Section 144-332-14-5 - INCOME CRITERIAIndividuals must use their income to meet their needs.
Gross non-excluded income is used in determining eligibility. Gross non-excluded income is defined in Part 17 with the following exception: If the income of the institutionalized spouse is being reduced due to previous overpayments by government agencies, the reduced payment amount is used.
Income exclusions used for SSI - Related categories are used to determine gross non-excluded income.
Unless exempt, a transfer of income by the individual is subject to a penalty. Refer to Part 15 to assess if a transfer has occurred and if a penalty needs to be applied.
Section 5.1:Income OwnershipThe income ownership rules for purposes of this Part supersede any State laws relating to community property or the division of marital property. The rules of ownership of income are as follows:
I. Income payments made solely in the name of one spouse are available only to that respective spouse.II. When an income payment is made in the names of both spouses, one half is considered to be available to each, unless there is documentation to the contrary.III. If the payment of income is made in the names of the institutionalized spouse or the community spouse, or both, and to another person or persons, the income is available to each spouse in proportion to the spouse's interest. When both spouses' names are on the payment and no interest is specified, one half of the couples 'interest is considered available to each spouse.IV. Income from a trust is counted to the extent it is considered available (Part 16, Section 4.53).Section 5.2:Income LimitsGross non-excluded income of the individual must be less than the private rate for a semi-private room in the facility where the individual resides. Section 5.2.1:Income below the Categorically Needy Income LimitIf an individual has income below the categorically needy income limit (see Chart 4.1). See Section 6 of this Part to determine the cost of care.
Section 5.2.2:Income equal to or over the Categorically Needy Income LimitIf an individual has income equal to or over the categorically needy income limit, but under the private rate for the facility a deductible must be met.
Depending on the gross income the deductible is always met by incurring the Medicaid rate or private rate for the facility. Specifics on which rate to use are explained below. Eligibility occurs on the first day of the month of eligibility for the six month period.
The deductible is met as follows:
A. Combine all gross unearned income.B. Subtract the $20.00 Federal Disregard, where applicable. The remainder is the net unearned income.C. Combine all gross earned income.D. Subtract any remainder of the $20.00 Federal Disregard not deducted for the unearned income.E. Subtract the earned income disregard of $65.00.F. Divide the remaining earned income by two. The remainder is the net earned income.G. Combine the net earned and unearned income.H. Subtract the Protected Income Level (PIL) for one (See Chart 5).I. Multiply this figure by six to determine the total for the deductible period. This is the individual's deductible.J. Subtract the cost of: 1. Medicare payments of the individual.2. Health insurance premiums incurred by the individual for the individual and/or the individual's spouse if the spouse is covered by Medicaid and is residing in an AFH, FRBH, CRBH, RCF, or AFCH, (as defined in Part 12, Section1), or receiving Home and Community Based Waiver services (See Part 13). Premiums must be incurred by the Medicaid recipient. If the health insurance is provided by the community spouse through his/her coverage, this is not considered to be a cost incurred by the Medicaid recipient. It is a cost incurred by the community spouse.
Note: Indemnity insurance premiums are not deducted. They are policies that pay for lengths of stay or for a condition and not for specific services. Third Party Liability should be contacted to assess cost effectiveness. If cost effective TPL will arrange for premium payment.
3. Outstanding medical bills incurred by the individual for necessary medical services (See Part 10).K. The balance is the remaining deductible. The deductible is met as follows: 1. If the gross income is in excess of the Categorical Income limit (Chart 4.1) and less than the Medicaid rate, subtract the Medicaid Rate for the six month period.2. If the gross income is equal to or over the Medicaid rate for the facility but less than the private rate, subtract the private rate for the six month period.
10-144 C.M.R. ch. 332, § 14-5