Examples: Two-step eligibility process
Example 1: Income below AABD community standard
Mr. H resides in a nursing home and has monthly income of $910 from Social Security. Mrs. H lives in the community and has gross monthly income of $600 from Social Security and a $500 pension.
Step 1: Mr. H's gross income, minus the $25 exemption, is $885, which is below the community standard of $931. He is eligible for medical assistance as a regular (non-spenddown) case.
Step 2: Deducting the $30 personal allowance from Mr. H's $910 income leaves $880. Mrs. H has a total of $1,100 income ($600 + $500 = $1,100) which is $1,639 less than the CSMNA of $2,739. Mr. H can therefore divert all of his remaining $880 to her. He has no available income remaining to pay the nursing facility.
Example 2: Spenddown met by LTC charges
Mr. I resides in a nursing home and has a total of $4,000 gross monthly income from Social Security and a pension. The LTC charges are projected to be $140 per day at the state payment rate. Mrs. I resides in the community and has a total of $1,000 gross monthly income.
Step 1: Mr. I's gross income of $4,000 minus the $25 income exemption equals $3,975. Compare this to the community standard: $3,975 - $931 = $3,044. Mr. I has a spenddown of $3,044. The spenddown is met by the LTC charges of $4,200 for the month (30 days x $140). Mr. I is eligible for medical assistance.
Step 2: Mr. I has $4,000 monthly gross income. Deducting his $30 personal allowance leaves $3,970. Mrs. I is eligible for $1,739 ($2,739 - $1,000) in additional income as the CSMNA, so Mr. I can divert $1,739 to her.
If Mr. I has no medical expenses, or any of the other deductions listed in PM 15-04-04, he will owe $2,231 ($3,970 - $1,739) to the LTC facility.
Example 3: Spenddown not met by LTC charges
Same as above, except that the state payment rate is $90 per day, or $2,700 per month.
Step 1: Mr. I's spenddown of $3,044 is not met. Enroll the case as unmet spenddown and take no further action at this point. Do not proceed to budgeting in Step 2.
Later: Mr. I brings in a medical receipt for $400. This, with the $2,700 LTC charges, meets the spenddown; proceed to Step 2.
Step 2: Mr. I has $4,000 monthly gross income. Deducting his $30 personal allowance, $1,739 diverted to Mrs. I as the CSMNA, and the $400 medical expense leaves countable income of $1,831, which is the group care credit.
Example 4: Earned income
Ms. L resides in a nursing facility and works part-time in supported employment. She has income of $420 from Social Security and $95 earned income from a workshop. Her employment expenses total $32 for the month. Ms. L has no spouse or other dependents in the community. She presents $120 of allowable medical expenses for the month.
Step 1: Figure Ms. L's total non-exempt income:
- $95 - $50 earned income exemption - $32 employment expenses = $95 - $82 = $13;
- $420 SSA income + $13 net earned income = $433; $433 - $25 exemption = $408;
- $408 is less than the standard of $931; Ms. L is eligible as a regular (non-spenddown) case.
Step 2: Budget income:
- total gross income is $420 + $95 = $515;
- allowable deductions are $30 personal allowance, $50 earned income exemption, $32 employment expenses and $120 medical expenses; $30 + $50 + $32 + $120 = $232;
- $515 - $232 = $283. Ms. L owes $283 to the facility.
Example 5: Excess resources
Mrs. M has been private pay through the month of June 2012; eligibility is being determined beginning with the month of July 2012. She has a savings account totaling $3,000. She has income of $900 per month in Social Security benefits, no spouse in the community, and no other medical expenses besides the LTC charges, which are $100 per day at the private rate and $80 per day at the Department rate.
Step 1: Deduct the $25 exemption from Mrs. M's $900 income; this leaves $875. This is less than the AABD MANG standard of $931; Mrs. M is eligible. Post-eligibility rules apply.
- excess resources ($3,000 - $2,000 allowable resources = $1,000 excess resources). Before her income is considered, Mrs. M has a $1,000 resource spenddown;
- income: $900 - $30 personal allowance = $870. Mrs. M has $870 monthly income to pay for her care;
- $1,000 resource spenddown + $870 available income = $1,870;
- Mrs. M has $1,870 available to pay the facility for July.
No excess resources are available this month; the excess was used in full in July. Mrs. M has only $900 - $30 = $870 available to pay the facility for this and future months.