C.M.R. 10, 144, ch. 332, app 144-332-F
STATE OF MAINE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
To: __________ Case No: ______________
____________________
CONSENT DECISION
On or about____________a hearing was requested on behalf of (applicant) _____ to appeal the allocation of spousal assets.
Both (applicant & spouse)_____________and the Department agree to the following:
(applicant)________ resides in a nursing facility and applied for Medicaid on ___________. (applicant's spouse) __________ is the community spouse.
As indicated below, (applicant's spouse) __________can keep $__________ of the couple's countable assets effective ___________.
INCOME ALLOWANCE
$ ____________ Monthly mortgage/rent
+ ____________ Real estate taxes
+ ____________ Condo fees
+ ____________ Home owners insurance
+ ____________ Utility standard
$ ____________ Total shelter expenses
- ______ 582.00 (30% of $1,939.00 - Chart 4.4)
$ ____________ Excess Shelter Expense
+ _____1,939.00 Minimum Monthly Income Standard (Chart 4.4)
$ ____________ Monthly Income Allowance (may not exceed $2841.00 - Chart 4.4)
- ____________ Community spouse's gross income
- ____________ Community spouse monthly income allocation
= ____________ Deficit in meeting Monthly Income Allowance
Average cost of an annuity to generate $__________ per month income is $__________.
Dated _______________ Signed ( Supervisor)
for the Department of Health and Human Services
Dated _______________ Signed ___________________
Institutionalized spouse or representative
Based upon the agreement between the parties, this CONSENT DECISION to the hearing requested in this matter is the final agency action on the appeal.
Dated_________________ Signed_____________________
Hearing Officer
C.M.R. 10, 144, ch. 332, app 144-332-F