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304.01 Introduction to Nursing Home, and Home and Community Based Services 238
304.02 Application Form 239
304.02.01 SSI or Other Medicaid Beneficiaries Applying for Nursing Home or Home and Community Based Services 239
304.02.02 Requests for Additional Information 241
304.03 Categorical Eligibility Criteria 242
304.03.01 Waiver Waitlist 244
304.04 Non-Financial Eligibility Criteria 244
304.05 Financial Eligibility Criteria 244
304.05.01 Income 244
304.05.01A Budgeting BHDD Work Therapy Wages 245
304.05.02 Resources 246
304.05.02A Reducing Excess Resources 248
304.05.03 Homestead Property 249
304.06 Level of Care 251
304.06.01 Level of Care Certification 251
304.06.02 When a Level of Care is Required 252
304.06.03 Client Status Document 254
304.06.04 Client Status Document From CLTC 254
304.06.05 Client Status Document From BHDD 256
304.06.06 Client Status Document for PACE 257
304.06.07 Client Status Document for the Psychiatric Residential Treatment Facility (PRTF) Waiver 259
304.07 Standard of Promptness 261
304.07.01 Arranging for Alternate Placement 262
304.08 Transfer of Assets Prior to February 8, 2006 262
304.09 Transfer of Assets on or after February 8, 2006 262
304.09.01 Definitions that Apply to Transfer of Assets and Trusts 262
304.09.02 Transfer of Assets for Less than Fair Market Value 264
304.09.02A Effective Date of Transfer of Assets Policy 265
304.09.02B Individuals Affected by Transfer of Assets Provisions 265
304.09.02C Look-Back Date/Period 266
304.09.02D Penalty Period – Important Points 277
304.09.02E Transfers by a Spouse 281
304.09.02F Transfers of Jointly Held Assets 282
304.09.02G Transfers and Lifetime Rights to Property 283
304.09.02H Transfer of Assets in Month of Receipt 285
304.09.02I Transfer of Income 286
304.09.03 Exceptions to the Penalty 286
304.09.04 Waiver of Transfer Penalty Procedure and 30-Day Hold 290
304.09.05 Calculating the Penalty Period 290
304.09.06 Notification of Penalty 293
304.09.07 Medicaid Benefits during Penalty Period 294
304.09.08 Annuities 294
304.10 Obtaining Other Assets/Elective Share 294
304.11 Promissory Notes 295
304.11.01 Actuarially Sound Notes 296
304.11.02 Transfer of Assets Related to Promissory Notes 297
304.11.03 Default on Payments 298
304.11.04 Forgiving Principal Portions of Promissory Notes 298
304.12 Annuities 299
304.12.01 Periodic Payments 299
304.12.02 Purpose of Annuity 299
304.12.03 Transfer penalty 302
304.13 Spousal Impoverishment Provisions 303
304.13.01 Definitions 303
304.14 Spousal Impoverishment and Resources 303
304.14.01 Separated Spouses 305
304.14.02 Undue Hardship 307
304.15 Budgeting Income and Resources Under Spousal Impoverishment Provisions 308
304.15.01 Eligibility 308
304.15.02 Post-Eligibility 308
304.15.02A Income Allocation 309
304.15.02B Resource Allocation 320
304.15.02C Changes in Community Spouse’s Resources after Approval 321
304.15.03 Prenuptial Agreement 321
304.15.04 Resource Assessment 321
304.16 30-Consecutive Day Requirement 322
304.16.01 Effective Date of Eligibility 328
304.16.02 Moving from a Medical Facility to Home and Community Based Services 329
304.16.03 Moving from Home and Community Based Services to a Medical Facility 329
304.17 Permit Days 329
304.18 Vendor Payment 329
304.18.01 Recurring Income Used to Determine Vendor Payment 330
304.18.02 Protected Income 343
304.18.03 Medicaid Eligibility and Vendor Payment 345
304.19 Income Trust 345
304.19.01 Who May Be Covered Under this Provision 345
304.19.02 Income Trust Requirements 346
304.19.03 Explanations and Forms to Give at Intake 346
304.19.04 Establishing an Income Trust 346
304.19.04A Who Can Sign the Trust Document? 347
304.19.04B Review of the Income Trust 348
304.19.04C Death of an Applicant 349
304.19.05 Funding the Income Trust 349
304.19.06 Income Eligibility 352
304.19.06A Allowable Deductions for Nursing Home 353
304.19.06B Allowable Deductions for Home and Community Based Services 365
304.19.07 Billing for Home and Community Based Services Waiver Program Participants 370
304.19.08 Annual Accounting 370
304.19.09 Trust Modification: Trustee or Bank Account Change 372
304.19.10 Non-Compliance with Terms of the Income Trust 372
304.19.11 Death of Income Trust Principal Beneficiary 373
304.19.12 Income Trust Dissolution 373
304.19.13 Income Trust and Transfer Penalties 374
304.19.14 Income Trust Identification/Set up Flow 374
304.20 Other Trusts 376
304.20.01 Undue Hardships and Trusts 376
304.21 Bed Hold Policy 377
304.22 Medicare/Co-Insurance 379
304.23 DHHS Form 181 (Notice of Admission, Authorization and Change of Status for Long-Term Care) 379
304.23.01 Initiation of DHHS Form 181 380
304.23.02 Signature Requirements 380
304.24 Program for All-inclusive Care for the Elderly (PACE) 381
304.24.01 PACE Participant Enters a Nursing Home 381
304.24.02 PACE Participant Enters a Residential Care Facility 382
304.24.03 PACE Participant Terminated from Program 382
304.25 Denial of Payment for New Admissions (DPNA) 382
304.26 Miscellaneous Facts about Nursing Facilities 383
304.26.01 Private vs. Semi-Private Rooms 383
304.26.02 Solicitation of Contributions from Medicaid Beneficiaries by Providers of Long-Term Care Services 384
304.26.03 Sitters 384
304.26.04 Condition of Admission 384
304.26.05 Continuing Care Retirement Communities (CCRCs) 384
304.27 Estate Recovery 385
304.28 Basic Application Process for Nursing Home and Home and Community Based Service Cases 387
304.29 Case Record Requirements 390
304.30 Annual Review Procedures 391
304.30.01 Nursing Home 391
304.30.02 Home and Community Based Services 392
304.31 Introduction to General Hospital 394
304.31.01 General Hospital vs. Nursing Home Assistance 394
304.31.02 Non-Financial Eligibility Criteria 394
304.31.03 Categorical Eligibility Criteria 395
304.31.04 Financial Criteria 397
304.31.05 Continued Eligibility 398
304.31.06 Basic Application Process 399
304.31.06A Receipt of Application/Intake 399
304.31.06B Processing of Application 399
304.31.06C Determination of Eligibility/Ineligibility 400
304.31.06D Continued Eligibility 400
304.32 Palmetto Coordinated System of Care (PCSC) Waiver 401
304 Appendix A Life Expectancy Table 402
304 Appendix B Non-Covered Medical Expenses and Allowable Deductions 403
304 Appendix C DHHS Form 181 404
304 Appendix D Current Average Monthly Nursing Facility and Medicaid Payment Rates 406
304 Appendix E Comparison of Applicable Required Elements for Institutional Programs (NH-HCBS-GH) 411
304 Appendix F Recurring Income (Cost of Care) Allowable Deductions – NH/HCBS Cases 412
304 Appendix G Home Equity Procedures Flowchart 413
304 Appendix H Waiver Programs Comparison Chart 414
304 Appendix I Look-back Procedures for ABD Applicants 417
304 Appendix J Phoenix Procedures 418
304 Appendix K Determining a Reasonable Rate of Interest for Promissory Notes 425
304.01 Introduction to Nursing Home, and Home and Community Based Services
(Eff. 09/01/17)
The South Carolina Medicaid program sponsors the payment of long-term care for individuals who reside in certain licensed and certified medical facilities. Such facilities include:
Skilled Nursing Facilities (SNF) and Intermediate Care Facilities (ICF)
Swing Beds
Intermediate Care Facilities for the Intellectually Disabled (ICF/ID)
The Medicaid program also pays for special services to individuals who participate in Home and Community Based Services (HCBS) waivers and a Program for All Inclusive Care of the Elderly (PACE). Refer to Appendix H for a comparison of the different waivers. Refer to Appendix H for a comparison of the different programs. These programs include:
Community Long-Term Care
Community Choices (formerly known as Elderly and Disabled)
HIV/AIDS
Ventilator (VENT)
Department of Behavioral Health and Developmental Disabilities (BHDD)
Head and Spinal Cord Injury (HASCI)
Intellectual Disability/Related Disabilities (ID/RD)
Psychiatric Residential Treatment Facility (PRTF)
Program of All Inclusive Care of the Elderly (PACE)
This chapter includes policies and procedures used to determine Medicaid eligibility for institutionalized individuals. For Medicaid purposes, an institutionalized individual is one who resides in a medical institution (nursing home) or receives home and community based services. The same eligibility requirements apply to both the Nursing Home (NH) and the Home and Community Based Services (HCBS) programs. The difference is that individuals who need nursing home care but choose to stay at home rather than in an institution, can receive special services through a waiver to help them remain in their home.
To qualify for the Medicaid coverage discussed in this chapter, an individual must meet categorical eligibility. Normally that means he must be aged, blind, or disabled. If the individual is eligible for full Medicaid benefits under another category that has different categorical eligibility requirements, he may still qualify for payment of Nursing Home or HCBS services if all other criteria discussed in this chapter are met and he remains Medicaid eligible.
Most individuals who qualify for Medicaid sponsorship in a long-term facility must contribute toward the cost of care. Individuals who qualify for HCBS with an Income Trust may be required to contribute toward the cost of the services they receive.
If an individual is not Medicaid eligible before he/she enters a medical institution or a waiver program, he/she must receive such services or a combination of such services for 30 consecutive days before he/she can be considered institutionalized.
Table of Contents
304.02 Application Form
(Eff. 10/01/13)
Generally, Form 3401, Application for Nursing Home, Residential or In-Home Care OR DHHS Form 3400, Healthy Connections Application, AND DHHS Form 3400-B, Additional Information for Nursing Home and In-Home Care, are used to obtain information needed to determine eligibility under the institutional categories.
304.02.01 SSI or Other Medicaid Beneficiaries Applying for Nursing Home or Home and Community Based Services
(Rev. 01/01/26)
The DHHS Form 3401 OR the DHHS Form 3400 with the DHHS Form 3400-B are:
NOT required when the SSI recipient:
Enters a nursing facility and the SSI payment is expected to continue
Enters a Home and Community Based Services waiver program
Is being evaluated under the SDX Ex Parte Process
Supplemental Security Income Recipients SSI recipients who enter a facility and have their SSI benefits terminated will be required to be evaluated through the SDX Ex Parte Process. A DHHS Form 3401, or 3400-B would not be required for nursing home applicants unless SSI was ended because of a transfer, or the member attested to a spouse/dependent. If PCAT 80 is closed prior to a decision being made on nursing home coverage, the Eligibility Specialist should authorize Non-MAGI Manual Eligibility under PCAT 32 for 12 months. Once a decision has been made, the Non-MAGI Manual Eligibility should be ended, and the nursing home coverage processed. Dual eligibles (recipients of both Retirement, Survivors, and Disability Insurance (RSDI) and SSI benefits) who enter a facility permanently (more than 90 calendar days) and whose RSDI benefit is greater than $50 will usually have their SSI benefits terminated. SDX Ex Parte Process is required. Medicaid application is not required unless SSI was ended because of a transfer or the member attested to a spouse/dependent, then a DHHS Form 3400-B will be required. Dual eligibles entering a facility temporarily (less than 90 calendar days) usually continue to qualify for SSI. A Medicaid application or the SDX Ex Parte Process is not required Dual eligibles (recipients of both Retirement, Survivors, and Disability Insurance (RSDI) and SSI benefits) who enter a facility permanently (more than 90 calendar days) and whose RSDI benefit is less than $50 will usually continue to receive SSI benefits. A Medicaid application or the SDX Ex Parte Process is not required The Payment category should be changed to 54 for the period during which the individual is both in a nursing facility and SSI eligible
SSI only Expected Length of Stay Less than 90 days in the facility | 90 days or more in the facility No application required Change PCAT 80 to PCAT 54 at approval Sign and send 181 | No application required Change PCAT 80 to PCAT 54 at approval Sign and send 181 SSI and another source of income Expected Length of Stay Less than 90 days in the facility | 90 days or more in the facility Other income less than or equal to $50 | No application required Change PCAT 80 to PCAT 54 at approval Sign and send 181 | No application required Change PCAT 80 to PCAT 54 at approval Sign and send 181 Other income greater than $50 | No application required Cúram rules will approve for PCAT 10 Sign and send 181 | The SDX Ex Parte Process will be required 3401 or 3400-B would not be required unless SSI was ended because of a transfer, or the member attested to a spouse/dependent. No look-back while SSI eligible After 90 days in facility, SSI should close If SSI terminates prior to approving application Conduct modified look-back (MPPM 304.09.02C) from date SSI was terminated (end of the month in which 90 th day falls/1 st month with no SSI eligibility) to decision date If approved prior to 90 th day No look-back needed for decision For all, change from PCAT 80 to PCAT 10 at decision DHHS Form 181 forms still need to be completed and signed
Other Medicaid Beneficiaries
Other Medicaid beneficiaries applying for Nursing Home or Home and Community Based Services waiver program are not required to complete a separate application, but a DHHS Form 3400-B should be completed to collect the information necessary to conduct the look-back period for transfers. The documentation contained in the beneficiary’s case record must be considered when conducting the look-back. A DHHS Form 1233 must be sent to the beneficiary requesting any additional information. For beneficiaries seeking Home and Community Based services who have been ex parted from PCAT 80 to PCAT 32 after the referral for CLTC was initiated, a DHHS Form 3400-B would not be required unless SSI was ended due to a transfer of assets. The SDX record should be reviewed to determine the reason for termination. If no transfer is indicated or attested, the eligibility workflow can be approved in Phoenix.
Beneficiaries active under a full coverage eligibility category are not subject to retroactive coverage limits when applying for Nursing Home services, provided there has been no interruption in their Medicaid coverage. In instances where a lapse in coverage has occurred, retroactive eligibility for Nursing Home services is limited to the most recent period during which the beneficiary maintained active full coverage status.
Example
A non-MAGI application was approved for ABD (PCAT 32) in June 2024 for Sam Green. He entered the nursing home on February 15, 2025. A Long-Term Care application was filed 10/15/2025, and Mr. Green requested retro. If all eligibility criteria are met, the application for PCAT 10 can be approved beginning February 2025.
For Nursing Home or Home and Community Based Services (HCBS) applicants who are current Medicaid beneficiaries in the Aged, Blind and Disabled Category (ABD), the DHHS Form 3400-B may be used to expedite the look-back process. The completed form must be submitted by the applicant before an eligibility determination can be made. If the DHHS Form 3400-B indicates that no transfers were made by the applicant below Fair Market Value, request bank statement for the current month and for the three months prior to the request and complete a property check. However, if the completed form reveals that a possible transfer has been made, current policy is to be used to determine the nature of the transfer(s) and whether it/they are sanctionable or meet any exclusions that prevent any impact on eligibility. See 304 APPENDIX I Look-back Procedures for ABD Applicants for current procedures.
Refer to MPPM 304.29 for case record requirements.
304.02.02 Requests for Additional Information
(Rev. 07/01/24)
The DHHS Form 1233, Medicaid Eligibility Checklist is used to request additional information from applicant/beneficiaries or Authorized Representatives. For LTC and OSS applications, the eligibility worker must attempt a contact by phone to discuss the required information before mailing the request to the individual and ask any questions that may prevent a second request for information. The date, time and outcome of the contact attempt must be documented in Cúram and OnBase.
Refer to MPPM 101.07.02 if the applicant responds to a request for information.
304.03 Categorical Eligibility Criteria
(Eff. 05/01/26)
To qualify for Medicaid as an institutionalized patient, an individual must meet all of the following categorical requirements:
Reside in a medical facility, be an inpatient in a hospital, participate in a Home and Community Based Services waiver program, or a combination of the three, for at least 30 consecutive days. Count the date of admission as the first day.
The nursing facility must be a licensed and certified Title XIX facility, such as:
Skilled Nursing Facilities (SNF) and Intermediate Care Facilities (ICF)
Swing Beds
Intermediate Care Facilities for the Intellectually Disabled (ICF/ID)
Home and Community Based Service waiver programs such as:
Community Long Term Care
Elderly and Disabled
HIV/AIDS
VENT
SC Choice
Department of Behavioral Health and Developmental Disabilities (BHDD)
Head and Spinal Cord Injury (HASCI)
Intellectual Disability/Related Disabilities (ID/RD)
Psychiatric Residential Treatment Facility (PRTF)
Program of All Inclusive Care of the Elderly (PACE)
Other Qualifying Admissions:
Inpatient Hospital
Health South Rehabilitation Center
Exceptions to 30-day rule: Individual is already Medicaid-eligible in another category. Individual dies before the 30-day period expires – it is assumed he/she would have remained in the facility for 30 days.
Example #1 Mr. Glen entered Gentle Shepherd Hospital on April 1 and transferred to XYZ Nursing Home on April 25. His wife applies for Nursing Home assistance on May 10 since he is still there. His 30 days were met May 1. If eligible, he may establish eligibility as early as April 1. Example #2 Mrs. Brown is an ABD recipient. She was in Sisters of Hope Nursing Home for three weeks and applies for nursing home coverage to assist with the bill. Although she was not a resident for 30 days, she was already Medicaid-eligible in another category. If all other criteria are met, she may qualify for a vendor payment to the nursing home. Example #3 James Brooks applied for Nursing Home assistance for his father, Jim Brooks. Mr. Brooks entered Caring Hearts Nursing Facility on June 10 and died June 28. If all other criteria are met, he may establish eligibility for June. It is assumed he would have remained in the nursing home for 30 days had he lived. Example #4 Martha Smith entered the local hospital on May 3. She transferred to Yoder’s Nursing Home on May 18 and was discharged home on June 10. She met the 30 consecutive day criteria in a combination of the two settings.
SCDHHS currently maintains waitlists for three HCBS waivers: the Community Choices Waiver, the HIV/AIDS Waiver, and the Ventilator (VENT) Waiver. For individuals not currently enrolled in HCBS, there must be slot availability.
Meet a Level of Care as certified by Community Long Term Care or its designee
The individual must meet one of these Levels of Care:
Intermediate or Skilled Nursing Care
Intermediate Care for the Intellectually Disabled
Hospital Level of Care (at risk for hospitalization for HIV/AIDS waiver)
Determination is required before a vendor payment may be authorized.
Important Notes If Medicare is sponsoring the admission to the nursing home, the individual meets a Skilled Level of Care. CLTC certification is not required until Medicare sponsorship terminates. For General Hospital, the Level of Care is presumed.
Must not be subject to a penalty for a transfer of assets
Assets are evaluated for a period prior to the month of application to determine:
If the applicant and/or his/her spouse transferred any property or assets
The value received for any property transfers
If a penalty should be imposed for any transfers for less than Fair Market Value (FMV). For transfers occurring before February 8, 2006, refer to MPPM 304.08. For transfers occurring on or after February 8, 2006, refer to MPPM 304.09.
Refer to MPPM 304.08.02C for the look-back period for applications received prior to February 8, 2006. For applications received on or after February 8, 2006, refer to MPPM 304.09.02C.
Exception There is no penalty for a transfer of assets under the General Hospital category. However, if an individual transfers from the hospital to a nursing home or seeks to participate in a HCBS waiver, a penalty may affect continued eligibility under the other category.
Must be Aged, Blind, or Disabled (based on SSI criteria), unless the individual is already eligible for Medicaid in another category.
304.03.01 Waiver Waitlist
(Eff. 05/01/26)
For the Home and Community-Based Services (HCBS) waiver programs, the South Carolina Department of Health and Human Services (SCDHHS) establishes annual enrollment capacity based on available funding. When the number of individuals who meet the eligibility criteria for a waiver exceeds the number of available funded slots, a waitlist is created. SCDHHS currently maintains waitlists for three HCBS waivers: the Community Choices Waiver, the HIV/AIDS Waiver, and the Ventilator (VENT) Waiver.
Table of Contents
304.04 Non-Financial Eligibility Criteria
(Rev. 04/01/11)
To qualify for assistance in this category, the individual must meet certain non-financial requirements. (Refer to MPPM Chapter 102 for specific information on the following.)
Identity MPPM 102.02
State Residency MPPM 102.03
Citizenship/Alienage MPPM 102.04
Enumeration/Social Security Number MPPM 102.05
Assignment of Rights to Third Party Medical Payments MPPM 102.07
304.05 Financial Eligibility Criteria
(Eff. 10/01/05)
The individual must meet certain income and resource criteria in order to be eligible. Financial eligibility requirements are based on SSI policy. This chapter covers the requirements specific to this category. (Refer to MPPM Chapter 301 for general income information and to MPPM Chapter 302 for general resource information.)
304.05.01 Income
(Rev. 09/01/23)
Current income must be verified at the time of application, re-budget, or annual review. When a beneficiary has not begun receiving Long-Term Care Services at the time of application, income must be verified and budgeted for the month of entry into the facility or program by reviewing interfaces and reported changes. At approval, any Cost-of-Living increases or income reductions must be budgeted (as appropriate) from one year to the next. (See MPPM 303.06.03A for individuals qualifying under ABD income criteria.)
Example 1
An applicant meets eligibility based on the income reported at the time of application in the month of 4/2023. The applicant enters the facility in the month of 5/2023, but an increase is received in social security benefits in May. The income increase must be counted and budgeted in the month of entry.
Example 2
An applicant meets eligibility based on the income reported at the time of application in the month of 12/2022. The applicant enters the facility in the same month, but an increase is received in social security benefits for 01/2023. Use 2022 income for the month of entry and the new amount for January.
Income Limits
Institutionalized individuals must meet a special income limit known as the Medicaid Cap.
The Medicaid Cap is equal to 300 percent of the current SSI Federal Benefit Rate (FBR) for an individual.
The individual’s gross monthly income must be at or below the Medicaid Cap.
If the income exceeds the Medicaid Cap, an Income Trust may be established in Nursing Home and Home and Community Based Services cases. (Refer to MPPM 304.19)
Only the institutionalized individual’s income is counted in the eligibility determination. If the individual has a community spouse and the individual agrees to provide a spousal allocation, the community spouse’s income must be verified and considered to calculate the allocation.
304.05.01A Budgeting BHDD Work Therapy Wages
(Eff. 10/01/25)
The Department of Behavioral Health and Developmental Disabilities (BHDD) will report wages earned by individuals who reside in a BHDD facility and participate in a work therapy program as part of the plan of care. Individuals participating in work therapy are allowed a deduction of $100.00 per month for personal needs. BHDD will use the DHHS Form 181 to communicate and verify the amount of gross income earned by each Medicaid beneficiary in the section labeled, “This Box for BHDD Therapy Wages Only.” BHDD will report the following actions and the effective date: Start, Significant Change, and Stop.
Eligibility workers will budget or rebudget recurring income based on the reported wages using the instructions below.
Start
When Start is checked on the DHHS Form 181 from BHDD, this indicates this is the first month in which the beneficiary received work therapy earnings. Budget the case using the amount of work therapy earnings shown and increase the Personal Needs Allowance to $100.00. The DHHS Form 181 must be filled out and returned to BHDD even if recurring income does not change after including the work therapy earnings in the budget. The form should be sent back to BHDD by the last day of the month it was received.
Significant Change
When Significant Change is checked on the DHHS Form 181 from BHDD, this indicates that there is a difference of $50.00 of more between the amount of the beneficiary’s current work therapy wages and the amount previously budgeted. Rebudget the case using the amount of work therapy earnings shown. The DHHS Form 181 must be filled out and returned to BHDD even if recurring income does not change after including the work therapy earnings in the budget. The form should be sent back to BHDD by the last day of the month it was received.
Stop
When Stop is checked on the DHHS Form 181 from BHDD, this indicates that the beneficiary no longer participates in work therapy. Rebudget the case to remove the work therapy earnings and reduce the Personal Needs Allowance to $60.00. The DHHS Form 181 must be filled out and returned to BHDD even if recurring income does not change after removing the work therapy earnings and reducing the Personal Needs Allowance in the budget. The form should be sent back to BHDD by the last day of the month it was received.
304.05.02 Resources
(Rev. 01/01/25)
Current resources must be verified and documented at application, annual review, and reported changes.
Documentation is the written record and explanation of verified information and methods used to complete the verification. Eligibility Specialists must provide an explanation or justification of methods used for counting or excluding resources on the Documentation Template.
Example
If “neighboring” balances are used for the lowest monthly balance for the application month, an explanation/justification is required on the Documentation Template under the comments for the specific resource.
Procedure for Verification: Refer to the resource chapter for acceptable forms of: Verification Rebuttal evidence Verify and document any alleged resources. Exception Verification of value is not required for resources that are totally excluded, regardless of value, but ownership must be verified for excluded Homestead property and excluded automobiles. Verify and document any resources revealed through IEVS checks. A current property check and lookback is required for all Long-Term Care applicants. Note: If each member of a couple has life insurance, each is entitled to the exclusion if the total face values for each insured person are $10,000 or less. Example Mr. Brown has life insurance totaling $5,000. Mrs. Brown has $4,000 in life insurance. No cash value is counted for either. Example Mrs. Price has two policies; one insures herself valued at 10,000. The other ensures Mr. Price valued at 10,000. Mr. Price also has two policies valued at 10,000 each. One insures himself. The other ensures Mrs. Price. All four policies are excluded. (See MPPM 302.17 Life Insurance)
Exception: Verification of current resources is not required for SSI recipients who are: · Entering a nursing home and who will continue to receive an SSI payment (that is, SSI is the only income); or · Entering a Home and Community Based Services waiver program.
Resource Limits
The institutionalized individual must have countable resources equal to or below $2,000. Allowable deductions include resource allocations under the Spousal Impoverishment Provision discussed later in this chapter.
Exception If an individual’s countable income is below the ABD limit, he/she may have up to $9, 660 in countable resources and still qualify for a Nursing Home vendor payment.
If married, the resources of both the institutionalized individual and the community spouse are considered in the initial eligibility determination.
304.05.02A Reducing Excess Resources
(Eff. 04/01/25)
The following policy applies to any institutional eligibility decision made on or after April 1, 2025.
If an applicant applying for Nursing Home or Waiver Services is over the resource limit after the eligibility specialist determines the individual is otherwise eligible, the eligibility specialist must determine if it is reasonable that the applicant can reduce the countable resources below the limit within 30 days. If the applicant has excess resources, they must be reduced within 30 days; however, a minimum 15-day notice must be given. The eligibility specialist must talk to the applicant during the application process to explain any remaining options for reducing excess resources. The eligibility specialist will use the following process to calculate a Reasonable Expectation Reduction Period. The decision considers the individual’s countable gross monthly income and the Average Private Pay Rate.
Procedure Average Private Pay Rate per Month – Countable Income = Net Cost per Month Gross Countable Resources – Resource Limit = Excess Countable Resources Excess Countable Resources ÷ Net Cost per Month = Reasonable Expectation Reduction Period The applicant has until the end of the month in which the 30 th day occurs to demonstrate they have reduced the countable resources. Examples John is applying for Nursing Home. His financials are as follows: Income: $1,500 $ 9,758.58 - $1,500 = $ 8, 258 . 58 Resources: $9,000 $9,000 - $2,000 = $7,000 $7,000 ÷ $ 8, 258 . 58 = 0. 8 4 Months 0. 8 4 x 30 = 2 5 .4 days There is a reasonable expectation that John’s resources may be under the limit within the next 30 days. His application will remain pending. Alfie is applying for HCBS. His financials are as follows: Income: $2,000 $9, 758 . 58 - $2,000 = $7, 758 . 58 Resources: $27,000 $27,000 - $2,000 = $25,000 $25,000 ÷ $7, 758 . 58 = 3. 2 2 Months There is NOT a reasonable expectation that Alfie’s resources may be under the limit within the next 30 days. His application is denied for Excess Resources. Anna Leigh is applying for ABD-SC Nursing Home. Her financials are as follows: Income: $925 $9, 758 . 58 - $925 = $8, 833 . 58 Resources: $15,000 $15,000 - $9, 950 = $5, 050 $5, 050 ÷ $8, 833 . 58 = 0. 57 Months 0. 57 x 30 = 17 . 1 days There is a reasonable expectation that Anna Leigh’s resources may be under the limit within the next 30 days. Her application will remain pending .
If the Reasonable Expectation Reduction Period is greater than 30 days, deny the application for excess resources
Prior to denying the case ensure that any encumbrances have been explored, and documentation is on the Documentation Template (See MPPM 302.29)
If the Reasonable Expectation Reduction Period is less than or equal to 30 days, leave the application in pending status. The applicant has until the end of the month in which the 30th day occurs to show they have reduced the countable resources
The eligibility specialist must contact the applicant to let them know they are over the resource limit and to discuss any remaining options available for reducing the value within 30 days
The applicant will be required to contact the agency within 30 days to report if they are under the limit
If the applicant reports that they are over the limit, deny the application for excess resources
If the applicant reports they are under the limit, the eligibility specialist must verify the current value of the resources
If the countable value is under the limit, determine eligibility
If the countable value is over the limit, deny for excess resources
If the applicant fails to contact the agency, the application is denied for excess resources.
Table of Contents
304.05.03 Homestead Property
(Eff. 01/01/26)
For applications filed before January 1, 2006, homestead property is excluded regardless of value with intent to return home and is not subject to the home equity requirement as long as there is no break in institutionalization (Refer to MPPM 302.14.01). No break in institutionalization occurs if a beneficiary remains in an institutional setting and does not have to file a new application for long-term care services to re-establish eligibility.
Note
If the individual has returned home during the process of making an eligibility determination, the intent to return is assumed and a DHHS Form 1277 is not needed.
Example 1 Mr. Jones is in the nursing home but is then admitted to the hospital. He stays for two months and remains Medicaid eligible. He subsequently returns to the nursing home. No break occurred because he was in an institutional setting and does not require a new application to re-establish eligibility for long-term care services. (If Mr. Jones were an Income Trust case, a break in institutionalization has occurred because he would lose Medicaid eligibility while in the hospital and would require an application to re-establish eligibility.) Example 2 Mr. Jones is due for annual review, but his authorized representative (AR) does not return information needed to complete the redetermination. Mr. Jones’ case is closed, but he remains in the nursing home. Forty days after the date on the closure notice, the AR returns the information. A break in institutionalization has occurred, and Mr. Jones’ is subject to the home equity requirement because a new application is required to re-establish Mr. Jones’ eligibility for long-term care services.
The Deficit Reduction Act of 2005 changes the way homestead property is evaluated for individuals applying for long-term care services effective with applications received on or after January 1, 2006. Homestead property for applicants whose spouse, child under age 21, or a child who is blind or disabled lawfully resides in the home is excluded regardless of equity value. The statement of the applicant/beneficiary or authorized representative is adequate verification of an individual lawfully residing in the home. Otherwise, individuals with an equity interest in their home over $752,000 are not eligible for vendor payment or other long-term care services, but may be eligible for MAO-NH, Payment Category 10, or other Medicaid category if all other eligibility criteria are met. (Refer to MPPM 101.04.01.) An applicant may seek to reduce his or her equity value by taking out a loan on the home including reverse mortgage arrangements. Verify the arrangements and the amount of funds the individual receives. The equity value does not decrease until the client actually receives the money from the loan. Any amount of funds received from a loan is an available resource when received. Any such arrangements must be done under a written contractual agreement. Chapter 104, Appendix HH contains additional information about reverse mortgages.
Procedure for Applications Received After January 1, 2006 If an applicant indicates homestead property, complete a DHHS Form 1255 ME, Verification of Real and Personal Property , and obtain the current assessed value of the property. If the applicant has a spouse, a child under age 21, or a child who is blind or disabled that lawfully lives in the home, exclude the value of the home regardless of value, and continue with the eligibility determination. If the applicant does not meet the criteria in step 2, and the assessed value is equal to or less than $ 752 ,000 , exclude the property, and continue with the eligibility determination. If the applicant does not meet the criteria in step 2, and the assessed value exceeds $ 752 ,000 , request verification of any mortgages, liens, judgments, or other encumbrances that may reduce the equity value of the property. Subtract the reductions from the assessed value of the property. If the remaining equity value is equal to or less than $ 752 ,000 , continue with the eligibility determination. If the remaining equity value exceeds $ 752 ,000 , deny for long-term care services. Determine Medicaid eligibility.
Refer to MPPM Chapter 304 Appendix G for a flowchart detailing the procedure for the Home Equity requirement.
304.06 Level of Care
(Eff. 07/01/17)
A Level of Care (LOC) is a determination of medical necessity for care. A qualified individual must meet either an Intermediate or Skilled level of care designation.
304.06.01 Level of Care Certification
(Rev. 09/01/17)
Community Long Term Care (CLTC) or its designee must certify the individual’s level of care before Medicaid can pay for long-term care services. The eligibility worker is notified of the findings in writing. The DHHS Form 185, Level of Care Certification Letter, issued by CLTC, or the DHHS Form 210, Resident Case Mix Classification Change, issued by a nursing facility, is used for notification on nursing home applicants/ beneficiaries. The DHHS Form 118/118A, Client Status Document, is used to notify the eligibility worker when the individual is a HCBS applicant/beneficiary.
Procedure – Certification of Level of Care Either Community Long Term Care or its designee certifies the medical necessity. The chart below indicates who provides the level of care certification. Facility Placement / HCBS Certifier Facility Placement Nursing Home placement Community Long Term Care (CLTC) Intermediate Care Facility for the Intellectually Disabled (ICF/ID) Department of Behavioral Health and Developmental Disabilities (BHDD) Home and Community Based Services Community Choice Waiver CLTC HIV/AIDS Waiver CLTC Ventilator Waiver CLTC Head and Spinal Cord Injury (HASCI) Waiver BHDD -OIDD Intellectual Disability and Related Disabilities (ID/RD) Waiver BHDD -OIDD Program of All Inclusive Care of the Elderly (PACE) Palmetto SeniorCare Program of All Inclusive Care of the Elderly (PACE) Palmetto SeniorCare
At the time of application, a level of care must be requested. Use the DHHS Form 1231 ME, Request for Level of Care. The DHHS Form 1231 is always sent to the certifying agency at the time of application, regardless of when the level of care needs to be determined.
Procedure to Request Level of Care The applicant’s location determines where the DHHS Form 1231 ME is sent Applicant’s Location Send DHHS Form 1231 to Level of Care is Certified by Hospital Hospital and CLTC CLTC Nursing Facility Nursing Facility and CLTC CLTC ICF/ID BHDD -OIDD BHDD -OIDD Community Waiting for Nursing Home placement CLTC CLTC Applying for CLTC services CLTC CLTC Applying for ID/RD, HASCI, or PDD waiver BHDD -OIDD BHDD -OIDD Applying for a Program of All Inclusive Care of the Elderly (PACE) PACE Provider (Only in Richland, Lexington, and Orangeburg Counties) PACE Provider
Table of Contents
304.06.02 When a Level of Care is Required
(Eff. 08/01/07)
A level of care certification, or re-certification, is required under the following circumstances:
Nursing Home Assistance
Before a Medicaid-sponsored admission
Before a vendor payment may be authorized
If an applicant enters or resides in a nursing facility within 30 days of the effective date shown on the DHHS Form 185, Level of Care Certification Letter, the certification remains valid as long as the applicant remains at the facility.
A new LOC certification IS NOT required at the time of approval as long as the individual did not leave the facility after the date of entry for any reason.
NOTE: If a LOC is required by the nursing facility for billing purposes, the facility is responsible for obtaining the updated certification.
A new LOC certification is required at the time of approval if the individual left the facility for any reason, including a hospital stay.
Exception: If an applicant transfers directly from one nursing facility to another nursing facility, a new LOC is not required.
Before a re-admission, if the vendor payment has terminated
A time-limited LOC certification expires and the vendor payment needs to continue
When a patient transfers from a:
Department of Behavioral Health and Developmental Disabilities (BHDD Office of Mental Health) IMD facility to a non-BHDD Office of Mental Health long-term care facility
Department of Behavioral Health and Developmental Disabilities - Office of Intellectual and Developmental Disabilities (BHDD-OIDD) ICF/ID facility to a non-BHDD-OIDD long-term care facility
A Medicaid level of care determination is not required while Medicare is paying for the admission. The level of care is presumed to be skilled during the period of Medicare sponsorship. The DHHS Form 1231, Request for Level of Care, must be sent at the time of application, with a notation the applicant will initially enter the facility under Medicare sponsorship. (Note: At the end of this period, a level of care is required for potential continuing benefits. This includes when a patient returns to a facility from a hospital after a bed hold expires.) A DHHS 3229-B ME, Notice of Cost of Care for Medicare Sponsorship in a Nursing Home, is used to advise the applicant/beneficiary or the authorized representative of both the cost of care and the need for a certified level of care when Medicare Sponsorship ends.
Example #1 Mr. Jones was a Medicaid patient at Caring Hearts Nursing Home before going into the hospital. He was in the hospital for 15 days. A new level of care is required before Medicaid will pay for the re-admission. Example #2 Jane Sons enters Sisters of Hope Nursing Home. She meets all the financial eligibility criteria for Medicaid. The facility has requested payment, but the eligibility worker has not received a certified level of care. A payment cannot be authorized until one is received. Example #3 Cindy Bouknight is a Medicaid patient at the Babcock Center’s Wire Road ICF/ID facility. She has an accident and must be transferred to the skilled care floor at Sisters of Hope Nursing Home. A level of care certification is required before payment may be authorized. Example #4 Stella King entered Regional Medical Center on March 5. She transferred to Caring Hearts Nursing Home under Medicare on March 10. She applied for Medicaid to assist with her bills there. The nursing home submitted a DHHS Form 181 , Notice of Admission, Authorization, and Change of Status for Long Term Care, for coverage. Her Medicare eligibility ends effective May 1. CLTC assessed her at an Intermediate level of care. Caring Hearts submitted a DHHS Form 181 with a copy of the level of care certification requesting vendor payment effective May 1. All other eligibility criteria were met in March. The eligibility worker approved the case effective March 1. A level of care was not required for the March 10 admission because an individual must meet a Skilled level of care before Medicare will sponsor an admission at a nursing facility.
Home and Community Based Services Waiver
A level of care must be certified before an individual may be approved to enter the waiver program.
General Hospital
A level of care certification is not required. The hospital’s Utilization Review Board completes a treatment plan to justify continued hospitalization, therefore a level of care is presumed.
Table of Contents
304.06.03 Client Status Document
(Rev. 09/01/12)
The DHHS Form 118/118-A/188-B, Client Status Document (CSD), is the primary tool used by CLTC/BHDD/PRTF Alternative CHANCE to communicate information to the Medicaid eligibility worker. Some of its uses are for:
CLTC/BHDD/PRTF Alternative CHANCE to notify the eligibility worker that an applicant/beneficiary meets level of care;
CLTC/BHDD/PRTF Alternative CHANCE to notify the eligibility worker that a beneficiary has requested waiver services and the look-back needs to be developed; and
Eligibility worker to notify CLTC/BHDD/PRTF Alternative CHANCE of information regarding the applicant/beneficiary, such as:
Financially eligibility
Needs to meet the 30 consecutive day requirement
Ineligibility
Do not forward the CSD to CLTC/BHDD/PRTF Alternative CHANCE until it is determined if all eligibility factors are met with the exception of the 30 consecutive day criteria. It is extremely important to complete the CSD accurately for a new beneficiary before returning it to CLTC/BHDD/PRTF Alternative CHANCE. CLTC/BHDD/PRTF Alternative CHANCE enters the applicant/beneficiary into the waiver and authorizes and starts waiver services for individuals based on the information provided on the CSD.
The appropriate completion of the CSD varies, depending on the individual’s category of assistance. For instructions on completing a CSD sent by CLTC, refer to MPPM 304.06.04; for a CSD sent by BHDD, refer to MPPM 304.06.05; for a CSD sent by PACE, refer to MPPM 304.06.06; and for a CSD sent by PRTF Alternative CHANCE Project Director, refer to MPPM 304.06.07.
304.06.04 Client Status Document From CLTC
(Rev. 07/01/24)
A. SSI Recipient Enters Waiver
When an SSI recipient enters the waiver, CLTC would enroll the recipient in the waiver and authorize services. A look-back for transfer of assets is not required. In Cúram, the category will remain 80.
B. Already Medicaid Eligible, But Without SSI, Beneficiary Enters Waiver
When a beneficiary who is already eligible for Medicaid in a category other than SSI enters the waiver, CLTC sends a CSD to the eligibility worker who maintains the open record with a message “CLIENT ENTERING WAIVER. CHECK FOR ANY TRANSFER OF RESOURCES WITHIN THE PAST 60 MONTHS.” This message is printed directly below the address of the CLTC and eligibility office. The local eligibility office will complete a DHHS Form 1233 ME, Medicaid Eligibility Checklist, and send to the beneficiary requesting the DHHS Form 3400-B, Additional Information for Nursing Home and In-Home Care, and other information necessary to complete a look-back for transfer of assets. The eligibility worker completes the look back and returns the CSD to CLTC with appropriate transfer information. If a transfer has occurred, a DHHS Form 932, Notice of Denial of Waiver Services or Nursing Home Care, must be sent to the beneficiary. Note
For beneficiaries seeking Home and Community Based services who have been ex parted from PCAT 80 to PCAT 32 after the referral for CLTC was initiated, a 3400-B would not be required unless SSI was ended due to a transfer of assets. The SDX record should be reviewed to determine the reason for termination. If no transfer is indicated or attested, the eligibility workflow can be approved in Phoenix.
If the beneficiary’s Medicaid category is to be changed by the eligibility worker from the original category to a category 15, this must be notated on the CSD.
Until the look back has been completed, CLTC does not enter the applicant/beneficiary into the waiver.
C. All Others, Subject to Medicaid Cap
Individuals who are not currently eligible for Medicaid may be eligible if their income is measured against the Medicaid Cap or if an Income Trust is established. When an individual requests to enter one of the home and community based waivers, CLTC will complete a telephone assessment. If it appears the applicant may meet level of care, a CSD will be sent to the local eligibility office. The eligibility worker must make contact using the information contained on the CSD to initiate the eligibility process.
When the eligibility worker completes the eligibility determination, the worker returns the properly annotated CSD with the correct eligibility information to CLTC. Please note the eligibility worker must check all boxes that apply in the Medicaid Eligibility Status section. If the applicant can be approved for another category of assistance, such as ABD, the eligibility worker can approve the application for Medicaid, and check all boxes that apply in the Medicaid Eligibility Status section of the CSD. If the beneficiary is not eligible for the waiver because of a transfer, a DHHS Form 932 must be sent to the beneficiary.
Once CLTC receives the CSD indicating the applicant will be Medicaid eligible, a formal level of care assessment will be completed. If the applicant meets level of care, CLTC will begin services and notify the eligibility worker concerning the date of entry into the waiver.
Important: The eligibility worker must determine that the applicant meets all eligibility criteria except for the 30 consecutive day requirement before the Client Status Document (CSD) is returned to CLTC. Once CLTC returns the CSD showing the date the applicant entered the waiver and the 30 consecutive day requirement has been met, the applicant can be approved for Medicaid.
304.06.05 Client Status Document From BHDD
(Rev. 07/01/24)
A. SSI Recipient Enters Waiver
When an SSI recipient enters the waiver, BHDD would enroll the recipient in the waiver and authorize services. A look-back for transfer of assets is not required. In Cúram, the category will remain 80.
B. Already Medicaid Eligible, But Without SSI, Beneficiary Enters Waiver
If the beneficiary is already Medicaid eligible, the action taken will depend upon the category.
If the beneficiary receives Medicaid in a category where his eligibility is established as an individual (such as TEFRA, ABD,) the BHDD sponsored eligibility worker will complete a DHHS Form 1233 ME, and send to the beneficiary requesting the DHHS Form 3400-B and other information necessary to complete a look-back for transfer of assets. The open Medicaid case must be requested from the Local Eligibility Processing office that has the case record. A new application is not required. Once the look-back for transfer of assets has been completed, the BHDD sponsored eligibility worker will return the DHHS Form 118-A to BHDD with the appropriate transfer information.
If the beneficiary receives Medicaid in a category where his eligibility is established as part of a budget group (such as Partners for Healthy Children (PHC) or Parent/Caretaker Relative (PCR)), the BHDD sponsored worker will complete a DHHS Form 1233, and send to the beneficiary requesting the DHHS Form 3400-B and other information necessary to complete a look-back transfer of assets. A new application is not required. Once the look-back for transfer of assets has been completed, the BHDD sponsored eligibility worker will return the DHHS Form 118-A to BHDD with the appropriate transfer information.
Until the look-back is completed, BHDD does not enter the applicant/beneficiary in the waiver. The BHDD sponsored eligibility worker will keep and maintain the case. If the beneficiary is not eligible for the waiver because of a transfer, the case record should be returned to the LEP office and a DHHS Form 932 must be sent to the beneficiary.
C. All Others, Subject to Medicaid Cap
Individuals who are not currently eligible for Medicaid may be eligible if their income is measured against the Medicaid Cap or if an Income Trust is established. When an individual requests to enter one of the BHDD waivers, a CSD is sent to the regional BHDD sponsored eligibility worker. The sponsored worker will contact the family to obtain an application. Occasionally an individual may come into the local eligibility office to file an application for a BHDD waiver. Assistance should be provided to complete the application, and the application forwarded to the regional BHDD sponsored worker for processing.
When the BHDD sponsored eligibility worker completes the eligibility determination, the worker returns the properly annotated CSD with the correct eligibility information to BHDD. Please note the worker must check all boxes that apply in Section II, Medicaid Eligibility Status.
In this situation, BHDD does not enter the applicant/beneficiary into the waiver or authorize waiver services until the BHDD sponsored eligibility worker returns the CSD to BHDD stating the applicant meets all eligibility criteria except for the level of care and 30 consecutive day requirement. If the applicant can be approved for another category of assistance, such as ABD, the eligibility worker can approve the application for Medicaid, and check all boxes that apply in Section II of the CSD. If the beneficiary is not eligible for the waiver because of a transfer, a DHHS Form 932 must be sent to the beneficiary.
Once the applicant enters the waiver, BHDD notifies the BHDD sponsored eligibility worker in writing of date of entry into the waiver and level of care by completing Section III of the CSD. If the DHHS Form 118-A is returned indicating the applicant did not meet the 30 consecutive day requirement, the application must be denied.
Important The eligibility worker must determine that the applicant meets all eligibility criteria except for the level of care and the 30 consecutive day requirement before the Client Status Document (CSD) is returned to BHDD . Until BHDD returns the CSD with Section III completed showing the level of care and the date the applicant entered the waiver, the application cannot be approved for category 15. Once the 30 consecutive day requirement has been met, the applicant can be approved for Medicaid.
304.06.06 Client Status Document for PACE
(Rev. 07/01/24)
A. SSI Recipient Enters PACE
When an SSI recipient enters the PACE, PACE would enroll the recipient and authorize services. A look-back for transfer of assets is not required. In Cúram, the category will remain 80.
B. Already Medicaid Eligible, But Without SSI, Beneficiary Enters PACE
When a beneficiary who is already eligible for Medicaid in a category other than SSI enters the program, PACE sends a CSD to the eligibility worker with a message “CLIENT ENTERING PACE. CHECK FOR ANY TRANSFER OF RESOURCES WITHIN THE PAST 60 MONTHS.” This message is printed directly below the address of the PACE and eligibility office. The eligibility worker will complete a DHHS Form 1233, and send to the beneficiary requesting the DHHS Form 3400-B and other information necessary to complete a look-back for transfer of assets. Once the look back for transfer of assets has been completed, the eligibility worker will return the CSD to PACE with appropriate transfer information. If the beneficiary’s Medicaid category is to be changed by the eligibility worker from the original category to a category 15, this must be notated on the CSD.
Until the look back has been completed; PACE does not enter the applicant/beneficiary into the program. If the beneficiary is not eligible for the waiver because of a transfer, a DHHS Form 932 must be sent to the beneficiary.
C. All Others, Subject to Medicaid Cap
Individuals who are not currently eligible for Medicaid may be eligible if their income is measured against the Medicaid Cap or if an Income Trust is established. When an individual requests to be in the program, PACE refers the individual to a local eligibility office to apply. PACE sends a CSD to the eligibility office when the level of care is determined.
When the eligibility worker completes the eligibility determination, the worker returns the properly annotated CSD with the correct eligibility information. Please note the eligibility worker must check all boxes that apply in the Medicaid Eligibility Status section. If the applicant can be approved for another category of assistance, such as ABD, the eligibility worker can approve the application for Medicaid, and check all boxes that apply in the Medicaid Eligibility Status section of the CSD.
PACE does not enter the beneficiary into the waiver or authorize waiver services until the eligibility worker returns the CSD to PACE stating that the eligibility determination has been completed and the beneficiary is eligible except for meeting the 30 consecutive day requirement. If the beneficiary is not eligible for the waiver because of a transfer, a DHHS Form 932 must be sent to the beneficiary.
Once applicant enters the program, PACE notifies the eligibility worker in writing of date of entry.
Important The eligibility worker must determine that the applicant meets all eligibility criteria except for the 30 consecutive day requirement before the Client Status Document (CSD) is returned to PACE. Once PACE returns the CSD showing the date the applicant entered the waiver and the 30 consecutive day requirement has been met, the applicant can be approved for Medicaid.
304.06.07 Client Status Document for the Psychiatric Residential Treatment Facility (PRTF) Waiver
(Rev. 07/01/24)
The Psychiatric Residential Treatment Facility (PRTF) Waiver is for children ages 4 through 18 (under age 19) who meet the criteria for a Residential Treatment Facility.
A. SSI Recipient Enters Waiver
When an SSI recipient enters the waiver, the SCDHHS PRTF Waiver Project Director would enroll the recipient in the waiver and authorize services. A look-back for transfer of assets is not required. In Cúram, the category will remain 80.
B. Already Medicaid Eligible, But Without SSI, Beneficiary Enters Waiver
The SCDHHS PRTF Waiver Project Director will inform the beneficiary that a look-back for transfer of assets is required.
The SCDHHS PRTF Waiver Project Director will complete the DHHS Form 118-B indicating the DHHS Form 3400-B was given to client to fill out, and fax the DHHS Form 118-B to the local eligibility office at 803-741-9475.
The SCDHHS PRTF Waiver Project Director will use the contact information on the DHHS Form 118-B for further/ongoing contact with the eligibility office.
The local eligibility office will complete a DHHS Form 1233 ME; and send to the beneficiary requesting the DHHS Form 3400-B and other information necessary to complete a look-back.
The specific action taken by the local eligibility office will depend upon the category under which the beneficiary is receiving Medicaid.
If the beneficiary receives Medicaid in a category where his eligibility is established as part of a budget group (such Partners for Healthy Children (PHC)), the eligibility worker will contact the family to obtain the information needed to conduct the look-back using the DHHS Form 3400-B. A new application is not required. Once the look-back has been completed, the eligibility worker will return the DHHS Form 118-B to the SCDHHS PRTF Waiver Project Director with the appropriate transfer information.
Until the look-back is completed, the SCDHHS PRTF Waiver Project Director does not enter the applicant/beneficiary into the waiver. If there is no transfer of assets, the SCDHHS PRTF Waiver Project Director can enroll the beneficiary into the waiver. There is no 30-day wait because the beneficiary is Medicaid eligible.
If the beneficiary receives Medicaid in category where his eligibility is established as an individual (such as TEFRA, Aged, Blind or Disabled) the eligibility worker will contact the family to obtain the information needed to conduct the look-back using the DHHS Form 3400-B. A new application is not required. Once the look-back for transfer of assets has been completed, the eligibility worker will return the DHHS Form 118-B to the SCDHHS PRTF Waiver Project Director with the appropriate transfer information.
Until the look-back is completed, the SCDHHS PRTF Waiver Project Director does not enter the applicant/beneficiary into the waiver. If there is no transfer of assets, the SCDHHS PRTF Waiver Project Director can enroll the beneficiary into the waiver. There is no 30-day wait because the beneficiary is Medicaid eligible.
If the beneficiary is not eligible for the waiver because of a transfer, a DHHS Form 932 must be sent to the beneficiary.
C. All Others not already Medicaid Eligible
When a request is made to enter the PRTF waiver, the SCDHHS PRTF Waiver Project Director will refer the individual to the local eligibility office to apply. The SCDHHS PRTF Waiver Project Director will complete the DHHS Form 118-B indicating the following forms were given to the family: DHHS Form 3400, Healthy Connections Application; and DHHS Form 3400-B. The SCDHHS PRTF Waiver Project Director will then fax the DHHS Form 118-B to the local eligibility office at 803-741-9475. The local eligibility office will complete a DHHS Form 1233 ME; and send to the beneficiary requesting the DHHS Form 3400, DHHS Form 3400-B, and other information necessary to complete a look-back.
Medicaid eligibility for the family should first be considered. Process the application to determine if the family is eligible for Partners for Healthy Children (PHC) or Parent/ Caretaker Relative (PCR). If the family is eligible, approve the family for Medicaid in Cúram. If there have been no sanctionable transfers by the child, return the Client Status Document indicating the child is currently Medicaid eligible and that the look back has been completed.
If the child does not qualify for Medicaid as part of the family, the worker must process the application to determine if the child would be eligible as an individual. For the family members that do not qualify for Medicaid, send a DHHS Form 3229-A, Notice of Approval/Denial for Medical Assistance/Optional Supplementation, to deny those applicants. Do not take action in Cúram to deny the Budget Group until a final determination is made on the child applying for PRTF.
Determine if the child would qualify as an individual for one of the Healthy Connections Plans for Children Under Age 19 groups. If eligible, indicate on the DHHS Form 118-B that the child has been determined financially eligible; except for the level of care (LOC), but his/her case cannot be certified until the 30 consecutive day requirement is met, and return the CSD to the SCDHHS PRTF Waiver Project Director.
When the SCDHHS PRTF Waiver Project Director receives the DHHS Form 118-B, a Level of Care will be completed. If the child meets the PRTF Level of Care, when a waiver slot is available, the SCDHHS PRTF Waiver Project Director will enter the child into the waiver and notify the Medicaid eligibility worker in writing of date of entry into waiver and verify the PRTF level of care. If the child must meet the 30 consecutive day requirement, once the 30 days has been met, approve the application back to the first day of the month in which the 30-day period began.
Important If the child must qualify as an individual, the eligibility worker must determine that the applicant meets all eligibility criteria except for the 30 consecutive day requirement before the DHHS Form 118-B is returned to the SCDHHS PRTF Waiver Project Director . Once the SCDHHS PRTF Waiver Project Director returns the DHHS Form 118-B showing the date the applicant entered the waiver and the 30 consecutive day requirement has been met, the applicant can be approved for Medicaid.
304.07 Standard of Promptness
(Rev. 07/01/24)
The standard of promptness for processing applications for institutional programs is 45 days unless a disability determination is required. For applications requiring a disability determination, the standard of promptness is 90 days.
For Nursing Home and Home and Community Based Service cases, the standard of promptness may exceed to 45/90 days if:
The eligibility determination is complete AND
The individual meets all other eligibility criteria but a bed and/or slot is not available.
While the applicant is waiting to enter a nursing facility or waiver slot, the application should remain in pending status for 90 days.
Nursing Home Pending Approval Determine the individual’s eligibility for Nursing Home. The applicant must meet all other financial and non-financial criteria, and be waiting for admission into a Nursing Home Send a CGIS717—Cover Letter-NH-Notification to Enter Nursing Facility —to the applicant The applicant has 90 days to be admitted to a nursing facility. Set the follow-up date in OnBase to 95 days to allow for mailing, scanning, and task creation If the applicant is admitted: The facility sends a completed DHHS Form 181 to DHHS indicating the date of admission T he Eligibility Specialist will determine the Cost of Care, approve the application, and send the DHHS Form 181 to the facility. If the applicant/beneficiary enters a nursing facility or waiver/HCBS after 90 days of being financially cleared and the application has not been denied in the SOR , t he Eligibility Specialist must obtain current income and resources for the month of entry. If a DHHS Form 181 admitting the applicant is not received from the facility within 90 days, the ES will check OnBase to confirm a form has not been received, and will deny the application as appropriate Note If the application has already been denied in the SOR due to not entering a facility, then the applicant/beneficiary will have to reapply, as the CGIS717—Cover Letter-NH-Notification to Enter Nursing Facility only allows the applicant an Extension of Promptness for 90 days after being financially cleared and is no longer valid once the application is denied.
304.07.01 Arranging for Alternate Placement
(Eff. 04/01/06)
When a Medicaid sponsored patient in a nursing facility or ICF/ID is awaiting placement due to a change in level of care and the individual no longer needs long term care, benefits continue for a maximum of 30 days while the individual is seeking alternate placement. If alternate placement is found within the 30 days and is refused by the individual or responsible party, the Medicaid payment will terminate immediately. Otherwise, payment will stop at the end of the 30-day period.
304.08 Transfer of Assets Prior to February 8, 2006
(Rev. 01/01/10)
MPPM 304.08 and the appropriate subsections regarding transfers that have occurred prior to February 8, 2006, have been moved to MPPM Chapter 304, Appendix J.
304.09 Transfer of Assets on or after February 8, 2006
(Eff. 06/01/06)
The Deficit Reduction Act of 2005 amended the rules regarding the transfer of assets for less than fair market value. Applications taken on or after February 8, 2006, must be evaluated under old and new policy (Refer to MPPM 304.08 for policy on transfers prior to February 8, 2006). Transfers occurring on or after February 8, 2006 must be evaluated under the new rules only.
304.09.01 Definitions that Apply to Transfer of Assets and Trusts
(Rev. 09/01/25)
The following definitions apply, as appropriate, to both transfer of assets and trusts.
TERM | Definition Assets | All income and resources of the individual and his/her spouse. This includes income and resources to which the individual or his/her spouse is entitled to but does not receive because of any action by the individual or his/her spouse or anyone authorized to act in their behalf (such as a Power of Attorney). Examples of actions that would cause income or resources not to be received: Irrevocably waiving pension income; Waiving an inheritance (including an elective share); Not accepting injury settlements; Diverting tort settlements into a trust (Structured Settlements); Refusing to take legal action to obtain a court-ordered payment; and Gifting portion(s) of the outstanding principal of a promissory note. Income | Same definition as SSI. (Refer to Chapter 301 on Income for discussion.) Individual | The individual applying for (applicant) or receiving (beneficiary) Medicaid; The applicant/beneficiary’s spouse who is acting on his/her behalf; A person (including a court or administrative body) acting at the direction of the individual or his/her spouse; or A person with legal authority (including a court or administrative body) to act in place of the applicant/beneficiary or his/her spouse. Resources | Same definition as SSI except for the home exclusion. (Refer to MPPM Chapter 302 on Resources for discussion. MPPM 304.05.03 for information on the Homestead exclusion.) Spouse | A person who is considered legally married to the individual.
The following definitions apply to transfer of assets.
TERM | Definition Open Market Sale | An economic market in which pricing is determined by competition among private enterprises and not regulated by a government: a free market. Ex: Listed with a Realtor or multiple listing service (MLS) Private Sale (Off-Market) | In an off-market sale, the seller doesn’t list their home on the MLS. Instead, they sell directly to a buyer. This can be done without an agent, such as by requesting an all-cash offer from a house-buying company, or by working with a real estate agent to share the listing with a private network of buyers as an office exclusive. Ex: For Sale by Owner; Sales to Family/friends Fair Market Value ( DHHS Form V): Actual Value of Property Current Market Value (CMV): Reasonable Amount Received. | Open Market Sales: The amount the resource can be expected to sell for on the open market in the area in which the property is located. Also called, Current Market Value (CMV). If the property was sold on the open market, assume the individual received DHHS Form V. The price paid on the open market establishes the CMV for that property If a resource sells for more than the value assigned to it, the DHHS Form V is equal to the sale price. Private Sales (Off-Market ) : Assume that the value received on the sale of property is reasonable if that value is at least two-thirds of the DHHS Form V/CMV. Property sold for less than two-thirds of the DHHS Form V/CMV is considered a transfer for less than DHHS Form V/CMV, absent verification of a lower value from a knowledgeable, third-party source. Transfers for less than DHHS Form V/CMV may be subject to a transfer penalty. Third-party Source Example: County Tax Assessor ( Online County Search or DHHS Form 1255, Verification of Real and Personal Property), Realtor, Private Appraiser Knowledgeable source Online NADA - http://www.nadaguides.com/ Online Kelley Blue Book - http://www.kbb.com Institutionalized individual | An individual who is: An inpatient in a nursing facility or hospital swing bed; An inpatient in a medical facility for whom payment is based on a nursing facility level of care; and An individual participating in a Home and Community Based Services waiver program. Non-institutionalized individual | An individual who is living in the community and not participating in a waiver program. Uncompensated value | The difference between the DHHS Form V at the time of transfer (less any encumbrances) and the amount received for the asset. Valuable consideration | What the individual receives in exchange for his/her right or interest in an asset. The object, service, or benefit received must have a value to the individual that is equal to or greater than the value of the transferred asset.
Table of Contents
304.09.02 Transfer of Assets for Less than Fair Market Value
(Rev. 10/01/06)
Many times, an individual may transfer assets to another person. If an asset is transferred and the individual does not receive the full value for it, it is assumed he did so with the intention of becoming Medicaid-eligible. If an institutionalized individual or his/her spouse transfers an asset for less than Fair Market Value, it may affect eligibility for services. If all the other Medicaid eligibility criteria are met, he/she may receive Medicaid but coverage for certain Medicaid services is denied. These services include:
Vendor payment to a nursing facility
Swing Bed
Home and Community Based (Waiver) Services
Denial of the coverage is known as a penalty. The transfer resulting in the penalty is also known as a sanctionable transfer or a penalty-liable transfer.
Procedure – Penalty-Liable Transfer If an individual or his/her spouse has a penalty-liable transfer but meets all of other eligibility criteria, the eligibility worker must follow the guidelines below. For Nursing Home Assistance: Deny or terminate the vendor payment (room and board payment.) Use DHHS Form 932, The Medicaid Card is authorized or continued. For Home and Community Based Services (HCBS) or other Waiver service: If an individual is applying for or receiving HCBS: Determine if the individual qualifies for Medicaid under any other category, Notify CLTC/ BHDD to deny or terminate services If the beneficiary receives services through CLTC, notify the CLTC Case Manager through Phoenix The Eligibility Specialist will navigate to the participant’s Dashboard and navigate to the Narratives tab. Once on the Narratives tab page, there will be two subtabs (Narratives and Conversations). Navigate to the Conversations subtab Add New Conversation Service: use the drop-down to select the current Case Management Subject Line should auto-fill Message: Notification to terminate services, No longer eligible for waiver or other long-term care services due to a transfer. If the beneficiary receives services through BHDD , notify BHDD using the DHHS Form 118A. If an individual is already Medicaid eligible under another payment category, such as ABD, continue Medicaid, and notify CLTC/ BHDD to deny or terminate services.
304.09.02A Effective Date of Transfer of Assets Policy
(Eff. 06/01/06)
The transfer of assets provisions apply to all transfers made on or after February 8, 2006.
304.09.02B Individuals Affected by Transfer of Assets Provisions
(Eff. 06/01/06)
These provisions apply when assets have been transferred for less than Fair Market Value by any of the following:
Institutionalized individual
Community spouse
Anyone acting in place of, on behalf of, or at the direction of the institutionalized individual or community spouse, such as:
A parent or guardian
Court or administrative body
Power of Attorney
Conservator
304.09.02C Look-Back Date/Period
(Rev. 08/01/26)
When an individual applies for Medicaid coverage for nursing home or HCBS, a look-back must be conducted to determine if there has been a transfer of assets. If a transfer has occurred, the Eligibility Specialist must determine if a penalty applies.
Note For any SSI recipients entering a nursing facility or a Home and Community Based Services waiver program, a look - back is NOT required. A modified look-back must be conducted for those individuals applying for institutional coverage who do not currently receive SSI but were SSI eligible in the past. The modified look-back period would begin the month the SSI was terminated.
The look-back period is 60 months prior to the date:
An institutionalized individual was institutionalized, and has applied for medical assistance for long term care coverage, or
A non-institutionalized individual applies for medical assistance for long-term care coverage.
The look-back date is the earliest date on which a penalty can be assessed.
Transfers of assets for less than Fair Market Value are:
Subject to penalty if the transfer took place on or after the look-back date, or
Not subject to penalty if the transfer took place prior to the look-back date.
Procedure – Conducting a Look-back Property /Deed Check Must be completed to verify no real property was transferred in the look-back period (60 months prior to the date of application). May be completed online or by sending a DHHS Form 1255 ME , Verification of Real and personal property if online information is not available. The property /deed check must be completed for: County of residence, and Other counties where the individual and/or spouse: In-state Alleges current or previous property ownership, and/or Resided for long periods in their adulthood. Out-of-state Alleges current ownership of property, and/or Alleges previous ownership of property within the past five years. Send a DHHS Form 1255 but do not wait for the return of the form to determine eligibility unless , the applicant alleges they currently own property or transferred property . Probate Check If the applicant/beneficiary (or spouse) indicates receiving an inheritance within five (5) years prior to the application date, obtain the name of the deceased person, when and where the person’s estate was probated, what type of resource was involved, and complete a probate court check. If the applicant/beneficiary’s spouse passed away during the look-back period, complete a probate court check to determine if the applicant/beneficiary received their elective share of the spouse’s estate (MPPM 304.10). Asset Verification System The Eligibility Specialist must examine the AVS response for evidence that a transfer may have occurred or that other resources may be available for their use. Look for total balance increases that exceed $10,000 and decreases in total balances that exceed income by $2200 for an individual or $4400 for a couple per month. If responses are received for multiple accounts owned by the applicant/beneficiary, the Eligibility Specialist should compare accounts side by side to determine if there is an indication funds were transferred between accounts prior to requesting additional information. For instance, Tom Dukes has checking and savings accounts. In September, there was a decrease of $8000 in the savings account balance and an increase of $7600 in the checking account balance. The funds were moved from one account to another. Example : Daisy Duke applied for Nursing Home assistance on November 20, 2022. She paid privately at Caring Hearts for August, September, and October. She has three accounts at Crossroads Bank. The AVS returned the following information. Month Account 1 balance Account 2 Balance Account 3 Balance November 2022 953.00 480.00 225.00 October 2022 5180.00 600.99 224.75 September 2022 10,632.74 626.21 224.50 August 2022 15,980.45 690.85 224.25 July 2022 158.90 752.60 16,200.10 June 2022 175.16 798.77 16,189.15 AVS results show funds were transferred from account 3 to account 1 in July 2022. There is no indication that funds were given away. With multiple accounts, it may be beneficial to print the combined customer resources from AVS and review the total balances for fluctuations. Fluctuations in the aggregate balance column (Note: the aggregate balance is the combined total of all account balances) may indicate a transfer. Fluctuations in individual accounts but no fluctuation in the combined balance indicates funds were transferred between accounts. NOTE: The individual bank records from AVS should also be uploaded into OnBase. Example: Asset Verification System - Balance Increases Balance increases are lead information. They may indicate there is another resource available to the applicant/beneficiary or community spouse or that some other resource was sold or converted to cash. For account increase(s) that exceed $10,000 per month within the look-back period, the Eligibility Specialist must Review all existing information in the case and information found during case processing to determine if there is an indication of where the funds originated. For example, Is there an indication real or personal property was sold? Does AVS indicate that funds were transferred from one account to another? Is there an indication of an inheritance or of receipt of life insurance proceeds? Was the individual approved for benefits such as SSA and possibly received a lump sum? Did the individual retire and possibly receive a lump sum? Is there an indication stocks or CDs were cashed in? If a review of the case file does not show an explanation, make a collateral call to discuss the fluctuation(s) and the reasons behind them. Ask questions about whether any property or vehicles were sold, stocks cashed in, or accounts closed. Any lump sums received, such as retirement or life insurance benefits, may assist with determining where funds came from (see questions in previous bullet). If the collateral call is unsuccessful, follow-up with a DHHS 1233 information request and request an explanation. If the applicant is unable to or does not provide verification or an explanation of an increase and no indication of another resource or of the sale of a resource is found, continue to process the case to try to determine eligibility. If there are questions, the case should be staffed with the supervisor. After reviewing the case, the supervisor should provide instructions on how to process the case from this point. If there is no indication of another resource being available to the applicant, the case should move forward. Example Jane Doe applied for Nursing Home Medicaid on December 31, 2023. Her SSA benefit of $1800.00 is deposited into her Bank of America account each month. An AVS search was completed for the 5-year look-back period. The AVS response is as follows: Month/Year Balance 12/2023 .90 11/2023 9.13 10/2023 16.46 09/2023 300.20 08/2023 1898.54 07/2023 2619.44 06/2023 3441.58 05/2023 4517.53 04/2023 6130.45 03/2023 8649.08 02/2023 9294.30 01/2023 11,589.29 12/2022 15,060.22 11/2022 17,229.53 10/2022 19,872.69 09/2022 7.77 08/2022 8.82 07/2022 1.24 Jane Doe’s total monthly SSA net income is $1800 + $2200= $4000. During the look-back period, the account balance increased from $7.77 in September 2022 to $19,872.69 in October 2022. The funds were then spent gradually from October 2022 through September 2023. The account increase was over $10,000 during a month in the look-back period. The worker should request verification/explanation of where the money came from. However, because the funds were spent gradually over time and never decreased by more than $2200 of the applicant’s income per month, verification of how the money was spent is not required. Bank / Financial Account – Balance Increase The Eligibility Specialist must examine the bank / financial account statement(s) for evidence that a transfer may have occurred. For instance: For account increase(s) that exceed $10,000 per month within the look-back period: If the information on the statement does not provide enough evidence to determine if a transfer occurred, the Eligibility Specialist must: Review all existing information in the case and information found during case processing to determine if there is an indication of where the funds originated. For example, Is there an indication real or personal property was sold? Does AVS indicate that funds were transferred from one account to another? Is there an indication of an inheritance or of receipt of life insurance proceeds? Was the individual approved for benefits such as SSA and possibly received a lump sum? Did the individual retire and possibly receive a lump sum? Is there an indication stocks or CDs were cashed in? If a review of the case file does not show an explanation, make a collateral call to discuss the fluctuation(s) and the reasons behind them. Ask questions about whether any property or vehicles were sold, stocks cashed in, or accounts closed. Any lump sums received, such as retirement or life insurance benefits, may assist with determining where funds came from (see questions in previous bullet). If the collateral call is unsuccessful, follow-up with a DHHS 1233 / information request and request an explanation. If the applicant is unable to or does not provide verification or an explanation of an increase and no indication of another resource or of the sale of a resource is found, continue to process the case to try to determine eligibility. If there are questions, the case should be staffed with the supervisor. After reviewing the case, the supervisor should provide instructions on how to process the case from this point. If there is no indication of another resource being available to the applicant, the case should move forward. Reminder If account statement(s) are provided, the Eligibility Specialist must review the statement(s) to determine if there are any sources of income that are not reported on the application. Look for indications such as consistent deposits were made to the account weekly, bi-weekly, monthly, semi-annually, annually, etc. Explanation or Verification of an Increase is not provided: If the applicant is unable to or does not provide verification or an explanation of an increase, the Eligibility Specialist should review the case and verifications obtained to answer the following questions: Is there any indication that another resource exists that an applicant could be drawing from? E.g.: alleged accounts, AVS results, bank statements that may be on file that show deposits from other accounts. Did the applicant allege any items or property were sold or was any found during the property look-back? If no indication of another resource or of the sale of a resource is found, continue to process the case to try to determine eligibility. If there is indication of a sale for less than FMV , the case should be evaluated for a possible transfer. If there are questions, the case should be staffed with the supervisor. After reviewing the case, the supervisor should provide instructions on how to process the case from this point. If there is no indication of another resource being available to the applicant, the case should move forward. Asset Verification System – Balance Decrease: For month-to-month balance decrease(s) that are less than or equal to the monthly income plus $2200 for an individual or $4400 for a couple, no additional information is needed. For other decreases that exceeds the income by $2 200 for an individual or $4400 for a couple per month, review the case record to determine if the decrease can be accounted for with the available verifications prior to requesting additional verification/documentation from the applicant. Example 1 AVS shows a decrease of $8000 between May 1 and June 1 of 2022 in the applicant’s only account. A copy of a preneed burial contract is on file dated May 15, 2022, verifying the individual purchased and paid it in full for $7500. Example 2 AVS shows a steady decrease of around $4500 per month for the past six months. The applicant was admitted to the nursing home six months ago. The Eligibility Specialist should reach out to the facility to verify private payments prior to requesting additional verification from the applicant. If there is no information in the case file that can account for decrease(s): Make a collateral call and request an explanation to verify whether a transfer of assets occurred. Follow-up with a DHHS form 1233 to request written verification/documentation: e.g.: Bank statement(s), receipts, cancelled checks and/or statements from the provider of service(s). If documentation is not provided, the account balance decrease(s) must be considered a penalty liable transfer of assets. If documentation is provided, determine if an exception may apply. NOTE: Additional verification may be needed to support an exception. Continue with the eligibility determination. Example 1 A Nursing Home application was submitted for Jane Doe in December 2021. Her SSA benefit of $1300 (net) and pension of $550 (net) are deposited into her Wells Fargo checking account each month. The AVS response is as follows: Month / Year Balance 12/2021 0.00 11/2021 9.13 10/2021 16.46 09/2021 300.20 08/2021 1898.54 07/2021 3441.53 06/2021 4517.53 05/2021 6130.45 04/2021 9294.30 03/2021 11,589.29 02/2021 20,060.22 01/2021 23,229.53 12/2020 29,872.69 Jane Doe’s total monthly net income is $1850.00 + $2200 = $4050. The account fluctuations are as follows: Dec 2020 to Jan 2021 – decrease of $6,643.16 Jan to Feb 2021 – decrease of $3169.31 Feb to March 2021 – decrease of $8470.93 April to May 2021, decrease of $3163.85 The Eligibility Specialist should: Search the case file to determine if there are any verifications on file that show what happened to the funds. Request verification of how the money was spent in Dec 2020 and Feb 2021. The decreases in Jan 2021 and April 2021 are below the threshold and are not questionable. Bank/Financial Account Statement(s) – Balance Decrease: For total monthly withdrawals or payments that exceed the applicant/beneficiary’s monthly income by more than $2200 (or $4400 for a couple): Review the case record to determine if the decrease can be accounted for with the available verifications prior to requesting additional verification/documentation from the applicant. If there is no information in the case file that can account for decrease(s): Make a collateral call and request an explanation to verify whether a transfer of assets occurred. Follow-up with a DHHS form 1233 to request written verification/documentation: e.g.: Bank statement(s), receipts, cancelled checks and/or statements from the provider of service(s). If documentation is not provided, the account balance decrease(s) must be considered a penalty liable transfer of assets. If documentation is provided, determine if an exception may apply. NOTE: Additional verification may be needed to support an exception. Continue with the eligibility determination. Request an explanation to help determine if a sanctionable transfer occurred. If the requested information does not provide sufficient information to determine if a sanctionable transfer occurred, request verification /documentation. Example: Receipts, cancelled checks, statement from the provider(s) of services, etc. If verification/ documentation is not provided, the payment or withdrawal must be counted as a transfer of assets. NOTE For investment accounts that have multiple accounts, stocks, or mutual funds, examine the overall account balances first. If the overall balances do not indicate a fluctuation, fluctuations within the individual accounts are generally funds transferred from one account to another. Economic Impact Payments – EIP – (Stimulus) and the look-back: During the Public Health emergency, individuals received three payments totaling $3200 in 2020 and 2021. These Economic Impact Payments (EIP) funds were excluded as income and any retained EIP amount is also excluded as a resource going forward. Effective 5/1/2026, if an applicant’s resources exceed the limit, the Eligibility Specialist must complete the DHHS Form 1766-EIP, Disaster Assistance Declaration Form, with the applicant through a collateral call to determine whether any portion of these resources consists of retained EIP funds. If the form cannot be completed with the applicant or Authorized Representative by phone, the form should be sent using DHHS Form 1233. If the form is not returned, the Eligibility Specialist should assume neither the applicant nor the spouse retained any EIP funds. Prior to 5/1/2026, the Eligibility Specialists determined the amount of retained EIP funds by assuming that any countable funds were spent first from the comingled bank balance. To do this, the Eligibility Specialist reviewed the applicant’s bank balance before deducting their income to identify the maximum amount of EIPs that remained. Month/Year Balance Eligibility Specialist can see the applicant’s AVS balance has fallen below $3200 (the maximum EIP amount for a couple is $6400) The EIP stimulus of only $2500 can be deducted. March 2026 20,000.00 February 2026 13,500.00 January 2026 2,500.00 December 2025 7,500.00 The applicants’ income and the $3200 in EIP is non-countable . Any of the EIP funds no longer in the account may be used to reduce a fluctuation occurring after the EIPs were issued. EIPs are excluded under SSI policy. Therefore, if they are given away, no transfer penalty is to be imposed (MPPM 304.09.03). NOTE : For retro months, the account balance(s) for the retro month is used. Otherwise, the balance for the month of application should be used. Disaster Assistance funds from Presidentially Declared Disasters are excluded as income in the month received and any retained funds are excluded. The DHHS Form 1766-EIP, Disaster Assistance Declaration Form, can be used to verify retained assistance for resource reduction purposes. Example 1 Archie Andrews is currently seeking Nursing Home services. His income is $1 , 500, his current bank balance is $6 , 200, and he has no other resources. The DHHS Form 1766-EIP, Disaster Assistance Declaration Form, has been completed verifying that he has retained his EIP. The countable value of his account is $1 , 500 after subtracting his income of $1500 and the EIP stimulus. During the look-back, in June 2023, he had a large decrease of $7000. The decrease exceeds his income plus $2 , 200 so the decrease must be verified. If we are unable to verify, it will be subject to a transfer penalty. Since the EIPs have been retained, we cannot consider the EIPs to reduce the amount of the unaccounted funds. Example 2 Victoria Black has income of $1 , 000. She has exhausted her resources, and her bank account is closed. She is applying for waiver. During the look-back, she had a fluctuation of $6 , 500 for which she is unable to account. The amount of fluctuation can be reduced by the EIPs since the DHHS Form 1766-EIP, Disaster Assistance Declaration Form, has been completed confirming she did not retain the funds. $6 , 500 - $3 , 200 (EIP) = $3 , 300 The remaining $3 , 300 would be considered a transfer penalty. It is over the $2 , 200 threshold and Victoria is unable to account for the funds. Example 3 Mack Corey is applying for nursing home. His income is $1 , 100 per month. During the look-back, he has an unaccounted-for decrease of $4 , 500 in Dec 2023. He completed the DHHS Form 1766-EIP, Disaster Assistance Declaration Form, confirming he did not retain any of the EIPs. Since Mack did not retain the EIP funds which are not subject to a transfer penalty, they can be subtracted from the decrease, leaving $1 , 300 in unaccounted funds ($4500 - $3 , 200 = $1 , 300). The remaining balance of $1 , 300 would not have a penalty imposed because his income is $1 , 100 and the remaining is under the $2 , 200 threshold. Examples of verification(s) of payments or withdrawals that are not considered a sanctionable transfer of assets include but are not limited to home repairs, doctor / hospital bills, other bills, church donations, adult personal care/sitter fees. Examples of payments or withdrawals that need to be clarified as they could be considered a sanctionable transfer of assets, include but are not limited to giving gifts or money to children or grandchildren, purchasing an annuity, receiving a promissory note, or property agreement. Note Annuities, property agreements, or promissory notes must be submitted to the Division of Policy and Process via a Service Manager ticket. For New Applications Determine if the applicant has included any bank statements with the application. If statements for the current application month and the seven (7) months prior to the month of application are included, evaluate for any potential transfers. An AVS request is also created for both an FI and GEO search requesting the month of application and 7 months prior, but it is not necessary to wait for the responses to be returned unless a potential transfer is indicated or all statements for the month of application and 7 months prior are not received. If no statements are included with the application, do not request the statements from the applicant. While a 60-month look-back is required, create an Asset Verification System (AVS) request to include the month of application and the 7 months prior. If an indication of a transfer is found or alleged , additional information may be requested. Adjust the dates necessary based on the date of the alleged transfer and/or any bank history that may be in the case record. Example 1 Ivy James applied for Nursing Home assistance on April 10. She alleged no transfers. She stated she has a checking account with Bank of America. When initiating the AVS request the worker must do the following: Initiate a FI search for Bank of America requesting September through April. In i tiate a GEO search requesting September through April. Example 2 Jessica Brown applied for Nursing Home in March of this year. She stated she has an account with First Citizens currently and closed an account at South State for $12,000 two years ago but did not indicate what was done with the funds. The worker was unable to reach via collateral call. Since a closed account was reported, the worker should initiate FI Searches for First Citizens, South State, and a GEO search beginning with Jan 2 years ago through the application month to verify the closed account, and hopefully verify the funds were transferred to the First Citizens account. Example 3 The application for Mae Bowman was received March 15. The application notes a checking account at TD Bank with $500 and that she sold a small lot in January last year for $15,000. The worker should initiate a FI search for January of last year through the month of application. Example 4 Susan Green applied for Nursing Home services in April. She reported that she had used money from a settlement in June two years ago to make repairs on her house for about $16,000. She had previous eligibility under the ABD at that time. A bank statement is in the file that verifies this. She initiates AVS for the month of application and the 7 months prior. Additional months do not need to be requested because the information has been verified. For Current or Past Beneficiaries If the beneficiary is currently eligible or has been eligible in an SSI-related category which required a resource determination, a 60-month look-back for bank accounts must still be conducted. Base the time of the look-back on the date of the request/application for HCBS or nursing home services Identify and use what bank/financial information is already available in the case history. Verify the current account balance by collateral call or by creating a request through the Asset Verification System (AVS). Do not ask for bank statements from the applicant Conduct a property search Evaluate other resources A fter reviewing any bank statements that may be on file , c ontact the applicant to clarify any potential transfers and request documentation if needed Complete the look-back Example 1 A Medicaid beneficiary has been continuously eligible for more than 60 months (was eligible prior to the 5-yr look-back period), and is currently eligible: Review the available bank statements from the case history Verify the current balance by collateral call If unable to verify by collateral call, create an AVS request for the month of application and the prior 7 months Evaluate other resources Conduct a property and deed search Contact the applicant to clarify any potential transfers and request documentation if needed Complete the look - back Example 2 A Medicaid beneficiary was eligible 60 months ago, is currently eligible but lost eligibility for a brief period due to a change in income Review available bank statements from the case history Verify the current balance by collateral call If unable to verify by collateral call, create an AVS request Conduct the property and deed search Evaluate other resources Contact the applicant to clarify any potential transfers and request documentation if needed Complete the look-back Example 3 A Medicaid beneficiary is currently eligible and has been eligible for the last three (3) years. Review the available back statements in the case record Verify the current balance by collateral call If unable to verify by collateral call, create an AVS request for the month of application and 7 months prior Complete a property and deed search Evaluate other resources Contact the applicant to clarify any potential transfers and request documentation if needed Conduct the look - back Procedure – Conducting a Look-back for a Child Use the following guidelines to conduct a look-back for a transfer of assets for a child applying for any institutional service (waiver or nursing home): Is the child currently eligible for Medicaid? If “Yes”, does the case record show any assets in the name of the child? If “Yes”, does the record show any possible transfers in the look-back period? Does the DHHS 3400-B allege any transfers in the look-back period months? If “Yes”, verify the details of the possible transfer, and calculate the transfer penalty if appropriate. If “No”, conduct a property search in the child’s name. If no property found, look-back is completed. If “No”, conduct a property search in the child’s name. If no property found, look-back is completed. If “No”, does the application allege any assets in the name of the child? If “Yes”, does the application show any possible transfers in the look-back period? If “Yes”, verify the details of the possible transfer, and calculate the transfer penalty if appropriate. If “No”, conduct a property search in the child’s name. If no property found, look-back is completed If “No”, conduct a property search in the child’s name. If no property found, look-back is completed.
304.09.02D Penalty Period – Important Points
(Rev. 07/01/24)
Maximum Penalty Period – There is no maximum penalty period. (Refer to MPPM 304.09.05 for computation of penalty period.)
Beginning Date of Penalty Period – For transfers occurring on or after February 8, 2006, the beginning date of the penalty period is the later of:
The first day of the month in which the asset was transferred, or
The date on which the individual is eligible for medical assistance for long term care and would otherwise be receiving a vendor payment if not for the application of the penalty period. In other words, the penalty begins when the individual would have been eligible for a vendor payment if there had been no transfer.
Procedure Nursing Home For initial applications, the start date of the transfer penalty is determined as the date the individual would have been authorized for vendor payment but for the application of the penalty period. Example Jack Bristow applied for Nursing Home coverage on March 12. He entered Vaughn Acres Nursing Home on April 23. It is determined there was a transfer that will result in a six (6) month penalty period. Mr. Bristow meets all other eligibility criteria. The penalty period for Mr. Bristow will begin April 23, the date he could have been authorized for a vendor payment but for the imposition of the penalty period, and he could be potentially eligible for Nursing Home or other long-term care services after October 23. Home and Community Based Services An application for Home and Community Based Services (HCBS) can trigger the start of a transfer penalty period. The Eligibility Specialist will process the Waiver application up to the point of a financial determination and ensure that all Exceptions to the Penalty have been explored. The Eligibility Specialist must: Complete a manual budget workbook Confirm that the applicant meets all the financial criteria but for having a sanctionable transfer. Calculate the penalty period using the current date as the effective date of the transfer to determine the length of the penalty on the manual workbook NH-HCBS tab. Note If the applicant/beneficiary or authorized representative asks about the length of the penalty, a workbook can be used to generate the length (months and days) of the penalty. Eligibility Specialists should not provide a start date and end date for the penalty. Upload the manual budget workbook into OnBase. Check the System of Record Cúram: Update all evidence. Do not add the Medical Institution, Level of Care, or Resource Transfer Evidence (only document on the Documentation Template under the Action summary). These three evidences will be completed by the EEMS Policy Coordinator. Complete the Check Eligibility Do not authorize the denial decision Do not send the DHHS Form 932 (EEMS Policy Coordinator will send the notice) The Eligibility Specialist must Complete the Waiver Transfer Penalty Checklist Form Attach the completed Waiver Transfer Penalty Checklist Form to the Service Manager Ticket Note If the Eligibility Specialist did not complete the key steps from the checklist, the case will be returned to be completed before the waiver penalty is processed. Submit a Service Manager ticket for case assignment to an EEMS Policy Coordinator who will work with CLTC to impose the penalty. Refer to the Service Manager Instructions below Update the Documentation Template Ensure it is thoroughly completed Action summary should include: Case is financially cleared but for a transfer penalty Service Manager Ticket has been submitted for the case to be completed by the Policy Team and no one should touch. Include the Service Manager ticket number Send the case to Follow-up in OnBase for 30 days. (Prevents case from coming back into workflow) Pend in Workload Pro. Do not take any action in Phoenix. The Policy Coordinator will complete the necessary actions in Phoenix. Note The completion of a Phoenix referral and the receipt of an active Application for Community Choice should be verified by Eligibility Specialists. Note The EEMS Policy Coordinator will complete the eligibility process; the Eligibility Specialist will not touch the case again until the next annual review. Service Manager Instructions Eligibility Specialists will use the following temporary procedure to submit a ticket in Service Manager: Under the EEMS (Eligibility Enrollment and Member Services) Category , select the Phoenix and CLTC Corrections hyperlink. Select the Phoenix and CLTC Corrections hyperlink/icon Answer the following questions: Specialist preferred contact number (Required) Applicant/Beneficiary Name (Required) Spouse’s name (if applicable) Date of Birth (Required) Medicaid ID (Required) Enter The Household Number (Current SOR), Application ID, and/or Phoenix ID if available in the appropriate box; separated with commas. From the Select a Category for this Ticket drop-down select: CLTC Eligibility issue. In the Provide Any Additional Details box, add: Waiver Applicant with a Transfer Penalty. Select Save to complete the ticket submission. Document SM Ticket # on Documentation Template in the appropriate section. Note If the penalty is 2 months or longer, the Eligibility Specialist will still submit a Service Manager Ticket as instructed. An EEMS Policy Coordinator will complete the eligibility process by denying the case in Phoenix and in the SOR. The Applicant will need to reapply when the penalty is over if Long-Term Care Services are still needed. The Eligibility Specialist that receives or pulls the new application from Workload Pro after the penalty has ended will not process the same transfer penalty. If the applicant has a new resource transfer penalty, the Eligibility Specialist will only apply the new transfer penalty that does not meet any of the Exceptions to the Penalty policy (MPPM 304.09.03). CGIS calculates the penalty using a 30-day month. The beginning of the penalty starts on the “but for enrollment” date. EEMS Policy Coordinator working from CGIS will include the “but for enrollment” date as the first day of the penalty period calculation to provide an accurate end date and payment eligibility date to the Notes under the Case Detail tab on the Income Support Case and on the Document Template. Example Jim Scott applied for HCBS Waiver on May 12th. The Eligibility Specialist found transfers within the look-back. The transfer penalty will be 2 months and 15 days (over 2 months). The “but for enrollment” date provided by CLTC is May 20th. The determination was made on May 20th. Mr. Scott’s penalty period would have ended August 2nd and he would have been eligible for HCBS or nursing home services on August 3rd; however, Mr. Scott’s transfer penalty is over 2 months so he will need to reapply. Mr. Scott reapplied on August 2nd. No additional transfers were found within the modified look- back from the date of the previous application. Mr. Scott was enrolled in HCBS Waiver (Community Choices) on August 13th. Mr. Scott met the level of care and the 30 consecutive day requirement on September 11th. He was approved for coverage effective August 1st in the system of record. Note CGIS determines if the applicant needs to reapply based on the current date of processing. In the example above, if the “but for enrollment” date was still in May, but the determination fell in June, Mr. Scott would not have needed to reapply. Penalty Period for Transfers Occurring After Approval If a transfer occurs after an individual has been approved for Nursing Home or HCBS, t he start date for the transfer penalty is determined as the first day of the month in which the transfer occurred. Because a beneficiary eligible for HCBS is already receiving waiver services, the start of penalty period is triggered. Once the penalty period is completed, the individual can be approved for institution services if he/she applies. For HCBS Waiver coverage, the participant will lose their Medicaid coverage unless eligible for another full Medicaid coverage. Note The Eligibility Specialist will need to notify CLTC to end the waiver services and follow the procedures that are in MPPM 304.09.02. Eligibility Specialist will need to treat new transfers as instructed in MPPM 304.09.03 to see if the new transfer penalty does not meet any of the Exceptions to the Penalty.
The penalty period cannot overlap with the term of a prior penalty period.
Multiple Transfers
If the individual made multiple transfers for less than Fair Market Value during the look-back period, and the transfers occurred in the same or different months, the transferred amounts are added together.
Example 1 Janice Wilkes applies for Medicaid in June. In February, she transferred $10,000 to each of her three grandchildren. The transferred amount is calculated as follows: $10,000 + $10,000 + $10,000 = $30,000 Example 2 Summer Blake applies for Medicaid on June 1. Last September, she gave $10,000 to her granddaughter. In October, she transferred property worth $15,000 to her grandson. The transferred amount is calculated as follows: $10,000 + $15,000 = $25,000 Example 3 Calvin Hobbs applies for Medicaid on December 15. In April, he transferred $30,000 to his son. In July, he transferred $35,000 to his daughter. The transferred amount is calculated as follows: $30,000 + $35,000 = $65,000
304.09.02E Transfers by a Spouse
(Eff. 05/01/26)
If the institutionalized individual is being penalized due to a transfer by the community spouse, and the community spouse becomes institutionalized and applies for Medicaid, the remaining active penalty period must be apportioned between both spouses. This applies to both Nursing Home and Waiver cases.
If one member of the couple leaves the facility or dies, the remaining portion of the penalty must be served by the remaining institutionalized spouse if eligible within the remaining penalty period.
Note Once initiated, the penalty continues despite death or discharge from the facility.
Example 1 Avery Anderson enters the nursing home and applies for Medicaid. He entered the facility on March 15 th , 2025. During the five-year look-back, it was determined that his community spouse, Amy Anderson, gave $90,000 to their daughter as a wedding gift in January of 2023. The transfer did not meet any exceptions to the transfer penalty, and a penalty of 9 months and 5 days was established. The penalty was set to expire on December 19 th , 2025. Three months into the penalty period, Amy Anderson’s health declines. She is approved for the Community Choices waiver on June 20 th , 2025. The remaining 6 months of the penalty must be apportioned between both spouses. Example 2 Jean Lopez enters the nursing home and applies for Medicaid. She entered the facility on February 12 th , 2025. During the five-year look-back, it was determined that her community spouse, John Lopez, gave $58,000 to a sick friend in August 2022. The transfer did not meet any exceptions to the transfer penalty, and a penalty of 5 months and 30 days was established. The penalty was set to expire on August 10 th , 2025. Mrs. Lopez serves 4 months of the transfer penalty and then passes away on June 12 th , 2025. The penalty continues after the death of Jean Lopez. John Lopez then applies for nursing home and enters on June 26 th , 2025. He must serve the remaining 1 month and 16 days of the six-month penalty. Example 3 Paula Brown enters the nursing home and applies for Medicaid. She enters the facility May 16 th , 2023. During the five-year look-back, it was determined that her community spouse, Michael Brown, sold their secondary property worth $125,000 in January 2021 for $5 love and affection. The transfer did not meet any exceptions to the transfer penalty, and a transfer penalty of 1 year and 23 days was established. The penalty was set to expire on June 7 th , 2024. Paula Brown serves 6 months of the transfer penalty and then passes away on November 16th, 2023. The penalty continues after the death of Paula Brown and expires on June 7 th , 2024. Michael Brown then applies for Community Choices on November 1 st , 2024. Since the initial penalty has expired, Michael Brown does not to serve the remainder of this penalty. Note Instructions for processing transfer penalty between spouses can be found in the LTC Ineligibility Period, Sanctions, and Undue Hardship Job Aid.
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304.09.02F Transfers of Jointly Held Assets
(Eff. 06/01/06)
Jointly held assets may also be transferred. Such transfers may be subject to a penalty.
An asset held by an individual jointly with another person is considered to be transferred by the individual when any action is taken to reduce or eliminate the individual’s ownership or control of the asset by the individual or the other owner(s).
The individual is not penalized for the transfer if the other person can prove that the institutionalized individual:
Has no ownership interest, or
Has only partial interest in the asset, and the part removed is the amount owned by the other person.
Joint bank accounts are the most common type of bank account and jointly-held asset. Adding another person’s name on an account or asset as a joint owner may not necessarily constitute a transfer of asset. There is no transfer if the account or asset may still be considered to belong to the individual.
WHEN A TRANSFER OF A JOINTLY HELD ASSET OCCURS Situation | Date of Transfer Other person withdraws funds. | Date of withdrawal Other person removes an asset. | Date of removal Placing the other person’s name on the account limits the individual’s right to sell or dispose of the property. | Date name was placed on the account or asset
Examples - No Transfer of Asset Example 1 Jason Young added his son’s name to his bank account as a precaution should he be unable to handle his account for some reason. Richard Young makes no deposits to the account from his own money. The only withdrawals he makes are for his father’s benefit. Example 2 Rachel Silver and her daughter, Joan Sox, had a jointly-held account. The account was closed three months ago for $25,000 and the money was placed in an account in Joan’s name only. Rachel states the money was not hers, and her name was only on the account in case her daughter became ill and money was needed for her young children. Joan provides verification that the bank account was established from funds transferred from her personal account.
Example - Transfer of Asset Rick Snow added his daughter Lela’s name to his bank account last year. Two months ago, Lela withdrew $15,000 to buy a swimming pool for her family. Rick is a nursing home patient, and Lela is applying for Medicaid to cover his bills. A transfer of asset took place the date the money was withdrawn. It was not used for Rick’s benefit.
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304.09.02G Transfers and Lifetime Rights to Property
(Rev. 04/01/24)
An individual with a life estate interest has the right to use property and obtain income from the property during his/her lifetime. An individual may receive a life estate interest through a will (for example, a husband wills the home to his wife during her lifetime and it passes to his children upon her death).
Sometimes an individual will transfer the ownership of rights to property to someone else but retain a life estate interest for himself/herself. Although the individual has the right to use the property and obtain income from it, he/she transferred the ownership interest. The value of the transfer is the difference between the value of the property and the value of the individual’s life estate interest in the property. The value of the life estate is calculated using the age of the individual at the time the transfer was done, rather than the date of the Medicaid application.
A transfer of a life estate is sanctionable, and the uncompensated value is calculated using the age of the individual at the time the transfer occurred.
When an applicant/beneficiary holds life estate interest and the property is sold, the applicant/beneficiary is entitled to receive the value of the life estate portion of the property from the proceeds of the sale.
If the applicant/beneficiary does not receive their portion of the funds from the sale, the portion belonging to the applicant (not the whole amount of the sale) will be used to determine the transfer penalty.
The tables used to establish the value of the life estate are found in Chapter 302 Appendix F.
Example 1 Last month, Paul Taylor, age 80, transferred his homestead to his son for $5 love and affection, and retained a life estate. The property is valued at $100,000. To determine the uncompensated amount to be used to calculate a transfer penalty : $100,000 x .43659 = $43,659 (life estate value) $100,000 - $5 (amount rec’d.) - $43,659 (life estate value) = $56,336 (uncompensated amount) Example 2 At the time of his death in 2000, Jane Eyre’s husband left her lifetime rights to the farm then valued at $150,000. She is now applying for nursing home care, and it is discovered she transferred her life estate interest to her son last month. She is currently age 95 and the property has increased in value to $250,000. To determine the uncompensated amount to be used to calculate a transfer penalty : $250,000 x .22887 = 57217.50 (uncompensated value of the life estate at the time of transfer) Example 3 John Thomas, age 85, owns life estate in his homestead. Last month the property was sold for $100,000 ( DHHS Form V). John did not receive any funds for the sale of the property. To determine the uncompensated amount to be used to calculate a transfer penalty: $100,000 x .35359 = $35,359 (life estate value & uncompensated amount) This amount will be used to determine the transfer penalty. Example 4 Jane Williams, age 85, owns life estate in her homestead. Last month the property was sold for $100,000 ( DHHS Form V). Jane received only $10,000 for the sale of the property. To determine the uncompensated amount to be used to calculate a transfer penalty: $100,000 x .35359 = $35,359 (life estate value) $35,359 (life estate value) - $10,000 (amount rec’d) = $ 25,359 (uncompensated amount)
The purchase of a life estate in another individual’s home on or after February 8, 2006, is a transfer of asset unless the purchaser resides in the home for at least 12 consecutive months after the date of purchase. Do not deduct vacations, overnight visits, and hospital stays from the one-year period as long as the home continued to be the individual’s legal residence. Count the entire purchase price as an uncompensated transfer if the purchaser resides in the home for any period less than one year. Determine the sanction period based on the purchase price.
In addition to the above requirement, the purchaser must not pay more than fair market value for the life estate. Any amount paid above fair market value is considered a transfer and should be penalized according to the transfer policy.
Procedure Verify the life estate purchase Copy of deed County tax records Verify the Fair Market Value ( DHHS Form V) of the property. The county tax assessed value may be used Verify the purchase price and calculate the fair market price of the life estate. Any amount over the fair market value of the life estate is considered a transfer Verify that the individual purchasing the life estate lived in the home for at least 12 consecutive months after the date of purchase. Acceptable forms of verification include: Old postmarked mail received at the address Bills such as electric or telephone in her name Statements from at least two persons who indicate the individual lived in the home for at least 12 consecutive months after the date of purchase
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304.09.02H Transfer of Assets in Month of Receipt
(Rev. 10/01/06)
Assets transferred in the month of receipt are subject to penalty under the transfer of assets provision, even though the asset may not be a countable resource in the month of receipt.
Examples
Cash proceeds of a loan, home equity loan, or reverse mortgage
An inheritance
304.09.02I Transfer of Income
(Rev. 05/01/25)
Income is considered an asset for transfer purposes. If an individual gives away or assigns income to another person, the gift or assignment can be considered a transfer of assets for less than fair market value,
When a single lump sum is transferred, such as an annual rent payment, the penalty period is calculated using the value of the lump sum. If the transfer of several payments has taken place, the total of the payments are added together and the penalty period is calculated based on the total.
If the transfer was a stream of income, determine the value of the stream of income by multiplying the life expectancy of the individual at the time of the transfer by the annual amount of income that would have otherwise been received.
Procedure Calculate the annual amount of the stream of income Determine the individual’s life expectancy using the Life Expectancy table located in Appendix A Multiply the individual life expectancy by the annual amount of the income stream If a transfer occurred, refer to MPPM 304.09.05 to calculate the transfer penalty Example Mr. George Wildcat, age 60, receives a royalty check for $100 each month. He transfers his right to receive this income to his nephew on May 6, 20 2 3. He applies for Nursing Home Medicaid on May 21, 20 2 5. $100.00 x 12 = 1200.00 The life expectancy table indicates a 60-year-old male has a life expectancy of 19.07 years $1200.00 x 19.07 = $22,884.00 The value of the transfer is $22,884.00.
304.09.03 Exceptions to the Penalty
(Rev. 09/01/25)
Resources excluded under SSI policy (except for the home) are not subject to the transfer of assets penalty. However, assets that are excluded by Medicaid but not by SSI are subject to the transfer of assets penalty.
If there has been a transfer of assets, no penalty is imposed if:
The asset transferred was a home, and title to the home was transferred to:
· The spouse of the institutionalized individual;
· A child who:
Is under age 21, or
Meets the Supplemental Security Income (SSI) definition of blindness or disability (may be at any age); or
Was residing in the home:
– For at least two years immediately before the individual became institutionalized; and
– Who provided care which delayed institutionalization.
· A sibling of the individual who:
Has an equity interest in the home; and
Was residing in the home for at least one year immediately before the date the individual became institutionalized.
Procedure – Home is Transferred to a Child The following must be verified: Relationship (Examples of verification: birth certificate, adoption papers, family Bible) Criteria for not imposing penalty Age, if under 21 Blindness or disability Length of residence Doctor’s statement verifying the child’s care delayed the need for institutionalization. Procedure – Home is Transferred to a Sibling The following must be verified: Relationship Sibling’s equitable interest Length of time sibling has resided in the home
Example Mr. Brownlee applied for Medicaid through the Nursing Home program. It was discovered that he transferred his home to his daughter one year before he applied for Medicaid. The home was valued at $250,000. The daughter explained that Mr. Brownlee wanted her to have the home because she had lived with him and cared for him since he had a stroke six years ago so that he would not have to be placed into a nursing home. She said she had occasionally hired a sitter to stay with him while she ran errands; but, for the most part, she had cared for him herself for the past six years. Now that his health had deteriorated to the point that she was no longer able to provide the care he needed, she has placed him in a nursing home. Treatment No penalty is imposed for this transfer of assets if the daughter can provide the following sources of verification: Verification of her relationship to Mr. Brownlee Birth certificate Family Bible Verification that she lived at the same address as her father for at least two years immediately before he was institutionalized. Acceptable forms of verification include: Old postmarked mail received at the address Bills such as electric or telephone in her name Statements from at least two persons who know she stayed at the same address and provided for her father’s care. Verification from her father’s doctor stating that the care she provided delayed institutionalization.
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The assets were transferred:
To the individual's spouse or to another person for the sole benefit of the spouse; or
From the individual's spouse to another person for the sole benefit of the individual's spouse;
To an individual’s child or to another person for the sole benefit of the child. The child MUST be blind or totally and permanently disabled as defined by SSI.
The assets may be transferred to a trust established solely for the benefit of the individual’s child.
To a trust established solely for the benefit of an individual under age 65 who is disabled as defined by SSI.
A transfer is considered to be "for the sole benefit of" a spouse, disabled child or individual under age 65 under the following circumstances:
The transfer is arranged in such a way that no individual except the spouse, child or individual under age 65 can benefit from the assets transferred in any way at the time of transfer or in the future.
The trust may provide for reasonable compensation for a trustee to manage the trust.
If a secondary beneficiary is named to receive the asset, or whatever is left, at the individual's death as long as:
The state Medicaid agency is:
– Named as the primary beneficiary of the asset, and
– Receives up to the amount paid by Medicaid; and
The other designated beneficiary is only to receive any remaining amounts after the obligation to Medicaid is satisfied.
The individual can show that he/she intended to dispose of the assets either at Fair Market Value or for other valuable consideration.
The individual can show that he/she transferred the assets exclusively for a purpose other than to qualify for Medicaid.
Procedure If the individual indicates the transfer was made for a reason other than to qualify for Medicaid: Request a written statement from the individual outlining the circumstances of the transfer. The statement should at least include the following: A listing of all transferred assets; The reason(s) for the asset transfer; To whom the assets were transferred; Compensation received for the asset; The financial condition of the applicant at the time of the transfer; A statement from the individual’s physician , nurse practitioner, or physician assistant detailing the health status of the applicant at the time of the transfer. Note: The statement should indicate whether or not the client’s health at the time of transfer anticipated a need for long-term care. Request the names and addresses of all principals involved including attorneys, realtors, or any individuals having knowledge of the circumstances surrounding the transaction; Request collaborative statements from anyone having supporting evidence that the transfer occurred exclusively for reasons other than to qualify for services; and After the county has reviewed the information, forward all material to the Division of Policy and Planning for a decision.
All assets transferred for less than Fair Market Value have been returned to the individual.
The individual can show that the transfer occurred because of exploitation.
Procedure – Verification of Exploitation Refer the applicant or authorized representative to DSS Adult Protective Services. Require verification that the exploitation has been reported to the Solicitor for prosecution.
A transfer that does not meet one of the above six exceptions and for which a denial of vendor payment or Home and Community Based Services has occurred may have the penalty waived if it is determined that the denial of eligibility would cause an undue hardship. Undue hardship is defined as depriving the applicant/beneficiary of medical care that would result in the individual’s health or life being endangered, or that would result in the individual being deprived of food, clothing, shelter, or other necessities of life. The applicant/beneficiary, an authorized representative, or a nursing facility with the consent of the applicant/beneficiary or his authorized representative may make a request for a waiver of the penalty. Refer to MPPM 304.09.04 for the waiver of transfer penalty procedure.
304.09.04 Waiver of Transfer Penalty Procedure and 30-Day Hold
(Eff. 04/01/07)
Within thirty (30) days of an applicant/beneficiary receiving the DHHS Form 932, Notice of Denial of Waiver Services or Nursing Home Care, indicating that a vendor payment or eligibility for HCBS services has been denied due to the imposition of a transfer penalty, the individual, the individual's spouse or authorized representative, or the institution where the individual resides (with the individual's consent) may submit a written request for a waiver of the penalty period based on a claim of undue hardship.
It must be demonstrated that all other possible exceptions to the imposition of the transfer penalty has been explored, including return of the asset to the applicant/ beneficiary.
The eligibility worker must obtain the following verifications:
Letter from a physician certifying that the applicant/beneficiary is at risk of death or permanent disability without the institutional care; AND
Letter from CLTC either denying or terminating services; OR
Letter from the nursing home either:
Refusing to admit the patient, or
Threatening discharge of the patient.
Send the letters, a copy of the DHHS Form 932, and other documentation to the DHHS Division of Policy and Planning in the Division of Policy and Planning for evaluation.
While an application for waiver of the penalty period is pending for an individual currently residing in a nursing facility, a payment may be made to the facility for up to 30 days from the date the request is made if the individual meets all other eligibility criteria. The nursing facility may request an earlier date, but in no event will the start date occur after the date of the request.
The DHHS Form 3229-C, Request for Waiver of Transfer Penalty, is used by the Medicaid eligibility worker to:
Notify applicants/beneficiaries the dates that have been approved for the bed hold and any recurring income to be paid to the facility, and/or
Notify the applicant/beneficiary if the request for the waiver of transfer penalty has been approved or denied.
If a request for a waiver of the penalty period is denied, the applicant/beneficiary may request a fair hearing. Refer to MPPM 101.12.11.
304.09.05 Calculating the Penalty Period
(Eff. 01/01/26)
The preferred method for calculating the penalty period is to use the eligibility budgeting workbook in effect at the time of the eligibility decision. The result is the period during which the individual would be ineligible for certain Medicaid services. (Refer to MPPM 304.09.07.)
Procedure to Calculate the Penalty Period Using the Eligibility Workbook Determine the uncompensated value of the transferred asset(s). Fair Market Value – amount received = amount transferred Amount transferred – amount of legal encumbrance (such as a mortgage or lien) = uncompensated value Total the uncompensated value of all assets transferred by the individual and/or his or her community spouse. Enter the Effective Date of Transfer (refer to MPPM 304.09.02D, Beginning Date of Penalty Period) and the Amount of Transfer into the Transfer Penalty Calculator on the NH-HCBS tab . Always use the most current eligibility workbook in effect at the time of the decision. The results will display the length of the penalty period, the end date of the penalty period, and the first date the individual may be able to qualify for services. Transfer Penalty Calculator Effective Date of Transfer Amount of Transfer 5 /1/202 6 25,000.00 Length of Transfer Penalty End of Penalty Period Date of Vendor Payment Eligibility 0 years, 2 months, 1 6 days 7 / 1 6 /202 6 7 / 1 7 /202 6 Procedure to Manually Calculate the Penalty Period Note The manual method shown below is included to demonstrate the steps used to determine the penalty. Using the manual method may produce slight differences in the length and end dates of the penalty period due to Excel being able to determine the length of the penalty period with more precision and account for the actual number of days in each month. Determine the uncompensated value of the transferred asset(s). Fair Market Value – amount received = amount transferred Amount transferred – amount of legal encumbrance (such as a mortgage or lien) = uncompensated value Total the uncompensated value of all assets transferred by the individual and/or his or her community spouse. Divide by the state’s most current average private pay nursing home rate (Refer to MPPM 103.07A). Do not use the average pay rate that was in effect at the time the transfer occurred. Do Not round answer down to the nearest whole number. Multiply the fractional amount of the month by 30 days to determine the partial month penalty period. Uncompensated Amount = Length of Penalty Period Current Average Nursing Home Private Pay Rate The result is the period the individual would be ineligible for certain Medicaid services. Example Alton Gray transferred $10,000. The penalty period is calculated as follows: $10,000 ÷ $9,758.58 = 1.0 2 (round to two places) . 02 x 30 = 6 (round down to whole day) Length of penalty period is 1 month, 0 days
Example 1 Sam Mills applied for Nursing Home Assistance on March 27, 202 6 . He meets level of care and all other eligibility criteria and entered the facility on May 1, 202 5 . On April 12, 202 4 , he gave his grandson Rick $10,000. On April 17, 202 4 , he gave his granddaughter Jean $10,000. On April 28, 202 4 , he gave his daughter Laura $15,000. Transfer Penalty Calculator Effective Date of Transfer Amount of Transfer 5 /1/202 6 35,000 Length of Transfer Penalty End of Penalty Period Date of Vendor Payment Eligibility 0 years, 3 months, 1 7 days 8 / 1 7 /202 6 8 / 18 /202 6 Example 2 Susie Moss gave her grandson an acre of land ( DHHS Form V $28,000) on February 19, 202 4 . On May 3, 202 4 , she gave her granddaughter $25,000. She applies for Nursing Home assistance on June 30, 202 6 . She meets level of care and all other eligibility criteria and entered the facility on July 15, 202 6 . Transfer Penalty Calculator Effective Date of Transfer Amount of Transfer 7/15/202 6 53,000.00 Length of Transfer Penalty End of Penalty Period Date of Vendor Payment Eligibility 0 years, 5 months, 1 2 days 1 2 / 26 /202 6 1 2 / 27 /202 6 Example 3 John Slick transferred $25,000 to his son on February 22, 202 4 . He meets level of care and all other eligibility criteria and entered Acres Nursing Facility on May 10, 202 6 . The transfer penalty is calculated as follows: Transfer Penalty Calculator Effective Date of Transfer Amount of Transfer 5 /10/202 6 25,000.00 Length of Transfer Penalty End of Penalty Period Date of Vendor Payment Eligibility 0 years, 2 months, 1 6 days 7 / 2 5 /202 5 7 / 2 6 /202 5 Note: Although the vendor payment cannot be authorized, the applicant may be eligible for MAO-NH, Payment Category 10, or other Medicaid category if all other eligibility criteria are met. Refer to MPPM 101.04.01. Example 4 Frank Purvis was approved for Nursing Home Medicaid effective June 12, 2009. In May 202 6 while reviewing the case, his eligibility worker discovers that Mr. Purvis transferred homestead property to his daughter on October 20, 202 5 . The property is valued at $135,000. The transfer penalty is calculated as follows: Transfer Penalty Calculator Effective Date of Transfer Amount of Transfer 10/1/202 5 135,000.00 Length of Transfer Penalty End of Penalty Period Date of Vendor Payment Eligibility 1 years, 1 months, 24 days 11 / 24 /20 6 5 11 / 25 /202 6 Note The eligibility worker will terminate vendor payment as soon as possible, giving the appropriate notice. An overpayment summary must be completed for any vendor payments made to the facility during the penalty period. The beneficiary’s Medicaid eligibility is not affected.
304.09.06 Notification of Penalty
(Rev. 04/01/07)
If an applicant/beneficiary or the community spouse has transferred assets for less than Fair Market Value and the transfer is penalty-liable, the eligibility worker must notify the applicant/beneficiary or authorized representative using a DHHS Form 932, Notice of Denial of Waiver Services or Nursing Home Care for Medicaid Beneficiaries.
Procedure – Notification of Penalty The written notification of penalty must include the following information: Item transferred; Value of the penalty; Beginning date of the penalty; Length of the penalty period; and Services that will not be covered by Medicaid during the penalty period: Vendor payment to a nursing facility, and/or Community Long-Term Care services. Note: The notification must be issued even if the individual is already eligible under an “at home” coverage group such as SSI, ABD. A copy of the DHHS Form 932 must be forwarded to CLTC/ BHDD if the individual is an applicant for or beneficiary of home and community based services.
304.09.07 Medicaid Benefits during Penalty Period
(Rev. 04/01/07)
An individual residing in a nursing facility while he/she is awaiting the expiration of a transfer of assets penalty, may receive Medicaid benefits to pay for non-institutional services provided, if:
The level of care has been certified, and/or
All other eligibility criteria (financial and non-financial) are met.
304.09.08 Annuities
(Rev. 04/01/07)
Refer to MPPM 304.12 for policy concerning annuities.
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304.10 Obtaining Other Assets/Elective Share
(Eff. 06/01/06)
If a benefit is available to an applicant/beneficiary, he/she must make an effort to obtain the benefit or asset. Failure to do so may result in a transfer of assets.
One such asset relates to the claiming of an elective share from a spouse’s estate. The South Carolina Probate Code gives a surviving spouse the right to claim an “elective share” of the deceased spouse’s estate.
The Elective Share is one-third of the estate remaining after deductions for:
Funeral expenses,
Administrative expenses, and
Enforceable claims (SC Code Ann.62-2-201 and –202).
The right to an Elective Share usually becomes an issue when:
The surviving spouse inherits nothing, or
The surviving spouse receives only a small inheritance.
In these types of cases, the surviving spouse can demand his/her elective share of 1/3 of the estate. The surviving spouse must claim the elective share by the later of these two dates:
Within 8 months of the decedent’s death; or
Within 6 months of the time the decedent’s will is probated.
An individual applying for Medicaid sponsorship of nursing facility services or Home and Community Based Services must claim the elective share. Failure to do so will be considered a transfer of assets.
If the surviving spouse received no inheritance and did not claim the elective share; the value of the transfer is 1/3 of the estate, after expenses
If the surviving spouse inherited an amount less than the elective share, the value of the transfer is 1/3 of the estate, after deductions for expenses, minus the amount actually received
Procedure – Elective Share and Calculating the Penalty Period Determine the Elective Share Value Determine the total value of the decedent’s estate. Deduct the following expenses: Funeral expenses Administrative expenses Enforceable claims filed against the estate Divide the remainder by 3; this amount represents the value of the elective share to which the surviving spouse is entitled. Determine the Amount Transferred Take the value of the elective share. Subtract the value of any of the decedent’s property passing to the surviving spouse. The difference is the amount transferred. Determine the Penalty Period The amount transferred is then divided by the monthly average private pay rate to determine the number of months to which the penalty applies. For purposes of the transfer penalty, the transfer is deemed to have occurred on the last day that the surviving spouse could have claimed the elective share. Example The husband is in a nursing facility as a Medicaid beneficiary. His wife dies on January 1, leaving him nothing in her will. Her will is probated on February 1, but the husband fails to make a claim against her estate. The estate consists of real property and certificates of deposit with a total value of $105,000. Expenses and claims against the estate total $27,000, leaving a “net” estate subject to the elective share provisions of $78,000. Treatment The husband is entitled to receive 1/3 of this net estate as his elective share ($26,000.) The last day on which he could have claimed the elective share was August 31 (that is, within 8 months from the date of her death, since this date is later than 6 months from the date the will was probated.) His failure to claim the $26,000 to which he is entitled is treated as a transfer of resources on August 31. Note If the cost of obtaining the asset is greater than the value of the asset, the individual is not required to pursue it.
304.11 Promissory Notes
(Rev. 11/01/23)
A promissory note is a written, unconditional promise by one party to pay a specified sum of money to another party. It may be:
Payable:
At a specified time
On a specified schedule
On demand
Given in return for goods, money loaned, or services rendered
Negotiable or non-negotiable
Negotiable Notes
May be sold or transferred, and
Value is a countable resource.
Non-Negotiable Notes
May not be sold or transferred under any circumstances.
May not be considered a transfer of an asset for less than Fair Market Value if:
It is actuarially sound – that is, expected to be paid back during the holder’s lifetime (refer to MPPM 304.11.01)
It requires monthly payments that fully amortize it over the life of the loan
Equal payments with no balloon payment at the end
Payments include both interest and principal
Reasonable rate of interest (refer to 304 Appendix K for instructions to determine if a reasonable rate of interest has been met.)
May NOT be self-canceling or conditional
Procedure – Promissory Notes All Promissory Notes must be forwarded for review by the Division of Policy and Process via a Service Manager Policy ticket under "Document for Review.” The assigned Policy and Process staff will advise the Eligibility Specialist on how to handle the Note. See Eligibility - Service Manager Desk Aid.pdf - All Documents (sharepoint.com) and Eligibility - Service Manager Ticket Submission Guide.pdf - All Documents (sharepoint.com) for instructions.
304.11.01 Actuarially Sound Notes
(Eff. 06/01/06)
Like an annuity, the non-negotiable note must be actuarially sound. The expected return on the note must be proportionate with a reasonable estimate of the life expectancy of the owner of the note (that is, it is expected to be paid off within the owner’s lifetime). If the note is NOT actuarially sound, it is considered a transfer of assets for less than Fair Market Value and the transfer of assets penalty applies. (Refer to MPPM 304.11.03.)
Procedure – Determining if Non-Negotiable Note is Actuarially Sound Use the Life Expectancy Table found in MPPM Chapter Appendix A . Life expectancy is based on the individual’s age at the time the promissory note was executed (the date signed), NOT the date of the Medicaid application. The average number of years of expected life remaining on the table for the owner’s age must be equal to or less than the number of years stated in the note to be paid. If the individual is not expected to live long enough to receive full payment on the note: Fair market value was not received, and The transfer penalty is applied.
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304.11.02 Transfer of Assets Related to Promissory Notes
(Eff. 01/01/26)
For notes created on or after February 8, 2006, the transfer penalty begins the later of the first day of the month in which the asset was transferred, or the date on which the individual is eligible for medical assistance for long term care and would otherwise be receiving institutional level care (vendor payment) if not for the application of the penalty period (Refer to MPPM 304.09.02D.)
Procedure – Promissory Notes and Calculating Transfer of Assets Penalty Period for notes created on or after February 8, 2006 If the promissory note, loan, or mortgage does not meet the criteria listed in MPPM 304.11, determine the outstanding balance due as of the date of application. Divide the uncompensated value by the average private pay nursing facility rate in the state. (Refer to MPPM Chapter 304 Appendix D .) Follow the procedure for calculating a transfer penalty as shown in MPPM 304.09.05. Example #1 Mr. Jones is 89 years old. He applies for assistance on May 1, 202 6 . He sold his home and surrounding property for $150,000. He holds the note, which is to be paid off in 30 years at 4% interest. The note is non-negotiable; therefore, it must be determined if the note meets the test of being actuarially sound. The note was signed, and payments began March 1, 202 5 , when he was age 88. The note is not actuarially sound because the length of time for payments through the note is 30 years, and Mr. Jones' life expectancy at the time the note was executed was 4.26 years. Therefore, Mr. Jones is not considered to have received Fair Market Value based on the projected return and the transfer of assets penalty is applied. To calculate the transfer of assets penalty: Determine the balance due on the note on the date of application, May 1, 202 6 : $1 47,358.45. Enter the date of application and the balance due into the Transfer Penalty Calculator. Transfer Penalty Calculator Effective Date of Transfer Amount of Transfer 5 /1/202 6 147,358.45 Length of Transfer Penalty End of Penalty Period Date of Vendor Payment Eligibility 1 years, 3 months, 2 days 8 / 2 /202 7 8 / 3 /202 7 Treatment The penalty period is 1 5 months and 2 days (1 year, 3 months, 2 days): May 1, 202 6 , through August 2 , 202 7 . The vendor payment may not be authorized earlier than August 3 , 202 7 . Medicaid may be approved if otherwise eligible. Example #2 Mr. Smith is 50 years old. He sells a piece of property valued at $10,000. On September 1, 202 5 , he signs the mortgage and payments begin that day. The mortgage is non-negotiable and will be paid off in 25 years. According to the Life Expectancy Table, Mr. Smith is expected to live 27.13 years. Treatment Since the mortgage will be paid off in 25 years, the note is considered actuarially sound. Note: If it is determined that a transfer of assets did not occur and the mortgage is actuarially sound, the scheduled loan payments, including the interest, are counted as income in the month received in the eligibility and post-eligibility steps. The loan payments will be counted as income according to the schedule stated in the mortgage.
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304.11.03 Default on Payments
(Eff. 06/01/06)
As long as the requirements in MPPM 304.11.01 are met and payments are made, no transfer has occurred. Should the borrower default on his/her payments, the owner of the note must take legal action to foreclose on the note. The owner must provide documentation of the action being taken. If the owner fails to take any action to foreclose on the note, he/she is considered to have transferred assets equal to the remaining value of the note. The effective date of this transfer is the date the payments stopped.
304.11.04 Forgiving Principal Portions of Promissory Notes
(Eff. 06/01/06)
Forgiving Principal Portions of Promissory Notes
If a promissory note was approved by the Eligibility, Enrollment, & Member Services, it has been determined the note:
Is actuarially sound; AND
Was established to create a stream of income; AND
Is fully amortized over the life of the note.
If the owner of the note later gifts a portion of the principal balance of the note, Medicaid cannot forgive the owner of the note for gifting the principal balance of the note. The monthly payments he/she gifted would still be counted as income to the beneficiary. This means the gift will not change the final payment or principal balance of the note.
Example Mrs. Smith is a Medicaid beneficiary. She established an actuarially sound non-negotiable promissory note prior to becoming eligible. The terms of the note state she is to receive $325 per month for a period of 5 years (60 months running from November 2004 through October 2009). At annual review, it is discovered that she “gifted” $5,000 of the principal balance to her daughter. Treatment The $325 remains countable income each month for the term of the original note ($325 per month through October 2009).
304.12 Annuities
(Eff. 06/01/06)
Annuities are generally purchased from a financial institution such as a bank or insurance company. The purchaser/annuitant is promised regular payments of income in certain amounts in exchange for the money paid to the financial institution.
304.12.01 Periodic Payments
(Eff. 06/01/06)
Payments from an annuity usually continue for a fixed period (such as 10 years) or as long as the annuitant or other designated beneficiary lives. These payments create an ongoing income stream for the individual.
The annuity may or may not include a remainder clause under which the financial institution converts and pays the remainder of the annuity in a lump sum to a designated beneficiary in the event the annuitant dies before the payout is completed.
304.12.02 Purpose of Annuity
(Rev. 02/01/22)
Policy for Annuities before February 8, 2006:
Annuities are generally purchased to provide a source of income for retirement. However, they are occasionally used as a mechanism to shelter assets. The following determinations must be made to decide if the transfer of assets penalty applies to an individual who has purchased an annuity.
Procedure to Determine Purpose of Annuity It is considered to be a creation of a stream of income if: It was purchased as part of a retirement plan and regular payments were made while employed; or It was purchased with a lump sum and is actuarially sound. It is considered a transfer of assets for less than Fair Market Value if it is not actuarially sound.
The ultimate purpose of an annuity must be determined to in order to distinguish an annuity purchased as part of a retirement plan from those used to shelter assets. To be considered valid, the annuity must be actuarially sound.
If the individual is not reasonably expected to live longer than the guarantee period of the annuity, the individual will not receive fair market value for the annuity based on the projected return; in this case, the annuity is not “actuarially sound” and a transfer of assets for less than fair market value has taken place.
Procedure – Determining if Annuity is Actuarially Sound To make this determination, use the Life Expectancy Table found in Appendix A of this chapter. Example A 65-year-old male purchases a $10,000 annuity to be paid over the course of 10 years. According to the tables, his life expectancy is 15.52 years. Therefore, the annuity is actuarially sound.
The average remaining life expectancy for the individual must coincide with the life of the annuity. If the individual is not reasonably expected to live longer than the guaranteed period of the annuity, the individual is not considered to receive Fair Market Value for the annuity based on the projected return and the penalty is applied.
Policy for Annuities on or after February 8, 2006
The Deficit Reduction Act of 2005 made many changes concerning annuities created on or after February 8, 2006.
At application and review, applicants/beneficiaries must disclose to the agency the existence of any annuities held by the applicant/beneficiary or the community spouse;
The purchase of an annuity may be treated as a disposal of an asset for less than fair market value unless the SC Department of Health and Human Services (SCDHHS) is named as the primary remainder beneficiary for at least the total amount paid by Medicaid for long-term care services, or is named as such a beneficiary after the community spouse and/or minor or disabled child;
SCDHHS must inform the issuer of the annuity of the requirement that the agency be named as the primary remainder beneficiary, and the responsibility of the issuer to inform the agency of any change in the amount of income or principal withdrawn from the annuity; and
An annuity may be treated as a disposal of assets for less than fair market value unless it is irrevocable and non-assignable, actuarially sound, and provide for payments in equal amounts during the term of the annuity, with no deferral and no balloon payments.
An annuity that is revocable and assignable must be considered as a countable resource, and not a transfer of assets. If the annuity is revocable, the resource value is the amount that the purchaser would receive if the annuity is canceled. If the annuity is assignable, the resource value is the amount the annuity can be sold for on the secondary market. A secondary market is an informal market where existing financial instruments, such as mortgages and annuities, are bought and sold.
Procedure to Determine Purpose of Annuity An annuity purchased by an applicant/beneficiary or a community spouse is not considered a transfer if it is: Purchased with the proceeds from certain retirement accounts, such as a Roth IRA The annuity is: Irrevocable and non-assignable; Is actuarially sound; and Provides for equal payments during the term of the annuity with no deferred or balloon payments
An annuity is now considered part of an estate that is subject to estate recovery unless the annuity is issued by a financial institution or other business that sells annuities in the state as part of its regular business.
A copy of the annuity must be submitted for evaluation. Refer to the Service Manager Ticket Submission Guide for instructions.
Changes in payments or withdrawals from the annuity must be reported to the Division of Policy and Planning.
304.12.03 Transfer penalty
(Eff. 06/01/06)
Procedure to Calculate an Annuity Penalty Period Divide the purchase price of the annuity by the number of payout years. This equals the annual rate. Using the Life Expectancy Table, determine the number of years the individual is expected to live. Subtract the number of years from the number of payout years. Multiply the difference by the annual rate. This is the uncompensated value. Divide the uncompensated value by the average private pay rate in the state. This is the number of months from the date of purchase of the annuity that the individual is penalty liable. Purchase Price ¸ Payout Years = Annual Rate Payout Years – Life Expectancy = Difference Difference X Annual Rate = Uncompensated Value Uncompensated Value ¸ Average Private Pay Rate = Penalty Period Example: An 80-year-old man purchases an annuity for $10,000 to be paid within 10 years. The purchase price ($10,000) is divided by the number of payout years (10) to get the annual rate of $1,000. ($10,000 ¸ 10 = $1,000) The number of payout years (10) minus the life expectancy years (7.16) equals 2.84. (10 – 7.16 = 2.84) 2.84 x annual rate of $1,000 = $2,840, which is the uncompensated value. The uncompensated value is divided by the average private pay rate in the state to determine the number of penalty months (refer to MPPM Chapter 304 Appendix D ).
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304.13 Spousal Impoverishment Provisions
(Eff. 06/01/06)
Institutionalized individuals who have a spouse in the community are allowed to give a portion of their income and resources to the community spouse. This applies regardless of whether the individual is receiving services:
In a nursing home, or
Through a Home and Community Based Services waiver program.
304.13.01 Definitions
(Rev. 12/01/07)
For purposes of spousal impoverishment, the following definitions apply:
Community Spouse – A community spouse of an institutionalized individual resides in a community setting (such as a home, residential care facility, assisted living facility). The spouse of a nursing home patient who receives Home and Community Based Services is considered a community spouse for the purposes of the income provisions of spousal impoverishment.
If a couple is separated, the community spouse must be considered as long as they are not legally divorced.
Note According to spousal impoverishment provisions, the community spouse may reside at home or with a relative, or in a residential care facility. The community spouse may be a legal or a common-law spouse. If the couple is separated, but not legally divorced, the community spouse must be considered. (Refer to MPPM 304.14.01)
Family Member – A family member may be a minor or dependent child, a dependent parent, and/or a dependent sibling who resides with the community spouse.
Institutionalized Individual – An institutionalized individual resides in a medical institution or receives Home and Community Based Services.
304.14 Spousal Impoverishment and Resources
(Eff. 01/01/26)
At the initial eligibility determination, the resources of both the institutional and community spouse must be considered. The procedure to consider the resources is given below.
Procedure to Consider Spousal Resources The DHHS Form 929 , Community Spouse Worksheet, is used to calculate the couple’s total resources and the spousal share. Apply all exclusions to both spouses. Total the couple’s countable resources. Subtract the spouse’s share of $66,480. After the spousal share is subtracted from the couple’s total countable resources, the remainder must meet the individual resource limit. The individual resource limit is $2,000 (or $ 9 ,9 5 0 if the individual can qualify under ABD criteria.) Example #1 Jean Hill applies for her husband Tom who is entering Caring Hearts Nursing Home. Tom’s income is $1,000 per month in Social Security. Their combined countable resources total $67,996. Mrs. Hill may keep $66,480. The remainder of $1,516 is less than the individual limit, so the resource limit is met. Example #2 Max Golden applies for his wife Jane who is entering a nursing home. Her only income is her SSA of $650 per month. Their combined countable assets total $69,415. Since $69,415 - $66,480 = $2,935, which exceeds the $2,000 individual resource limit, and Mrs. Golden’s income is less than the individual ABD income limit, the larger ABD resource limit may be applied. Example #3 Sam Piper is in a nursing home, and his wife has applied. Sam’s total income is $1,400 per month. Their combined resources total $75,520. Since $75,520 – $66,480 = $9,040 which exceeds the individual resource limit, Mr. Piper would be ineligible due to excess resources.
If eligibility is established, the spousal share must be separated from the institutionalized spouse’s resources within 30 days of the case’s approval. This may be accomplished by:
Having jointly owned assets transferred into the community spouse’s name only, or
Transferring resources from the institutionalized spouse’s name to the community spouse’s name.
Note
If the institutionalized individual fails to transfer the assets to the community spouse within 30 days and no court order exists, the institutionalized individual becomes ineligible for Medicaid beginning the month following the month in which the 30-day period ends.
Procedure – Separation of the Spousal Share Verification of the separation of the spousal share must be documented in the case record. The eligibility worker must : Advise the beneficiary/authorized representative that: The spousal share must be separated within 30 days, AND Verification of the separation must be submitted to the Medicaid office. Place the case into follow-up for 30 days to ensure appropriate action is taken. Send a 10-day notice and initiate closure procedures if the resources are not separated or verification is not returned. Example Steve Cohen is approved for nursing home assistance on June 1. He has a community spouse, Eve. Their countable assets are as follows: Countable Asset Owner(s) Value Money Market account Steve & Eve $20,000 CD Eve $5,000 CD Steve $5,000 CD Steve & Eve $10,000 Checking account Steve $200 Checking account Eve $800 Life Insurance - FV $10,000 Steve $500 Life Insurance - FV $8,000 Eve $100 Eve’s spousal share must be separated within 30 days (by July 1) for Steve to remain eligible. The eligibility worker sets up a tickler file. The Cohen’s close the jointly owned Money Market account and deposit the money into a new Money Market account in Eve’s name only. Their jointly owned CD and Steve’s CD both mature in July. They cash them in and open a new CD in Eve’s name with the proceeds of $15,550. They provide all verifications to the eligibility worker on June 25. The case record must have verifications of the following: Closing date and balance of the joint Money Market account (such as a closing statement or letter from the bank) Opening date and balance of the new Money Market account and owner’s name Closing date and proceeds of the two CDs Opening date and amount of the new CD and owner’s name Note: If the eligibility worker had not received verification of the transactions; on July 1, the eligibility worker would have sent a 10-day notice of closure.
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When an institutionalized individual loses eligibility and re-applies:
If he/she remained institutionalized, the community spouse’s resources are not considered at re-application.
If he/she was not institutionalized during any of the ineligible months, the community spouse’s resources are considered at re-application.
304.14.01 Separated Spouses
(Eff. 07/01/24)
If a person who is separated, but not divorced, applies for an institutional program, the eligibility worker MUST contact the community spouse and obtain resource information.
Procedure – Separated Spouses Who Are Not Divorced The eligibility worker is to obtain asset information and evaluate the information as though the couple were not separated. The eligibility worker must use the following guidelines to decide how to proceed with the eligibility determination. These guidelines apply regardless of the length of separation. If the community spouse receives SSI, the eligibility worker must: Document receipt of SSI in the case record (SDX, copy of letter); AND Count only the assets of the institutionalized spouse. If the community spouse is currently ABD, SLMB or OSS eligible, the eligibility worker must: Review the existing case record; Contact the community spouse to: Complete the DHHS Form 3295 , Request for Additional Information – Separated Spouse. Before sending the DHHS Form 3295 to the spouse, fill in the names of the individuals and the Household number. Collect current asset information, Request the appropriate bank statements and other necessary information Verification of the community spouse’s income is not required unless a spousal allocation is being budgeted. Do not give a spousal allocation if unable to verify the community spouse’s income If the community spouse returns the necessary information, complete normal spousal impoverishment budgeting If the community spouse refuses to provide the necessary information or fails to respond, treat the institutionalized spouse as an individual If the community spouse’s whereabouts are known, the eligibility worker must: Request information/verification of the spouse’s resources using the DHHS Form 3295 , Request for Additional Information – Separated Spouse, and DHHS Form 1233 , Medicaid Eligibility Checklist, UNLESS good cause is alleged. Attempt to contact the spouse to obtain the information: Document all efforts to obtain the information in OnBase or Cúram notes. This may include: Copies of correspondence, Returned mail, Documentation of telephone or face-to-face conversations If requested information is not returned, assume the Community Spouse refuses to cooperate and only count the assets of the institutionalized spouse. If the requested information is returned, evaluate as a couple. If the spouse refuses to cooperate, the eligibility worker must: Document all attempts to obtain the verification and/or contact in the case record. Count only the assets of the institutionalized spouse. If good cause is alleged, the eligibility worker must obtain a written or verbal statement from the applicant/authorized representative detailing the reasons for good cause not to contact the separated spouse. If the applicant/authorized representative is unable to obtain the information, the eligibility worker must: Attempt to contact the spouse to obtain the information: Document all efforts to obtain the information in OnBase or Cúram notes. This may include: Copies of correspondence, Returned mail, Documentation of telephone or face-to-face conversations If the community spouse’s whereabouts are unknown , the eligibility worker must: Document all attempts to locate the community spouse, through such processes as: Telephone directory listing, Real and personal property searches, CHIP, or Online people and reverse number look-up searches via Internet. If unable to locate, only count the assets of the institutionalized spouse.
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304.14.02 Undue Hardship
(Eff. 10/01/13)
Undue hardship may exist if a denial of eligibility would:
Result in a Medicaid facility refusing to admit or threatening to discharge an individual, or
Result in the individual being placed in a life-threatening situation.
A community spouse refusal to make resources available to the institutionalized spouse, may result in an undue hardship.
Procedure – Community Spouse and Undue Hardship The eligibility worker must: Document the community spouse’s refusal to cooperate. Obtain verification/documentation that: Either The facility is either refusing to admit or is threatening to discharge the applicant/beneficiary, or Community Long Term Care is denying or terminating services AND There is a life-threatening situation (such as an individual would have no care) The facility is either refusing to admit or is threatening to discharge the applicant/ beneficiary, OR Community Long Term Care is denying or terminating services Make a local decision based on the verification/documentation received.
304.15 Budgeting Income and Resources Under Spousal Impoverishment Provisions
(Eff. 06/01/06)
Determining the amount to be allocated to the community spouse is a two-step process. The Electronic Budgeting Workbook or the DHHS Form 1296-A ME, Medical Assistance Only (MAO) Institutional Worksheet, is used for budgeting. The DHHS Form 929, Community Spouse Resource Worksheet, may also be used to budget resources.
304.15.01 Eligibility
(Eff. 06/01/06)
The first step is to determine if the institutionalized individual is income eligible. Only the institutionalized spouse’s income is considered in this step. However, the resources of both the institutionalized and the community spouse must be considered.
Procedure – Step One - Eligibility Income – Consider only the income of the institutionalized spouse in this step. Resources – Consider the resources of both the institutionalized spouse and the community spouse at these times: (1) initial eligibility determination, and (2) at the beginning of the first continuous period of institutionalization.
304.15.02 Post-Eligibility
(Rev. 05/01/07)
If the institutionalized individual is eligible, the post-eligibility step is next. In this step, the eligibility worker must determine:
Procedure – Step Two – Post-Eligibility The eligibility worker must determine: How much income and resources the institutionalized individual keeps, How much income and resources are allocated to the community spouse, and How much the institutionalized individual must contribute toward the cost of his/her care after allowable deductions (that is, recurring income). Note Only the income and resources that the institutionalized individual actually makes available to the community spouse will be allowed as a deduction from his/her income or resources.
304.15.02A Income Allocation
(Eff. 01/01/26)
In the post-eligibility step, the deductions from gross income are made in the order shown below. The remaining income must be applied to the institutionalized individual’s cost of care (that is, recurring income).
Personal Needs Allowance (PNA) | $100 – Work Therapy Allowance – if the institutionalized individual participates in a work therapy program as a part of the plan of care; or $ 6 0 – Standard Allowance – if the institutionalized individual does not participate in a work therapy program. $ 2, 982 – Waiver Allowance – for individuals participating in a HCBS waiver Note s For cost of care e ffective October 1, 2025 , or later , PNA increased to $60 . For cost of care effective before October 1, 2025, PNA is $30. Individuals receive the personal needs allowance from countable income in addition to any excluded income such as VA Aid and Attendance or the $90 reduced VA pension.
Court Ordered Guardianship Fees | The lesser of 10% of gross income or $25 for court ordered guardianship fees
Community Spouse Income Allowance | Institutionalized spouse must choose to give the allocation; and The amount must not exceed $ 4,066.50 per month. Procedure to Determine the Amount of the Community Spouse Income Allowance Determine the community spouse’s gross income. Subtract this amount from $ 4,066.50 . The difference is the maximum allocation amount. Allocation for Spouse Only: Example 1 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2000. He has requested allocation for his community spouse. His spouse, Jane, has a gross income of $3000. Jane’s allocation: $ 4,066.50 (Max Allocation Limit) -$3 , 000.00 (Jane’s Gross Income) $ 1 ,066.50 (Jane’s Total Allocation) Total Allocation Awarded: $ 1,066 . 5 0 Example 2 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2000. He has requested allocation for his community spouse. His spouse, Jane, has a gross income of $900. However, Jane currently has active ABD-Medicaid Coverage. Jane wants to keep her current coverage while still getting an allocation. Jane’s allocation: $ 4,066.50 (Max Allocation Limit) -$900.00 (Jane’s Gross Income) $ 3 166 . 5 0 (Jane’s Total Allocation) Calculation for Jane to keep ABD coverage: $1 30 5.00 (ABD Income Limit) +$50.00 (General Disregard) -$900.00 (Jane’s Gross Income) $ 4 5 5.00 (Allocation allowed for Jane to keep ABD coverage) Total Allocation Awarded: $ 4 5 5.00 Note A lower amount may be allocated if the community spouse wishes to maintain or establish eligibility for SSI benefits or Medicaid under another payment category such as ABD. The institutionalized individual must make the income available to the community spouse in order for it to be deducted. The spouse of a nursing home patient who receives Home and Community Based Services is considered a community spouse for the purposes of the income provisions of spousal impoverishment. Procedure – Amount of Community Spouse Allocation Questioned If the community spouse disagrees with the amount allocated or needs a higher amount to maintain him/her, the E ligibility Specialist should inform the spouse of his/her right to appeal (Fair Hearing). The community spouse must justify the need for the additional amount due to exceptional circumstances or significant financial duress. A higher amount can only be allowed if it is ordered through an appeal.
Allowance for Other Dependent Family Members | Institutionalized individual must choose to give the allocation May include minor children or dependent adults of the institutionalized or community spouse. A dependent adult is an adult family member (such as a mother, father, child, brother, sister) living in the home who depends on the applicant/beneficiary or community spouse for meeting physical, medical, or financial needs. A signed statement completed by the applicant/beneficiary or authorized representative indicating the relationship of the dependent adult and the nature of the dependency is acceptable verification to provide the allowance. Procedure to Determine the Amount of Income Allowances for Other Dependent Family Members Dependent(s) residing with Community Spouse Determine the gross income of each dependent family member. Subtract the total gross income of each dependent family member from $ 4,066.50 . One-third of the remaining amount is each dependent family member’s income allowance. Add each dependent family member’s income allowance together to determine the total family income allowance. This is the amount allowed for allocation to dependent family members. Allocation for Spouse w/Dependent ( s ) (Dependent Living with a Community Spouse): Example 1 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2000. He has requested allocation for both his community spouse and his one dependent child who currently lives with Jane. His spouse, Jane, has a gross income of $3000 and his dependent child, Mark, has a gross income of $1000. Jane’s allocation: $ 4,066.50 (Max Allocation Limit) -$3 , 000.00 (Jane’s Gross Income) $ 1,066.50 (Jane’s Total Allocation) Mark’s allocation: $ 4,066.50 (Max Allocation Limit) -$1 , 000.00 (Mark’s Gross Income) $ 3 ,066.50 $ 4,066.50 ÷ 3 $ 1,022.16 (Mark’s Total Allocation) Total Allocation Awarded: Jane $ 1,066.50 Mark $9 82 . 6 6 Total: $ 1930 .66 Example 2 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2000. He has requested allocation for both his community spouse and his one dependent child who currently lives with Jane. His spouse, Jane, has a gross income of $4 ,5 00 and his dependent child, Mark, has a gross income of $1500. Jane’s allocation: $ 4,066.50 (Max Allocation Limit) - $4 , 5 00.00 (Jane’s Gross Income) No Allocation Award to Spouse Mark’s allocation $ 4,066.50 (Max Allocation Limit) -$1 , 500.00 (Mark’s Gross Income) $ 2,566 . 5 0 $ 2,566 . 5 0 ÷ 3 $ 855 . 5 0 (Mark’s Total Allocation) Total Allocation Awarded: $ 855 . 5 0 Example 3 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $3715 (Income Trust). He has requested allocation for both his community spouse and his one dependent child who currently lives with Jane. His spouse, Jane, has a gross income of $715 and his dependent child, Mark, has a gross income of $1000. He entered the Nursing Home on September 15, 2025. Cost of Care must be calculated separately for September and October due to the increase in the PNA from $30 to $60. Cost of Care Calculation for September 2025 Joe’s Allowed Deductions: $30 Personal Needs Allowance $10 Trust Administration Fee $20 Bank Service Charge Jane’s allocation: $3948.00 (Max Allocation Limit) - $715.00 (Jane’s Gross Income) $3233.00 (Jane’s Allocation) Mark’s allocation: $3948.00 (Max Allocation Limit) -$1000.00 (Mark’s Gross Income) $ 2948.00 $2948.00 ÷ 3 $982.66 (Mark’s Allocation) Allocation Calculation: $3715.00 (Joe’s Gross Income) -$60.00 (Joe’s Allowed Deductions) $3655.00 (Funds left to give for allocation) -$3233.00 1,067.00(Jane’s Allocation) $422.00 (Remaining Allocation Mark can receive) Total Allocation Awarded: $ 3655.00 Cost of Care Calculation for October 2025 Joe’s Allowed Deductions: $60 Personal Needs Allowance $10 Trust Administration Fee $20 Bank Service Charge Jane’s allocation: $3948.00 (Max Allocation Limit) - $715.00 (Jane’s Gross Income) $3233.00 (Jane’s Allocation) Mark’s allocation: $3948.00 (Max Allocation Limit) -$1000.00 (Mark’s Gross Income) $ 2948.00 $2948.00 ÷ 3 $982.66 (Mark’s Allocation) Allocation Calculation: $3715.00 (Joe’s Gross Income) -$90.00 (Joe’s Allowed Deductions) $3625.00 (Funds left to give for allocation) -$3233.00 (Jane’s Allocation) $392.00 (Remaining Allocation Mark can receive) Total Allocation Awarded: $3625.00 Cost of Care Calculation for January 2026 Note: The max Spousal Allocation increased to 4,066.50 effective January 2026. Joe’s Allowed Deductions: $60 Personal Needs Allowance $10 Trust Administration Fee $20 Bank Service Charge Jane’s allocation: $4,066.50 (Max Allocation Limit) - $735.00 (Jane’s Gross Income) $3,331.50 (Jane’s Allocation) Mark’s allocation: $4,066.50 (Max Allocation Limit) -$1,028.00 (Mark’s Gross Income) $3,038.50 $3,038.50 ÷ 3 $1,012.83 (Mark’s Allocation) Allocation Calculation: $3,819.00 (Joe’s Gross Income) -$90.00 (Joe’s Allowed Deductions) $3,729.00 (Funds left to give for allocation) -$3,331.50 (Jane’s Allocation) $397.50 (Remaining Allocation Mark can receive) Total Allocation Awarded: $3,729.00 Example 4 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2000. He has requested allocation for both his community spouse and his one dependent child who currently lives with Jane. His spouse, Jane, has a gross income of $4000 and his dependent child, Mark, has no income. Jane’s allocation: $4,066.50 (Max Allocation Limit) - $4,250.00 (Jane’s Gross Income) No Allocation Award to Spouse Mark’s allocation $4,066.50 (Max Allocation Limit) (Mark has no Income) $4,066.50 $4,066.50 ÷ 3 $1,355.50 (Mark’s Total Allocation) Total Allocation Awarded: $1,355.50 Dependent(s) residing with someone other than the Community Spouse Determine the gross monthly income of all dependents living together Compare the gross income of all dependents living together to the TANF/FI Need Standard (PCR Income Limit, refer to MPPM 103.03) for a family of the appropriate size. For example, 2 dependents would use PCR Income Limit for 2. If gross monthly income is equal to or greater than the standard, no allocation is made. If gross monthly income is less than the standard, subtract the income from the standard. The resulting figure is the allocation to the dependents. NOTE The institutionalized individual must make the income available to the family in order for it to be deducted. Allocation for Dependents (Dependent Not Living with a Community Spouse): Example 1 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2,000. He has requested allocation for his one dependent child. Mark is currently living outside of the home and there is no community spouse. His dependent child, Mark, has a gross income of $500. Mark’s allocation: $808.58 (2025 PCR Income Limit for a Family of One) -$500.00 (Mark’s Gross Income) $308.58 (Mark’s Allocation) Total Allocation Awarded: $308.58 Example 2 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2000. He has requested allocation for both his community spouse and his one dependent child who currently does not live with his community spouse. His spouse, Jane, has a gross income of $3000 and his dependent child, Mark, has a gross income of $900. Jane’s allocation: $4,066.50 (Max Allocation Limit) -$3000.00 (Jane’s Gross Income) $1,066.50 (Jane’s Total Allocation) Mark’s allocation $808.58 (2025 PCR Income Limit for a Family of One) -$900.00 (Mark’s Gross Income) $0.00 (Mark’s Allocation) Total Allocation Awarded: $1,066.50 Example 3 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2000. He has requested allocation for both his community spouse and his two dependent children, Mark and Mary, who currently do not live with his community spouse. His spouse, Jane, has a gross income of $3000. Mark has a gross income of $160 and Mary has a gross income of $200. Jane’s allocation: $4,066.50 (Max Allocation Limit) -$3000.00 (Jane’s Gross Income) $1,066.50 (Jane’s Total Allocation) $160.00 Mark’s Income +$200.00 Mary’s Income $360.00 (Total Income Together) Calculating Allocation for Joe’s Children $1092.75 (2025 PCR Income Limit for a Family of Two) -$360.00 $732.75 (Total Allocation for Mark and Mary) Total Allocation Awarded: $1,799.25 NOTE: If the institutionalized applicant/beneficiary has chosen not to make his/her income available for allocation to a spouse or other qualified dependent relative at application, but later chooses to do so, the applicant/beneficiary or their authorized representative must provide a signed declaratory statement of the new intent to make the income available for allocation. Once a new written request statement for allocation has been received along with verification of the spouse and any dependents’ gross income, the Eligibility Specialist can rebudget the case granting the allocation back to the date of application .
Health Insurance Premiums Note Does not include Medicare Parts A and B Refer to the next table for Medicare Part D | Must only be paid by or for the Medicaid beneficiary out of the beneficiary’s funds. May only be deducted the month the premium is due or the month after. (See table below) Must be verified. Convert premiums paid at a frequency other than monthly to a monthly amount. Procedure – Health Insurance Premiums Acceptable forms of verification include: Premium notice Copy of cancelled check Bank statement verifying draft When Premium is reported Effective Date of Change Month premium due/paid Recurring Income may be rebudgeted effective the month the premium is due/paid Month after premium due/paid Recurring Income may be rebudgeted effective the month the premium is due/paid Two or more Months after premium due/paid Recurring Income may be rebudgeted effective the month the premium is reported to the agency Reminder: Regardless when the rebudget is being completed, the effective date is based on when the information was reported to DHHS If the amount a beneficiary must pay goes up once the rebudget is completed, adequate and advance notice must be given before the change becomes effective unless the beneficiary waives the 15-day notice requirement For premiums paid at a frequency other than monthly, average the premium to determine a monthly amount for the Cost of Care calculation Example 1 Joe’s income is $300 , and he reports on October 2 nd that his quarterly insurance premium of $450 is due on October 3 1 . He has no other deductions other than his personal needs allowance. Health Insurance: $450.00 (Quarterly Premium) ÷ 3 $150.00 (Monthly Average) Cost of Care: $300.00 (Gross Income) – $ 6 0.00 (Personal Needs) – $150.00 (Health Insurance Premium) $ 9 0.00 (Cost of Care) Example 2 Alice’s income is $500 , and she reports on October 10 that her monthly insurance premium changed in July from $100 per month to $150 per month. She has no other deductions except for her personal needs allowance. July, August , and September recurring income: $500 - $30 = $470, then $470 - $100 = $370 October recurring income: $500 - $ 6 0 = $4 4 0, then: $4 4 0 - $150 = $2 9 0 Note The Health Insurance Premium was reported two or months after the premium was due, so the effective date of change is October, the month the premium was reported.
Health Insurance Premiums – Medicare Part D, Drug Coverage | For individuals approved for Nursing Home coverage who are not already Medicaid eligible, subtract the Medicare Part D Benchmark from the verified Part D premium being paid by the individual and allow the remainder as a Health Insurance Premium deduction from countable income. For individuals receiving Medicaid who are then approved for Nursing Home coverage, the adjustment for the Medicare Part D Benchmark has already been applied. Allow the Medicare Part D premium being paid by the beneficiary as a Health Insurance Premium deduction from countable income. At COLA or Annual Review, the adjustment for the Medicare Part D Benchmark has already been applied. Allow the Medicare Part D premium being paid by the beneficiary as a Health Insurance Premium deduction from countable income. Refer to MPPM 103.07 for the current Medicare Part D Premium Benchmark for South Carolina Procedure – Health Insurance Premiums Verify the Part D Medicare premium Is the individual currently Medicaid eligible? If Yes, the benchmark adjustment has already been applied. Allow the premium being paid as a Health Insurance Premium deduction in the cost of care calculation If No, subtract the benchmark from the premium being paid and allow the remainder as a Health Insurance Premium deduction in the cost of care calculation Example John Allen is admitted to Happy Trails Nursing Facility on June 23 and approved for Medicaid. He currently has Medicare Part D and pays a $ 50.71 premium per month. 50.71 (Medicare Part D Premium) – 35.66 (2025 Part D Benchmark) $15.05 (Health Insurance Premium deduction) Example Alice Kramer was approved for Medicaid coverage last year. She has now been admitted to Green’s Awesome Care Nursing Facility on May 12 and approved for coverage. She currently has Medicare Part D and pays a $12.93 premium per month. Allow $12.93 as a Health Insurance Premium deduction in the cost of care calculation.
Home Maintenance Allowance | A maximum of six months is allowed. A physician must certify the individual is expected to return home within six months of admission to an institutional setting. The first full calendar month following the month of admission to a hospital or nursing facility begins the six-month count. Given for actual expenses, not to exceed the maximum SSI payment level for an individual. May be given even if someone continues to reside in the home. Examples of expenses that are allowed include: Rent or Mortgage Homeowners or renters’ insurance Utilities Basic Cable, Internet or Satellite TV service Examples of expenses that are not allowed include: Premium Cable or Satellite TV services and channels Special telephone features, such as call waiting Expenses can be documented using a written or verbal statement from the individual. The statement must show: The type of payment; (for example: mortgage, electricity, water and sewer, trash pickup, cable, phone) To whom the payment is made; and The amount paid. A copy of the actual bill is not required unless the person appears to be paying for extra or premium services Note A request for the Home Maintenance Allowance can be made at any time during the six-month period. The allowance can be budgeted retroactively to when the applicant entered the facility The deduction is applied when determining the amount of recurring income, the individual is responsible for paying to a facility The time an individual is in a hospital counts toward the maximum six-month period. For example, if the individual is in the hospital for two months and then enters a nursing facility, the home maintenance allowance can only be applied for up to four months
Protected Income | Allowable for the month of admission from or discharge to a community setting Income is protected if the individual was in a community setting at any point during the month of admission to a nursing facility Examples of a community setting are the person’s home, the home of another person, an assisted living facility or a community residential care facility A hospital admission is considered an institutional setting EXCEPTION: Income Trust Cases. Income is not protected for individuals with an Income Trust.
Cost of Pre-Eligibility Non-Covered Medical Expenses | The nursing facility may deduct pre-eligibility non-covered medical expenses. These are expenses: Recognized by State or Federal law as medical expenses; Not covered by Medicaid, Medicare, or other third-party payers; and Incurred by an individual before becoming eligible for Medicaid Note Deductions for non-covered medical expenses cannot exceed a beneficiary’s monthly recurring income and cannot be made if the beneficiary has zero ($0) reported monthly income. The deduction for medical and remedial care expenses that were incurred as the result of imposition of a transfer of assets penalty is limited to zero. See the SCDHHS Nursing Facility Services Manual , Chapter 7, Non-Covered Medical Expense Deductions, for a list of allowable deductions.
Cost of Post Eligibility Non-Covered Medical Expenses | The nursing facility may deduct post-eligibility non-covered medical expenses. These are expenses: Recognized by State or Federal law as medical expenses; Not covered by Medicaid, Medicare, or other third-party payers (Refer to Appendix B ); and Incurred by an individual currently Medicaid eligible in a Nursing Home Note Deductions for non-covered medical expenses cannot exceed a beneficiary’s monthly recurring income and cannot be made if the beneficiary has zero ($0) reported monthly income. The deduction for medical and remedial care expenses that were incurred as the result of imposition of a transfer of assets penalty is limited to zero. See the SCDHHS Nursing Facility Services Manual , Chapter 7, Non-Covered Medical Expense Deductions, for a list of allowable deductions.
Table of Contents
304.15.02B Resource Allocation
(Eff. 01/01/26)
The community spouse of an institutionalized individual can retain a portion of the couple’s countable resources.
If an applicant is separated but not divorced, the resources of the community spouse are still considered. Contact with the spouse must be made. The eligibility specialist must document the case record if the community spouse refuses to cooperate with the applicant or authorized representative. If the whereabouts of the spouse is unknown, the eligibility specialist must attempt to locate the spouse and fully document this in the case record. Procedures for this are discussed earlier in this chapter.
Procedure – Determining Resources and the Spousal Resource Allocation Determine the total value of the couple’s combined countable resources. Deduct the community spouse’s share, not to exceed $66,480, at both: The point of the initial eligibility determination, and The beginning of first continuous period of institutionalization. The remaining resources are considered to be the institutionalized individual’s and the eligibility worker must compare this amount to the resource limit ($2,000 or $ 9, 950 if ABD eligible) at both: The point of the initial eligibility determination, and The beginning of first continuous period of institutionalization. Note The community spouse’s share of the countable resources must be separated from the institutionalized spouse’s share within 30 days of certification for Medicaid. Verification of the change of ownership must be submitted to the eligibility worker and filed in the case record. If the institutionalized individual fails to transfer the assets to the community spouse within 30 days and no court order is involved, the institutionalized individual becomes ineligible for Medicaid beginning the month following the month in which the 30-day period ends. The community spouse can request an extension if the change in ownership cannot be completed within 30 days for reasons outside the control of the spouse. The eligibility specialist must place the case into follow-up for 30 days to ensure appropriate action is taken.
Procedure – Amount of Community Spouse Allocation Questioned The eligibility specialist must inform the spouse of his/her right to appeal if the community spouse disagrees with the amount allocated or needs a higher amount to maintain his/her living arrangements. The community spouse must justify the need for the additional amount due to exceptional circumstances or significant financial duress. A higher amount can only be allowed if it is ordered through an appeal.
304.15.02C Changes in Community Spouse’s Resources after Approval
(Eff. 06/01/06)
Once the institutionalized spouse is certified eligible for Medicaid, the following DO NOT affect eligibility:
An increase in the community spouse’s resources, and
A transfer by the community spouse for less than Fair Market Value.
Note If the community spouse needs institutionalization later, such a transfer may affect his/her own eligibility.
304.15.03 Prenuptial Agreement
(Eff. 06/01/06)
The existence of a prenuptial agreement has no effect on the treatment of income or resources under Spousal Impoverishment provisions. The resources owned by both spouses must be combined regardless of any State laws relating to community property or the division of marital property. This includes a prenuptial agreement covering the division of assets in the event of divorce.
304.15.04 Resource Assessment
(Eff. 06/01/06)
In some cases, a couple may request an assessment of their resources before they apply for assistance. An assessment is a snapshot of the couple’s countable resources in the month of institutionalization.
An assessment is separate from an application for Medicaid.
Procedure – Resource Assessment Requested by Individuals The DHHS Form 3228 ME , Assessment Questionnaire for Medicaid Institutional Programs, is used to collect information. The assessment must be completed in the following manner: Verification of all the countable resources must be provided. Written notice must be given to spouses advising them of: The couple’s total countable resources, and The maximum community spouse share of $66,480. A copy of the assessment and the notice must be kept on file in the event an application is made later. The DHHS Form 3227 ME , Notice of Resource Assessments, is used to advise individuals of the outcome.
304.16 30-Consecutive Day Requirement
(Eff. 11/01/23)
To qualify for Medicaid for Nursing Home or Home and Community Based Services, an applicant must meet the 30-consecutive day requirement. Count the date of admission, or the date services begin, as the first day.
An applicant meets the requirement when they:
Reside in a Nursing Facility or medical facility (in-state or out-of-state) for 30 consecutive days or longer:
Must reside for 30 consecutive days or longer; or
Receive Home and Community Based Services:
Must receive waiver services for 30 consecutive days or longer; or
Must be certified by CLTC that the applicant is likely to receive waiver services for 30 consecutive days or longer.
Have been in a hospital for 30 consecutive days or longer;
Are enrolled in a Program of All-inclusive Care for the Elderly (PACE) for 30 consecutive days or longer; or
Meet the criteria through a combination of the above.
Note
An individual who is Medicaid-eligible prior to entering a medical facility or a Home and Community Based Services waiver program or can be determined eligible in a non-LTC full benefit category does not have to meet the 30-day criteria.
If an individual dies before the 30 days are met, it is assumed he or she would have continued to receive services for 30 consecutive days or longer.
A person loses institutional status when they:
Are absent from a medical institution for at least 30 consecutive days, or
Do not receive HCBS or PACE for at least 30 days.
Likely to Remain "Likely to Remain" means there is a reasonable expectation the applicant will be in an institutional setting for 30-consecutive days or longer. Once made, the determination remains valid even if the applicant does not remain institutionalized for 30 days. Note “Likely to Remain” cannot be applied to transfer penalty cases while an applicant is serving their penalty. Home and Community Based Services When CLTC or BHDD enrolls an individual in an HCBS or Waiver program and begins to provide services, the enrolling agency will document that the individual is likely to remain in the program for at least 30-consecutive days. When the Eligibility Specialist confirms the enrollment date for the individual, the specialist will approve Medicaid eligibility for the waiver program on the first day of the month in which they enroll. If the individual is disenrolled from the program before meeting the 30-day requirement without being admitted into another institutional setting, end eligibility after giving the appropriate notice. The Eligibility Specialist will process the application to be financially clear for eligibility. Once the case is financially cleared, the Eligibility Specialist is ready to update the Phoenix Community Choices workflow. Procedures Phoenix Referral (Community Choices/Waiver/HCBS): During the application process, the Eligibility Specialist will submit a referral ( https://phoenix.scdhhs.gov/cltc_referrals/new ) for service in Phoenix for Nursing Home Placement or Community Choices (Waiver/HCBS): If a referral was already completed however, Community Choices workflow has not been added to Phoenix and the Eligibility Specialist is ready to tentatively approve the applicant in Phoenix; the Eligibility Specialist should place the case in “Not Finished” for 7 days to give Centralized Intake time to process the referral and place it in Phoenix workflow. The Eligibility Specialist should search by using either the applicant’s name and date of birth, SSN, Medicaid number, or Medicare number. Note If the referral was submitted more than 30 days ago, the Eligibility Specialist should check the confirmation referral number ( https://phoenix.scdhhs.gov/cltc_referrals/new ). The Eligibility Specialist will search in “ Enter a confirmation number to search for an existing referral:” using the Referral Confirmation Number that was uploaded to OnBase If the Referral Confirmation Number pulls up and the “Status” shows “Awaiting Participant Match”, the Eligibility Specialist should email Centralized Intake ( centralizedintake@scdhhs.gov ) to escalate the referral. The email should include: Applicant’s Full Name Medicaid Number Referral Confirmation Number The Eligibility Specialist will put the case in “Not Finished” until a response comes back from Centralized Intake confirming that the referral was added to the Phoenix workflow. Once the response has come back from Centralized Intake confirming that the referral was added to the Phoenix workflow, the Eligibility Specialist will log into Phoenix and tentatively approve the Community Choices workflow ( MPPM 304 APPENDIX J-Phoenix Procedures ): Note The Eligibility Specialist must enter all required fields and save approval: Approval Effective On Eligibility category Eligibility waiting period Medicaid number If the case has been financially cleared and is ready to be tentatively approved and the referral has NOT been added to Phoenix workflow, the Eligibility Specialist should email Centralized Intake ( centralizedintake@scdhhs.gov ) to escalate the referral. The email should include: Applicant’s Full Name Medicaid Number Referral Confirmation Number Once the Community Choices workflow in Phoenix has been tentatively approved ( Do not approve in SOR ), the Eligibility Specialist will put the case in “Not Finished” for seven (7) days Already Tentatively Approved in Phoenix and the Applicant is Participating On the 7 th day, the Eligibility Specialist will “Resume” the task from their “Not Finished” in Workload Pro. The Eligibility Specialist will first check OnBase to see if the “CLTC Notification Form” (Form 171) was uploaded to the case file. If the “CLTC Notification Form” (Form 171) was uploaded to OnBase, the Eligibility Specialist will verify that the letter states “Likely to Remain in waiver services for 30 consecutive days or longer”. If “Likely to Remain in waiver services for 30 consecutive days or longer” is stated on the “CLTC Notification Form” (Form 171), the Eligibility Specialist will approve eligibility for the Waiver/HCBS application in the pending SOR (MPPM 304.28). Note for CGIS: the Eligibility Specialist will follow CGIS Medical Institution Procedure listed below. If “Likely to Remain in waiver services for 30 consecutive days or longer” is NOT on the “CLTC Notification Form” (Form 171), the Eligibility Specialist will put the case in Follow-up for the remaining 30 days from the date the applicant started participating (unless the applicant is already participating/eligible in a full Medicaid payment category). ( MPPM 304 APPENDIX J-Phoenix Procedures ) If the “CLTC Notification Form” (Form 171) was NOT uploaded to OnBase: The Eligibility Specialist will log into Phoenix and pull the applicant’s workflow: If there is an open Community Choices (Green) workflow: The Eligibility Specialist will check to see if the applicant has started participating. If participating, the Eligibility Specialist will check Phoenix “Scans” tab (located at the top of the Phoenix dashboard of the participant) to see if CLTC has uploaded “CLTC Notification Form” (Form 171) requesting that the applicant be enrolled into services and if CLTC has advised that the applicant is “Likely to Remain in waiver services for 30 consecutive days or longer”. Note The “CLTC Notification Form” (Form 171) is password-protected ( CGIS Manual 6.03 Phoenix Procedures ), so the Eligibility Specialist must follow CGIS Procedure Manual; 6.03 Phoenix Procedures to open the document. “CLTC Notification Form” (Form 171) must be uploaded to the case file in OnBase as “Categorical Verification”. If the “CLTC Notification Form” (Form 171) and the indication “Likely to Remain” is stated, then the Eligibility Specialist will approve eligibility for the Waiver/HCBS application in the pending SOR (MPPM 304.28). Note for CGIS: the Eligibility Specialist will follow CGIS Medical Institution Procedure listed below for indicating 30 consecutive days or longer. If “Likely to Remain in waiver services for 30 consecutive days or longer” is NOT on the “CLTC Notification Form” (Form 171), the Eligibility Specialist will put the case in Follow-up for the remaining 30 days from the date the applicant started participating. ( MPPM 304 APPENDIX J-Phoenix Procedures ) If the participant has started participating and the “CLTC Notification Form” (Form 171) is NOT in the Phoenix “Scans” tab, the Eligibility Specialist: Will notate the SOR and documentation template. Put the case in Follow-up for 30 days from the date the applicant started participating. ( MPPM 304 APPENDIX J-Phoenix Procedures ) Already Tentatively Approved in Phoenix and the Applicant is NOT Participating On the 7 th day, the Eligibility Specialist will “Resume” the task from their “Not Finished” in Workload Pro. The Eligibility Specialist will first check OnBase to see if the “CLTC Notification Form” (Form 171) was uploaded to the case file. If the “CLTC Notification Form” (Form 171) was NOT uploaded to OnBase: The Eligibility Specialist will log into Phoenix and pull the applicant’s workflow: If there is an open Community Choices (Green) workflow: The Eligibility Specialist will check to see if the applicant has started participating. If the applicant is still NOT participating and the “CLTC Notification Form” (Form 171) is not in Phoenix “Scans”, the Eligibility Specialist will put the case in “Not Finished” for 7 days. On the 7 th day, the Eligibility Specialist will “Resume” the task from their “Not Finished” in Workload Pro. The Eligibility Specialist will first check OnBase to see if the “CLTC Notification Form” (Form 171) was uploaded to the case file. If Participating, the Eligibility Specialist will follow Already Tentatively Approved in Phoenix and the Applicant is Participating Note The Eligibility Specialist must check Phoenix for verification that they are still participating in Community Choices. If NOT Participating and there has been no contact between CLTC and the applicant, the Eligibility Specialist will follow Already Tentatively Approved in Phoenix and No Contact Between CLTC and the Applicant If the “CLTC Notification Form” (Form 171) is there and the indication “Likely to Remain” is stated, then the Eligibility Specialist will approve eligibility for the Waiver/HCBS application in the pending SOR (MPPM 304.28). Note for CGIS: the Eligibility Specialist will follow CGIS Medical Institution Procedure listed below. If the “CLTC Notification Form” (Form 171) is not uploaded to Phoenix “Scans”, the Eligibility Specialist will check the “Narratives” tab to see if there was contact between CLTC and the participant. If the 10-day letter was sent out by CLTC, the Eligibility Specialist will put the case in “Not Finished” for 11 days from the date the 10-day letter was mailed. On the 11 th day, the Eligibility Specialist will “Resume” the task from their “Not Finished” in Workload Pro and check Phoenix for the Community Choices workflow status: If the Community Choices workflow has been closed (Inactive) by CLTC, the Eligibility Specialist will deny the case in SOR (Follow MPPM 304.28). If the Community Choices workflow is still active (GREEN) and there still has been NO contact, the Eligibility Specialist will follow MPPM 304.28. If the Community Choices workflow is still active (GREEN) and there has been contact between CLTC & the applicant, the Eligibility Specialist will follow MPPM 304.28. If no contact, the Eligibility Specialist will put the case in “Not Finished” for seven (7) days. On the 7 th day, the Eligibility Specialist will “Resume” the task from their “Not Finished” in Workload Pro. The Eligibility Specialist will first check OnBase to see if the “CLTC Notification Form” (Form 171) was uploaded to the case file. If Participating, the Eligibility Specialist will follow Already Tentatively Approved in Phoenix and the Applicant is Participating Note The Eligibility Specialist must check Phoenix for verification that they are still participating in Community Choices. If NOT Participating and there has been no contact between CLTC and the applicant, the Eligibility Specialist will follow Already Tentatively Approved in Phoenix and No Contact Between CLTC and the Applicant Already Tentatively Approved in Phoenix and NO Contact Between CLTC and the Applicant The Eligibility Specialist will contact the CLTC area office (See Community Long-Term Care Area List) for an update. If CLTC informs the Eligibility Specialist that the workflow will be closed due to “No Contact” from the applicant, the Eligibility Specialist will deny the case in SOR (Follow MPPM 304.28). If CLTC informs the Eligibility Specialist that there has been contact from the applicant and that the Community Choices workflow will stay active to continue communication with the applicant, the Eligibility Specialist will put the case in “Not Finished” for 7 days. Note The Eligibility Specialist will notate the SOR and documentation template regarding the communication between CLTC and the Eligibility Specialist. Already Tentatively Approved in Phoenix and there is Contact Between CLTC and the Applicant The Eligibility Specialist will check for the applicant’s participation in the Community Choices workflow. If the applicant is still NOT participating and the “CLTC Notification Form” (Form 171) is not in Phoenix “Scans”, the Eligibility Specialist will put the case in “Not Finished” for 7 days. On the 7 th day, the Eligibility Specialist will follow either: Already Tentatively Approved in Phoenix and the Applicant is Participating OR Already Tentatively Approved in Phoenix and the Applicant is NOT Participating CGIS Medical Institution Procedure When the Waiver/HCBS application is ready to be approved in CGIS, the Eligibility Specialist will need to update the Medical Institution evidence. Follow the LTC Waiver Service Job Aid Click the plus sign to add Medical Institution evidence. Complete the following information in the Medical Institution Evidence pop-up: Medical Institution Details Section Household Member: Select the member’s name from the drop-down. Institution Type: When requesting Waiver services, leave this field blank. Waiver Type: Select the appropriate option from the drop-down. Expected Length of Stay: Select “30 days or more” or “Less than 30 days” from the drop-down. If CLTC provides “Likely to Remain in waiver services for 30 consecutive days or longer”, the Eligibility Specialist will complete the field “Expected Length of Stay” and select the drop-down option “30 Days or Longer”. Placed In Institution By Section Application Filed By Details Section Click the Save button The Eligibility Specialist will process the case with normal procedures ( LTC_Waivers_Services_JA.pdf ). Note If both CLTC and SCDHHS deny and close the application, the applicant will have to reapply with a new DHHS Form 3401 , Application for Nursing Home, Residential or In-Home Care.
304.16.01 Effective Date of Eligibility
(Rev. 10/01/23)
The individual must meet the 30 consecutive day requirement and be otherwise eligible. The beginning date of eligibility is the first day of the month in which he/she became institutionalized in a medical facility, or a combination of medical facilities, or begins participating in Home and Community-Based Services.
Note
The beginning date of eligibility for Home and Community-Based Services typically will not start effective the month the application was received.
Example #1 Lillie Smith enters the hospital after an accident on May 10. On May 29, she is transferred to Caring Hearts Nursing Home until she is able to return home on June 29. Ms. Smith was in the hospital 19 days. However, she went directly to the nursing home where she spent 31 days. She met the 30 consecutive day criteria on June 9 through a combination of hospital and nursing home days. If otherwise eligible, she may qualify for Medicaid effective May 1. Example #2 Jamie Green is a SSI recipient who enters a nursing home on July 15 after breaking his hip. He returns home on August 1. He was only in the facility for 18 days. Since he was already Medicaid-eligible, he may qualify for assistance without having been institutionalized for 30 consecutive days. Example #3 Jean Mills entered the nursing home on June 6 and died on June 14. It is assumed she would have remained in the facility for 30 consecutive days if she had lived. Therefore, if otherwise eligible, her benefits are effective June 1.
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304.16.02 Moving from a Medical Facility to Home and Community Based Services
(Eff. 06/01/06)
A Medicaid applicant/beneficiary who: (1) is in a nursing home, (2) has met the 30 consecutive day requirement, and (3) wishes to enter a Home and Community Based Services waiver program, does NOT have to meet the 30 consecutive day requirement again if he/she enters the waiver program within 10 calendar days of discharge from a nursing home.
Note If the break in service from the date of discharge from the nursing home to the date of enrollment in the waiver will exceed 10 calendar days, prior approval to exempt the 30 consecutive day requirement must be obtained from the State DHHS Community Long Term Care Office.
304.16.03 Moving from Home and Community Based Services to a Medical Facility
(Rev. 04/01/24)
For any Medicaid applicant/beneficiary who is approved and enrolled in Home and Community Based Services and then enters a Nursing Home with no break in service, the Eligibility Specialist should follow the guidelines for the Ex Parte process (MPPM 101.08.06). Do not complete an additional look-back or request a new application or addendum.
Note
A DHHS Form 1277, Statement of Intent to Return, may be needed when moving from HCBS to NH coverage. See MPPM 302.14.01 to determine if the home can remain excluded without an Intent to Return. If the individual has returned home during the process of making an eligibility determination, the intent to return is assumed and a DHHS Form 1277 is not needed.
304.17 Permit Days
(Eff. 06/01/06)
Because nursing facility beds are sometimes limited, some Medicaid applicants have difficulty locating a facility willing to accept a Medicaid patient. In instances when an individual has been determined to be Medicaid-eligible and is residing in a Medicaid certified facility, the eligibility worker should approve the application; notify the individual; and complete the DHHS Form 181, Notice of Admission, Authorization, and Change of Status for Long Term Care. Whether the nursing facility accepts the vendor payment becomes a matter between the nursing facility and the patient’s family.
Procedure Prior to Approving an Application and Completing the DHHS Form 181 The eligibility worker is required to determine that the applicant/beneficiary meets all financial and non-financial eligibility criteria, including level of care, prior to approving the application and completing the DHHS Form 181.
304.18 Vendor Payment
(Eff. 06/01/06)
Medicaid sponsored individuals in a nursing home actually receive two distinct services. They receive a Medicaid Insurance Card for assistance with medical services such as prescription medicines, physician’s visits, and hospitalizations. Secondly, they receive a vendor payment, or room and board assistance. Generally, the individual must contribute toward his/her cost of care. The individual’s contribution to his/her cost of care is referred to as the recurring income. Medicaid’s contribution is referred to as the vendor payment.
304.18.01 Recurring Income Used to Determine Vendor Payment
(Eff. 01/01/26)
When individuals apply for Medicaid to assist with payment of institutional care, the financial eligibility determination is a two-step process.
The first step determines whether Medicaid eligibility requirements are met.
If eligible, the second step determines the amount of available income that must be contributed toward the cost of care. This is called the monthly recurring income.
The monthly recurring income amount is determined by the Eligibility Specialist and reported to the medical provider on the DHHS Form 181, Notice of Admission, Authorization, and Change of Status for Long-Term Care.
To calculate the cost of care, the eligibility worker must determine the individual’s gross countable income and then deduct allowable expenses. The Eligibility Specialist is responsible for making all of the deductions except the non-covered medical expenses. That deduction is the responsibility of the nursing facility.
Allowable deductions for nursing home patients who have not established an Income Trust include the following:
Personal Needs Allowance | $100 – Work Therapy Allowance – if the institutionalized individual participates in a work therapy program as a part of the plan of care; or $ 6 0 – Standard Allowance – if the institutionalized individual does not participate in a work therapy program. $ 2, 982 – Waiver Allowance – for individuals participating in a HCBS waiver Notes For cost of care effective October 1, 2025, or later, PNA increased to $60. For cost of care effective before October 1, 2025, PNA is $30. Individuals receive the personal needs allowance from countable income in addition to any excluded income such as VA Aid and Attendance or the $90 reduced VA pension.
Court Ordered Guardianship Fees | The lesser of 10% of gross income or $25 for court ordered guardianship fees
Community Spouse Income Allowance | Institutionalized spouse must choose to give the allocation; and The amount must not exceed $ 4 , 066 . 5 0 per month. Procedure to Determine the Amount of the Community Spouse Income Allowance Determine the community spouse’s gross income. Subtract this amount from $ 4,066.50 . The difference is the maximum allocation amount. Allocation for Spouse Only: Example 1 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2000. He has requested allocation for his community spouse. His spouse, Jane, has a gross income of $3000. Jane’s allocation: $ 4,066.50 (Max Allocation Limit) -$3 , 000.00 (Jane’s Gross Income) $ 1 ,066.50 (Jane’s Total Allocation) Total Allocation Awarded: $ 1,066 . 5 0 Example 2 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2000. He has requested allocation for his community spouse. His spouse, Jane, has a gross income of $900. However, Jane currently has active ABD-Medicaid Coverage. Jane wants to keep her current coverage while still getting an allocation. Jane’s allocation: $ 4,066.50 (Max Allocation Limit) -$900.00 (Jane’s Gross Income) $ 3 , 166 . 5 0 (Jane’s Total Allocation) Calculation for Jane to keep ABD coverage: $1 , 30 5.00 (ABD Income Limit) +$50.00 (General Disregard) -$900.00 (Jane’s Gross Income) $ 45 5.00 (Allocation allowed for Jane to keep ABD coverage) Total Allocation Awarded: $ 45 5.00 Note A lower amount may be allocated if the community spouse wishes to maintain or establish eligibility for SSI benefits or Medicaid under another payment category such as ABD. The institutionalized individual must make the income available to the community spouse in order for it to be deducted. The spouse of a nursing home patient who receives Home and Community Based Services is considered a community spouse for the purposes of the income provisions of spousal impoverishment. Procedure – Amount of Community Spouse Allocation Questioned If the community spouse disagrees with the amount allocated or needs a higher amount to maintain him/her, the E ligibility Specialist should inform the spouse of his/her right to appeal (Fair Hearing). The community spouse must justify the need for the additional amount due to exceptional circumstances or significant financial duress. A higher amount can only be allowed if it is ordered through an appeal.
Allowance for Other Dependent Family Members | Institutionalized i ndividual must choose to give the allocation May include minor children or dependent adults of the institutionalized or community spouse. A dependent adult is an adult family member (such as a mother, father, child, brother, sister) living in the home who depends on the applicant/beneficiary or community spouse for meeting physical, medical, or financial needs. A signed statement completed by the applicant/beneficiary or authorized representative indicating the relationship of the dependent adult and the nature of the dependency is acceptable verification to provide the allowance. Procedure to Determine the Amount of Income Allowances for Other Dependent Family Members Dependent(s) residing with Community Spouse Determine the gross income of each dependent family member. Subtract the total gross income of each dependent family member from $4,066.50. One-third of the remaining amount is each dependent family member’s income allowance. Add each dependent family member’s income allowance together to determine the total family income allowance. This is the amount allowed for allocation to dependent family members. Allocation for Spouse w/Dependent(s) (Dependent Living with a Community Spouse): Example 1 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2000. He has requested allocation for both his community spouse and his one dependent child who currently lives with Jane. His spouse, Jane, has a gross income of $3000 and his dependent child, Mark, has a gross income of $1000. Jane’s allocation: $4,066.50 (Max Allocation Limit) -$3,000.00 (Jane’s Gross Income) $1,066.50 (Jane’s Total Allocation) Mark’s allocation: $4,066.50 (Max Allocation Limit) -$1,000.00 (Mark’s Gross Income) $3,066.50 $4,066.50 ÷ 3 $1,022.16 (Mark’s Total Allocation) Total Allocation Awarded: Jane $1,066.50 Mark $982.66 Total: $1930.66 Example 2 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2000. He has requested allocation for both his community spouse and his one dependent child who currently lives with Jane. His spouse, Jane, has a gross income of $4,500 and his dependent child, Mark, has a gross income of $1500. Jane’s allocation: $4,066.50 (Max Allocation Limit) - $4,500.00 (Jane’s Gross Income) No Allocation Award to Spouse Mark’s allocation $4,066.50 (Max Allocation Limit) -$1,500.00 (Mark’s Gross Income) $2,566.50 $2,566.50 ÷ 3 $855.50 (Mark’s Total Allocation) Total Allocation Awarded: $855.50 Example 3 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $3,715 (Income Trust). He has requested allocation for both his community spouse and his one dependent child who currently lives with Jane. His spouse, Jane, has a gross income of $715 and his dependent child, Mark, has a gross income of $1,000. He entered the Nursing Home on September 15, 2025. Cost of Care must be calculated separately for September and October due to the increase in the PNA from $30 to $60. Cost of Care Calculation for September 2025 Joe’s Allowed Deductions: $30 Personal Needs Allowance $10 Trust Administration Fee $20 Bank Service Charge Jane’s allocation: $3948.00 (Max Allocation Limit) - $715.00 (Jane’s Gross Income) $3233.00 (Jane’s Allocation) Mark’s allocation: $3948.00 (Max Allocation Limit) -$1000.00 (Mark’s Gross Income) $ 2948.00 $2948.00 ÷ 3 $982.66 (Mark’s Allocation) Allocation Calculation: $3715.00 (Joe’s Gross Income) -$60.00 (Joe’s Allowed Deductions) $3655.00 (Funds left to give for allocation) -$3233.00 (Jane’s Allocation) $422.00 (Remaining Allocation Mark can receive) Total Allocation Awarded: $ 3655.00 Cost of Care Calculation for October 2025 Joe’s Allowed Deductions: $60 Personal Needs Allowance $10 Trust Administration Fee $20 Bank Service Charge Jane’s allocation: $3948.00 (Max Allocation Limit) - $715.00 (Jane’s Gross Income) $3233.00 (Jane’s Allocation) Mark’s allocation: $3948.00 (Max Allocation Limit) -$1000.00 (Mark’s Gross Income) $ 2948.00 $2948.00 ÷ 3 $982.66 (Mark’s Allocation) Allocation Calculation: $3715.00 (Joe’s Gross Income) -$90.00 (Joe’s Allowed Deductions) $3625.00 (Funds left to give for allocation) -$3233.00 (Jane’s Allocation) $392.00 (Remaining Allocation Mark can receive) Total Allocation Awarded: $ 3625.00 Example 3 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $3715 (Income Trust). He has requested allocation for both his community spouse and his one dependent child who currently lives with Jane. His spouse, Jane, has a gross income of $715 and his dependent child, Mark, has a gross income of $1000. He entered the Nursing Home on September 15, 2025. Cost of Care must be calculated separately for September and October due to the increase in the PNA from $30 to $60. Cost of Care Calculation for September 2025 Joe’s Allowed Deductions: $30 Personal Needs Allowance $10 Trust Administration Fee $20 Bank Service Charge Jane’s allocation: $3948.00 (Max Allocation Limit) - $715.00 (Jane’s Gross Income) $3233.00 (Jane’s Allocation) Mark’s allocation: $3948.00 (Max Allocation Limit) -$1000.00 (Mark’s Gross Income) $ 2948.00 $2948.00 ÷ 3 $982.66 (Mark’s Allocation) Allocation Calculation: $3715.00 (Joe’s Gross Income) -$60.00 (Joe’s Allowed Deductions) $3655.00 (Funds left to give for allocation) -$3233.00 1,067.00(Jane’s Allocation) $422.00 (Remaining Allocation Mark can receive) Total Allocation Awarded: $ 3655.00 Cost of Care Calculation for October 2025 Joe’s Allowed Deductions: $60 Personal Needs Allowance $10 Trust Administration Fee $20 Bank Service Charge Jane’s allocation: $3948.00 (Max Allocation Limit) - $715.00 (Jane’s Gross Income) $3233.00 (Jane’s Allocation) Mark’s allocation: $3948.00 (Max Allocation Limit) -$1000.00 (Mark’s Gross Income) $ 2948.00 $2948.00 ÷ 3 $982.66 (Mark’s Allocation) Allocation Calculation: $3715.00 (Joe’s Gross Income) -$90.00 (Joe’s Allowed Deductions) $3625.00 (Funds left to give for allocation) -$3233.00 (Jane’s Allocation) $392.00 (Remaining Allocation Mark can receive) Total Allocation Awarded: $3625.00 Cost of Care Calculation for January 2026 Note: The max Spousal Allocation increased to 4,066.50 effective January 2026. Joe’s Allowed Deductions: $60 Personal Needs Allowance $10 Trust Administration Fee $20 Bank Service Charge Jane’s allocation: $4,066.50 (Max Allocation Limit) - $735.00 (Jane’s Gross Income) $3,331.50 (Jane’s Allocation) Mark’s allocation: $4,066.50 (Max Allocation Limit) -$1,028.00 (Mark’s Gross Income) $3,038.50 $3,038.50 ÷ 3 $1,012.83 (Mark’s Allocation) Allocation Calculation: $3,819.00 (Joe’s Gross Income) -$90.00 (Joe’s Allowed Deductions) $3,729.00 (Funds left to give for allocation) -$3,331.50 (Jane’s Allocation) $397.50 (Remaining Allocation Mark can receive) Total Allocation Awarded: $3,729.00 Example 4 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2000. He has requested allocation for both his community spouse and his one dependent child who currently lives with Jane. His spouse, Jane, has a gross income of $4000 and his dependent child, Mark, has no income. Jane’s allocation: $4,066.50 (Max Allocation Limit) - $4,250.00 (Jane’s Gross Income) No Allocation Award to Spouse Mark’s allocation $4,066.50 (Max Allocation Limit) (Mark has no Income) $4,066.50 $4,066.50 ÷ 3 $1,355.50 (Mark’s Total Allocation) Total Allocation Awarded: $1,355.50 Dependent(s) residing with someone other than the Community Spouse Determine the gross monthly income of all dependents living together Compare the gross income of all dependents living together to the TANF/FI Need Standard (PCR Income Limit, refer to MPPM 103.03) for a family of the appropriate size. For example, 2 dependents would use PCR Income Limit for 2. If gross monthly income is equal to or greater than the standard, no allocation is made. If gross monthly income is less than the standard, subtract the income from the standard. The resulting figure is the allocation to the dependents. NOTE The institutionalized individual must make the income available to the family in order for it to be deducted. Allocation for Dependents (Dependent Not Living with a Community Spouse): Example 1 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2,000. He has requested allocation for his one dependent child. Mark is currently living outside of the home and there is no community spouse. His dependent child, Mark, has a gross income of $500. Mark’s allocation: $808.58 (2025 PCR Income Limit for a Family of One) -$500.00 (Mark’s Gross Income) $308.58 (Mark’s Allocation) Total Allocation Awarded: $308.58 Example 2 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2000. He has requested allocation for both his community spouse and his one dependent child who currently does not live with his community spouse. His spouse, Jane, has a gross income of $3000 and his dependent child, Mark, has a gross income of $900. Jane’s allocation: $4,066.50 (Max Allocation Limit) -$3000.00 (Jane’s Gross Income) $1,066.50 (Jane’s Total Allocation) Mark’s allocation $808.58 (2025 PCR Income Limit for a Family of One) -$900.00 (Mark’s Gross Income) $0.00 (Mark’s Allocation) Total Allocation Awarded: $1,066.50 Example 3 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2000. He has requested allocation for both his community spouse and his two dependent children, Mark and Mary, who currently do not live with his community spouse. His spouse, Jane, has a gross income of $3000. Mark has a gross income of $160 and Mary has a gross income of $200. Jane’s allocation: $4,066.50 (Max Allocation Limit) -$3000.00 (Jane’s Gross Income) $1,066.50 (Jane’s Total Allocation) $160.00 Mark’s Income +$200.00 Mary’s Income $360.00 (Total Income Together) Calculating Allocation for Joe’s Children $1092.75 (2025 PCR Income Limit for a Family of Two) -$360.00 $732.75 (Total Allocation for Mark and Mary) Total Allocation Awarded: $1,799.25 NOTE: If the institutionalized applicant/beneficiary has chosen not to make his/her income available for allocation to a spouse or other qualified dependent relative at application, but later chooses to do so, the applicant/beneficiary or their authorized representative must provide a signed declaratory statement of the new intent to make the income available for allocation. Once a new written request statement for allocation has been received along with verification of the spouse and any dependents’ gross income, the Eligibility Specialist can rebudget the case granting the allocation back to the date of application.
Health Insurance Premiums Note Does not include Medicare Parts A and B Refer to the next table for Medicare Part D | Must only be paid by or for the Medicaid beneficiary out of the beneficiary’s funds. May only be deducted the month the premium is due or the month after. (See table below) Must be verified. Convert premiums paid at a frequency other than monthly to a monthly amount. Procedure – Health Insurance Premiums Acceptable forms of verification include: Premium notice Copy of cancelled check Bank statement verifying draft When Premium is reported Effective Date of Change Month premium due/paid Recurring Income may be rebudgeted effective the month the premium is due/paid Month after premium due/paid Recurring Income may be rebudgeted effective the month the premium is due/paid Two or more Months after premium due/paid Recurring Income may be rebudgeted effective the month the premium is reported to the agency Reminder: Regardless when the rebudget is being completed, the effective date is based on when the information was reported to DHHS If the amount a beneficiary must pay goes up once the rebudget is completed, adequate and advance notice must be given before the change becomes effective unless the beneficiary waives the 15-day notice requirement For premiums paid at a frequency other than monthly, average the premium to determine a monthly amount for the Cost of Care calculation Example 1 Joe’s income is $300 , and he reports on October 2 nd that his quarterly insurance premium of $450 is due on October 3 1 . He has no other deductions other than his personal needs allowance. Health Insurance: $450.00 (Quarterly Premium) ÷ 3 $150.00 (Monthly Average) Cost of Care: $300.00 (Gross Income) – $ 6 0.00 (Personal Needs) – $150.00 (Health Insurance Premium) $ 9 0.00 (Cost of Care) Example 2 Alice’s income is $500 , and she reports on October 10 that her monthly insurance premium changed in July from $100 per month to $150 per month. She has no other deductions except for her personal needs allowance. July, August , and September recurring income: $500 - $30 = $470, then $470 - $100 = $370 October recurring income: $500 - $ 6 0 = $4 4 0, then: $4 4 0 - $150 = $2 9 0 Note The Health Insurance Premium was reported two or months after the premium was due, so the effective date of change is October, the month the premium was reported.
Health Insurance Premiums – Medicare Part D, Drug Coverage | For individuals approved for Nursing Home coverage who are not already Medicaid eligible, subtract the Medicare Part D Benchmark from the verified Part D premium being paid by the individual and allow the remainder as a Health Insurance Premium deduction from countable income. For individuals receiving Medicaid who are then approved for Nursing Home coverage, the adjustment for the Medicare Part D Benchmark has already been applied. Allow the Medicare Part D premium being paid by the beneficiary as a Health Insurance Premium deduction from countable income. At COLA or Annual Review, the adjustment for the Medicare Part D Benchmark has already been applied. Allow the Medicare Part D premium being paid by the beneficiary as a Health Insurance Premium deduction from countable income. Refer to MPPM 103.07 for the current Medicare Part D Premium Benchmark for South Carolina Procedure – Health Insurance Premiums Verify the Part D Medicare premium Is the individual currently Medicaid eligible? If Yes, the benchmark adjustment has already been applied. Allow the premium being paid as a Health Insurance Premium deduction in the cost of care calculation If No, subtract the benchmark from the premium being paid and allow the remainder as a Health Insurance Premium deduction in the cost of care calculation Example John Allen is admitted to Happy Trails Nursing Facility on June 23 and approved for Medicaid. He currently has Medicare Part D and pays a $ 50.71 premium per month. 50.71 (Medicare Part D Premium) – 35.66 (2025 Part D Benchmark) $15.05 (Health Insurance Premium deduction) Example Alice Kramer was approved for Medicaid coverage last year. She has now been admitted to Green’s Awesome Care Nursing Facility on May 12 and approved for coverage. She currently has Medicare Part D and pays a $12.93 premium per month. Allow $12.93 as a Health Insurance Premium deduction in the cost of care calculation.
Home Maintenance Allowance | A maximum of six months is allowed. A physician must certify the individual is expected to return home within six months of admission to an institutional setting. The first full calendar month following the month of admission to a hospital or nursing facility begins the six-month count. Given for actual expenses, not to exceed the maximum SSI payment level for an individual. May be given even if someone continues to reside in the home. Examples of expenses that are allowed include: Rent or Mortgage Home owners or renters insurance Utilities Basic Cable, Internet or Satellite TV service Examples of expenses that are not allowed include: Premium Cable or Satellite TV services and channels Special telephone features, such as call waiting Expenses can be documented using a written or verbal statement from the individual. The statement must show: The type of payment; (for example: mortgage, electricity, water and sewer, trash pickup, cable, phone) To whom the payment is made; and The amount paid. A copy of the actual bill is not required unless the person appears to be paying for extra or premium services Note A request for the Home Maintenance Allowance can be made at any time during the six-month period. The allowance can be budgeted retroactively to when the applicant entered the facility. The deduction is applied when determining the amount of recurring income the individual is responsible for paying to a facility. The time an individual is in a hospital counts toward the maximum six-month period. For example, if the individual is in the hospital for two months and then enters a nursing facility, the home maintenance allowance can only be applied for up to four months.
Protected Income | Allowable for the month of admission from or discharge to a community setting Income is protected if the individual was in a community setting at any point during the month of admission to a nursing facility Examples of a community setting are the person’s home, the home of another person, an assisted living facility or a community residential care facility. A hospital admission is considered an institutional setting. EXCEPTION Income Trust Cases. Income is not protected for individuals with an Income Trust.
Cost of Pre-Eligibility Non-Covered Medical Expenses | The nursing facility may deduct pre-eligibility non-covered medical expenses. These are expenses: Recognized by State or Federal law as medical expenses; Not covered by Medicaid, Medicare, or other third-party payers; and Incurred by an individual before becoming eligible for Medicaid Note Deductions for non-covered medical expenses cannot exceed a beneficiary’s monthly recurring income and cannot be made if the beneficiary has zero ($0) reported monthly income. The deduction for medical and remedial care expenses that were incurred as the result of imposition of a transfer of assets penalty is limited to zero. See the SCDHHS Nursing Facility Services Manual , Chapter 7, Non-Covered Medical Expense Deductions, for a list of allowable deductions.
Cost of Post Eligibility Non-Covered Medical Expenses | The nursing facility may deduct post-eligibility non-covered medical expenses. These are expenses: Recognized by State or Federal law as medical expenses; Not covered by Medicaid, Medicare, or other third-party payers (Refer to Appendix B ); and Incurred by an individual currently Medicaid eligible in a Nursing Home Note Deductions for non-covered medical expenses cannot exceed a beneficiary’s monthly recurring income and cannot be made if the beneficiary has zero ($0) reported monthly income. The deduction for medical and remedial care expenses that were incurred as the result of imposition of a transfer of assets penalty is limited to zero. See the SCDHHS Nursing Facility Services Manual , Chapter 7, Non-Covered Medical Expense Deductions, for a list of allowable deductions.
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304.18.02 Protected Income
(Eff. 10/01/25)
An individual is not responsible for paying toward his/her cost of care during the calendar month of admission from, or discharge to, a non-institutional living arrangement. Income is protected the month of admission to a nursing home if the individual was in a non-institutional setting (home or Community Residential Care Facility) anytime during that same month. Institutional living arrangements would be a hospital, rehabilitation center, or a nursing home. If the individual goes from home to hospital to nursing home within the same month, the income would be protected since the individual was in the home during the month of admission to the nursing home.
Exception Income is not protected in either the month of admission or the month of discharge in Income Trust cases.
Example 1 Joe Green enters Caring Hearts Nursing Home directly from home on May 15 and does not have an Income Trust. His income his protected for May. He must begin paying his recurring income effective June. Example 2 Susan Blackwell entered the local hospital on May 15 and was transferred to Sisters of Charity Nursing Home on June 8. Her income is below the Medicaid Cap. Susan must begin paying her recurring income effective June. Her month of admission is May. Example 3 Alonzo Evening entered Georgetown Medical Hospital on March 9 from home. He was transferred to Hoya Nursing Home on March 22. His income is below the Medicaid Cap. His income is protected for the month of March, and he must begin paying recurring income in April. Example 4 Steve Norris entered Jamestown Nursing Center on June 14 from home. He established eligibility by executing an Income Trust. He must begin paying his recurring income effective June.
It is the provider's responsibility to collect recurring income amounts from the Medicaid eligible recipient and/or responsible party. There is nothing to prevent the nursing facility from collecting recurring income a month in advance.
Procedure to Calculate Recurring Income When an Applicant/Beneficiary in a Nursing Facility Has Not Established an Income Trust Use the DHHS Form 1296-A ME , Medical Assistance Only (MAO) Institutional Budget Sheet, to reflect the following calculations: Determine gross countable monthly income. Subtract allowable deductions in the following order: Personal needs allowance Community spouse income allocation Child allocation (regardless of whether living with the community spouse) Home maintenance allowance Health insurance premiums (other than Medicare) for the beneficiary only Enter the remaining amount on the DHHS Form 181 . The institutionalized individual must contribute this amount toward his/her cost of care/recurring income. Note The nursing facility is resp onsible for deducting any non-covered medical expenses. Example #1 Jill Smalls, a widow, entered a skilled nursing home on October 20 from home. Her gross income is $800 per month SSA. She is paying $50 per month in premiums for health insurance coverage. Month of October : $800 Countable gross income -$ 6 0 Personal needs allowance -$50 Health insurance premium $ 690 -$800 Protected income for October $0 Recurring income for October Month of November : $800 Countable gross income -$ 6 0 Personal needs allowance -$50 Health insurance premium $ 69 0 Recurring income for November Example 2 Henry Jones entered the hospital on June 25 , 2025, and transferred to a skilled nursing home on July 8. His income is $900 per month SSA and $300 from a pension. He and his community spouse have health insurance coverage through his former employer and pays $75 per month, but his portion of the premium is $50. His wife’s only income is $500 in SSA. Month of July: $1,200 Social Security + Pension -$30 Personal needs allowance -$50 Health insurance premium $1,120 - $ 3,448 Spousal allocation ($ 3 , 948 – $500) $0 Recurring income for July Month of October $1,200 Social Security + Pension -$ 6 0 Personal needs allowance -$50 Health insurance premium $1,120 - $ 3,448 Spousal allocation ($ 3,948 – $500) $0 Recurring income for October
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304.18.03 Medicaid Eligibility and Vendor Payment
(Eff. 01/01/26)
An individual residing in a nursing facility awaiting the expiration of a transfer of assets penalty or whose home equity is over $752,000 may receive Medicaid benefits for payment of non-institutional services if:
The level of care has been certified, and/or
All other eligibility criteria (financial and non-financial) are met.
304.19 Income Trust
(Rev. 07/01/15)
The Omnibus Budget Reconciliation Act of 1993 (OBRA 93) provides that certain individuals whose income exceeds the Medicaid Cap may be able to qualify for Medicaid using an income trust. Income trusts are commonly called "Miller" trusts. The intent of the legislation is to enable individuals who need institutional care to qualify for Medicaid even if the state does not have a spend down (Medically Needy) program.
304.19.01 Who May Be Covered Under this Provision
(Eff. 06/01/06)
Individuals who may be covered under this provision are individuals who:
Reside in nursing facilities or receive Home and Community Based Services; and,
Meet all eligibility requirements with the exception of their income exceeding the Medicaid Cap. There is no upward income limit for Income Trusts.
Example
The individual could place a monthly income of $3,000 in the Income Trust account each month, and this amount would not cause him/her to be ineligible.
304.19.02 Income Trust Requirements
(Rev. 04/01/10)
An institutionalized individual who meets all eligibility requirements except income may establish an Income Trust with his/her monthly income.
An Income Trust may be exempt from the transfer of assets policy if the following apply:
The single State Medicaid agency must be named as a beneficiary of the trust.
The applicant is the primary beneficiary.
The Medicaid agency is the secondary beneficiary.
Other beneficiaries may be named but may not receive any money until Medicaid has been repaid in full.
If funds remain in the Income Trust account at the time of the individual’s death, it is required that:
The trust reimburses the Medicaid agency for expenses paid on the individual’s behalf.
304.19.03 Explanations and Forms to Give at Intake
At application, if the stated income exceeds the Medicaid Cap, the LTC worker must explain to the applicant or authorized representative that the income exceeds the allowable limit and the only way to qualify for Medicaid is to set up an Income Trust. The LTC worker must also give the applicant or authorized representative copies of all of the following:
DHHS Form 905, Income Trust Agreement Form
DHHS Form 906, Management of the Income Trust
DHHS Form 925, Income Trust Notice to Beneficiary
Note
The applicant should also be advised that the earliest possible beginning date of eligibility may be the first day of the month in which the trust document is executed.
304.19.04 Establishing an Income Trust
(Rev. 07/01/26)
To establish an Income Trust, the applicant/beneficiary or their legal representative must:
Properly complete and execute (sign) an Income Trust Document. The earliest possible date for eligibility is the first day of the month when the trust document is properly executed.
A DHHS Form 905 Income Trust document must be given to the applicant/beneficiary or the authorized representative immediately when the need to establish an Income Trust is identified.
The applicant/beneficiary must appoint a trustee to handle the Income Trust. The applicant/beneficiary may not act as his/her own trustee.
The Schedule A must list any income that is assigned to the Income Trust. All income listed on the Schedule A must be placed in the trust.
Designate or establish a separately identifiable account to work in connection with the Income Trust.
The account may be a regular checking account.
The Income Trust account must include only the Applicant and the Trustee as account holders. This requirement will not delay the approval process. The Eligibility Specialist will follow up to ensure the requirement is met at annual review.
Only the applicant/beneficiary’s income that is assigned to the Income Trust on the Schedule A can be deposited into the account.
Only certain withdrawals are allowed (ref MPPM 304.19.06A and 304.19.06B
The account used for this purpose must be documented on the documentation tool and on the Income Trust document.
NOTE
If a Nursing Home serves as the trustee for an applicant or beneficiary’s Income Trust, the facility must maintain two distinct and identifiable ledger accounts: one for the Income Trust and another for Personal Needs.
Place the income in the account for any month that eligibility is needed and provide verification. The income does not initially have to be placed in the account the month of receipt but must be deposited before the case can be approved.
Note
If an individual deposits only a portion of his/her income from a specific source, the Schedule A must specify how much of the income is to be placed in the trust.
Example
If Ms. Jones receives $1,800 per month from her pension but only places $1,700 in the trust, the Schedule A must specify $1,700 of her pension.
304.19.04A Who Can Sign the Trust Document?
(Eff. 07/01/15)
The applicant/beneficiary must sign the trust document. The applicant/beneficiary may sign with a mark if properly witnessed by two persons. If the applicant/beneficiary is unable to sign, only their legal representative can sign on their behalf. A legal representative may be a Power of Attorney, conservator, or legal guardian. If there is no legal representative, the Income Trust cannot be executed until one is appointed. The earliest possible date of coverage is the date the Income Trust is executed.
If a legal representative signs, copy of the legal paperwork must be in the case file.
NOTE
The Power of Attorney must be for financial purposes. A health care only power of attorney is not acceptable.
304.19.04B Review of the Income Trust
(Rev. 07/01/26)
The executed Income Trust document must be reviewed to ensure it has been executed properly and that the language meets the requirements. The document must be submitted to Eligibility Enrollment and Member Services for review via Service Manager Ticket.
To submit the ticket, the Eligibility Specialist must select the following:
Category: Eligibility Enrollment and Member Services
Subcategory: Medicaid Policy
Option: Income Trust
Select: Income Trust Approvals
If the language of the trust meets the requirements and has been properly executed, a memorandum will uploaded into OnBase approving the trust and giving the effective date.
If the language of the trust meets the requirements and has been properly executed, a memorandum will be uploaded into OnBase by the EEMS Policy Coordinator approving the trust and giving the effective date.
If the language of the trust does not meet the requirements and/or the trust is not properly executed, it will be returned to the Trustee, and the applicant/beneficiary or Authorized Representative for correction along with a letter detailing the needed corrections and allowing 15 days for corrections to be returned. A copy of the letter will be uploaded into OnBase.
If the corrections are returned, they will be reviewed for accuracy. A memorandum will be uploaded giving an effective date of approval.
If the corrections are not returned, the EEMS Policy Coordinator will upload a memorandum denying the application into OnBase.
The Eligibility Specialist will use the information from the memorandum to complete the eligibility determination.
NOTE
The Eligibility Specialist is responsible for verifying that the information entered on the Income Trust Schedule A is accurate. Please note that the Income Trust Schedule A is not reviewed by an EEMS Policy Coordinator as part of the Income Trust document.
304.19.04C Death of an Applicant
(Rev. 07/01/26)
If an applicant passes away during the application process
The Eligibility Specialist must ensure the case is thoroughly documented and all documentation uploaded into OnBase.
An Income Trust must be signed prior to the applicant’s death. An Income Trust cannot be established after death.
Once an eligibility decision has been made, the Eligibility Specialist will submit a Service Manager Ticket to have the Income Trust dissolved.
Category: Eligibility Enrollment and Member Services
Subcategory: Medicaid Policy
Option: Income Trust
Select: Income Trust Dissolutions
An EEMS Policy Coordinator will respond with guidance.
Table of Contents
304.19.05 Funding the Income Trust
(Rev. 03/01/19)
Only income may be placed into the Income Trust. Placing other assets into the Income Trust changes the terms of the trust. It is then subject to the same treatment as other trusts. Any other assets placed into the trust must remain there, a transfer of assets penalty may result.
A transfer of assets penalty:
May be assessed when an asset is transferred from one person to another for less than its Fair Market Value.
Results in the individual being ineligible for Medicaid to pay for either:
Nursing Home Vendor Payment
Home and Community Based Services
The account must be funded before the application can be approved. Income may be:
Directly Deposited
Counter Deposit
Direct Transfer from another account
LTC Intake worker responsibilities at Application If it is determined an Income Trust is needed when the application is filed, the LTC Intake Team worker must: Provide all explanations as indicated in MPPM 304.19.02. Provide all appropriate Income Trust paperwork DHHS Form 905 DHHS Form 906 DHHS Form 925 Complete a DHHS 1233 ME if necessary, requesting the Income Trust and any additional information needed to complete the application. Send case to follow-up to await the return of information. LTC worker responsibilities When the Need for an Income Trust is Determined Later in the Application Process When it is determined that the income exceeds the Medicaid CAP, the LTC Intake Team worker or Assessment/Processing Team worker must immediately: Complete a DHHS 1233 ME, providing all appropriate Income Trust paperwork DHHS Form 905 DHHS Form 906 DHHS Form 925 Request Income Trust and verification of separately identifiable account be returned within 10 days. Send case to follow-up to await return of the information. LTC worker responsibilities When the Need for an Income Trust is Determined at Annual Review When it is determined that the income exceeds the Medicaid CAP, the LTC Review Team worker or Assessment/Process Team worker must immediately: If discovered prior to or during a collateral call with the beneficiary/authorized representative, use Income Trust Script to explain the Income Trust provision and what is needed to establish one. If income has been verified, rebudget the case with the new income. Complete a DHHS 1233 ME, providing all appropriate Income Trust paperwork DHHS Form 905 DHHS Form 906 DHHS Form 925 Request Income Trust and verification of separately identifiable account and any other needed verifications be returned within 15 days. Send case to follow-up pending receipt of information. LTC worker responsibilities When the Need for an Income Trust is Determined at Reported change When it is determined that the income exceeds the Medicaid CAP, the LTC Change Team worker or Assessment/Processing Team worker must immediately: If discovered prior to or during a collateral call with the beneficiary/authorized representative, use Income Trust Script to explain the Income Trust provision and what is needed to establish one. If income has been verified, rebudget the case with the new income. Complete a DHHS 1233 ME, providing all appropriate Income Trust paperwork DHHS Form 905 DHHS Form 906 DHHS Form 925 Request Income Trust and verification of separately identifiable account and any other needed verifications be returned within 15 days. Send case to follow-up pending receipt of information.
Procedure Before Establishing Eligibility The LTC worker MUST verify: The bank account has been established or designated, and The money is in the trust for any month that eligibility is needed. Note It is not necessary at initial approval that the income be placed in the trust the month it is received. However, it must have been placed in the trust prior to the case being approved. Example #1 Cheri is seeking eligibility for June. The case is not completed until August. The LTC worker obtains bank statements verifying the income for June and July was not placed into the trust until August. Provided all other criteria were met, eligibility can be established effective June. Example #2 Susan Doe applies on March 20 for her mother who just entered Caring Hearts Nursing Home. Her mother’s income exceeds the Medicaid Cap so she establishes an Income Trust to qualify. The trust document was signed on March 22. Susan opened a bank account on March 30 and places all her mother’s income in the account beginning April, including the amount received in March. The LTC worker is ready to complete the case on May 3. The LTC worker must have verification of the trust account and the amount in the account. Eligibility may be established effective March. Example #3 John Black entered a nursing home on April 7. His income exceeds the Medicaid Cap. His son applied for Medicaid on April 15 and signed an Income Trust document on April 18. The LTC worker verifies the account was set up and the income for May and June deposited in June. April’s income was not placed in the trust. Eligibility may be established effective May. Mr. Black is not eligible for April because the income received outside the trust exceeded the limit. Budgeting Reminders In the eligibility determination process, the Income Trust account is NOT a countable resource to be listed on the Electronic Budget Workbook when determining eligibility. Any income not included on the Income Trust Schedule A which is not placed in the trust must be counted and compared to the Medicaid Cap. Any income placed in the Income Trust is NOT counted toward the Medicaid Cap. Example #1 An applicant/beneficiary has $3,000 gross monthly income: $2,500 in Retirement and $500 in SSA. All income is listed on the Schedule A and deposited into the Income Trust account. Therefore, it is not counted as income and compared with the Medicaid Cap in the eligibility determination. Example #2 Only the $500 SSA check is listed on Schedule A and deposited into the account. The $2,500 Retirement check is neither listed nor placed in the trust. Therefore, the $2,500 Retirement check is counted as income and must be compared to the Medicaid Cap to determine income eligibility.
304.19.06 Income Eligibility
(Eff. 06/01/06)
The income determination for institutional Income Trust individuals is a two-step process.
Step One - Eligibility
Compare the gross countable income against the Medicaid Cap using the Electronic Medicaid Budgeting Workbook If the income exceeds the Medicaid Cap, the applicant or beneficiary may establish an Income Trust.
Step Two – Post-Eligibility
If an applicant/beneficiary establishes an Income Trust, determine the cost of care by using the Electronic Medicaid Budgeting Workbook The procedure for this step is listed below.
Procedure – Income Determination Step One: Eligibility Use the Electronic Medicaid Budgeting Workbook. Enter all Budget Group Information on the BG Info Tab. On the NH_HCBS Tab, Income Trust will display in red letters below the Countable Income Computation when gross income exceeds the Medicaid Cap. Verify what income is being placed in to the trust (refer to Schedule A and bank deposits) Exclude any income placed into the trust. Count any income received outside of the Income Trust toward the Medicaid Cap. Note If the money received outside the trust is listed on the Income Trust Schedule A, the terms of the trust are changed, and eligibility may be affected. Exclude any income placed into the Trust. Step Two: Post-Eligibility: All of the individual's total countable gross income is considered in the post-eligibility step, regardless if placed in the trust or not. On the IT Tab of the Electronic Budget workbook, enter the amounts of income placed in the trust and received outside the trust in the appropriate Budget (Nursing Facility or Waiver. Nursing Home Waiver Subtract any allowable deductions (Refer to MPPM 304.19.06A Subtract any allowable deductions (Refer to MPPM 304.19.06B On Line 11, choose the appropriate facility from the drop down box Any remaining income the Cost of Care for Waiver Services. Line 12 will reflect any amounts that must remain in the Trust each month, if any. Line 13 is the Recurring Income.
304.19.06A Allowable Deductions for Nursing Home
(Eff. 01/01/26)
Personal Needs Allowance | $100 – Work Therapy Allowance – if the institutionalized individual participates in a work therapy program as a part of the plan of care; or $ 6 0 – Standard Allowance – if the institutionalized individual does not participate in a work therapy program. Notes For cost of care effective October 1, 2025, or later, PNA increased to $60. For cost of care effective before October 1, 2025, PNA is $30. Individuals receive the personal needs allowance from countable income in addition to any excluded income such as VA Aid and Attendance or the $90 reduced VA pension.
Court Ordered Guardianship Fees | The lesser of 10% of gross income or $25 for court ordered guardianship fees
Income Trust Specific | $10 Trustee Fee to manage the trust (Note: A higher amount must be approved by the SC Department of Health and Human Services) Actual Bank Charges up to a maximum $20 per month if charged by the bank for the account used for the trust Payment of Federal and/or State Income taxes Must be owed by the Income Trust, not the individual. Copy of the tax return must be provided. Allowed only once per calendar year.
Community Spouse Income Allowance | Institutionalized spouse must choose to give; and The amount must not exceed $ 4,066.50 per month. Procedure to Determine the Amount of the Community Spouse Income Allowance Determine the community spouse’s gross income. Subtract this amount from $ 4,066.50 . The difference is the maximum allocation amount. Allocation for Spouse Only: Example 1 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2000. He has requested allocation for his community spouse. His spouse, Jane, has a gross income of $3000. Jane’s allocation: $ 4,066.50 (Max Allocation Limit) -$3 , 000.00 (Jane’s Gross Income) $ 1 ,066.50 (Jane’s Total Allocation) Total Allocation Awarded: $ 1,066 . 5 0 Example 2 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2000. He has requested allocation for his community spouse. His spouse, Jane, has a gross income of $900. However, Jane currently has active ABD-Medicaid Coverage. Jane wants to keep her current coverage while still getting an allocation. Jane’s allocation: $ 4,066.50 (Max Allocation Limit) -$900.00 (Jane’s Gross Income) $ 3166 . 5 0 (Jane’s Total Allocation) Calculation for Jane to keep ABD coverage: $1 30 5.00 (ABD Income Limit) +$50.00 (General Disregard) -$900.00 (Jane’s Gross Income) $ 45 5.00 (Allocation allowed for Jane to keep ABD coverage) Total Allocation Awarded: $ 45 5.00 Note A lower amount may be allocated if the community spouse wishes to maintain or establish eligibility for SSI benefits or Medicaid under another payment category such as ABD. The institutionalized individual must actually make the income available to the community spouse in order for it to be deducted. The spouse of a nursing home patient who receives Home and Community Based Services is considered a community spouse for the purposes of the income provisions of spousal impoverishment. Procedure – Amount of Community Spouse Allocation Questioned If the community spouse disagrees with the amount allocated or needs a higher amount to maintain him/her, the E ligibility Specialist should inform the spouse of his/her right to appeal (Fair Hearing). The community spouse must justify the need for the additional amount due to exceptional circumstances or significant financial duress. A higher amount can only be allowed if it is ordered through an appeal.
Allowance for Other Dependent Family Members | Institutionalized individual must choose to give the allocation May include minor children or dependent adults of the institutionalized or community spouse. A dependent adult is an adult family member (such as a mother, father, child, brother, sister) living in the home who depends on the applicant/beneficiary or community spouse for meeting physical, medical, or financial needs. A signed statement completed by the applicant/beneficiary or authorized representative indicating the relationship of the dependent adult and the nature of the dependency is acceptable verification to provide the allowance. Procedure to Determine the Amount of Income Allowances for Other Dependent Family Members Dependent(s) residing with Community Spouse Determine the gross income of each dependent family member. Subtract the total gross income of each dependent family member from $4,066.50. One-third of the remaining amount is each dependent family member’s income allowance. Add each dependent family member’s income allowance together to determine the total family income allowance. This is the amount allowed for allocation to dependent family members. Allocation for Spouse w/Dependent(s) (Dependent Living with a Community Spouse): Example 1 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2000. He has requested allocation for both his community spouse and his one dependent child who currently lives with Jane. His spouse, Jane, has a gross income of $3000 and his dependent child, Mark, has a gross income of $1000. Jane’s allocation: $4,066.50 (Max Allocation Limit) -$3,000.00 (Jane’s Gross Income) $1,066.50 (Jane’s Total Allocation) Mark’s allocation: $4,066.50 (Max Allocation Limit) -$1,000.00 (Mark’s Gross Income) $3,066.50 $4,066.50 ÷ 3 $1,022.16 (Mark’s Total Allocation) Total Allocation Awarded: Jane $1,066.50 Mark $982.66 Total: $1930.66 Example 2 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2000. He has requested allocation for both his community spouse and his one dependent child who currently lives with Jane. His spouse, Jane, has a gross income of $4,500 and his dependent child, Mark, has a gross income of $1500. Jane’s allocation: $4,066.50 (Max Allocation Limit) - $4,500.00 (Jane’s Gross Income) No Allocation Award to Spouse Mark’s allocation $4,066.50 (Max Allocation Limit) -$1,500.00 (Mark’s Gross Income) $2,566.50 $2,566.50 ÷ 3 $855.50 (Mark’s Total Allocation) Total Allocation Awarded: $855.50 Example 3 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $3715 (Income Trust). He has requested allocation for both his community spouse and his one dependent child who currently lives with Jane. His spouse, Jane, has a gross income of $715 and his dependent child, Mark, has a gross income of $1000. He entered the Nursing Home on September 15, 2025. Cost of Care must be calculated separately for September and October due to the increase in the PNA from $30 to $60. Cost of Care Calculation for September 2025 Joe’s Allowed Deductions: $30 Personal Needs Allowance $10 Trust Administration Fee $20 Bank Service Charge Jane’s allocation: $3948.00 (Max Allocation Limit) - $715.00 (Jane’s Gross Income) $3233.00 (Jane’s Allocation) Mark’s allocation: $3948.00 (Max Allocation Limit) -$1000.00 (Mark’s Gross Income) $ 2948.00 $2948.00 ÷ 3 $982.66 (Mark’s Allocation) Allocation Calculation: $3715.00 (Joe’s Gross Income) -$60.00 (Joe’s Allowed Deductions) $3655.00 (Funds left to give for allocation) -$3233.00 1,067.00(Jane’s Allocation) $422.00 (Remaining Allocation Mark can receive) Total Allocation Awarded: $ 3655.00 Cost of Care Calculation for October 2025 Joe’s Allowed Deductions: $60 Personal Needs Allowance $10 Trust Administration Fee $20 Bank Service Charge Jane’s allocation: $3948.00 (Max Allocation Limit) - $715.00 (Jane’s Gross Income) $3233.00 (Jane’s Allocation) Mark’s allocation: $3948.00 (Max Allocation Limit) -$1000.00 (Mark’s Gross Income) $ 2948.00 $2948.00 ÷ 3 $982.66 (Mark’s Allocation) Allocation Calculation: $3715.00 (Joe’s Gross Income) -$90.00 (Joe’s Allowed Deductions) $3625.00 (Funds left to give for allocation) -$3233.00 (Jane’s Allocation) $392.00 (Remaining Allocation Mark can receive) Total Allocation Awarded: $3625.00 Cost of Care Calculation for January 2026 Note: The max Spousal Allocation increased to 4,066.50 effective January 2026. Joe’s Allowed Deductions: $60 Personal Needs Allowance $10 Trust Administration Fee $20 Bank Service Charge Jane’s allocation: $4,066.50 (Max Allocation Limit) - $735.00 (Jane’s Gross Income) $3,331.50 (Jane’s Allocation) Mark’s allocation: $4,066.50 (Max Allocation Limit) -$1,028.00 (Mark’s Gross Income) $3,038.50 $3,038.50 ÷ 3 $1,012.83 (Mark’s Allocation) Allocation Calculation: $3,819.00 (Joe’s Gross Income) -$90.00 (Joe’s Allowed Deductions) $3,729.00 (Funds left to give for allocation) -$3,331.50 (Jane’s Allocation) $397.50 (Remaining Allocation Mark can receive) Total Allocation Awarded: $3,729.00 Example 4 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2000. He has requested allocation for both his community spouse and his one dependent child who currently lives with Jane. His spouse, Jane, has a gross income of $4000 and his dependent child, Mark, has no income. Jane’s allocation: $4,066.50 (Max Allocation Limit) - $4,250.00 (Jane’s Gross Income) No Allocation Award to Spouse Mark’s allocation $4,066.50 (Max Allocation Limit) (Mark has no Income) $4,066.50 $4,066.50 ÷ 3 $1,355.50 (Mark’s Total Allocation) Total Allocation Awarded: $1,355.50 Dependent(s) residing with someone other than the Community Spouse Determine the gross monthly income of all dependents living together Compare the gross income of all dependents living together to the TANF/FI Need Standard (PCR Income Limit, refer to MPPM 103.03) for a family of the appropriate size. For example, 2 dependents would use PCR Income Limit for 2. If gross monthly income is equal to or greater than the standard, no allocation is made. If gross monthly income is less than the standard, subtract the income from the standard. The resulting figure is the allocation to the dependents. NOTE The institutionalized individual must make the income available to the family in order for it to be deducted. Allocation for Dependents (Dependent Not Living with a Community Spouse): Example 1 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2,000. He has requested allocation for his one dependent child. Mark is currently living outside of the home and there is no community spouse. His dependent child, Mark, has a gross income of $500. Mark’s allocation: $808.58 (2025 PCR Income Limit for a Family of One) -$500.00 (Mark’s Gross Income) $308.58 (Mark’s Allocation) Total Allocation Awarded: $308.58 Example 2 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2000. He has requested allocation for both his community spouse and his one dependent child who currently does not live with his community spouse. His spouse, Jane, has a gross income of $3000 and his dependent child, Mark, has a gross income of $900. Jane’s allocation: $4,066.50 (Max Allocation Limit) -$3000.00 (Jane’s Gross Income) $1,066.50 (Jane’s Total Allocation) Mark’s allocation $808.58 (2025 PCR Income Limit for a Family of One) -$900.00 (Mark’s Gross Income) $0.00 (Mark’s Allocation) Total Allocation Awarded: $1,066.50 Example 3 Joe, who is applying for nursing home vendor payment, has a gross income with SSA of $2000. He has requested allocation for both his community spouse and his two dependent children, Mark and Mary, who currently do not live with his community spouse. His spouse, Jane, has a gross income of $3000. Mark has a gross income of $160 and Mary has a gross income of $200. Jane’s allocation: $4,066.50 (Max Allocation Limit) -$3000.00 (Jane’s Gross Income) $1,066.50 (Jane’s Total Allocation) $160.00 Mark’s Income +$200.00 Mary’s Income $360.00 (Total Income Together) Calculating Allocation for Joe’s Children $1092.75 (2025 PCR Income Limit for a Family of Two) -$360.00 $732.75 (Total Allocation for Mark and Mary) Total Allocation Awarded: $1,799.25 NOTE: If the institutionalized applicant/beneficiary has chosen not to make his/her income available for allocation to a spouse or other qualified dependent relative at application, but later chooses to do so, the applicant/beneficiary or their authorized representative must provide a signed declaratory statement of the new intent to make the income available for allocation. Once a new written request statement for allocation has been received along with verification of the spouse and any dependents’ gross income, the Eligibility Specialist can rebudget the case granting the allocation back to the date of application.
Health Insurance Premiums Note: Does not include Medicare Parts A and B Refer to the next table for Medicare Part D | Must only be paid by or for the Medicaid beneficiary out of the beneficiary’s funds. May only be deducted the month the premium is due or the month after. (See table below) Must be verified. Convert premiums paid at a frequency other than monthly to a monthly amount. Procedure – Health Insurance Premiums Acceptable forms of verification include: Premium notice Copy of cancelled check Bank statement verifying draft When Premium is reported Effective Date of Change Month premium due/paid Recurring Income may be rebudgeted effective the month the premium is due/paid Month after premium due/paid Recurring Income may be rebudgeted effective the month the premium is due/paid Two or more Months after premium due/paid Recurring Income may be rebudgeted effective the month the premium is reported to the agency Reminder: Regardless when the rebudget is being completed, the effective date is based on when the information was reported to DHHS If the amount a beneficiary must pay goes up once the rebudget is completed, adequate and advance notice must be given before the change becomes effective unless the beneficiary waives the 15-day notice requirement For premiums paid at a frequency other than monthly, average the premium to determine a monthly amount for the Cost of Care calculation Example 1 Joe’s income is $300 , and he reports on October 2 nd that his quarterly insurance premium of $450 is due on October 31 . He has no other deductions other than his personal needs allowance. Health Insurance: $450.00 (Quarterly Premium) ÷ 3 $150.00 (Monthly Average) Cost of Care: $300.00 (Gross Income) – $ 6 0.00 (Personal Needs) – $150.00 (Health Insurance Premium) $ 90 .00 (Cost of Care) Example 2 Alice’s income is $500 and she reports on October 10 that her monthly insurance premium changed in June from $100 per month to $150 per month. She has no other deductions except for her personal needs allowance. July, August, and September recurring income: $500 - $30 = $470, then $470 - $100 = $370 October recurring income: $500 - $60 = $440, then: $440 - $150 = $290 Note The Health Insurance Premium was reported two or months after the premium was due, so the effective date of change is the month the premium was reported.
Health Insurance Premiums – Medicare Part D, Drug Coverage | For individuals approved for Nursing Home coverage who are not already Medicaid eligible, subtract the Medicare Part D Benchmark from the verified Part D premium being paid by the individual and allow the remainder as a Health Insurance Premium deduction from countable income. For individuals receiving Medicaid who are then approved for Nursing Home coverage, the adjustment for the Medicare Part D Benchmark has already been applied. Allow the Medicare Part D premium being paid by the beneficiary as a Health Insurance Premium deduction from countable income. At COLA or Annual Review, the adjustment for the Medicare Part D Benchmark has already been applied. Allow the Medicare Part D premium being paid by the beneficiary as a Health Insurance Premium deduction from countable income. Refer to MPPM 103.07 for the current Medicare Part D Premium Benchmark for South Carolina Procedure – Health Insurance Premiums Verify the Part D Medicare premium Is the individual currently Medicaid eligible? If Yes, the benchmark adjustment has already been applied. Allow the premium being paid as a Health Insurance Premium deduction in the cost of care calculation If No, subtract the benchmark from the premium being paid and allow the remainder as a Health Insurance Premium deduction in the cost of care calculation Example John Allen is admitted to Happy Trails Nursing Facility on June 23 and approved for Medicaid. He currently has Medicare Part D and pays a $ 50.71 premium per month. 50.71 (Medicare Part D Premium) – 35.66 (2025 Part D Benchmark) $15.05 (Health Insurance Premium deduction) Example Alice Kramer was approved for Medicaid coverage last year. She has now been admitted to Green’s Awesome Care Nursing Facility on May 12 and approved for coverage. She currently has Medicare Part D and pays a $12.93 premium per month. Allow $12.93 as a Health Insurance Premium deduction in the cost of care calculation.
Home Maintenance Allowance | A maximum of six months is allowed. A physician must certify the individual is expected to return home within six months of admission to an institutional setting. The first full calendar month following the month of admission to a hospital or nursing facility begins the six-month count. Given for actual expenses, not to exceed the maximum SSI payment level for an individual. May be given even if someone continues to reside in the home. Examples of expenses that are allowed include: Rent or Mortgage Homeowners or renters insurance Utilities Basic Cable, Internet or Satellite TV service Examples of expenses that are not allowed include: Premium Cable or Satellite TV services and channels Special telephone features, such as call waiting Expenses can be documented using a written or verbal statement from the individual. The statement must show: The type of payment; (for example: mortgage, electricity, water and sewer, trash pickup, cable, phone) To whom the payment is made; and The amount paid. A copy of the actual bill is not required unless the person appears to be paying for extra or premium services Note: A request for the Home Maintenance Allowance can be made at any time during the six-month period. The deduction is applied when determining the amount of recurring income the individual is responsible for paying to a facility. The time an individual is in a hospital counts toward the maximum six-month period.
Protected Income | Income is not protected for the month of admission from or discharge to a community setting for individuals with an Income Trust.
Cost of Pre-Eligibility Non-Covered Medical Expenses | The nursing facility may deduct pre-eligibility non-covered medical expenses. These are expenses: Recognized by State or Federal law as medical expenses; Not covered by Medicaid, Medicare, or other third-party payers; and Incurred by an individual before becoming eligible for Medicaid Note Deductions for non-covered medical expenses cannot exceed a beneficiary’s monthly recurring income and cannot be made if the beneficiary has zero ($0) reported monthly income. The deduction for medical and remedial care expenses that were incurred as the result of imposition of a transfer of assets penalty is limited to zero. See the SCDHHS Nursing Facility Services Manual , Chapter 7, Non-Covered Medical Expense Deductions, for a list of allowable deductions.
Cost of Post Eligibility Non-Covered Medical Expenses | The nursing facility may deduct post-eligibility non-covered medical expenses. These are expenses: Recognized by State or Federal law as medical expenses; Not covered by Medicaid, Medicare, or other third-party payers (Refer to Appendix B ); and Incurred by an individual currently Medicaid eligible in a Nursing Home Note Deductions for non-covered medical expenses cannot exceed a beneficiary’s monthly recurring income and cannot be made if the beneficiary has zero ($0) reported monthly income. The deduction for medical and remedial care expenses that were incurred as the result of imposition of a transfer of assets penalty is limited to zero. See the SCDHHS Nursing Facility Services Manual , Chapter 7, Non-Covered Medical Expense Deductions, for a list of allowable deductions.
Procedure – Computing Allowable Deductions for Individuals in Nursing Home Facilities Use the Electronic Budgeting Workbook or the DHHS Form 1729 ME , Income Trust Budget Worksheet. Combine any income received outside the trust with any income placed in the trust. Subtract any allowable deductions Appropriate Personal Needs Allowance $10 Trustee Fee Court ordered guardianship fees (lesser of 10% of gross income, or $25) Actual Bank Service Charges, up to $20 per month Federal or State Income Tax payment (once per calendar year, IF the trust owes the taxes – not the individual.) Family Maintenance Allowance, if any Health insurance premium (for individual only) Home Maintenance Allowance, if any Medical Expenses not subject to third-party payment such (for individual only ). These adjustments are made by the nursing facility as part of billing Pre-Eligibility Expenses Post Eligibility Expenses Note: In Income Trust Cases, income is NOT protected in the months of entry and discharge. The recipient must contribute recurring income. The nursing home may pro-rate the actual payment based on the number of days the individual was a patient. Compare the remainder to the facility’s average monthly Medicaid payment rate (Refer to Appendix D of this chapter.) If the remainder is less than or equal to the monthly rate: The remainder is the cost of care, and No money will be left in the trust. If the remainder is greater than the monthly rate: The cost of care is equal to the monthly rate, and Any additional income must be left to accumulate in the trust. Note: If these funds are used for any other purpose, they may be considered a Transfer of Assets or Countable Income. A copy of the budget calculations must be given to the trustee. If using the Budgeting Workbook, for an initial approval, provide a copy of the following tabs: BG Info, NH-HCBS, IT. At each subsequent review, provide a copy of the BG Info and IT tabs .
304.19.06B Allowable Deductions for Home and Community Based Services
(Eff. 10/01/26)
Personal Needs Allowance | $2, 982 – Waiver Allowance – Individuals participating in a HCBS waiver receive a Personal Needs Allowance equal to the Medicaid Cap
Court Ordered Guardianship Fees | The lesser of 10% of gross income or $25 for court ordered guardianship fees
Income Trust Specific | $10 Trustee Fee to manage the trust (Note: A higher amount must be approved by the SC Department of Health and Human Services) Actual Bank Charges up to a maximum $20 per month if charged by the bank for the account used for the trust Payment of Federal and/or State Income taxes Must be owed by the Income Trust, not the individual. Copy of the tax return must be provided. Allowed only once per calendar year.
Community Spouse Income Allowance | Institutionalized spouse must choose to give; and The amount must not exceed $ 4066.50 per month. Procedure to Determine the Amount of the Community Spouse Income Allowance Determine the community spouse’s gross income. Subtract this amount from $ 4066.50 . The difference is the maximum allocation amount. Procedure – Amount of Community Spouse Allocation Questioned If the community spouse disagrees with the amount allocated or needs a higher amount to maintain him/her, the eligibility worker should inform the spouse of his/her right to appeal (Fair Hearing). The community spouse must justify the need for the additional amount due to exceptional circumstances or significant financial duress. A higher amount can only be allowed if it is ordered through an appeal.
Allowance for Other Dependent Family Members | Institutionalized individual must choose to give the allocation May include minor children or dependent adults of the institutionalized or community spouse. A dependent adult is an adult family member (such as a mother, father, child, brother, sister) living in the home who depends on the applicant/beneficiary or community spouse for meeting physical, medical, or financial needs. A signed statement completed by the applicant/beneficiary or authorized representative indicating the relationship of the dependent adult and the nature of the dependency is acceptable verification to provide the allowance. Procedure to Determine the Amount of Income Allowances for Other Dependent Family Members Dependent(s) residing with Community Spouse Determine the gross income of each family member. Subtract the total gross income of each family member from $ 4066.50 . One-third of the remaining amount is each family member’s income allowance. Add each family member’s income allowance together to determine the total family income allowance. This is the amount allowed for allocation to family members. Dependent(s) residing with someone other than the Community Spouse Determine the gross monthly income of all dependents living together Compare the gross income of all dependents living together to the TANF/FI Need Standard (PCR Income Limit, refer to MPPM 103.03) for a family of the appropriate size. For example, 2 dependents would use PCR Income Limit for 2. If gross monthly income is equal to or greater than the standard, no allocation is made. If gross monthly income is less than the standard, subtract the income from the standard. The resulting figure is the allocation to the dependents. NOTE: The institutionalized individual must actually make the income available to the family in order for it to be deducted.
Health Insurance Premiums Note: Does not include Medicare Parts A and B Refer to the next table for Medicare Part D | Must only be paid by or for the Medicaid beneficiary out of the beneficiary’s funds. May only be deducted the month the premium is due or the month after. (See table below) Must be verified. Convert premiums paid at a frequency other than monthly to a monthly amount. Procedure – Health Insurance Premiums Acceptable forms of verification include: Premium notice Copy of cancelled check Bank statement verifying draft When Premium is reported Effective Date of Change Month premium due/paid Recurring Income may be rebudgeted effective the month the premium is due/paid Month after premium due/paid Recurring Income may be rebudgeted effective the month the premium is due/paid Two or more Months after premium due/paid Recurring Income may be rebudgeted effective the month the premium is reported to the agency Reminder: Regardless of when the rebudget is being completed, the effective date is based on when the information was reported to DHHS If the amount a beneficiary must pay goes up once the rebudget is completed, adequate and advance notice must be given before the change becomes effective — unless the beneficiary waives the 15-day notice requirement For premiums paid at a frequency other than monthly, average the premium to determine a monthly amount for the Cost of Care calculation Example 1 Joe’s income is $300 and he reports on June 2 nd that his quarterly insurance premium of $450 is due on June 30. He has no other deductions other than his personal needs allowance. Health Insurance: $450.00 (Quarterly Premium) ÷ 3 $150.00 (Monthly Average) Example 2 Alice reports on October 10 that her monthly insurance premium changed in June from $100 per month to $150 per month. She has no other deductions except for her personal needs allowance. The $150 insurance premium can be deducted from income starting October 2025. The Health Insurance Premium was reported two or months after the premium was due, so the effective date of change is the month the premium was reported
Health Insurance Premiums – Medicare Part D, Drug Coverage | For individuals approved for Nursing Home coverage who are not already Medicaid eligible, subtract the Medicare Part D Benchmark from the verified Part D premium being paid by the individual and allow the remainder as a Health Insurance Premium deduction from countable income. For individuals receiving Medicaid who are then approved for Nursing Home coverage, the adjustment for the Medicare Part D Benchmark has already been applied. Allow the Medicare Part D premium being paid by the beneficiary as a Health Insurance Premium deduction from countable income. At COLA or Annual Review, the adjustment for the Medicare Part D Benchmark has already been applied. Allow the Medicare Part D premium being paid by the beneficiary as a Health Insurance Premium deduction from countable income. Refer to MPPM 103.07 for the current Medicare Part D Premium Benchmark for South Carolina Procedure – Health Insurance Premiums Verify the Part D Medicare premium Is the individual currently Medicaid eligible? If Yes, the benchmark adjustment has already been applied. Allow the premium being paid as a Health Insurance Premium deduction in the cost of care calculation If No, subtract the benchmark from the premium being paid and allow the remainder as a Health Insurance Premium deduction in the cost of care calculation Example John Allen is admitted to Happy Trails Nursing Facility on June 23 and approved for Medicaid. He currently has Medicare Part D and pays a $ 50.71 premium per month. 50.71 (Medicare Part D Premium) – 35.66 (2025 Part D Benchmark) $15.05 (Health Insurance Premium deduction) Example Alice Kramer was approved for Medicaid coverage last year. She has now been admitted to Green’s Awesome Care Nursing Facility on May 12 and approved for coverage. She currently has Medicare Part D and pays a $12.93 premium per month. Allow $12.93 as a Health Insurance Premium deduction in the cost of care calculation.
Cost of Post Eligibility Non-Covered Medical Expenses | The nursing facility may deduct post-eligibility non-covered medical expenses. These are expenses: Recognized by State or Federal law as medical expenses; Not covered by Medicaid, Medicare, or other third-party payers (Refer to Appendix B ); and Incurred by an individual currently Medicaid eligible Note Deductions for non-covered medical expenses cannot exceed a beneficiary’s monthly recurring income and cannot be made if the beneficiary has zero ($0) reported monthly income. The deduction for medical and remedial care expenses that were incurred as the result of imposition of a transfer of assets penalty is limited to zero. See the SCDHHS Nursing Facility Services Manual , Chapter 7, Non-Covered Medical Expense Deductions, for a list of allowable deductions.
Procedure Computing Allowable Deductions for Individuals Receiving Home and Community Based Services Use the DHHS Form 1729 ME , Income Trust Budget Worksheet, or the IT tab in the Budget Workbook. Combine any income received outside the trust with any income placed in the trust. Subtract any allowable deductions Waiver Allowance (equal to the Medicaid Cap) $10 Trustee Fee Court ordered guardianship fees (lesser of 10% of gross income, or $25) Actual bank service charges up to $20 per month Federal or State Income Tax payment (once per calendar year, IF the trust owes the taxes – not the individual.) Family Maintenance Allowance, if any Medical Expenses not subject to third-party payment (for the applicant/beneficiary only) Health insurance premiums Non-covered post eligibility medical expenses (Refer to Appendix B of this chapter.) The remainder of the income is the cost of care. Enter the amount on the DHHS Form 3229 ME , Notice of Cost of Care, as the amount that will be billed for the waiver services. Example Mr. Lee Brown applies for Home and Community Based Services. He receives Social Security benefits of $1,349 and a Union Retirement check in the amount of $2,219 per month. He pays a health insurance premium of $185 per month. He establishes an income trust and opens the trust bank account. Upon approval, he has been accepted into the Palmetto SeniorCare a PACE. Mr. Brown is a widow and lives with his daughter at night. Treatment The Eligibility Specialist should use the electronic budgeting workbook or DHHS Form 1729 ME, Income Trust Budget Worksheet, to calculate the maximum cost of care. ( Note: Be sure to use the side for Waiver Participants.) A copy of the DHHS Form 1729 ME must be given to the trustee. Gross monthly income $3,568 Deductions: Waiver Allowance $2, 982 Trust Administration Fee + 10 Health Insurance Premium + 185 Total Deductions $ 3, 177 Gross Income $3,568 Total Deductions - 3, 177 Payable Monthly Recurring Income $ 391 A copy of the DHHS Form 3229 must be emailed to the Division of Accounting at ARrequests@SCDHHS.gov to inform them of approval and the beneficiary’s recurring income.
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304.19.07 Billing for Home and Community Based Services Waiver Program Participants
(Eff. 07/01/15)
Upon approval, the LTC worker will forward a copy of the DHHS Form 3229 to the Division of Accounting when a beneficiary has a recurring income (cost of care).
State DHHS, Division of Accounting is responsible for billing the trustee for the recurring income (cost of care).
The trustee must pay on a monthly basis for the Home and Community Based Services the beneficiary receives.
Eligibility Enrollment and Member Services (EEMS) will reconcile the actual amount of Medicaid funds expended to the cost of care at the time the trust is dissolved.
Failure to Pay for Services
If the trustee fails to make monthly payments for the Home and Community Based Services received, the Principal Beneficiary (the client) will be required to change the trustee.
If the Principal Beneficiary refuses to change the trustee, Home and Community Based Services and Medicaid benefits will be terminated.
Refer to MPPM 304.19.10 regarding non-compliance.
304.19.08 Annual Accounting
(Eff. 06/01/06)
Annually, the trustee must provide an accounting of the Income Trust and its activity to the eligibility worker. This must include verification of:
All income placed in the trust,
All funds distributed from the trust,
The purpose of all funds that were distributed, and
The total amount of funds remaining in the trust, if applicable.
Procedures for Conducting an Annual Accounting: First annual accounting after approval: Examine all budget workbooks beginning with the effective month of eligibility forward. Determine how much, if any, funds were to remain in the Income Trust. Examine the statements for the Income Trust account that were submitted with the review form. Deposits – Do the sources and amounts deposited match the income that is assigned to the trust? Withdrawals Are the withdrawals for allowable expenses? If not, what things are being withdrawn? Obtain additional statements, if needed. Balance – Does the balance reflect what should have been left in the account according to the budget workbooks? If the balance is less than what it should be, contact the trustee to discuss. If unable to reach the trustee by telephone, send DHHS 1233 requesting additional statements to determine if the trust is in compliance. If the trust is not in compliance, refer to MPPM 304.19.10 Document the annual accounting on the Budget workbook and send a copy to the trustee. Annual Accounting Year 2 and after: Examine all budget workbooks beginning with the last accounting. Determine how much, if any, funds were to remain in the Income Trust. Examine the statements for the Income Trust account that were submitted with the review form. Deposits – Do the sources and amounts deposited match the income that is assigned to the trust? Withdrawals Are the withdrawals for allowable expenses? If not, what things are being withdrawn? Obtain additional statements, if needed. Balance – Does the balance reflect what should have been left in the account according to the budget workbooks? If the balance is less than what it should be, contact the trustee to discuss. If unable to reach the trustee by telephone, send DHHS 1233 requesting additional statements to determine if the trust is in compliance. If the trust is not in compliance, refer to MPPM 304.19.10 Document the annual accounting on the Budget workbook and send a copy to the trustee.
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304.19.09 Trust Modification: Trustee or Bank Account Change
(Eff. 06/01/06)
Eligibility, Enrollment and Member Services (EEMS) must approve all Income Trust modifications.
Procedure – Income Trust Modifications A change of Trustee requires that the LTC worker Provide all explanations as indicated in MPPM 304.19.02. Provide all appropriate Income Trust paperwork DHHS Form 905 DHHS Form 906 DHHS Form 925 Complete a DHHS 1233 ME if necessary, requesting the Income Trust document any additional information needed to complete the application. The new Income Trust document must be reviewed and approved (refer to MPPM 304.19.04B A change in Bank Account information requires that the eligibility worker: Verify any change made and file the documentation in the case record.
304.19.10 Non-Compliance with Terms of the Income Trust
(Rev. 07/01/26)
Several things may result in non-compliance with terms of the Income Trust, such as:
Failure to place income listed on the Income Trust Schedule A into the Income Trust (Either the Schedule A included in the DHHS Form 905 or a separate DHHS Form 3270)
Failure to pay the cost of care for Nursing Home or Waiver Services
Funds from the Income Trust distributed for expenses other than those allowed on the Income Trust Worksheet of the Budget Workbook.
Failure to maintain a separately identifiable account
The Eligibility Specialist may become aware of possible non-compliance in several ways:
The Eligibility Specialist may discover problems while conducting the annual accounting.
A Nursing Home may advise the Eligibility Specialist of non-payment.
When non-compliance is detected or reported, the Eligibility Specialist must:
Review the case with their LTC Supervisor.
The LTC Supervisor will submit a Service Manager Ticket as an Income Trust Policy Question to have the case evaluated. The Eligibility Specialist will not take any action on the case.
Category: Eligibility Enrollment and Member Services
Subcategory: Medicaid Policy
Option: Medicaid Policy Questions
Select: Income Trust
Provide Additional Details: Explain why the trust is in non-compliance.
An EEMS Policy Coordinator will contact the Applicant/Trustee to advise them that the trust is not in compliance.
The EEMS Policy Coordinator will explain what steps are needed to bring the trust into compliance. For example:
Placing the correct income into the trust
Amending the Schedule A
Bringing payments up to date
The EEMS Policy Coordinator will explain if the trust is not brought into compliance, Medicaid will be terminated unless a new trustee is named
The EEMS Policy Coordinator will give a time frame of 15 days to verify the trust has been brought into compliance
If a new trustee is not appointed, the Eligibility Specialist will be notified by the EEMS Policy Coordinator, and the case must be closed by the Eligibility Specialist.
304.19.11 Death of Income Trust Principal Beneficiary
(Eff. 06/01/06)
If the Principal Beneficiary of an income trust dies, the Division of Policy & Planning must dissolve the trust.
Procedure to Dissolve the Income Trust Upon the Death of the Principal Beneficiary If a Principal Beneficiary dies and the Income Trust case is closed, the following steps must be taken: The LTC worker must submit a Service Manager ticket to refer the Income Trust for dissolution. Refer to MPPM 304.19.14
304.19.12 Income Trust Dissolution
(Rev. 07/01/26)
An Income Trust may need to be dissolved for a number of reasons, (such as, death of beneficiary, non-compliance, income falls below the Medicaid Cap, and termination of case).
Procedure to Dissolve an Income Trust If an Income Trust needs to be dissolved for any reason, the Eligibility Specialist must: Submit a Service Manager Ticket for dissolution of the Income Trust to Category: Eligibility Enrollment and Member Services Subcategory: Medicaid Policy Option: Income Trust Select: Income Trust Dissolutions Explain the reason for the dissolution (such as discharged from nursing facility); and Give dates of eligibility under Income Trust The Service Manager Policy Team will: Verify the Gross income is below the program limit. For Nursing Home Cases: Pull claims for the associated time frame Determine how much money is due to the agency under the terms of the Income Trust Send a certified letter to the trustee notifying them: That the trust has been dissolved Of any amounts due to the agency under the terms of the Income Trust and how to remit payment; and That the account may be closed For Waiver cases: Pull claims for the associated time frame Determine how much money is due the agency under the terms of the Income Trust Advise the Division of Accounting of the amount of claims paid. If the beneficiary has paid the agency more than amount that Medicaid has paid, a refund will be issued for the difference. Send a certified letter to the trustee, copying Estate Recovery, advising the trustee that the dissolution of the trust has been completed and the account may be closed. If the Income Trust is dissolved because the beneficiary’s income has fallen below the Medicaid Cap, any funds remaining in the account after the trust is dissolved becomes a countable resource.
304.19.13 Income Trust and Transfer Penalties
(Rev. 07/01/24)
When an applicant/beneficiary with an Income Trust is subject to a penalty due to a transfer of assets, funds must remain in the Income Trust and cannot be used to pay the facility. This must be explained to the applicant/beneficiary. If all eligibility criteria are met, except for the penalty period, the application may be approved for the month eligibility established only so the penalty may start. The case must then be closed. A new application will be needed when the penalty period is over.
NOTE
If the penalty period expired while the application is pending, a new application will not be required. The worker should:
Approve in Cúram effective the month vendor payment will begin.
Submit a Service Manager Ticket for a Cúram correction to add the initial month of eligibility.
304.19.14 Income Trust Identification/Set up Flow
(Rev. 07/01/26)
Initial Application Process Eligibility Specialist | Identifies the need to establish an Income Trust through stated and/or verified income. If stated income is within $200 of Medicaid cap, the Income Trust should be pursued. If the Income Trust document has been submitted with the application: Submits the Income Trust to Eligibility Enrollment and Member Services for review via Service Manager Ticket. To submit the ticket, the Eligibility Specialist must select the following: Category: Eligibility Enrollment and Member Services Subcategory: Medicaid Policy Option: Income Trust Select: Income Trust Approvals If telephone interview is conducted, explains Why an Income Trust is needed General information about the Income Trust Packet, Management of the Income Trust account. Eligibility cannot be established prior to the month the trust document is signed so it is crucial to complete and return the Income Trust document as soon as possible NOTE If it is near the end of the month, see if the documents can be emailed or faxed in an effort to have it completed by the end of the month. Service Manager Policy Team | When information is received, reviews Income Trust or corrected Income Trust for accuracy. If incomplete or incorrectly signed, Attempt to contact via telephone to discuss necessary corrections. Returns document to the applicant/trustee for corrections. If the corrections are not returned, a memorandum denying the application will be uploaded into OnBase If accurately completed and signed, approves the document.
Eligibility Determination Reminders With Income Trust:
Must have verification of Separately Identifiable Account
Account must be funded for any months for which Medicaid eligibility is needed. That is, income for that month must run through the account.
Income is NOT protected for the month of entry.
Annual Case Review Eligibility Specialist | During review, current stated and/or verified income indicates the need to establish an Income Trust through stated and/or verified income. If successful in collateral call with the beneficiary/authorized representative, explains: Why an Income Trust is needed General information about the Income Trust Packet, Management of the Income Trust account. Eligibility cannot be established prior to the month the trust document is signed so it is crucial to complete and return the Income Trust document as soon as possible Send s a DHHS Form 1233 checklist with the Income Trust packet requesting return within 15 days. Rebudgets case if income has been verified Sends to follow-up awaiting return of the Income Trust document and account. When Income Trust document is returned Submits the Income Trust to the Division of Policy & Planning for review via Service Manager Ticket. To submit the ticket, the Eligibility Specialist must select the following: Category: Eligibility Enrollment and Member Services Subcategory: Medicaid Policy Option: Income Trust Select: Income Trust Approvals Service Manager Policy Team | When the Service Manager Ticket is received, reviews Income Trust or corrected Income Trust for accuracy. If incomplete or incorrectly signed, Attempt s to contact via telephone to discuss necessary corrections. Returns document to the applicant/trustee for corrections. If accurately completed and signed, approves the document. If the corrections are not returned, a memorandum denying the application will be uploaded into OnBase.
304.20 Other Trusts
(Eff. 06/01/06)
In the Omnibus Budget Reconciliation Act of 1993 (OBRA 93), Congress provided that certain trusts must be exempt from a Transfer of Assets penalty. These trusts are generally called:
Special Needs Trusts (Refer to MPPM 302.30.06.)
Pooled Trusts (Refer to MPPM 302.30.07.)
Procedure The trusts discussed in this section must be submitted for evaluation. Refer to the Service Manager Ticket Submission Guide for instructions.
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304.20.01 Undue Hardships and Trusts
(Eff. 02/01/09)
Undue hardship exists when the application of trust provisions or the post eligibility cost of care determination would deprive the individual of:
Medical care such that his/her health or life would be endangered; OR
Food, clothing, shelter, or other necessities of life.
The eligibility worker must obtain a letter from the applicant/beneficiary or his/her authorized representative claiming an undue hardship exists and verifications to substantiate the claim. Such verifications include, but are not limited to the following:
Letter from a physician certifying that the applicant/beneficiary’s health or life may result in the individual being placed in a life-threatening situation.
===AND===
Verification that services are not available through a Medicaid Provider; AND/OR
Verification of necessary medical expenses not otherwise covered; AND/OR
Verification of necessary household expenses not being paid (e.g.; mortgage, utilities).
For nursing home and waiver service applicants/recipients, the eligibility worker must obtain the above verifications as well as the verifications listed below:
Letter from CLTC/BHDD/PACE
Denying or terminating services OR
Verifying the inability to provide this service to the extent necessary through the waiver;
===OR===
Letter from the nursing home either:
Refusing to admit the patient, or
Threatening discharge of the patient.
Send the letters and other documentation to the DHHS Division of Policy and Planning for evaluation to determine if undue hardship exists.
304.21 Bed Hold Policy
(Eff. 06/01/06)
Medicaid may continue to make a vendor payment to a nursing facility in the following instances and within the specified limitations:
For up to 10 days, if an individual is in a hospital. An individual may be in the hospital 10 full days, returning to the facility on the 11th day.
For an absence of up to 18 days per fiscal year for a de-institutionalization program, not to exceed nine days at any one time.
For up to 30 consecutive days for the purpose of participating in an approved rehabilitation program.
For up to 96 days each fiscal year for individuals who reside in Intermediate Care Facilities for the Intellectually Disabled (each period of leave is for a maximum of eight days and may be two 16-consecutive days if authorized by a physician).
A one-time 30-day consecutive leave per admission is allowed for discharge planning and permanent placement to a home environment. The attending physician must prescribe this leave as a vital part of the discharge planning activity. A leave of absence exceeding the allowed days requires a discharge from the facility.
Note The majority of the bed holds the eligibility worker will work with are 10-day bed holds for hospital admissions. The chart below indicates the steps to take when an individual transfers from a nursing facility to a hospital.
Upon Admission to a Hospital What the Nursing Facility Should Do | What the Eligibility Worker MUST Do Send a DHHS Form 181 to advise the eligibility worker of the hospital admission date. Ideally, this should be done within a few days of the individual’s admission. | Set up a tickler file to count the 10 days. When the 10 Days are Up What the Nursing Facility Should Do | What the Eligibility Worker MUST Do Send a DHHS Form 181 to notify the eligibility worker of either: · The re-admission date (if Medicare is paying for the re-admission, this should be verified); or · The individual’s inability to return to the facility and the vendor payment termination date. | If a DHHS Form 181 is not received from the nursing facility: Contact the nursing facility and/or hospital to verify the individual’s location. If individual is re-admitted to the nursing facility within the 10 days: Document the case record; no other action is needed. If individual remains hospitalized: Generate a DHHS Form 181 to terminate the vendor payment, Send a notice to the authorized representative notifying him/her of the termination, and Ex parte to General Hospital (or another payment category, if applicable). If individual is not eligible for Medicaid in another payment category: Begin closure action for Medicaid.
Example #1 Jennifer Ward is a patient at Sisters of Charity Nursing Home. She is transferred to the local hospital on March 5 suffering from pneumonia. The nursing home sent a DHHS Form 181 to the county Medicaid eligibility office on March 6 notifying them of the change. The eligibility worker marked her calendar for follow up on March 15. On March 10, the county Medicaid eligibility office received a DHHS Form 181 verifying Ms. Ward was readmitted to the nursing facility at the same level of care. No further action was needed. Example #2 On April 5, the county Medicaid eligibility office received a DHHS Form 181 from Caring Hearts notifying them that Davis Mathews was transferred to the local hospital on April 2. On April 13, the eligibility worker contacted the nursing home, verified Mr. Mathews remained hospitalized, and that the DHHS Form 181 had been mailed terminating the vendor payment. On April 20, the eligibility worker verified Mr. Mathews was still in the hospital and was expected to remain there indefinitely. Mr. Mathews did not have an income trust so the eligibility worker changed the payment category to General Hospital. Example #3 Same scenario as Example #2 except that Mr. Mathews qualified for Nursing Home by establishing an Income Trust. The eligibility worker-initiated closure of his Medicaid because the General Hospital has no Income Trust provision.
304.22 Medicare/Co-Insurance
(Rev. 07/01/07)
Under certain conditions, Medicare Part A may cover an individual’s costs in a nursing facility for a short period. After a qualifying hospital stay, Medicare pays in full for services during the first 20 days of skilled care for a spell of illness. Beginning with the 21st day, only a portion of the cost is covered. Coverage may be available for up to 100 days if all the Medicare criteria are met.
If an individual is eligible for both Medicare Part A and Medicaid, the Medicaid program is not responsible for the co-insurance amount due from the 21st day up to the 100th day (maximum of 80 days). However, the individual must meet all eligibility criteria for nursing home, and is still responsible for contributing his/her recurring income during that time. The DHHS Form 3229-B, Notice of Cost of Care for Medicare Sponsorship in a Nursing Home, is used to notify the beneficiary or authorized representative of the cost of care.
When Medicare sponsorship is terminated, an assessment for Medicaid Level of Care will be conducted. Generally, the nursing facility initiates this process for individuals whose Medicare coverage is ending.
304.23 DHHS Form 181 (Notice of Admission, Authorization and Change of Status for Long-Term Care)
(Eff. 01/01/10)
The DHHS Form 181, Notice of Admission, Authorization, and Change of Status for Long-Term Care, is the form used by nursing facilities to bill Medicaid for a vendor payment. Eligibility workers and nursing facilities use it to communicate information about:
Approvals
Changes such as:
Transfers to another facility
Admissions to or re-admissions from a hospital
Level of Care changes
Increases or decreases in recurring income
Terminations due to such things as:
Death of beneficiary
Expiration of bed hold
Medicare-sponsored admissions
Medicare terminations
Denials
If an applicant/beneficiary is denied for Medicaid or Vendor payment eligibility, one of the following reasons must be shown on the DHHS Form 181:
You failed to meet financial eligibility
You failed to meet non-financial eligibility
Vendor Payment denied, eligible for Medicaid card only
(Refer to the Processing LTC Form 181/MSCs Types job aid and Appendix C for detailed instructions on completing the DHHS Form 181.)
304.23.01 Initiation of DHHS Form 181
(Eff. 06/01/06)
Generally, the provider initiates the DHHS Form 181 by completing Sections I and II. However, if the eligibility worker becomes aware of a change, the eligibility worker initiates the DHHS Form 181 and forwards it to the appropriate nursing facility.
304.23.02 Signature Requirements
(Eff. 06/01/06)
The eligibility worker must sign and date the form for each of these actions:
New admissions under either Medicare or Medicaid
Income changes
Discharges that affect recurring income
A signature is not required for routine Level of Care changes or most termination actions.
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304.24 Program for All-inclusive Care for the Elderly (PACE)
(Eff. 11/01/07)
A Program for All-inclusive Care for the Elderly (PACE) is a federal Medicaid and Medicare capitated program for beneficiaries age 55 and older who meet a Nursing Facility Level of Care. Using an interdisciplinary team approach, PACE coordinates and provides all needed preventative, primary, acute and long-term care services to enable participants to continue living in their homes or with family. The following chart compares the HCBS waivers and PACE program.
HCBS | PACE Plan of Care | Case Manager | Interdisciplinary Team Appeals and Hearings | Medicaid | Medicaid and Medicare Focus of Care | Home | Center Payment Source | Fee for Service | Capitated Payment Estate Recovery | Required | Not Required Age Limit | Varies by Waiver | 55 and Older Services | Established by waiver | All-inclusive Service Area | Statewide | County Specific
Since PACE provides all-inclusive care, beneficiaries who participate in the program receive all care through the PACE provider and providers with whom they have contracted. Special procedures are in place for beneficiaries who require nursing home or residential care placement. Refer to the following sections for the procedures.
304.24.01 PACE Participant Enters a Nursing Home
(Eff. 11/01/07)
If a PACE participant is placed in a nursing home under PACE sponsorship or resided in a nursing home under PACE sponsorship, the beneficiary is responsible for paying any recurring income directly to PACE.
Procedure PACE staff will complete Section I of the DHHS Form 181, with the exception of parts eight (8) and nine (9) and forward to the Medicaid eligibility worker. The Medicaid eligibility worker will determine recurring income in the same manner as for any nursing home beneficiary and complete Section III, Item 12-C as appropriate. Retain the white copy for the case record. The pink and canary copies will be returned to the PACE social worker for their use.
If an SSI eligible PACE beneficiary enters a nursing facility, PACE will be responsible for notifying Social Security to have the SSI payment recalculated.
Although the PACE participant is in a nursing facility, the Medicaid category will not change. The beneficiary remains in original category. Also if the beneficiary is placed in a nursing facility in another county, the case will remain in the original county and not be transferred.
304.24.02 PACE Participant Enters a Residential Care Facility
(Eff. 01/01/15)
If a PACE participant is placed in a Residential Care Facility (RCF) under PACE sponsorship, or resides in a RCF under PACE sponsorship, the beneficiary will become responsible for paying appropriate income directly to PACE. The PACE program will be responsible for calculating the amount the participant will pay using the following procedure.
Procedure From all unearned income, except for SSI, subtract $20 General Disregard. From any earned income Subtract any of the remaining $20 General Disregard not used in the above step Subtract $65 from the remaining Earned Income Subtract ½ of the remaining Earned Income Add the Unearned and Earned Income Subtract $65 for the beneficiary’s Personal Needs The remainder is the PACE participant’s liability
Although the PACE participant is in a RCF, the case will continue to be a PACE case. Do not change the Medicaid category to Optional State Supplement (OSS). Also if the beneficiary is placed in a RCF in another county, the case will remain in the original county and not be transferred.
304.24.03 PACE Participant Terminated from Program
(Eff. 11/01/07)
When a PACE participant is terminated from the program, the termination will always occur at midnight the last day of the month. PACE will notify the appropriate Medicaid office and appropriate action should be taken.
Terminations occur when the beneficiary dies, move out of the service area, become Medicaid ineligible, there is failure to cooperate with the service plan, or at the beneficiary’s request. If a beneficiary is terminated from PACE because the family chose to place the beneficiary in a nursing home or in a regular waiver, the case can be changed. It will be necessary to coordinate the change between PACE and the nursing home or CLTC to avoid interruption of Medicaid coverage.
304.25 Denial of Payment for New Admissions (DPNA)
(Eff. 03/01/25)
When the Department of Public Health (DPH) finds deficiencies with a nursing facility, DPH may recommend a DPNA to the Centers for Medicare and Medicaid (CMS). The nursing facility is aware the recommendation has been made. Generally, the facility is given a time frame for corrective action. DPH will visit the facility again to determine if the deficiencies have been cleared up. If the corrective action has been taken, DPH will recommend that CMS rescind the DPNA. CMS must rescind the DPNA before payment can be made.
E-mail notifications are sent to eligibility staff statewide when DPNA sanctions are applied and rescinded.
Procedure – Denial of Payment for New Admissions If an applicant/beneficiary is in a facility under a DPNA, the eligibility worker must verify if the admission date and requested date for vendor payment on the DHHS Form 181 is prior to the effective date of the DPNA sanction. The effective date of the sanction must be documented in the case record. If the admission is prior to the DPNA effective date and all other eligibility criteria are met, the case may be certified and the DHHS Form 181 authorized. If the admission is on or after the DPNA effective date, the DHHS Form 181 cannot be authorized unless the eligibility worker has been notified the DPNA was rescinded. The eligibility worker must determine if the applicant is Medicaid-eligible under another payment category. If eligible under another category, the eligibility worker must: Approve under the other payment category and Deny the vendor payment. If not eligible under another category and all other eligibility criteria are met for PC 10: Extend the standard of promptness to the 90 th day (refer to MPPM 304.07.01 ) for a bed slot to become available. After the 90 th day, deny the application if the DPNA has not been rescinded. If the DPNA is rescinded within 45 days of the date on the denial notice and the facility or family requests it, the eligibility worker must: Determine eligibility using the same application, and File a copy of the e-mail verifying the DPNA was rescinded in the case record.
304.26 Miscellaneous Facts about Nursing Facilities
(Eff. 06/01/06)
Eligibility workers are frequently asked questions about the following issues regarding nursing facilities.
304.26.01 Private vs. Semi-Private Rooms
(Eff. 06/01/06)
Private rooms are not a covered service under Medicaid. The difference between the private and semi-private room rates may not be billed to Medicaid. If the family requests a private room, the facility may charge the patient or responsible party the difference.
The Medicaid beneficiary cannot be charged more than any other resident is charged.
The charge is usually the difference between the customary private and semi-private room rates.
304.26.02 Solicitation of Contributions from Medicaid Beneficiaries by Providers of Long-Term Care Services
(Eff. 06/01/06)
Medicaid policy prohibits providers from directly soliciting contributions, donations, or gifts from Medicaid long-term care beneficiaries or their relatives.
304.26.03 Sitters
(Eff. 06/01/06)
Medicaid beneficiaries may have sitters; however, the sitters:
May not provide services reimbursable under the Medicaid program, and
Cannot perform duties that are part of the total nursing needs provided by an employee of the facility.
304.26.04 Condition of Admission
(Eff. 06/01/06)
A nursing facility must not require a third-party guarantee of payment to the facility as a condition of admission or expedited admission, or continued stay in the facility. However, the facility may require an individual who has legal access to a beneficiary's income or resources available to pay for facility care to sign a contract, without incurring personal financial liability, to provide facility payment from the beneficiary's income or resources.
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304.26.05 Continuing Care Retirement Communities (CCRCs)
(Eff. 06/01/06)
Continuing Care Retirement Community (CCRC): sometimes referred to as a “life care community,” the service is the provision of multiple residential options all in one location. Residential options typically include independent living arrangements, assisted living, and skilled nursing care. Usually, a contract is required that obtains a financial commitment from the aging person in return for assurances that the appropriate level of care will be provided when needed. The SC Department of Consumer Affairs licenses CCRC’s in this state. A list of licensed facilities can be found at www.scconsumer.gov.
Treatment of Entrance Fees of Individuals Residing in Continuing Care Retirement Communities (CCRCs) and applies for Long-term Care: Entrance fees for CCRCs or life care communities are considered to be countable resources to the applicant, to the extent that: The individual has the ability to use the entrance fee, or the contract provides that the entrance fee may be used, to pay for care should other resources or income of the individual be insufficient. The individual is eligible for a refund of any remaining entrance fee when the individual dies or terminates the CCRC or life care community contract and leaves the community; and The entrance fee does not confer an ownership interest in the CCRC or life care community.
304.27 Estate Recovery
(Rev. 12/01/21)
In August of 1993, Congress passed a law that requires states to recover amounts that Medicaid has paid for certain beneficiaries. In South Carolina, the Estate Recovery program went into effect on 07/01/94. The state will recover amounts paid by Medicaid for services received on 07/01/94 or later.
Estate Recovery applies to the following beneficiaries:
A person who was 55 years of age or older and received medical assistance consisting of:
Nursing facility services,
Home and community based services, and
Hospital and prescription drug services provided to individuals in nursing facilities or receiving Home and Community Based Services paid by Medicaid. Exception: A Program of All Inclusive Care of the Elderly (PACE Program) such as Palmetto SeniorCare is not subject to estate recovery provisions;
A person of any age who was:
An inpatient in
A nursing facility,
An intermediate care facility for the Intellectually Disabled, or
A long-term care facility at the time of death.
Required to pay most of his/her monthly income to the facility toward the cost of care.
Applicants/Beneficiaries must be informed about the Estate Recovery provisions when applying for services subject to recovery. The DHHS Estate Recovery Brochure 24116 must be given to the applicant/beneficiary. A CLTC or BHDD case manager must complete a DHHS Form 1296 ER, Estate Recovery Notification, for Medicaid beneficiaries that do not require a separate application (such as SSI recipients), and forward the original to:
Mail: SCDHHS
Attn: Medicaid Estate Recovery
Post Office Box 100127
Columbia, SC 29202-3127
The state files a claim with the probate court against the beneficiary's estate to recover amounts paid by Medicaid for the deceased beneficiary's medical care. No recovery will be made as long as there is:
A surviving spouse,
A minor child (under age 21), or
A disabled child, as defined according to SSI criteria.
In addition, no recovery will be made for beneficiaries who died before 07/01/94, and recovery may be waived if it would cause undue hardship to a surviving family member.
Questions about Medicaid Estate Recovery should be directed to:
Department of Health and Human Services
Attn: Medicaid Estate Recovery
Post Office Box 100127
Columbia, SC 29202
Phone 1-888-289-0709, option 5, option 3
Fax (803) 462-2579
Procedure – Beneficiary Who Meets the Estate Recovery Criteria Dies The eligibility worker must: Complete the DHHS Form 238 , Medicaid Estate Recovery Notification of Death. Attach copies of the following to the DHHS Form 238: Form 3401, Application for Nursing Home, Residential or In-Home Care OR DHHS Form 3400, Healthy Connections Application for Medicaid and/or Affordable Health Coverage AND DHHS Form 3400-B, Additional Information for Select Medicaid Programs DHHS Form 1253 ME , Request for Financial Investigation Asset Verification System (AVS) responses DHHS Form 1255 ME , Verification of Real and Personal Property Any other pertinent financial documents Forward all of the above to the State DHHS Medicaid Estate Recovery Department. Mail: SCDHHS Attn: Medicaid Estate Recovery Post Office Box 100127 Columbia, S C 29202-3127 Staff in Medicaid Estate Recovery may share information with the Medicaid eligibility staff when they receive information regarding news of beneficiaries’ deaths from other sources. It is the responsibility of the eligibility specialist to ensure that eligibility has been terminated and the appropriate documents have been forwarded to Medicaid Estate Recovery.
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304.28 Basic Application Process for Nursing Home and Home and Community Based Service Cases
(Rev. 01/01/26)
Application Received/Intake
The DHHS Form 3401, Application for Nursing Home, Residential or In-Home Care, OR the DHHS Form 3400, Healthy Connections Application, and the DHHS 3400-B, Additional Information for Nursing Home and In-Home Care, are used to collect necessary information for the institutional programs. The DHHS Form 3400 Espanol and DHHS Form 3400-B Espanol may be used when an individual’s primary language is Spanish.
When an application for an institutional program is received, the LTC eligibility specialist will attempt to call the applicant/authorized representative and use the Long-Term Care Application Script to confirm and verify the provided information and to explain what else may be required.
Prior to placing the call, the LTC eligibility specialist will:
Ensure the case is entered and submitted in Cúram-CGIS
Review the information submitted on the application
Review case history
Conduct any available data matches and online property searches
During the call, the LTC eligibility specialist will:
Use the Long-Term Care Application Script to:
Ask relevant questions needed to determine eligibility
Discuss any discrepancies between information reported on the application, case history, and found via data matches and online searches.
Share information about the eligibility process including Income Trust when needed.
Explain what verifications are needed and why
Describe the interaction with the nursing home and Community Long Term Care
Relay the Rights and Responsibilities
Utilize three-way calls to assist applicant/authorized representative in obtaining as many verifications as possible.
Send a DHHS Form 1233 requesting any additional information needed from the applicant/authorized representative.
If attempts to complete the call are unsuccessful, the LTC eligibility specialist must:
Ensure all necessary information is gathered to include:
Any unanswered questions
Any discrepancies found on the application or between the current and any past applications
Complete a manual DHHS Form 1233, Medicaid Eligibility Checklist, and mail the form to the applicant and any active Authorized Representatives. The following information must be included:
Information about the eligibility process, including Income Trust when needed.
What verifications are needed and why
Rights and Responsibilities
Processing
The LTC eligibility specialist must:
Have case submitted in Cúram-CGIS within 4 working days of receipt
Ensures all third-party verifications are requested/received. Examples include:
Level of Care
Property search (online searches or DHHS Form 1255, Verification of Real and Personal Property)
Bank Forms
Asset Verification System (AVS) Bank responses,
DHHS Form 1253, Request for Financial Verification (Only if unable to verify with AVS)
Insurance Cash Values (DHHS Form 1280, Verification of Life Insurance Values)
Income requests: VA, Railroad, or Civil Service for example
Performs Data Matching on Computer system and follows up on any lead or verified information
Bendex
SDX
ESC
State Retirement
Assesses all the verifications provided by the applicant/AR and obtained from Third Parties and
Determines
If any clarification is needed
There are any discrepancies between reported and verified information
Contacts appropriate party to clarify
Policy
Applies all financial and non-financial policy to the specific situation
Requests clarifications from supervisor or trainer as needed
Determination
Financial Determination
Applies all income and resource exclusions
For Income Trust cases,
Ensures Income Trust document has been completed, reviewed, and approved.
Ensures separately identifiable account has been designated or opened and Income assigned to it has been deposited for month coverage is needed.
Budget countable income and resources using the Electronic Budget Workbook for cases when manual eligibility is used
If eligible, determine recurring income
Non-Financial Determination
Ensure all non-financial criteria has been met
Categorical (aged, blind, disabled)
Common Non-financial (citizenship, residency, enumeration, identity)
Level of Care
30 consecutive days
If case is not eligible for institutional due to non-financial criteria such as level of care or not entering a facility, be sure to look at eligibility under other categories such as ABD-SC or SLMB.
Approve or deny application in the System of Record. Change to appropriate payment category, if necessary. An application that requires both a level of care and disability determination cannot be denied by the eligibility worker until both decisions have been received.
If case is eligible, take the following actions:
Approve in the System of Record
Authorize the DHHS Form 181, Notice of Admission, Authorization and Change of Status for Long Term Care
For CGIS cases, if the automated notices are correct, allow the notices to be sent by the system. If the automated notices are incorrect, suppress the notices and send a manual DHHS Form 3229
NOTE
When authorizing the Long-Term Care (LTC) coverage in the System of Record (SOR), the eligibility specialist must ensure that all coverage for which the applicant/beneficiary qualifies has been authorized. This includes QMB and SLMB Plus. For example: If the beneficiary meets the eligibility criteria for LTC and SLMB or QMB, authorize both the LTC coverage and the SLMB or QMB coverage in Cúram-CGIS.
Refer to MPPM 304.02.01 for details regarding retroactive period for active MAGI and Non-MAGI beneficiaries applying for Nursing Home coverage.
NOTE
SLMB Plus eligibility can only be determined when CGIS is the System of Record.
304.29 Case Record Requirements
(Rev. 01/01/26)
Element | Nursing Home: No SSI/SSI Terminating | Nursing Home: Receiving SSI | HCBS: Non-SSI Recipient | HCBS: SSI Recipient OR | DHHS Form 3401Application | Required | Not Required | Required | Not Required DHHS Form 3400 Application and DHHS Form 3400-B | Required | Not Required | Required | Not Required Look-back | Required | Not Required** (See Note) | Required | Not Required Verification of Current Income | Required | Required | Required | Not Required Verification of Current Resources | Required | Not Required | Required | Not Required DHHS Form 181 | Required | Required | N/A | N/A DHHS Form 185 Level of Care | Required | Required | N/A | N/A DHHS Form 118/118A Client Status Document | N/A | N/A | Required | Not Required Cúram Payment Category | 10, 33 | 54 | 15, 32 | 80 Other | N/A | N/A | N/A | CLTC enters Recipient Special Program (RSP) code into MMIS
**Note
If the applicant once received SSI, but is no longer eligible for SSI, a look-back must be conducted for the period between the last month of SSI eligibility and the month of application.
If an applicant is Medicaid eligible (not SSI), the current case record must be examined to determine what resource information is available for completion of the look-back for a transfer of resources. A request for additional documentation should only be made if the information is incomplete, or if there is an indication a transfer may have occurred, and further verification is required. If the case record contains bank information for the look-back period and the balances have remained consistent, no further information should be needed. A routine property check must be conducted to verify current ownership and to determine if a transfer occurred. Routine system checks should also be completed.
For an applicant who was Medicaid eligible (not SSI) at any time during the look-back period, use the available information in the case record to conduct the look-back, and request documentation for the time not covered by the record.
Example: Joe Green has received ABD for the past five years. He has made a referral to CLTC for HCBS and the DHHS Form 118 is sent to the local eligibility office to request a look-back for a transfer of assets. The eligibility worker examines the case record and determines that Mr. Green has a checking account that has been consistent for the entire period, and homestead property. When Mr. Green returns the DHHS Form 3400-B, there is no indication any transfers have occurred. A property check is completed and verifies: Mr. Green still owns the homestead property The value of his homestead is under $ 7 52 ,000. He owns no other property He did not transfer any property during the look-back period The file contains bank information from each year in the look-back period. His balances have been consistent during that time. There is no indication of a transfer so additional information is not requested from Mr. Green. The eligibility worker returns the DHHS Form 118 to CLTC indicating the look-back has been completed.
304.30 Annual Review Procedures
304.30.01 Nursing Home
(Rev. 08/01/25)
Annual re-determinations are required.
P rocedure for Annual Review Cúram generates a review form based on the Certification End Date. Eligibility Specialist Responsibilities: Acknowledge the receipt of the review form into Cúram Compare the information on the form to the case history Note any alleged changes or discrepancies and ensure categorical eligibility for Nursing Home. For reviews sent prior to 07/01/25, resources were not considered due to the PHE Unwinding Flexibilities. For reviews sent on or after 07/01/25, t he Eligibility Specialist should compare reported resources to case history and verify any new and existing resources. If the member attests to a possible transfer on the review form, obtain the necessary information to determine if a sanctionable transfer took place. Refer to MPPM 304.09. Cont act Beneficiary /AR to clarify information or request any verification Obtain current verification of all Income and Resources through such methods as: Requesting verification from the Beneficiary /AR Checking all available data matches such as IEVS; BENDEX; SDX; State Retirement; ESC Wage Match; Unemployment; CHIP; and Person Composite Service (PCS) Wage Verification Obtaining necessary information/verification from third parties through such methods as: Online Internet searches such as Asset Verification System (AVS); Property search/Verification of Car Values Telephone contact – make sure to document the following: Date of Contact; Company/Business Name; Phone Number; Individual’s Name (and Title, if possible) that provided the verification Send ing forms and letters, such as, DHHS Form 1255 ; DHHS Form 1280 ; DHHS Form 1212 ; DHHS Form 1253 ME (If unable to verify with AVS) Letter to a funeral home; Civil Service Obtain and document all verifications but do not apply changes to the evidence in edit. Complete the eligibility check in Cúram to determine continued eligibility: If eligible in the current category, Apply changes to the evidence in edit in Cúram and complete the review. Refer to Annual_Case_Review_ACR_JA.pdf If there is a change in recurring income, advise the Beneficiary /AR and facility of the change DHHS Form 181 Cost of Care Letter ( DHHS Form 3229 ME ) to advise the facility and the Beneficiary/AR of the new amount If ineligible in the current category Determine if the individual would be eligible in any other Payment Category. Refer to MPPM 101.08.06 for additional guidance on completing the ex parte process Approve the new PDC if eligible in another category If unable to determine eligible in another category, apply changes to the evidence in edit and begin closure actions in Cúram Apply changes to the evidence in edit and begin closure actions in Cúram Send a DHHS Form 181 to the facility
304.30.02 Home and Community Based Services
(Rev. 08/01/25)
Annual re-determinations are required.
P rocedure for Annual Review Cúram generates a review form based on the Certification End Date Eligibility Specialist Responsibilities: Acknowledge the receipt of the review form into Cúram Compare the information on the form to the case history Note any alleged changes or discrepancies and ensure categorical eligibility for HCBS . For reviews sent prior to 07/01/25, resources were not considered due to the PHE Unwinding Flexibilities. For reviews sent on or after 07/01/25, t he Eligibility Specialist should compare reported resources to case history and verify any new and existing resources. If the member attests to a possible transfer on the review form, obtain the necessary information to determine if a sanctionable transfer took place. Refer to MPPM 304.09. Contact Beneficiary /AR to clarify information or request any verification Obtain current verification of all Income and Resources through such methods as: Request verification from the Beneficiary /AR Checking all available data matches such as IEVS; BENDEX; SDX; State Retirement; ESC Wage Match; Unemployment; CHIP; and Person Composite Service (PCS) Wage Verification Obtaining necessary information/verification from third parties through such methods as: Online Internet searches such as Asset Verification System (AVS); Property search/Verification of Car Values Telephone contact – make sure to document the following: Date of Contact; Company/Business Name; Phone Number; Individual’s Name (and Title, if possible) that provided the verification Send ing forms and letters, such as, DHHS Form 1255 ; DHHS Form 1280 ; DHHS Form 1212 ; DHHS Form 1253 ME (If unable to verify with AVS) L etter to a funeral home; Civil Service Obtain and document all verifications but do not apply changes to the evidence in edit. Complete the eligibility check in Cúram to determine continued eligibility: If eligible in the current category, Update evidence in Cúram and complete the review. Refer to Annual_Case_Review_ACR_JA.pdf For Income Trust Cases : if there is a change in recurring income, Advise the PI/AR by sending Cost of Care Letter ( DHHS Form 3229 ME ) Send a copy of the DHHS Form 3229 ME and DHHS Form 1729 ME to Accounts Receivable . If ineligible in the current category, Determine if the individual would be eligible in any other Payment Category. Refer to MPPM 101.08.06 for additional guidance on completing the ex parte process If unable to determine eligible in another category, apply changes to the evidence in edit and begin closure actions in Cúram Apply changes to the evidence in edit and be gin closure actions in Cúram
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304.31 Introduction to General Hospital
(Eff. 06/01/06)
An individual of any age who is hospitalized for an extended period of 30 consecutive days or more may be eligible for Medicaid benefits if he/she meets all of the financial and non-financial criteria. This category of assistance is similar to the Nursing Home category of assistance.
304.31.01 General Hospital vs. Nursing Home Assistance
(Rev. 05/01/09)
General Hospital | Nursing Home Assistance Countable Income | Countable income must be at or below the Medicaid Cap; no Income Trust provisions. | If countable income exceeds the Medicaid Cap, eligibility may be established using Income Trust provisions. Level of Care | Level of Care is presumed; no certification required. | Level of Care certification required Look-back for Transfers | Look-back not required | Look-back required Recurring Income (Cost of Care) | No recurring income or Cost of Care determination required. | Cost of Care determination is required. Spousal Income | No spousal income allocation | Possible income allocation to a community spouse Spousal Resource | Resources of both spouses are considered, even if separated. | Resources of both spouses are considered, even if separated. Transfer of Assets | No penalty for transfer of assets for less than Fair Market Value. | Penalty applied if there is a transfer of assets for less than Fair Market Value.
304.31.02 Non-Financial Eligibility Criteria
(Eff. 06/01/06)
To qualify for assistance in this category, the individual must meet certain non-financial requirements. (Refer to MPPM Chapter 102 for specific information on the following criteria.)
Identity MPPM 102.02
State Residency MPPM 102.03
Citizenship/Alienage MPPM 102.04
Enumeration/Social Security Number MPPM 102.05
Assignment of Rights to Medical Support MPPM 102.07
304.31.03 Categorical Eligibility Criteria
(Rev. 07/01/26)
To qualify categorically under the General Hospital Category, an individual must:
Reside in a licensed and certified Title XIX Acute Care Medical Facility
The admission must be 30 consecutive days or longer, beginning with the date of admission. The 30 days may be spent in:
A hospital
A combination of Hospital, nursing facility, and/or home and community-based services waiver
If the 30-day requirement is met and otherwise eligible, eligibility may be established effective the month of admission.
Exceptions to 30-day requirement Death prior to completion of the 30 days Eligibility in another full benefit payment category (such as ABD , PHC, or PCR )
Meet a Level of care – presumed because the hospital’s Utilization Review Board completes a treatment plan to justify the stay.
Be Aged, Blind, or Disabled
Children under age 19 are considered part of the family for an admission lasting fewer than 30 days, as long as they continue to be claimed as tax dependents in their parents’ household.
Beginning on the 31st day of admission, the child may be considered an individual for a non-MAGI determination. If eligible, coverage can be authorized beginning the month of admission into the hospital. If the child can be approved for Partners for Healthy Children (PHC) coverage or ABD Child, there is no need to backdate the General Hospital coverage. Process General Hospital coverage for any retroactive coverage dates for which PHC or ABD Child could not be authorized.
Infants born in and remaining in the hospital after birth can be processed for General Hospital coverage because the household has not been established for PHC or ABD-Child. The infant is considered an individual and is processed as any other General Hospital applicant is processed.
Non-MAGI Income Treatment of Child/Infant Before 30 Days in Hospital | Parents’ income is Deemed to child/infant. They are considered part of entire HH composition After 30 Days in Hospital | The child is treated as an individual back to the admission date. Only the child/infant’s income and resources are considered Infant Born and Remaining in Hospital | The child is treated as an individual. Only the child/infant’s income and resources are considered
Note
Do not end the PHC coverage on the 31st day if the beneficiary still qualifies for coverage unless a change is reported that impacts eligibility. Any child under the age of 19 who does not qualify for PHC or ABD coverage must be processed for General Hospital coverage if they have met the 31-day requirement or have passed away in the hospital.
Adult Examples Example #1 Sarah Phillips was admitted to the hospital on January 6 and was discharged on February 28. The 30-day requirement was met. Example #2 A General Hospital application was filed for Jimmy Wood. Mr. Wood was admitted to Memorial Hospital on March 10 after breaking his hip. He was transferred to Manor Care Nursing Home under Medicare for therapy on March 31. On April 13, he was discharged home from Manor Care. The 30-day requirement was met in the combined admissions. Example #3 Hannah Green was admitted to County Hospital on April 3 and passed away on April 22, while still a patient. The General Hospital category may still be considered as it is assumed that she would have remained in the hospital for 30 days had she lived. Example #4 The DHHS Medicaid office received a General Hospital application on Stan Smart. Mr. Smart was a patient at Doctor’s Hospital from February 20 until his discharge home on March 20. He did not meet the 30-day criteria, so eligibility could not be established under the General Hospital category. The eligibility worker must determine if he may qualify under another payment category. Note In all of the above examples, the categorical eligibility of each of the applicants was established (that is, the individuals are aged or have been determined to be blind or disabled). Infant and Children Examples Example 1 Lily Smith was born in the hospital on August 15. Her original application was for PHC. She is presently still in the hospital on September 18. Lily does not qualify for any other coverage but meets all eligibility criteria for General Hospital including disability. Only Lily’s income and resources are countable. Do not use the deeming process. The 30 consecutive day requirement has been met. Lily is authorized for coverage beginning August 1. Example 2 Jake Hill was born in the hospital on September 12. He was discharged home on September 18. On September 21, a General Hospital application was received because he returned to the hospital on September 19 and is expected to remain for more than 30 days. He does not qualify for any other coverage because his deemed income is over the income limit for PHC as well as ABD Child. Since Jake’s parents’ income is not used to determine eligibility for the General Hospital category, Jake meets all eligibility requirements (including disability) for the General Hospital coverage except the 30-consecutive days requirement. The eligibility specialist placed the case in follow-up until the 31st day of hospital admittance. If still in the hospital on the 31st day, Jake can be authorized for General Hospital beginning September 1. Example 3 Lacy Gray is a child who was admitted to the hospital from home on June 3. Her application was received on September 5, and retroactive coverage was requested. On October 15, Lacy is still in the hospital. Lacy qualifies for PHC beginning September 1. Lacy needs General Hospital coverage for the retroactive months because her parents were over the income limit for PHC Medicaid in the Retroactive months. She does not qualify for any other coverage because her deemed income is over the income limit for ABD Child. Since Lacy’s parents’ income is not used to determine eligibility for the General Hospital category, Lacy meets all eligibility requirements (including disability) for the General Hospital coverage. Lacy was authorized for General Hospital coverage beginning June 1 st and ending August 31. Her PHC was authorized beginning September 1. Note In all of the above examples, the categorical eligibility of each of the applicants was established (that is, the individuals have been determined to be blind or disabled).
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304.31.04 Financial Criteria
(Eff. 01/01/26)
Income Limit – Income must be equal to or below the Medicaid Cap (three times the SSI Federal Benefit Rate). The Income Trust provision does not apply in a General Hospital situation. If the individual’s income exceeds the Medicaid Cap limit, he/she is not eligible under this category. (Refer to MPPM 103.07.)
Resource Limit – Countable resources must be equal to or below $2,000 for an individual who is not ABD eligible. Countable resources must be equal to or below $9,950.00 for an individual who would be ABD eligible. The spousal resource policy must be applied, if applicable. Resource reduction must also be considered for applicants that are eligible but for excess resources (Refer to MPPM 302.02A).
If there is a spouse, the eligibility worker must consider the resources of both the applicant and the community spouse. The total value of the applicant’s and the ineligible spouse’s resources must be determined. The ineligible spouse is allowed to keep a maximum of $66,480 of the couple’s countable resources. This is known as the spousal share. The remainder of the total countable resources must be considered available to the applicant. (Refer to MPPM 304.15.02B.)
Example #1
John Hampton applies for General Hospital coverage. John’s countable income is $1,000 per month in Social Security. His countable resources total $5,000. As John’s income meets the guidelines for ABD, the non-institutional resource limit may be applied.
Example #2
Mable Green applies for General Hospital coverage for her husband Jacob Green. Their combined countable income totals $1,550 per month. Their combined countable resources total $9,000. As their combined income meets the guideline for ABD, the non-institutional resource limit may be applied. Note: The community spouse’s share of the countable resources must be separated from the institutionalized spouse’s share within 30 days of certification for Medicaid.
Example #3
Saul Peterson applies for General Hospital coverage. Saul’s total countable income is $1,400 per month. His countable resources total $2,500. As Saul is not ABD eligible, the institutional resource limit may be applied.
Example #4
Joe Jones applies for General Hospital coverage for his wife Jane Jones. Their combined countable income totals $2,500. Their combined countable resources total $55,000. As their combined countable income exceeds the ABD limit for a couple, the institutional resource limit for a couple may be applied. Note: The community spouse’s share of the countable resources must be separated from the institutionalized spouse’s share within 30 days of certification for Medicaid.
Liberalized income and resource policy applies.
304.31.05 Continued Eligibility
(Rev. 07/01/24)
General Hospital cases must be closely monitored to determine continued hospitalization as eligibility ends with the month of discharge. Also, while hospitalized, the beneficiary’s monthly income may be retained into subsequent months resulting in excess resource accumulation.
Procedure – Continued Hospitalization The eligibility worker must set up a tickler file to check these cases a minimum of every three months to verify the individual remains hospitalized. At the end of the hospitalization, appropriate action must be taken to either ex parte to another payment category or initiate a closure action.
A complete eligibility review must be completed every 12 months. The cases must be re-budgeted if changes occur during the 12-month period. Exception: A child approved for General Hospital remains eligible throughout their continuous period of eligibility, for up to one year.
304.31.06 Basic Application Process
304.31.06A Receipt of Application/Intake
(Rev. 07/01/15)
DHHS Form 3401, Application for Nursing Home, Residential or In-Home Care, OR DHHS Form 3400, Healthy Connections Application, AND DHHS Form 3400-B, Additional Information for Select Medicaid Programs, are used to collect necessary information.
An application may be received in person or by mail. There is no requirement for a face-to-face interview although one may be beneficial in this type case.
If a face-to-face interview is conducted, either the applicant or the authorized representative is interviewed.
During the interview, the eligibility worker
Asks relevant questions needed to determine eligibility
Shares information about the eligibility process
What verifications are needed and why
Rights and Responsibilities
If there is no face-to-face interview, the eligibility worker must:
Ensure all necessary information is gathered to include:
Contact applicant/AR if there are
Any unanswered questions
Any discrepancies found on the application or between the current and any past applications
Share information about the eligibility process
What verifications are needed and why
Rights and Responsibilities
Standard of Promptness – 45 days; 90 if disability determination is required
304.31.06B Processing of Application
(Eff. 09/01/16)
The eligibility worker must:
Pend the case in Cúram-CGIS within 3 working days of receipt
Ensure all third party verifications are requested. Examples include:
Property search (on line or DHHS Form 1255 ME, Verification of Real and Personal Property)
Bank forms
Asset Verification System (AVS) request for bank accounts
DHHS Form 1253 ME, Request for Financial Verification (Only if unable to verify with AVS)
Insurance cash values (DHHS Form 1280 ME, Verification of Life Insurance Values)
Income requests: Such as VA (DHHS Form 1212 ME), Railroad, Civil Service
Perform data matching on computer system and follows up on any lead or verified information
Bendex
SDX
ESC
State Retirement
Assess all the verifications provided by the applicant/Authorized Representative and obtained from Third Parties and
Determine
If any clarification is needed
There are any discrepancies between reported and verified information
Contact appropriate party to clarify
Policy
Apply all financial and non-financial policy to the specific situation
Request clarifications from supervisor or trainer as needed
304.31.06C Determination of Eligibility/Ineligibility
(Eff. 07/01/24)
Financial Determination
Applies all income and resource exclusions
Budgets countable income and resources (Should use the workbook.)
Non-Financial Determination
Ensures that all of the non-financial criteria has been met
Categorical (aged, blind, disabled)
Common Non-financial (citizenship, residency, enumeration, identity)
Level of Care
30 consecutive days
If the case is not eligible for some reason, be sure to look at eligibility under other categories such as ABD or SLMB.
Approve or deny application in Cúram. Change to appropriate payment category, if necessary.
Table of Contents
304.31.06D Continued Eligibility
(Rev. 09/01/16)
The eligibility worker must put the case in follow-up for no more than 90 days to verify the individual remains hospitalized. At the end of the hospitalization, appropriate action must be taken to ex parte to another payment category or to initiate a closure action.
304.32 Palmetto Coordinated System of Care (PCSC) Waiver
(Eff. 08/01/25)
SCDHHS sunset the Palmetto Coordinated System of Care (PCSC) Waiver on July 31, 2025.
304 Appendix A Life Expectancy Table
(Eff. 10/01/05)
LIFE EXPECTANCY TABLE MALES | FEMALES Age | Average Number of Years of Life Remaining | Age | Average Number of Years of Life Remaining 0 10 20 30 40 50 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 100 110 | 73.26 64.03 54.41 45.14 35.94 27.13 19.07 18.33 17.60 16.89 16.19 15.52 14.86 14.23 13.61 13.00 12.41 11.82 11.24 10.67 10.12 9.58 9.06 8.56 8.07 7.61 7.16 6.72 6.31 5.92 5.55 5.20 4.86 4.55 4.26 3.98 3.73 2.05 1.14 | 0 10 20 30 40 50 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 100 110 | 79.26 69.93 60.13 50.43 40.86 31.61 22.99 22.18 21.38 20.60 19.82 19.06 18.31 17.58 16.85 16.14 15.44 14.85 14.06 13.40 12.74 12.09 11.46 10.85 10.25 9.67 9.11 8.57 8.04 7.54 7.05 6.59 6.15 5.74 5.34 4.97 4.63 2.39 1.22
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304 Appendix B Non-Covered Medical Expenses and Allowable Deductions
(Rev. 11/01/23)
See the SCDHHS Nursing Facility Services Manual, Chapter 7, Non-Covered Medical Expense Deductions, for a list of allowable deductions.
Table of Contents
304 Appendix C DHHS Form 181
(Eff. 10/01/05)
The following are instructions for completing the DHHS Form 181, Notice of Admission, Authorization, and Change of Status for Long Term Care.
Section I Identification of Provider and Patient – To be completed by the nursing facility or the DHHS Medicaid eligibility worker.
Item 1 Enter the individual’s first name, middle initial and last name.
Item 2 Enter the individual’s date of birth (two digits each for day, month, year).
Item 3 Enter the individual’s 10-digit Medicaid ID number.
Item 4 Enter the street number and name, the city, and the state in which the individual resides.
Item 5 Enter the name of the county in which the individual resides.
Item 6 Enter the individual’s Social Security claim number, including the suffix.
Item 7 Enter the name and address of the nursing facility.
Item 8 Enter the provider's 6-digit Medicaid ID number.
Item 9 Enter the termination date of Medicare benefits reimbursed to the provider. If no Medicare benefits were involved, leave this item blank. (This is a through date.)
Item 10 Enter the date the form was prepared.
Section II Type of Coverage and Statistical Data – To be completed by the nursing facility or the DHHS Medicaid eligibility worker.
Item 11 (A) Check the box that indicates the Level of Care: Skilled, Intermediate, SNF Co-insurance or Psychiatric.
Item 11 (B) Enter the appropriate change in type of care and the effective date.
Item 11 (C) Enter the date the individual was admitted as a Medicaid patient.
Item 11 (D) Enter the date the individual was transferred to another facility and the name of the facility to which he/she was transferred.
Item 11 (E) Enter the date the patient transferred from another facility and the name of the transferring facility.
Item 11 (F) Enter the date the individual transferred and the name of the hospital.
Item 11 (G) Enter the date the individual was re-admitted to the hospital.
Item 11 (H) Enter the number of days the individual was absent from the facility.
Item 11 (I) Enter the effective date of termination. If the patient died, enter the date of death. Specify the reason for termination or other change of status, if not covered by the above. Enter any changes not listed above. If the termination is for a reason other than death, write the reason for termination in the Remarks section on the DHHS Form 181, (such as the 80 days were exhausted, the individual was discharged to the home, the individual no longer meets level of care.)
Item 11 (J) Enter the date the individual was admitted under Medicare for the current spell of illness.
Item 11 (K) Enter the co-insurance dates for the current spell of illness.
Section III Authorization and Change of Status – To be completed by the DHHS Medicaid eligibility worker.
Item 12 (A) Enter the date Medicaid sponsorship of stay is authorized to begin.
Item 12 (B) Enter the reason that the individual was not qualified for long-term care.
Item 12 (C) Enter the individual’s recurring income, which is the total monthly income less the personal needs allowance.
Item 12 (D) Enter any change in the individual’s monthly recurring income and the effective date of the change.
Item 12 (E) Enter the current name and any correction necessary.
Item 12 (F) Enter other changes or information.
Note
The DHHS Medicaid supervisor or lead eligibility worker must sign and date the DHHS Form 181 when Section III is used.
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304 Appendix D Current Average Monthly Nursing Facility and Medicaid Payment Rates
(Eff. 01/01/26)
Note: The current average private pay nursing home rate in South Carolina is $9,758.58 per month ($320.83 per day).
AVERAGE MONTHLY NURSING FACILITY AND MEDICAID PAYMENT RATES Payment Rates Effective January 1, 2026 MMIS Provider # | MMIS Facility Name | Average Monthly Medicaid Cost 0098SB | Abbeville County Memorial | 7,570.00 NF1108 | Achieve Rehabilitation and Nursing Center | 6,804.00 NF1126 | Aiken Rehabilitation and Care Center | 7,577.00 0041SB | Allendale County Hospital | 7,570.00 NF1118 | Anchor Post Acute | 8,015.00 NF1112 | Angel Oak Nursing & Rehab | 8,176.00 NF1152 | Ashley River Healthcare | 7,925.00 NF1075 | Azaleawoods Rehab & Nursing Center | 6,876.00 NF1148 | Bennettsville Healthcare LLC | 6,147.00 0189NF | Bethea Baptist Health Care Center | 8,972.00 173286 | Brian Center of St Andrews | 7,344.00 NF1138 | Brookview Healthcare Center | 6,450.00 NF1070 | Brushy Creek Post Acute | 9,440.00 NF1059 | Calhoun Convalescent Center | 5,896.00 NF1142 | Carlyle Senior Care of Blackville | 6,134.00 NF1073 | Carlyle Senior Care of Florence | 6,937.00 NF1072 | Carlyle Senior Care of Fork | 6,359.00 NF1076 | Carlyle Senior Care of Kingstree | 6,748.00 NF1141 | Carlyle Senior Care of Williston | 7,605.00 0602NH | Cheraw Healthcare, Inc. | 7,246.00 NF1058 | Chesterfield Convalescent Center | 6,342.00 NF1079 | Compass Post Acute Rehabilitation | 7,512.00 0918NF | Dr. Ronald E. McNair Nursing & Rehab | 6,467.00 NF1119 | Edgefield Post Acute | 6,939.00 NF1055 | Edisto Post Acute | 7,768.00 NF1065 | Ellen Sagar Nursing Home | 7,837.00 0927NF | Faith Healthcare Center | 7,062.00 NF1113 | Fleetwood Post Acute | 7,108.00 NF1159 | Forest Acres Post Acute | 7,496.00 NF1074 | Fountain Inn Post Acute | 8,586.00 NF1155 | Franke at Seaside | 7,671.00 NF1045 | Golden Age-Inman | 7,884.00 NF1056 | Greenville Post Acute | 7,306.00 NF1114 | Greer Post Acute | 7,619.00 NF1105 | Hallmark Healthcare Center | 7,504.00 0450NH | Heritage Home of Florence, Inc | 6,742.00 117042 | Honorage Nursing Home | 8,818.00 NF1149 | Inman Healthcare | 7,726.00 NF1120 | Iva Post Acute | 7,915.00 NF1032 | JF Hawkins Nursing Home | 6,837.00 118285 | John Edward Harter Nursing Center | 7,379.00 NF1052 | Johns Island Post Acute | 7,299.00 0929NF | Jolley Acres Healthcare Center | 7,830.00 332258 | Karesh at Beechwood | 9,466.00 0928NF | Lake City-Scranton Healthcare | 6,715.00 0862NF | Lake Emory Post Acute Care | 6,732.00 0736NF | Lake Marion Nursing Facility, Inc. | 8,362.00 0738NF | Lake Moultrie Nursing Home | 8,580.00 NF1147 | Lakelands Nursing and Rehabilitation Center | 6,475.00 NF1061 | Lancaster Health Care | 6,472.00 0730NF | Lexington Medical Center Extended Care | 9,058.00 0878NF | Life Care Center of Charleston | 8,103.00 0634NF | Life Care Center of Columbia | 7,247.00 0725NF | Life Care Center of Hilton Head | 7,410.00 NF1145 | Lila Doyle Post Acute | 8,227.00 NF1117 | Linley Park Post Acute | 8,169.00 NF1057 | Loris Rehab and Nursing Center | 9,450.00 0860NF | Magnolia Manor-Greenville | 6,707.00 0866NF | Magnolia Manor-Greenwood | 7,405.00 0863NF | Magnolia Manor-Inman | 5,834.00 0859NF | Magnolia Manor-Rock Hill | 6,881.00 0867NF | Magnolia Manor-Spartanburg | 6,569.00 NF1135 | Manna Post Acute | 7,722.00 0435NF | Martha Franks Baptist Retirement Center | 8,113.00 NF1136 | McCormick Post Acute | 6,955.00 NF1077 | McCoy Memorial Nursing Center | 6,747.00 0891NF | Medford Nursing Center | 9,135.00 0868NF | Midlands Health and Rehab Center | 7,553.00 NF1066 | Millennium Post Acute Rehab | 9,925.00 291168 | Mountainview Nursing Home | 8,454.00 0895NF | MUSC Health Chester Nursing Center | 8,402.00 NF1010 | MUSC Health Mullins Nursing Center | 8,125.00 262441 | NHC Healthcare-Anderson | 8,456.00 NF1008 | NHC Healthcare-Bluffton | 9,321.00 NF1110 | NHC Healthcare-Charleston | 7,671.00 0601NH | NHC Healthcare-Clinton | 7,810.00 0574NH | NHC Healthcare-Garden City | 7,895.00 0570NH | NHC Healthcare-Greenville | 8,589.00 400227 | NHC Healthcare-Greenwood | 7,767.00 155210 | NHC Healthcare-Laurens | 7,233.00 0629NH | NHC Healthcare-Lexington | 7,873.00 0732NF | NHC Healthcare-Mauldin | 8,238.00 0569NH | NHC Healthcare-North Augusta | 8,067.00 0722NF | NHC Healthcare-Parklane | 8,901.00 0471NH | NHC Healthcare-Sumter | 7,729.00 NF1140 | Oak Harbor Healthcare | 7,275.00 NF1064 | Oak Hollow of Georgetown Rehab Center LLC | 6,430.00 NF1132 | Oak Hollow of Sumter Rehabilitation Center, LLC | 6,955.00 NF1139 | Oak View | 6,510.00 NF1086 | Oakbrook Health and Rehabilitation | 6,916.00 0890NF | Oakhaven Nursing Center | 8,555.00 0952NF | Oakmont East Greenville | 7,338.00 NF1000 | Oakmont of Union SC | 7,424.00 0953NF | Oakmont West Nursing Center | 7,893.00 NF1078 | Opus Post Acute Rehabilitation | 8,363.00 NF1116 | Patewood Post Acute | 8,337.00 NF1068 | Peachtree Centre | 6,955.00 0861NF | Physical Rehabilitation and Wellness Center | 6,999.00 NF1054 | Piedmont Post Acute | 6,044.70 NF1115 | Piedmont Post Acute | 7,736.00 0737NF | Pocotaligo River Health & Rehab Center | 8,744.00 NF1122 | Powdersville Post Acute | 7,988.00 NF1034 | Presbyterian Communities of South Carolina | 7,671.00 0930NF | Prince George Healthcare | 7,329.00 0942NF | Pruitt Health Aiken | 7,483.00 NF1007 | Pruitt Health Bamberg | 9,573.00 NF1011 | Pruitt Health Barnwell | 9,400.00 NF1012 | Pruitt Health Blythewood | 8,802.00 0880NF | Pruitt Health Columbia | 8,528.00 NF1096 | Pruitt Health Conway | 8,424.00 0835NF | Pruitt Health Dillon | 7,081.00 0922NF | Pruitt Health Estill | 7,181.00 0943NF | Pruitt Health Moncks Corner | 8,166.00 NF1004 | Pruitt Health North Augusta | 8,303.00 NF1006 | Pruitt Health Orangeburg | 7,962.00 NF1005 | Pruitt Health Pickens | 8,827.00 0710NF | Pruitt Health Ridgeway | 7,148.00 0836NF | Pruitt Health Rock Hill | 10,373.00 0711NF | Pruitt Health Walterboro | 7,239.00 NF1144 | Resorts at Beaufort | 8,654.00 NF1153 | Rice Estates Rehab and Healthcare | 7,671.00 NF1123 | Ridgeland Nursing and Rehab Center | 6,862.00 NF1087 | Ridgeway Manor Healthcare | 6,654.00 NF1158 | River Falls Post Acute | 7,645.00 0870NF | Riverside Health and Rehab | 6,586.00 NF1071 | Rock Hill Post Acute Care Center | 7,476.00 NF1154 | Rosecrest | 7,671.00 421834 | Saluda Nursing Center | 8,408.00 NF1121 | Sandpiper Post Acute | 7,830.00 NF1109 | Sedgewood Manor Health Care Center LLC | 8,063.00 NF1130 | Seneca Facility LLC | 7,893.00 NF1111 | Senior Care of Marion LLC | 7,671.00 NF1134 | Simpsonville Post Acute | 6,927.00 NF1128 | Southland Health Care Center | 8,394.00 0869NF | Southpointe Healthcare and Rehabilitation | 7,092.00 NF1060 | Spartanburg Health Care LLC | 6,713.00 NF1150 | Sprenger Health Care of Bluffton | 7,671.00 NF1151 | Sprenger Health Care of Port Royal | 7,671.00 0925NF | Springdale Healthcare Center | 6,858.00 NF1082 | St. George Health Care Center | 7,328.00 NF1129 | Sumter East Health & Rehab | 6,921.00 332134 | The Heritage at Lowman Rehab | 7,320.00 NF1131 | The Oaks Healthcare | 8,170.00 NF1127 | The Palms at Florence | 7,596.56 NF1156 | The Reserve Healthcare and Rehab | 8,126.00 271877 | Wesley Commons | 10,357.00 NF1137 | West Village Post Acute | 6,957.00 NF1081 | White Oak at North Grove | 9,369.00 0466NH | White Oak Estates | 8,825.00 0458NH | White Oak Manor-Charleston | 8,625.00 0461NH | White Oak Manor-Columbia | 7,747.00 0508NH | White Oak Manor-Lancaster | 8,225.00 0462NH | White Oak Manor-Newberry | 6,867.00 0459NH | White Oak Manor-Rock Hill | 8,597.00 0460NH | White Oak Manor-Spartanburg | 9,890.00 0565NH | White Oak Manor-York | 8,999.00 0881NF | Wilson Senior Care | 8,001.00 NF1085 | Woodruff Manor | 7,090.00
304 Appendix E Comparison of Applicable Required Elements for Institutional Programs (NH-HCBS-GH)
(Eff. 01/01/26)
Comparison of Applicable Required Elements for Institutional Programs Element | Nursing Home | HCBS | General Hospital 30 Consecutive Day Criteria | Required, UNLESS Medicaid-eligible in another category | Required, UNLESS Medicaid-eligible in another category | Required Look-back; Transfer of Assets Penalty | Applicable | Applicable | Not Applicable Categorical Eligibility | Aged, Blind or Disabled | Aged, Blind or Disabled | Aged, Blind or Disabled Estate Recovery | Applicable | Applicable | Not Applicable Income Limit | Medicaid Cap IF income exceeds the Medicaid Cap, an Income Trust must be established. | Medicaid Cap IF income exceeds the Medicaid Cap, an Income Trust must be established. | Medicaid Cap An Income Trust is not an option. Level of Care | Certification required, UNLESS entering facility under Medicare Sponsorship | Certification required | Level of Care is presumed. Obtaining Other Assets/ Elective Share | Applicable | Applicable | Not Applicable Recurring Income (Cost of Care) | Applicable | Not applicable, UNLESS an Income Trust must be established | Not Applicable Resource Limit | $2,000 $ 9, 950 - IF eligibility can be established under the ABD program. | $2,000 $ 9, 950 - IF eligibility can be established under the ABD program. | $2,000 Spousal Resource Provisions | Applicable | Applicable | Applicable Standard of Promptness | 45 days May be extended to 90 days, IF eligible but a bed is not available. | 45 days May be extended to 90 days, IF eligible but a slot is not available. | 45 days Vendor Payment | Applicable | Not Applicable | Not Applicable
Table of Contents
304 Appendix F Recurring Income (Cost of Care) Allowable Deductions – NH/HCBS Cases
(Eff. 10/01/25)
Allowable Deductions When Calculating Recurring Income Nursing Home Case | HCBS Case Deduction | Standard | Income Trust | Standard | Income Trust Bank Service Charge | Not Applicable | Actual amount – up to $20/mo. | Not Applicable | Actual amount – up to $20/mo. Family Income Allocation | Allowed – (Refer to 304.15.02 .) | Allowed – (Refer to 304.15.02 .) | Not Applicable | Allowed – (Refer to 304.15.02 .) Health Insurance Premiums | Actual amount – IF paid for, and by the beneficiary | Actual amount – IF paid for, and by the beneficiary | Actual amount – IF paid for, and by the beneficiary | Actual amount – IF paid for, and by the beneficiary Home Maintenance Allowance | Actual amount – up to SSI FBR Allowed up to 6 months, IF a physician certifies beneficiary is expected to return home within 6 months | Actual amount – up to SSI FBR Allowed up to 6 months, IF a physician certifies beneficiary is expected to return home within 6 months | Not Applicable | Not Applicable Income Tax Payments | Not Applicable | Allowed once per year, IF owed by the trust, not the beneficiary | Not Applicable | Allowed once per year, IF owed by the trust, not the beneficiary Non-Covered Medical Expenses | Limited amount - deducted by the facility | Limited amount - deducted by the facility | Not Applicable | Limited amount deducted by the eligibility worker Personal Needs Allowance | $ 6 0/mo. or $100/mo.- IF has earnings from Work Therapy | $ 6 0/mo. or $100/mo. - IF has earnings from Work Therapy | Equal to the Medicaid Cap | Equal to the Medicaid Cap Protected Income | Allowed month of entry and/or discharge from a community setting | Not Allowed | Not Applicable | Not Applicable Spousal Income Allocation | Up to a max. of $ 4,066.50 /mo. | Up to a max. of $ 4,066.50 /mo. | Not Applicable | Up to a max. of $ 4,066.50 /mo. Trustee Fee | Not Applicable | $10/mo. | Not Applicable | $10/mo.
Note: Recurring Income is not applicable for General Hospital.
Table of Contents
304 Appendix G Home Equity Procedures Flowchart
(Eff. 01/01/26)
304 Appendix H Waiver Programs Comparison Chart
(Rev. 01/01/20)
Pro g ram | Commun i ty C h o i ces Wa i v er | H IV/ A I D S W a iv er G r oup S er v ed | Med i caid eli g i b le, age 1 8 o r o l d er, & me e ts Nu rsi n g F aci l i t y l e vel o f c a re | Med i caid eli g i b le, any age, d ia g n o sed w i th H I V/A I DS, & me e ts A t - Risk o f H o sp i tali z at i o n l e vel o f c a re Conta c t Ag ency | D HHS /C L TC C entral iz ed I n t ake: 8 88 - 9 7 1 - 1 6 3 7 For e l ec t r o n ic r eferr a l s : h tt p s: / / ph o en i x.scd h h s. gov /clt c _ref e rr a ls/ n ew Level of Ca r e | Nur s ing Faci l ity | A t - R i s k of H o s pitalization Av a il ab l e S er vi ces | Case Management Personal Care I/II Attendant Care Companion Care Home Delivered Meals Nutritional Supplements Adult Day Health Care Adult Day Health Care Transportation Adult Day Health Care Nursing Respite Care Personal Emergency Response System Tele-monitoring Pest Control Home Accessibility Adaptations Residential Personal Care II Specialized medical Equipment & Supplies Enhanced Pest Control | Case Management Personal Care I/II Attendant Care Companion Home Delivered Meals Nutritional Supplements Pest Control Private Duty Nursing Home Accessibility Adaptations Specialized medical Equipment & Supplies Enhanced Pest Control
Pro g ram | Mechanical Ventilator Waiver | Medically Complex Children’s (MCC) Waiver G r oup S er v ed | Med i caid eli g i b le, age 2 1 o r o l d er, req u ires mecha n ical v enti l ation, & me e ts Nu rsi n g F aci l i t y l e vel o f c a re | M e dicaid el i g ibl e , u nd e r age 1 8, m e e ts med i cal cri t eria & A t - Risk o f H o sp i tali z at i o n l e vel o f c are Conta c t Ag ency | D HHS /C L TC C entral iz ed I n t ake: 8 8 8 - 9 7 1 - 1 6 3 7 For e l ec t r o n ic r eferr a l s : h tt p s: / / ph o en i x.scd h h s. gov /clt c _ref e rr a ls/ n ew Level of Ca r e | Nur s ing Faci l ity & d e p e nd e nt on M e cha n ical Ventilation | A t - Risk o f H o sp i tali z at i o n & Med i cal Criter i a Av a il ab l e S er vi ces | Case Management Personal Care I/II Attendant Care Private Duty Nursing Specialized Medical Equipment & Supplies Respite Care Personal Emergency Response System Home Accessibility Adaptations Pest Control Home Delivered Meals Nutritional Supplements Enhanced Pest Control | Care Coor d i nation Pediatric M e dical Day C a re
Pro g ram | Intellectual Disabilities & Related Disabilities (ID/RD) Waiver | Head & Spinal Cord Injuries (HASCI) Waiver G r oup S er v ed | M e dicaid e li g ibl e , a ll ag e s , w ith intel le ctual or r e lat e d d i s a b il i t y , & m ee t s IC F /I I D l e v e l o f care | M e dicaid el i g ible, a ge 0 -65 , w ith h e ad or s pinal cord inj u r y , or s i m ilar di s a b il i ty ,& m ee t s N ur s ing Faci l ity or IC F /IID l e v e l o f care Conta c t Ag ency | BH DD-OIDD Sing l e Point of E ntry 1-80 0 - 2 8 9 - 7 012 (tol l -f r e e ) Level of Ca r e | IC F/ IID | Nur s ing Faci l ity or IC F/ I I D Av a il ab l e S er vi ces | Personal Care I/II Residential Habilitation Environmental Modifications Private Vehicle Modifications Private Vehicle Assessment/Consultation Specialized Medical Equipment, & Assistive Technology Specialized Medical Equipment, & Assistive Technology Assessment/ Consultation Incontinence Supplies Respite Care Audiology Services Adult Companion Services Nursing Services Adult Dental Adult Vision Adult Day Health Care Adult Day Health Care Nursing Adult Day Health Care Transportation Adult Attendant Care Behavior Support Services Career Preparation Employment Services Day Activity Community Services Support Center Services Personal Emergency Response System Pest Control Waiver Case Management | Career Preparation Day Activity Employment Services Attendant Care/Personal Assistance Health Education for Consumer Directed Care Peer Guidance for Consumer Directed Care Residential Habilitation Supplies, Equipment & Assistive Technology Incontinence Supplies Respite Care Personal Emergency Response System Physical Therapy Occupational Therapy Psychological Services Behavior Support Services Nursing Services Speech and Hearing Private Vehicle Modifications Environmental Modifications Assistive Technology Consultation Vehicle Modification Consultation Pest Control Waiver Case Management
Pro g ram | Community Supports (CS) Waiver G r oup S er v ed | Med i caid eli g i b le, all a g es, with intel le ctual o r rel a ted d isa b i l ity, & me e ts IC F /I I D l e v el o f ca r e Conta c t Ag ency | BHDD-OIDD Si n g le P o i n t o f Ent r y 1 - 8 0 0 - 2 8 9 - 7 0 1 2 ( t o ll - fr e e) Level of Ca r e | IC F /I I D Av a il ab l e S er vi ces | Personal Care I/II Adult Day Health Care Adult Day Health Care Nursing Adult Day Health Care Transportation Respite Care Environmental Modifications Assistive Technology and Appliances Assistive Technology and Appliances Assessment/Consultation Incontinence Supplies Private Vehicle Modifications Private Vehicle Assessment/Consultation Behavior Support Services Day Activity Services Career Preparation Services Community Services Employment Services Support Center Services In-Home Support Personal Emergency Response System Waiver Case Management
304 Appendix I Look-back Procedures for ABD Applicants
(Rev. 09/01/22)
For Nursing Home or Home and Community Based Services (HCBS) applicants who are current Medicaid beneficiaries in the Aged, Blind and Disabled Category (ABD), the DHHS Form 3400-B may be used to expedite the look-back process. The completed form must be submitted by the applicant before an eligibility determination can be made.
Procedure ABD Eligible NH and HCBS Applicants: If the individual is receiving Medicaid benefits as an ABD beneficiary, the individual should complete the DHHS Form 3400-B , Additional Information for Nursing Home and In-Home Care A look-back is required to determine if the beneficiary’s self-reported information indicates a sanctionable transfer occurred during the 60 months preceding the date of application. (For more information about look-backs refer to MPPM 304.09.02C.) Review the DHHS Form 3400-B for any transfers If no transfers are alleged, Create an AVS request for the current month and for the three months prior to the request. Complete a property check. Include a check in Probate court if an inheritance is indicated in the past five years. Refer to Procedure – Conducting a Look-back in MPPM 304.09.02C. If a potential transfer is indicated, create an AVS request for the period when the transfer may have occurred and a property check. Request any additional information needed to evaluate the alleged transfer If the beneficiary is eligible, with no sanctionable transfers, approve the application. If the beneficiary is eligible, but has any transfers that do not meet exclusion criteria, follow MPPM policies and procedures to impose penalty If the beneficiary is not eligible, deny the application Following the notification of NH or HCBS approval, SC DHHS will send the applicant a DHHS Form 3229 , Notice of Cost of Care , which lists the amount of the applicant’s cost of care and any payments due
304 Appendix J Phoenix Procedures
(Eff. 07/01/24)
Nursing Home New Applicant Phoenix Procedure (Pilot Sites ONLY) WORKER | TASK | PROCEDURE APPLICANT, PROVIDER, OR ELIGIBILITY WORKER | REFERRAL | A referral for Nursing Home (NH) Level of Care (LOC) is submitted by an applicant, provider, or eligibility worker to CLTC. The referral is submitted through the Phoenix system at the following website: https://phoenix.scdhhs.gov/cltc_referrals/new After submitting a Phoenix referral, the applicant is assigned a reference number. The reference number is a unique CLTC client identifier. The reference number should be recorded on the Tracking Form for future use but is only needed to check a referral’s status that does not appear in Eligibility Workflow. If a referral is made by an eligibility worker, the eligibility worker will send the appropriate forms to the applicant and document the referral in Cúram and OnBase. If a referral is not made by an eligibility worker, the worker may locate the referral in the Phoenix dashboard daily check. The eligibility worker will send the appropriate forms to the applicant and document the referral in Cúram and OnBase. NOTE The Request for Assessment of Level of Care, DHHS Form 1231, is obsolete and must not be used. REMEMBER Phoenix must be used in the Google Chrome web browser. CLTC NURSE | FORMS AND INTAKE | CLTC receives the referral through centralized intake, and the referral is assigned to a nurse consultant. The nurse contacts the client to complete the appropriate forms. The CLTC worker inserts information in Phoenix’s NF Active Workflow. The eligibility worker sends the applicant the appropriate forms if the applicant is awaiting an application. CLTC NURSE | LOC DECISION | The CLTC worker determines the LOC. ELIGIBILITY WORKER | ELIGIBILITY DECISION | The eligibility worker conducts a look-back to determine if the applicant is financially eligible. The eligibility worker will check the Phoenix’s Active NF Workflow for updates to active and pending cases on a daily basis. The following events would trigger a necessary update by the eligibility worker: LOC submission, NF admittance, NF discharge, Medicare co-insurance, Medicaid conversion, Medicaid bed hold, and recurring income changes. In the comments section, the worker must update when the following actions occur: when an application is received, when an application is not received, and when financial eligibility is determined in Phoenix, Cúram , and OnBase. If an application is not received within 45 days, the worker should enter a comment to deny the application in Phoenix. PROVIDER | UPDATE | The Provider will post in Phoenix when an event triggers a necessary update.
Nursing Home (NH) Phoenix Procedure for Aged, Blind, Disabled (ABD) Recipients WORKER | TASK | PROCEDURE APPLICANT, PROVIDER, OR ELIGIBILITY WORKER | REFERRAL | A referral for Nursing Home (NH) Level of Care (LOC) is submitted by an applicant, provider, or eligibility worker to CLTC. The referral is submitted through the Phoenix system at the following website: https://phoenix.scdhhs.gov/cltc_referrals/new After submitting a Phoenix referral, the applicant is assigned a reference number. The reference number is a unique CLTC client identifier. The reference number should be recorded on the Tracking Form for future use, but is only needed to check a referral’s status that does not appear in Eligibility Workflow. If a referral is made by an eligibility worker, the eligibility worker will send the appropriate forms to the applicant, and document the referral in OnBase and Cúram . If a referral is not made by an eligibility worker, the worker will receive notification that a referral has been created. The worker should conduct a name search and document information in OnBase and Cúram . NOTE The Request for Assessment of Level of Care, DHHS Form 1231, is obsolete and must not be used. REMEMBER Phoenix must be used in the Google Chrome web browser. CLTC NURSE | FORMS AND INTAKE | CLTC receives the referral through centralized intake, and the referral is assigned to a nurse. The nurse contacts the client to complete the appropriate forms. The CLTC worker inserts information in Phoenix’s Active Workflow. The eligibility worker sends the applicant the appropriate forms if the applicant is awaiting an application. DHHS Form 3400-D, Statement of Transfer of Assets, is used for ABD beneficiaries only. DHHS Form 3400-D may be distributed by the eligibility worker when a request for LTC services is received or by CLTC’s initial assessment by phone or home visit. CLTC SCANNER | SCAN DHHS Form 3400-D | The scanner scans DHHS Form 3400-D into Phoenix. The form must be signed by the applicant or the Authorized Representative. CLTC NURSE | LOC DECISION | The CLTC worker determines the LOC. ELIGIBILITY WORKER | ELIGIBILITY DECISION | The eligibility worker conducts an expedited look-back as described in MPPM 304, Appendix I. The eligibility worker will check the Dashboard’s Active NF Workflow tab for updates to active and pending cases on a daily basis. The following events would trigger a necessary update by the eligibility worker: LOC submission, NF admittance, NF discharge, Medicare co-insurance, Medicaid conversion, Medicaid bed hold, and recurring income changes. In the comments section, the worker must update when an application is received, an application is not received, and financial eligibility is determined. If an application is not received within 45 days, the worker should enter a comment to deny the application in Phoenix. PROVIDER | UPDATES | The Provider will post in Phoenix when an event triggers a necessary update.
Community Long Term Care (CLTC) Phoenix Procedure for New Medicaid Applicants WORKER | TASK | PROCEDURE APPLICANT, PROVIDER, OR ELIGIBILITY WORKER | REFERRAL | A referral for Community Long Term Care (CLTC) services is entered into the Phoenix by an applicant, provider, or eligibility worker on behalf of an applicant who wishes to apply for CLTC services. The referral is submitted through the Phoenix system at the following website: https://phoenix.scdhhs.gov/cltc_referrals/new NOTE DHHS Form 1231, Request for Assessment of Level of Care, is obsolete and must not be use d REMEMBER Phoenix must be used in the Google Chrome web browser. CLTC INTAKE WORKER | PHONE ASSESSMENT | A phone assessment is conducted between the applicant and the CLTC Intake Worker. If the applicant is not receiving Medicaid services and appears to meet the LOC requirements, the CLTC worker sends DHHS Form 3401, Application for Nursing Home, Residential, or In-Home Care, to the applicant, and documents that they provided the necessary forms in the Phoenix Dashboard. If the applicant does not appear to meet the LOC requirements, the CLTC worker documents that the applicant does not meet the LOC criteria in the Phoenix Dashboard. The case should not be added to the Eligibility Workflow. CLTC NURSE | HOME ASSESSMENT | For applicants who appear to be medically eligible, the CLTC Nurse conducts a home assessment to determine if the applicant meets the LOC. If the applicant is not receiving Medicaid services and meets the LOC, the nurse asks the applicant if DHHS Form 3401 was submitted to SCDHHS. If the applicant has not submitted DHHS Form 3401, the nurse will issue a new DHHS Form 3401 and/or assist the applicant with completion of the form if needed. The nurse should document that she provided and/or assisted with completion of DHHS Form 3401 in the Phoenix Dashboard. ELIGIBILITY WORKER | ELIGIBILITY DECISION | After retrieving a case from the Phoenix Dashboard, the eligibility worker reviews the case, and determines the applicant’s eligibility. If the applicant meets the LOC, the eligibility worker: Reviews the documents in OnBase; Conducts a look-back to determine if the applicant is financially eligible; Assesses whether the applicant meets all other LTC eligibility criteria; Completes the eligibility determination in Phoenix, Cúram , and OnBase; Notifies CLTC of the applicant’s status by documenting the eligibility status in Phoenix. If the applicant does not meet the LOC and the eligibility worker created the referral, the worker must document that the applicant does not meet the LOC criteria in Phoenix, Cúram , and OnBase, and deny the case. NOTE DHHS DHHS Form 118, Client Status Document (CSD), is no longer valid as of 1/1/2014. CLTC WORKER | SERVICES BEGIN | Once the eligibility worker notifies CLTC of the applicant’s tentative approval in Phoenix, CLTC services begin. A final approval determination will not occur until 30 days after services begin. The CLTC worker should document the start date as a Phoenix Comment. The start date for services occurs when the applicant enters the HCBS waiver. This action is completed after the LOC is determined and the financial eligibility status is approved. ELIGIBILITY WORKER | UPDATES | The eligibility worker checks the Phoenix Enrollment Tab to confirm the applicant has met the 30-day requirement for CLTC services. Once confirmed, the eligibility worker approves the case in OnBase and Cúram .
Community Long Term Care (CLTC) Phoenix Procedure for Aged, Blind, Disabled (ABD) Recipients WORKER | TASK | PROCEDURE APPLICANT, PROVIDER, OR ELIGIBILITY WORKER | REFERRAL | A referral for Community Long Term Care (CLTC) services is entered into the Phoenix by an applicant, provider, or eligibility worker on behalf of an applicant, who wishes to apply for CLTC services. The referral is submitted through the Phoenix system at the following website: https://phoenix.scdhhs.gov/cltc_referrals/new NOTE The Request for Assessment of Level of Care, DHHS Form 1231, is obsolete and must not be used. REMEMBER: Phoenix must be used in the Google Chrome web browser. CLTC INTAKE WORKER | PHONE ASSESSMENT | A phone assessment is conducted between the applicant and the CLTC Intake Worker. If the ABD beneficiary is likely to meet the Level of Care (LOC), the worker will add the case to Phoenix, add the case to the Eligibility workflow, and send the appropriate application and addendum. An ABD beneficiary should complete DHHS Form 3400-B, Additional Information for Nursing Home and In-Home Care. Once the phone assessment is complete, CLTC services for the ABD beneficiary begin. CLTC NURSE | HOME ASSESSMENT | For applicants who appear to be medically eligible, the CLTC nurse conducts a home assessment to determine if the applicant meets the LOC. If the applicant is an ABD beneficiary and meets the LOC, the nurse conducts the following actions: Asks the applicant if DHHS Form 3400-B was submitted to SCDHHS. If the applicant has not submitted DHHS Form 3400-B, the nurse will issue a new DHHS Form 3400-B and/or assist the applicant with completion of the form if needed, Assists in completing and signing DHHS Form 3400-D, and Documents that she provided assistance with the completion of DHHS Form 3400-B in the Phoenix Dashboard. CLTC SCANNER | SCAN | The CLTC scanner scans DHHS Form 3400-D into Phoenix. ELIGIBILITY WORKER | ELIGIBILITY DECISION | After retrieving a case from the Phoenix Dashboard, the eligibility worker reviews the case, and determines the applicant’s eligibility. If the applicant meets the LOC, the eligibility worker: Reviews the documents in OnBase; Assesses whether the applicant meets all other LTC eligibility criteria; Completes the eligibility determination in Phoenix, Cúram , and OnBase; Notifies CLTC of the applicant’s status by documenting the eligibility status in Phoenix. If the applicant does not meet the LOC and the eligibility worker created the referral, the worker must document that the applicant does not meet the LOC criteria in Phoenix, Cúram , and OnBase, and deny the case. If the applicant is already receiving Medicaid benefits, the applicant is given 30 days to return DHHS Form 3400-B/3401. If the applicant returns DHHS Form 3400-B/3401 within 30 days, the eligibility worker should click the “Receive Application” button on the Phoenix Dashboard. If the applicant does not return DHHS Form 3400-B/3401 within 30 days, the eligibility worker should click the “Close Workflow” button on the Phoenix Dashboard. NOTE DHHS DHHS Form 118, Client Status Document (CSD), is no longer valid as of 1/1/2014. CLTC WORKER | SERVICES BEGIN | Once the eligibility worker notifies CLTC of the applicant’s tentative approval in Phoenix, CLTC services begin. A final approval determination will not occur until 30 days after services begin. The CLTC worker should document the start date as a Phoenix Comment. The start date for services occurs when the applicant enters the HCBS waiver. This action is completed after the LOC is determined and the financial eligibility status is approved. ELIGIBILITY WORKER | UPDATE | The eligibility worker checks the Phoenix Enrollment Tab to confirm the applicant has been enrolled in CLTC services. Once confirmed, the eligibility worker approves the case in Cúram and OnBase. The 30-day requirement does not apply to ABD beneficiaries.
304 Appendix K Determining a Reasonable Rate of Interest for Promissory Notes
(Eff. 11/01/23)
For a Promissory Note to meet the requirements of being actuarially sound, a loan/note must call for a reasonable rate of interest. Use the following instructions to determine if the interest indicated in the terms of the loan/note meet the reasonable rate of interest requirement.
The Applicable Federal Rate (AFR) is used by the IRS as a point of comparison to determine the minimum interest rate for loans between related parties, such as family members. These rates change monthly.
Select the IRS hyperlink https://apps.irs.gov/app/picklist/list/federalRates.html,
Identify the month and year the Promissory Note was created and select the time frame.
Less than or equal to three years—Short-term
Greater than three and less than or equal to nine years—Mid-term
Greater than nine years—Long-term.
Determine how the interest is compounded - annually, semi-annually, quarterly, or monthly. This information can be found in the terms of the loan agreement/note.
Go to the appropriate section based on the term length of the loan and use the 100% AFR figures for the corresponding column that identifies the period of interest compounded.
Example Promissory Note was created on 03/11/2018. The term of repayment is 6 years, and the interest is compounded monthly. The reasonable rate of interest for these specifications is 2.54%. Note Short-Term loans/notes are bonds with maturity dates that are 3 years or less. Mid-term loans/notes are bonds with maturity dates that are 3 to 9 years. Long-term loans/notes are bonds with maturity dates that are more than 9 years.