Section 210-RICR-50-00-8.6 - Personal and Family Maintenance of Need AllowancesA. Personal Needs Allowances. In general, LTSS beneficiaries receiving services in a health care institution receive a monthly personal needs allowance to cover the costs of daily needs that are not covered by the facility such as grooming, reading materials, cell phone fees and the like. A personal needs allowance is also provided to LTSS beneficiaries living in community settings such as Medicaid-certified assisted living residences under certain circumstances - that is, when eligible to receive the optional State supplement payment for low-income beneficiaries. The amount of the personal needs allowance is also a function of whether the LTSS beneficiary was receiving a pension from the Veterans Administration and has no spouse or dependents or qualifies as a surviving spouse. 1. Personal Need Allowance - A personal needs allowance is provided to LTSS beneficiaries who reside in a health care institution. (The maintenance of need allowances set aside for Medicaid LTSS beneficiaries residing in certain HCBS living arrangements are set forth in § 8.6(B) of this Part below). The personal needs allowance amounts indicated below include optional State supplemental payments as well as required Federal amounts, except as provided for veterans:a. Monthly Personal Needs Allowance of seventy-five dollars ($75.00). LTSS beneficiaries residing in a NF, ICF-ID, or hospital providing long-term services receive a personal needs allowance of seventy-five dollars ($75.00). The personal needs allowance consists of a mandated Federal allowance of thirty dollars ($30.00) and the State-only - personal needs allowance through State supplement payment of forty-five dollars ($45.00) per month.b. Veterans Personal Needs Allowance of Ninety Dollars ($90.00). The Veterans Benefit Act of 1992, Pub. Law 102-568(U.S.C. Title 38), entitles veterans who had received a pension to obtain what is known as the "veteran's improved pension" of ninety dollars ($90.00) per month when residing in a health care institution. This ninety dollar ($90.00) benefit is treated as a personal needs allowance and is deducted from income when determining liability for veterans who are Medicaid LTSS beneficiaries. The ninety dollar ($90.00) veteran's improved pension is available to Medicaid LTSS beneficiaries who are veterans and do not have a spouse or dependent child; or are the surviving spouse of a veteran who does not have a dependent child(ren). The improved pension is provided instead of the seventy-five dollar ($75.00) monthly personal needs allowance for non-veteran Medicaid LTSS beneficiaries.2. Expanded - Personal Needs Allowance - The personal needs allowance of LTSS beneficiaries may be expanded in certain circumstances as indicated below: a. Therapeutic Employment - Personal Needs Allowance. LTSS beneficiaries may retain a higher personal needs allowance if they have earned income as result of therapeutic employment. The personal needs allowance is deducted from the total amount of earned income related to public or private employment. To be considered therapeutic, the employment must be part of a written plan developed by the Office of Rehabilitative Services, of the Department of Human Services, or a similar entity and be for the purpose of enhancing the beneficiary's ability to achieve the highest level of independence. For these beneficiaries, the therapeutic employment - personal needs allowance is an additional eighty-five dollars ($85.00) plus one half (1/2) the remainder of earned income per month, subsequent to deducting actual FICA tax withheld, transportation costs, employment expenses, such as tools and uniforms, and State and Federal taxes if the person is not exempt from withholding. The total may be protected for personal needs. The maximum therapeutic employment - personal needs allowance will vary but may not exceed four hundred dollars ($400.00) per month. See below for the expanded HCBS special maintenance needs allowance for employed LTSS beneficiaries with developmental disabilities residing at home.b. Allowable fees. LTSS beneficiaries who incur expenses related to a guardianship or conservatorship, legal fees and/or tax assessments, court-orders or other legally binding instruments may receive an expanded personal needs allowance, or in the case of attachments or liens, a pre-emptive allowance to cover associated costs or legal obligations in certain circumstances when appropriate documentation is provided: (1) Guardianship/conservatorship. LTSS beneficiaries who have court-appointed guardians or conservators are allowed an expanded personal needs allowance to pay for certain court-approved or ordered fees. To be considered, the expense must be required for the LTSS beneficiary to make income or resources available, or to gain access to or consent for necessary medical treatment if the LTSS beneficiary does not have the capacity to make decisions on his or her own.(2) Requests and documentation - probate order and itemized bills - are reviewed by the EOHHS legal team and LTSS specialists. The total amount allowed must be reasonable based on applicable rates and fee schedules approved by the Rhode Island Supreme Court. Monthly deductions of up to one hundred twenty-five dollars ($125.00) may be allowed for guardianship expenses. Monthly deductions up to one hundred twenty-five dollars ($125.00) may also be allowed for related legal fees. An additional deduction from income of up to two hundred fifty dollars ($250.00) is recognized for allowable expenses related to a guardian ad litem during the month in which the LTSS beneficiary pays the expense.(3) Legal Fees. LTSS beneficiaries who incur fees resulting from legal action to obtain income or resources for their support may retain income in the form of an expanded personal needs allowance to pay such fees. The maximum which may be deducted from income is the lesser of the actual fee, or one third (1/3) of the settlement amount.(4) Tax Assessments. LTSS beneficiaries ordered by the Federal Internal Revenue Service, the Rhode Island Department of Revenue or other State or municipal taxing authority to pay income taxes may retain an expanded personal needs allowance or a lump-sum of income for such purposes.(5) Legal Attachments or Obligations. LTSS beneficiaries who are court-ordered to pay all or a portion of income to address an outstanding debt, or obligation such as spousal or child support, receive an expanded personal needs allowance equal to the amount due to meet that court ordered monthly obligation. The allowance may also be based on the terms of a settlement agreement that, although not court ordered, is legally binding. In instances in which this allowance absorbs all income, the State reviews the applicable legal documentation before proceeding with the cost of care calculation.B. Home and Community-Based Services Maintenance of Need Allowance. Medicaid LTSS does not cover room and board when provided in a home or community-based living arrangement. To ensure LTSS beneficiaries opting for care in these settings have adequate resources to meet these and other person need expenses, a maintenance of need allowance has been established for those receiving HCBS. LTSS beneficiaries in HCBS living arrangements may qualify for the HCBS maintenance of needs allowance only; or a State-optional (SO) personal needs allowance and HCBS maintenance of needs allowance; or a special maintenance of need allowance based on setting or LTSS need in addition to non-LTSS spousal and family allowances; or a family maintenance of need allowance: 1. HCBS Maintenance of Needs Allowance Only - The HCBS maintenance needs allowance is set at three hundred percent (300%) of the Federal Benefit rate, for a family of one (1), and is taken as a deduction from the Medicaid LTSS beneficiary's gross income subsequent to any required exclusions. Beneficiaries who qualify for the State-optional supplement receive an additional payment, as indicated below. Although the HCBS maintenance needs allowance is protected income that cannot be included in the calculation of beneficiary liability, the income is available for room and board, personal effects, and any attendant health costs that are not covered by Medicaid. The HCBS maintenance needs allowance is based on a reasonable assessment of need provided in lieu of a home maintenance allowance, unless statutory requirements direct otherwise.2. State-Only - Personal Needs Allowance - R.I. Gen. Laws § 40-6-27 establishes the State's optional supplemental payment and requires that a portion of the monthly cash payment provided to LTSS beneficiaries who are residing in certain living arrangements be set aside as a State-only personal needs allowance. Only beneficiaries with income at or below three hundred percent (300%) of the federal benefit rate are eligible for this deduction. This State-only - personal needs allowance is in addition to the Special HCBS maintenance needs allowance and varies in accordance with the State supplement payment category and/or type of residence: a. Living in own household - thirty-nine dollars and ninety-two cents ($39.92) for an individual and seventy-nine dollars and thirty-six cents ($79.36) for a coupleb. Living in the household of another - fifty-one dollars and ninety-two cents ($51.92) for an individual and ninety-seven dollars and thirty cents ($97.30) for a couplec. Medicaid certified assisted living residence - one hundred twenty dollars ($120.00)d. Medicaid beneficiaries who qualify for Category D, but do not meet the eligibility requirements for long-term care, receive a State-only personal needs allowance of fifty-five dollars ($55.00).3. Assisted Living - Special Maintenance Needs Allowance for Room and Board - LTSS beneficiaries in Medicaid LTSS certified assisted living residences receive a special maintenance of need allowance to pay for room and board. The amount of this allowance varies depending on whether the beneficiary's income is above or below three hundred percent (300%) of the Federal Benefit Rate, whether the beneficiary qualifies for the State supplement payment as Category D, and whether the beneficiary is in a single or double room in certain circumstances. a. State Supplement - Beneficiaries who qualify for the Category D State supplement payment and reside in a Medicaid LTSS certified assisted living residence receive a set assisted living - special maintenance needs allowance to pay for room and board which is equal to the Federal Benefit Rate (FBR) for one (1) plus the State supplement payment of three hundred thirty-two dollars ($332.00) per month, less the State-only - monthly personal needs allowance of one hundred twenty dollars ($120.00). The room and board allowance for these beneficiaries does not vary by type of room-that is, double versus single occupancy. However, the Federal Benefit rate changes annually as is set forth in §40-00-3.1.7(A)(1) of this Title.b. No State Supplement-The special maintenance of need allowance for Medicaid LTSS beneficiaries who do not qualify for the State supplement varies depending on the basis of eligibility as follows: (1) Categorically Eligible. Medicaid LTSS beneficiaries who have income at or below three hundred percent (300%) of the SSI Federal Benefit Rate are categorically eligible for coverage under applicable Federal and State authorities. The special maintenance of need assisted living room and board allowance for these beneficiaries is the same as for recipients of Category D (FBR for 1 + $332.00 less the personal needs allowance of $120.00 per month).(2) Medically needy eligible. Medicaid LTSS beneficiaries who have income above three hundred percent (300%) of the SSI FBR are medically needy eligible for coverage under applicable Federal and State authorities and must spenddown excess income to maintain eligibility. The special maintenance of need ALR allowance for these beneficiaries is three hundred percent (300%) of the Federal Benefit Rate adjusted for a single versus double room unless they have a spouse, in which case § 8.6(C) of this Part below also applies. The amount of the allowance for a double room is eighty-five percent (85%) of the total allocated for a single room. The adjustment is applied before the deduction of the personal need allowance, which is fixed without regard to whether a beneficiary resides in a single room. Both the assisted living provider and the beneficiary are notified of this adjustment upon the determination of eligibility.c. Cost of Care for Medicaid LTSS - All income above the assisted living - special maintenance needs allowance for room and board, less the applicable personal needs allowance that is not allocated to a spouse or dependent is available to pay the cost of care, including the pension portion of Veteran's Administration Aid and Attendance payments. The State supplement payment is reduced by the non-pension portion of Aid amp; Attendance, which must be allocated for room and board or toward the spousal allowance.4. Intellectual/Developmental Disabilities - Special Maintenance Needs Allowance - LTSS beneficiaries participating in the Rhode Island Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) Development Disabilities (DD) Program or the EOHHS Habilitation Program who are employed are eligible for the intellectual/developmental disabilities - special maintenance needs allowance and an additional amount of earned income up to but not exceeding three hundred percent (300%) of the SSI Federal Benefit rate.5. Exceptions - A beneficiary may receive an allowance that is above the maintenance of need allowance set by the State when:a. Court-ordered. A court-order may require the allocation of a different portion of the beneficiary's income to a spouse or a dependent as indicated in § 8.6(A)(2)(b)(5) of this Part; orb. EOHHS Hearing Decision. Upon presenting evidence of hardship in an EOHHS administrative fair hearing, the maintenance of need allowance for a beneficiary living at home may be increased if the amount provided is insufficient based on a reasonable assessment of need, as is required in 42 C.F.R. § 435.735(c)(1). Such an assessment must consider evidence that pertains directly to a beneficiary's need to maintain shelter including, but not limited to, rent or mortgage payments, property related taxes, fees and/or insurance, and utility costs. Hardships affecting home stability resulting from natural or human-made disasters such as a fire, weather damage, criminal acts may also be considered. The HCBS maintenance needs allowance increase may not exceed the minimum monthly maintenance of needs allowance in any given year.C. Monthly Spousal Allowances. The monthly spousal and family allowances are the principal mechanisms for assuring that the dependents of an LTSS beneficiary do not become impoverished as a result the obligation to pay income toward the Medicaid cost of care. The method for determining what type of spousal and family allowance and the amount also varies depending on family structure and living arrangements. 1. Monthly Non-LTSS Spousal Allowance - In instances in which the LTSS beneficiaries is married and the spouse is not requesting or receiving Medicaid LTSS, the monthly spousal allowance is established by:a. Determining gross income of the spouse. The gross income of a non-LTSS spouse is the total of earned and the unearned income, without applying the disregards and exclusions used when determining income eligibility.b. Calculating shelter costs. The shelter costs for maintaining the household of a non-LTSS beneficiary's principal place of residence are calculated by adding together monthly rental or mortgage payments (principal and interest), taxes and insurance, condominium or cooperative required maintenance charges, and the standard utility allowance, as applicable. The minimum is the Community Spouse Housing Allowance set annually by the Federal government.c. The standard utility allowance. The standard utility allowance, as updated annually in 218-RICR-20-00-1, Supplemental Nutrition Assistance Program, serves as a proxy for utility costs when calculating shelter costs without respect to actual costs incurred by a non-LTSS spouse. This allowance is only included in the computation of shelter costs if the non-LTSS spouse is responsible for paying such expenses.d. Excess shelter allowance. To determine the excess shelter allowance, the sum of all shelter costs is deducted from the minimum monthly maintenance of need allowance. Any expenses above the standard constitutes the excess shelter allowance and is added to the minimum monthly maintenance of needs allowance and the determination proceeds as follows: (1) If there is no excess shelter allowance or the sum of the excess shelter allowance and the minimum monthly maintenance of needs allowance are at or below the standard minimum allowance standard established for the year, the minimum monthly maintenance of needs allowance is used as the basis for determining the monthly spousal allowance.(2) If the sum of the excess shelter allowance and minimum monthly maintenance of needs allowance are above the standard but below the maximum monthly maintenance of need allowance, then the sum serves as the basis for determining the monthly spousal allowance.(3) If the sum of the excess shelter allowance and minimum monthly maintenance of needs allowance is at or above the standard maximum allowance, the maximum monthly maintenance of need allowance serves as the basis for determining the monthly spousal allowance.e. Monthly Spousal Allowance. To determine the monthly spousal allowance, the non-LTSS spouse's gross income is deducted from the sum of the excess shelter allowance and minimum monthly maintenance of needs allowance. The monthly spousal allowance is the amount remaining after this calculation and determines the amount of the LTSS beneficiary's income that is protected - available to the spouse - to meet the spouse's monthly needs and, as such cannot be included in the calculation of the LTSS beneficiary's liability toward the cost of care.f. Exceptions. A non-LTSS spouse may obtain a monthly spousal allowance that exceeds the maximum monthly maintenance of need allowance standard when: (1) Court-ordered. A court-order may require the allocation of a larger portion of the beneficiary's income to the spouse; or(2) EOHHS Hearing Decision. Upon presenting evidence of hardship in an EOHHS administrative fair hearing, the monthly spousal allowance may be increased in certain circumstances.2. No Monthly Spousal Allowance - If a Medicaid LTSS beneficiary does not have a spouse, there is no monthly spousal allowance regardless of LTSS living arrangement. Certain family allowances may apply, however.D. Family Allowances. The Medicaid LTSS beneficiary's income may be reduced by deductions for dependent family members. There are two (2) types of family allowances that apply depending on whether there is a non-LTSS spouse. If there is a non-LTSS spouse, a family allowance is provided in addition to the monthly spousal allowance; if there is no spouse, a family monthly maintenance of need allowance is calculated. The family maintenance of needs allowance varies depending on whether the Medicaid LTSS beneficiary is residing with family members. 1. Family Allowance (FA) - A family allowance is determined when there is a non-LTSS community spouse residing with family members who are the dependents of the spouse or the LTSS beneficiary. The LTSS living arrangement of the beneficiary is not a factor in determining whether this allowance applies. The family allowance is the sum total of the allowances determined separately for each family member as follows: a. Determination of gross income. The earned and unearned income for each family member is calculated without any disregards or exclusions.b. Family allowance standard. The minimum monthly maintenance of needs allowance standard is multiplied by one third (1/3). The result of this computation is the family allowance standard that applies when determining the allowance for each family member.c. Individual family member's allowance. The gross income of each family member is subtracted from the family allowance standard. The amount remaining from this calculation is the family allowance for that family member.d. Total Family Allowance. The individual allowances for each family member are added together to determine the total family allowance. The family allowance counts toward the maximum MMN allowance.2. Family maintenance of need allowance - When the Medicaid LTSS beneficiary does not have a spouse, a family maintenance of need allowance is established that provides for a broader range of expenses than are considered when there is a monthly spousal allowance. This family maintenance of needs allowance is calculated in accordance with the following: a. Determination of gross income. The earned and unearned income for each family member is calculated without any disregards or exclusions.b. Family maintenance of need (FMN) standard. The gross income of each family member is added together and deducted from the FMN standard, which is the medically needy income limit based on family size.(1) If the Medicaid LTSS beneficiary resides with family members in a HCBS living arrangement, he or she is included in the family when determining family size;(2) If the Medicaid LTSS beneficiary is in a health care institution or does not reside with family members, family size is based on the number of family members only - that is, the LTSS beneficiary is not counted.c. Family maintenance of needs allowance. The difference between the family maintenance of need standard and total gross income of the family members is the family maintenance of need allowance. The family maintenance of needs allowance counts toward the maximum monthly maintenance of need standard.210 R.I. Code R. 210-RICR-50-00-8.6
Amended effective 6/3/2021
Amended effective 9/2/2021
Amended Effective 11/3/2021
Amended effective 7/29/2023(EMERGENCY)
Amended effective 11/22/2023