State of Wisconsin Department of Health Services

Release 24-03 December 18, 2024

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24.5 Calculating the Deductible

24.5.1 Deductible Amount

To calculate the dollar amount of a Medicaid deductible for an SSI-related fiscal test group:

1. Determine the fiscal test group's total income for each month of the deductible period (see Section 24.3 Deductible Period). Subtract the applicable income disregards and deductions (see Section 15.3 Exempt/Disregarded Income and Section 15.7 Income Deductions).
   
   Certain income disregards and deductions allowed in other forms of Medicaid, such as the COLA and OASDI disregards for Special Status Medicaid and medical/remedial expenses for MAPP, are not deducted when calculating a deductible.
2. Compare the total countable income of each month to the SSI-related medically needy income limit (see Section 39.4 Elderly, Blind, Or Disabled Assets and Income Tables).
   • If a given month's income is less than or equal to the medically needy limit, ignore it.
   • If a given month's income is more than the medically needy limit, find the excess income by subtracting the income limit from the net income of that month.
3. Add together the excess income of the months in the deductible period. The result is the Medicaid deductible.

24.5.2 Institution Cases  

24.5.2.1 Backdating

Institutionalized and non-institutionalized persons can be eligible back to the 1st of the month, three months prior to the month of application. Even if they are ineligible in the month of application, they may still be eligible for retroactive coverage. When an institutionalized person requests retroactive Medicaid, test him or her against the nonfinancial and financial standards that are appropriate to the month being tested. For the months he or she was not institutionalized, use the EBD asset and income limits (39.4 Elderly, Blind, or Disabled Assets and Income Tables). For the months he or she was institutionalized, use the institutional eligibility criteria found in 27.1 Institutions.

24.5.2.2 Deductible

For the months in which he or she was not institutionalized, he or she may be eligible in some, but ineligible in others, due to excess income.  In this situation, he or she has two choices:

1. To be certified for the months he or she is eligible, and accept the ineligibility of the other months in which he or she has excess income, or
2. To meet a deductible. The deductible period begins in the backdate month that he or she chooses, and extends six months. Calculate the deductible for the full 6-month deductible period. Calculate the deductible by comparing his or her monthly income for each of the 6 months to the SSI-related medically needy income limit, not the institutional income limit.

Expenses which can be counted against the deductible are those listed in 24.7 Meeting the Deductible plus his or her cost of care (27.7 ILTC Cost of Care Calculation). Expenses that cannot be counted are listed in 24.7.2 Meeting the Deductible> Noncountable Costs.

When he or she meets the deductible, she can be certified to the end of the deductible period. At the end of the deductible period, redetermine his or her eligibility using the institutional financial tests.

24.5.3 Deductible Examples

Example 1:

Artie applies for Medicaid in July. He wants to backdate his Medicaid three months. His Medicaid deductible period is April through September. In April, May, June, and July his AGassistance group had excess income of $50 each month. His prospective excess income for August and September is $50 each month. 6 X $50 = $300. Artie's Medicaid deductible is $300.

 

Example 2:

Clarice applies for Medicaid in July. She wants to backdate her Medicaid to May 1. Her Medicaid deductible period is May 1 through October 31. In May and June her AG had excess income of $100 each month. In July it has excess income of $200. Its prospective excess income for August, September, and October is $200 a month. Clarice's Medicaid deductible is $1,000.

 

Example 3:

Myron applies for Medicaid in July. He wants to backdate Medicaid to June 1. His Medicaid deductible period is June 1 through November 30.  In June his AG had excess income of $50. In July it has no excess income. Its prospective excess income for August, September, October, and November is $0. Myron's Medicaid deductible is $50.

 

Example 4:

Tyler applies for Medicaid in July. He wants his Medicaid to begin July 1. His Medicaid deductible period is July 1 through December 31. In July his AG has $100 excess income. Its prospective excess income for August, September, October, November, and December is $100 each month. Tyler's Medicaid deductible is $600.

 

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The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.

Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.

Publication Number: P-10030