Revision 19-1; Effective March 1, 2019

 

The following information is effective Jan. 1, 2019.

Section 1924 of the Social Security Act (U.S. Code Title 42, Chapter 7, Subchapter XIX, §1396r-5) allows special resource and income provisions for institutionalized persons with community spouses.

Resource Assessments

When one member of a couple enters an institution with the intention of remaining for 30 consecutive days, the couple may request an assessment of their combined resources. The purpose of this assessment is to determine a spousal protected resource amount or that portion of the couple's combined resources upon entry to a medical care facility reserved for the community spouse.

An assessment can be completed from the date of entry to a medical care facility to the date of application for Medicaid, even if there are no immediate plans to file an application for Medicaid. Calculation of the spousal protected resource amount occurs only once, as of the beginning of the first continuous period of institutionalization.

Resource Provisions

Evaluate the couple's combined resources, without regard to community and separate property laws or the spouses' respective ownership interests, as of the month of institutionalization.

In determining total resources, exclude the following assets regardless of value:

  • home;
  • household goods; and
  • one automobile.

The spousal protected resource amount is the greater of the following:

  • the state minimum resource standard, currently $25,284; or
  • one-half of the couple's combined countable resources, not to exceed the maximum resource standard, currently $126,420.

Give the couple a copy of the assessment that shows the protected resource amount. The spousal protected resource amount determined at assessment is constant and does not change during the initial eligibility period (i.e., the certification date to the first annual review), unless it was based on incomplete or inaccurate information. The couple may not request a fair hearing at assessment, but they may appeal the spousal protected resource amount when they file an application for Medicaid.

Case Example A: Upon nursing home entry, the couple's combined countable resources are $19,500.

  1. $19,500 divided by 2 = $9,750 spousal share.
  2. The spousal protected resource amount is the greater of:
  • $9,750 spousal share (not to exceed $126,420); or
  • $25,284, the state minimum spousal resource standard.
  1. Thus, the spousal protected resource amount is $25,284.

The couple files a Medicaid application at the time of entry.

$19,500 Combined countable resources
- $25,284 Spousal protected resource amount
$0 Compared to the $2,000 resource standard for an individual

At the first annual review of eligibility, only resources in the name of the institutionalized spouse are considered and compared to the $2,000 resource standard for an individual.

Case Example B: Upon nursing home entry, the couple's combined countable resources are $50,000.

  1. $50,000 divided by 2 = $25,000 spousal share.
  2. The spousal protected resource amount is the greater of:
  • $25,000 spousal share (not to exceed $126,420); or
  • $25,284, the state minimum spousal resource standard.
  1. Thus, the spousal protected resource amount is $25,284.

The couple files a Medicaid application 10 months later. The couple's combined resources are now $25,500 as of 12:01 a.m. on the first day of the month of application.

$25,500 Combined countable resources
– $25,284 Spousal protected resource amount
$216 Compared to the $2,000 resource standard for an individual

At the first annual eligibility review, only resources in the name of the institutionalized spouse are considered and compared to the $2,000 resource standard for an individual.

Income Provisions

A. Income Eligibility — Test the income of only the institutionalized spouse against the individual income limit. The institutionalized person must be eligible using the individual income limit before the protected spousal needs allowance is determined.

B. Co-pay — The co-pay provisions apply to all eligible institutionalized recipients with community spouses. The co-pay calculation is the process of determining what portion of total monthly income the person must contribute toward the cost of their institutional care. From the eligible institutionalized person's income, first deduct the personal needs allowance to determine the amount available for diversion to the community spouse and dependent family members, before determining the co-pay. Add the community spouse's monthly income to the amount available for diversion, and use the community spousal needs allowance to reduce the co-pay. If there are any dependent family members, use the dependent allowance next to reduce the co-pay and use certain incurred medical expenses of the institutionalized person to reduce the co-pay.

1. Spousal Needs Allowance — An allowance of up to $3,160.50 per month is currently allowed for the community spouse. Deduct this amount from the couple's combined monthly income. If the community spouse’s monthly income exceeds $3,160.50, there is no spousal needs allowance.

Case Example:

$1,330 Recipient's total income
– $60 Personal needs allowance
$1,270 Amount available for diversion
+ $750 Spouse's total income
$2,020 Total
– $3,160.50 Spousal needs allowance
$0 Co-pay

2. Dependent Allowance — A dependent is defined as the couple's child (minor or adult), parent, or sibling (including half siblings, stepsiblings and siblings acquired through adoption) of either spouse who was living in the person's home before the person's absence, who continues to reside with the community spouse, and who cannot self-support outside the home due to medical, social or other reasons. A college student who would be capable of self-support does not meet the definition of a dependent.

Determine the dependent allowance by calculating for each dependent the deficit remaining after subtracting the dependent's total income from  $2,058.00, adding the deficits for all dependents, and dividing the total by three. Deduct this amount, too, from the couple's combined monthly income when determining the amount the person must contribute toward the cost of care.

* When determining the co-pay in a spousal impoverishment situation, there must be a community-based spouse before using a dependent allowance to reduce the co-pay of the eligible institutionalized person.

Case Example:

First dependent: $2,058 $550 income = $1,508
Second dependent: $2,058 $650 income = $1,408
            $2,916
 $2,916 divided by 3 = $972.00 Dependent allowance