IMA POLICY MANUAL
PART VII: SPECIAL MA PROCESSING
CHAPTER 2: LONG-TERM CARE/IMPOVERISHED SPOUSE
If an individual is a recipient of MA as a community-assistance unit and is also a recipient of SSI, s/he or his/her authorized representative is responsible for notifying the SSA of his/her plans to enter a LTC facility.
The SSI payment will be reduced to $70 (or less in some instances) if the individual has no other income. SSI will be terminated if the individual has other income that totals $45 or more. If SSI is terminated, then categorical eligibility (see Chapter 12: Categorical Eligibility in Part IV) is also terminated. If the individual's categorical eligibility is terminated, the SSR must advise him/her or the authorized representative to submit a new application for MA to the LTC Eligibility Unit.
MA INCOME ELIGIBILITY DETERMINATION 2.5
If an individual or couple is about to enter or has entered a LTC facility and is seeking assistance for the costs of LTC, s/he must first establish eligibility for MA (in many cases, individuals will already be MA-eligible; if this is the case, this section does not apply). An individual or couple over-income for MA but otherwise eligible for MA, may be eligible for LTC placement. LTC eligibility or payability is determined after MA eligibility is established (see Section 2.14: Patient Pay Amount (PPA) in this Chapter).
If the individual applies while residing in the community, the SSR should follow the policies detailed in Chapters 4-8 in Part VI for the appropriate MA category. If, however, an individual applies while residing in the LTC facility, then the LTC Eligibility Unit processes the application and not a service center. After a child has remained in the institution for 30 days, the parent's income is disregarded when determining MA eligibility and LTC payability.
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Mr. Goldman is divorced and lives in the community. He currently does not receive MA. Mr. Goldman learns that he may have to enter a LTC facility in the next few weeks following his scheduled surgery. He applies for MA. Since he is living in the community at the time of his MA application, the policies in Chapter 4 - 8 in Part VI apply, and an SSR in the appropriate service center determines his eligibility.
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Example 2 |
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Ms. Raikes is widowed and unexpectedly enters a LTC facility. She applies for MA after her admittance to the LTC facility. Because she is residing in the LTC facility at the time of her MA application, the LTC Eligibility Unit processes her application. |
Impoverished Spouse: If an individual with a community spouse is about to enter or has entered a LTC facility and is seeking assistance for the costs of LTC, s/he must first establish income eligibility for MA (in many cases, individuals will already be MA-eligible; if this is the case, this section does not apply). LTC eligibility (payability) is determined after MA eligibility (see Section 2.14: Patient Pay Amount (PPA) in this Chapter). If, however, the individual is over income for MA but has income of less than the cost of care in the LTC facility, the individual is eligible for LTC coverage.
If s/he applies while residing in the LTC facility, then his/her income is treated differently than it would be if s/he applied while residing in the community. In addition, if an individual applies while residing in the LTC facility, then the LTC Eligibility Unit processes the application and not a service center.
Determine the individual's income using the following rules irrespective of District laws governing division of marital property.
If the individual applies while residing in the community, then the SSR should follow the policies detailed in Chapters 4-8 in Part VI for the appropriate MA category.
If the individual applies while residing in the LTC facility, the SSR should separate the income of the couple and follow the SR policies detailed in Chapters 4-8. The SSR should not deem any income of the community spouse as available to the institutionalized spouse for any month in which the institutionalized spouse is in an institution. In addition, the SSR should subtract the following two allowances (known as the Impoverished Spouse Allowances; see Section 2.6: LTC Income Allowances in this Chapter) in addition to those discussed in Chapter 6: Income Disregards and Deductions in Part VI:
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Community Spouse Monthly Income Allowance (see Section 2.6.6: Community Spouse Monthly Income Allowance in this Chapter) but only to the extent income of the institutionalized spouse is made available to (or for the benefit of) the community spouse; and
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family allowance (see Section 2.6.7: Family Members' Monthly Income Allowance in this Chapter) for each family member, including minor or dependent children, dependent parents, or dependent siblings of the institutionalized or community spouse who are residing with the community spouse.
When a Community Spouse Monthly Income Allowance is not made available to (or for the benefit of) the community spouse, do not deduct the allowance. When determining MA eligibility for the community spouse, include the Community Spouse Monthly Income Allowance in the income of the community spouse. Deduct allowances for other family members, whether or not the institutionalized spouse makes the income available to such persons.
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Mr. Harris is married and lives in the community. He currently does not receive MA. Mr. Harris learns that he may have to enter a LTC facility in the next few weeks because his wife is no longer able to care for him at home. He applies for MA. Since he is living in the community at the time of his MA application, the policies in Chapters 4 - 8 in Part VI apply, and he is not eligible for the Impoverished Spouse Income Allowances.
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Example 2 |
| Mrs. Bigley is married and lives with her husband. She has a stroke, and her doctors expect her to be in the hospital or a LTC facility for at least 30 days. She applies for MA after her admittance to the LTC facility. Because she is residing in the LTC facility and her husband is living in the community, the Impoverished Spouse Income Allowances are applied when determining her eligibility for MA |
LTC INCOME ALLOWANCES 2.6
The LTC Income Allowances are the amounts of monthly income that are set aside for the maintenance needs of the LTC resident and his/her family. They are used when calculating the PPA (see Section 2.14: Patient-Pay Amount (PPA) in this Chapter).
The LTC Income Allowances include the following:
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PNA (see Section 2.6.1: Personal Needs Allowance (PNA) in this Chapter),
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allowance for health insurance premiums, including Medicare (see Section 2.6.2: Allowance for Health Insurance Premiums in this Chapter),
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allowance for maintenance of the unoccupied home (see Section 2.6.3: Allowance for Maintenance of the Unoccupied Home in this Chapter),
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allowance for representative payee or conservator (see Section 2.6.4: Allowance for Representative Payee/Conservator in this Chapter), and
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allowance for incurred expenses for medical or remedial care for the institutionalized spouse (see Section 2.6.5: Allowance for Medical Expenses in this Chapter).
See Exhibit VII-3: Provisions for Pre-October 1989 Institutionalization for the LTC Income Allowances an individual institutionalized before October 1, 1989 who has a community spouse is eligible and how the allowances are applied.
Impoverished Spouse: If a married person is institutionalized after September 30, 1989 and has a community spouse, then s/he is eligible for certain allowances in addition to and in lieu of those listed above.
The following are all the income allowances a married person institutionalized after September 30, 1989 who has a community spouse may be eligible for:
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PNA (see Section 2.6.1: Personal Needs Allowance (PNA) in this Chapter);
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allowance for health insurance premiums, including Medicare (see Section 2.6.2: Allowance for Health Insurance Premiums in this Chapter);
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allowance for representative payee or conservator (see Section 2.6.4: Allowance for Representative Payee / Conservator in this Chapter);
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allowance for incurred expenses for medical or remedial care for the institutionalized spouse (see Section 2.6.5: Allowance for Medical Expenses in this Chapter);
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Community Spouse Monthly Income Allowance (see Section 2.6.6: Community Spouse Monthly Income Allowance in this Chapter) but only to the extent income of the institutionalized spouse is made available to (or for the benefit of) the community spouse (this allowance is unique to the Impoverished Spouse provisions); and
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family allowance (see Section 2.6.7: Family Members' Monthly Income Allowance in this Chapter) for each family member, including minor or dependent children, dependent parents, or dependent siblings of the institutionalized or community spouse who are residing with the community spouse (this allowance is unique to the Impoverished Spouse provisions).
When a Community Spouse Monthly Income Allowance is not made available to (or for the benefit of) the community spouse by the institutionalized spouse, do not deduct the allowance. Deduct allowances for other family members, whether or not the institutionalized spouse makes the income available to such persons.
Personal Needs Allowance (PNA) 2.6.1
The PNA is a portion of monthly income that an individual in LTC retains for his/her personal needs. Only goods and services not covered by the cost of care rate at the facility may be purchased with this PNA.
The PNA for an individual is $70 per month.
The PNA for a Veteran's Aid and Allowance recipient is $90.
If the PNA is not spent but allowed to accumulate in an account maintained by the facility or a bank, the balance in the account is considered a countable resource (see Section 1.4.1: Liquid Assets in Part VI).
The SSR must advise the individual or his/her authorized representative (see Section 1.6.2: Filing an Application/Accessing Benefits on Behalf of an Individual or Group in Part III) before the account exceeds the asset limit that the accumulating PNA may result in termination of eligibility on the basis of excess resources.
