Current through 2024-38, September 18, 2024
For all living arrangements, when determining eligibility
for Medicaid "countable income" is gross income minus exclusions (See Part 17)
and disregards (See Part 7, Section 2.1).
Section
4.1:
Adult Foster Homes (AFH)
Residents are considered to be individuals 'living with
others". If a married couple resides in the facility, at the option of the
couple, eligibility may be determined as a couple if either member of a couple
is not eligible when treated as an individual. The countable income of each
spouse is totaled. Each spouse is deemed to receive one-half of this total and
each is compared to 100% FPL.
I. If
countable income is under the income limit for SSI/State Supplement the
individual needs to apply for SSI/State Supplement in order to get help with
their costs for residing in the AFH. When eligible for SSI/State Supplement,
Medicaid coverage is also provided.
Note: Residents of "State Assisted" AFH are
potentially eligible for a $49.00 State Supplement. Residents of "Private AFH"
are potentially eligible for $10.00 State Supplement.
II. If countable income is equal to or over
the State Supplement income limit for this living arrangement the individual is
eligible for Medicaid if countable income is equal to or under 100%
FPL.
III. If countable income is
over 100% FPL the individual may be eligible for Medicaid under Medically Needy
(See Part 10).
IV. If countable
income is over 100% FPL and the individual is applying for a Home and Community
Based Waiver Program (See Part 13), Medicaid eligibility is determined using
the rules of that program.
Section
4.2:
Flat Rate Boarding Homes (FRBH)
Residents of FRBH are considered to be individuals "living
with others". If a married couple resides in the facility, at the option of the
couple, eligibility may be determined as a couple if either member of a couple
is not eligible when treated as an individual. The countable income of each
spouse is totaled. Each spouse is deemed to receive one-half of this total and
each is compared to 100% FPL.
I. If
countable income is under the income limit for SSI/State Supplement the
individual needs to apply for SSI/State Supplement in order to get help with
their costs for residing in the FRBH. When eligible for SSI/State Supplement,
Medicaid coverage is also provided.
II. If countable income is equal to or over
the State Supplement income limit for this living arrangement the individual is
eligible for Medicaid if countable income is equal to or under 100%
FPL.
III. If countable income is
over 100% FPL the individual may be eligible for Medicaid under Medically Needy
(See Part 10).
IV. If countable
income is over 100% FPL and the individual is applying for a Home and Community
Based Waiver Program, Medicaid eligibility is determined using the rules of
that program (See Part 13).
Section
4.3:
Cost Reimbursement Boarding Homes (CRBH), Residential
Care Facilities (RCF) and Adult Family Care Homes (AFCH)
Residents of these facilities are considered to be
individuals "living with others". If a married couple resides in the facility,
at the option of the couple, eligibility may be determined as a couple if
either member of a couple is not eligible when treated as an individual. The
countable income of each spouse is totaled. Each spouse is deemed to receive
one-half of this total and each is compared to the private rate for the CRBH
and RCF or the income limit in Chart 3.9 for AFCH.
I. If countable income is under the income
limit for SSI/State Supplement the individual needs to apply for SSI/State
Supplement in order to get help with the cost of their care. When eligible for
SSI/State Supplement, Medicaid coverage is also provided.
II. If countable income is equal to or over
the State Supplement income limit for this living arrangement, the individual
is eligible for coverage if countable income is equal to or under the
thirty-one day private rate for the CRBH and RCF, or the income limit in Chart
3.9 for the AFCH in which they reside.
III. If countable income is over the private
rate, the individual may become eligible if they meet a deductible (See Part 10
for the rules on Medically Needy).
Medical services provided by the facility are medical costs
incurred by the individual. They are used before other medical expenses to
determine if the individual meets the deductible. These medical services are
projected over a six month period. They are identified by the Office of
MaineCare Services and are assigned a daily rate (cost). The daily rate is
multiplied by thirty-one days to determine the monthly amount.
IV. If countable income is over
100% FPL and the individual is applying for a Home and Community Based Waiver
Program (See Part 13), Medicaid eligibility is determined using the rules of
that program. The rules in this section are used to determine the cost of care.
The cost of care is paid to the facility.
Section 4.3.1:
Determining the Cost of
Care for an Individual
I. A cost of
care or assessment is determined for all individuals. The cost of care is the
monthly amount the individual is expected to contribute toward the cost of
his/her care in the facility.
II.
The individual has a zero cost of care for the month they are admitted to the
facility. There is a cost of care for the month of discharge.
III.
Cost of Care for an
IndividualA.
Determine gross
monthly income. Total gross monthly income includes the State Supplement
benefit:
1. If the individual has elected an
option under his or her retirement plan that results in a reduced benefit to
the individual in exchange for a continued benefit to the spouse upon the
individual's death, (e.g. a joint and survivor annuity option), then that
reduce damount will be considered to be gross income. However, the reduced
amount may be used only if both the election is irreversible and the reduction
amount does not exceed $1,000 per month.
2. If income is garnished due to a court
order for child support the reduced amount of the income is used. The maximum
reduction allowed is up to and including $1,000 per month per child.
B. From total gross monthly
income, subtract:
1. Earned income disregard
(See Part 7, Section 2.1),
2.
Current federal, state or local income tax deductions,
An adjustment may be made if there are current federal,
state or local income tax deductions from the individual's gross income.
Usually the amount of taxes withheld will be based on the previous year's
income tax return. The adjustment for taxes cannot exceed the current tax
liability. A deduction for past due taxes is not allowed.
Examples
* Last year $600 was the tax liability. $80.00 per month is
withheld for income tax. Only $50.00 per month can be allowed as a deduction as
this is the current tax liability ($600 ÷ 12 = $50.00).
* Last year $600 was the tax liability. $25.00 per month is
being withheld for income tax. A deduction of $50.00 per month is allowed as a
deduction as this is the current tax liability ($600 ÷12 =
$50.00).
Note: If an individual is paying estimated
quarterly taxes, use these for an adjustment in the gross income. The procedure
is the same as if the taxes were being withheld.
3. $70 (personal needs and federal
disregard);
4. Medicare premium for
the individual;
5. HUD Standard
-The HUD Standard is a monthly subsidy given to a facility by the Department of
Housing and Urban Development on behalf of residents of the facility;
and
6. health insurance premiums
incurred by the individual for the individual and/or the individual's spouse if
the spouse is covered by Medicaid and is residing in a CRBH, RCF, Nursing
Facility or covered by a Home and Community Based Waiver,
Premiums must be incurred by the individual residing in the
specified facility. If the health insurance is provided by the individual's
spouse through his/her coverage, this is not considered to be a cost incurred
by the individual who resides in a facility. It is a cost incurred by the
individual's spouse.
Note: Indemnity insurance premiums are not
deducted. They are policies that pay for lengths of stay or for a condition and
not for specific services. Third Party Liability should be contacted to assess
cost effectiveness. If cost effective TPL will arrange for premium
payment.
C. The
result is the cost of care.
Note: If there is a partial month transfer of
asset penalty, the individual may be responsible for an amount in addition to
his or her cost of care (see Chapter 336 of this Manual).
Section 4.3.2:
Determining the Cost of Care for a Couple
I. Determine gross monthly income of the
couple. Total gross monthly income includes the State Supplement benefit.
A. If the individual has elected an option
under his or her retirement plan that results in a reduced benefit to the
individual in exchange for a continued benefit to the spouse upon the
individual's death, (e.g. a joint and survivor annuity option), then that
reduced amount will be considered to be gross income. However, the reduced
amount may be used only if both the election is irreversible and the reduction
amount does not exceed $1,000 per month.
B. If income is garnished due to a court
order for child support the reduced amount of the income is used. The maximum
reduction allowed is up to and including $1,000 per month per child.
II. From total gross monthly
income, subtract:
A. Earned income disregard
(Part 7, Section 2.1);
B. Current
federal, state or local income tax deductions;
An adjustment may be made if there are current federal,
state or local income tax deductions from the individual's gross income.
Usually the amount of taxes withheld will be based on the previous year's
income tax return. The adjustment for taxes cannot exceed the current tax
liability. A deduction for past due taxes is not allowed. tax return. The
adjustment for taxes cannot exceed the current tax liability. A deduction for
past due taxes is not allowed.
Examples
* Last year $600 was the tax liability. $80.00 per month is
withheld for income tax. Only $50.00 per month can be allowed as a deduction as
this is the current tax liability ($600÷12 = $50.00).
* Last year $600 was the tax liability. $25 per month is
being withheld for income tax. A deduction of $50 per month is allowed as a
deduction as this is the current tax liability ($600÷12 =
$50.00).
Note: If an individual is paying estimated
quarterly taxes, use these for an adjustment in the gross income. The procedure
is the same as if the taxes were being withheld.
B. $120 (personal needs and federal
disregard);
C. Medicare premium for
the individual;
D. HUD Standard -
The HUD Standard is a monthly subsidy given to a facility by the Department of
Housing and Urban Development on behalf of residents of the facility;
and
E. health insurance premiums
incurred by either or both spouses for either or both spouses.
Note: Indemnity insurance premiums are not
deducted. They are policies that pay for lengths of stay or for a condition and
not for specific services. Third Party Liability should be contacted to assess
cost effectiveness. If cost effective TPL will arrange for premium
payment.
III.
Divide the result by two. The result is the cost of care for each spouse.
Note: If there is a partial month transfer of
asset penalty, the individual may be responsible for an amount in addition to
his or her cost of care (see Chapter 336 of this Manual).
Section 4.3.3:
Determining
the Cost of Care for an Individual or Couple open on SSI
I. For an individual or a couple receiving
only an SSI benefit, the cost of care is the maximum SSI and State Supplement
benefit for an individual/couple (see Chart 3.6) minus the following
deductions:
1. Personal needs of $50.00 for an
individual/$100 for a couple;
2.
health insurance premiums incurred by the individual for the individual and/or
the individual's spouse if the spouse is covered by Medicaid and is residing in
a CRBH, RCF, Nursing Facility or covered by a Home and Community Based
Waiver
3. the HUD Standard - The
HUD Standard is a monthly subsidy given to a facility by the Department of
Housing and Urban Development on behalf of residents of the facility.
II. For an individual or a couple
open for an SSI benefit and receiving another income, the cost of care is
determined by deducting the following from gross monthly income:
1. Personal needs of $50.00 for an
individual/$100 for a couple;
2.
Federal Disregard of $20.00 for those with income in addition to SSI/State
Supplement as long as their income is not based on need (for example, VA
pension does not get this disregard, but VA compensation does);
3. health insurance premiums incurred by the
individual for the individual and/or the individual's spouse if the spouse is
covered by Medicaid and is residing in a CRBH, RCF, Nursing Facility or covered
by a Home and Community Based Waiver; and
4. the HUD Standard - The HUD Standard is a
monthly subsidy given to a facility by the Department of Housing and Urban
Development on behalf of residents of the facility.
Section 4.3.4:
Changes in
the cost of care are made in the following situations
I. The individual paid a cost of care that
was more than what was actually due. When this was due to Department error, the
individual cost of care is adjusted retroactively up to one year from the date
the error is discovered by the Department. When this was due to error by the
individual, no adjustment is made.
II. The individual paid a cost of care that
was less than what was actually due. Whether this is due to error by the
Department or the individual, the individual's cost of care is adjusted
retroactively up to three months from the date the error is discovered by the
Department without advance notice. This includes an adjustment for a lump sum
payment.
