PM 15-04-04.

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 Revised text$4,300 gross monthly income from Social Security and a pension. The LTC charges are projected to be Revised text$150 per day at the Revised textprivate 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 Revised text$4,300 minus the $25 income exemption equals Revised text$4,275. Compare this to the community standard: Revised text$4,275 - $931 = Revised text$3,344. Mr. I has a spenddown of Revised text$3,344. The spenddown is met by the LTC charges of Revised text$4,500 for the month (30 days x Revised text$150). Mr. I is eligible for medical assistance.

Step 2: Mr. I has Revised text$4,300 monthly gross income. Deducting his $30 personal allowance leaves Revised text$4,270. 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 Revised text$2,531 (Revised text$4,270 - $1,739) to the LTC facility.

Example 3: Spenddown not met by LTC charges

Same as above, except that the Revised textprivate payment rate is Revised text$105 per day, or Revised text$3,150 per month.

Step 1: Mr. I's spenddown of Revised text$3,344 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 Revised text$3,150 LTC charges, meets the spenddown; proceed to Step 2.

Step 2: Mr. I has Revised text$4,300 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 Revised text$2,131, 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.

July 2012

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.

Step 2:

  • 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.

August 2012

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.