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:
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The Spousal Share, provided it does not exceed $104,400 for 2008 (see Section 2.9.2: Spousal Share in this Chapter)
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The Community Spouse Assets Allowance ($20,880 for 2008)
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An amount transferred under a court support order (court-ordered support)
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An amount designated by the OFH
| 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 $20,880. All of the couple's assets ($12,000) are protected for the community spouse because they are below the Community Spouse Assets Allowance of $20,880. Therefore, the Protected Spousal Amount is $12,000. |
Protected Spousal Amounts are revised:
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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)
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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.
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.
| 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.
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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.
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Example 2 |
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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.
| Mrs. Cox has been found to be eligible for MA and LTC coverage and is currently residing in a LTC facility. Her husband is living in the community. His sister dies, and he inherits a vehicle worth $12,000. Mrs. Cox's MA eligibility is not affected by this new vehicle. |
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
For applications and redetermination of MA, a period of restricted MA coverage is provided in the case of an otherwise eligible institutionalized individual if s/he or his/her spouse disposes of any countable assets for less than fair market value during or after the 36-month period immediately before:
- The date the individual becomes an institutionalized individual if s/he is eligible for MA on that date
- The date the individual applies for assistance while an institutionalized individual if s/he is not eligible for MA on the date of institutionalization and the uncompensated value 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 period of restricted coverage cannot exceed 30 months (less if a lesser period of restricted coverage results when the total uncompensated value is divided by the cost of care).
In determining periods of ineligibility, count only full months regardless of the date in a month the transfer actually occurs. The period of restricted coverage begins with the first day of the month in which the transfer is made.
| Mr. Barth makes a transfer on September 28. The period of restricted coverage begins September 1. |
If the calculation of a penalty results in a partial month at the end of the penalty period, round the days down to the end of the preceding month (i.e., if the penalty period ends November 12, round down to make October the last month in the period).
During the period of restricted coverage, the individual is eligible for all medical services except nursing facility services, equivalent care in a medical institution, and home and community-based services.
Impoverished Spouse: Once initial MA 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.
When the institutionalized spouse acquires additional assets after the Protected Spousal Amount (see Section 2.9.1: Protected Spousal Amount in this Chapter) has been calculated and initial 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.
- 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 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.
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Two months after Mr. Ross is determined to be eligible for 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 Medicaid because his assets ($2,000) are below the asset limit for one person. |
