10-144-332 Me. Code R. § 12-4

Current through 2024-51, December 18, 2024

Section 144-332-12-4 - RESIDENTIAL CARE INCOME CRITERIA

For all living arrangements, when determining eligibility for Medicaid "countable income" is gross income minus exclusions (See Part 17) and disregards (See Part 7, Section 2.1).

Section 4.1:Adult Foster Homes (AFH)

Residents are considered to be individuals 'living with others". If a married couple resides in the facility, at the option of the couple, eligibility may be determined as a couple if either member of a couple is not eligible when treated as an individual. The countable income of each spouse is totaled. Each spouse is deemed to receive one-half of this total and each is compared to 100% FPL.

I. If countable income is under the income limit for SSI/State Supplement the individual needs to apply for SSI/State Supplement in order to get help with their costs for residing in the AFH. When eligible for SSI/State Supplement, Medicaid coverage is also provided.

Note: Residents of "State Assisted" AFH are potentially eligible for a $49.00 State Supplement. Residents of "Private AFH" are potentially eligible for $10.00 State Supplement.

II. If countable income is equal to or over the State Supplement income limit for this living arrangement the individual is eligible for Medicaid if countable income is equal to or under 100% FPL.

III. If countable income is over 100% FPL the individual may be eligible for Medicaid under Medically Needy (See Part 10).

Section 4.2:Flat Rate Boarding Homes (FRBH)

Residents of FRBH are considered to be individuals "living with others". If a married couple resides in the facility, at the option of the couple, eligibility may be determined as a couple if either member of a couple is not eligible when treated as an individual. The countable income of each spouse is totaled. Each spouse is deemed to receive one-half of this total and each is compared to 100% FPL.

I. If countable income is under the income limit for SSI/State Supplement the individual needs to apply for SSI/State Supplement in order to get help with their costs for residing in the FRBH. When eligible for SSI/State Supplement, Medicaid coverage is also provided.

III. If countable income is over 100% FPL the individual may be eligible for Medicaid under Medically Needy (See Part 10).

IV. If countable income is over 100% FPL and the individual is applying for a Home and Community Based Waiver Program, Medicaid eligibility is determined using the rules of that program (See Part 13).

Section 4.3:Cost Reimbursement Boarding Homes (CRBH), Residential Care Facilities (RCF) and Adult Family Care Homes (AFCH)

Residents of these facilities are considered to be individuals "living with others". If a married couple resides in the facility, at the option of the couple, eligibility may be determined as a couple if either member of a couple is not eligible when treated as an individual. The countable income of each spouse is totaled. Each spouse is deemed to receive one-half of this total and each is compared to the private rate for the CRBH and RCF or the income limit in Chart 3.9 for AFCH.

I. If countable income is under the income limit for SSI/State Supplement the individual needs to apply for SSI/State Supplement in order to get help with the cost of their care. When eligible for SSI/State Supplement, Medicaid coverage is also provided.

II. If countable income is equal to or over the State Supplement income limit for this living arrangement, the individual is eligible for coverage if countable income is equal to or under the thirty-one day private rate for the CRBH and RCF, or the income limit in Chart 3.9 for the AFCH in which they reside.

III. If countable income is over the private rate, the individual may become eligible if they meet a deductible (See Part 10 for the rules on Medically Needy).

Medical services provided by the facility are medical costs incurred by the individual. They are used before other medical expenses to determine if the individual meets the deductible. These medical services are projected over a six month period. They are identified by the Office of MaineCare Services and are assigned a daily rate (cost). The daily rate is multiplied by thirty-one days to determine the monthly amount.

IV. If countable income is over 100% FPL and the individual is applying for a Home and Community Based Waiver Program (See Part 13), Medicaid eligibility is determined using the rules of that program. The rules in this section are used to determine the cost of care. The cost of care is paid to the facility.

Section 4.3.1:Determining the Cost of Care for an Individual

I. A cost of care or assessment is determined for all individuals. The cost of care is the monthly amount the individual is expected to contribute toward the cost of his/her care in the facility.

II. The individual has a zero cost of care for the month they are admitted to the facility. There is a cost of care for the month of discharge.

III.Cost of Care for an Individual

A.Determine gross monthly income. Total gross monthly income includes the State Supplement benefit:

1. If the individual has elected an option under his or her retirement plan that results in a reduced benefit to the individual in exchange for a continued benefit to the spouse upon the individual's death, (e.g. a joint and survivor annuity option), then that reduce damount will be considered to be gross income. However, the reduced amount may be used only if both the election is irreversible and the reduction amount does not exceed $1,000 per month.

2. If income is garnished due to a court order for child support the reduced amount of the income is used. The maximum reduction allowed is up to and including $1,000 per month per child.

B. From total gross monthly income, subtract:

1. Earned income disregard (See Part 7, Section 2.1),

2. Current federal, state or local income tax deductions,

An adjustment may be made if there are current federal, state or local income tax deductions from the individual's gross income. Usually the amount of taxes withheld will be based on the previous year's income tax return. The adjustment for taxes cannot exceed the current tax liability. A deduction for past due taxes is not allowed.

Examples

* Last year $600 was the tax liability. $80.00 per month is withheld for income tax. Only $50.00 per month can be allowed as a deduction as this is the current tax liability ($600 ÷ 12 = $50.00).

* Last year $600 was the tax liability. $25.00 per month is being withheld for income tax. A deduction of $50.00 per month is allowed as a deduction as this is the current tax liability ($600 ÷12 = $50.00).

Note: If an individual is paying estimated quarterly taxes, use these for an adjustment in the gross income. The procedure is the same as if the taxes were being withheld.

3. $70 (personal needs and federal disregard);

4. Medicare premium for the individual;

5. HUD Standard -The HUD Standard is a monthly subsidy given to a facility by the Department of Housing and Urban Development on behalf of residents of the facility; and

6. health insurance premiums incurred by the individual for the individual and/or the individual's spouse if the spouse is covered by Medicaid and is residing in a CRBH, RCF, Nursing Facility or covered by a Home and Community Based Waiver,

Premiums must be incurred by the individual residing in the specified facility. If the health insurance is provided by the individual's spouse through his/her coverage, this is not considered to be a cost incurred by the individual who resides in a facility. It is a cost incurred by the individual's spouse.

Note: Indemnity insurance premiums are not deducted. They are policies that pay for lengths of stay or for a condition and not for specific services. Third Party Liability should be contacted to assess cost effectiveness. If cost effective TPL will arrange for premium payment.

C. The result is the cost of care.

Note: If there is a partial month transfer of asset penalty, the individual may be responsible for an amount in addition to his or her cost of care (see Chapter 336 of this Manual).

Section 4.3.2:Determining the Cost of Care for a Couple

I. Determine gross monthly income of the couple. Total gross monthly income includes the State Supplement benefit.

A. If the individual has elected an option under his or her retirement plan that results in a reduced benefit to the individual in exchange for a continued benefit to the spouse upon the individual's death, (e.g. a joint and survivor annuity option), then that reduced amount will be considered to be gross income. However, the reduced amount may be used only if both the election is irreversible and the reduction amount does not exceed $1,000 per month.

B. If income is garnished due to a court order for child support the reduced amount of the income is used. The maximum reduction allowed is up to and including $1,000 per month per child.

II. From total gross monthly income, subtract:

A. Earned income disregard (Part 7, Section 2.1);

B. Current federal, state or local income tax deductions;

Examples

* Last year $600 was the tax liability. $80.00 per month is withheld for income tax. Only $50.00 per month can be allowed as a deduction as this is the current tax liability ($600÷12 = $50.00).

* Last year $600 was the tax liability. $25 per month is being withheld for income tax. A deduction of $50 per month is allowed as a deduction as this is the current tax liability ($600÷12 = $50.00).

Note: If an individual is paying estimated quarterly taxes, use these for an adjustment in the gross income. The procedure is the same as if the taxes were being withheld.

B. $120 (personal needs and federal disregard);

C. Medicare premium for the individual;

D. HUD Standard - The HUD Standard is a monthly subsidy given to a facility by the Department of Housing and Urban Development on behalf of residents of the facility; and

E. health insurance premiums incurred by either or both spouses for either or both spouses.

III. Divide the result by two. The result is the cost of care for each spouse.

Note: If there is a partial month transfer of asset penalty, the individual may be responsible for an amount in addition to his or her cost of care (see Chapter 336 of this Manual).

Section 4.3.3:Determining the Cost of Care for an Individual or Couple open on SSI

I. For an individual or a couple receiving only an SSI benefit, the cost of care is the maximum SSI and State Supplement benefit for an individual/couple (see Chart 3.6) minus the following deductions:

1. Personal needs of $50.00 for an individual/$100 for a couple;

2. health insurance premiums incurred by the individual for the individual and/or the individual's spouse if the spouse is covered by Medicaid and is residing in a CRBH, RCF, Nursing Facility or covered by a Home and Community Based Waiver

3. the HUD Standard - The HUD Standard is a monthly subsidy given to a facility by the Department of Housing and Urban Development on behalf of residents of the facility.

II. For an individual or a couple open for an SSI benefit and receiving another income, the cost of care is determined by deducting the following from gross monthly income:

1. Personal needs of $50.00 for an individual/$100 for a couple;

2. Federal Disregard of $20.00 for those with income in addition to SSI/State Supplement as long as their income is not based on need (for example, VA pension does not get this disregard, but VA compensation does);

3. health insurance premiums incurred by the individual for the individual and/or the individual's spouse if the spouse is covered by Medicaid and is residing in a CRBH, RCF, Nursing Facility or covered by a Home and Community Based Waiver; and

4. the HUD Standard - The HUD Standard is a monthly subsidy given to a facility by the Department of Housing and Urban Development on behalf of residents of the facility.

Section 4.3.4:Changes in the cost of care are made in the following situations

I. The individual paid a cost of care that was more than what was actually due. When this was due to Department error, the individual cost of care is adjusted retroactively up to one year from the date the error is discovered by the Department. When this was due to error by the individual, no adjustment is made.

II. The individual paid a cost of care that was less than what was actually due. Whether this is due to error by the Department or the individual, the individual's cost of care is adjusted retroactively up to three months from the date the error is discovered by the Department without advance notice. This includes an adjustment for a lump sum payment.

10-144 C.M.R. ch. 332, § 12-4