Florida Administrative Code
65 - DEPARTMENT OF CHILDREN AND FAMILIES
65A - Economic Self-Sufficiency Program
Chapter 65A-1 - PUBLIC ASSISTANCE PROGRAMS
Section 65A-1.7141 - SSI-Related Medicaid Post Eligibility Treatment of Income
Universal Citation: FL Admin Code R 65A-1.7141
Current through Reg. 50, No. 187; September 24, 2024
After an individual is determined eligible for Hospice, Institutional Care Program (ICP), Program of All-Inclusive Care for the Elderly (PACE), Individual Budgeting (iBudget), or Statewide Medicaid Managed Care Long-Term Care (SMMC-LTC) Program, the Department determines the individual's patient responsibility. "Patient responsibility" is the amount the Agency for Health Care Administration (AHCA) must reduce its payments to a medical institution and intermediate care facility or payments for home and community based services provided to an individual towards their cost of care. Patient responsibility is based on the amount of income remaining after the following deductions are applied pursuant to 42 CFR § 435.725 and 42 CFR § 435.726. This process is called "post eligibility treatment of income."
(1) For institutional care services and Hospice, the following deductions are applied to the individual's income to determine patient responsibility in the following order:
(a) A Personal Needs
Allowance (PNA) of $130. Individuals residing in medical institutions and
intermediate care facilities shall have $130 of their monthly income protected
for their personal need allowance.
(b) A PNA for individuals residing in the
community. Individuals electing hospice services shall have an amount equal to
the federal poverty level (FPL) protected as their personal needs
allowance.
(c) An additional PNA
for therapeutic wages. If the institutionalized individual earns therapeutic
wages, an additional deduction from income equal to one-half of the monthly
therapeutic wages, up to a maximum of $111, shall be applied and treated as an
additional PNA protected for personal need.
(d) An additional PNA for court ordered child
support. If the institutionalized individual is court ordered to pay child
support an additional PNA is deducted in an amount equal to the court ordered
support paid by the individual to meet their court ordered obligation. The
additional PNA is applied only if a court ordered deduction was not made under
another provision under the post eligibility process.
(e) The community spouse income allowance.
The Department applies the formula and policies under §1924 of the
Social-Security Act, and Rule
65A-1.716, F.A.C., to compute
the community spouse income allowance after the institutionalized spouse is
determined eligible for institutional care benefits.
(f) The community spouse's excess shelter and
utility expenses. The amount by which the sum of the spouse's expenses for rent
or mortgage payment (including principal and interest), taxes and insurance
and, in the case of a homeowner's association, condominium or cooperative,
required maintenance charge, for the community spouse's principal residence and
utility expense exceeds thirty percent of the amount of the Minimum Monthly
Maintenance Needs Allowance (MMMNA) is allowed. The utility expense is based on
the current Food Assistance Program's standard utility allowance as referenced
in subsection 65A-1.603(2),
F.A.C.
(g) For community hospice,
spousal allowance. This allowance is equal to the Supplemental Security Income
(SSI) Federal Benefit Rate (FBR), minus the spouse's monthly income. A portion
of the individual's income equal to 100% of the Federal Poverty Level (FPL),
minus the spouse and dependent's income, if the individual has a spouse and
dependent child in the community. (For FPL criteria, refer to subsection
65A-1.716(1),
F.A.C.)
(h) For ICP or
institutional Hospice, income is protected for the month of admission and
discharge, if the individual's income for that month is obligated to directly
pay for their cost of food or shelter outside of the facility.
(i) Uncovered medical expense deduction. The
following policy will be applied in considering medical deductions for
institutionalized individuals and individuals receiving HCBS services to
calculate the amount allowed for the uncovered medical expense deduction:
1. For institutionalized persons or residents
of medical institutions and intermediate care facilities, the deduction
includes:
a. Any premium, deductible, or
coinsurance charges or payments for health insurance coverage.
b. For other incurred medical expenses, the
expense must be for a medical or remedial care service and be medically
necessary as specified in the Florida Medicaid Definitions Policy, incorporated
by reference in subsection
59G-1.010(2),
F.A.C., and be recognized in state law. For medically necessary care, services
and items not paid for under the Medicaid State Plan, the actual billed amount
will be the amount of the deduction, not to exceed the maximum payment or fee
recognized by Medicare, commercial payors, or any other third party payor, for
the same or similar item, care, or service.
2. The expense must have been incurred no
earlier than the three month period preceding the month of application
providing eligibility.
3. The
expense must not have been paid for under the Medicaid State Plan.
4. Other health insurance policies, including
long term care insurance, are considered to be the first payor for medical
items, care, or services covered by such policies and the remaining items can
be used as an uncovered medical expense deduction. Therefore, to be deducted
from the individual's income, the individual must demonstrate that other
insurance does not cover such medical items, care, or services.
5. The medical and remedial care expenses
that were incurred as the result of imposition of a transfer of asset penalty
is limited to zero.
(2) For the Program of All-Inclusive Care for the Elderly (PACE), the following deductions are applied to the individual's income to determine patient responsibility:
(a) A deduction is made for the PNA based on
the individual's living arrangement as follows:
1. For an individual residing in the
community, not in an assisted living facility (ALF), the PNA is equal to 300%
of the FBR.
2. For an individual
who is residing in an ALF, the PNA is computed using the ALF basic monthly rate
(for three meals per day and a semi-private room), plus 20% of the
FPL.
3. For an individual residing
in a nursing home, the PNA is $130.
(b) A deduction is allowed when there is a
spouse residing in the community for HCBS and ICP services.
1. For HCBS, a spousal deduction equal to the
SSI standard FBR minus the spouse's monthly income is allowed.
2. The Department will apply the formula and
policies § 1924 of the Social-Security Act, and rule
65A-1.716, F.A.C., to compute
the community spouse income allowance after the institutionalized spouse is
determined eligible for institutional care benefits.
(c) A deduction for incurred medical or
remedial care expenses not subject to payment by a third party, and subject to
the following reasonable limits:
1. The
service or item claimed as a deduction from the individual's income must be a
medical or remedial care service, be medically necessary as specified in the
Florida Medicaid Definitions Policy, incorporated by reference in subsection
59G-1.010(2),
F.A.C., be recognized in state law, have been incurred no earlier than the
three months preceding the month of application providing eligibility, and have
not been paid for under the Medicaid State Plan.
2. For medically necessary care, services and
items not paid for under the Medicaid State Plan, the actual billed amount will
be used as the deduction not to exceed the maximum payment or fee recognized by
Medicare, commercial payers or any other third party payer for the same or
similar item, care, or service.
3.
Other resident health insurance policies will be treated as first payor and the
beneficiary will have to demonstrate that the other insurance has not or will
not cover the expense.
4. The
medical or remedial care expenses that were incurred as the result of
imposition of a transfer of assets penalty is limited to
zero.
(d) If the
institutionalized individual is court ordered to pay child support an
additional PNA is deducted in an amount equal to the court ordered support paid
by the individual to meet their court ordered obligation. Funds are protected
only to the extent that the income was not already deducted under another
provision in the post eligibility process.
(3) For the iBudget Florida waiver, the following deductions are applied to the individual's income to determine patient responsibility in accordance with 42 CFR § 435.726:
(a)
A deduction is made for PNA in an amount that is equal to 300% of the
FBR.
(b) A spousal deduction equal
to the SSI standard FBR minus the spouse's monthly income is allowed when the
spouse is residing in the community.
(c) A deduction for the family at the
Temporary Cash Assistance CNS.
(d)
A deduction for incurred medical or remedial care expenses not subject to
payment by a third party, and subject to the following reasonable limits:
1. The service or item claimed as a deduction
from the individual's income must not be a medical or remedial care service, be
medically necessary as specified in the Florida Medicaid Definitions Policy,
incorporated by reference in subsection
59G-1.010(2),
F.A.C., be recognized in state law, have been incurred no earlier than the
three months preceding the month of application providing eligibility, and have
not been paid for under the Medicaid State Plan.
2. For medically necessary care, services and
items not paid for under the Medicaid State Plan, the actual billed amount will
be used as the deduction not to exceed the maximum payment or fee recognized by
Medicare, commercial payers or any other third party payer for the same or
similar item, care, or service.
3.
Other resident health insurance policies will be treated as first payor and the
beneficiary will have to demonstrate that the other insurance has not or will
not cover the expense.
4. The
medical or remedial care expenses that were incurred as the result of
imposition of a transfer of assets penalty is limited to
zero.
(4) For the Statewide Medicaid Managed Care Long-Term Care Program, the following deductions are applied to the individual's income to determine patient responsibility in accordance with 42 CFR § 435.726:
(a) A deduction is made for the PNA based on
the individual's living arrangement as follows:
1. For an individual residing in the
community, not in an ALF, the PNA is equal to 300% of the FBR.
2. For an individual who is residing in an
ALF, the PNA is computed using the ALF basic monthly rate (for three meals per
day and a semi-private room), plus 20% of the FPL.
(b) A deduction is allowed when there is a
spouse residing in the community for HCBS and ICP services.
1. The Department will apply spousal
impoverishment policy according to Section 1924 of the Social Security Act,
Treatment of Income and Resources for Certain Institutionalized Spouses, as
amended by Section 2404 of the Patient Protection and Affordable Care
Act.
2. The Department will apply
the formula and policies under §1924 of the Social Security Act, and rule
65A-1.716, F.A.C., to compute
the community spouse income allowance after the institutionalized spouse is
determined eligible for institutional care benefits.
(c) A deduction for incurred medical or
remedial care expenses not subject to payment by a third party, and subject to
the following reasonable limits:
1. The
service or item claimed as a deduction from the individual's income must be a
medical or remedial care service, be medically necessary as specified in the
Florida Medicaid Definitions Policy, incorporated by reference in subsection
59G-1.010(2),
F.A.C., be recognized in state law, have been incurred no earlier than the
three months preceding the month of application providing eligibility, and have
not been paid for under the Medicaid State Plan.
2. For medically necessary care, services and
items not paid for under the Medicaid State Plan, the actual billed amount will
be used as the deduction not to exceed the maximum payment or fee recognized by
Medicare, commercial payers or any other third party payer for the same or
similar item, care, or service.
3.
Other resident health insurance policies will be treated as first payor and the
beneficiary will have to demonstrate that the other insurance has not or will
not cover the expense.
4. The
medical or remedial care expenses that were incurred as the result of
imposition of a transfer of assets penalty is limited to
zero.
Rulemaking Authority 409.919, 409.961 FS. Law Implemented 409.902, 409.903, 409.904, 409.906, 409.919, 409.961 FS.
New 5-29-05, 8-12-15, Amended 9-30-18.
Disclaimer: These regulations may not be the most recent version. Florida may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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