004.01
EFFECTIVE
DATES. Spousal impoverishment Medicaid program (SIMP) budgeting
procedures begin the first month, including a partial month, in which an
eligible spouse enters an institutional living arrangement. The budgeting
procedures end the first full month that an institutionalized spouse ceases to
receive an institutional level of care or when the community spouse no longer
meets the definition of a community spouse, whichever occurs first.
004.02
ALLOCATION OF
INCOME . Only the income of the institutionalized spouse is used
to determine whether any cost sharing amount is due to the provider. The income
of a community spouse is not considered available to the institutionalized
spouse. Some of the income of the institutionalized spouse may be allocated to
the community spouse and dependent family members. The amount that may be
allocated is determined in accordance with the procedures in this
chapter.
004.03
DETERMINING OWNERSHIP OF INCOME. All income must be
verified to determine the amount of the income and the individual to whom the
income is due. Income is considered to be owned by the person legally entitled
to receive it. Ownership of income may be appealed.
004.03(A)
MULTIPLE
OWNERS. When a source of income is payable to more than one party,
the following rules apply:
(i) If payment is
made payable to both spouses, one-half is considered available to each
spouse;
(ii) Income must be divided
by the number of payees if payment is made payable to one or both spouses and a
third party;
(iii) Only the
spouse's proportionate share is considered available to that spouse;
(iv) If income is paid to one spouse and a
third party but the verification reveals that the income is intended for both
spouses, both spouses must be included in the division to determine the
proportionate share; and
(v) If
income does not specify either spouse, one-half of the amount is considered
available to each spouse.
004.04
BUDGETING THE
INSTITUTIONALIZED SPOUSE. The budget of the institutionalized
spouse is calculated using the procedure below. Only the income of the
institutionalized spouse is used to determine whether any cost sharing applies.
The institutionalized spouse must be allowed sufficient income to meet their
personal needs before determining whether any income is allocated to the
community spouse. If the income of the community spouse is not provided or
verified then no allocation is allowed. If an allocation for the maintenance
needs of the community spouse is calculated, but is not made available to the
community spouse, then no deduction is allowed. A deduction for the maintenance
of dependent family members is always allowed, even if the income is not made
available to those family members. Any amount remaining after deductions are
paid to the provider.
004.04(A)
BUDGET CALCULATION. The following amounts are deducted
from the gross, verified income of the institutionalized spouse in the
following order:
(i) The income standard for
the appropriate living arrangement. See 477-000-012;
(ii) A fee for a guardian or
conservator;
(iii) The amount
calculated for the maintenance needs of the community spouse;
(iv) The amount calculated for the
maintenance needs of dependent family members; and
(v) Incurred medical expenses allowed under
this title.
004.05
DETERMINING THE
MAINTENANCE ALLOWANCE. The maintenance needs of a spouse or
dependent family member are calculated. The calculation is subject to a minimum
and maximum amount. See 477-000-012. In comparing income of a spouse or family
member, all income is used, even if such income would normally be subject to a
deduction or exclusion for Medicaid eligibility. The gross amount of income is
used except for self-employment. Adjusted gross income is used for
self-employment. The amount calculated for the maintenance needs of a spouse or
dependent family member may be appealed.
004.05(A)
DETERMINING THE
COMMUNITY SPOUSE MAINTENANCE ALLOCATION. A portion of the income
of the institutionalized spouse can be allocated to the community spouse when
necessary to maintain the living standard of the community spouse. The
allocation is subject to a minimum and maximum amount which is adjusted
annually. If the community spouse has income in excess of the maximum amount,
then no allocation is allowed. If the community spouse has income less than the
maximum, then the calculation below is used. If the income of the community
spouse is less than the calculated amount, then the institutionalized spouse
may allocate income up to the calculated amount. The income of the community
spouse is compared to a sum of the following factors:
(i) The minimum maintenance
allowance;
(ii) Excess shelter
costs, as defined; and
(iii) A
standard utility amount.
004.05(B)
DETERMINING A DEPENDENT
FAMILY MEMBER'S MAINTENANCE ALLOCATION. A portion of the income of
the institutionalized spouse will be allocated to assist in the maintenance of
dependent family members. The maintenance amount is a sum of the needs of each
dependent family member. For each dependent family member, the remaining income
of the institutionalized spouse is compared to an amount calculated below. The
sum of the needs of each dependent family member is used as the allocated
amount. For each dependent family member, calculate the maintenance need amount
as follows:
(i) The minimum spousal
maintenance amount minus
(ii) The
gross amount of income for the dependent family member, and then
(iii) Divide the result by three.
004.05(C)
EXCEPTIONS. An allocation above the maximum amount is
only allowed under the following circumstances:
(i) A court has ordered the institutionalized
spouse to provide more financial support than the calculated maintenance
amount. A court order takes precedence over the calculated amount; or
(ii) The family alleges that a need in excess
of the calculated amount is needed due to exceptional circumstances resulting
in significant financial duress and appeals the calculated amount. The family
must show that there are insufficient resources reserved for the community
spouse to meet the financial need. If the family prevails on appeal, then an
additional amount may be allowed.
