Current through Register Vol. 35, No. 18, September 24, 2024
Once financial eligibility for a MAP category of
institutional care has been established, the ISD worker must determine the
following.
A.
Medical care
credit: The medical care credit is the amount of the applicant's or
recipient's income used to reduce the MAD payment to the institution where they
reside. An applicant or recipient must make this payment directly to the
institution. Applicants or recipients eligible for a MAP category of
institutional care due to institutionalization in an acute care hospital or an
in-state in-patient rehabilitation center are not charged a medical care
credit. The amount of the medical care credit is always determined
prospectively. The ISD worker computes a medical care credit starting with the
first full month of institutional care. No medical care credit is required for
the month the recipient enters the institution if they are admitted after the
first moment of the first day of the month.
(1)
No medical care credit for the
month of discharge or death: An applicant or recipient is not required
to pay a medical care credit for the month of discharge from the institution.
The medical care credit must be paid if the applicant or recipient is
transferred to another institution or makes a short visit outside the
institution. No medical care credit is charged for the month in which a
recipient who received MAD institutional care services dies. This will prevent
a deficit for the institution when a benefit, such as social security, must be
returned due to the death of a beneficiary.
(2)
Application delay: If there
is a delay between application and approval, an applicant or recipient incurs a
liability for a medical care credit. The ISD worker notifies the applicant or
recipient of this liability during the application process and informs them of
the amount of the medical care credit they should pay. The applicant or
recipient is encouraged to pay the medical care credit to the institution
before approval of the application.
(3)
Medical care credit during
retroactive months: No medical care credits are applied for any period
of retroactive eligibility under this provision.
B.
Computing the medical care
credit: The current personal needs amount (PNA) of an applicant or
recipient monthly income is protected for their personal use in a nursing
facility. Each year thereafter, the amount of an applicant's or recipient's
monthly income shall be adjusted according to the consumer price index as
indicated in 8.200.510 NMAC. The excess over the amount protected, subject to
other deductions, is applied toward payment for care in the nursing facility as
a medical care credit.
(1) See Paragraph (6)
of Subsection B of 8.281.500.22 NMAC for personal needs allowance for veterans
or surviving spouses.
(2) An
applicant's or recipient's total income, including amounts disregarded in
determining eligibility, is used to compute the medical care credit with the
following exceptions:
(a) Indian tribe per
capita payments (see Subsection B of
8.281.500.19
NMAC);
(b) German reparation
payments; and
(c) social security
administration overpayments.
(i) When the
social security administration withholds an amount due to an overpayment, the
social security gross payment amount is used to determine eligibility per
Subsection A of
8.281.500.19
NMAC. To determine the amount used in calculating the medical care credit, the
ISD worker ascertains whether a social security (Title II) overpayment is being
recouped or whether an SSI overpayment is being recouped from a social security
benefit check (a cross-program recoupment). Cross-program recoupments are at
the recipient's option so the gross benefit amount is used to calculate the
medical care credit.
(ii)
Recoupment of a social security overpayment from a social security benefit
check is mandatory. In such cases, the net social security benefit amount is
used to calculate the medical care credit.
(d) payments from the Radiation Exposure
Compensation Act.
(e) 'remembrance,
responsibility and the future' payments.
(3) Dependent children at home: If an
institutionalized applicant or recipient with no spouse has dependent children
at home who are ineligible for TANF or assistance from any other program, or
are eligible for an amount less than the TANF need standard, an allowance for
each child of up to the current TANF standard of need may be deducted from the
institutionalized applicant's or recipient's income which is in excess of the
applicant's or recipient's personal allowance.
(4)
Expenses not subject to third party
payment
42
CFR 435.725: Amounts for incurred
expenses for medical or remedial care that are not subject to payment by a
third party, including:
(a) medicare and
other health insurance premiums, deductibles, or coinsurance charges;
and
(b) necessary medical or
remedial care recognized under state law but not covered under the state
medicaid plan, subject to reasonable limits on amounts of these expenses. HSD
has the following reasonable limits on amounts for necessary medical or
remedial care not covered under medicaid:
(i)
For expenses not covered under the state Plan or expenses covered under the
state plan, but not paid for by medicaid, the amount of the deduction is the
billed amount not to exceed the provider's usual and customary charges except
for unpaid nursing facility expenses.
(ii) To be deducted, an expense must be for
medically necessary medical or remedial care rendered to the applicant or
beneficiary and prescribed by a health care practitioner acting within their
scope of practice who meet the qualifications of an eligible medicaid provider
as listed in the New Mexico Administrative Code (NMAC) 8.310.3.9 even if such
practitioner is not a medicaid provider.
(iii) A deduction for incurred medically
necessary non-covered medical or remedial care expenses will be allowed when
the bill is incurred during a period which is no more than three months prior
to the month of the current application. For each month of unpaid nursing
facility services incurred during this period, deductions are allowed at an
amount not to exceed the average monthly private rate of nursing facility
services, as used to calculate asset transfer penalties and which is updated
annually in
8.200.510.13
NMAC or a prorated amount of this figure, for unpaid nursing facility services
that are for less than a full month.
(iv) The deduction for medical and remedial
care expenses that were incurred as the result of a transfer penalty period is
limited to zero.
(v) Expenses for
cosmetic/elective procedures (e.g., face lifts or liposuction etc.) are not
allowed as deductions except when prescribed by a health care
practitioner.
(vi) Expenses from
medical or remedial procedures that were denied coverage by an insurer,
including medicaid, on the basis of a lack of medical necessity are not
allowed.
(5)
Court-ordered support: A deduction for the full amount of
court-ordered child or spousal support is also allowed for the applicant or
recipient.
(6)
Personal needs
allowance for recipients in an ICF-IID: If an applicant or recipient who
is institutionalized in an intermediate care facility for individuals with
intellectual disabilities (ICF-IID) has a monthly income from employment in a
sheltered workshop or other work activity program, up to the first $100 of this
earned income is protected for the applicant's or recipient's personal needs.
This amount is in addition to the applicant's or recipient's personal needs
allowance protected from income from any source. If the applicant's or
recipient's income is from any other source, the personal needs allowance is
set at the amount as set forth in
8.281.500.12
NMAC.
(7)
Veterans
administration (VA) benefits: The ISD worker must contact the VA on each
veteran's case to verify how much of the benefit is for pension, aid and
attendance (A & A) or unusual medical expenses (UME).
(a) For MAP eligible veterans with no spouse
or dependent children, and for surviving spouses of veterans without dependent
children who do not reside in a state veteran's home (Fort Bayard or Truth or
Consequences):
(i) exclude the A & A and
UME in the medical care credit computation;
(ii) allow the personal needs allowance as
set forth in
8.281.500.12
NMAC;
(iii) the benefit for
applicant or recipient will be reduced to $90 per month effective the latest of
the following;
(iv) the last day of
the calendar month in which medicaid coverage begins;
(v) the last date of the month following 60
calendar days after issuance of a reduction notice;
(vi) the earliest date on which payment may
be reduced without creating an overpayment;
(vii) when the benefit is reduced to $90,
recomputed the medical care credit to allow $90 for personal needs.
(b) For MAP eligible veterans with
no spouse or dependent children, and for surviving spouses of veterans without
dependent children who do reside in a state veteran's home (Fort Bayard or
Truth or Consequences):
(i) include the A
& A and UME in the medical care credit computation;
(ii) allow $90 for their personal
needs;
(iii) the benefit for the
applicant or recipient is not reduced to $90.
(c) Benefits for the following applicants or
recipients are not reduced to $90 a month, regardless of whether or not they
reside in a state veteran's home:
(i)
veterans who have a spouse or dependent child(ren);
(ii) surviving spouses of veterans who have
dependent child(ren).
(d)
The ISD worker allows these applicants or recipients the allowance as set forth
in
8.281.500.12
NMAC, for personal needs.
C.
Computing medical care credits for
married institutionalized applicants or recipients: To calculate the
medical care credit for a married institutionalized applicant or recipient, the
"name-on-the-check" rule applies. The ISD worker uses only the income belonging
to the institutionalized applicant or recipient to compute their medical care
credit. Total gross income before any deductions is used in this process.
(1)
Treatment of VA aid and attendance
(A & A) and unusual medical expenses (UME): Allowances for A &
A; and UME are considered when computing the medical credit in accordance with
Subsection B of 8.281.500.22 NMAC.
(2)
Court-ordered support: A
deduction for the full amount of court-ordered child or spousal support is also
allowed for the applicant or recipient.
D.
Computing medical care credits for
an institutionalized couple: To compute medical care credits for each of
an eligible institutionalized couple, the ISD worker totals the couple's gross
income and divides by two. The personal needs allowance as set forth in
Subsection B of 8.281.500.22 NMAC is subtracted from each amount for each
applicant's or recipient's personal needs and added to any allowable amount(s)
paid by that applicant or recipient for noncovered medical expenses.
E.
Medical care credit
deductions: The ISD worker applies the deductions listed below in the
following order when determining the medical care credit:
(1) institutionalized spouse's personal needs
allowance as set forth in
8.281.500.12
NMAC;
(2) community spouse monthly
income allowance (CSMIA); the CSMIA deduction is permitted only to the extent
that the income is available and is actually contributed to and accepted by the
community spouse or other dependent family members:
(a) the CSMIA is calculated by starting with
the minimum monthly maintenance needs allowance (MMMNA) and subtracting the
community spouse's total gross income;
(b) both spouses shall be given notice of the
amount of the CSMIA;
(c) if either
spouse is dissatisfied with the amount of the CSMIA, they can request a HSD
administrative hearing pursuant to 8.352.2 NMAC, to establish that the
community spouse needs income above the minimum monthly maintenance needs
allowance; the spouse must demonstrate that the community spouse needs the
additional income above the level otherwise provided by the minimum monthly
maintenance needs allowance due to exceptional circumstances resulting in
significant financial duress; if the spouse establishes that the community
spouse needs additional income due to exceptional circumstances resulting in
significant financial duress, there shall be substituted for the CSMIA such
amount as is necessary to alleviate the financial duress and for so long as the
exceptional circumstances exist; if as a result of a HSD administrative hearing
final decision or district court hearing, additional income is granted to the
community spouse for a specified period of time, when that time expires, the
original CSMIA, as calculated by the ISD worker is reinstated; the exceptional
circumstances can include medical, remedial or other support expenses that
jeopardize the ability of the community spouse to remain self-sufficient in the
community;
(d) if as a result of a
district court hearing or a HSD administrative hearing final decision, a
request for a revision of the CSMIA is granted, the revised amount shall be
substituted for the CSMIA calculated by the ISD worker; and
(e) when the institutionalized applicant's or
recipient's income is insufficient to provide the minimum authorized deduction
for the community spouse, either spouse can request a HSD administrative
hearing pursuant to 8.352.2.NMAC if either spouse establishes that the CSRA (in
relation to the amount of income generated by such an allowance) is inadequate
to raise the community spouse's income to the MMMNA, there shall be
substituted, for the CSRA, an amount adequate to provide the
MMMNA;
(3) an excess
shelter allowance for allowable expenses of the community spouse which exceed
thirty percent of the MMMNA standard up to a specified maximum; the following
expenses are allowed for the primary residence of the community spouse:
(a) rent or mortgage payment, including
interest or principal;
(b) home
taxes and insurance;
(c)
maintenance charges for a condominium or cooperative; and
(d) amount equal to the standard utility
allowance used by the food stamp program if the community spouse incurs a
heating or cooling expense; utility expenses included in the rent or the basic
maintenance fee for a condominium or cooperative, are not allowed.
(4) The total CSMIA and excess
shelter allowance combined may not exceed the standard amount per month, unless
the MAD director or a district court orders the institutionalized spouse to pay
an increased amount.
(5) An
allowance for each eligible family member equal to one-third of the balance
obtained after deducting the family member's gross income from the MMMNA.
Family members include the couple's minor child(ren) under the age of 18 years,
disabled adult child(ren) of the couple who meet the social security
administration's definition of disability and dependent sibling(s) or parent(s)
of the couple. These family members must reside with the community spouse. The
dependency requirements are met if either member of the couple could claim the
family member as a dependent for tax purposes.
(6) The deductions for the community spouse
and dependent family members apply only so long as there is a community spouse.
Deductions for the community spouse and other family members shall cease in the
first full calendar month after the community spouse dies, becomes divorced, or
is institutionalized.
(7) Health
insurance premiums and non-covered medical expense
deduction.
F.
Reporting requirements: An applicant or recipient, spouse, or
authorized representative is required to report to the ISD worker any change in
circumstances which may affect eligibility or the medical care credit amount
within 10 working days after the date the change occurs. Changes which cause
adjustments in an applicant's or recipient's medical care credit amount are
effective the month after the change occurs. Family members receiving
allowances must also report all changes of gross income and residence within 10
working days after the date the change occurs. Changes must be reported when
the institutionalized spouse stops making all or part of a maintenance
allowance available to the community spouse or other family member(s), or when
the recipient of a maintenance allowance begins to refuse all or part of the
income.
G.
Changes in income
and recipient medical care credit: Payments received by an applicant or
recipient, such as social security, VA, retirement or other benefits, are
applied to billing for services for the same month in which the payment is
received. If the income increases, the institution must continue to collect the
amount indicated on the medical care credit report in the eligible recipient's
file and immediately advise the ISD worker of the change. The ISD worker
processes the change, notifies the institution and the eligible recipient of
the new medical care credit amount and indicates the month in which the higher
amount is to be collected. The difference between the medical care credit
amounts is deposited in the eligible recipient's personal fund account until
the change is effective.
