Revision 14-2; Effective June 1, 2014

 

The purpose of the assessment is to determine a protected resource amount, which is that portion of total resources reserved for the community spouse and deducted from the couple's combined resources in determining eligibility.

 

J-4100 Time Frame to Request the Assessment

Revision 09-4; Effective December 1, 2009

 

Upon request of either the institutionalized spouse or the community spouse, or either spouse's authorized representative, assess the couple's resources to determine the spousal protected resource amount. The request and assessment may be made any time from the beginning of the continuous period in an institutional setting to the date of application for Medicaid.

 

J-4110 Automatic SPRA

Revision 09-4; Effective December 1, 2009

 

An automatic SPRA occurs when a community Medicaid recipient requests a program transfer to an institutional setting; use minimum SPRA at the time of the request.

 

J-4200 Assessment Request

Revision 09-4; Effective December 1, 2009

 

If the request for the assessment of resources to determine the SPRA is not part of an application for Medicaid, the couple must provide information on their resources and verification as required by HHSC.

Inform the couple and/or representative of the verifications required to complete an assessment and the time frame to return the verification(s). The couple must provide requested verification of resources within 30 days of the request for assessment, or the request is void. Complete the assessment within 45 days after receipt of verification requested.

If the couple does not provide the verification(s) within the time frame requested by HHSC, HHSC does not complete the assessment and takes no further action.

Note: The couple may not appeal the SPRA at the time of the assessment. The couple may appeal the SPRA after an application for Medicaid is filed.

 

J-4210 Procedures for Processing the Assessment Request

Revision 09-4; Effective December 1, 2009

 

Step Procedure
1 Assessment is requested.
2 Send Form H1272, Declaration of Resources.

Note: Form H1272 is not used as an application. If the assessment and application are requested at the same time, only an HHSC application for MEPD Medicaid is needed.
3 If all necessary documentation is not received within 15 calendar days of return of completed Form H1272, send Form H1273, Request for Assessment Information. If the needed documentation is not received by the 30th calendar day, discontinue the assessment.
4 If all necessary documentation is received by the 30th calendar day, the assessment must be completed by the 45th calendar day from the receipt of the signed Form H1272.
5 When the assessment is complete, send Form H1274, Medicaid Eligibility Resource Assessment Notification, showing the protected resource amount.

Note: This form must be sent whether or not the assessment is completed at the same time as an application.

 

J-4300 Assessment Date

Revision 09-4; Effective December 1, 2009

 

HHSC assesses the couple's combined countable resources as of 12:01 a.m. on the first day of the month in which the first continuous period in an institutional setting began. When determining the first day of the month in an institutional setting for the SPRA, HHSC may count days the person spent in a hospital if the person is admitted directly from the hospital to an institutional setting. After the continuous period begins, hospital stays and therapeutic home visits are not considered as breaks in the 30-consecutive-day period. See Section G-6210, 30 Consecutive Days and the Special Income Limit.

Note: When determining the first day of month of institutionalization for the SPRA, institutionalization can be based on hospitalization if the individual is admitted directly to the nursing facility from the hospital stay.

 

J-4310 Determining the Assessment Date for a Home and Community-Based Services Waiver

Revision 09-4; Effective December 1, 2009

 

The SPRA is assessed as of 12:01 a.m. on the first day of the month that the application was received for the financial Medicaid eligibility component. See Chapter O, Waiver Programs, Demonstration Projects and All-Inclusive Care.

  • If the waiver application is certified, the SPRA assessment date does not change unless it was based on incomplete or inaccurate information.
  • If the waiver application is not certified and the individual reapplies, the SPRA assessment date is 12:01 a.m. on the first day of the month of the re-application month.

 

J-4311 Examples of the Assessment Date

Revision 09-4; Effective December 1, 2009

 

If spousal impoverishment is applicable and:

an institutionalized Medicaid recipient requests a program transfer to a waiver,

use the established SPRA.

This is considered an institutional SPRA.

a community applicant applies for a waiver,

assess resources as of 12:01 a.m. on the first day of the month of the MEPD application.

This is considered a waiver SPRA if the waiver application is certified.

an institutionalized applicant applies for Medicaid and then a waiver before being certified,

assess resources as of 12:01 a.m. on the first day of the month of institutionalization.

Institutionalization can be based on hospitalization if the individual is admitted directly to the facility from the hospital stay.

This is considered an institutional SPRA.
Note: When determining the 30-day stay requirement, consider both the days in a medical facility and the days in the waiver setting.

a community applicant applies for a waiver and then enters a medical facility before being certified,

assess resources as of 12:01 a.m. on the first day of the month of institutionalization from a medical facility regardless if the applicant remains in the medical facility or returns to community waiver services before certification.

This is considered an institutional SPRA. Note: When determining the 30-day stay requirement, consider both the days in a medical facility and the days in the waiver setting.

 

Note: When determining the first day of month of institutionalization for the SPRA, institutionalization can be based on hospitalization if the individual is admitted directly to the nursing facility from the hospital stay.

 

J-4400 SPRA Calculation

Revision 14-2; Effective June 1, 2014

 

Use the following for the calculation of the SPRA at the time of the assessment request without an application or with the receipt of the MEPD application.

Calculate the SPRA as of the assessment date described in Section J-4300, Assessment Date. When determining the SPRA, determine countable resources using policy in Section J-2200, Spousal Treatment of Resources. To determine the amount of the SPRA, divide the countable resources by two and the result will be the amount to compare to the maximum and minimum SPRA amount set by federal law.

The SPRA is the greater of:

  • one-half of the couple's combined countable resources, not to exceed the maximum resource amount set by federal law; or
  • the minimum resource amount set by federal law.

Calculate the SPRA as described above whether the SPRA is calculated at the time of application for Medicaid or before an application for Medicaid is filed.

Resource exclusions determined in the SPRA are the same exclusions used in the eligibility determination at application.

Note: The equity value of the home does not impact spousal impoverishment policy and treatment of the home during the assessment process. If the person’s community spouse, child or disabled adult child is living in the home, substantial home equity policy does not apply. See Section F-3600, Substantial Home Equity.

 

J-4500 Changing the Assessment Amount

Revision 09-4; Effective December 1, 2009

 

With an automatic SPRA, no additional verification is necessary to establish the amount of the SPRA. Send Form H1274, Medicaid Eligibility Resource Assessment Notification, indicating the minimum SPRA and the right to appeal. See Section J-4110, Automatic SPRA.

See Section J-4311, Examples of the Assessment Date, for information about an institutional SPRA or Home and Community-Based Services waiver SPRA.

With an institutional SPRA, the SPRA assessment date and amount do not change unless they are based on incomplete or inaccurate information.

With a Home and Community-Based Services waiver SPRA, if the application is certified, the SPRA assessment date and amount do not change unless they are based on incomplete or inaccurate information. If the application is not certified, the SPRA assessment date is re-established if the individual reapplies.

The SPRA amount must not be deducted from resources for an individual who is found eligible, who is certified, or who is subsequently denied and then reapplies. Only those resources in the name of the Home and Community-Based Services waiver (institutionalized) spouse are considered at reapplication.

If an institutional spouse was certified incorrectly because of unreported resources and the case is subsequently denied, the original SPRA amount is not used when the institutional spouse reapplies for Medicaid. A new SPRA amount that includes the previously unreported resources must be calculated.

The SPRA can change if it is expanded as described in Section J-6000, SPRA Expansion.