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To meet the prospective spend-down liability, the assistance unit must submit incurred allowable medical expenses (see Section 7.4: Allowable Medical Expenses in Part VI). Payments the individual makes to the LTC facility at the 'private pay' rate are countable medical expenses for purposes of meeting the spend- down liability.

When total submitted medical expenses equal or exceed the spend-down liability, eligibility is established. The assistance unit is certified for the balance of the prospective budget period with a PPA of zero. The Department pays the remainder of the cost of care through the sixth month of the budget period. At recertification, eligibility is conditionally terminated until the subsequent six-month prospective spend- down liability is met.

DETERMINATION TOTAL COUNTABLE INCOME FOR PPA CALCULATION 2.15

The LTC SSR should consult the policies for SR (unless the LTC resident is under 21 and is MA-eligible under AR or AX; in this case, consult the policies for AR or AX) in Chapters 4-6 and 8 in Part VI to determine total countable income. In addition, if the individual in LTC has an MA-eligible spouse who is also residing in a LTC facility, each spouse is considered to be financially responsible for the other for the month of their physical separation.

Impoverished Spouse: No income from the community spouse should be deemed to the institutionalized spouse for any month in which s/he is institutionalized (see Section 2.5: MA Income Eligibility Determination and Section 2.12: Treatment of Assets After MA Eligibility Determination in this Chapter).

Apply the following rules to determine income for the purposes of the PPA calculation for institutionalized spouses who have a community spouse and who were institutionalized after September 30, 1989:

 Determine the individual's total countable income following SR policies (unless the individual is under 21 and is MA-eligible under AR or AX; then follow AR or AX policies), and  Deduct the applicable LTC Income Allowances (see Section 2.6: LTC Income Allowances in this Chapter) from the individual's total income.

Treatment of Income from Non-Trust Property 2.15.1

Impoverished Spouse: When determining the income of an institutionalized or community spouse for purposes of the PPA calculation and post-eligibility income determination, use the following policies, regardless of any District laws relating to community property or the division of marital property, to determine ownership in non-trust property unless otherwise specified as a part of the non-trust property and unless the institutionalized spouse establishes through the fair hearings process (see Chapter 7: Grievances and Fair Hearings in Part VIII) that ownership interest is other than that prescribed below:

 If payment of income is made solely in the name of the institutionalized spouse or the community spouse, the income shall be considered available only to that respective spouse.  If payment of income is made in the names of the institutionalized spouse and the community spouse, one-half of the income shall be considered available to each of them.  If payment of income is made in the names of the institutionalized spouse or the community spouse, or both, and to another person or persons, the income shall be considered available to each spouse in proportion to the spouse's interest.

If there is no instrument establishing ownership, one-half of the income shall be considered available to the institutionalized spouse and one-half shall be considered available to the community spouse.