Cost Share Calculations For Long Term Care Medicaid. August 25, 2009. HOME AND COMMUNITY BASED WAIVERS. Applicants for Home and Community Based Waivers fall into one of three groups based on income and eligibility for other categories of full benefit Medicaid. Group A Group B Group C
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August 25, 2009
Applicants for Home and Community Based Waivers fall into one of three groups based on income and eligibility for other categories of full benefit Medicaid.
The cost share calculation will depend on which group the applicant is in.
Group A Waiver members:
Group B Waiver members:
From the individual’s gross income subtract:
The personal maintenance allowance is for room, board and personal expenses. It is the total, (up to the EBD Maximum Personal Maintenance Allowance), of the:
1.Community Waivers Basic Needs Allowance. This amount can change yearly. The current amount is $854.00.
2. $65 ½ earned income deduction. To calculate this deduction subtract $65 from the member’s gross monthly income, divide the result by 2 and add the $65 to that amount.
3. Special Housing Amount. This is an amount of the person’s income set aside to help pay housing costs. If the Group B Waiver member’s housing costs are over $350, add together the following costs:
The total minus $350.00 equals the Special Housing amount. The Special Housing amount is not given to members under 18.
Special Housing Amount (con’t)
When both spouses are applying for HCBW and both have income:
Special Housing Amount (con’t)
When one spouse has income and both are applying:
Special Exempt income includes:
IRWEs are anticipated incurred expenses by the member related to the member’s impairment and employment. The expense cannot be one that a similar worker without a disability would have, such as uniforms. The expense cannot be reimbursable by a legally obligated third party such as Medicaid, private insurance, or the member’s employer. The expense can not exceed the member’sgross monthly income (plus room and board, if any) and must be reasonably related to his/her earned income.
All health and dental insurance premiums covering the Waiver member (including Medicare Part D) and for which the member is responsible and pays a premium can be used as expense.
If the waiver participant is part of a covered group, but not responsible for the premium, find his/her proportionate share by dividing the premium by the number of people covered.
If both members of a couple apply, but only one pays the premium, divide the premium equally. Prorate premiums over the months payment covers.
Medical expenses are anticipated incurred expenses for:
The Care Manager is responsible for calculating the remedial expenses and submitting them to the IM worker.
Examples of Medical Expenses are:
Examples of Remedial Expenses are:
Gross income 1400.00 (Unearned)
Basic need allowance 854.00
65 ½ earned income 0.00
Special housing allowance 250.00
Health Insurance 100.00
Guardian fee 50.00
Monthly cost share amount 26.00
Group C members:
The eligibility determination for a Group C member is a 3 part process. The first step is to calculate the Countable Net Income.
The Countable Net income is the income that is left after subtracting:
The second step is to calculate the Net Income.
Subtract from the Net Countable Income:
If the Net Income is at or below $591.67 the person is eligible for HCBW as a Group C member
The last step in the eligibility determination is to calculate the spenddown amount.
The spenddown is the monthly amount the Group C member must incur and be held financially responsible for to remain eligible.
Take the countable Net Income (the Net Income with the medical, remedial and MA card coverable expenses added back in) and subtract $591.67.
Group C Eligibility Determination and Spenddown Calculation
For Medicaid purposes “institution” means a medical institution. A medical institution can be, but is not limited to, skilled nursing facilities (SNF ), intermediate care facilities (ICF ), institutions for mental disease (IMD), and hospitals.
Medical institution means a facility that:
"Institutionalized person" means someone who:
An exception to the 30-day period is that a resident of an IMD is considered an institutionalized person until s/he is discharged.
The 30-day period includes situations in which the person resides in more than one medical institution during 30 or more consecutive days.
A person residing in an institution must either have income below the Institutions Categorically Needy income limit ($2022) or have monthly allowable expenses that exceed the their income.
The amount by which the member’s expenses exceed his/her income is called the Monthly Need.
To determine the monthly need add together the following costs:
Once the person is determined eligible the cost of care (also called patient liability) must be calculated.
Subtract the following expenses from the person’s monthly gross income:
Spousal Impoverishment is a Medicaid policy that allows persons to retain assets and income that are above the regular MA financial limits. Spousal impoverishment policy applies to Long Term Care Medicaid.
Under Spousal Impoverishment rules, income can be allocated from the Long Term Care member to his/her Community Spouse to reduce the Long Term Care Member’s cost share.
A Community Spouse is:
Income that is allocated to the Community Spouse must actually be given to the Community Spouse each month.
The Long Term Care member must decide how much income to allocate up to the maximum allocation amount.
The maximum allocation amount is the lesser of $2739 or $2428.33 plus excess shelter allowance.
The excess shelter amount is the community spouse’s shelter expenses above $728.00.
Community spouse shelter costs include the community spouse’s expenses for:
Do not allow excess shelter expenses if the HCBW member is living with his/her community spouse
Once you’ve determined the maximum allocation amount, subtract the community spouse’s gross monthly income from that amount. The difference is the amount the Long Term Care Member can allocate to the community spouse.
The amount allocated to the community spouse is used as a deduction in the cost of care calculation for Group B HCBW and Institutional Long Term Care.
Any amount allocated to the community spouse is counted as his/her income in any eligibility determination for the community spouse.
Spousal Impoverishment and Group C members.
If a Group C member has a community spouse, an additional process is completed to determine the cost share amount for the Group C member.
After determining the eligibility and the spenddown amount, the Spousal Impoverishment Income Allocation Worksheet must be filled out to calculate the amount of income that can be allocated to the community spouse and to calculate the cost share amount.
The Medicaid Purchase Plan (MAPP ) is a subprogram of the Wisconsin Medicaid Program. It allows disabled people who are working or want to work to become or remain Medicaid eligible, even if employed, since there are higher income and asset limits.
DDB must certify disability. There is no requirement that a member be a current or former SSI or SSDI beneficiary to qualify for MAPP. Earned income is not used as evidence in MAPP disability determinations.
If the member’s income exceeds 150% of the FPL, he/she will have to pay a monthly premium to stay eligible for MAPP. Only the member’s income is used to calculate a MAPP premium.
The balance is the Adjusted Countable Unearned Income. This number maybe a negative number.
When a person has received both an OASDI payment (SSDI/SSDC, etc) along with an SSI payment and loses that SSI payment he or she may be eligible for a disregard of a portion of their income when determining eligibility for Medicaid programs.
The disregard is only used in the eligibility determination, not in any post eligibility calculations such as cost shares and premiums.
A 503 member is someone who:
Disregard all COLA increases since the last month he or she was eligible and received both OASDI and SSI benefits.
A Disabled Adult Child (DAC) is:
Disregard for a DAC:
A widow or widower who lost SSI remains eligible for Medicaid
if he or she meets all of the following conditions:
Disregard the entire W/W payment.