Florida Administrative Code: Patient Responsibility/Community Spouse Income Allowances
65A-1.7141 SSI-Related Medicaid Post Eligibility Treatment of Income.
After an individual is determined eligible for Hospice, Institutional Care Program (ICP), Program of All-Inclusive Care for the Elderly (PACE), Cystic Fibrosis waiver, Individual Budgeting (iBudget ), or Statewide Medicaid Managed Care Long-Term Care (SMMC-LTC) Program, the Department determines 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, 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 of their monthly income protected for their personal need allowance.
(b) A PNA for individuals residing in the community. Individuals electing hospice services shall have an amount equal to the federal poverty level (FPL) protected as their personal needs allowance.
(c) An additional PNA for therapeutic wages. If the institutionalized individual earns therapeutic wages, an additional deduction from 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.
(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) The community spouse income allowance. The Department applies the formula and policies under § 1924 of the Social-Security Act, 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.
(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 homeowner’s association, 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 subsection 65A-1.603(2) F.A.C.
(g) For community hospice, spousal allowance. This allowance is equal to the Supplemental Security Income (SSI) Federal Benefit Rate (FBR), minus the spouse’s monthly income. 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 subsection 65A-1.716(1), F.A.C.)
(h) For ICP or institutional 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) 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:
1. For institutionalized persons or residents of medical institutions and intermediate care facilities, the deduction includes:
a. Any premium, deductible, or coinsurance charges or payments for health insurance coverage.
b. For other incurred medical expenses, the expense must be for a medical or remedial care service and be medically necessary as specified in subsection 59G-1.010(166), F.A.C., and be recognized in state law. 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.
2. The expense must have been incurred no earlier than the three month period preceding the month of application providing eligibility.
3. The expense must not have been paid for under the Medicaid State Plan.
4. 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.
5. The medical and remedial care expenses that were incurred as the result of imposition of a transfer of asset penalty is limited to zero.
(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 standard FBR minus the spouse’s monthly income is allowed.
2. The Department will apply the formula and policies § 1924 of the Social-Security Act, 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 as specified in subsection 59G-1.010(166), F.A.C., be recognized in state law, 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 is allowed when the spouse is residing in the community.
(c) A deduction for the family at the Temporary Cash Assistance consolidated need standard (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 as specified in subsection 59G-1.010(166), F.A.C., be recognized in state law, 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 is allowed when the spouse is 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 as specified in subsection 59G-1.010(166), F.A.C., be recognized in state law, 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. The Department will apply spousal impoverishment policy according to Section 1924 of the Social Security Act, Treatment of Income and Resources for Certain Institutionalized Spouses, as amended by Section 2404 of the Patient Protection and Affordable Care Act.
2. The Department will apply the formula and policies under § 1924 of the Social Security Act, 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 as specified in subsection 59G-1.010(166), F.A.C., be recognized in state law, 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 409.919, 409.961 FS. Law Implemented 409.902, 409.903, 409.904, 409.906, 409.919, 409.961, 409.063 FS. History–New 5-29-05, 8-12-15.
