16 Del. Admin. Code § 20000-20720

Current through Register Vol. 28, No. 7, January 1, 2025

Section 20000-20720 - Patient Pay Calculation

This policy applies to all individuals receiving Medicaid through the Division of Developmental Disabilities Services (DDDS) Lifespan Waiver and the Long Term Care Community Services (LTCCS) Program.

1. The Medicaid recipient's total income will be used in the post eligibility treatment of income. This includes income that is counted for eligibility and income that is excluded for eligibility.

2. Allowable deductions are given based on an individual's circumstances. Not all deductions will apply to all individuals.

3. Any amount of income remaining after allowable deductions is the patient pay amount. This amount must be paid on a monthly basis as indicated below:

*	Individuals receiving Residential Habilitation funded by the DDDS waiver will submit their patient pay amount directly to the provider of Residential Habilitation.

*	Individuals residing in an Assisted Living Facility will submit their patient pay amount directly to the Assisted Living Facility.

The following deductions from the Medicaid recipient's total gross income should be taken in the following order:

20720.1 Daily Living Needs

Individuals receiving Medicaid under the Division of Developmental Disabilities Services (DDDS) Lifespan Waiver who receive Residential Habilitation services are allowed a deduction equal to the current Adult Foster Care (AFC) rate. The AFC rate is based on the current SSI income level plus the Optional State Supplement amount.

Individuals receiving Medicaid under the Long-Term Care Community Services (LTCCS) program and residing in an Assisted Living Facility are given a deduction based on the Adult Foster Care rate less an amount payable for room and board.

Individuals receiving Medicaid under the DDDS Lifespan Waiver who do not receive a residential habilitation service and individuals receiving Medicaid under the LTCCS program (excluding those residing in an Assisted Living Facility) are allowed a deduction equal to their total income, including income that is placed in a Miller Trust. All earned income in the form of wages shall be allowed to be protected.

20720.2 Support & Maintenance of Spouse and/or Children

In order to be considered a dependent, the spouse and/or children must be claimed on the applicant's income taxes as a dependent. A spouse is the husband or wife of the applicant who is living with the applicant or was living with the applicant prior to institutionalization.

If the applicant is responsible for the support and maintenance of the spouse and/or children, (i.e. provides them with food and shelter) the following calculations would be completed to determine the protected amount.

An amount up to the current SSI payment standard may be protected for the spouse. Monthly allowances for dependents other than the spouse are based on the current TANF standard of need.

If the spouse or other dependents have income their net income (gross income minus work expense and child care costs) should be deducted from the standards given above. Use standard SSI and TANF deductions. The amount remaining (if any) would then be protected for the dependent.

Please note, spouses with income less than the SSI standard should be encouraged to contact the Social Security Administration Office to apply for benefits.

20720.3 Additional Protected Amounts

Medical expenses not subject to payment by 3rd party, such as:

1. Health insurance premiums

2. Necessary medical or remedial care not covered under the Medicaid State Plan such as hearing aids, dentures, etc.

NOTE: Medicare deductibles and co-insurance charges are paid by Medicaid directly.

16 Del. Admin. Code § 20000-20720

15 DE Reg. 1718 (06/01/12)
20 DE Reg. 552(1/1/2017)
21 DE Reg. 574(1/1/2018)
26 DE Reg. 957( 5/1/2023) (Final)