IMA POLICY MANUAL
PART VII: SPECIAL MA PROCESSING
CHAPTER 2: LONG-TERM CARE/IMPOVERISHED SPOUSE
Allowance for Health Insurance Premiums 2.6.2
When an individual or a couple residing in or entering LTC is purchasing health insurance coverage, the health insurance premiums, including those for Medicare, are deducted from the total value of countable income in order to encourage the LTC resident to maintain the third party coverage.
The Medicare premium should only be deducted if the LTC individual or couple is paying the premium. Once the Department assumes responsibility for payment of the Medicare premium, the LTC SSR should no longer deduct the Medicare premium as part of the allowance for health insurance premiums.
The allowance for health insurance premiums is the amount of the monthly premium or the amount of the premium if paid on a monthly basis.
Allowance for Maintenance of the Unoccupied Home 2.6.3
A home, whether it is owned or rented, is exempt from countable assets if the LTC resident provides a statement by his/her physician which states that the LTC resident is expected to return to the community residence within the first six months of the eligibility period. If the physician does not expect the LTC resident to return within the first six months, then the home is a countable asset as of the date of admission. If the physician did provide a statement noting an expected return date within six months but the LTC resident does not return within six months, the community residence becomes a countable asset the first day of the seventh month following the month of admission to the LTC facility. If, however, the individual is trying to sell the property, the asset is excluded, see Section 1.23: Pending Sale of Property in Part VI.
If the individual or couple residing in or entering a LTC facility has a home that is not occupied by a spouse or a dependent child and the home is exempt from countable assets, deduct an amount from the total countable income of the assistance unit receiving LTC coverage for maintenance of the unoccupied home. Apply the allowance only during the month or months the unoccupied home is exempt from countable assets for a maximum of six consecutive months per admission to a LTC facility.
The deduction is equal to the MNIL for one person or the actual cost of maintaining the home, whichever is less.
Allowance for Representative Payee/Conservator 2.6.4
If the LTC resident is paying a representative payee or conservator to handle his/her affairs, then deduct the monthly costs of this service.
Allowance for Medical Expenses 2.6.5
Deduct required and optional medical or remedial expenses from the individual's income (for types of allowed medical expense, see Section 7.3: Allowable Medical Expenses in Part VI). Determine the amount of the medical or remedial expenses to be deducted from the total income by considering the expenses as actually incurred each month.
Community Spouse Monthly Income Allowance 2.6.6
Impoverished Spouse: Unless a spousal support order requires support (court-ordered support) in a greater amount or a hearing officer has determined that a greater amount is needed because of exceptional circumstances resulting in extreme financial duress, deduct the minimum monthly maintenance needs allowance from the community spouse's gross monthly income.
The minimum monthly maintenance needs allowance is $2,610.00 for 2008.
When a deficit remains after a community spouse's gross income is compared to the minimum monthly maintenance needs allowance, the remaining deficit is the amount of the Community Spouse Monthly Income Allowance. If no deficit remains, there is no Community Spouse Monthly Income Allowance.
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The community spouse's monthly income equals $800.
$2,610.00 (minimum monthly maintenance needs allowance)
- $800.00 (community spouse income)
$1,810.00 (community spouse monthly income allowance)
The community spouse contributes $800 to monthly costs which is $1,810.00 less than the minimum allowance of $2,610.00. Therefore, there is a deficit of $1,810.00 remaining which is the allowable Community Spouse Monthly Income Allowance.
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Example 2 |
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The community spouse's monthly income equals $2,700.
$2,700.00 (community spouse monthly income)
- $2,610.00 (minimum maintenance allowance)
$ 90.00(excess monthly community spouse income)
Since the spousal income is over the minimum allowance amount, there is no deficit remaining in this example. Therefore, no Community Spouse Monthly Income Allowance is deducted. |
Do not recalculate the Community Spouse Monthly Income Allowance when the institutionalized spouse does not actually transfer the amount to the community spouse.
Family Members' Monthly Income Allowance 2.6.7
Impoverished Spouse: Deduct for maintenance of each family member one-third of any deficit remaining after the family member's gross income is compared to a family monthly income allowance equal to the minimum monthly maintenance needs allowance of $2,610.00 (see Section 2.6.6: Community Spouse Monthly Income Allowance in this Chapter). The term 'family member' only includes minor or dependent children, dependent parents, or dependent siblings of the institutionalized or community spouse who are residing with the community spouse.
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Mrs. Boria is institutionalized. Her husband, 15-year-old daughter (Ellen), and 12-year-old son (Ethan) live in the community. Ethan has a gross monthly income equal to $1,400, and Ellen has a gross monthly income equal to $1,600. The monthly income allowance for both Ethan and Ellen is calculated in the following manner:
$2,610.00 $2,610.00 Minimum Monthly Maintenance Needs Allowance
- $1,400.00 $1,600.00 Monthly Gross Income
$1,210.00 $1,010.00
$1,210.00/ 3 = $403.33 $1,010.00/ 3 = $336.66
Consequently, subtract $403.33 for Ethan and $336.66 for Ellen from Mrs. Boria's income. |
Any one or more of the following may be projected for a prospective period not to exceed six months:
Projections are based on no more than six-month periods, and periodic adjustments of amounts must be made. However, adjustments must be made sooner when there are significant changes in specific projected amounts.
See Exhibit VII-3: Provisions for Pre-October 1989 Institutionalization for additional items that may be projected for individuals institutionalized before October 1, 1989 who have a community spouse.
Impoverished Spouse: See above. In addition, the following can also be projected for a prospective period not to exceed six months:
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monthly income allowance for the community spouse (see Section 2.6.6: Community Spouse Monthly Income Allowance in this Chapter), and
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monthly income allowance for family members based on income family members expect to receive (see Section 2.6.7: Family Members' Monthly Income Allowance in this Chapter).
Impoverished Spouse: The assessment of assets can occur prior to or during institutionalization and prior to the MA-eligibility determination.
Promptly assess the couple's combined countable assets when requested by either spouse or a representative acting on behalf of either spouse at the beginning of each continuous period of institutionalization.
Documentation (or verification if deemed appropriate in lieu of documentation) showing ownership interest and current value of resources must be provided. When necessary documentation and/or verification is not provided in a timely manner, advise requesting parties that assessments cannot be completed.
Assessments must be made within 45 days from the date of request unless relevant documentation or verification is not provided in a timely manner. If persons requesting assessments do not provide necessary information in a timely manner, assessments must be made within 45 days of receipt of documentation or verification.
Provide each spouse with a copy of the assessment and an explanation of how the assessment was calculated. Retain copies for the case file. Also, provide each spouse with a notice advising them that only community spouses of MA-eligible institutionalized spouses have a right to appeal the determination of countable assets at the time of the assessment. If the assessment was conducted prior to submitting an MA application, community spouses have an opportunity to appeal assessment findings if and when their institutionalized spouses actually apply for Medicaid.
Nursing homes are required to advise new admissions and their families that asset assessments are available upon request. A nursing home patient has the right to be advised of such assessment.
