SSI-Related Medicaid Post Eligibility Treatment of Income

 

DEPARTMENT OF CHILDREN AND FAMILY SERVICES

Economic Self-Sufficiency Program

RULE NO.:RULE TITLE:

65A-1.7141SSI-Related Medicaid Post Eligibility Treatment of Income

NOTICE OF CHANGE

Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 40 No. 203, October 17, 2014 issue of the Florida Administrative Register.

65A-1.7141 SSI-Related Medicaid Post Eligibility Treatment of Income

After an individual is determined eligible satisfies all non-financial and financial eligibility criteria for Hospice, Iinstitutional Ccare Program (ICP), Program of All-Inclusive Care for the Elderly (PACE), services or Assisted Living waiver (ALW/HCBS), Cystic Fibrosis waiver, Individual Budgeting (iBudget ), or Statewide Medicaid Managed Care Long-Term Care (SMMC-LTC) Program, the Ddepartment determines the amount of the individual’s patient responsibility. “Patient responsibility” is the amount the Agency for Health Care Administration (AHCA) must reduce its payments to a medical institution and intermediate care facility or payments for home and community based services provided to an individual towards their cost of care. Patient responsibility is based on the amount of income remaining after the following deductions are applied pursuant to 42 CFR § 435.725 and 42 CFR § 435.726. This process is called “post eligibility treatment of income”.

(1) For institutional care services and Hospice and institutional care services, the following deductions are applied to the individual’s income to determine patient responsibility in the following order:

(a) A Personal Needs Allowance (PNA) of $105. Individuals residing in medical institutions and intermediate care facilities shall have $105 35 of their monthly income protected for their personal needs allowance.

(b) A PNA for individuals residing in the community. Individuals electing hospice services shall have an amount of equal to the federal poverty level (FPL) protected as their personal need allowance.

(c)(b) An additional PNA for therapeutic wages. If the institutionalized individual earns therapeutic wages, an additional deduction from amount of income equal to one-half of the monthly therapeutic wages, up to a maximum of $111, shall be applied and treated as an additional PNA protected for personal need. This protection is in addition to the $35 personal need allowance.

(c) Individuals who elect Hospice services have an amount of their monthly income equal to the federal poverty level protected as their personal need allowance unless they are a resident of a medical institution, in which case $35 of their income is protected for their personal need allowance.

(d) An additional PNA for court ordered child support. If the institutionalized individual is court ordered to pay child support an additional PNA is deducted in an amount equal to the court ordered support paid by the individual to meet their court ordered obligation. The additional PNA is applied only if a court ordered deduction was not made under another provision under the post eligibility process.

(e)(d) The community spouse income allowance. The Ddepartment applies the formula and policies in 42 U.S.C. under § 1924 of the Social-Security Act, section 1396r-5 and Rule 65A-1.716, F.A.C. to compute the community spouse income allowance after the institutionalized spouse is determined eligible for institutional care benefits. The standards used are found in subsection 65A-1.716(5), F.A.C. The current Food Assistance Program standard utility allowance is used to determine the community spouse’s excess utility expenses.

(f) The community spouse’s excess shelter and utility expenses. The amount by which the sum of the spouse’s expenses for rent or mortgage payment (including principal and interest), taxes and insurance and, in the case of a condominium or cooperative, required maintenance charge, for the community spouse’s principal residence and utility expense exceeds thirty percent of the amount of the Minimum Monthly Maintenance Needs Allowance (MMMNA) is allowed. The utility expense is based on the current Food Assistance Program’s standard utility allowance as referenced in Rule 65A-1.603(2).

(g) For community hHospice, cases, a spousal allowance. This allowance is equal to the Supplemental Security Income (SSI) Federal Benefit Rate (FBR), minus the spouse’s own monthly income shall be deducted from the individual’s income. If the individual has a spouse and a dependent child(ren) they are entitled to a portion of the individual’s income equal to the Temporary Cash Assistance consolidated need standard (CNS) minus the spouse and dependent’s income. For CNS criteria, refer to subsection 65A-1.716(1), F.A.C. A portion of the individual’s income equal to 100% of the Federal Poverty Level (FPL), minus the spouse and dependent’s income, if the individual has a spouse and dependent child in the community . (For FPL criteria, refer to Rule 65A-1.716(1), F.A.C.).

(h)(f) For ICP or Institutional institutionalized Hospice, income is protected for the month of admission and discharge, if the individual’s income for that month is obligated to directly pay for their cost of food or shelter outside of the facility.

(i)(g) Uncovered medical expense deduction. The following policy will be applied in considering medical deductions for institutionalized individuals and individuals receiving HCBS services to calculate the amount allowed for the uncovered medical expense deduction: Effective January 1, 2004, the department allows a deduction for the actual amount of health insurance premiums, deductibles, coinsurance charges and medical expenses, not subject to payment by a third party, incurred by a Medicaid recipient for programs involving post eligibility calculation of a patient responsibility, as authorized by the Medicaid State Plan and in accordance with 42 CFR 435.725.

1. For institutionalized persons or residents of medical institutions and intermediate care facilities, the deduction includes The medical/remedial care service or item must meet all the following criteria:

a. Any premium, deductible, or coinsurance charges or payments for health insurance coverage. Be recognized under state law;

b. For other incurred medical expenses, the expense must be for a medical or remedial care service and be medically necessary and recognized under state law as specified in Rule 59G-1.010 (166) F.A.C.. For medically necessary care, services and items not paid for under the Medicaid State Plan, the actual billed amount will be the amount of the deduction, not to exceed the maximum payment or fee recognized by Medicare, commercial payors, or any other third party payor, for the same or similar item, care, or service. Be medically necessary;

2.c. The expense must have been incurred no earlier than the three month period preceding the month of application providing eligibility. Not be a Medicaid compensable expense; and

3.d. The expense must not have been paid for under the Medicaid State Plan. Not be covered by the facility or provider per diem.

2. For services or items not covered by the Medicaid State Plan, the amount of the deduction will be the actual amount for services or items incurred not to exceed the highest of a payment or fee recognized by Medicare, commercial payers or any other contractually liable third party payer for the same or similar service or item.

4.3. Other health insurance policies, including long term care insurance, are considered to be the first payor for medical items, care, or services covered by such policies and the remaining items can be used as an uncovered medical expense deduction.  Therefore, to be deducted from the individual’s income, the individual must demonstrate that other insurance does not cover such medical items, care, or services. Expenses for services or items received prior to the first month of Medicaid eligibility can only be used in the initial projection of medical expenses if the service or item was provided during the three month period prior to the month of application and it is anticipated that the expense for the service or item will recur in the initial projection period.

5.4. The medical and remedial care expenses that were incurred as the result of imposition of a transfer of asset penalty is limited to zero. For the initial projection period, the department will allow a deduction for the anticipated amount of uncovered medical expenses incurred during the three month period prior to the date of application, and that are recurring (reasonably anticipated to occur) expenses in the initial projection period.

5. Actual incurred and recognized expenses will be deducted in each of the three months prior to the Medicaid application month when an applicant requests three months prior Medicaid coverage and is eligible in the prior month(s).

6. The initial projection period is the first day of the first month of Medicaid eligibility beginning no earlier than the application month through the last day of the sixth month following the month of approval. A semi-annual review is scheduled for the fifth month after the month approved to evaluate the recipient’s actual incurred medical expenses for the prior six months.

7. For the semi-annual review, the department will request documentation of the recipient’s actual incurred medical expenses for the prior six months.

a. If the recipient documents their actual expenses, staff must compare the total projected expenses budgeted with the total actual recurring expenses to determine if the projection was accurate. If the projection was overstated or understated by more than $120, the department must use the amount overstated or understated by more than $120 combined with the total expenses anticipated to recur and any non-recurring expenses incurred during the period to compute an average amount to deduct from patient responsibility for the next projection period, if possible. If an adjustment is not possible, the department must adjust the patient responsibility for each past month in which an expense was overstated.

b. If a recipient fails to document their actual expenses for the last projection period at the time of their semi-annual review, the department must assume the recipient did not incur the expense(s) which was projected. The department will remove the deduction for the next projection period and calculate the total amount of deductions incorrectly credited in the prior projection period to adjust the recipient’s future patient responsibility. If an adjustment is not possible, the department must adjust the patient responsibility for each past month in which an expense was overstated.

8. The steps in subparagraph (g)7. above must be repeated for each semi-annual review.

9. Recipients must report their uncovered medical expenses timely.

a. New, recurring uncovered medical expenses must be reported no later than the tenth day of the month in which the next semi-annual review is due. If the due date falls on a weekend or holiday, the recipient must report by the end of the next regularly scheduled business day. Recurring expenses reported timely will be included in the calculation of patient responsibility beginning with the month the expense was incurred. Recurring expenses not reported timely will be included in the calculation of patient responsibility beginning the month reported and will be prorated for the remaining months of the projection period, but no adjustments in patient responsibility will be made for past months in which expenses went unreported.

b. Non-recurring uncovered medical expenses must be reported no later than the tenth day of the month in which the next semi-annual review is due. If the due date is a weekend or holiday, the recipient must report by the end of the next regularly scheduled business day. Non-recurring expenses reported timely will be held until the semi-annual review month and prorated over the next six-month period. Non-recurring expenses not reported timely will not be included as a deduction in the patient responsibility calculation.

(2) For ALW/HCBS, the following deductions shall apply in computing patient responsibility:

(a) An allowance for personal needs in the amount equal to the Optional State Supplementation (OSS) (as defined in Chapter 65A-2, F.A.C.), cost of care plus the OSS personal need allowance.

(b) An amount equal to the, cash assistance consolidated need standard minus the dependent’s income for the client’s dependent unmarried child under age 21, or their disabled adult child living at home, when there is no community spouse.

(c) Deductions in paragraphs (1)(b), (d), (f) and (g), as applicable.

(2) For the Program of All-Inclusive Care for the Elderly (PACE), the following deductions are applied to the individual’s income to determine patient responsibility:

(a) A deduction is made for the PNA based on the individual’s living arrangement as follows:

1. For an individual residing in the community, not in an assisted living facility (ALF), the PNA is equal to 300% of the FBR.

2. For an individual who is residing in an ALF, the PNA is computed using the ALF basic monthly rate (for three meals per day and a semi-private room), plus 20% of the FPL.

3. For an individual residing in a nursing home, the PNA is $105.

(b) A deduction is allowed when there is a spouse residing in the community for HCBS and ICP services.

1. For HCBS a spousal deduction equal to the SSI FBR minus the spouse’s monthly income.

2. The Ddepartment will apply the formula and policies in 42 U.S.C. § 1924 of the Social-Security Act, section 1396r-5 and Rule 65A-1.716, F.A.C. to compute the community spouse income allowance after the institutionalized spouse is determined eligible for institutional care benefits.

(c) A deduction for incurred medical or remedial care expenses not subject to payment by a third party, and subject to the following reasonable limits:

1. The service or item claimed as a deduction from the individual’s income must be a medical or remedial care service, be medically necessary, recognized under state law as specified in Rule 65A-1.716, F.A.C., and have been incurred no earlier than the three months preceding the month of application providing eligibility and have not been paid for under the Medicaid State Plan.

2. For medically necessary care, services and items not paid for under the Medicaid State Plan, the actual billed amount will be used as the deduction not to exceed the maximum payment or fee recognized by Medicare, commercial payers or any other third party payer for the same or similar item, care, or service.

3. Other resident health insurance policies will be treated as first payor and the beneficiary will have to demonstrate that the other insurance has not or will not cover the expense.

4. The medical or remedial care expenses that were incurred as the result of imposition of a transfer of assets penalty is limited to zero.

(d) If the institutionalized individual is court ordered to pay child support an additional PNA is deducted in an amount equal to the court ordered support paid by the individual to meet their court ordered obligation. Funds are protected only to the extent that the income was not already deducted under another provision in the post eligibility process.

(3) For the Cystic Fibrosis waiver, the following deductions are applied to the individual’s income to determine patient responsibility in accordance with 42 CFR 435.726:

(a) A deduction is made for PNA in an amount that is equal to 300% of the FBR.

(b) A spousal deduction equal to the SSI standard FBR minus the spouse’s monthly income when residing in the community.

(c) A deduction for the family at the Temporary Cash Assistance CNS.

(d) A deduction for incurred medical or remedial care expenses not subject to payment by a third party, and subject to the following reasonable limits:

1. The service or item claimed as a deduction from the individuals income must be a medical or remedial care service, be medically necessary, have been incurred no earlier than the three months preceding the month of application providing eligibility and have not been paid for under the Medicaid State Plan.

2. For medically necessary care, services and items not paid for under the Medicaid State Plan, the actual billed amount will be used as the deduction not to exceed the maximum payment or fee recognized by Medicare, commercial payers or any other third party payer for the same or similar item, care, or service.

3. Other resident health insurance policies will be treated as first payor and the beneficiary will have to demonstrate that the other insurance has not or will not cover the expense.

4. The medical or remedial care expenses that were incurred as the result of imposition of a transfer of assets penalty is limited to zero.

(4) For the iBudget Florida waiver, the following deductions are applied to the individual’s income to determine patient responsibility in accordance with 42 CFR 435.726:

(a) A deduction is made for PNA in an amount that is equal to 300% of the FBR.

(b) A spousal deduction equal to the SSI standard FBR minus the spouse’s monthly income when residing in the community.

(c) A deduction for the family at the Temporary Cash Assistance CNS.

(d) A deduction for incurred medical or remedial care expenses not subject to payment by a third party, and subject to the following reasonable limits:

1. The service or item claimed as a deduction from the individuals income must not be a medical or remedial care service, be medically necessary, have been incurred no earlier than the three months preceding the month of application providing eligibility and have not been paid for under the Medicaid State Plan.

2. For medically necessary care, services and items not paid for under the Medicaid State Plan, the actual billed amount will be used as the deduction not to exceed the maximum payment or fee recognized by Medicare, commercial payers or any other third party payer for the same or similar item, care, or service.

3. Other resident health insurance policies will be treated as first payor and the beneficiary will have to demonstrate that the other insurance has not or will not cover the expense.

4. The medical or remedial care expenses that were incurred as the result of imposition of a transfer of assets penalty is limited to zero.

(5) For the Statewide Medicaid Managed Care Long-Term Care Program, the following deductions are applied to the individual’s income to determine patient responsibility in accordance with 42 CFR 435.726:

(a) A deduction is made for the PNA based on the individual’s living arrangement as follows:

1. For an individual residing in the community, not in an ALF, the PNA is equal to 300% of the FBR.

2. For an individual who is residing in an ALF, the PNA is computed using the ALF basic monthly rate (for three meals per day and a semi-private room), plus 20% of the FPL.

(b) A deduction is allowed when there is a spouse residing in the community for HCBS and ICP services.

1. For HCBS a spousal deduction equal to the SSI FBR minus the spouse’s monthly income.

2. The Ddepartment will apply the formula and policies in 42 U.S.C. under § 1924 of the Social Security Act, section 1396r-5 and Rule 65A-1.716, F.A.C. to compute the community spouse income allowance after the institutionalized spouse is determined eligible for institutional care benefits.

(c) A deduction for incurred medical or remedial care expenses not subject to payment by a third party, and subject to the following reasonable limits:

1. The service or item claimed as a deduction from the individuals income must be a medical or remedial care service, be medically necessary, have been incurred no earlier than the three months preceding the month of application providing eligibility and have not been paid for under the Medicaid State Plan.

2. For medically necessary care, services and items not paid for under the Medicaid State Plan, the actual billed amount will be used as the deduction not to exceed the maximum payment or fee recognized by Medicare, commercial payers or any other third party payer for the same or similar item, care, or service.

3. Other resident health insurance policies will be treated as first payor and the beneficiary will have to demonstrate that the other insurance has not or will not cover the expense.

4. The medical or remedial care expenses that were incurred as the result of imposition of a transfer of assets penalty is limited to zero.

Rulemaking Authority 409.212, 409.919, 409.961. FS. Law Implemented 409.902, 409.903 409.904, 409.906, 409.212, 409.919, 409.961, 409.963, FS. History–New 5-29-05, _____

 

IF REQUESTED WITHIN 7 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW (IF NOT REQUESTED, THIS HEARING WILL NOT BE HELD):

DATE AND TIME: January 28, 2015, 10:30 a.m.

PLACE: 1317 Winewood Boulevard, Building 3, Room 455 Tallahassee, Florida 32399-0700

Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 7 days before the workshop/meeting by contacting: Vonsenita Tranquille. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Vonsenita Tranquille [e-mail], Economic Self-Sufficiency Program, [phone], 1317 Winewood Boulevard, Tallahassee, Florida 32399-0700