Current through September 17, 2024
003.01
MEDICALLY NEEDY NOT RECEIVING LONG-TERM CARE SERVICES AND
SUPPORTS. Medically needy individuals who are not residing in a
medical institution or who do not receive Home and Community-Based Services
(HCBS) have a share of cost (SOC) calculated according to the factors below.
When countable income is reduced to at or below the appropriate Medically Needy
Income Limit (MNIL), the individual is eligible to receive Medicaid.
003.01(A)
MEDICAL
EXPENSES. The individual must obligate payment for medical and
remedial care expenses incurred by the individual or another person in the
individual's financial unit. This may include medical costs not covered by
Medicaid or medical premiums paid by the members of the unit. See 477-000-045
for the process by which these expenses are counted and recorded. Expenses are
used to meet the share of cost (SOC) obligation in the order in which the
expenses are received.
003.01(B)
EFFECTIVE DATE. The individual is eligible for
Medicaid on the first day of the month in which the share of cost (SOC)
obligation is met, and remains eligible for the entire month.
003.01(C)
COSTS NOT
COVERED. Medical and remedial care costs used to meet the share of
cost (SOC) obligation will not be covered by Medicaid.
003.02
MEDICALLY NEEDY WHO
RECEIVE HOME AND COMMUNITY-BASED SERVICES. A medical need is
established for a medically needy individual using a hypothetical amount of
services in order to begin receiving Home and Community-Based Services. The
share of cost (SOC) for medically needy individuals who receive Home and
Community-Based Services is calculated according to the provisions below.
003.02(A)
INCOME
USED. The gross income is used to determine the share of cost for
medically needy individuals. Income which is excluded or disregarded in
determining eligibility is used to calculate the share of cost (SOC).
003.02(B)
DEDUCTIONS. The following deductions are made to
determine the share of cost (SOC) owed to the Home and Community-Based Services
(HCBS) provider:
(i) The appropriate personal
needs allowance is deducted from an individual's income. The personal needs
allowance will vary according to the living arrangement in which the individual
resides and the type of waiver used to provide the Home and Community-Based
Services (HCBS);
(ii) The expense
of a guardian or conservator of up to ten dollars ($10) per month, or as
ordered by a court, is allowed as a deduction; and
(iii) Expenses for medical services not
provided by the Home and Community-Based Services (HCBS) provider which are
incurred by the individual may be deducted from the share of cost (SOC) owed to
the provider. This may include medical expenses not covered by Medicaid or
medical premiums paid by the individual.
003.02(C)
EFFECTIVE
DATE. These budgeting regulations are effective the first full
month that an individual is both eligible as medically needy and receiving Home
and Community-Based Services.
003.02(D)
COSTS NOT
COVERED. Medical and remedial care costs used to meet the share of
cost (SOC) obligation will not be covered by Medicaid.
003.03
MEDICALLY NEEDY RESIDING
IN MEDICAL INSTITUTIONS. A medically needy individual who resides
in a medical institution may establish a medical need using a reasonable
projection of institutional expenses. The share of cost (SOC) for a medically
needy individual who resides in a medical institution is calculated according
to the provisions below.
003.03(A)
INCOME USED. The gross income is used to determine the
share of cost (SOC) for medically needy individuals. Income that is excluded or
disregarded in determining eligibility is used to calculate the share of cost
(SOC).
003.03(B)
DEDUCTIONS. The following deductions are made in
determining the share of cost (SOC) due to the provider of institutional
services:
(i) A personal needs allowance
appropriate to the type of facility in which the individual resides is deducted
from income;
(ii) The expense of a
guardian or conservator of up to ten dollars ($10) per month, or as ordered by
a court, is an allowable deduction;
(iii) An allowance for the cost of mortgage,
rent, utilities, real estate taxes, or homeowner's insurance may be allowed for
up to six months if it is possible that the individual will return home. This
amount may not exceed the maximum shelter amount for a single individual listed
in 477-000-012; and
(iv) Medical
expenses not provided by the institutional service provider are deducted from
the share of cost (SOC) amount owed to the provider. This may include expenses
not covered by Medicaid or medical insurance premiums.
003.03(C)
EFFECTIVE
DATE. This budget procedure is used the first full month that a
budget for a medical institution is used for the individual.
003.03(D)
COSTS NOT
COVERED. Medical and remedial care costs used to meet the share of
cost obligation will not be covered by Medicaid.
