
Revised: 1/11/2017
Update #15-34
9. Budgeting
page 9-23
9.3 Bounce Back Rule
•
•
•
•
•
Date Received/Expected to be Received: September 2, 2016
Pay Period Begin Date: August 22, 2016
Pay Period End Date: August 29, 2016
Gross Amount: $347
Complete all other applicable fields.
After the EW completes all other Data Collection windows, as necessary for CIC, and runs
EDBC to call the BRE, CalHEERS will continue to grant Lawrence MAGI MC appropriately.
Starting in September, Lawrence’s monthly income is over 138% FPL ($347/weekly x 4.33 =
$1,502.51/monthly) due to his new job, but less than 100% for the year between both jobs.
• Soccer referee ($347/weekly x 4.33 = $1502.51/monthly x 4 months = $6,010.04/annually)
• Piano teacher ($150/weekly x 4.33 = $649.50/monthly x 7 months = $4,546.50/annually).
Since his total annual income is $10,556.54, CalHEERS will grant him MAGI MC initially, not
APTC/CSR because the Bounce Back Rule applies.
Note:
If Lawrence’s income does not change, after January 1, 2017 at MC RD or CIC he will be
financially eligible for APTC/CSR. His income will be calculated for 12 months ($1502.51 x 12 =
$18,030.12) which will be over 138% FPL monthly and over 100% FPL annually.
Example:
Chastinne Bubbly is currently receiving MAGI MC and has been working as a movie extra
earning $250 paid weekly for the past two years. She reports a CIC on November 8, 2016. She
started working as an Election Specialist at Voter Registration on October 1, 2016. She earns
$5900 monthly. Chastinne also reported that she ended her job as a movie extra on September
3, 2016. In CalWIN, the EW end dates all windows related to the movie extra job. In addition,
the EW makes new entries for the new job (Voter Registration) information as follows:
• Collect Employment History Detail
• Effective Begin Date: October 1, 2016
• Begin Date: October 1, 2016
• Complete all other applicable fields.
• Collect Earned Income Detail
• Effective Begin Date: October 1, 2016
• Frequency: Weekly
• Type: Earnings, Wages, Salaries, Bonuses, Commissions, Military Pay
• Collect Income Received Detail
Revised: 1/11/2017
Update #15-34
page 9-24
9. Budgeting
9.4 Use of Medi-Cal Budget Worksheets For Non-MAGI MC
•
•
•
•
•
Date Received/Expected to be Received: November 4, 2016
Pay Period Begin Date: October 1, 2016
Pay Period End Date: October 31, 2016
Gross Amount: $5900
Complete all other applicable fields.
After the EW completes all other Data Collection windows, as necessary for CIC, and runs
EDBC to call the BRE, CalHEERS will grant APTC as of December 1, 2016. Chastinne’s
monthly income is over 138% FPL ($5900/monthly) and her annual income is also over
100% due to her new job.
• Election Specialist ($5900 x 2 months = $11,800/annually)
• Movie Extra ($250/weekly x 4.33 = $1082.50/monthly x 9 months = $9,742.50/annually).
Since her total annual income in 2016 is $21,542.50, CalHEERS will grant her APTC/CSR
immediately, because the Bounce Back Rule does not applies.
Table 2: Bounce Back Rule Guidelines
138% FPL Monthly
100% FPL Annually
Program Eligibility
Bounce Back Rule
Income Over
Income Under
MAGI MC
Yes
Income Over
Income Over
APTC/QHP
No
Income Under
Income Under
MAGI MC
No
*Bounce Back Rule generally applies when income begins on or after the month of June.
9.4
Use of Medi-Cal Budget Worksheets For Non-MAGI MC
Completion of these forms is optional as CalWIN automatically calculates the budget based on the
information entered by the EW. However, in some circumstances a Letter of Authorization is required
for a period that cannot be updated in CalWIN; a MC Budget Worksheet is required.
Form MC 176M, Share of Cost Determination - MFBUs Which Do Not Include Long Term Care (LTC)
Persons, is used for computing the share of cost (SOC) for all MFBUs which do not include persons in
LTC.
Revised: 1/11/2017
Update #15-34
9. Budgeting
page 9-25
9.5 Completion of Medi-Cal Budget Worksheets for Non-MAGI MC
9.5
Completion of Medi-Cal Budget Worksheets for Non-MAGI
MC
9.5.1
Column I of MC 176M
Income of MFBU members applying as aged, blind, or disabled plus income of spouse or parent(s). No
members are in LTC.
9.5.2
Column II of MC 176M
• Income of MFBU members not listed in Column I (those members who are not aged, blind, or
disabled and their spouses). This would include persons who are AFDC-MN/MI linked. No
members are in LTC.
• DO NOT include the income of family members who are Public Assistance (PA) or other PA (but
four or nine month continuing persons' income must be included). DO NOT include the income of
excluded children.
• Court ordered alimony or child support, or child support paid under an agreement with the District
Attorney, is an income deduction.
9.5.3
Column III of MC 176M
• Count the income from computation on MC 176W, Part III, in which the spouse and/or children at
home have unmet needs and there is an allocation from the spouse in LTC/B&C who is in a
separate MFBU. This amount is added to the countable income.
• Allocations and Deductions
• When an excluded child does not have enough income to meet his/her needs, an amount from
the parent's MFBU can be allocated to this child. The computation is done on MC 176W, Part I,
and the amount of allocation is entered here. This amount of allocation is subtracted from the
countable income.
• When some of a family member's income is used to determine PA eligibility, the amount is an
allowable income deduction in the MFBU. That amount is entered here and subtracted from the
countable income.
• ROUND the net nonexempt income to the nearest dollar. If $50 or more, round up to the nearest
dollar. If $49 or less, round down to the nearest dollar.
• Maintenance Need
Revised: 1/11/2017
Update #15-34
9. Budgeting
page 9-26
9.6 Use of MC 176W, Allocation/Special Deduction Worksheet-A
• Include the ineligible members (IE) and four and nine month continuing family members in the
maintenance need.
• Any current SOC adjustments due to a previous month's overstated SOC or due to Hunt v. Kizer is
entered.
9.6
Use of MC 176W, Allocation/Special Deduction
Worksheet-A
1. Calculate:
a. Allocations to excluded children.
b. The amount of SSI/SSP income deemed available.
c. An allocation from a person in board and care to the spouse and/or children at home.
d. An allocation from an ABD MN LTC person with no community spouse to children at home.
e. AFDC-MN/MI earned income deductions.
f. DO NOT USE Section V. of the MC 176 W to do a stepparent calculation, effective 4/1/91, due
to the Sneede v. Kizer lawsuit. Use the “Stepparent Computation” (MC 176 W.1) to determine
property and income.
g. ABD income deductions.
Note:
Only those portions of the form that are applicable to the case should be completed. Unused
sections should be crossed out.
9.6.1
MC 176W-Allocation/Special Deduction Worksheet-A
Part I. Children with Separate Income or PropertyExcluded from the MFBU
This portion of the form is completed whenever a child(ren) over two months of age with separate
income or property is excluded from the MFBU. Part I is used to determine if the excluded child has
enough income to meet his/her needs. If not, an allocation from the family's income towards the
excluded child's unmet needs is made. This allocation is an income deduction on the parent's budget,
entered on Column III, line 5 of the MC 176M.
Revised: 1/11/2017
Update #15-34
9. Budgeting
page 9-27
9.6 Use of MC 176W, Allocation/Special Deduction Worksheet-A
Part II. SSI/SSP or IHSS Recipient(s) in Family - Income Available/Allocated
This portion of the form is completed when a family member receives an SSI/SSP grant or IHSS. This
person is not included in the MFBU but a computation must be made to determine how much of the
family's income was used to calculate the SSI/SSP grant or IHSS eligibility.
Note:
When an SSI/SSP person is receiving a full SSI/SSP grant amount according to his/her living
situation, no allocation from the family has been made and it is not necessary to complete this
section.
Part III. Allocation from Board and Care Person to Spouseand/or Children at Home, or
from LTC Person with NoCommunity Spouse to Children at Home
[Refer to Chapter 29, Section 29.18.3 "Use of the MC 176W, Allocation Special Deduction
Worksheet-B,” page-88]
Do not complete this section for family members who receive PA. Do not complete this section when the
ABD-MN person has a community spouse. Complete the MC 176WB, Parts VII through X if the
ABD-MN person with LTC status has a community spouse.
Part IV: AFDC-MN/MI Earned Income Deductions
This portion of the form is completed when deductions are allowed from the gross earned income of
AFDC-MN/MI persons in the MFBU.
Part V.
Due to the Sneede v Kizer lawsuit, effective 4/1/91 DO NOT USE this form for stepparent budgeting
when MC is requested for only the separate child(ren) of one parent. Use the “Stepparent Computation”
(MC 176 W.1) to determine property and income.
Part VI. Aged, Blind, and Disabled (ABD) Income Deductions
This portion of the form is used only in conjunction with the MC 176M and is completed only when any
of the following deductions apply to a person’s income (listed in Column I, MC 176M):
• Educational Expenses
• Absent Parent Support
• Student Deduction
Revised: 1/11/2017
Update #15-34
9. Budgeting
page 9-28
9.6 Use of MC 176W, Allocation/Special Deduction Worksheet-A
• Work Experience for the Blind
• Income for Self-Support
• Conservator/guardian fees (not allowed from Title II disability benefits)
Revised: 1/11/2017
Update #15-34