The Department is aligning policy with the Medicaid State Plan by amending the uncovered medical expense deduction policy and adding an additional personal needs allowance. The Department is also adding the Program of All-Inclusive Care for the ...

 

DEPARTMENT OF CHILDREN AND FAMILY SERVICES

Economic Self-Sufficiency Program

RULE NO.:RULE TITLE:

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

PURPOSE AND EFFECT: The Department is aligning policy with the Medicaid State Plan by amending the uncovered medical expense deduction policy and adding an additional personal needs allowance. The Department is also adding the Program of All-Inclusive Care for the Elderly, the Cystic Fibrosis, IBudget Florida and Statewide Medicaid Managed Care Long-Term Care waivers and their deduction policies. These policies are used to determine an individual’s cost of care paid to nursing facilities and waiver providers in the post eligibility determination process. Included in this proposed rule amendment are wording changes to improve the overall content of the rule and technical changes of a non-substantive nature.

SUMMARY: The proposed rule amends SSI-Related Medicaid post eligibility determination language.

SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS AND LEGISLATIVE RATIFICATION:

The Agency has determined that this will not have an adverse impact on small business or likely increase directly or indirectly regulatory costs in excess of $200,000 in the aggregate within one year after the implementation of the rule. A SERC has not been prepared by the agency.

The Agency has determined that the proposed rule is not expected to require legislative ratification based on the statement of estimated regulatory costs or if no SERC is required, the information expressly relied upon and described herein: The Department considered the factors in Section 120.541, F.S. The proposed rule is not expected to exceed the criteria in paragraph 120.541(2)(a), F.S., therefore, legislative ratification is not required under subsection 120.541(3), F.S.

Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.

RULEMAKING AUTHORITY: 409.919 FS.

LAW IMPLEMENTED: 409.902, 409.903, 409.904, 409.906, 409.919 FS.

IF REQUESTED WITHIN 21 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: October 23, 2013, 10:00 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, Economic Self-Sufficiency Program, [phone], 1317 Winewood Boulevard, Tallahassee, Florida 32399-0700, [e-mail]

 

THE FULL TEXT OF THE PROPOSED RULE IS:

 

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), services or Assisted Living waiver (ALW/HCBS), Cystic Fibrosis, iBudget Florida and Statewide Medicaid Managed Care Long-Term Care (SMMC-LTC), the Ddepartment determines the amount of the individual’s patient responsibility. “Patient responsibility” is the amount the individual must pay from their income towards their cost of care. Patient responsibility is based on the amount of income remaining after authorized deductions from income are made. This process is called “post eligibility treatment of income”. The following deductions are made from the individual’s income in the amount indicated.

(1) For Hospice, and ICP and all individuals residing in medical institutions institutional care services, the following deductions are applied to the individual’s income to determine patient responsibility:

(a) A Personal Needs Allowance of $35 Individuals residing in medical institutions shall have $35 of their monthly income protected for their personal need allowance.

1.(b) If the 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 made and treated as an additional PNA deduction protected for personal need. This protection is in addition to the $35 personal need allowance.

2.(c) A PNA for non-residents of a medical institution Individuals who elect electing hHospice service will be have an amount of their monthly income equal to the federal poverty level (FPL) 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.

3. An additional deduction will be made as a PNA in an amount equal to the amount of a court-ordered child support payment required to be paid by the individual provided that the deduction will not be a duplicate deduction of any other deduction.

(b)(d) The community spouse income allowance is determined in accordance with department applies the formula and policies in 42 U.S.C. § section 1396r-5, 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.

(c) The community spouse’s excess utility expenses are based on the current Food Assistance Program’s standard utility allowance.

(d)(e) For community hHospice, cases, a spousal allowance deduction that 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.

(e) A portion of the individual’s income equal to the Temporary Cash Assistance (TCA) Consolidated Need Standard (CNS), minus the spouse and dependent’s income, if the individual has a spouse and dependent child. (For CNS criteria, refer to Rule 65A-1.716, F.A.C.)

(f) For ICP or Institutional institutionalized Hospice, a deduction for food and shelter, as applicable, for the months of admission and discharge that the individual must pay, provided that the facility will not be providing food and/or shelter for those months 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.

(g) Unreimbursed medical expense. There will not be a deduction from income for medical and remedial care expenses that were incurred as the result of imposition of a transfer of assets penalty period. For all other such incurred expenses, the following requirements must be met: 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 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 recognized under state law and be medically necessary. 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. Have been incurred no earlier than the eligibility period, including the three month period preceding the month of application. Not be a Medicaid compensable expense; and

3.d. 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 residential health insurance policies are considered to be first payor for medical items, care, or services covered by such policies. 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.

4. 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 Assisted Living ALW/HCBS, the following deductions are made from the individual’s income shall apply in computing patient responsibility:

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

(b) A deduction in the An amount equal to the TCA CNS as provided in paragraph (1)(e) above, cash assistance consolidated need standard minus the dependent’s income for the individual’s client’s dependent unmarried child(ren) child under age 21, or the individual’s their disabled adult child(ren) child living in the individual’s at home, if the individual does not have a when there is no community spouse.

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

(d) An additional deduction will be made as a PNA in an amount equal to the amount of a court-ordered child support payment required to be paid by the individual, provided that the deduction will not be a duplicate deduction of any other deduction.

(3) For PACE, the following deductions will be made from the individual’s income:

(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 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 (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 $35.

(b) Deductions in subparagraph (1)(a)1., and paragraphs (1)(b), (f) and (g) as applicable.

(c) An additional deduction will be made as a PNA in an amount equal to the amount of a court-ordered child support payment required to be paid by the individual, provided that the deduction will not be a duplcate deduction of any other deduction.

(4) For Cystic Fibrosis, the following deductions will be made from the individual’s income:

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

(b) Deductions in subparagraph (1)(a)1., and paragraphs (1)(b), (f) and (g) as applicable.

(c) An additional deduction will be made as a PNA in an amount equal to the amount of a court-ordered child support payment required to be by the individual, provided that the deduction will not be a duplicate deduction of any other deduction.

(5) For iBudget Florida, the following deductions will be made from the individual’s income:

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

(b) A Community spouse income allowance deduction in the amount equal to the FBR, minus the spouse’s own income.

(c) A deduction as provided for in paragraph (2)(b) above.

(d) Deductions in subparagraph (1)(a)1., and paragraph (1)(g) as applicable.

(e) An additional deduction will be made as a PNA in an amount equal to the amount of a court-ordered child support payment required to be paid by the individual, provided that the deduction will not be a duplicate deduction of any other deduction.

(6) For the Statewide Medicaid Managed Care Long-Term Care, the following deductions will be made from the individual’s income:

(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 an assisted living facility, the PNA is equal to 300% of the FBR.

2. For an individual residing in an ALF, the PNA is computed using the actual ALF room and board charge, plus 20% of the FPL.

(b) Deductions described in paragraphs (1)(b) and (1)(g).

(c) An additional deduction will be made as a PNA in an amount equal to the amount of a court-ordered child support payment required to be paid by the individual, provided that the deduction will not be a duplicate deduction of any other deduction.

Rulemaking Authority 409.919 FS. Law Implemented 409.902, 409.903, 409.904, 409.906, 409.919 FS. History–New 5-29-05, Amended_________.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Diana Laffey

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Esther Jacobo

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: September 17, 2013

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: July 1, 2013