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Louisiana Medicaid Eligibility Manual Eligibility Determinations

Reissued July 31,2024

Page 1 of H-1050 Replacing November 06, 2023

Revised/added text indicated by underscore

Deleted text indicated by “**” H-1050 SPEND-DOWN MEDICALLY NEEDY - HOME AND COMMUNITY-BASED SERVICES (HCBS) - SSI-RELATED H-1051 ELIGIBILITY DETERMINATION PROCESS

Eligibility in SD MNP HCBS cannot be considered prior to establishing income ineligibility for the HCBS program. Refer to H-900 Home and Community-Based Services (HCBS).

Individuals who meet the eligibility requirements for the Community Choices, Adult Day Health Care, Residential Options Waiver, Supports, or New Opportunities Waiver Programs, but have countable monthly income that is over the special income limit (SIL), may be eligible for Medicaid healthcare coverage and payment of waiver services under the Spend-down Medically Needy HCBS Program. The applicant/beneficiary must incur monthly medical expenses in an amount greater than or equal to their excess income to be eligible for Medicaid.

The Medicaid Program considers the anticipated or projected cost for home and community-based waiver services as an incurred medical expense deduction. The projected waiver rate is based on the average monthly waiver costs associated with the waiver and is used to reduce the excess monthly income. Refer to Z-2400 Average Projected Rates for MNP By Program.

Other allowable incurred medical expenses include Medicare and private health insurance premiums, deductibles, coinsurance or copayment charges, and medical/remedial care expenses incurred by an individual that are not subject to payment by a third party. Verification of the applicant/beneficiary’s responsibility for payment of the incurred expense is required.

The projected waiver rate must be prorated when the applicant/beneficiary was not medically certified for the entire month. (Refer to the effective date recorded on the BHSF 142, Notice of Medical Certification.) When the projected waiver rate and the incurred medical expenses are equal to or greater than the applicant/beneficiary’s excess income, income eligibility is established for the budget period. Medicaid eligibility begins the first day of the budget period. Vendor payment eligibility will begin the later of the effective date recorded on the BHSF 142 or the date financial eligibility is established.