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Medicaid couple rules: encode the states whose rule is neither SSI's nor budgeting together #10641
Description
What happens
#10640 applies three methods for a Medicaid applicant whose spouse is not aged, blind or disabled: SSI's rule, budgeting the couple together, and the couple limit without deeming. These states' published rules fit none of the three exactly, so that PR gives each the closest method.
What the rules say
Aged, blind and disabled pathway
| State | Rule | Source | PR 10640 uses |
|---|---|---|---|
| AK | Combined income against a third standard for a couple with one eligible member ($1,515 in the 2026 APA table). 7 AAC 40.330(b) also invokes 20 CFR 416.1163, and the rules don't fully reconcile the two. | 7 AAC 40.310 | Budget together |
| CA | Combined gross income, less a $600 maintenance need, against the limit for one. | ACWDL 20-24, Example 2 | SSI's rule; #10543 covers the deduction |
| ME | Combined income against the guideline for two, with half the SSI rate excluded from the spouse's income. | 10-144 C.M.R. ch. 332, Part 7 | Couple limit without deeming; #10474 covers the rest |
| NC | SSI's shape, with a living-allowance threshold ($472 in the December 2023 manual). | MA-2260 Section IV | SSI's rule |
| NY | SSI's shape, with the threshold set by the medically needy gap ($653 in 2026), and income equal to it counts as a couple. | 18 NYCRR 360-4.2(b) | SSI's rule |
| OK | At 100% of poverty, own income against the individual limit and income of both against the couple limit. | OAC 317:35-7-40(1) | Budget together |
| PA | SSI's threshold, but the applicant may elect to count a low-income spouse. | 55 Pa. Code 140.232 | SSI's rule |
Own-income test first: NJ (N.J.A.C. 10:72-4.4(d)), OK (OAC 317:35-5-42), WA (WAC 182-512-0900(6)) and NC fail an applicant whose own income exceeds the individual limit, even when the couple's total is under the couple limit.
Medically needy
| State | Rule | Source | PR 10640 uses |
|---|---|---|---|
| GA, NC | Threshold of half the individual limit ($158.50 and $121). | Georgia PAMMS 2507, North Carolina MA-2260 | SSI's rule |
| KY | Threshold of the gap between the limits ($56). Above it, combined income against the limit for one, using the larger spend-down. This may be a drafting slip in the rule. | 907 KAR 20:040 Section 1(4)(b) | SSI's rule |
| NY | Same as the pathway above. | 18 NYCRR 360-4.2(b) | SSI's rule |
| WA | Always the one-person limit. The spouse keeps up to one limit, and only the excess is deemed. | WAC 182-512-0920(10) | SSI's rule with its one-person limit |
| FL | SSI's rule, plus the higher share of cost of two budgets. | Florida ESS Manual 2640.0216 | SSI's rule |
At the threshold: Oregon and West Virginia word the threshold with "less than", so income exactly at it may differ from SSI's "not more than".
Also to settle, ruled or noted on 2026-11-02:
| State | Question | Source | PR 10640 does |
|---|---|---|---|
| IA | A spouse with no income to deem "is not a responsible relative for Medically Needy", so that spouse's bills don't count. The project lead ruled to follow Iowa's manual. A state setting needs a survey of whether other states say the same. | Employees' Manual Title 8, Chapter J | Deducts a spouse's bills in every state (42 CFR 435.831(d)) |
| ME | Medically needy "budgeting rules in Part 7 are used to determine countable income", and "The PIL is based on family size". Family size is unstated, while Maine's other pathway reads Part 7 as a couple limit. | 10-144 C.M.R. ch. 332, 10-3 | SSI's rule by default |
| ID | "The couple chooses the most useful method, based on their circumstances", in sections that also limit a community property method to some cases. The model has no input for separate or community income. | IDAPA 16.03.05 sections 761-766 | SSI's rule, with the limit noted in the code |
| WV and others | POMS SI 01320.400 A makes the own-income test part of SSI's own rule: "the SSI applicant or recipient must be eligible based on their own income." The state research also shows it in IA, LA, OH, OR and FL, so the list above may be too short, and SSI itself needs checking. In West Virginia, $13,200 of own income and $7,200 of spouse wages give own countable income above the limit, yet the model says eligible and uncapped_ssi is $1,722. |
POMS above | No own-income test |
Example
New York, 2026. An aged applicant's spouse has $600 a month of income after allocations. SSI's threshold is $497, so the model deems it. New York's threshold is $653, so the state tests the applicant alone against the one-person standard.
Scope and fix
- Most of this is a state threshold parameter and an own-income pretest parameter, read by the new couple-standard variables.
- Alaska needs a reading of how 7 AAC 40.330(b) and 40.310 fit together, and of whether AK-26-0001 sets a figure for one eligible spouse.
- California needs the limit for one even when spouse income counts, alongside California Aged and Disabled FPL program: deduct the ineligible spouse's maintenance need level and use the FPL for the people evaluated (MC 176 lines 19 and 21) #10543.
- Kentucky's text needs a decision on whether to follow the rule as written.
- Pennsylvania's election needs the model to take the better of two results.
- State plans weren't read for any of this.
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