10-144-332 Me. Code R. § 14-6
Institutionalized individuals are responsible for paying toward their cost of care for stays of a full calendar month. This includes those who may have paid privately for a portion of the month.
If an individual moves from one nursing facility to another the payment goes to the facility where the individual was residing on the first day of the month. If the individual moves from one facility to another on the first day of the month, the facility to which the individual moves is paid the cost of care.
If the individual was institutionalized on the first day of the month for which eligibility is being requested, the cost of care begins with that month.
If an individual was living in the community on the first day of the month for which eligibility is being requested then the first cost of care is owed for the following month.
If the individual was in acute status in a hospital for a full calendar month the individual may not owe anything for hospital costs due to payments from Medicare and/or other insurance. A cost of care is still determined. The hospital will be responsible to collect any portion that is actually owed.
When, after third party payments, the balance owed is less than the individual's cost of care, the lesser amount will be collected by the facility. This also applies when an individual is in a skilled nursing facility and covered by Medicare and QMB. A cost of care will be established. Since QMB covers the Medicare co-insurances and deductibles no cost of care will be collected until the Medicare days end.
There is no cost of care for SSI recipients in a medical institution if the Social Security Administration determines that the individual will be returning home within three months of entering the facility.
Individuals who receive SSI and whose total income is less than $60.00 (based on being in a nursing facility) have no cost of care.
The amount of an individual's cost of care may be adjusted without advance notice (See Section 6.2 of this Part).
Individuals who are no longer in a nursing facility are to be refunded their cost of care for that month by the facility. If the individual is entering a AFH, FRBH, CRBH, RCF, or AFCH (as defined in Part 1 2, Section1), or receiving Home and Community Based Waiver services (see Part 13). a cost of care may be owed to the new provider based on the eligibility requirements for this new program.
The individual's cost of care is what the individual is expected to pay towards the cost of their care at the institution. The cost of care is determined by considering the individual's income minus certain expenses and the Community Spouse Monthly Income Allocation.
For individuals who are categorically eligible, there is one determination process to follow. For those who are medically needy the determination process varies, depending on the individual's income.
For any month that an individual is considered to be institutionalized, a community spouse's income is never used in determining the cost of care, including a partial month, except in determining the Community Spouse Monthly Income Allocation.
At the time of application a determination is made of the Community Spouse Monthly Income Allocation.
The Community Spouse Monthly Income Allocation is the amount of income the institutionalized spouse is allowed to give to the community spouse before paying the cost of care.
Definitions
Minimum Monthly Income Standard - This is an amount set by Federal law used in the formula to determine the Monthly Income Allowance (See Chart 4.4).
Monthly Income Allowance - This is the Minimum Income Standard plus excess shelter costs.
Monthly Excess Shelter Standard - This is an amount set by Federal law. If the community spouse has shelter costs that exceed this amount, the excess can be used in determining the Community Spouse Monthly Income Allowance (See Chart 4.4).
Maximum Monthly Income Allocation - This is an amount set by Federal law that establishes the limit on income that can be allocated to the community spouse.
Community Spouse Monthly Income Allocation - This is the Monthly Income Allowance minus the community spouse's income.
The Community Spouse Monthly Income Allocation is determined as follows:
Total the following shelter expenses for the community spouse's primary residence:
The Monthly Income Allowance must not exceed the Maximum Monthly Income Allocation (See Chart 4.4).
This allocation can only be increased by:
Examples
1. Excess Shelter | $547 |
Minimum Monthly Income Standard(Chart 4.4) | +$1967 ________ |
Monthly Income Allowance | $2514 |
Community Spouse Gross Income | -$500 ________ |
Community Spouse Monthly Income Allocation | $2014 |
2. Excess shelter | $1098 |
Minimum Monthly Income Standard(Chart 4.4) | +$1967 ________ |
Monthly Income Allowance | $3065 |
The Monthly Income Allowance exceeds the cap set by the Maximum Monthly Income Allocation. This limits the Allowance to the Maximum Monthly Income Allocation.
Monthly Income Allowance Allowed (Chart 4.4) | $ 2931 |
Minus Community Spouse gross income - | $700 ________ |
Community Spouse Monthly Income Allocation | $ 2231 |
The community spouse or institutionalized spouse may request an administrative hearing if they have filed an application and they are dissatisfied with the determination of:
Either spouse may request a revision of the Monthly Income Allowance if they can establish a need, due to exceptional circumstances, which would create a financial hardship if more funds were not made available. This may occur either through the hearing process or a court order. The circumstances that caused the request are subject to departmental review yearly to determine if continued receipt of the increased allowance is warranted.
If either spouse establishes that the community spouse needs income above the level otherwise provided by the Monthly Income Allowance, due to exceptional circumstances resulting in significant financial duress, there shall be supplemented to the Monthly Income Allowance, an amount adequate to provide such additional income as is necessary. "Financial duress" is defined as the inability of the community spouse to meet current monthly household and/or medical expenses. "Such additional income as is necessary" is defined as the amount by which the community spouse's actual and necessary household and/or medical expenses exceed the Monthly Income Allowance.
In order to establish exceptional circumstances resulting in significant financial duress, either spouse must establish that the community spouse has made use of resources and income to meet current monthly household and medical expenses, and that he or she has no other ability to meet those expenses. Exceptional circumstances will not be deemed to exist where application of the Monthly Income Allowance results in a change or inconvenience to the lifestyle of the community spouse if necessary monthly household and medical expenses can nevertheless be met.
Once an application has been filed, either spouse may request an administrative hearing to increase the Community Spouse Asset Allowance (see Section 4.2 of this Part) if the community spouse's monthly income does not meet the Monthly Income Allowance. The additional assets are requested so that they will generate income and raise the community spouse's total available income to meet the Monthly Income Allowance. The additional allocation of assets to the community spouse may be revised as of the month of application. The Community Spouse Asset Allowance may not be revised prior to that month.
When an institutionalized individual has dependents living at home, an allocation may be allowed for their needs. The method of determining the allocation amount depends on whether there is a community spouse.
For purposes of this section, a dependent is defined as a minor or dependent child, dependent parent(s), or dependent sibling(s) of the institutionalized individual or community spouse, who are residing with the community spouse. These dependents are individuals who may be claimed by the institutionalized or community spouse for tax purposes under Internal Revenue Code.
To determine the allocation:
If the gross monthly income is equal to or greater than the Standard, no allocation is made.
If the gross monthly income is less than the Minimum Monthly Income Standard, subtract the income from the Standard. Divide the remainder by three. The resulting figure is the allocation for each dependent.
To determine the allocation:
If gross monthly income is equal to or greater than the standard, no allocation is made.
If gross monthly income is less than the standard, subtract the income from the standard. The resulting figure is the allocation to the dependents.
Examples
Note: If an institutionalized 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.
The deductions of $40.00 and $50.00 and the one-half remainder figure are added together. This figure is the personal needs allowance. This figure may not exceed the maximum dependent allowance (Chart 4.2).
Premiums must be incurred by the Medicaid recipient. If the health insurance is provided by the community 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 community 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 (TPL) should be contacted to assess cost effectiveness. If cost effective TPL will arrange for premium payment.
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).
Example
John enters the hospital on 2/17 from home. He moves to a nursing facility on 2/27. He is married and his wife Joan continues to live in their apartment. They have a $13,500 certificate of deposit from which they receive the interest monthly. They also have a checking account with a balance of $738.29. John receives Social Security benefits of $729.50 and Joan receives $529.80. The subsidized rent is $550.00 monthly, including heat and lights.
Income Allocation
Joan's income | John's income |
$529.80 Social Security | $729.50 Social Security |
+65.26 interest income ____________________ | |
$595.06 |
$600.00 | Rent |
+24.00 __________________ | Telephone |
$624.00 | |
-590.00 ___________ | (30% of $1967 - Chart 4.4) |
$34.00 | Excess shelter |
+1967.00 ________ | Minimum Monthly Income Standard (Chart 4.4) |
$2001.00 | (<$2931 maximum - Chart 4.4) |
-595.06 ______________ | Joan's income |
$1405.94 | Income allocation to community spouse |
Cost of Care
$729.50 | John's income |
-40.00 | personal needs |
$689.50 | |
-104.90 ____________ $584.60 | Medicare premium (Appendix C) |
-1405.94 _______________ | Income allocation to community spouse |
0.00 | Cost of care |
An individual is not expected to pay more than the Medicaid rate of the facility for a cost of care.
If the individual's gross income is over the Categorical Income limit but under the Private rate of the facility, multiply the daily Medicaid rate of the facility by thirty-one days. Compare the cost of care as calculated in Section 6.1.4 of this Part to the thirty-one day Medicaid rate. The individual is responsible to pay the lesser of the two amounts, either the cost of care or the Medicaid rate.
Example
Dick Reel entered a nursing facility on 1/17/08, from home. Dick receives $2972 in Civil Services benefits, $798 in Social Security benefits and a pension of $1800 monthly. The private rate is $200 per day and the Medicaid rate is $100 per day.
Income
$2972.00 | Civil Service |
$798.00 | Social Security |
$1800.00 | Pension |
$5570.00 | Total |
Deductible (See Section 5.2 of this Part)
$ 5570.00 | Dick's gross income |
-20.00 ___________ | Federal disregard |
$ 5550.00 | |
-315.00 __________ | PIL (1) |
$ 5235.00 | |
X 6 _________ | Deductible period |
$31410.00 | Deductible |
-629.40 ____________ | Medicare premiums |
$30780.60 | |
18600.00 ___________ | Medicaid rate for 6 months |
$12180.60 |
Because there is a remaining deductible use the Private rate instead of the Medicaid rate for 6 months.
$30,780.60 | |
- $37,200.00 ____________ | Private rate for 6 months |
0.00 | Remaining deductible |
Cost of Care
$ 5570.00 | Dick's gross income |
-40.00 ___________ | Personal needs |
$ 5530.00 | |
- 104.90 ______________ | Medicare premium |
$5425.10 | Cost of Care |
Dick's cost of care will be $3100 monthly. This is the Medicaid rate for the facility and it is less than the cost of care calculated using the rules in section 6.1.4.
Verified medical expenses that can be deducted from the cost of care are deducted for the month following the month the bills are received in the office.
For individuals who die and had incurred non-covered medical expenses, the last cost of care can be adjusted for the month in which they die.
Individuals who only receive $40.00 per month SSI and have a $0 cost of care are not reimbursed for non-covered medical expenses.
Example
Jack Snow purchases two bottles of Tylenol at $11.49 each and two hearing aide batteries at $10.00 each. Receipts are submitted on 3/5. Gross Social Security is $891.80.
Cost of Care
$891.50 | Gross Social Security |
- 40.00 | Personal needs |
- 104.90 | Medicare premium |
- 20.00 ___________ | Uncovered medical expenses (see note below) |
$726.60 | Cost of care |
Note: Cannot allow Tylenol - (generic brand for Tylenol is supplied by the facility. If Tylenol is prescribed by a physician and included in the plan of care, it is supplied by the facility and the cost is not allowed as an uncovered medical expense).
All lump sum payments, with the exception of SSI, are treated as income in the month received.
Any portion of a lump sum remaining the following month is an asset. Social Security and SSI retroactive payments are an excluded asset for nine months.
Medicare Buy-In is determined the same as for those who live in the community. See Part 8 for a description of the Buy-In programs.
If a couple is residing in the same room they are considered to be living together. If they are residing in separate rooms they are considered to be living apart.
Aid and Attendance is not used in this process.
10-144 C.M.R. ch. 332, § 14-6