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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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Cost Share Calculations For Long Term Care Medicaid

August 25, 2009


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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

    The cost share calculation will depend on which group the applicant is in.


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Group A

Group A Waiver members:

  • Are functionally eligible for HCBW

  • Eligible for full benefit Medicaid through SSI, SSI related Medicaid, MAPP or BadgerCare Plus Standard Plan

  • Eligible for full benefit Medicaid through meeting a deductible.

  • Have no HCBW cost share


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Group B

Group B Waiver members:

  • Are functionally eligible for HCBW

  • Have gross income at or below the Community Waivers Special Income Limit (currently $2022)

  • May have a cost share based on the members income and allowable deductions


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Group B Cost Share Calculation

From the individual’s gross income subtract:

  • Personal Maintenance Allowance

  • Special Exempt Income

  • Health Insurance premiums

  • Medical/Remedial expenses


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Personal Maintenance Allowance

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.


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Personal Maintenance Allowance (con’t)

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:

  • Rent

  • Home or Renter’s Insurance

  • Mortgage

  • Property tax (including special assessments)

  • Utilities (heat, water, sewer, electricity)

  • ‘Room’ amounts for members in a CBRF, RCAC, or AFH.

    The total minus $350.00 equals the Special Housing amount. The Special Housing amount is not given to members under 18.


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Personal Maintenance Allowance (con’t)

Special Housing Amount (con’t)

When both spouses are applying for HCBW and both have income:

  • And they reside together in the same residence, divide the special housing amount equally between them.   

  • And they reside in separate rooms in a substitute care facility, but there is only one room and board contract for both, divide the special housing amount equally between them.

  • And they reside in separate living arrangements (e.g. they reside in two different substitute care facilities OR they reside in the same substitute care facility but each has a private room and his/her own individual room and board contract) then calculate a separate special housing amount for each, based on their individual "rent" costs that are obtained from the care manager.  


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Personal Maintenance Allowance (con’t)

Special Housing Amount (con’t)

When one spouse has income and both are applying:

  • And they reside together in the same residence, allocate the full special housing amount to the spouse with income.

  • And they reside in separate rooms in a substitute care facility, but there is only one room and board contract for both, allocate the full housing amount to the spouse with income.

  • And they reside in separate rooms in a substitute care facility, but each has an individual room and board contract, only the spouse with income gets a deduction for the special housing amount, and it is based on their individual “rent” costs that are obtained from the care manager.


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Special Exempt Income

Special Exempt income includes:

  • Income used for supporting others: these are payments, either court-ordered or non-court ordered made to a person outside the Fiscal Test Group for purpose of supporting and maintaining that person.

  • Court-ordered attorney’s fees

  • Court-ordered guardian and guardian ad litem fees

  • Expenses associated with establishing and maintaining a guardianship


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Special Exempt Income (con’t)

  • Expenses associated with a Self-Support Plan. Allows the disabled member to receive income and accumulate resources for training or purchasing equipment necessary for self support. Must be approved by the IM agency.

  • Maintaining a home or apartment: allowed only when a physician certifies the member is likely to return home within 6 months and the spouse is not living in the home or apartment.

  • Minimal costs for heat, electricity and property insurance for homes listed for sale


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Special Exempt Income (con’t)

  • Impairment Related Work Expenses. This expense is used in eligibility determinations for Medicaid and MAPP and in MAPP premium calculations. It is not used as a deduction in the cost share calculation for HCBW

    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.


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Health Insurance

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.


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Medical Expenses

Medical expenses are anticipated incurred expenses for:

  • Services or goods that have been prescribed or provided by a professional medical practitioner (licensed in Wisconsin or another state).  

  • Diagnosis, cure, treatment, or prevention of disease or for treatment affecting any part of the body.  

  • Are the responsibility of the member, and cannot be reimbursable by any other source, such as Medicaid, private insurance, or employer.


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Remedial Expenses

Remedial expenses:

  • Costs incurred for goods and services that are provided for the purpose of relieving, remedying, or reducing a medical or health condition.

  • The responsibility of the member

  • Not reimbursable by any other source such as Medicaid, private insurance or employer

  • Do not include housing or room and board services.

    The Care Manager is responsible for calculating the remedial expenses and submitting them to the IM worker.


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Examples of Medical Expenses

Examples of Medical Expenses are:

  • Deductibles and co-payments for Medicaid, Medicare, and private health insurances.

  • Health insurance premiums.

  • Bills for medical services which are not covered by the Wisconsin Medicaid program.

  • For purposes of meeting a Medicaid deductible, medical services received before the person became eligible for Medicaid.  (Past medical bills cannot be used for MAPP premium calculations.)


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Examples of Remedial Expenses

Examples of Remedial Expenses are:

  • Case management.

  • Day care.

  • Housing modifications for accessibility.

  • Respite care.

  • Supportive home care.

  • Transportation.

  • Services recognized under s.46.27, Wis. Stats.

  • Community Options Program, that are included in the person's service plan.


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Calculating the Group B Cost Share

Gross income 1400.00 (Unearned)

Basic need allowance 854.00

65 ½ earned income 0.00

Special housing allowance 250.00

(Rent 600-350=250)

Health Insurance 100.00

Guardian fee 50.00

Med/remedials 120.00

Monthly cost share amount 26.00


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Group C

Group C members:

  • Are functionally eligible for HCBW

  • Have gross income above the Community Waivers Special Income Limit (currently $2022)

  • Have medical expenses that allow them to meet the medical needy income test.

  • Must meet a spenddown to remain eligible


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Group C Eligibility Determination

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:

  • 65 ½ earned income disregard

  • $20 unearned income disregard

  • Health Insurance costs

  • Special Exempt Income


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Group C Eligibility Determination (con’t)

The second step is to calculate the Net Income.

Subtract from the Net Countable Income:

  • Medical/Remedial Expenses

  • MA Card Coverable Expenses - these are medical expenses incurred by the person that Medicaid will pay once the person is found eligible.

    If the Net Income is at or below $591.67 the person is eligible for HCBW as a Group C member


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Group C Eligibility Determination (con’t)

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.


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Calculate the Group C Spenddown

Take the countable Net Income (the Net Income with the medical, remedial and MA card coverable expenses added back in) and subtract $591.67.


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Group C Eligibility Determination and Spenddown Calculation


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Institutional Long Term Care

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:

  • Is organized to provide medical care, including nursing and convalescent care,

  • Has the necessary professional personnel, equipment, and facilities to manage the medical, nursing, and other health needs of patients on a continuing basis in accordance with accepted standards,

  • Is authorized under State law to provide medical care, and,

  • Is staffed by professional personnel who are responsible to the institution for professional medical and nursing services.


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Institutional Long Term Care (con’t)

"Institutionalized person" means someone who:

  • Has resided in a medical institution for 30 or more consecutive days, or

  • Is likely to reside in a medical institution for 30 or more consecutive days, as attested to by the medical institution.

    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.


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Institutional Long Term Care (cont’)

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.


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Institutional Long Term Care (con’t)

To determine the monthly need add together the following costs:

  • Personal needs allowance ($45.00).

  • Cost of institutional care (use private care rate).

  • Cost of health insurance (only if the member owns the policy and is billed for the premium)

  • Support payments

  • Out-of-pocket medical costs.

  • Work related expenses (IRWE).

  • Self-support plan

  • Expenses for establishing and maintaining a court-  ordered guardianship or protective placement, including court ordered attorney or guardian fees.

  • Other medical expenses.

  • Other deductible expenses.


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Calculating the cost of care for Institutional Long Term Care

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:

  • $65 and ½ earned income disregard

  • Monthly cost for health insurance

  • Support payments

  • Personal needs allowance ($45.00)

  • Home maintenance costs, if applicable

  • Expenses for establishing and maintaining a court-ordered guardianship or protective placement, including court-ordered attorney and/or guardian fees

  • Medical Remedial Expenses


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Calculating the cost of care for Institutional Long Term Care (con’t)


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Spousal Impoverishment

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:

  • Married to an institutionalized person and

  • Not living in a nursing home or other medical institution for 30 or more consecutive days.


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Spousal Impoverishment Income Allocation

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.


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Spousal Impoverishment Income Allocation (con’t)

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:

  • Rent.

  • Mortgage principal and interest.

  • Taxes and insurance for principal place of residence. This includes renters insurance.

  • Any required maintenance fee if the community spouse lives in a condominium or cooperative.

  • The standard utility allowance established under the FoodShare program

    Do not allow excess shelter expenses if the HCBW member is living with his/her community spouse


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Spousal Impoverishment Income Allocation (con’t)

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.


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Spousal Impoverishment Income Allocation (con’t)

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.


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Spousal Impoverishment Income Allocation (con’t)


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Medicaid Purchase Plan (MAPP)

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.


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MAPP Premium Calculation

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.

Step 1.

  • From gross monthly unearned income, subtract the following:

    • Special Exempt Income

    • Standard Living Allowance ($777.00 for the current year)

    • Impairment Related Work Expenses ( IRWE ).  For MAPP , use only anticipated incurred expenses, past medical expenses are not allowed.

    • Medical Remedial Expenses ( MRE ).  For MAPP, use only anticipated incurred expenses, past medical expenses are not allowed.

    • Current COLA Disregard from January 1st through the date the FPL is effective in CARES for that year.  (503, DAC, widow/widower disregards allowed in eligibility determinations can not be allowed in premium calculations.)

      The balance is the Adjusted Countable Unearned Income.  This number maybe a negative number.


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MAPP Premium Calculation (con’t)

  • Step 2. From gross monthly earned income, subtract any remaining deductions from Step 1. If the result from Step 1 is a negative amount, change it to a positive number.  The balance is the Adjusted Earned Income.

  • Step 3. Multiply the adjusted earned income by three percent (.03).

  • Step 4. Add the results of #3 and #1 together.

  • Step 5. Compare the result from #4 to the Premium Schedule to determine monthly premium amount.


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MAPP Premium Calculation (con’t)


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503, DAC and Widow/Widower Disregards

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.


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503

A 503 member is someone who:

  • Is receiving Old Age, Survivors, Health and Disability Insurance (OASDI ) Benefits .

  • Was receiving Supplemental Security Income (SSI ) concurrently with OASDI but became ineligible for SSI

    Disregard all COLA increases since the last month he or she was eligible and received both OASDI and SSI benefits.


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Disabled Adult child (DAC)

A Disabled Adult Child (DAC) is:

  • At least 18 years old at the time SSI was lost.

  • Classified by the Social Security Administration as disabled before age 22.

  • Receives an OASDI (DAC) payment that is based on the earnings of a parent who is disabled, retired, or deceased.

  • Was receiving SSI, but lost SSI eligibility because the (DAC) payment exceeded the SSI income limits.


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DAC (con’t)

Disregard for a DAC:

  • All DAC payments which caused him/her to lose SSI eligibility

  • All COLA increases since the last month he or she was eligible and received both OASDI and SSI benefits.


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Widow/Widower

A widow or widower who lost SSI remains eligible for Medicaid

if he or she meets all of the following conditions:

  • Disabled

  • Age 50 or older

  • Married to the deceased person at the time of death or at least 10 years, divorced from him or her and now single

  • Received SSI in the month before the month she began receiving the W/W benefit and lost SSI

  • Would be eligible for SSI except for the receipt of the W/W payment.

  • Not entitled to Medicare Part A

    Disregard the entire W/W payment.


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