H-4100, Individual and Couple Cases

Revision 24-1; Effective March 1, 2024

After determining eligibility, calculate a co-payment for a person or couple living in an institutional setting.

The total countable income for the co-payment budget may be different from the total countable income for the eligibility budget. Refer to H-1200, Income That Is Not Used in the Co-Payment.

When determining the co-payment, consider the following:

HHSC nets the person's and spouse's earned income each month by subtracting the following mandatory payroll deductions:

  • Income tax
  • Social Security tax
  • Required retirement withholdings
  • Required uniform expenses

Due to automation limitations and requirements, special treatment for the co-payment occurs when the person:

  • receives certain Department of Veterans Affairs (VA) benefits; or
  • does not have vendor payment coverage due to a transfer penalty or a substantial home equity disqualification.

People whose VA benefits are capped at $90 per month keep the full $90 as a personal needs allowance (PNA).

The VA pension amount for an institutionalized Medicaid recipient without a spouse or child (or in the case of a surviving spouse, no child) cannot exceed $90 per month. Do not use the $90 VA pension to determine how much a person in an institutional setting must pay to the facility toward the cost of care. Do not count the limited VA pension, up to the amount of $90, as income in the eligibility or co-payment budget. There is no interaction between the reduced pension and the PNA. If the veteran has income from other sources, the income from other sources may be considered countable for co-payment purposes. HHSC performs the co-payment calculations to determine the amount of the veteran’s liability toward the cost of care.

The VA $90 capped pension is included in the PNA calculation in the system.

  • For a non-SSI Medicaid recipient in an institutional living arrangement who does not have a VA pension capped at $90 per month, the total PNA will be up to the current maximum of $75.
  • For a non-SSI Medicaid recipient in an institutional setting who has a VA pension capped at $90 per month, the total PNA may be up to $165 ($90 VA plus up to $75 PNA).
  • For a Medicaid recipient living in an ICF-IID facility, the $90 VA capped pension and PNA calculation do not impact the protected earned income allowance.

If the veteran does not have another source of income to deduct the $75 PNA from, the PNA is the VA $90 capped pension, and the co-payment is zero. If the veteran’s other source of income is less than $75, the PNA is $90 plus the amount of other income, not to exceed $75. The PNA deduction comes first in the order of all co-payment deductions, including those for incurred medical expenses (IMEs).

Note: Refer to E-4300, VA Benefits, for treatment of payments from the Department of Veterans Affairs. Refer to E-4311.2, $90 VA Pension and Institutional Setting, for automation limitations and the VA $90 capped pension.

If the person is eligible for Medicaid but has a transfer of assets penalty or a substantial home equity disqualification, follow Appendix XXIII, Procedure for Designated Vendor Number to Withhold Vendor Payment. For policy information on transfer penalties and substantial home equity disqualifications, refer to the following:

  • Chapter I, Transfer of Assets
  • F-3600, Substantial Home Equity
  • F-3610, Persons Impacted by Substantial Home Equity Disqualification
  • F-3620, Persons Not Impacted by Substantial Home Equity Disqualification
  • F-3630, When the Equity Value is Greater Than the Limit
  • F-3640, Reverse Mortgage or Home Equity Loan
  • F-3650, Documentation
  • F-3660, Undue Hardship

Use the following budget steps to determine the co-payment for a person or couple.

Step 1. Determine the person's monthly net earned and gross unearned income.

Notes:

  • VA aid and attendance benefits, housebound allowances, and reimbursements for unusual or continuing medical expenses are exempt from both eligibility and co-payment. However, if these payments are deposited into a qualifying income trust (QIT) account, they are countable for co-payment.
  • Do not consider child support as a deduction from a person’s co-pay if it is withheld from unearned income because of garnishment. Refer to E-1400, Garnishment or Seizure.

Step 2. Add net earned and gross unearned income.

Step 3.

Individual Budget

Subtract the personal needs allowance of $75 from available income for an individual budget. Subtract the guardian fee allowance and the Medicare Part B premium, if applicable. Subtract incurred medical expenses. Subtract the home maintenance allowance, if applicable. The remainder is the co-payment.

Couple Budget

Subtract the personal needs allowance of $150 from the combined available income for a couple budget. Subtract the guardian fee allowance and the Medicare Part B premium, if applicable. Subtract incurred medical expenses. Subtract the home maintenance allowance, if applicable. Divide the remainder by 2 to determine the co-payment for each spouse.