Revision 19-4; Effective December 1, 2019
Revision 12-2; Effective June 1, 2012
The following is taken from Subchapter C, Financial Requirements, Division 6, Budgeting for Eligibility and Co-Payment.
§358.438. Determination of Co-payment.
(a) After a person or couple in an institutional setting is determined eligible for a Medicaid-funded program for the elderly and people with disabilities, the Texas Health and Human Services Commission (HHSC) determines the person's or couple's co-payment in accordance with:
(1) Section 1902(a)(17) of the Social Security Act (42 U.S.C. §1396a(17)), relating to the general authority;
(2) Section 1902(a)(50) and (q) of the Social Security Act (42 U.S.C. §1396a(50) and (q)), relating to personal needs; and
(3) Section 1924 of the Social Security Act (42 U.S.C. §1396r-5), relating to institutionalized spouses with community spouses.
(b) To determine the co-payment for a person or couple in an institutional setting, HHSC follows 42 CFR §§435.725, 435.726, and 435.735, including the optional deduction for a home maintenance allowance for a person or couple described in 42 CFR §435.725(d).
(c) To determine the co-payment for a person or couple receiving services under the Program of All-Inclusive Care for the Elderly (PACE) in a PACE setting, HHSC follows §1934(i) of the Social Security Act (42 USC §1396u-4(i)).
(d) HHSC follows §1924(d) of the Social Security Act (42 U.S.C. §1396r-5(d)), concerning the protection of income for the community spouse, to determine the minimum monthly maintenance needs allowance, and to determine an institutionalized spouse's co-payment.
§358.439. Guardianship Fee.
In determining the co-payment for a person receiving services in an institutional setting, the Texas Health and Human Services Commission (HHSC) may deduct a guardianship fee, if any, up to an amount set by the court, from the person's total countable income.
(1) The deduction is limited to guardianship-related costs and fees, subject to the limitations of §32.02451 of the Texas Human Resources Code, Section 670 of the Texas Probate Code, and this section, as determined by HHSC.
(2) HHSC deducts the guardianship-related costs and fees from total countable income after deducting the personal needs allowance, but before deducting any other allowances.
(3) The deduction is effective the later of:
(A) the month the judge signs the court order awarding guardianship-related costs and fees;
(B) the first month of eligibility for which the person has a co-payment; or
(C) the first day of the month that the applicant or recipient provides HHSC with a copy of the court order awarding the guardianship-related costs and fees.
(4) HHSC does not deduct any amount of guardianship-related costs and fees awarded before the date the court order was signed. The deduction is prospective only.
(5) HHSC does not deduct a guardianship establishment fee unless a new guardian is named in the most recent court order.
(6) HHSC does not deduct any guardianship-related costs and fees ordered after the recipient has died.
(7) To receive the deduction, an applicant or recipient must provide a copy of the court order to HHSC no later than the date specified by HHSC. No deduction will be given until the applicant or recipient provides HHSC with a copy of the court order awarding the guardianship-related costs and fees by submitting the court order as specified by HHSC.
(8) The deduction authorized by this section is limited to a guardianship of the person. No deductions are allowed for any other type of guardianship.
§358.440. Dependent Allowance.
(a) In determining a person's co-payment, the Texas Health and Human Services Commission (HHSC) may deduct a dependent allowance from a person's total countable income.
(1) For a person with at least one dependent relative at home, HHSC allows the individual Social Security Income (SSI) federal benefit rate for each dependent relative and deducts the individual SSI federal benefit rate from the dependent relative's countable income.
(2) For a person with a spouse and at least one dependent relative at home, when spousal impoverishment provisions apply, HHSC determines the dependent allowance in accordance with 42 U.S.C. §1396r-5.
(b) The amount of the dependent allowance may be appealed based on undue hardship caused by financial duress as determined by HHSC, in accordance with HHSC's fair hearing rules in Chapter 357 of this title (relating to Hearings).
§358.441. Payroll Deductions.
(a) In determining a person's co-payment, the Texas Health and Human Services Commission (HHSC) calculates earned income each month by subtracting the following mandatory payroll deductions:
(1) income tax;
(2) social security tax;
(3) required retirement withholding; and
(4) required uniform expenses.
(b) After a person or couple in an institutional setting is determined eligible, HHSC applies the payroll deductions described in subsection (a) of this section to:
(1) an applicant or recipient;
(2) an applicant's or recipient's spouse; and
(3) a dependent relative of either spouse.
Revision 18-1; Effective March 1, 2018
Determine the copayment for a Medicaid eligible individual or couple residing in an institution, receiving services under the Program of All Inclusive Care for the Elderly (PACE) in a PACE setting, or receiving services under a Home and Community Based Waiver program.
When determining the copayment, consider the total income available to the individual from all sources. Certain payments that are not income and certain exempt income are not considered in the copayment budget. The total income for the copayment budget may be different from the total income for the eligibility budget.
When determining the copayment, do not include the following:
- exempt income (see Section E-2000);
- things that are not income (see Section E-1700), such as:
- medical care and services;
- certain social services;
- receipts from the sale of a resource;
- miscellaneous items, such as income tax refunds;
- proceeds of a loan;
- wage-related payments;
- mandatory payroll deductions from earned income (see E-1770); and
- cafeteria plans.
- interest or dividends accrued on certain excluded or partially excluded resources (see E-3331.2);
- interest and dividends earned on an ABLE account (see E-3331.4); and
- VA Aid and Attendance allowance, housebound allowance, and payment adjustment for unusual medical expenses (see E-4300, E-4311.2, E-4315). Reminder: If these payments are deposited into a qualifying income trust (QIT) account, they are countable as copayment.
Note: Income tax withheld from unearned income is not a deductible expense for the copayment calculation.
Revision 09-4; Effective December 1, 2009
See Section E-5000, Variable Income.
See Section E-3331, Interest and Dividends.
- Determine if any interest or dividends are accrued on fully countable resources and count the interest or dividends as income in the co-payment budget.
- Determine if any interest or dividends are accrued on all other resources and count the interest or dividends accrued as income in the co-payment budget (refer to the treatment of that particular resource as outlined in the handbook).
Revision 12-1; Effective March 1, 2012
HHSC deducts the following amounts, in the following order, from the person's total countable income:
- Personal needs allowance. See Section H-1500, Personal Needs Allowance (PNA).
- Guardianship fees. See Section H-1550, Guardianship Fees.
- Maintenance needs of spouse. See Section J-7200, Spousal Co-Payment.
- Maintenance needs of family (for a person with a family at home, an additional amount for the maintenance needs of the family). See Section H-1600, Dependent Allowance.
- Incurred Medical Expenses. See Section H-2000, Incurred Medical Expenses.
Optional deduction: Allowance for home maintenance. See Section H-1700, Deduction for Home Maintenance.
Revision 10-1; Effective March 1, 2010
A personal needs allowance (PNA) is an amount of a recipient's income that a recipient in an institutional setting may retain for personal use. It will not be applied against the costs of medical assistance furnished in the facility. Each recipient in an institutional setting may retain a PNA in an amount set by the executive commissioner of the Health and Human Services Commission in accordance with Chapter 32 of the Texas Human Resources Code. For SSI recipients who receive the $30 reduced federal benefit, the state will issue a supplement to allow for a PNA at the minimum level set by the executive commissioner.
Beginning Jan.1, 2006, the PNA is $60.
From Sept. 1, 2003, through Dec. 31, 2005, the PNA was $45.
From Sept. 1, 2001, through Aug. 31, 2003, the PNA was $60.
From Sept. 1, 1999, through Aug. 31, 2001, the PNA was $45; prior to that, it was $30.
Note: See Section E-4300, VA Benefits, for treatment of payments from the Department of Veterans Affairs. See Section E-4311.2, $90 VA Pension and Institutional Setting, regarding automation limitations and the VA $90 capped pension.
Revision 19-4; Effective December 1, 2019
When determining the co-payment for a person receiving services in an institutional setting, guardianship fees, up to an amount set by the court, are deducted from the person's total countable income.
The allowable court-ordered guardianship fee deduction may include the following:
- Monthly guardianship fees up to $250
- Costs related to establishing the guardianship up to $1,000
- Costs related to terminating the guardianship up to $1,000
- Administrative costs related to the guardianship up to $1,000 over a three-year period
Note: Costs related to establishing or terminating the guardianship can exceed $1,000 if the costs in excess are supported by documentation acceptable to the court and the costs are approved by the court. Costs might include compensation and expenses for an attorney ad litem, guardian ad litem, and reasonable attorney fees for an attorney representing the guardian.
Only allow a deduction for actual amounts in the court order.
Allow the reduction in the person's co-payment to be effective the later of the following:
- the month in which the judge signs the court order awarding guardianship fees;
- the first month of Medicaid eligibility in which the person has a co-payment; or
- the first day of the month the person provides HHSC with a copy of the court order.
Route any administrative cost more than $1,000 over a three-year period, or any cost exceeding the $1,000 for establishing or terminating the guardianship, through the regional attorney for guidance.
Do not allow a reduction in the person's co-payment for guardianship fees ordered after HHSC receives verification that the person has died. If the date of death is not verified, staff must clear the discrepancy. Do not allow the guardianship fees as a deduction in the co-payment until the discrepancy has been cleared.
Revision 10-3; Effective September 1, 2010
A dependent family member may be either spouse's minor or dependent children, dependent parents and dependent siblings (including half brothers, half sisters and siblings gained through adoption) who were living in an institutionalized client's home before the client's institutionalization, and who are unable to support themselves outside the client's home because of medical, social or other reasons.
The dependent allowance is calculated by subtracting the dependent's income from the SSI federal benefit rate for an individual when there is not a community spouse. Mandatory payroll deductions also apply to a dependent's earned income.
If in a spousal situation, the dependent allowance is calculated by subtracting the dependent's income from 150% of the monthly federal poverty level (FPIL) for a family of two, and dividing by three. Mandatory payroll deductions also apply to a dependent's earned income. The dependent family member must have been living in the person's home before the person's absence, must continue to live with the community spouse and must be unable to support himself outside the home because of medical, social or other reasons. See Section J-7400, Spousal Impoverishment Dependent Allowance, for more information on dependent allowance in a spousal budget.
Revision 12-4; Effective December 1, 2012
HHSC allows a deduction from co-payment if a person intends to return home within six months of admission to an institutional setting and needs to meet expenses in maintaining the home. The deduction is based on the person's mortgage or rent payment and average utility charges, excluding telephone. The amount deducted cannot exceed the SSI income limit, not including the $20 disregard. The first month of the six-month period is the month of admission to the institution.
Note: A separate deduction for maintenance of the home is not allowable in companion cases. The spousal allowance provides for home maintenance in those cases.
The home maintenance deduction is allowable if:
- the person notifies the eligibility specialist that he expects to be in an institutional setting for at least 30 consecutive days, but no more than six months;
- the eligibility specialist receives a practitioner's certification within 90 days of admission. The practitioner certifies that the person is likely to leave the institution within six months of admission; and
- the eligibility specialist receives evidence within 90 days of admission that the person needs to maintain and provide for the expenses of the home to which he may return.
Note: The day of admission to the institutional setting is day zero.
- Example 1: An individual entered a nursing facility on March 1. An application was received on May 30, which included a completed and signed Form H1280, Statement of Residence Maintenance Needs. The applicant signed the form on March 28 and the physician's signature was dated April 15. The day of entry to the nursing home on March 1 would be counted as day zero. The 90th day would be May 30. It is calculated by the following: 31 days in March (30 countable days, since March 1 would be counted as day zero), 30 days in April (30 countable days) and 31 days in May (30 countable days) for a total of 90 days. May 31 would be 91 days. Application was received on May 30; thus, Form H1280 was received by the 90th day.
- Example 2: An individual entered a nursing facility on April 1. An application was received on July 10, which included a completed and signed Form H1280. The applicant signed the form on April 29 and the physician's signature was dated May 15. The day of entry to the nursing home on April 1 would be counted as day zero. The 90th day would be June 30. It is calculated by the following: 30 days in April (29 countable days, since April 1 would be counted as day zero), 31 days in May (31 countable days) and 30 days in June (30 countable days) for a total of 90 days. Application was received on July 10; thus, Form H1280 was not received by the 90th day. The individual is not eligible for the home maintenance deduction.
Form H1280, Statement of Residence Maintenance Needs, is the prescribed document for obtaining the person's and practitioner's declaration. Use the amount reported on Form H1280 as the home maintenance deduction amount as long as it does not exceed the SSI income limit, not including the $20 disregard. No additional verification is needed.
The eligibility specialist sets a special review for the fifth month of institutionalization to determine if the person will be discharged by the end of the sixth month. If the person is not discharged, the eligibility specialist adjusts the co-payment to remove the home maintenance deduction beginning with the seventh month and sends TF0001, Notice of Case Action.
Revision 19-1; Effective March 1, 2019
In most cases, the Medicare Part B premium is deducted from the Social Security or Railroad Retirement check. In some situations, an individual will be billed for the Medicare Part B premium, usually via a quarterly invoice.
The base or standard Medicare Part B premium changes from year to year. For 2019, the standard premium is $135.50 per month. This amount can vary due to several factors:
- An individual did not enroll in Medicare the year that they became eligible, so the premium is higher.
- An individual's premium can be lower than the standard premium if the cost of living (COLA) increase on the RSDI is less than the increase in the monthly Medicare premium. In other words, the monthly RSDI benefit cannot be less than the previous year's benefit.
- An individual may be enrolled in a Medicare Advantage Plan (Medicare Part C), which may have a lower Medicare Part B premium deduction due to the discount offered by the plan.
In all situations, the Medicare Part B premium is indicated on the State Online Query (SOLQ) or Wire Third-Party Query (WTPY). Staff must use the amount as verified in SOLQ.
The monthly standard Medicare Part B premium is:
|Jan. 1, 2019 to present||$135.50|
|Jan. 1, 2018 to Dec. 31, 2018||$134.00|
|Jan. 1, 2017 to Dec. 31, 2017||$134.00|
|Jan. 1, 2016 to Dec. 31, 2016||$121.80|
|Jan. 1, 2013 to Dec. 31, 2015||$104.90|
|Jan. 1, 2012 to Dec. 31, 2012||$99.90|
|Jan. 1, 2011 to Dec. 31, 2011||$115.40|
For additional monthly Medicare Part B standard premiums, see Appendix LV, Historical Medicare Part B Premiums.