IMA POLICY MANUAL
PART VII: SPECIAL MA PROCESSING
CHAPTER 2: LONG-TERM CARE/IMPOVERISHED SPOUSE
PATIENT PAY AMOUNT (PPA) 2.14
After the assistance unit has been determined eligible for MA or eligible but over-income for MA, the LTC SSR must determine LTC payability by calculating the monthly amount the assistance unit must pay to the LTC facility toward the cost of care. This monthly amount is called the PPA. The PPA is determined by deducting the applicable LTC Income Allowances (see Section 2.6: LTC Income Allowances in this Chapter) from the total countable income of the assistance unit (see Section 2.15: Determining Total Countable Income for PPA Calculation in this Chapter).
The PPA is prorated for any month the individual enters the facility later than the first day of the month or leaves earlier than the last day of the month. When prorating the PPA, include the day admission occurred, but do not include the day discharge occurred.
If the assistance unit consists of a married couple residing in or entering the same facility, calculate two separate PPAs, one for the wife and one for the husband.
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) is responsible for submitting the PPA directly to the facility on a monthly basis. The Department pays the balance of the cost of care up to the established rate.
PPA and Spend-Downs 2.14.1
If the PPA is greater than the cost of care rate, eligibility for LTC coverage is conditionally denied as over-income until a six-month prospective spend-down liability is met. The conditionally-denied individual becomes a private-pay patient until s/he meets the six-month prospective spend-down liability. The liability is the sum of the PPAs for each of the six months in the prospective budget period.
To meet the prospective spend-down liability, the assistance unit must submit incurred allowable medical expenses (see Section 7.4: Allowable Medical Expenses in Part VI). Payments the individual makes to the LTC facility at the 'private pay' rate are countable medical expenses for purposes of meeting the spend-down liability.
When total submitted medical expenses equal or exceed the spend-down liability, eligibility is established. The assistance unit is certified for the balance of the prospective budget period with a PPA of zero. The Department pays the remainder of the cost of care through the sixth month of the budget period. At recertification, eligibility is conditionally terminated until the subsequent six-month prospective spend-down liability is met.
Determination Total Countable Income For PPA Calculation 2.15
The LTC SSR should consult the policies for SR (unless the LTC resident is under 21 and is MA-eligible under AR or AX; in this case, consult the policies for AR or AX) in Chapters 4-6 and 8 in Part VI to determine total countable income. In addition, if the individual in LTC has an MA-eligible spouse who is also residing in a LTC facility, each spouse is considered to be financially responsible for the other for the month of their physical separation.
Impoverished Spouse: No income from the community spouse should be deemed to the institutionalized spouse for any month in which s/he is institutionalized (see Section 2.5: MA Income Eligibility Determination and Section 2.12: Treatment of Assets After MA Eligibility Determination in this Chapter).
Apply the following rules to determine income for the purposes of the PPA calculation for institutionalized spouses who have a community spouse and who were institutionalized after September 30, 1989:
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Determine the individual's total countable income following SR policies (unless the individual is under 21 and is MA-eligible under AR or AX; then follow AR or AX policies), and
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Deduct the applicable LTC Income Allowances (see Section 2.6: LTC Income Allowances in this Chapter) from the individual's total income.
Treatment of Income from Non-Trust Property 2.15.1
Impoverished Spouse: When determining the income of an institutionalized or community spouse for purposes of the PPA calculation and post-eligibility income determination, use the following policies, regardless of any District laws relating to community property or the division of marital property, to determine ownership in non-trust property unless otherwise specified as a part of the non-trust property and unless the institutionalized spouse establishes through the fair hearings process (see Chapter 7: Grievances and Fair Hearings in Part VIII) that ownership interest is other than that prescribed below:
- If payment of income is made solely in the name of the institutionalized spouse or the community spouse, the income shall be considered available only to that respective spouse.
- If payment of income is made in the names of the institutionalized spouse and the community spouse, one-half of the income shall be considered available to each of them.
- If payment of income is made in the names of the institutionalized spouse or the community spouse, or both, and to another person or persons, the income shall be considered available to each spouse in proportion to the spouse's interest.
If there is no instrument establishing ownership, one-half of the income shall be considered available to the institutionalized spouse and one-half shall be considered available to the community spouse.
Treatment of Income from Trust Property 2.15.2
Impoverished Spouse: When determining the income of an institutionalized or community spouse for purposes of the PPA calculation and post-eligibility income determination, use the following policies, regardless of any District laws relating to community property or the division of marital property, to determine ownership in trust property unless otherwise provided in the trust and unless the institutionalized spouse establishes through the fair hearings process that ownership interest is other than that prescribed below (see Chapter 7: Grievances and Fair Hearings in Part VIII):
- If payment of income is made solely in the name of the institutionalized spouse or the community spouse, the income shall be considered available only to that respective spouse.
- If payment of income is made in the names of the institutionalized spouse and the community spouse, one-half of the income shall be considered available to each of them.
- If payment of income is made in the names of the institutionalized spouse or the community spouse, or both, and to another person or persons, the income shall be considered available to each spouse in proportion to the spouse's interest.
Adjustment of Spend-Down Liability 2.16
If the individual who is entering a LTC facility is already eligible for MA as a community-assistance unit and has a spend-down liability, the spend-down liability must be adjusted. The spend-down liability must be prorated to reflect only the months in the budget period prior to the date of admission to the LTC facility.
| Mr. Franco is eligible for MA and has a $600 spend-down liability. His monthly spend-down liability is $100. Unexpectedly, he enters a LTC facility in the third month of his budget period. Since he is residing in the LTC facility for the last three months of his budget period, his spend-down liability should be prorated to $300 ($100*3). |
If the individual has already met the original spend-down liability, adjust the eligibility dates and the payments made by the LTC resident and the Department to the community medical providers.
Pursuant to the Medicaid State Plan, the Medical Assistance Administration will continue payment to the facility for up to 18 therapeutic days per 12-month period. Absences of less than 24 hours are not counted toward the total number of therapeutic days. The 12-month period is defined as the District's fiscal year, October 1 through September 30.
Therapeutic leaves include visits with relatives and friends as well as leaves to participate in District-approved therapeutic and rehabilitive programs.
Notification Requirements 2.18
All policies governing notifications apply to assistance units receiving LTC coverage. In addition, notify the assistance unit, any responsible party, and the LTC facility in writing of the effective date of the LTC coverage by sending the Notice of the Patient Pay Amount which must state:
- the monthly amounts of each source of countable income,
- the applicable LTC Income Allowances (see Section 2.6: LTC Income Allowances in this Chapter),
- the prorated PPA for the month of admission which should include the day of admission (see Section 2.14: Patient Pay Amount (PPA) in this Chapter), and
- the ongoing PPA, including the PNA.
Complete a revised Notice of the Patient Pay Amount when changes occur in the individual's income, LTC Income Allowances, or other eligibility factors. If the individual is discharged from the facility, complete a revised Notice of the Patient Pay Amount showing the prorated PPA for the month of discharge. When prorating the PPA for the month of discharge, do not include the day of discharge or death.
Community Based LTC Waiver 2.19
The District was awarded a waiver that allows the Medicaid program to pay for community-based care services in lieu of placing an individual in a LTC facility. This program is alternatively known as the “Elderly and Physically Disabled Home- and Community-Based Waiver.” Please see Section 3.4: Elderly and Physically Disabled Home- and Community-Based Waiver in Chapter 3 in this Part for more information.
Generally, to be eligible for these services, the individual:
- Must have income below 300 percent of the SSI payment level.
- Have assets below the Medicaid categorically needy resource level.
- Would be eligible for Medicaid if placed in an institution.
- Must require a level of care provided in LTC facilities.
- Could be served in a more cost-effective manner with community-based services.
The waiver limits the number of individuals who can receive Medicaid-funded community-based services under this waiver. Customers may apply be calling (202) 535 2178 or (202) 442 5912.
