24.04 Allowable deductions from patient-share

Income deductions. When determining the actual patient share payable by an individual, the following are deducted from the individual’s gross income: SSI/AABD, AABD only and Reach Up benefit payments still being received when the person first enters long-term care; SSI/AABD payments intended to be used to maintain the community residence of an individual temporarily (not to exceed 3 months) in an institution; Austrian Reparation Payments; German Reparation Payments; Japanese and Aleutian Restitution Payments; Payments from the Agent Orange Settlement Fund; Radiation Exposure Compensation; and VA payments for aid and attendance paid to a veteran residing in a nursing facility or to the veteran’s surviving spouse residing in a nursing facility. Other deductions. The following items are then deducted from the individual’s patient share in the following order: A personal-needs allowance (PNA) or community-maintenance allowance (CMA) (see paragraph (c) of this subsection); Home-upkeep expenses, if applicable (see paragraph (d) of this subsection); Allocations to a community spouse or maintenance needs of family members living in the community, if applicable (see paragraph (e) of this subsection); and Reasonable medical expenses incurred, if applicable (see §§ 30.05 and 30.06). For the purposes of this paragraph (b)(4), “reasonable medical expenses” do not include expenses for long-term care services and supports received during penalty periods for Medicaid coverage of long-term care services and supports. Special Rules for Medicaid Coverage of Long-Term Care Services and Supports – Eligibility and Post Eligibility Part 4 – Page 5 (Sec.24.00, Sub.24.04) NOTE: Unpaid patient-share obligations may not be used to reduce a current patient share obligation. Personal-needs allowance and community-maintenance allowance. A reasonable amount for clothing and other personal needs of an individual is deducted from their monthly income, as follows: For an individual receiving Medicaid coverage of long-term care services and supports in an institutional setting, a standard personal needs deduction (PNA)2 is applied. For an individual receiving Medicaid coverage of long-term care services and supports in a home and community-based setting, a standard community maintenance deduction (CMA)3 is applied. (NOTE: Unlike the individual in the institutional setting whose room and board is covered by Medicaid, an individual receiving long-term care services and supports in a home and community-based setting has a higher deduction to provide a reasonable amount for food, shelter, and clothing to meet their personal needs.) Home-upkeep deduction Expenses from the monthly income of an individual receiving Medicaid coverage of long-term care services and supports in an institution or receiving enhanced residential care (ERC) services in a residential care home are deducted to help maintain their owned or rented home in the community. This deduction is allowed for six months. It is available for each separate admission to long-term care, as long as the criteria listed below are met. The home-upkeep standard deduction is three-fourths of the SSI/AABD payment level for a single individual living in the community. The home-upkeep deduction is granted when the individual has income equal to or greater than the standard home-upkeep deduction and greater than their PNA. An individual who has less income than the standard home-upkeep deduction may deduct an amount for home upkeep equal to the difference between the individual’s income and the PNA. (i) The home-upkeep deduction may be applied at any point during the individual’s institutionalization or receipt of ERC services, as the case may be, as long as both of the following criteria for the deduction are met: No one resides in the individual’s home and receives an allocation as a community spouse or other eligible family member; and The individual submits a doctor’s statement before the six-month deduction period, stating that the individual is expected to be discharged from the institution or ERC setting within six months and to return home immediately after discharge. (ii) If the situation changes during the period the individual is receiving the home-upkeep deduction, the 2 For the current PNA, see Vermont’s Eligibility Standards for Healthcare Programs on the Department of Vermont Health Access website. 3 For the current CMA, see Vermont’s Eligibility Standards for Healthcare Programs on the Department of Vermont Health Access website. Special Rules for Medicaid Coverage of Long-Term Care Services and Supports – Eligibility and Post Eligibility Part 4 – Page 6 (Sec.24.00, Sub.24.04) individual’s eligibility for the deduction is redetermined. The deduction is denied or ended when: The individual’s home is sold or rented; The rented quarters of the individual are given up; or The individual’s health requires the long-term care admission period to last longer than six months. Allocations to family members An individual is allowed to allocate their income to certain family members as described in this paragraph. Allocation to community spouse (i) If an individual receiving Medicaid coverage of long-term care services and supports (the institutionalized spouse) has a spouse living in the community (the community spouse), an allocation may be deducted from the institutionalized spouse’s income for the needs of the community spouse. The term “community spouse” applies to the spouse of the institutionalized spouse even if the community spouse is also receiving Medicaid coverage of long-term care services and supports in a home and community-based setting. When one spouse is receiving Medicaid coverage of long-term care services and supports in an institutional setting and the other is receiving Medicaid coverage of long-term care services and supports in a home and community- based setting, the spouse receiving home and community-based services and supports may receive an allocation. When both spouses are receiving home and community-based services and supports, either may allocate to the other. (ii) “Assisted living” is considered a community setting and not an institutional setting provided that assisted living does not include 24-hour care, has privacy, a lockable door, and is a homelike setting. If the spouse of an institutionalized spouse is living in an assisted living setting, they are considered a community spouse for purposes of the community spouse income allocation. (iii) An institutionalized spouse may allocate less than the full amount of the allocation to their community spouse or may allocate nothing. The allocation is reduced by the gross income, if any, of the community spouse. A community spouse, as well as an institutionalized spouse, has a right to request a fair hearing on the amount of the allocation. (iv) The standard community spouse income allocation equals 150 percent of the FPL for two. The actual community spouse income allocation equals the standard allocation plus any amount by which actual shelter expenses of the community spouse exceed the standard allocation, up to a maximum amount. The maximum community spouse income allocation equals a maximum provided by the federal government each year by November 1st. (v) The presumptions set forth below are applied to the ownership interests in income when determining a community spouse’s community spouse income allocation unless the institutionalized spouse establishes by a preponderance of the evidence that the ownership interests are other than as presumed. Income paid in the name of one spouse is presumed available only to the named spouse. Special Rules for Medicaid Coverage of Long-Term Care Services and Supports – Eligibility and Post Eligibility Part 4 – Page 7 (Sec.24.00, Sub.24.04) Income paid in the name of both spouses is presumed available in equal shares to each spouse. Income paid in the name of either spouse and any other person is presumed available to that spouse in proportion to their ownership interest. Income paid in the name of both spouses and any other person is presumed available to each spouse in an amount of one-half of the joint interest. Allocation to other family members (i) A deduction from the individual’s income is allowed for the maintenance needs of certain other family members. If the individual has no community spouse living in the home, the countable resources of any such family member cannot exceed the community spouse resource allocation (CSRA) minimum.4 If the individual has a community spouse living in the home, there is no limit on the amount of countable resources of any such family member. For purposes of this deduction, a family member must be: A child of either the individual or the individual’s spouse under age 18; or A child age 18 or older, parent, or sibling of either the individual or the individual’s spouse who is dependent on the individual or spouse. For the purposes of this subparagraph, a family member is considered dependent if they meet each of the following three criteria: (I) They have been or will be a member of the household of the individual or their spouse for at least one year; (II) More than one half of their total support is provided by the individual or the individual’s spouse; and (III) They have gross annual income below $2,500 or are a child of the individual (or spouse) under age 19 or under age 24 and a full-time student during any five months of the tax year. (ii) Deduction for family members living with the community spouse. When family members live with the community spouse of the individual receiving Medicaid coverage of long-term care services and supports, the deduction equals the maintenance income standard reduced by the gross income of each family member and divided by three. The resulting amount is the maximum allocation that may be made to each family member. (iii) Deduction for family members not living with the community spouse. When family members do not live with the community spouse of the individual receiving Medicaid coverage of long-term care services and supports, the deduction equals the applicable PIL for the number of family members living in the same household, reduced by the gross income, if any, of the family members in the household. (iv) The family members described above may be required to apply for SSI, AABD or Reach Up, as 4 For the current CSRA minimum, see Vermont’s Eligibility Standards for Healthcare Programs on the Department of Vermont Health Access website. Special Rules for Medicaid Coverage of Long-Term Care Services and Supports – Eligibility and Post Eligibility Part 4 – Page 8 (Sec.24.00, Sub.24.05) long as this would not disadvantage them financially.