Page 11

11

2. [XX] NO. GROSS IS LESS, ENTER BASE ALLOWANCE HERE a. Subtract CUSP’s gross from Base Allowance: GROSS (B.) (always round down) b. Result is CUSP’s needs. : c. Do CUSP’s NEEDS exceed or equal maximum available from ISP in A., above? [ ] YES. DEEM MAXIMUM AVAILABLE IN A.5. ABOVE. Do not consider shelter cost. Stop here.

[XX] NO. NEEDS ARE LESS THAN MAXIMUM IN A.5. ABOVE. Continue to C.3.below.

3. Does CUSP state monthly shelter expenses are equal to or less than the Standard Excess Shelter Cost. [XX] YES. Shelter costs are equal to or less than SES, DEEM CUSP's NEED in C.2.b., above. Stop. Enter amount on DHB-5008, Supplement B worksheet.

D. A/B Returns Home Within Six Months (Refer to II.A. for CPI Rules): When the a/b intends to return to a private home (or to any private living arrangement) within six months, allow a portion of the a/b’s income for maintenance of their home. This section explains the procedures for handling these situations.

The doctor’s statement of intent to return home within 6 months has no bearing on exclusion of the homesite from countable resources.

1. A written statement from the "physician of record" is required, in addition to the FL-2/MR-2. The statement must confirm that the a/b may reasonably be expected to return home within 6 months from the date their CPI began.

2. Flag the case for review in the 6th month from the date their CPI began. (e.g. Enters LTC 9/23, 6 months equals 3/23. The review should be conducted in the first week of March allowing the a/b a full six months to return home.)

a. If the beneficiary has not returned home by the first week of the 6th month, verify with the physician or medical facility whether they will return home before the end of the 6th month. If they are to return home in this month, budget PLA after notice requirements is met.

b. If the physician/medical facility indicates the individual will remain institutionalized beyond the 6th month, stop deducting the medically needy income level for one after sending timely notice. Increase the patient liability beginning with the 7th month.

3. If a single a/b (no spouse/dependents at home) returns home within 6 Docusign Envelope ID: 950E9248-29CC-8930-81BC-BCEC667EB493