Section 144-332-13-6 - WAIVER COST OF CAREA cost of care is determined for any month in which eligibility exists.
Cost of care is determined by the budgeting process for that waiver and paid to the appropriate agency.
The cost of care is due for each month for which services are provided even if services are not provided for a full calendar month.
The cost of care may be adjusted without timely notice and may be adjusted retroactively (See Part 14, Section 6.2).
Individuals who are Medicaid eligible under the following coverage groups do not have a cost of care:
II. an SSI - Related group with an income limit of 100% FPL. Note: If there is a partial month transfer of asset penalty the individual may be responsible for an amount in addition to their cost of care (See Part 15, section 1.8).
Section 6.1:BudgetingNote: VA pensions that are Aid and Attendance or based on unusual medical expenses are not used to determine the cost of care in the Home and Community Based Waivers.
I. Determine the individual's gross monthly income. If this figure is over the Categorical Nursing Care limit (see Chart 4.1), use the SSI-Related budget for an individual (Part 7) and the deductible process (Part 10) to determine eligibility. Once the individual is Medicaid eligible, use the following steps to determine the individual's cost of care.
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 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.C. 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
1. 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).2. 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.
D. When a husband and wife are living together and are both covered by a Waiver, they each may have a cost of care. However, they may allocate income to each other to reduce or eliminate the cost of care. Example
Husband and wife are both eligible for Waiver. The husband has SSA of $1,400. The wife has SSA of $700. We allocate $350 to the wife so each will have $1,050 used in the calculation of their individual costs of care.
II. Subtract 200% Federal Poverty Level for a single-person household. This is the Personal Needs Allowance for the individual.III. Subtract the cost of: A. Medicare payments for the individual.B. 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, AFCH, Nursing Facility or covered by a Home and Community-Based Waiver. Notes
Premiums must be incurred by the Medicaid recipient. If the health insurance is provided by the non-waivered spouse through his/her coverage, this is not considered to be a cost incurred by the Medicaid recipient. It is a cost incurred by the non-waivered spouse.
Indemnity insurance premiums are not allowed. These are policies that pay for length of stay or a condition but not for a specific service. Third Party Liability should be contacted to assess cost effectiveness. If cost-effective, TPL will arrange for premium payment.
C.Certain Medical Expenses1. Unpaid medical expenses incurred by the individual for necessary medical services. This includes payment on the unpaid balance of a loan taken out to pay for medical expenses incurred prior to Medicaid coverage provided the proceeds of the loan were used to pay the medical bill. Only the amount of the loan actually used to pay the medical bill may be deducted and only the principal (and not the interest) part of the unpaid balance may be used as a deduction.2. Disability related expenses that are not payable by the waiver, the Medicaid program, or a third-party payer. Disability related expenses include: a. Home access modifications: ramps, tub/shower modifications and accessories, power door openers, shower seat/chair, grab bars, door widening.b. Communication devices: adaptations to computers for communication or environmental control, speaker telephone, teletext devices.c. Wheelchair (manual or power) accessories: accessories, lab tray, seats and back supports.d. Adaptations to transportation vehicles: adapted carrier and loading devices, one communication device for emergencies (limited to purchase and installation), adapted equipment for driving.f. Glasses and adapted visual aids.g. Environmental control units: devices that substitute for touch control such as a voice activated device to adjust lighting.h. Assistive animals (purchase only).i. Personal emergency response systems.3. A medical expense or disability related expense will not be deducted from the cost of care if: a. the expense was covered by insurance (including Medicare).b. the expense was not covered due to a Medicaid penalty period of ineligibility.c. the Department has determined that the expense was not the responsibility of the individual because a medical assessment was not timely and requested by the facility or because the facility did not timely and adequately assist the individual with filing a Medicaid application. This determination is made by the Office of Aging and Disability Services (OADS).d. the expense is the cost of care to a medical institution or a waiver agency during periods of Medicaid coverage.e. the expense was for a Medicaid covered service and the individual was covered by Medicaid.4. Verified medical expenses are deducted from the cost of care in the month following the month in which the bills are received in the regional office.IV. Subtract any spousal allocation. To determine this: A. Determine the spouse's gross monthly income, including SSI and TANF payments.B. Subtract the gross monthly income from the maximum spousal allowance (see Chart 4.2).C. The balance is the spousal allocation.V. Subtract any dependent allocation. When an individual eligible under the Waivers has dependents living at home, an allocation may be allowed for their needs. For purposes of this section, a dependent is defined as a minor or dependent child, dependent parents, or dependent siblings of the waivered individual or non-waivered spouse. These dependents are individuals who may be claimed for tax purposes under Internal Revenue Code. To determine the allocation: A. determine the dependent(s) gross monthly income, including SSI and TANF payments.B. subtract the gross monthly income from the appropriate maximum dependent allowance (See Chart 2). The balance is the dependent allocation.VI. The remainder is the individual's cost of care. Example
Don Renoir is 75 years old. He has applied for the Elderly Waiver. Assets in his name only are under $2,000. He receives Social Security and a pension totaling $1,500 per month.
His spouse, Claudette, has Social Security of $500 per month.
The 19-year old son, who is the couple's dependent, lives with them. He has zero monthly income.
$1,500.00 | Mr. Renoir's gross monthly income |
- 1,945.00 _________________ | personal needs allowance for Mr. Renoir (200% of FPL) |
$ -445.00 |
- 96.40 ____________ | Medicare Part B premium |
$ Not applicable |
- 123.00 _____________ | spousal allocation |
$ not applicable |
- 154.00 | dependent allowance |
$ 0.00 | Mr. Renoir's cost of care |
Spousal allocation is determined as follows:
$ 623.00 | maximum spousal allocation |
- 500.00 ________ | spouse's gross income |
$ 123.00 | spousal allocation |
Dependent allocation is determined as follows:
$ 154.00 | maximum dependent allowance |
- 0.00 _________ | income of Mr. Renoir's son |
$ 154.00 | dependent allocation |
10-144 C.M.R. ch. 332, § 13-6