(A)
Request for an Adjustment to the Community Spouse's Asset
Allowance. After the institutionalized spouse has applied for
MassHealth Standard and has received a notice of approval or denial for
MassHealth Standard, either spouse may appeal to the Office of Medicaid Board
of Hearings to request an adjustment to the asset allowance. The purpose of the
adjustment is to generate sufficient income, as determined by the MassHealth
agency, for the community spouse to remain in the community.
(B)
Minimum-monthly-maintenance-needs Allowance. The
minimum-monthly-maintenance- needs allowance is the amount needed by the
community spouse to remain in the community. This amount is based on a
calculation that includes the community spouse's shelter and utility costs in
addition to certain federal standards, in accordance with
130 CMR
520.026(B)(1).
(C)
Adjustment of the Amount of
Asset Allowance. If either spouse claims at a fair hearing that
the amount of income generated by the community spouse's asset allowance as
determined by the MassHealth agency is inadequate to raise the community
spouse's income to the minimum- monthly-maintenance-needs allowance, the
fair-hearing officer determines the gross income available to the community
spouse as follows
(1) The fair-hearing officer
determines the gross amount of income available to the community spouse. The
fair-hearing officer includes the amount of the income that would be generated
by the spouse's asset allowance if $10,000 of the asset allowance were
generating income at an interest rate equal to the deposit yield quoted in the
Bank Rate Monitor Index as of the hearing date for money market accounts, and
if the remainder of the spouse's asset allowance were generating income at an
interest rate equal to the highest deposit yield quoted in the Bank Rate
Monitor Index as of the hearing date for any term not to exceed 21/2
years.
(2) If the community
spouse's gross income under 130 CMR 520.017(C)(1) is less than the
minimum-monthly-maintenance-needs allowance (MMMNA), then the fair-hearing
officer allows an amount of income from the institutionalized spouse (after the
personal-needs deduction described in
130 CMR
520.026(A) ) that would
increase the community spouse's total income to equal, but not to exceed, the
MMMNA. 130 CMR 520.017(C)(2) applies to all hearings held on or after September
1, 2003, regardless of the date of application.
(3) If after the fair-hearing officer has
increased the community spouse's gross income under 130 CMR 520.017(C)(1) and
(2), the community spouse's gross income is still less than the MMMNA, then the
fair-hearing officer increases the community spouse's asset allowance by the
amount of additional assets that, if generating income at an interest rate
equal to the highest deposit yield in the Bank Rate Monitor Index as of the
hearing date for any term not to exceed 21/2 years, would generate sufficient
income to raise the income total to the MMMNA.
(D)
Adjustment to the
Minimum-monthly-maintenance-needs Allowance Due to Exceptional
Circumstances. After the institutionalized spouse has received
notice of either approval or denial for MassHealth Standard, either spouse may
appeal to the Office of Medicaid Board of Hearings the calculation of income
available to the community spouse and request an increase in the MMMNA, based
on exceptional circumstances, as defined in 130 CMR 520.017(D)(1).
(1)
Exceptional
Circumstances. Exceptional circumstances exist when there are
circumstances other than those already taken into account in establishing the
maintenance standards for the community spouse under
130 CMR
520.026(B) and these
circumstances result in significant financial duress. Since the federal
standards used in calculating the MMMNA cover such necessities as food,
shelter, clothing, and utilities, exceptional circumstances are limited to
those necessities that arise from the medical condition, frailty, or similar
special needs of the community spouse. Such necessities include, but are not
limited to, special remedial and support services and extraordinary uncovered
medical expenses. Such expenses generally do not include car payments, even if
the car is used for transportation to medical appointments, or home-maintenance
expenses such as security systems and lawn care.
(a) In determining an increased MMMNA, the
fair-hearing officer ensures that no expense (for example, for food or
utilities) is counted more than once in the calculation.
(b) If the community spouse lives in an
assisted-living facility or similar facility and requests an increase in his or
her minimum-monthly-maintenance-needs allowance, the fair-hearing officer
reviews the housing agreement, service plan, fee schedule, and other pertinent
documents to determine whether exceptional circumstances exist. Additional
amounts are allowed only for specific expenses necessitated by exceptional
circumstances of the community spouse and not for maintaining any pre-set
standard of living.
(2)
Determination of Increase for Exceptional
Circumstances. If the fair-hearing officer determines that
exceptional circumstances exist, the fair-hearing officer may increase the
community spouse's MMMNA to meet the expenses caused by the exceptional
circumstances as follows.
(a) The fair-hearing
officer verifies that the calculation of the gross income of the community
spouse in determining the existing spousal-maintenance-needs deduction includes
the income generated by the community spouse's asset allowance. If the
community spouse has no assets remaining from the allowance, he or she must
verify the dollar amount of the remaining assets, if any, and how the money was
spent. The fair-hearing officer considers how the assets were spent in
determining whether or not significant financial duress exists.
(b) The fair-hearing officer determines the
revised MMMNA by including in the calculation the amount needed to meet the
exceptional circumstances.
(c) The
fair-hearing officer compares the revised MMMNA to the community spouse's total
income. If the community spouse's total income is less than the amount of the
revised MMMNA, the fair-hearing officer first deducts the personal-needs
allowance from the institutionalized spouse's countable-income amount and then
a spousal- maintenance-needs deduction needed to reach the revised
MMMNA.
