14005.7. (Amended by Stats. 2023, Ch. 42, Sec. 67.)

(a) Medically needy persons and medically needy family persons are entitled to health care services under Section 14005 providing all eligibility criteria established pursuant to this chapter are met.

(b) Except as otherwise provided in this chapter or in Title XIX of the federal Social Security Act, no medically needy family person, medically needy person or state-only Medi-Cal persons shall be entitled to receive health care services pursuant to Section 14005 during any month in which their spend down of excess income has not been met.

(c) In the case of a medically needy person, monthly income, as determined, defined, counted, and valued, in accordance with Title XIX of the federal Social Security Act, in excess of the amount required for maintenance established pursuant to Section 14005.12, exclusive of any amounts considered exempt as income under Chapter 3 (commencing with Section 12000), less amounts paid for Medicare and other health insurance premiums shall be the spend down of excess income to be met under Section 14005.9.

(e) In determining the income of a medically needy person residing in a licensed community care facility, income shall be determined, defined, counted, and valued, in accordance with Title XIX of the federal Social Security Act, any amount paid to the facility for residential care and support that exceeds the amount needed for maintenance shall be deemed unavailable for the purposes of this chapter.

(f) (1) For purposes of this section the following definitions apply:

(A) “SSI” means the federal Supplemental Security Income program established under Title XVI of the federal Social Security Act.

(B) “MNL” means the income standard of the Medi-Cal medically needy program defined in Section 14005.12.

(C) Board and care “personal care services” or “PCS” deduction means the income disregard that is applied to a resident in a licensed community care facility, in lieu of the board and care deduction specified in subdivision (e) of Section 14005.7, when the PCS deduction is greater than the board and care deduction.

(2) (A) For purposes of this section, the SSI recipient retention amount is the amount by which the SSI maximum payment amount to an individual residing in a licensed community care facility exceeds the maximum amount that the state allows community care facilities to charge a resident who is an SSI recipient.

(B) For purposes of this section, the personal and incidental needs deduction for an individual residing in a licensed community care facility is either of the following:

(i) If the deduction specified in subdivision (e) is applicable to the individual, the amount, not to exceed the amount by which the SSI recipient retention amount exceeds twenty dollars ($20), nor to be less than zero, by which the sum of the amount that the individual pays to their licensed community care facility and the SSI recipient retention amount exceed the sum of the individual’s MNL, the individual’s board and care deduction, and twenty dollars ($20).

(ii) If the deduction specified in paragraph (1) is applicable to the individual, an amount, not to exceed the amount by which the SSI recipient retention amount exceeds twenty dollars ($20), nor to be less than zero, by which the sum of the amount that the individual pays to their community care facility and the SSI recipient retention amount exceed the sum of the individual’s MNL, the individual’s PCS deduction and twenty dollars ($20).

(3) In determining the countable income of a medically needy individual residing in a licensed community care facility, the individual shall have deducted from their income the amount specified in subparagraph (B) of paragraph (2).

(g) No later than one month after the effective date of subparagraph (B) of paragraph (2) of subdivision (f), the department shall submit to the federal medicaid administrator a state plan amendment seeking approval of the income deduction specified in subdivision (f), and of federal financial participation for the costs resulting from that income deduction.

(h) The deduction prescribed by paragraph (3) of subdivision (f) shall be applied no later than the first day of the fourth month after the month in which the department receives approval for the federal financial participation specified in subdivision (g). Until approval for federal financial participation is received by the department, there shall be no deduction under paragraph (3) of subdivision (f).