*** The Health Care Programs Manual (HCPM) has been replaced by the Minnesota Health Care Programs Eligibility Policy Manual (EPM) as of June 1, 2016. Please refer to the EPM for current health care program policy information. ***
Effective: March 1, 2009 |
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23.10 - Determining Which Income Calculation to Use |
Archived: June 1, 2016 (Previous Version) |
There are two different income calculations used to determine what amount, if any, a person is obligated to contribute toward the cost of LTC services. Use either a community income calculation or a LTC income calculation as described in this section.
A person requesting LTC services is treated as a household of one regardless of which income calculation is used.
Exception: Use the standard MA household size for people who are concurrently enrolled in a disability waiver and MA-EPD.
Special Income Standard (SIS).
Use a community income calculation for people who:
l request home and community-based services through a disability waiver program (CAC, CADI, DD, and BI).
l request EW and have gross income above the Special Income Standard (SIS) but do not have a community spouse.
l are expected to reside in a long-term care facility (LTCF) for less than 30 consecutive days.
Follow the community income calculation instructions to determine the amount of income that a person must contribute toward the cost of LTC services. If the community income calculation results in an amount the person is obligated to pay toward the cost of care, the person has a medical spenddown. The person can use the cost of LTC services to meet the medical spenddown.
Example:
Gerry lives in the community with her husband Sam. She and Sam receive MA with a certification period from June through November. On August 10, a Long-Term Care Consultation (LTCC) and care plan are completed for Gerry. The case manager notifies the worker on August 15 that Gerry will begin receiving CADI services on September 1.
Action:
Redetermine eligibility for September for Gerry using a household size of one. Approve eligibility for September with adequate notice or with a 10-day notice if the change results in a negative action. Continue to use a household size of two for Sam.
Example:
Peter, a widowed client, is approved by a case manager to begin receiving EW on December 3. He applies for MA on December 12 and requests two months retroactive coverage. His income exceeds the SIS.
Action:
Use a community income calculation and determine a medical spenddown for all months beginning with October.
Example:
Margaret entered the hospital on June 11. She moved to a nursing facility on June 17 and is expected to stay there through July 3 when she will return to her son’s home. Margaret applies for MA on June 15.
Action:
Begin counting consecutive days from the day Margaret entered the hospital. Because Margaret will reside in an LTCF for less than 30 days, use a community income calculation and determine a medical spenddown for all months beginning with June.
Use a LTC income calculation for people who:
1. are expected to reside in a long-term care facility (LTCF) for at least 30 consecutive days.
Note: An MA enrollee who is absent from a LTCF on a leave day is still considered to be residing in a LTCF.
2. request EW and have income at or below the Special Income Standard (SIS). This group is referred to as SIS-EW.
3. request EW and have income above the Special Income Standard (SIS) and have a community spouse. This group is referred to as EW.
Note: A Group Residential Housing (GRH), assisted living, or a non-Medicaid facility, such as a Veteran’s Administration nursing home, is not an LTCF.
Follow the LTC income calculation instructions to determine when to begin or end the LTC calculation and apply allowable deductions to determine the amount of income that a person is obligated to contribute toward the cost of LTC services. The person has a LTC spenddown or a waiver obligation if the LTC income calculation results in an amount the person is obligated to contribute toward their cost of care.
Example:
Glenda enters a nursing facility in June. She applies for MA and requests eligibility to start the day she entered the facility. Glenda is single and expects to reside in the nursing facility for more than 180 days.
Action:
Since Glenda anticipates residing in the LTCF for more than 30 days, use a LTC income calculation and LTC spenddown for her eligibility in the LTCF beginning the month following the month that she entered the facility. Use a community budget for the month she entered the LTCF.
Example:
Theodore lives in his own home. His case manager determines he is eligible for EW beginning September 15. He applies for MA on September 20 and his income is below the SIS.
Action:
Use the LTC income calculation to determine Theodore’s eligibility and waiver obligation beginning October 1. October is the first full calendar month after his case manager determined he was eligible for EW. Use a community budget and a medical spenddown, if applicable, based on Theodore’s income for September.
Example:
Imelda and her husband Marcos live in senior housing and both currently receive MA with monthly medical spenddowns. A county case manager determines that Imelda is eligible for EW beginning June 1. The case manager notifies the worker on June 5 that EW has begun. Imelda’s RSDI and retirement income exceeds the SIS. She doesn’t want to allocate income to Marcos (her community spouse) because it will make his spenddown too high.
Action:
Redetermine Imelda’s eligibility based on the change. For June, change household size to one and use the LTC income calculation to determine Imelda’s eligibility. A 10-day notice is not required to change Imelda’s spenddown from a community spenddown to an LTC spenddown. Approve the LTC spenddown beginning June 1.
Redetermine Marcos’ eligibility beginning in June. Change household size to one and determine eligibility based solely on his income. Because his spenddown decreases with the change in household size and the end of deemed income from Imelda, approve eligibility with a reduced spenddown beginning June 1.
The SIS is equal to three times the Federal Benefit Rate (FBR). Compare the client's gross earned and unearned income, and net self-employment income to the SIS to determine if an EW client is at or below the SIS.
Do not include the following income:
l A spouse’s income.
l Income tax refunds.
l Property tax refunds, both homeowner’s and renter’s.
l Earned Income Credit (EIC).
l LTC Excluded Income.
A client with gross income at or below the SIS is referred to as SIS-EW eligible.
A client with gross income greater than the SIS is referred to as EW eligible.
The SIS is updated annually in January. See Special Income Standard (SIS) for exact figures.
Follow the LTC income calculation instructions to determine the amount of income a person must contribute toward the cost of LTC services.