PM 15-08-14-a

  1. (AIS) Calculates the monthly countable income and assets that apply to NH and SLF costs.
  2. (FCRC) Complete the HFS 2500 for applications not processed through AIS.
  3. (FCRC) Revised text Enroll the case for spenddown when the monthly countable income and resources are greater than the standard. The anticipated cost of long term care at the private pay rate can be used to meet the spenddown.

Code Form 552, Item 80:

  • enter code 391 SPDGC followed by the amount of monthly countable income; Revised text enter code 1 or 2 following the amount, to show whether the case is in met or unmet status;
  • Enter code 392 AST followed by the amount of the excess resources; if none, enter 0.00.

When the FCRC receives medical bills and/or receipts, immediately figure if spenddown is met. This determination should be made and, if spenddown has been met, Form 552 completed and entered in the computer within 2 workdays of the receipt of the bills and/or receipts. If the bill(s) and/or receipts are mailed to the FCRC, the 2 days begin with the day received in the FCRC.

When the customer meets monthly spenddown, complete a blank Form 552, Authorization of Benefits Action, to report the case in met status from the day of the month spenddown is met through the last day of the same month. Use TA 55 in Item 3 and TAR 96 in Item 33. Enter the date spenddown was met in Item 77. A Form 552 showing this action will not be saved. The action will appear on the Mercury payroll. A MediPlan Card will be generated.

Use TA 55 for cases in active or canceled status when it is necessary to report monthly spenddown is met. Do not use TA 55 to report eligibility for a non-consecutive backdated month.

Examples

New textAll the following examples refer to residents of nursing homes. Unless otherwise specified, the budget is for the first complete month the person is a resident of the NH.

 Example 1 - Income below AABD MANG standard

Revised text Mr. A has gross monthly non-exempt income of $910 from Social Security. The community spouse has gross monthly income of $600 from Social Security and $500 from a pension. They have no available excess resources. The private pay rate is $3,000 per month; the state rate is $2,100.

Step 1 (eligibility):  Deducting the $25 income exemption from $910 leaves $885. This is less than the AABD medical standard for one person of $931. The applicant is eligible. Authorize this case as regular long term care, and use post-eligibility budgeting to figure the group care credit.

Step 2 (post-eligibility budgeting): The applicant is entitled to a personal allowance of $30, and could divert $1,639 ($2,739 - $1,100) to the community spouse. $910 - $30 - $880; Mr. A can divert $880 to Mrs. A, leaving a group care credit of 0.

Example 2 - Spenddown met by NH charges

New text Mr. I has gross monthly income of $4,000 from Social Security and has no excess resources. Mrs. I, in the community, has $1,000 monthly income from SSA. The private pay rate is $5,100; the state payment rate is $4,200.

Step 1 (Eligibility): Deducting the $25 income exemption from $4,000 leaves $3,975. This exceeds the AABD medical standard for one person of $931. The applicant has a spenddown liability of $3,975 - $931 = $3,044.

Anticipated group care charges at the state payment rate of $4,200 meet the spenddown; the applicant is eligible. Authorize as a spenddown-met case, and use post-eligibility budgeting to figure the group care credit.

Step 2 (Post-eligibility budgeting): The applicant is entitled to a personal allowance of $30. Mrs. I is eligible for $2,739 - $1,000 = $1,739 as the CSMNA. $4,000 - $30 - $1,739 = $2,231. This is the amount of the group care credit. 

Example 3 - Spenddown not met by NH charges

New text Mr. and Mrs. I have income as above. The private pay rate is $2,700; the Department rate is $2,400.

Step 1 (eligibility): Deducting the $25 income exemption from $4,000 leaves $3,975. This exceeds the AABD medical standard for one person of $931. The applicant has a spenddown liability of $3,975 - $931 = $3,044.

Anticipated group care charges at the state rate of $2,400 do not meet the spenddown; the applicant is not eligible. Enroll the case with an unmet spenddown; take no further action.

In the following month, Mr. I presents a receipt for a payment to a doctor of $785. This, with the LTC charges of $2,400, meets the spenddown for that month. Mr. I is now eligible, and post-eligibility rules apply.

Step 2 (post-eligibility budgeting):

From Mr. I's gross income of $4,000, deduct the following:

  1. Mr. I's $30 personal allowance;
  2. Income diverted to Mrs. I as the CSMNA: $2,739 - $1,000 = $1,739;
  3. Medical receipt of $785.

$4,000 -  $30 - $1,739 - $785 =  $1,446. This is the amount of the group care credit.

Example 4 - Spenddown met by NH charges and medical bills

New text A long term care applicant has gross monthly non-exempt income of $4,000. There are no available excess resources.

Revised textStep 1 (eligibility): Deducting the $25 income exemption from $4,000 leaves $3,975. This exceeds the AABD medical standard for one person of $931. The applicant has a spenddown liability of $3,044 ($3,975 - $931).

Monthly anticipated group care charges at the state payment rate are $2,100 ($70 per day). This does not meet the spenddown. Authorize this person as an enrollee in the Medical program with a monthly spenddown amount of $3,044.

In June the person incurs $2,600 in long term care charges at the private pay rate and has $972 in other medical costs carried over from an earlier month. Medical eligibility begins on 06/01 and continues only through 06/30.

In July the NH charges are $2,686. The person pays $50 in other medical costs. Therefore the customer is not eligible for medical assistance during that month (unless bills or receipts have been carried over from an earlier month). However, the $50 receipt may be carried over and used to meet spenddown for a later month. The NH charges are not to be carried over to a later month after they are paid by the customer.

In August the person incurs $2,686 in long term care charges, incurs $860 in other medical costs on 08/23, and has $50 carried over from July. Medical eligibility begins on 08/23 and continues for the remainder of the month.