Individuals must use their assets to meet their needs. Specific types and amounts may be retained by the individual and community spouse to meet current and future needs.
All available assets are to be used in determining eligibility. Countable assets are defined in Part 16. Asset limits are defined in Part 7, Section 1.
Unless exempt, a transfer of assets by the individual is subject to a penalty. Refer to Part 15 to assess if a transfer has occurred and if a penalty needs to be applied.
Countable assets of the individual must be under $2000 on any day of the month for which eligibility is determined.
Section 4.1:Long Term Care Partnership ProgramThis program provides incentives to Maine's citizens to purchase long term care insurance by disregarding some assets of the person, if they must apply for financial assistance for help with their long term care needs.
I.Insurance PolicyA. To meet the requirements of this MaineCare program, the long term careinsurance policy must be a qualified State long term care insurance partnership as certified by the Maine Bureau of Insurance. Certification requires several factors which include: 1. The policy must cover an insured who was a Maine resident when coverage became effective under the policy. If the individual has a long term care partnership policy from another state which also participates in this program and has agreed to provide reciprocal disregards for Medicaid applicants with qualified partnership plans, Maine will provide the same disregards. The individual must still otherwise qualify for MaineCare assistance as detailed in sub-sections II and III of this section.2. The policy must meet the definition of a qualified long term care insurance policy in the IRS Code §7702 B(b) and 26 U.S.C. § 7702B(b), and must meet the Model regulations specified in 42 USC § 1396p(b)5.3. the policy must have been issued or re-issued on or after July 1, 2009 (the effective date of the applicable approved State Plan Amendment.4. the policy must meet consumer protection standards of inflation protection, and its issuers are subject to training requirements of the Bureau of Insurance (Maine Bureau of Insurance Regulations 02-031 CMR chapter 425).B. Prior to making application for MaineCare the individual must have used the available coverage and benefits under the approved Long Term Care Policy.II.Eligibility for MaineCareA. All non-financial eligibility requirements as detailed in Section 1000 of this manual must be met.B. Applicant must meet the medical qualifications for assistance.C. Applicant's long term care insurance policy will be reviewed to determine if it meets the qualifications stated above, and to determine the extent of benefits paid so far by the terms of the policy.D. In addition to exempting assets routinely exempted under MaineCare rules, the amount of benefits paid to or on behalf of the insured applicant will be disregarded in the eligibility determination.III.Post-Eligibility ConsiderationsA. MaineCare benefits will only be paid for those expenses otherwise covered as outlined in the MaineCare Benefits Manual and for which the recipient's insurance policy has exhausted the benefits.B. The amount of the individual's assets disregarded under the above provisions continues to be disregarded post-eligibility throughout the lifetime of the individual, even if the disregarded assets have been transferred post-eligibility.C. If the policy benefits paid exceed the individual's assets at the time of application, additional assets up to the value of the benefits paid will be disregarded.Section 4.2Assets of Couples Residing in a Nursing FacilityIf the total assets of a couple in the same room in a nursing facility exceed the standard for a couple, they can decide who will be the eligible spouse and assets can be transferred to the ineligible spouse. Each spouse is treated as an individual. Coverage can begin for the eligible spouse effective the month countable assets for the eligible spouse are below the standard for an individual.
If the couple reside in different rooms in the same facility or in different facilities, then each is treated as an individual when determining the asset limit. Coverage can begin for the eligible spouse effective the month countable assets for the eligible spouse are below the standard for an individual.
No spousal allowance of income or assets is determined since the ineligible spouse is not living in the community.
Section 4.3:Assets of the Institutionalized Individual with a community spouseWhen an institutionalized individual has a community spouse, the couple's assets are looked at under special rules. These special rules determine how much of the couples assets are attributed to the community spouse and the institutionalized spouse. The amount attributed to the community spouse is called the Community Spouse Asset Allowance. The amount attributed to the institutionalized spouse is an available asset for the individual.
Determine the Community Spouse Asset Allowance
I. Total all countable assets owned by the community spouse and the institutionalized spouse (his, hers, theirs) on the first day of the month of application.II. The community spouse is allowed to keep all countable assets owned by the couple up to the Spousal Impoverishment amount in Chart 4.4. This is the Community Spouse Asset Allowance. Any share of the couple's assets over this amount is considered to be available to the institutionalized spouse. The Community Spouse Asset Allowance may be increased over the Spousal Impoverishment amount of Chart 4.4 if the gross monthly income of the community spouse and the Community Spouse Monthly Income Allocation is less than the Monthly Income Allowance (See Section 6.1.1 in this Part for definitions). This determination is made through the Administrative hearings process described in Section 4.4 of this Part.
III. The $8000 savings exclusion (See Part 16, Section 4.47) is applied to the amount available to the institutionalized spouse. This exclusion is not applied to the total countable assets or to the Community Spouse Asset Allowance.IV. The result is compared to the asset limit for an individual. The assets required to meet the Monthly Income Allowance shall be based on the Monthly Income Allowance set at the time of application.
Section 4.4:Hearing to Increase the Community Spouse Asset AllowanceEither the community spouse or institutionalized spouse may request a hearing if they have filed an application and they are dissatisfied with the determination of:
I. The Community Spouse Asset Allowance.II. The amount of assets attributed to the institutionalized individual. The hearing will be held within thirty days of the request.
The Department will make a determination of whether an amount greater than the Community Spouse Asset Allowance (Chart 4.4) is needed to raise the community spouse income to the Monthly Income Allowance.
If the individual agrees with the Department's decision, a hearing is requested using the Consent Decree in Appendix F.
If the individual disagrees with the Department's determination, s/he may request a face-to-face hearing.
A determination is made as follows on whether assets in addition to the Community Spouse Asset Allowance (Chart 4.4) are needed to meet the Monthly Income Allowance:
I. Monthly Income Allowance and the Community Spouse Income Allocation are determined according to Section 6.1.1 of this Part.II. the community spouse's gross monthly income and the Community Spouse Monthly Income Allocation (from the institutionalized spouse) are subtracted from the Monthly Income Allowance. This is the income deficit.III. the Department will get two estimates of the price of a single premium lifetime annuity that will generate a payment equal to the deficit.IV. the average of these two estimates shall be substituted for the amount of assets attributed to or protected for the community spouse when the Community Spouse Asset Allowance (Chart 4.4) is less than the averaged cost of an annuity. If the Community Spouse Asset Allowance in Chart 4.4 is greater than the averaged cost of the annuity, there shall be no substitution for the cost of an annuity.;
V. the spouse is not required to purchase this annuity.Section 4.5:Transfer of Assets to the Community SpouseOnce the Community Spouse Asset Allowance has been established, the couple has twelve months to transfer the protected assets to the sole ownership of the Community Spouse.
Section 4.6: Non-Cooperation from the Community SpouseIf the community spouse does not make assets available to the institutionalized spouse, eligibility will not be denied if:
I. the institutionalized spouse has assigned to the State any rights to support from the community spouse. A referral will be made to the Third Party Liability Unit (TPL) on behalf of the institutionalized spouse who gains eligibility for nursing care assistance when deemed assets are not made available by the community spouse;II. the institutionalized spouse is unable to execute an assignment of support due to physical or mental impairment. The State has the right to bring a support proceeding against a community spouse without an assignment under these conditions; orIII. the State determines that denial of eligibility would cause an undue hardship. The consequences of being denied Medicaid for nursing care by itself does not constitute undue hardship.10-144 C.M.R. ch. 332, § 14-4