29.04 Formation of the Medicaid group

In general. The Medicaid group consists of individuals whose needs are included in the financial eligibility determination for MABD. The following paragraphs set forth the rules for determining membership in the Medicaid group. AHS compares countable income and resources of the financial responsibility group to maximums based on the size of the Medicaid group. Medicaid group for a single adult. A single adult requesting MABD, including Medicaid coverage of long-term care services and supports under MABD, is treated as a Medicaid group of one. Medicaid group for an adult with a spouse When spouses are living together, both the individual requesting MABD and the individual’s spouse are considered members of the individual’s Medicaid group, a Medicaid group of two, unless one of the exceptions specified in paragraph (d) of this subsection applies. This is true whether or not the individual’s spouse is also requesting MABD. Spouses are considered living together in any of the following circumstances: (i) Until the first day of the month following the calendar month of death or separation, when one spouse dies or the couple separates. (ii) When one spouse is likely to need long-term care for fewer than 30 consecutive days. (iii) When the resources of the couple are assessed and allocated as of the date of initial application for Medicaid coverage of long-term care services and supports under MABD. Exceptions for an adult with a spouse. An adult requesting MABD with a spouse is treated as a Medicaid group of one in the following circumstances: When one spouse is applying for Medicaid coverage of long-term care services and supports under MABD, they are considered a Medicaid group of one for: (i) The determination of their initial and ongoing income eligibility; and (ii) Resource reviews of their eligibility. Financial Methodologies Part 5 – Page 13 (Sec.29.00, Sub.29.05) (iii) AHS considers the spouses to be no longer living together as of the first day of the calendar month one spouse begins receiving Medicaid coverage of long-term care services and supports under MABD. This remains true even if the other spouse begins receiving Medicaid coverage of long-term care services and supports in a subsequent month. When AHS determines the eligibility of one spouse for MABD when the other spouse already receives Medicaid coverage of long-term care services and supports in a home and community-based setting. When both spouses are admitted to the same residential care home, each spouse is considered a Medicaid group of one if the residential care home is designed for four or more residents. When both spouses have been admitted to the same institution for long-term care in the same month and have lived there at least six months beginning with the first month following the month of their admission, for purposes of determining each spouse’s eligibility for Medicaid coverage of long-term care services and supports under MABD, each spouse is considered a Medicaid group of one for the determination of their initial and ongoing income eligibility and resource reviews of their eligibility. However, if it works to their advantage, they may be considered a Medicaid group of two. When one spouse is receiving custodial care in their home, as defined in AABD Rule 2766, they are considered a Medicaid group of one. Medicaid group for a child A child requesting MABD is treated as a Medicaid group of one. When a parent and child living together are both requesting MABD, they are treated as two Medicaid groups of one, if the parent is not living with a spouse. If the parent is living with a spouse, the parent and their spouse are treated as a Medicaid group of two and the child as a Medicaid group of one.