Add Medicaid LTSS financial eligibility screen (TX, DE, WA)

[MaxGhenis]

Adds an opt-in Medicaid long-term services and supports (LTSS) financial-eligibility screen: an effective-dated 2026 federal chassis with Texas, Delaware, and Washington parameters covering the special income limit routes (300% of SSI in TX/WA; Delaware's 250% route with the $20-disregard mechanics), qualified income trusts, institutional medically-needy budgeting (WA), resource limits, home-equity caps, and spousal impoverishment protections (CSRA floor/half/maximum regimes and MMMNA).

Six new variables (medicaid_ltss_financial_pathway, is_medicaid_ltss_income_eligible, medicaid_ltss_csra_resource_eligible, medicaid_ltss_home_equity_eligible, medicaid_ltss_mmmna, is_medicaid_ltss_financial_threshold_eligible) — deliberately not integrated into is_medicaid_eligible, enrollment/take-up, or Medicaid benefit values. Functional/level-of-care eligibility is out of scope and labeled as such; QIT-adjusted income and countable resources are trusted inputs with the limitation in metadata; unknown HCBS waivers fail closed to unmodeled rather than inheriting statewide rules.

Every parameter value traces to a cited primary source (Texas HHS Appendix XXXI, Delaware's 2026 income-standards notice and LTC regulation, Washington's 2026 standards and WACs) with reference URLs in the YAML metadata; where a state document does not establish a value (e.g., Delaware's numeric home-equity cap), it remains unmodeled rather than inferred.

35 YAML contract tests cover every SIL/resource/home-equity boundary, TX QIT sufficiency both ways, DE's 250% + disregard, WA SIL-failure→institutional-MN, all three CSRA control regimes, an MMMNA non-conversion assertion, home-equity exceptions, identical-household cross-state comparisons, fail-closed unknown-waiver, and vectorized cases.

🤖 Generated with Claude Code

[codecov]

Codecov Report

✅ All modified and coverable lines are covered by tests.
✅ Project coverage is 100.00%. Comparing base (74f045a) to head (02a7c0b).
⚠️ Report is 6 commits behind head on main.

Additional details and impacted files

@@            Coverage Diff             @@
##              main     #9184    +/-   ##
==========================================
  Coverage   100.00%   100.00%            
==========================================
  Files            3        25    +22     
  Lines           63       338   +275     
  Branches         3         0     -3     
==========================================
+ Hits            63       338   +275     

Flag	Coverage Δ
unittests	100.00% <100.00%> (ø)

Flags with carried forward coverage won't be shown. Click here to find out more.

☔ View full report in Codecov by Harness.
📢 Have feedback on the report? Share it here.

🚀 New features to boost your workflow:

• ❄️ Test Analytics: Detect flaky tests, report on failures, and find test suite problems.

[DTrim99]

Program Review

PR #9184 — "Add Medicaid LTSS financial eligibility screen (TX, DE, WA)" (author: @MaxGhenis). Opt-in financial-threshold screen (special income limits/QIT, medically-needy, resource limits, CSRA, home equity, MMMNA) for 2026, deliberately not wired into is_medicaid_eligible, with QIT-adjusted income and countable resources as documented trusted inputs.

Source Documents

#	Source	URL	Pages
1	TX HHS MEPD Handbook, Appendix XXXI — Budget Reference Chart (Rev. 26-2, eff. June 1, 2026)	https://fhb.hhs.texas.gov/handbooks/medicaid-elderly-people-disabilities-handbook/appendix-xxxi-budget-reference-chart	HTML chart (n/a)
2	DE DMMA Administrative Notice A-14-2025 — 2026 SSI-Related Income Standards and Medicare Premiums	https://dhss.delaware.gov/wp-content/uploads/sites/11/2026/06/2026-SSI-Related-Income-Standards-and-Medicare-Premiums.pdf	2
3	WA HCA — Apple Health Income and Resource Standards (1/1/2026)	https://www.hca.wa.gov/assets/free-or-low-cost/income-standards-20260101.pdf	7
4	CMS CMCS Informational Bulletin (4/27/2026) — Updated 2026 SSI and Spousal Impoverishment Standards	https://www.medicaid.gov/sites/default/files/2026-04/cib04272026.pdf	2
5	Supplementary regulations (HTML/PDF) — WAC 182-513-1395, WAC 182-515-1508 (+1505/1506 cross-checked); DE DSSM, 16 DE Admin Code 20000 (LTC), re-collected clean (83 pp.)	https://app.leg.wa.gov/wac/default.aspx?cite=182-515-1505 ; https://regulations.delaware.gov/api/AdminCode/title16/20000/13aee487-1cd1-4726-addf-63603af28a78	n/a / 83

• Year: 2026 — Scope: PR changes only (merge-base diff, 64 files: 32 parameters, 25 variables, 6 test YAMLs, 1 changelog fragment)

Branch Status

⚠ PR branch is 24 commit(s) behind main. Consider rebasing before merging. Review was scoped to the PR's actual changes — staleness did not affect findings.

Critical (Must Fix)

1. Delaware can never pass the composite screen — home-equity fails closed even for non-homeowners, and the DE cap is in fact established by DE regulation.
   Files: policyengine_us/variables/gov/hhs/medicaid/eligibility/long_term_care/financial/medicaid_ltss_home_equity_eligible.py (home_cap_is_modeled = (state == TX) | (state == WA), default=0), is_medicaid_ltss_financial_threshold_eligible.py (ANDs home-equity in), tests medicaid_ltss_home_equity_eligible.yaml Case 7 and is_medicaid_ltss_financial_threshold_eligible.yaml Case 2.
   Because DE has no modeled cap, every Delaware applicant returns medicaid_ltss_home_equity_eligible = False absent a residency/hardship exception — including an applicant with home_market_value: 0 — so is_medicaid_ltss_financial_threshold_eligible is false for all DE applicants regardless of income/resources. Delaware is one of the three states the PR adds, yet it can never produce a positive composite result. This is legally wrong on two counts: (a) under 42 USC 1396p(f) the home-equity payment bar applies only to a person with an equity interest in a home — a non-homeowner is not barred (https://www.law.cornell.edu/uscode/text/42/1396p); and (b) the PR's premise that "no DE document establishes a numeric cap" is contradicted by the re-collected DE regulation: DSSM 20320.7.B/E (16 DE Admin Code 20000) bars payment only where equity "exceeds the home equity cap as set by federal regulations" and adopts the CPI-indexed federal-minimum tier ($500,000 base in 2006), i.e., $752,000 for 2026 — the value already present in the PR's own federal/home_equity/minimum.yaml and confirmed on the CMS CIB chart (https://www.medicaid.gov/sites/default/files/2026-04/cib04272026.pdf). Fix: at minimum let zero-equity applicants pass the home-equity component; preferably give DE the federal-minimum $752,000 cap citing DSSM 20320.7.B/E (https://regulations.delaware.gov/api/AdminCode/title16/20000/13aee487-1cd1-4726-addf-63603af28a78).

Should Address

1. The new home-equity subsystem duplicates the existing federal LTC home-equity chassis.
   Files: medicaid_ltss_home_equity_eligible.py plus seven manual home-input variables (medicaid_ltss_home_market_value/encumbrances/ownership_share/occupied_by_spouse/child_under_21/blind_or_disabled_child/hardship_waiver) and parameters financial/{tx,wa}/home_equity/limit.yaml, financial/federal/home_equity/{minimum,maximum}.yaml.
   The model already implements the 42 USC 1396p(f) bar via is_medicaid_long_term_care_home_equity_eligible and medicaid_home_equity_limit_family_exception (which derive spouse/child residence from actual household structure, is_blind/is_disabled, and age), backed by gov.hhs.medicaid.eligibility.long_term_care.home_equity.limit — which already carries the 2026 value $1,130,000 and 2027/2028 values incl. the H.R.1 (P.L. 119-21) Sec. 71108 change. The new wa/home_equity/limit.yaml (2026-only) will silently diverge from the tracked federal figure in 2027+. Prefer reusing/extending the existing chassis and parameters over the parallel financial/*/home_equity/* tree. (Note: the code-pattern auditor read the new medicaid_ltss_* names as intentionally namespaced trusted inputs; the regulatory reviewer flagged the duplication as blocking. Consolidated here as a strong should-address given the screen is opt-in and un-integrated.)

2. TX MMMNA regime mismatch — verified (code-path CONFIRMED), informational-value only.
   Files: medicaid_ltss_mmmna.py, test medicaid_ltss_mmmna.yaml (TX state_code).
   Texas sets the community-spouse MMMNA as a single flat figure equal to the federal maximum — TX Appendix XXXI lists exactly one line, "MMMNA also known as Spousal Allowance — $4,066.50", with no minimum and no shelter standard (https://www.hhs.texas.gov/handbooks/medicaid-elderly-people-disabilities-handbook/appendix-xxxi-budget-reference-chart; corroborated by MEPD J-7200). The PR applies the generic federal formula ($2,705 + excess shelter over $811.50, capped at $4,066.50) to all states, and its own TX-coded test pins the federal-formula outputs [2_705, 2_705, 4_066.50] — understating the TX MMMNA by up to $1,361.50/month for low-shelter cases. Verification confirmed medicaid_ltss_mmmna feeds no eligibility output anywhere in the PR (exhaustive consumer trace) — it is a standalone informational quantity, hence should-address rather than critical. Remedies (any one): add a TX flat-maximum branch/parameter; re-scope the test off TX; or explicitly document that state MMMNA regimes are unmodeled and label the variable federal-only. (Open question noted for any follow-up: whether WA pays the maximum flat — check WAC 182-513-1380; DE regime likewise unmodeled.)

3. Seven federal "chassis" parameters are declared but never referenced.
   Files: financial/federal/ssi_fbr/{individual,couple}.yaml, federal/resources/{individual,couple}.yaml, federal/special_income_limit/maximum.yaml, federal/home_equity/{minimum,maximum}.yaml.
   Flagged independently by three validators. Only federal/csra/{minimum,maximum} and federal/mmmna/* are read by formulas. The orphans also duplicate canonical values living elsewhere (SSI FBR = gov.ssa.ssi.amount; home-equity limit = gov.hhs.medicaid.eligibility.long_term_care.home_equity.limit), inviting drift. Remove them or wire them to real use (the values themselves are all correct per the CMS CIB).

4. No aged/blind/disabled categorical gate on the SSI-related pathways.
   Files: is_medicaid_ltss_financial_threshold_eligible.py, is_medicaid_ltss_income_eligible.py, medicaid_ltss_financial_pathway.py.
   The 300% special-income level and institutional/medically-needy routes exist only for the SSI-related (aged 65+/blind/disabled) population (42 CFR 435.236, 435.1005; SSA SI 01110). A non-ABD person meeting the thresholds returns True. The model already has is_ssi_aged_blind_disabled. Gate on it, or document the omission prominently in medicaid_ltss_financial_pathway. (Kept at should-address given the PR's explicit financial-only scope.)

5. MMMNA test coverage: the two load-bearing zero branches and the additive interior are untested.
   File: medicaid_ltss_mmmna.yaml (1 case, 3 people — all landing on the floor or the cap). Missing: has_community_spouse: false → 0; pathway == UNMODELED → 0 (both false branches of the gate prevent phantom spousal allowances and are unverified); an excess-shelter interior point (e.g., shelter $1,811.50 → $3,705) so the minimum + excess arithmetic is checked off-boundary; and shelter one cent below the $811.50 threshold.

6. Edge-case test gaps on already-tested variables (all six formula variables have coverage; these harden it):

   • Home equity: (value − encumbrances) × share never checked at the cap with non-trivial encumbrance/share (e.g., TX $1,000,000 − $248,000 → exactly $752,000, then +$1); invalid ownership_share (<0 or >1) fail-closed guard unexercised.
   • CSRA: no has_community_spouse: true with assistance_unit_size: 2 case (confirming the couple case bypasses the CSRA branch); no both-spouses-institutionalized case; floor/interior crossovers asserted from one side only (add ±1 brackets to Cases 5–6); no half-snapshot-equals-state-minimum tie.
   • Cross-state: no identical-facts case showing TX/DE/WA divergence on the income pathway (WA flips to medically-needy above the SIL while TX/DE fail) or resource limits, mirroring the existing home-equity cross-state case.
   • Fail-closed defaults: no explicit assistance_unit_size: 0 case; no zero-income-eligible case (lowest tested income is $2,000).

7. Reference precision and durability (all values corroborate; these make citations self-verifying):

   • federal/mmmna/shelter_threshold_rate.yaml: cite the subsection — 42 USC 1396r-5(d)(4) (excess shelter, 30% of (d)(3)(A)(i)), e.g. https://www.law.cornell.edu/uscode/text/42/1396r-5#d_4 — rather than bare 1396r-5.
   • All 11 federal CMS-bulletin citations: add #page=2 (the standards chart is file-page 2; the link currently lands on the cover letter). WA standards sheet: add #page=7 (LTSS block).
   • DE files: include the notice identifier "DMMA Administrative Notice A-14-2025" in titles (the /wp-content/uploads/ URL will rot on re-issue), and now that the DSSM has been cleanly re-collected, cite the durable sections directly: DSSM 20910.10 (CSRA $25,000 state spousal share), 20100.2.2 (250% SIL), 20240.1/20990 ($20 disregard incl. needs-based carve-out), 20400.11 (Miller trusts).
   • TX: pin "Revision 26-2; Effective June 1, 2026" in the title (living chart). WA csra/state_minimum: note the source stamps $72,529 as "(7/1/25), changes in odd years" — add the odd-year July cycle to the description so the 2026-01-01 date isn't misread as WA's action date.

8. Style/formatting nits (code-pattern audit): shelter_threshold_rate.yaml value 0.30 → 0.3 (trailing zero; the .50 cent values in de/special_income_limit/couple.yaml and federal/mmmna/maximum.yaml are legitimate); parameter descriptions read as full explanatory sentences rather than the terser house pattern ("...under the [Program Name] program").

Suggestions

1. DE csra/state_minimum ($25,000) — now verified verbatim in DSSM 20910.10 ("$25,000.00 (current state spousal share)", raised from $14,148 by DE SB 99 for applications on/after 10/1/93) and correctly inert in code via max_(state_minimum, federal_minimum) (the federal $32,532 governs, matching 42 USC 1396r-5(f)(2)). Add the DSSM 20910.10 section citation to the YAML and note in the description that the federal floor supersedes it.
2. period: month metadata on stock parameters (resources, CSRA, home-equity, SIL limits): semantically odd for one-time/stock limits though behaviorally correct for the un-annualized read; consider a label/description note that these are stocks. Same nit applies to the WA waiver booleans.
3. /2 statutory one-half in medicaid_ltss_csra_resource_eligible.py is the fixed 42 USC 1396r-5(f)(2)(A) spousal share and acceptable as a literal; a csra_share (0.5) parameter is optional for traceability.
4. Document modeling simplifications: WA WAC 182-515-1507 CN route (no SIL test) and the 182-515-1508(2) / 182-513-1395(5) spend-down fallbacks are unmodeled; WAC 182-513-1395(4)(a) tests "remaining income plus excess resources" against the facility cost while the model omits the excess-resources term (slightly lenient, resources screened separately). A short scope note in the WA variables would lock these in.
5. Nice-to-have tests: DE mixed needs-based/ordinary income so min_(non_needs_based, 20) binds at an interior value; WA HCBS medically-needy ±1 bracket at the $994 MNIL; medicaid_ltss_setting: UNKNOWN fail-closing to UNMODELED; an unsupported state (e.g., CA) returning UNMODELED/all-false; note that the WA waiver enabled: false branch is reform-only-reachable.
6. Reference niceties: prefer the canonical app.leg.wa.gov WAC link over the hca.wa.gov landing page for COPES; add WAC 182-513-1100 (SIL definition) to complete the WA rule chain; name the exact table/row in citation titles; note that tx/csra/state_minimum is the federal floor as adopted by TX (the chart's own wording: "the minimum resource amount set by federal law").

Investigated and Cleared

• DE CSRA state minimum $25,000 — initially flagged critical (uncorroborated, below federal floor); the DSSM PDF was re-collected cleanly (83 pp.) and DSSM 20910.10 states the figure verbatim; the code's federal-floor max_ matches both the DSSM and 42 USC 1396r-5(f)(2). Cleared (residual: Suggestion 1).
• WA waiver flags (COPES, New Freedom, RSW) — WAC 182-515-1505/1506 confirm these are exactly the three HCS-authorized HCB waivers, and WAC 182-515-1508 + 182-513-1100 confirm the 300%-SSI SIL route. The five DDCS waivers (WAC 182-515-1510) correctly fail closed. Cleared.
• DE 250% SIL / $20 disregard / QIT regulatory basis — verified against DSSM 20100.2.2, 20240.1, 20990, and 20400.11 (Miller trusts). The DE income + disregard modeling is exactly right. Cleared.
• MMMNA minimum $2,705 (eff. 7/1/2026) — one reviewer flagged it as an unpublished projection; the collected CMS CIB chart itself lists "Minimum Monthly Maintenance Needs Allowance (Effective 7-1-26): 2,705.00", and 0.30 × 2,705 = the chart's $811.50 housing allowance. Corroborated; cleared. (The Jan–Jun 2026 minimum is documented as intentionally unmodeled.)
• Test period 2026-07 — flagged as potentially rejected by the YAML runner; all CI checks pass and the MMMNA assertions can only pass if the July-2026 parameters actually resolved, empirically confirming the runner accepts 2026-07. Cleared (mid-year months are novel in this repo's baseline tree, which otherwise uses YYYY / YYYY-01).

Source Audit Summary

Category	Count
Parameter values confirmed correct against primary sources	28 (10 income + 18 resources/CSRA/MMMNA/home-equity; every dollar figure exact, Jan-1 vs Jul-1 effective dates correct)
Verified mismatches	1 (TX MMMNA regime — federal formula vs TX flat $4,066.50; code-path CONFIRMED, informational-only, no eligibility impact)
Cleared by verification	5 (DE CSRA $25,000; 3 WA waiver flags; MMMNA 7/1/26 minimum)
Unmodeled items noted (documented scope, not errors)	7 (DE home-equity cap — escalated to Critical 1; WA couple resources; Jan–Jun 2026 MMMNA minimum; WA MNIL sizes 2+; TX CAS/community pathways and couple deeming; DE 30-day acute-care standard; AK/HI figures)

Validation Summary

Check	Result
Regulatory Accuracy	⚠ 1 critical (DE home-equity fail-closed contradicts 42 USC 1396p(f) and DSSM 20320.7); all encoded dollar values and boundary arithmetic verified correct
Reference Quality	✔ All 32 parameters cite correct-jurisdiction primary sources; 31/32 corroborated on first pass, 32/32 after DSSM re-collection; durability/anchor improvements recommended
Code Patterns	✔ 0 critical (no hard-coded values, changelog present, vectorization clean, fail-closed defaults documented); 3 should-address style items; home-equity chassis duplication flagged
Test Coverage	✔ All 6 formula variables tested (35 cases, hand-reverified arithmetic); no non-functional boolean tests; edge-case gaps listed above
Source Value Audit	✔ 28 matches / 1 confirmed mismatch (informational-only) across 5 source documents
CI Status	✔ All CI checks passing

Review Severity: REQUEST_CHANGES

One critical issue: the Delaware fail-closed home-equity design means a state the PR adds can never pass the composite screen — including non-homeowners — and the underlying premise (no DE cap exists) is contradicted by DSSM 20320.7.B/E, which adopts the federal-minimum $752,000 cap. Everything else is non-blocking: values are accurate and unusually well sourced, arithmetic is correct at every tested boundary, and the confirmed TX MMMNA mismatch affects an informational quantity only.

Next Steps

To auto-fix issues: /fix-pr 9184

---

This review was generated by the /review-program multi-agent pipeline (regulatory, reference, code-pattern, and test validators; income and resources source audits; code-path, cross-reference, and external-source verification agents).