Department of Human Services: Chapter 2: 2.9 thru 2.13
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IMA POLICY MANUAL
PART VII: SPECIAL MA PROCESSING
 
CHAPTER 2: LONG-TERM-CARE/IMPOVERISHED SPOUSE
 
MA ASSET ELIGIBILITY DETERMINATION 2.9
 
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 asset eligibility for MA (in many cases, individuals will already be MA-eligible; if this is the case, this section does not apply). LTC eligibility or payability will be 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 or while residing in the LTC facility, then the SSR should follow the policies detailed in Chapters 1-3 in Part VI for the appropriate MA category. If an individual applies while residing in the LTC facility, then the LTC Eligibility Unit processes the application and not a service center. The LTC SSR should follow the SR policies detailed in Chapters 1-3 in Part VI (if the individual is under 21 and is MA-eligible under AR, then follow the AR policies).
 
Impoverished Spouse: 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 asset eligibility for MA (in many cases, individuals will already be MA-eligible; if this is the case, this section does not apply). LTC eligibility or payability will be determined after MA eligibility is established (see Section 2.14: Patient Pay Amount (PPA) in this Chapter).
 
If s/he applies while residing in the LTC facility, then his/her assets are treated differently than they 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.
 
If the individual applies while residing in the community, the SSR should follow the policies detailed in Chapters 1-3 in Part VI for the appropriate MA category (however, after the individual enters the LTC facility, then s/he is eligible for the designation of a Protected Spousal Amount; see Section 2.9.1: Protected Spousal Amount in this Chapter and Section 2.12: Treatment of Assets After MA Eligibility Determination in this Chapter).
 
If the individual applies while residing in the LTC facility, the SSR should consider all the resources held by either the institutionalized spouse and/or the community spouse as available to the institutionalized spouse, regardless of any District laws relating to community property or the division of marital property, and should do the following to determine the MA eligibility of the institutionalized spouse.
  • Determine the couple's combined countable assets for the month of application (see SR policies unless institutionalized spouse under 21 and eligible for MA under AR in Chapter 1: Determining Countable Assets in Part VI).
  • Deduct from the couple's combined countable assets owned at the time of application a Protected Spousal Amount (see Section 2.9.1: Protected Spousal Amount in this Chapter).
  • Deduct the Protected Spousal Amount from assets held in the name of the institutionalized spouse from the time of the initial eligibility determination until the first regularly scheduled recertification.
  • Compare the remaining asset amount to the SR resource standard for one person (unless institutionalized spouse under 21 and eligible for MA under AR) (see Section 3.3: Asset Limits in Part VI).
If the remaining assets are equal to or below the appropriate standard, the institutionalized spouse is eligible for MA. If the remaining asset amount is above the standard, the institutionalized spouse is not eligible for MA.
 
Do not deny MA eligibility to an institutionalized spouse who has resources in excess of the SR resource standard when one or more of the following circumstances exists:
  • the institutionalized spouse has assigned to the District any rights to support from the community spouse,
  • support rights cannot be assigned to the District because the institutionalized spouse has physical or mental impairments of a degree which under D.C. law prohibits him/her from legally assigning rights but the District has rights under D.C. law to bring support proceedings against the community spouse without such an assignment, or
  • an impartial review has determined that a denial of eligibility creates undue hardship.
When changes in the amount of resources of the institutionalized spouse occur after initial eligibility for MA is established, recalculate the asset eligibility of the institutionalized spouse unless:
  • The new assets combined with the other assets the institutionalized spouse intends to retain do not exceed the asset limit for one person.
  • The institutionalized spouse intends to transfer the new assets to the community spouse who has assets below the Spousal Share allowance (see Section 2.9.2: Spousal Share and Section 2.13: Transfer of Assets Before or After MA Eligibility Determination in this Chapter).
Assets owned by the community spouse are not deemed available to the institutionalized spouse after the initial eligibility determination (see Section 2.12: Treatment of Assets After MA Eligibility Determination in this Chapter).
 
 
Protected Spousal Amount 2.9.1
 
Impoverished Spouse: The Protected Spousal Amount is the greatest of the following amounts:
  • The Spousal Share, provided it does not exceed $109,560 for 2009 (see Section 2.9.2: Spousal Share in this Chapter)
  • The Community Spouse Assets Allowance ($21,912 for 2009)
  • An amount transferred under a court support order (court-ordered support)
  • An amount designated by the OFH
Example
Mr. and Mrs. Lopez's combined countable assets at the time of Mr. Lopez's Medicaid application are $12,000. The Community Spouse Assets Allowance is $21,912. All of the couple's assets ($12,000) are protected for the community spouse because they are below the Community Spouse Assets Allowance of $21,912. Therefore, the Protected Spousal Amount is $12,000.
Protected Spousal Amounts are revised:
  • When either spouse alleges that the initial determination was incorrect and the OAH confirms such allegations (see Section 7.4.8: Hearing Decisions in Part VIII)
  • When a SSR determines that inaccurate information was provided at the time the Spousal Share was calculated for the current eligibility period.
If either spouse establishes during redetermination of eligibility that income generated from the Protected Spousal Amount is inadequate to raise the community spouse's income to the minimum monthly maintenance needs allowance (see Section 2.6.6: Community Spouse Monthly Income Allowance in this Chapter), recalculate the Protected Spousal Amount.
 
 
Spousal Share 2.9.2
 
Impoverished Spouse: The Spousal Share is equal to one-half of the couple's combined countable assets as of the beginning of the most recent continuous period of institutionalization. Spousal Shares are calculated between the time a spouse is admitted to an institution and the time the spouse applies for Medicaid and eligibility is determined. Calculation may be made even when there are no immediate plans for an institutionalized spouse to apply for Medicaid.
 
The amount of the Spousal Share remains the same for purposes of determining the amount of assets used to determine the institutionalized spouse's initial Medicaid eligibility in the current period. It does not change even when calculated prior to application.
Example
Mr. and Mrs. Smith's combined countable assets are assessed at $20,000 at the beginning of the most recent continuous period of Mr. Smith's institutionalization. The Spousal Share is $10,000 (one-half of the initial asset assessment amount).
 
RETROACTIVE ASSET ELIGIBILITY DETERMINATION 2.10
 
Determine the institutionalized spouse's assets for a retroactive eligibility determination for LTC coverage by using the policies in Section 2.9: MA Asset Eligibility Determination in this Chapter.
 
 
MULTIPLE APPLICATIONS IN THE SAME CONTINUOUS PERIOD OF INSTITUTIONALIZATION 2.11

Impoverished Spouse: If a person applies for MA coverage in the current continuous period of institutionalization and is determined ineligible due to excess resources, deduct the Protected Spousal Amount (see Section 2.9.1: Protected Spousal Amount in this Chapter) from the couple's combined resources when determining eligibility for each subsequent re-application filed in the same period of institutionalization. Following a determination of eligibility, deduct the Protected Spousal Amount until the next regularly scheduled redetermination. Do not deduct the Protected Spousal Amount when determining eligibility for a person applying for MA following a determination of eligibility and subsequent ineligibility in the same period of institutionalization.
Example 1
Mr. Black is residing in a LTC facility and Mrs. Black lives in the community. Mr. Black applies for MA, but he is found to have excess resources. Two weeks later, Mr. Black sells his car (he is still residing in the LTC facility). He re-applies for MA. The SSR should deduct a Protected Spousal Amount when determining eligibility.
 
Example 2
Mrs. Steel is residing in a LTC facility and is currently receiving MA and LTC coverage. Her husband is residing in the community. Mrs. Steel's brother dies, and she inherits $3,000. Mrs. Steel is now ineligible for MA and LTC coverage because of excess resources. One month later, Mrs. Steel is still residing in the LTC facility. Mrs. Steel reapplies for MA and LTC coverage. The SSR should not deduct a Protected Spousal Amount when determining eligibility.
 
TREATMENT OF ASSETS AFTER MA ELIGIBILITY DETERMINATION 2.12
 
Impoverished Spouse: Assets owned by the community spouse are not deemed available to the institutionalized spouse after the initial eligibility determination for MA coverage. Consequently, if a community spouse acquires additional assets after the initial eligibility determination, the eligibility of the institutionalized spouse is not affected.
 
If an individual applied for MA while living in the community and is now living in a LTC facility, s/he is now eligible for a Protected Spousal Amount (see Section 2.9.1: Protected Spousal Amount in this Chapter).
 
 
LIMITATION ON HOME EQUITY FOR LONG TERM CARE ASSISTANCE 2.12.a
 
Individuals who have an equity interest in their home that exceeds $750,000 are not eligible for LT unless one of the following conditions apply:
  • The individual has a spouse who lives in the home;
  • The individual has a child under 21 who lives in the home;
  • The individual has an adult child who is disabled living in the home; or
  • The limitation has been waived by the Medical Assistance Administration in the Department of Health, due to undue hardship.
 
TRANSFER OF ASSETS BEFORE OR AFTER ELIGIBILITY DETERMINATION 2.13
 

When an otherwise eligible institutionalized individual disposes of any countable assets for less than fair market value during or after a “look-back period”, impose a period of restricted Community Medicaid coverage.  The look-back period is a period of time immediately before:

  • The date the individual becomes an institutionalized individual if s/he is eligible for Community Medicaid on that date
  • The date the individual applies for assistance while an institutionalized individual if s/he is not eligible for Community Medicaid on the date of institutionalization and the uncompensated value of the transferred asset exceeds the monthly cost of care. The uncompensated value is the difference between the fair market value and the amount that was actually paid for the item.

The look-back period depends upon the date of asset transfer:

  • For transfers made before February 8, 2006, the look-back period is 36 months.
  • For transfers made on or after February 8, 2006, the look-back period is 60 months.
  • Effective February 8, 2011, the look-back period will always be 60 months.

·         Determine the period of restricted coverage in months by dividing the total uncompensated value by the average monthly cost of nursing home care in DC. If the calculation results in a partial month at the end of the period, the individual is only eligible for LTC for the portion of the month after the partial period ends. The total uncompensated value is the result of subtracting the payment actually received, if any, from the fair market value of the asset.

 

Effective September 1, 2010, the average monthly cost of nursing home care in DC is $10,333.00. For periods prior to September 1, 2010, the average cost of care was $7,149.00.

 

The start date of the period of restrictive coverage depends upon the date of the asset transfer:

·         For transfers made before February 8, 2006, the period of restrictive coverage begins on the first day of the month in which the transfer was made, regardless of the date of the month the transfer actually occurs;

·         For transfers that occurred on or after February 8, 2006, the period of restricted coverage begins on the later of the following;

o    The month of transfer, regardless of the date in a month the transfer is made, or

o    The first month for which the institutionalized person has applied for LTC and has been found to meet all eligibility requirements except for the transfer of assets for less than full market value.

 

If the calculation of a restricted period of coverage results in a partial month at the end of the restricted period, the payability for the partial month will be prorated, using the following formula:

 

            (Payability for full month) x (1-part of month not covered).

 

During the period of restricted Community Medicaid coverage, if the individual is otherwise eligible for Community Medicaid, the individual is eligible for all covered medical services except nursing facility services, equivalent care in a medical institution, and home and community-based services.

 

Example 1

Mr. Barth makes a transfer on January 2, 2006. The period of restricted coverage begins September 1.

 

 
 

Example 2

Ms. Adams makes a transfer on March 31, 2010. She enters a nursing home in June, 2010 and applies for LTC on July 16, 2010. She is found otherwise eligible for LTC effective July 1, 2010. The period of restricted coverage begins July 1, 2010.

 
 
 
 
 
 
 

Once a period of restricted Community Medicaid coverage is established, the period may only be recalculated if the LTC applicant provides documentation within forty-five days after the LTC application that all or part of the total uncompensated value was returned to the applicant. In such a case, divide the remaining uncompensated value by the average cost of care to establish the adjusted period of restricted coverage.

  

Undue Hardship

  

Once a period of restricted eligibility is assigned, an applicant can claim undue hardship when a penalty will result in inability to get necessary medical services so that health or life would be endangered.  Undue hardship also exists when imposing the penalty would result in deprivation of food, clothing, shelter or other necessities of life.  Undue hardship does NOT exist when the penalty causes inconvenience, restricts a person’s lifestyle, or does not put a person at risk of serious deprivation.

 

Applicants can request an undue hardship waiver by calling Yvette Thomas on (202) 698-4247 within 15 days of the notice of restricted coverage.

Applicants need to provide the following information regarding eligibility for a Hardship waiver:

 

  • the reason for the transfer
  • attempts that have been made to recover the transferred asset
  • notice of pending discharge from the nursing facility due to the denial of payment of LTC services
  • notice of pending termination of community-based services due to denial of payment
  • statement from doctor(s) saying that the inability to get LTC or community-based services would result in NOT getting medical services needed to prevent the endangerment of  health or life
  • proof that the restriction would result in an inability to get food, clothing or shelter
  • lists of all assets and their value at the time of the transfer, if the applicant claims the assets were not transferred to become Medicaid eligible
  • documents such as deeds or wills if real property was transferred

 

IMA will notify the applicant of a decision regarding a hardship waiver. A denial of a hardship waiver may be appealed at the Office of Administrative Hearings.

 

See also AZ: Elderly and Physically Disabled Home-And-Community-Based Services Waiver in Section 1.28: Transfer of Assets in Part VI.

 

Impoverished Spouse: Once initial Community Medicaid eligibility has been established, assets that were not used to determine the eligibility of the institutionalized spouse (i.e., the Protected Spousal Amount) must be legally transferred to the community spouse. In order for an institutionalized spouse to maintain eligibility, assets cannot be attributed to the community spouse but must actually be made available (i.e., transferred to the community spouse's name) to meet his/her needs in the community. This transfer must be completed by the first annual recertification following the initial LTC determination that considered the assets. Any assets that are not transferred by the first annual recertification must be counted to determine the eligibility of the institutionalized spouse until they are actually transferred to the community spouse.

When the institutionalized spouse acquires additional assets after the Protected Spousal Amount (see Section 2.3.3a: Protected Spousal Amount in this Chapter) has been calculated and initial Community Medicaid eligibility has been established, the additional assets are excluded and do not affect continuing eligibility when either of the following conditions exists:

  • The new assets combined with the other assets the institutionalized spouse intends to retain do not exceed the asset limit for one person, or
  • The institutionalized spouse intends to transfer the new assets to the community spouse who has assets below the Spousal Share allowance (see Section 2.3.3b: Spousal Share in this Chapter).

To exclude the additional assets, the institutionalized spouse 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) must promptly report the receipt of the new assets and must provide the SSR with a written statement that s/he intends to transfer the new assets to the community spouse immediately.

 

Example

Two months after Mr. Ross is determined to be eligible for Community Medicaid, he inherits $4,000 from a deceased sibling. He promptly reports his inheritance and provides the worker with a written statement that he intends to transfer $2,000 of the $4,000 to Mrs. Ross.

 

When the $2,000 of the inheritance is added to the Protected Spousal Allowance amount of $9,000, the community spouse's assets now total $11,000, which is less than the Community Spouse Assets Allowance. Mr. Ross continues to be eligible for Community Medicaid because his assets ($2,000) are below the asset limit for one person.

 

 

 

 

 

 

 

 

 

 

 

Annuities

 

For the purpose of this chapter, the purchase of an annuity by an institutionalized or community spouse will be treated as a transfer of assets for less than fair market value unless:

·         The District of Columbia is named as the remainder beneficiary in the first position for at least the total amount of medical assistance paid on behalf of the annuitant; or

·         The District of Columbia is named as a remainder beneficiary in the second position after the community spouse or a disabled child and is named in the first position if the community spouse or the disabled child or the disabled child’s representative disposes of any remainder for less than fair market value.

 

The purchase of an annuity by or on behalf of an applicant for LTC will be considered a transfer of assets for less than fair market value unless:

·         The annuity meets the Internal Revenue requirements of a 408(b) or (q) Individual Retirement Plan (IRA) under a qualified employer plan; or

·         The annuity is purchased with the proceeds from;

o     a 408(a) or (c) or (p) retirement account,

o     a 408(k) simplified employee pension, or

o     a 408A Roth IRA, or

·         The annuity is:

o     irrevocable,

o     nonassignable,

o     is actuarily sound,

o     and provides for payments in equal amounts during the term of the annuity with no deferral or balloon payments made.

 

 

 

 
 
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