Luisa

Luisa* is 62 years old and self-employed, working 35-40 hours per week selling her homemade chocolates and other confections at trade shows and farmers’ markets. Earlier this year, she contacted PHLP because her Medicaid was terminated. According to the County Assistance Office (CAO), she was no longer eligible for Medicaid because she failed to pursue retirement benefits. Right away, PHLP knew something was wrong with this decision. While it is a general condition of Medicaid eligibility that you must pursue all available benefits, including applying for early retirement benefits (RSDI), there is an exception for people working at least 30 hours per week.

The confusion arose due to how the Medicaid program calculates income for self-employed individuals, considering business expenses and net proceeds instead of the typical gross income used for non-self-employed individuals. Because Luisa had significant business expenses resulting in relatively low net profits, the CAO's income calculation failed to accurately show that she was indeed working enough to qualify for the exception, and thus did not need to apply for retirement benefits to keep her Medicaid. After identifying the issue, PHLP advocated with state policymakers, requesting intervention in Luisa's case as well as a broader policy update. We hoped they would change the language of the policy to make it clearer how the exception can apply for self-employed individuals and avoid this happening to others.

 Recognizing that the policy as written was disadvantageous to self-employed individuals, the state agreed to amend the policy and update guidance in the Medical Assistance Eligibility Handbook to permit CAO caseworkers to more easily apply this exception in cases like this.  If they can otherwise verify that the person works at least 30 hours per week (such as through an affidavit or tax records), even if their net income on paper is not reflective of this, that’s enough to satisfy the requirement.

Thanks to PHLP’s advocacy, the Medical Assistance Eligibility Handbook now reflects this policy change.  Under the updated language, CAO caseworkers must use pay stubs or tax records, if the Medicaid applicant provides them, in order to determine hours worked. This case is an example of how PHLP aims to turn our clients’ experiences into policy solutions that work not only for that client, but for the many other Medicaid recipients and consumers who never reach us for help.

To learn more about PHLP’s approach to our work through both individual client work and policy advocacy, visit our “What We Do” page.