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Effective: December 1, 2006 |
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17.05.05ar1 - Exceptions to MA/GAMC Household Size (Archive) |
Archived: October 1, 2009 |
In some situations the household size differs from standard policy. This may be because of a person’s living arrangement or the services he or she is receiving.
MA-EPD - Household Size Exceptions.
Medicare Savings Programs - Household Size Exceptions.
LTC - Household Size Exceptions.
Use a household size of one for people whose eligibility is based solely on their own income and assets. This includes:
l A child that does not live with a biological or adoptive parent.
n This is true even if the child lives with siblings.
n Do not count the non-relative caretaker in the household size.
n A parental fee may need to be assessed.
l TEFRA children.
n A parental fee may need to be assessed.
l Blind or disabled children ages 18 to 21 who live with their parents unless:
n The child is married. Count the spouse in the household size.
n The child has children of his/her own. Count the children in the household size.
n A parental fee may need to be assessed.
l Clients who are eligible for the listed waiver programs and who do not receive MA-EPD .
Note: Follow standard household size policy in determining household size for other family members. Include the waiver recipient accordingly.
n CAC .
n CADI.
n DD.
n TBI.
l Clients who are eligible for the Elderly Waiver (EW) and who do not receive MA-EPD.
Note: Follow standard household size policy for the spouse, if the spouse is not on EW themselves, and other household members for the month of entry, except do not include the EW client.
Example:
Nick and Jessica are married and apply for MA in June. Nick began receiving EW services in June.
Action:
Nick and Jessica have a household size of one for June, the month Nick began receiving EW services.
Nick’s 15 year old daughter, Ashley, moves into the house in August.
Action:
Nick remains a household of one while receiving EW services.
Jessica’s household size increases to two for the month of September. Ashley is Jessica’s step-daughter, and because Nick is in the home she is part of Jessica’s household size.
Follow standard household size policy for clients when an unmarried person or one spouse of a married couple is applying for or eligible for MA-EPD.
If both spouses are applying or eligible for MA-EPD:
l Do not count the spouse in the household size.
l Do count other people in the household as outlined in standard household size policy for each spouse.
l Use this household size even when the client is receiving services through one of the waiver programs.
Example:
Shannon and Matt, a married couple, apply for MA-EPD. Shannon is self-employed as an in-home day care provider with gross countable income of $625 per month. She receives RSDI of $800 per month based on disability. Matt has earned income of $3,000 per month and is certified disabled by SMRT.
Action:
MA-EPD eligibility and the premium amount are calculated separately for each spouse, using each spouse's income and a household size of one.
Shannon and Matt adopt a child.
Action:
Continue to determine their MA-EPD separately for Shannon and Matt. The household size for each of them would increase to two because the child is counted in both households, but the spouse is still not counted.
Example:
Amanda has earned income of $2,500 per month. She is certified disabled by SMRT. She has not received SSI for several years because of her income. She lives with her husband Dave, who is not disabled. Dave has earned income of $1,000 per month.
Action:
To determine MA-EPD eligibility and premium amount, use only Amanda's income of $2,500 and a household size of two.
Medicare Savings Programs - Household Size Exceptions
Elderly Waiver (EW) is the one exception to using standard household size policy for the Medicare Savings Programs (MSP).
When determining the household size for a Medicare Savings Program for a household where one member is receiving EW follow these rules for:
l The client who receives EW. Use a household size of one when determining Medicare Savings Programs.
l The client who is the spouse of an EW client or another person who would be included in the EW client’s household size if standard household size rules were followed. Follow standard household size policy except do not count the EW client in that person’s household size.
For all other people, follow standard household size policy in determining eligibility for Medicare Savings Programs, including people on other waiver programs.
Example:
Ralph lives with his wife Shirley. He receives MA through the CADI waiver.
Action:
Ralph is a household size of two, which includes him and Shirley, when determining eligibility for QMB, SLMB and QI.
Ralph turns 65 and his eligibility for MA is now through the Elderly Waiver.
Action:
Ralph is now a household size of one when determining his Medicare Savings eligibility.
Example:
Beulah, age 80, lives with her husband Henry, age 86, and receives EW. Henry is applying for health care including the Medicare Savings Programs to cover his Medicare premium and potentially his copayments.
Action:
Both Beulah and Henry are a household size of one for MA, and for the Medicare Savings Programs because Beulah is receiving EW.
The household size for a client in an LTCF or receiving EW services depends on:
l Whether or not there is a community spouse .
l When the client entered the facility or when they began receiving EW services.
Follow these rules when working with LTC and EW clients, and other household members:
l For an LTC client without a community spouse, use a household size of one for the month following the month of admission. Follow standard household size policy for the month of admission.
Note: If the client lives with a child under age 18 and enters LTC, follow standard household size policy for the month of entry. Do not count the LTC client in the household size for the month after the month of entry.
Example:
Louis lives with his son, Wynton (age 19). Louis is in a severe accident and enters an LTCF in March. Louis applies for retro coverage for himself and Wynton back to January.
Action:
Louis has a household size of two, which includes himself and his son, for the months of January, February and March. His household size changes to one for the month of April.
Wynton also has a household size of two for January, February and March. His household size changes to one for April due to his father’s placement in March.
l For an LTC client with a community spouse, use a household size of one beginning in the month the client enters an LTCF.
Note: Follow standard household size policy for the community spouse and other household members for the month of entry, except do not include the LTC client.
Example:
Penelope entered an LTCF in October. She lived with her husband and two minor children before she was admitted. Penelope and her family apply for coverage to begin in September.
Action:
Penelope, her husband and two children each have a household size of four for September as they are all counted in each other’s household size.
Penelope has a household size of one for October, the month she entered the LTCF, because she has a community spouse.
The husband and children each have a household size of three for October because Penelope is no longer considered part of their household.