20610 Definitions

Total amount of benefit before deductions. Examples of deductions are:

Medicare premiums,

health insurance premiums,

life insurance premiums, etc.

Gross income is always used in determining eligibility.

Income before taxes or other deductions such as insurance premiums, savings, union dues, etc. Gross wages are used to determine eligibility.

To be considered regularly employed or regularly attending, the recipient must be working or attending at least 3 1/2 hours per day and 4 days a week.

Nursing facility recipients who are eligible for Medicaid are entitled to retain some of their available income for personal needs.

20620 Patient Pay Amount Deductions

The total income to be used in the post eligibility process will include all amounts that meet the definition of income. This includes both income that is counted for eligibility and income that is excluded for eligibility.

Take the following deductions from the Medicaid recipients total gross income in the following order:

1. personal needs

2. expenses incurred for necessary medical care

3. community spouse income allowance or $75 home maintenance disregard (if applicable)

4. family allowance (if applicable)

a) $44.00 per month of available income is to be protected for the recipients direct personal needs; or

b) If the recipient regularly attends a rehab/educational program off the grounds of his nursing facility, including employment for the purpose of rehabilitation in a sheltered workshop off the grounds of the facility, $50.00 per month (rather than $44) will be protected; or

c) For nursing facility residents who are participating in substantial gainful activity (SGA) (20 CFR 416.971), the following amounts, not to exceed the Adult Foster Care rate will be deducted from gross earned income:

Mandatory payroll deductions that are a condition of employment including, but not limited to:

Federal, State and Local Taxes

FICA

Union Dues

Insurance premiums

Pension contributions

Transportation costs as paid to & from work

Clothing and personal needs allowance of $75/month.

If earnings average more than $700 a month in a calendar year, this is considered SGA and DSS can allow a personal needs allowance of up to the AFC rate. If earnings average less than $300 a month in a calendar year, this is not ordinarily considered SGA and DSS can allow the $44 or $50 personal needs allowance. If average earnings are between $300 and $700, DSS must consider other factors to determine whether or not the work constitutes SGA. Other factors include considering if the work is comparable to unimpaired people in the community performing similar jobs.

Cost of medical insurance premiums carried by the recipient shall be set aside from his/her income. A medical insurance premium which is payable less often than monthly (for example, quarterly) may be averaged out so that a consistent amount of the recipient's income is protected for this purpose each month. The recipient, or other person responsible for his financial affairs, will be responsible for handling this money and assuring that is available for paying the premium when due.

Cost of necessary medical care not covered under the recipient's medical insurance, Medicaid or Medicare but recognized under state law may be set aside from his/her income. The care must be ordered by a professional, such as a physician, dentist, optometrist, physical therapist, etc. For items such as dentures and hearing aids to be approved a medical professional will have to state, in writing that the patient will benefit medically (as opposed to cosmetically only). Other approved medical care items which might occur frequently are eye exams, eyeglasses, dental care, prostheses and appliances.

When in doubt as to whether the care is recognized under state law or is appropriate to be charged to the patient under this policy, consult the Long Term Care Operation’s Administrator. The recipient and the provider must understand that these are not Medicaid payments but are an arrangement between recipient and provider, and that it is the responsibility of the recipient, or his representative to see that payments are made. If both parties are agreeable, payments may be spread out over a period of months.

10 DE Reg. 703 (10/01/06)

Medical costs incurred in a prior period of ineligibility (if approved by Medicaid) may be protected from his/her income. Costs incurred in a period of ineligibility must be approved by the Medicaid State Office prior to being protected and will only be considered if incurred within 30 days of the beginning date of Medicaid eligibility.

The recipient's reimbursement level and patient pay amount must be identified. Medicaid will protect at the Medicaid reimbursement rate, not the private pay rate.

The period of ineligibility may be caused by excess resources or excess income.

Protections for which the individual is seeking coverage will not be granted if the ineligible period occurred during a transfer of assets penalty phase.

10 DE Reg. 703 (10/01/06)

Temporary Institutionalization - If the attending physician has certified that a recipient is likely to return to his own home within a definite period (not to exceed 2 months) up to $75.00 per month may be protected for maintenance of the home. This allowance may be used for mortgage payments, rent, insurance, utility bills, repairs, etc. Copies of receipts, contracts or other types of verification shall be obtained and kept in the DSS record.

The $75 home maintenance disregard may not be allowed if the community spouse is receiving the spousal income allowance.

9 DE Reg. 1076 (01/01/06)

To determine community spouse income allowance and family allowance for recipients institutionalized after 9/30/89 see section on Spousal Impoverishment. For recipients institutionalized prior to 9/30/89, an additional amount must be protected for the maintenance needs of the recipient's needy spouse and/or dependents in accordance with TANF standards.

If the family has earned and/or unearned income, work expense and dependent care costs should be deducted to determine monthly net income. Use standard TANF deductions. The monthly net income should then be deducted from allowances given above to determine the amount to be protected.

Standard TANF deductions:

$90 per each employed person

$30 and 1/3 disregard

up to $200/month/child under two

up to $175/month/child age two and older and incapacitated adult

PLEASE NOTE: spouses with income less than the SSI standard should be referred to the Social Security Administration for benefits.

20630 Cost Of Care In The Facility

After taking all of the above appropriate income disregards, any remaining income will be applied toward the cost of care in the facility. The cost of care computation is totally distinct from the eligibility computation. For instance, the $20.00 that is disregarded from income when determining if an applicant is eligible is not disregarded when budgeting for patient pay amount.

Another example is that any "infrequent and inconsequential income" (gifts, contributions and interest amounting to less than $20.00 per month and received less than quarterly) that is disregarded for the eligibility determination would be counted as available income when computing the budget for the nursing facility recipient.

In some cases, the amount protected for the recipient's direct personal needs may accumulate in a savings account. Even when the individual has no immediate use for such income, personal needs monies are not to be applied towards medical care costs. However, should the amount accumulated exceed the resource limit, the recipient becomes temporarily ineligible for Medicaid. At that time, any amount above the resource limit may be applied to medical cost.

20640 Patient Pay Calculation

The patient pay amount equals total gross income minus all protected amounts and disregards.

The fiscal agent will compute the payment to the Nursing Facility for each recipient by multiplying the established per diem rate by the number of days of nursing facility care received in a month and deducting the patient pay amount.

The per diem rate is established by DSS through an evaluation of nursing facilities' cost reports.

If vendor payment is made to the nursing facility for part of the month, a Patient Pay Calculation must be done to prorate the patient pay amount for that month.

For example: If a patient normally would be expected to pay $120.00 toward his care in a nursing facility for a full month, but enters the home on the 21st day of June, (10 days remaining in the month), his patient pay amount for that month would be $40.00 (see calculation below).

Patient pay divided by # of days in month = per diem

$120.00 divided by 30 = $4.00

Per Diem x # of days in facility = prorated patient pay

$4.00 x 10 = $40.00

20650 Temporary Absence from Nursing Facility for Hospitalization

If a recipient is hospitalized for a short period of time and is expected to return to the facility, payment to the facility may continue for a period of not more than 7 days provided the nursing facility agrees to hold the bed for the resident. Medicaid reimbursement is available for no more than seven (7) days within any 30-day period. The 30-day count begins with the first day of hospitalization. If payments are suspended because recipient remains hospitalized more than seven (7) days and the 30 count expires, a new 30 day count starts with readmission to the nursing facility. In other words DSS will not pay 7 days out of every 30 days for people who remain in the hospital for weeks at a time.

7 DE Reg. 781 (12/1/03)

1. A recipient may be absent from the nursing facility for reasons other than hospitalization for a period of 18 days per year without interruption of payment to the nursing facility, as long as such absences are provided for in the recipient's plan of care.

2. If a recipient's physical condition is being negatively impacted by his emotional need to be in a family setting, prior approval may be obtained for a waiver of the 18-day leave of absence limitation (for other than acute care hospitalization) from the Title XIX Medical Consultant in order to allow the patient more time to visit with his family.

To obtain approval, a written request must be submitted by the nursing facility to the Long-Term Care Coordinator and must include:

a. reason for the request,

b. medical summary,

c. statement from the nursing facility's medical director regarding the medical necessity of the patient being absent from the nursing facility in excess of 18 days per year,

d. anticipated frequency of absence, and

e. number of days the recipient was absent from the nursing facility during the previous six month period.

If the approval is given, the 18-day restriction will be waived for six months from the date of approval. Any request for a waiver after the six month limit must be resubmitted and approved for payments to be continued.

20660 Interim Changes

Interim changes are any changes in circumstances which could result in a change in eligibility (i.e. discharge, income increases or decreases, death). Interim changes must be evaluated at the time they occur or at the time they are reported to determine the effect on eligibility. Unreported changes could cause loss of Medicaid and/or overpayment. Interim changes which do not affect eligibility may affect monthly patient pay amounts (i.e. health insurance premium change, increases or decreases in income, COLA). Unreported changes may also affect payment to providers such as nursing facilities, hospitals, doctors, etc.

If the nursing facility recipient's income changes anytime during the year, perform the following:

update the eligibility system, and

notify the recipient/representative and facility.

If a Medicaid nursing facility recipient becomes ineligible due to a change in income or resources and remains in the facility, give 30 days notice of termination to the recipient and the facility. For example, a Medicaid nursing facility resident is determined ineligible on May 10. DSS must give 30 days notice (i.e. June 10).

If a Medicaid nursing facility recipient is transferred to another facility, the following steps are required:

1. compute the pro-rated patient pay amount for each facility

2. update DCIS

3. notify recipient's representative and the facility.

When a Medicaid recipient leaves the nursing facility and is discharged by the facility, the following steps must be taken:

1. complete budget to determine pro-rated patient pay amount

2. update DCIS. The case would be closed effective the last day of discharge month if the client received 10 days notice. Vendor payment would stop the day prior to discharge.

3. notify the recipient's representative and facility.

When a Medicaid nursing facility recipient expires the following steps must be taken:

1. complete budget to determine pro-rated patient pay amount

2. update DCIS. The case would be closed effective the date of death; vendor payment would stop the day prior to death.

3. notify the recipient's representative and facility.

20670 Redetermination

A redetermination is identical to an application. A new application form must be completed and all elements which have the potential for changing must be reverified.

A complete redetermination of eligibility must be done at least every 12 months. This must include:

1. a newly signed application form;

2. verification of current income and resources documented in the recipient's record

A redetermination of eligibility is not needed for those patients receiving an SSI payment of $30.00. It is SSA's responsibility to redetermine these cases for continued eligibility. However, it is the responsibility of the financial unit to monitor the patient accounts for this group of recipients and to verify their continued receipt of SSI payment once a year.

20680 Inappropriate Placement

If a recipient's condition changes and he requires a nursing facility level of care that the facility is not certified to provide or the recipient no longer needs nursing facility care, the vendor payment must be terminated. From the time it is determined that the recipient is inappropriately placed he or she will be given a 30 day planning period to secure alternate placement.

The Long Term Care Coordinator will determine the planning period and notify the recipient's facility in writing. She will contact the case worker who will notify the recipient's responsible party, first of the need to transfer the recipient and second, that failure to make the transfer will result in case closing. If the level of care reverts back to a level appropriate to the current facility before the 30 days expire, payments will not be terminated.

20690 Disposition of Deceased Nursing Facility Residents Effects

Nursing Facility Administrators must turn over the clothing, valuables and unexpended patient funds of a deceased recipient to the administrator of the estate.

If a recipient dies leaving no will and having no heirs, his property reverts to the State. The Secretary of Delaware's Department of Finance has the responsibility of handling the transfer of the property to the State.