Revision 18-3; Effective September 1, 2018

 

Reminders:

  • Monitor eligibility at least every three months if the individual's total countable income is within $10 of the income limit.
  • When income tax is withheld from retirement, pensions and disability benefits, use the gross amount for the eligibility calculation.
  • If the person has VA, see Section E-4311.2, $90 VA Pension and Institutional Setting.

The person or couple is considered to be living in a institutional living arrangement beginning with the first day that:

  • the person (or couple) lives in a Medicare-SNF or Medicaid certified long-term care facility; and
  • the person (or couple) has been confined to one or more Medicaid certified long-term care facilities (for example, Medicare-SNF, NF or ICF/IID) for at least 30 consecutive days.

 

G-6100 Institutional Eligibility Budgets

Revision 09-4; Effective December 1, 2009

 

Eligibility is determined for individuals and couples (in institutional living arrangements) who:

  • apply for retroactive Medicaid coverage; or
  • apply for or have eligibility redetermined under federally optional MEPD programs.

When a person not already eligible for Medicaid moves to an institutional setting, the income standard used and the income counted depend on whether the budget is for an individual, companion or couple case. Income is tested against the special income limit. See Appendix XXXI, Budget Reference Chart.

 

G-6110 Individual Institutional Eligibility Budget

Revision 09-4; Effective December 1, 2009

 

When a person applies for Medicaid, an individual budget is prepared if a person in an institutional setting is:

  • single;
  • widowed; or
  • divorced.

Note: An individual budget is also used when a person is married and has a community spouse, but the community spouse refuses to cooperate in providing information and circumstances indicate possible abuse or neglect by the community spouse.

The income of the person is considered against the special income limit standard for an individual.

 

G-6120 Couple Institutional Eligibility Budget

Revision 18-3; Effective September 1, 2018

 

A couple budget is prepared when a person is residing in the same institutional setting with an eligible spouse (i.e., a spouse who is aged or has a disability) and they are:

  • presenting themselves to the community as a married couple;
  • determined to be married for purposes of receiving Social Security benefits; or
  • recognized as married under state law.

The incomes of both spouses are considered against the special income limit standard for a couple.

Prepare two individuals budgets when a married couple:

  • resides in different institutional settings; or
  • is ineligible as a couple.

 

G-6130 Companion Institutional Eligibility Budget

Revision 09-4; Effective December 1, 2009

 

An institutional companion budget is prepared for a person in an institutional setting if:

  • the person has a community spouse; and
  • the couple meets the definition of a couple in Section G-6120, Couple Institutional Eligibility Budget, except the criterion that the couple live together does not apply.

Note: If the institutional setting is a waiver, the couple could be living together. If the institutional setting is a Medicaid certified facility, then the couple will not be living together since the criterion for a companion budget is a community spouse.

In preparing a companion institutional budget for a person, spousal impoverishment treatment of income and resources applies. See Chapter J, Spousal Impoverishment.

For the eligibility budget, the income of the person in the institutional setting is considered against the special income limit standard for an individual.

 

G-6200 Special Income Limit for the Eligibility Budget

Revision 09-4; Effective December 1, 2009

 

A special income limit is used to determine income eligibility for a person in an institutional setting who is not already eligible for Medicaid or for a person who becomes ineligible for Medicaid because of the move to an institutional setting.

The special income limit for a person is equal to or less than 300% of the full individual Supplemental Security Income (SSI) federal benefit rate.

The special income limit for a couple is twice the special income limit for an individual.

To qualify for the special income limit, a person or couple must:

  • have countable income that exceeds the reduced SSI federal benefit rate; and
  • reside in a Medicaid-certified long-term care facility for 30 consecutive days;
  • receive a level of care or medical necessity determination that qualifies the person or couple for Medicaid; or
  • be approved by a Texas health and human services agency to receive services under a Home and Community-Based Services waiver program and receive the services within one month after approval.

Note: The special income limit is used if the person is 65 years of age or older and in a Medicaid-certified institution for mental diseases for 30 consecutive days.

 

G-6210 30 Consecutive Days and the Special Income Limit

Revision 09-4; Effective December 1, 2009

 

Eligibility under the special income limit is not effective until the person has been in an institutional setting for a period of 30 consecutive days. Once the person has been in the institutional setting for the 30 consecutive days, use the special income limit retroactively for the month in which the person started the 30 consecutive days period.

Note: When a full Medicaid-eligible recipient moves into an institutional setting, the recipient does not have to meet the 30 consecutive days requirement to be eligible for Medicaid in an institutional setting.

The 30 consecutive days are not disrupted if the person:

  • makes a three-day therapeutic home visit with a planned return to the facility;
  • is admitted to a hospital with a planned return to the facility;
  • moves from a Medicaid-certified facility to another Medicaid-certified facility; or
  • moves to a Home and Community-Based Services waiver program.

If a person dies before meeting the 30 consecutive days requirement without moving to a noninstitutional setting, the person is considered to have met the requirement for application of the special income limit.

If the person does not complete the 30 consecutive days stay in an institutional setting, the special income limit is not used. The income limit for a noninstitutional program must be used instead and the person must meet the criteria in another MEPD group as described in Chapter A, General Information and MEPD Groups.

 

G-6300 Institutional Eligibility Budget Steps

Revision 09-4; Effective December 1, 2009

 

Step Procedure

1

Determine the appropriate income limit for either an individual or couple using the special income limit. See Appendix XXXI, Budget Reference Chart.

2

Determine monthly earned income.

See the following:
Section G-2000, Income Treatment
Section E-3000, Earned and Unearned Income
Section E-2000, Exempt Income
Section E-2200, Earned Income Exemption
Section E-1700, Things That Are Not Income
Section E-1770, Mandatory Payroll Deductions

3

Determine monthly unearned income, including income from support and maintenance, if appropriate.

See the following:
Section G-2000, Income Treatment
Section E-3000, Earned and Unearned Income
Section E-1700, Things That Are Not Income
Section E-2000, Exempt Income
Section E-4000, Fixed Income
Section E-5000, Variable
Section E-9000, Infrequent or Irregular

 

If the person has VA, see Section E-4311.2, $90 VA Pension and Institutional Setting.

4

Do not subtract either the:

  • $20-general exclusion, or
  • earned income exclusion in Section G-4000, Noninstitutional Exclusions.

Compare the remainder to the appropriate SSI FBR to test for the income element of eligibility

Note: If the remainder is less than the reduced SSI federal benefit rate, refer the person to the Social Security Administration.

5

The remainder is countable income. Compare the remainder to the appropriate income limit to test for the income element of eligibility.

 

The remainder must be equal to or less than the special income limit.

See Section G-5130, Medicare Savings Programs (MSP), for determination of a MSP program.

 

G-6400 Institutional Excess Income

Revision 09-4; Effective December 1, 2009

 

When the applicant is obviously income ineligible based on the submitted application, see Section B-2500, Explaining Policy vs. Giving Advice, in determining the appropriate actions to take and the actions to avoid.

See Section F-6800, Qualified Income Trust (QIT), for policy information, and Appendix XXXVI, Qualified Income Trusts (QITs) and Medicaid for the Elderly and People with Disabilities (MEPD), for more information concerning a QIT and a sample.

The QIT option is not available for individuals in a noninstitutional setting such as Community Attendant Services.