Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 332 - MAINECARE ELIGIBILITY MANUAL
Part 14 - INDIVIDUALS IN MEDICAL INSTITUTIONS
Section 144-332-14-1 - INSTITUTIONALIZED

Universal Citation: 10 ME Code Rules ยง 144-332-14-1

Current through 2024-38, September 18, 2024

Institutionalization: A person is considered institutionalized when he/she resides in a hospital or nursing facility and is expected to remain for thirty consecutive days.A hospital is one that is primarily for the care and treatment of patients with disorders other than tuberculosis or mental disease.

Individuals who die prior to the end of the thirty day period are considered to be institutionalized.

Special income and asset rules are triggered for the person who is institutionalized. These special rules are effective on the first day of the month in which the thirty days of institutionalization starts.

Example

The individual enters a hospital or nursing facility on March 20th and remains for at least thirty consecutive days. Special income and asset rules are effective March 1st.

Section 1.1: Special income and asset limits

The special income and asset limits for institutionalization are as follows:

I. Residing in a Hospital
A. Gross income of the individual must be equal to or less than the Categorically Needy Income Limit in Chart 4.1. If the individual's gross income exceeds the Categorically Needy Income Limit in Chart 4.1, eligibility is determined using Medically Needy rules. See Part 7.

B. Countable assets of the individual must be under $2,000. If there is a community spouse, the Community Spouse Share of Assets is determined as defined in Section 4.3 of this Part.

C. The cost of care for the individual starts in the first full calendar month residing in a hospital. If there is a community spouse, a Community Spouse Monthly Income Allowance and Income Allocation is determined, as defined in this Part.

II. Residing in a Nursing Facility or skilled section of a hospital
A. Gross income of the individual must be less than the private rate for a semi-private room in the facility where the individual resides. If the income of the individual is over the Categorically Needy Income Limit in Chart 4.1 but under the private rate for the facility, a deductible must be met (See Section 5 of this Part).

B. Countable assets of the individual must be under $2,000. If there is a community spouse, the Community Spouse Share of Assets is determined as defined in Section 4.3 of this Part.

C. The cost of care for the individual starts in the first full calendar month they reside in a nursing facility or skilled level of care. Cost of care is determined as defined in this Part.

If there is a community spouse, a Community Spouse Monthly Income Allowance and Income Allocation is determined, as defined in Section 6.1.1 of this Part.

D. If the gross income of the individual exceeds the private rate for a semi-private room in the facility where the individual resides:
1. the individual may be eligible under Medically Needy, but no nursing care costs are covered;

2. a Community Spouse Asset Allocation is given (See Section 4.3 of this Part); and

3. no cost of care is determined and as a result no Community Spouse Monthly Income Allowance is given.

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