FEDERAL SPOUSAL IMPOVERISHMENT HANDBOOK

Transcription

1 FEDERAL SPOUSAL IMPOVERISHMENT HANDBOOK PART 1 - INTRODUCTION AND BACKGROUND... Introduction - 1 THE NEED FOR NURSING HOME CARE... Introduction - 1 PART 2 - DEFINITIONS...Definitions - 1 IDAHO SPOUSAL IMPOVERISHMENT (ISI)...Definitions - 1 SSI METHOD (SSI)...Definitions - 1 COMMUNITY PROPERTY METHOD (CP)...Definitions - 1 COMMUNITY PROPERTY...Definitions - 2 SEPARATE PROPERTY...Definitions - 2 FEDERAL SPOUSAL IMPOVERISHMENT (FSI)...Definitions - 2 INSTITUTIONAL SPOUSE (NURSING HOME SPOUSE)...Definitions - 3 COMMUNITY SPOUSE...Definitions - 3 CONTINUOUS PERIOD OF INSTITUTIONALIZATION...Definitions - 3 BEGINNING OF CONTINUOUS PERIOD OF INSTITUTIONALIZATIONDefinitions - 3 RESOURCE ASSESSMENT...Definitions - 4 SPOUSAL SHARE...Definitions - 4 COUNTABLE RESOURCES...Definitions - 4 COMMUNITY SPOUSE RESOURCE ALLOWANCE...Definitions - 4 RESOURCE TRANSFER ALLOWANCE (RTA)...Definitions - 4 MARRIAGE SETTLEMENT AGREEMENT...Definitions - 5 ESTATE PLANNING...Definitions - 5 PATIENT LIABILITY and CLIENT PARTICIPATION...Definitions - 5 Patient Liability...Definitions - 5 Client Participation...Definitions - 5 COMMUNITY SPOUSE ALLOWANCE (CSA)...Definitions - 5 COMMUNITY SPOUSE NEED STANDARD (CSNS)...Definitions - 5 FAMILY MEMBER ALLOWANCE (FMA)...Definitions - 5 DIVERTING -V- DEEMING...Definitions - 6 ESTATE RECOVERY...Definitions - 6 PART 3 - THE CHOICE OF SSI OR COMMUNITY PROPERTY...SSI or CP - 1 Idaho Spousal Impoverishment...SSI or CP - 1 SSI Method...SSI or CP - 1 Community Property Method...SSI or CP - 1 Other Considerations in the SSI or Community Property Choice.SSI or CP - 2 Both Spouses Must Choose the Same Method...SSI or CP - 2 Community Property Method is for Medicaid Only, Not AABD CashSSI or CP - 2 Explain the SSI or Community Property Choice...SSI or CP - 2 Written Decision for SSI or Community Property...SSI or CP - 2 SSI Participant...SSI or CP - 2

2 Changing from Community Property to SSI...SSI or CP - 2 Same Method for All Medicaid Programs...SSI or CP - 3 PART 4 - USING SPOUSAL IMPOVERISHMENT... ISI or FSI - 1 IDAHO SPOUSAL IMPOVERISHMENT (ISI)... ISI or FSI - 1 FEDERAL SPOUSAL IMPOVERISHMENT (FSI)... ISI or FSI - 1 WHEN TO USE FSI... ISI or FSI - 1 WHEN TO USE ISI... ISI or FSI - 1 USE FSI FOR INCOME AND RESOURCES... ISI or FSI - 2 PART 5 - INCOME...Income - 1 FSI - v - SSI INCOME CALCULATION METHOD CHART...Income - 2 IDAHO SPOUSAL IMPOVERISHMENT INCOME LIMITS...Income - 3 SSI Income Limits...Income - 3 Community Property Income Limits...Income - 4 FSI Income Limits...Income - 4 PART 6 - RESOURCES... Resources - 1 FSI - v - SSI RESOURCE CALCULATION METHOD CHART... Resources - 2 COMPUTING RESOURCES USING THE SSI METHOD... Resources - 3 Couple Living Together... Resources - 3 Couple Not Living Together... Resources - 4 COMPUTING RESOURCES USING THE COMMUNITY PROPERTY METHODResources - Couple Living Together... Resources - 4 Couple Not Living Together... Resources - 5 COMPUTING RESOURCES USING THE FEDERAL SPOUSAL IMPOVERISHMENT METHOD... Resources - 6 Counting Resources for FSI... Resources - 6 FSI RESOURCE ASSESSMENT... Resources - 6 COMPLETING RESOURCE ASSESSMENT... Resources - 7 COMPUTING THE COMMUNITY SPOUSE RESOURCE ALLOWANCEResources - 8 Spousal Share... Resources - 8 Maximum and Minimum Resource Standards... Resources - 8 Community Spouse Resource Allowance... Resources - 8 Resources of the Nursing Home Spouse... Resources - 9 Higher CSRA...Resources - 10 DETERMINE INITIAL RESOURCE ELIGIBILITY...Resources - 11 DETERMINE ONGOING RESOURCE ELIGIBILITY...Resources - 12 How to Treat an Increase in Resources...Resources - 12 FSI RESOURCE ELIGIBILITY DETERMINATIONS IN RETROACTIVE MONTHS...Resources - 13 Application Month...Resources - 13 Retroactive Months...Resources - 13

3 Statement of Intent...Resources - 14 FSI RESOURCE TRANSFERS...Resources - 15 Resource Transfer Allowance...Resources - 16 Resource Transfer Allowance (RTA)...Resources - 16 Protected Period for Resource Transfer...Resources - 16 Initial Eligibility...Resources - 16 Ongoing Eligibility...Resources - 16 New Resources of Community Spouse...Resources - 16 Methods of Transferring Resources...Resources - 17 Follow Up on Resource Transfers...Resources - 17 RESOURCES RECEIVED AFTER MEDICAID ELIGIBILITY ESTABLISHEDResources - 18 Unlimited Transfer to Community Spouse...Resources - 18 Property of Nursing Home Spouse...Resources - 18 Property of Community Spouse...Resources - 18 Property of Both Spouses...Resources - 18 Restriction on Transfers by Community Spouse Before Eligibility Is Established...Resources - 19 Break in Eligibility...Resources - 19 Transfers by Community Spouse After Eligibility Is EstablishedResources - 19 EFFECT OF ANNUAL CHANGE IN MINIMUM AND MAXIMUM RESOURCE STANDARDS...Resources - 19 Effect of Annual Resource Standard Change on Current ParticipantResources - 1 INCOME AND RESOURCE OWNERSHIP...Resources - 20 RESOURCE DEFINITIONS...Resources - 22 RESOURCE CONSIDERATIONS...Resources - 26 Resources...Resources - 26 Evaluating Resources...Resources - 26 Ownership of Resources...Resources - 26 Liquid and Nonliquid Resources...Resources - 26 Counting a New Resource...Resources - 26 Resource Exclusions...Resources - 27 Conditional Exclusion for Excess Nonliquid Resources Resources - 28 Exclusion of Certain Jointly Owned Real Property...Resources - 28 INVESTMENTS...Resources - 29 Savings Accounts...Resources - 29 NOW and Super NOW Accounts...Resources - 29 MMDA (Money Market Deposit Account)...Resources - 29 CD (Certificate of Deposit)...Resources - 29 Corporate Bonds...Resources - 29 Municipal bonds...resources - 29 UIT (Unit Investment Trust)...Resources - 30 Zero Coupon Bonds...Resources - 30 Buying and Selling Bonds...Resources - 30

4 Reading Bond Quotations...Resources - 30 Treasury Bills (T-Bills)...Resources - 30 Treasury Notes and Bonds...Resources - 31 TIGERS and CATS...Resources - 31 Federal Agency Securities...Resources - 31 Mutual Funds...Resources - 31 Common Stocks...Resources - 32 Preferred Stock...Resources - 33 Reading Stock Quotations...Resources - 33 Options...Resources - 34 Buying and Selling Options...Resources - 34 Reading Option Quotations...Resources - 34 IRA, KEOGH and 401K Accounts...Resources - 35 TRUSTS...Resources - 35 PART 7 - APPLICATION PROCESSING...Application Processing - 1 APPLICATION PROCESSING - NURSING HOME...Application Processing - 1 EPICS AND FSI...Application Processing - 4 EPICS PROCEDURES FOR FSI...Application Processing - 4 REGISTERING RESOURCE ASSESSMENTS FOR NON-APPLICANTSApplication Proces TRACKING INCOME AND RESOURCE METHODS (CP, SSI, & FSI)Application Processing FSI NURSING HOME CASES -- RECORDING RESOURCESApplication Processing - 6 FSI HCBS CASES -- RECORDING RESOURCES...Application Processing - 7 PART 8 - CASE MAINTENANCE... Case Maintenance - 1 FSI PATIENT LIABILITY AND CLIENT PARTICIPATION... Case Maintenance - 1 Patient Liability - Nursing Home Patient... Case Maintenance - 1 HCBS CLIENT PARTICIPATION... Case Maintenance - 3 ASSETS TRANSFERRED TO SPOUSE ON DEATH... Case Maintenance - 4 ESTATE RECOVERY IN IDAHO... Case Maintenance - 6

5 NOTICE AND DISCLAIMER This handbook is not a substitute for the Department of Health and Welfare's rules in IDAPA , Rules Governing Eligibility for Aid to the Aged Blind and Disabled (AABD). This handbook gives an overview of the Department's AABD rules. It is not promulgated, does not carry the force of law, and cannot be cited as a basis for case actions. PART 1 - INTRODUCTION AND BACKGROUND THE NEED FOR NURSING HOME CARE. Nursing home care is divided into short term care and long term care. Short term nursing home care lasts from a few days to a few weeks. For example, a person with a hip fracture may need short term care. They may not be well enough to return home after discharge from the hospital. They may need physical therapy or other skilled services. Medicaid will pay for some short term care. Private pay and Medicare will cover most of it. A patient with a severe mental or physical condition often needs long term nursing home care. This is especially true when social and financial resources no longer permit home care or assisted living. The family is usually involved in the decision about nursing home care. Long term nursing home care is needed when alternatives are not practical. The options to nursing home care are: Staying at home with Aged and Disabled Waiver services. Staying with family or friends. Assisted living. Senior citizen housing. The expense of medical care is a controlling factor in long term care placement. The patient needs medically complex expensive treatments. The family can help care for the patient but they can t afford the cost. The patient doesn t qualify for Medicaid because of their income or their spouse s income. Long term care permits eligibility because of the higher income limits and lack of spousal deeming. The patient can receive the needed medical care and drugs. Admission to the nursing home is stressful for the patient and the family. Families are frequently guided through this process. If the patient is admitted to the nursing home from a hospital, the hospital discharge planner usually helps. If the patient is admitted from home, the nursing home social worker usually helps.

6 PART 2 - DEFINITIONS IDAHO SPOUSAL IMPOVERISHMENT (ISI). Idaho Spousal Impoverishment is a provision of state law. ISI protects against the impoverishment of a married person when: Both spouses are in a nursing home. Both spouses are HCBS participants. One spouse is in a nursing home and the other is an HCBS participant. Both spouses are at home and only one spouse applies for non-hcbs Medicaid. One spouse is an HCBS participant, starting before The other spouse is at home, but is not an HCBS participant. ISI went into effect July 1, ISI added the Community Property Method for calculating income and resources. Until then, the SSI Method was the only method available. Idaho Spousal impoverishment offers the participant two choices for calculating income and resources: Community Property Method. SSI Method. SSI METHOD (SSI). The SSI Method calculates income and resources using AABD rules. Calculate income and resources by attributing to each spouse only the income or resources in his or her name. Divide joint income and resources. Attribute one-half to each spouse. This is the "name on the check" rule. Until July 1, 1988, it was the only method of calculating income or resources for the AABD programs. COMMUNITY PROPERTY METHOD (CP). The Community Property Method became available July 1, 1988 with the new state ISI law. The Community Property Method calculates income and resources by: Totaling the community property income and community property resources of both spouses. This is regardless of whose name is on the check or account. Attributing one-half of the community property income and one-half of the community property resources to each spouse. Adding the separate income and resources of the spouse.

7 COMMUNITY PROPERTY. Community property is income, personal property and real property a couple obtains during their marriage. Some couples commingle separate and community property. Count property not identified as separate property as community property. A spouse with ownership in separate property can change the status to community property. The spouse makes a declaration the property is community property. Participants can rebut the Department's determination on community property or separate property by providing evidence to support their claim. SEPARATE PROPERTY. Separate Property is income, personal property and real property owned by a spouse before marriage, and kept as separate property. Income received during marriage is usually community, not separate, property. Exceptions are: Personal injury awards. Retirement benefits paid to a spouse from a job ending before marriage. Disability benefits. The spouse owning the income or resource can change its status from separate to community property. Income owned by one spouse used to meet the couple's needs is community property. Resources, like gifts or inheritances, are usually separate property, whether acquired before or during the marriage. FEDERAL SPOUSAL IMPOVERISHMENT (FSI). Federal Spousal Impoverishment is a federal law protecting income and resources of a married person when the spouse: Enters a nursing home. or Gets home-care through HCBS.

8 INSTITUTIONAL SPOUSE (NURSING HOME SPOUSE). An Institutional Spouse is called the nursing home spouse in this handbook. The nursing home spouse meets one these conditions. Condition 1: Is an inpatient in a medical institution providing nursing facility services. Remains (or is likely to remain) in the institution for thirty (30) consecutive days. Is married to a spouse who is not institutionalized and is not an HCBS participant. OR Condition 2: Is an HCBS participant. Needs, receives or is likely to receive personal care services for thirty (30) consecutive days. (PCS is defined in Medical Assistance Handbook Section ) Is married to a spouse, who is not institutionalized and is not an HCBS participant. COMMUNITY SPOUSE. A Community Spouse is the husband or wife of the nursing home spouse. The Community Spouse is not in a nursing home and is not an HCBS participant. CONTINUOUS PERIOD OF INSTITUTIONALIZATION. A Continuous Period of Institutionalization means: At least thirty (30) consecutive days of residence in a nursing home. Thirty (30) consecutive days of HCBS. A thirty (30) day combination of the two. The thirty (30) consecutive cannot start on a day the participant is in a hospital. If the participant goes into a hospital later it does not interrupt the thirty (30) days. Absence from the institution or lapse in HCBS eligibility for at least thirty (30) consecutive days breaks the continuity. BEGINNING OF CONTINUOUS PERIOD OF INSTITUTIONALIZATION. The beginning of the continuous period of institutionalization is: The date the participant enters into the nursing home. OR The first day (after ) the participant gets personal care services under the HCBS waiver.

9 RESOURCE ASSESSMENT. The resource assessment is a "snapshot" of the couples income and resources on the date one spouse enters a nursing home, or begins HCBS. This is the start of the continuous period of institutionalization. Evaluate all resources owned by the couple. This includes community and separate property of each spouse. Assess and verify resource ownership and values as of the first day of the first continuous period of institutionalization. After the person applies, determine eligibility as of the first day of the application month. Federal law requires nursing care providers to advise all new admissions of the assessment process. The assessment provides beginning figures used for future resource computations. It is best, for the participant and the Department, to perform the assessment close to the nursing home entry date. This is regardless of whether or not a participant applies for Medicaid. The assessment is a one-time event. It is not redone, whether completed before application, or as part of the application process. SPOUSAL SHARE. The Spousal Share is one-half the couple's countable resources from the resource assessment. The amount calculated as the spousal share does not change, even if eligibility stops and restarts. COUNTABLE RESOURCES. Countable Resources are those counted for the AABD program. Exclude household goods, personal effects, and one (1) automobile. Use the conditional eligibility exclusion (AABD Handbook Section ) to determine countable resources of the nursing home spouse for eligibility. Do not use the conditional exclusion to calculate the spousal share if the joint owner is the community spouse. COMMUNITY SPOUSE RESOURCE ALLOWANCE. The Community Spouse Resource Allowance (CSRA) is the resources protected for the community spouse. Minimum and maximum amounts for the CSRA increase each year, based on changes in the Consumer Price Index. These increases can change the CSRA on cases using the minimum or maximum amounts from year to year. RESOURCE TRANSFER ALLOWANCE (RTA). The Resource Transfer Allowance (RTA) is the amount of resources transferred, without penalty, to the community spouse. The RTA increases the community spouse's resources up to the protected resource amount.

10 MARRIAGE SETTLEMENT AGREEMENT. A Marriage Settlement Agreement is a written agreement between the husband and wife. The Marriage Settlement Agreement changes ownership of property from separate to community, or vice versa. The Marriage Settlement Agreement may be done before or during the marriage. Accept a notarized agreement as evidence of the transfer of personal property. The agreement must itemize the property transferred. If real property is involved, the couple must record the agreement in the county where the property is located. The couple can use the HW-0970 "Marriage Settlement Agreement" form. The date the property transfer is notarized or recorded is the effective date of property transfer. ESTATE PLANNING. Estate Planning has two meanings: Managing assets to reduce federal tax liability. Managing assets to assure the couple has enough to live on during retirement. PATIENT LIABILITY and CLIENT PARTICIPATION. Patient Liability is the amount a nursing home participant must pay toward the cost of nursing home care. Client Participation is the amount an HCBS participant must pay toward the cost of personal care services. COMMUNITY SPOUSE ALLOWANCE (CSA). The Community Spouse Allowance is a reduction of the nursing home spouse's patient liability or client participation. The nursing home spouse must pay at least that amount to the community spouse. COMMUNITY SPOUSE NEED STANDARD (CSNS). The Community Spouse Need Standard is the maximum the nursing home spouse can give to the community spouse. FAMILY MEMBER ALLOWANCE (FMA). The Family Member Allowance is a reduction of the nursing home spouse's patient liability or client participation. Unlike the CSA, the FMA reduction does not depend on the nursing home spouse paying the amount for family member care.

11 DIVERTING -V- DEEMING. Idaho state law recognizes a mutual support obligation between: Husband and wife. Parents and dependent children. Diverting assigns income or resources from the participant to the participant's non-participant spouse or child. Deeming assigns income or resources from the participant's non-participant spouse to the participant. ESTATE RECOVERY. Estate Recovery gets back the value of Medical Assistance paid for an individual. The individual must have been age fifty-five or older when he got medical assistance. The Department does not use Estate Recovery: For services received before July 1, 1988 by a person 65 or older. For services received before July 1, 1994 by those between 5 and 65. For services needed because of a crime. While the spouse survives. Before a surviving child reaches age 21. As long as there is a surviving child, who became blind or permanently disabled before age 21.

12 PART 3 - THE CHOICE OF SSI OR COMMUNITY PROPERTY Idaho Spousal Impoverishment. The Idaho Spousal Impoverishment law gives couples the choice of using SSI or Community Property rules to determine Medicaid income and resource eligibility. The couple chooses the best method for Medicaid eligibility for one spouse. If the couple fails to choose, use the SSI method. If the couple chooses the Community Property method first, and is not eligible, use the SSI method. SSI Method. The SSI method uses AABD rules to calculate income and resources. The SSI method is called the "name on the check" rule. If a couple lives together their income and resources count jointly against the couple income limit. If a couple lives separately, each spouse's income and resources count for him or her alone. Single person income and resource limits apply. Community Property Method. The Community Property method protects the income and resources of the spouses. Toward each spouse, Community Property counts: One-half share of community property. AND The person s separate property. (Do not count the person s separate property toward the other spouse.) This method helps couples when one spouse has a larger share of the couple's income or resources because of his separate property. Community property helps the other spouse be Medicaid eligible. Only one spouse can be eligible using Community Property. If both apply, the total community income and each spouse's separate income counts toward the couple limit for the programs that spouse applies for. The result is the same as choosing the SSI method, and neither spouse will be eligible. One will need to withdraw his application. If one spouse applies, use the single person income and resource limits. EXAMPLE: Mr. and Mrs. Albatross have total joint income of $600. Mrs. Albatross has another $400 in separate income. The couple income limit for the Albatross' is $768. The single person limit is $545. Mr. Albatross is the applicant. Using Community Property, Mr. Albatross has $300 (one-half of the couple's $600 community income). Mrs. Albatross has $700 (one-half of the community income, plus her separate $400). Mr. Albatross is income eligible. His income is less than $545, the single person income limit.

13 Using the SSI method, the Albatross' total income is $1,000. The couple income limit is $768. Neither Albatross is eligible. Other Considerations in the SSI or Community Property Choice. Both Spouses Must Choose the Same Method. Both spouses must use the SSI method, or both must use the Community Property method. If they can t agree, use the SSI method. If the couple agrees on a choice later, use that choice. Community Property Method is for Medicaid Only, Not AABD Cash. Use Community Property only to determine Medicaid eligibility. Do not use Community Property for AABD cash. Explain the SSI or Community Property Choice. Explain the choice of SSI or Community Property to the couple. Calculate the couple's income and resources under both methods. Determine the better method for the couple. Tell the couple of the advantages and disadvantages of both methods. Let the couple choose. Give the couple an HW1022, You Have a Choice for Medicaid. This form is the written explanation required in Section of the AABD Reference Guide. Written Decision for SSI or Community Property. The couple must make their SSI or Community Property decision in writing. They can use the "Certification of Choice--Community Property/SSI," (HW401) form. If one spouse can t sign, these persons can sign: The spouse. A court-appointed guardian. A person with power of attorney. If both spouses are unable to sign, the guardian or person with power of attorney may sign in their behalf. SSI Participant. An SSI participant can t use Community Property. An SSI participant may voluntarily stop his SSI if he wants to use Community Property. He can t be penalized for stopping his SSI for Community Property. Explain the advantages and disadvantages of stopping his SSI. Changing from Community Property to SSI. A couple can change from Community Property to SSI or vice versa. The couple must notify the Department in writing. A change is effective the month after they notify the Department in writing.

14 EXAMPLE: One spouse starts receiving separate income. The income makes both ineligible using SSI. The couple can change to Community Property and keep one spouse eligible for Medicaid. One spouse stops receiving separate income from a sales contract. The couple changes from Community Property to SSI to make them eligible for AABD cash. EXAMPLE: Mr. and Mrs. Shelly choose the SSI method. Their total community income is $600. They don t have separate income. Both are eligible for Medicaid. Mr. Shelly starts receiving separate income of $400 monthly from a trust. Under the SSI method, the couple's total income of $1000 is too high to qualify. Using Community Property, Mrs. Shelly is eligible for Medicaid. Only $300, her one-half share of the community income, is counted for her. Mr. Shelly is not eligible using Community Property. His income is too high. EXAMPLE: Mr. Shelly's trust income ends a year later. The total community income is now $700. Mr. Shelly reapplies for Medicaid and AABD cash. The choice of SSI or Community Property is not available, because the Shellys want AABD cash assistance. Use AABD rules (the SSI method) to determine AABD cash eligibility. The Shellys are eligible for AABD cash because their combined income is now under the couple income limit. The Shellys will get Medicaid along with AABD cash. Same Method for All Medicaid Programs. One spouse may apply for Qualified Medicare Beneficiary (QMB) benefits. The other spouse may apply for regular Medicaid. Use the same method, either Community Property or SSI, for both spouses. For example, Mr. Greenie wants regular Medicaid and Mrs. Greenie wants QMB. Both spouses must use the same method. If their income is too high for regular Medicaid using the SSI method, only one can qualify. See AABD Reference Guide Sections through 768.

15 PART 4 - USING SPOUSAL IMPOVERISHMENT Idaho Spousal Impoverishment (ISI) and Federal Spousal Impoverishment (FSI) allow one spouse to be eligible for Medicaid. The other spouse can keep his or her share of the couple's resources. Before ISI and FSI, the couple s combined income and resources were counted. Many couples had to spend down their resources before they were eligible. This left one spouse in poverty, or both ineligible. ISI and FSI do not change how we define or count income and resources. IDAHO SPOUSAL IMPOVERISHMENT (ISI). Idaho Spousal Impoverishment (ISI) is a State law protecting income and resources for the spouse not receiving AABD cash or Medicaid. This law went into effect July 1, ISI is the "SSI or Community Property" choice described in part 3. FEDERAL SPOUSAL IMPOVERISHMENT (FSI). Federal Spousal Impoverishment (FSI) is a Federal law protecting part of a couple's income and resources for the spouse at home, when one spouse is in a nursing home or on HCBS. Federal Spousal Impoverishment began October 1, FSI replaces ISI when: One spouse entered the nursing home or started HCBS after September 30, The other spouse remains at home. WHEN TO USE FSI. Use FSI for Medicaid, even for a nursing home spouse getting SSI. If the SSI participant is not eligible using FSI, he isn t eligible for Medicaid. This can happen when the Community Spouse has sizeable assets and the couple has lived apart for a month. SSI does not deem income or resources starting the month after the month a couple separates. The assets of the Community Spouse do not count for SSI eligibility. FSI does count the assets of the Community Spouse for Medicaid eligibility. WHEN TO USE ISI. Use Idaho Spousal Impoverishment for income and resources when: Both spouses are at home. Neither is on HCBS. Or Both spouses are in a nursing home or both are on HCBS. They entered the nursing home or started HCBS before September 30, Or One spouse entered the nursing home or started HCBS before September 30, The other spouse is not in a nursing home or on HCBS. Use FSI for patient liability. Or One spouse is in a nursing home. The other is on HCBS.

16 USE FSI FOR INCOME AND RESOURCES. Use Federal Spousal Impoverishment for income and resources when: One spouse is in the nursing home. The other is at home and not on HCBS. Or One spouse is on HCBS. The other is not in a nursing home or on HCBS. Use Federal Spousal Impoverishment for Patient Liability and Client Participation. Calculate patient liability and client participation using FSI, even if ISI was used for eligibility. Use the AABD rules to calculate AABD or Medicaid Benefits for the Community Spouse. Use AABD rules for the community spouse, no matter what method is used for eligibility of the nursing home or HCBS spouse.

17 PART 5 - INCOME The definition of income is the same for ISI and FSI. ISI and FSI assign income differently for eligibility, patient liability, and client participation. The chart on the next page shows how to count income for ISI and FSI, based on the couple s circumstances.

18 FSI - v - SSI INCOME CALCULATION METHOD CHART Spouse In NH Start Date Before 9/30/89 In NH Start Date On/After 9/30/89 At Home No HCBS At Home HCBS Start Date Before 9/30/89 At Home HCBS Start Date On/After 9/30/89 In NH Start Date Before 9/30/89 ISI ISI *FSI ISI ISI Sp ou s e In NH Start Date On/After 9/30/89 ISI ISI *FSI ISI ISI At Home No HCBS *FSI *FSI FREE! **FSI ***FSI At Home HCBS Start Date Before 9/30/89 ISI ISI **FSI ISI ISI At Home HCBS Start Date On/After 9/30/89 ISI ISI ***FSI ISI ISI * If ineligible using FSI income calculation, use CP for income calculation. ** If ineligible using FSI income calculation, use ISI for income calculation. *** If ineligible using FSI income calculation, use ISI for income and resource calculations. ISI = Idaho Spousal Impoverishment Method (SSI/CP Choice) FSI = Federal Spousal Impoverishment Method SSI = SSI Method (Same as AABD Money Payment Method) CP = Community Property Method

19 IDAHO SPOUSAL IMPOVERISHMENT INCOME LIMITS. The ISI income limit for a married person depends on the Medicaid eligibility method the couple chooses: SSI. or Community Property. SSI Income Limits. The SSI method uses the AABD couple income limit. Use the single person HCBS income limit for each spouse in an HCBS couple. The couples in the following living situations do not have HCBS. Use the Independent Basic Allowance for a couple living independently. Use the single person nursing home income limit for each spouse when both are in a nursing home. For a couple living together in one of the living situations below, use twice the income limit for a single person in that living situation. Board and room. Certified family home. Residential and assisted living facility. Semi-independent group residential care. Use the single person Independent Basic Allowance for each spouse, when they live apart in independent living situations. Use the single person income limit for each spouse s living situation, when they live apart and neither lives in a nursing home.

20 Community Property Income Limits. The Community Property method uses the AABD income limits. Use the: Single person income limit if the spouses live together, and only one applies. Single person income limit if the spouses live apart. This applies whether one or both are applicants. Couple income limit if the couple lives together and both apply. Use the limits given in the following living situations. Use the single person HCBS income limit for each spouse of an HCBS couple, living together or apart. Use the single person Independent Basic Allowance for the applicant spouse living independently if only one applies or the couple lives apart. Use the couple Independent Basic Allowance if both apply and live together independently. Use the single person income limit for one of the living situations below, for each spouse, living together or apart. Board and room. Certified family home. Residential and assisted living facility. Semi-independent group residential care. Use the single person nursing home income limit for each spouse when the couple lives in: The same room in a nursing home. Different rooms in the nursing home Separate nursing homes. FSI Income Limits The FSI method uses the nursing home single person income limit for the spouse in the nursing home. Use the AABD single person limit for the spouse at home. The AABD limit depends on the spouse s living situation. Use the HCBS single person income limit for an HCBS spouse. See AABD Reference Guide Sections ; ; ; ; ;

21 PART 6 - RESOURCES The definition of resources is the same for ISI and FSI. ISI and FSI assign resources differently for eligibility, patient liability, and client participation. The chart on the next page shows how to count resources for ISI and FSI, based on the couple s circumstances.

22 FSI - v - SSI RESOURCE CALCULATION METHOD CHART Spouse In NH Start Date Before 9/30/89 In NH Start Date On/After 9/30/89 At Home No HCBS At Home HCBS Start Date Before 9/30/89 At Home HCBS Start Date On/After 9/30/89 In NH Start Date Before 9/30/89 ISI ISI ISI ISI ISI Sp ou s e In NH Start Date On/After 9/30/89 ISI ISI FSI ISI ISI At Home No HCBS ISI ISI FREE! ISI *FSI At Home HCBS Start Date Before 9/30/89 ISI ISI ISI ISI ISI At Home HCBS Start Date On/After 9/30/89 ISI ISI *FSI ISI ISI *If ineligible using FSI resource calculation, use ISI for income and resource calculation ISI = Idaho Spousal Impoverishment Method (SSI/CP Choice) FSI = Federal Spousal Impoverishment Method SSI = SSI Method (Same as AABD Money Payment Method) CP = Community Property Method

23 COMPUTING RESOURCES USING THE SSI METHOD. Couple Living Together. One Spouse Applies for Medicaid. Determine the couple s resources after exclusions. Compare the resources to the couple resource limit. If there is a deficit, the applicant spouse is eligible. Step 1: Step 2: Step 3: Step 4: Total the couple's resources, separate and community. Subtract the applicable AABD resource exclusions, to determine the couple's countable resources. The couple gets one home exclusion and one vehicle exclusion. They each get the life insurance and burial fund exclusion. Compare the couple's countable resources to the AABD couple resource limit. If no deficit, check eligibility for one spouse using Community Property. Both Spouses Apply for Medicaid Step 1: Step 2: Step 3: Step 4: Total the couple's resources, separate and community. Subtract the applicable AABD resource exclusions to determine the couple's countable resources. The couple gets one home exclusion and one vehicle exclusion. They each get the life insurance and burial fund exclusion. Compare the couple's countable resources to the AABD couple resource limit. If no deficit, check eligibility for one spouse using Community Property.

24 Couple Not Living Together. One or Both Apply for Medicaid. Step 1: Step 2: Step 2: Step 3: Step 4: During the month of separation, compute the couple's resources as though they were still living together in their original living situation that month. Beginning the month after the month the couple stopped living together, treat each spouse as a separate individual. Total the applicant's resources. Subtract the applicable AABD resource exclusions. Compare the applicant's countable resources to the single person AABD resource limit. If no deficit, check eligibility for one spouse using Community Property. COMPUTING RESOURCES USING THE COMMUNITY PROPERTY METHOD. Couple Living Together. One Spouse Applies for Medicaid. Step 1: Step 2: Step 3: Step 4: Step 5: Total the couple's community resources. Subtract the applicable AABD resource exclusions. The couple gets one home exclusion and one vehicle exclusion. They each get the life insurance and burial fund exclusion. Divide the result by 2. This is each spouse's one-half share of the community resources. Add each spouse's separate resources, less exclusions, to his or her onehalf share of community resources. Compare the result from Step 4 to the single person resource limit. If there is a deficit, the individual is resource eligible.

25 Couple Living Together. Both Spouses Apply for Medicaid. Step 1: Step 2: Step 3: Total the couple's community and separate resources. Subtract the applicable AABD resource exclusions. The couple gets one home exclusion and one vehicle exclusion. They each get the life insurance and burial fund exclusion. Compare the result from Step 2 to the couple resource limit for programs each spouse is applying for. Couple Not Living Together. One or Both Apply for Medicaid. Step 1: Step 2: Step 3: Step 4: Step 5: Total the couple's community resources. Subtract the applicable AABD resource exclusions. The couple gets one home exclusion and one vehicle exclusion. They each get the life insurance and burial fund exclusion. Divide the result by 2. This is each spouse's one-half share of the community resources. Add each spouse's separate resources, less exclusions, to his one-half share of community resources. For each spouse, compare the result from Step 4 to the single person resource limit. If there is a deficit, that spouse is resource eligible. Each spouse gets the single person resource limit. The single person limit is effective the first day of the month after they separate.

26 COMPUTING RESOURCES USING THE FEDERAL SPOUSAL IMPOVERISHMENT METHOD. Counting Resources for FSI. The FSI resource determination process has three parts: Assessment Calculating resources protected for the community spouse in the Community Spouse Resource Allowance (CSRA). Calculating resources available to the nursing home spouse for determining eligibility. Use the FSI resource counting rules for HCBS, when a couple lives together and one spouse is on HCBS. FSI RESOURCE ASSESSMENT. Complete an assessment for couples under FSI rules. Nursing homes should immediately advise the couple of the need for a resource assessment. The assessment should be done close to the nursing home entry date. This benefits the couple. Verification is more readily available closer to the entry date. An assessment can be done without an application. The pamphlet, Can I Get Help with Nursing Home Costs? (HW1031) describes the resource assessment for the couple. A resource assessment is a record of the type, value, and ownership of all resources owned by a couple. The RMU must say the participant will be in the nursing home for at least 30 days. If the participant leaves the nursing home before 30 days is up the resource assessment does not count. Do a new assessment if the participant goes back in the nursing home for 30 days or more. Assess the resources the couple has the first day of the 30 days. This assessment is the only assessment if the participant stays in the nursing home 30 days or more. Do not do another assessment, even if the participant leaves the nursing home after the first 30 days and then re-enters a month or more later. For HCBS participants, the RMU must say the participant is likely to require HCBS for at least 30 days. Assess the resources the HCBS couple has the first day of the 30 days.

27 COMPLETING RESOURCE ASSESSMENT. A resource assessment is complete when: The couple completes and signs the "Medicaid Resources Declaration for Couples Assessment" (HW 1014). This form is their declaration of all the resources they owned on the first day of the nursing home stay. The Application substitutes for the HW 1014 when the couple applies the month one spouse goes into the nursing home. Identify the assessment date for the couple. Verify the type, value and ownership of all resources declared on the HW 1014 or Application. Include excess resources offered for sale and jointly owned real property in the couple's countable resources. Use AABD resource exclusions, except: Unlike AABD cash and non-fsi Medicaid, there is no limit on the total value of household goods and personal effects. Exclude one vehicle regardless of its value. Count additional vehicles using their equity value. To determine the nursing home spouse's resource eligibility, apply the regular AABD vehicle exclusion. Complete the "Resources Assessment for Couples" (HW 1015), and give a copy to the couple, along with a notice of hearing rights. The HW 1015 shows the couple: The type, value and ownership of each countable resource owned by the couple. The community spouse s share of the resources (spousal share). Complete the "FSI Resource Eligibility Worksheet" (HW 1016) as a trial eligibility. Use the HW 1016 information to tell the couple if they are resource eligible. If they are ineligible, tell them how much resources they need to spend to be eligible. Register the assessment on EPICS, if the couple is not applying for Medicaid when they request the assessment. See Part 7, EPICS and FSI, page 1, for instructions. When a couple requests an assessment before applying for Medicaid, manually notify them of the assessment results. Send their copy of the HW 1015, with a short cover letter. Do not use EPICS notices. See AABD Reference Guide Sections and

28 COMPUTING THE COMMUNITY SPOUSE RESOURCE ALLOWANCE. After the assessment is done and the nursing home spouse applies for Medicaid, calculate the CSRA. The CSRA is the Community Spouse Resource Allowance. It is the part of the couple's resources protected for the community spouse. The CSRA shows if the nursing home spouse has too many resources to qualify for Medicaid. Spousal Share. Step 1: Calculate the Spousal Share. Divide the couple's countable resources from the assessment by 2. This is the Spousal Share. The Spousal Share stays at the original amount. It does not matter if the couple's resources increase or decrease after the assessment. EXAMPLE: Mr. Participant enters a nursing home on November 7. Mrs. Participant requests an assessment. The assessment shows the Participants own a total of $55,000 in resources, that are not excluded. The Spousal Share is $27,500, one-half the assessment value of the couple's resources. The Participants wait until June to apply for Medicaid. In June, the Participant's total resources have decreased to $40,000. The spousal share remains $27,500. If the Participant's resources had increased, the spousal share would remain at $27,500. Maximum and Minimum Resource Standards. Step 2: Compare the spousal share to the maximum and minimum resource standards. The standards change annually in January. In 2000, the resource standards used to calculate the CSRA are: Maximum $84,120 Minimum $16,900 Community Spouse Resource Allowance. Step 3: If the Spousal Share is lower than the Minimum Resource Standard, the Minimum Resource Standard is protected for the community spouse. If the Spousal Share is higher than the Maximum Resource Standard, the Maximum Resource Standard is protected for the community spouse.

29 EXAMPLE 1: Mr. Woofard and his wife, Millie have countable resources of $50,000. The Spousal Share is one-half, $25,000. $25,000 is higher than the Minimum Resource Standard of $16,900 and lower than the Maximum Resource Standard of $84,120. Millie s CSRA is $25,000. The CSRA always equals the Spousal Share when the couple s resources are higher than the Minimum and lower than the Maximum. EXAMPLE 2: Mrs. Whatnot and her husband Orv have countable resources of $20,000. One-half is $10,000. $10,000 is lower than the Minimum Resource Standard. The Spousal Share is less than the Minimum Resource Standard of $16,900 so the CSRA is equal to the Minimum Resource Standard. The CSRA for Orv Whatnot is the $16,900, the Minimum Resource Standard. EXAMPLE 3: Mr. Crease and his wife Eloise have countable resources of $200,000. One-half is $100,000. $100,000 is higher than the Maximum Resource Standard of $84,120. The Spousal Share for Eloise is $100,000. $100,000 is higher than the Maximum Resources Standard so the CSRA for Eloise Crease is $84,120. Resources of the Nursing Home Spouse. Step 4: The resources over the CSRA count toward the nursing home spouse. This is regardless of which spouse owns the resource. EXAMPLE 1: Mr. and Mrs. Case have $100,000 in resources. Mrs. Case is the nursing home spouse. $50,000 counts toward her Medicaid resource limit of $2,000. $50,000 is the amount of the couple's resources exceeding the $50,000 CSRA. EXAMPLE 2: The Lemps have $88,120 in resources. Mrs. Lemp s spousal share is $84,120. Mr. Lemp is the nursing home spouse. $4,000 in resources count toward his $2,000 resource limit. This is the amount of the couple's resources exceeding the CSRA. EXAMPLE 3: The Cruises have $300,000 in resources. Mrs. Cruise is the nursing home spouse. $215,880 counts as her resources. This is the couple's resources over the $84,120 CSRA.

30 Higher CSRA. The couple may get a higher CSRA through the hearing process. The couple must first prove their combined income is less than the minimum Community Spouse Need Standard (CSNS). This is the Income First test. Couple income is the community spouse s gross income, plus the nursing home spouse s income. EXAMPLE: The nursing home spouse has $950 in gross income. Gross income is income after exclusions, but before disregards. He pays his own buy-in premium. His only other deduction is the $30 personal needs allowance. The community spouse has Social Security of $550. Nursing Home Spouse Income: $ Nursing home spouse income before deductions Personal needs Buy-in premium $ Nursing home spouse s income for the Income First test Community Spouse Income: $ Community spouse income Nursing home spouse income $ Total couple income for "Income First" test Community Spouse Need Standard - $1,407. Community spouse has no excess shelter. Note: The CSNS changes from $1,383 to $1,407 in July, The couple s income of $1, is higher than the $1,407 CSNS. Their CSRA cannot be higher than originally computed. The couple has enough income to meet the community spouse's needs. If their income, less deductions, was less than the CSNS, they could ask for a higher CSRA through the hearing process. If the couple passes the Income First test, the community spouse must prove she needs a greater share of the couple's income-producing resources than the CSRA allows. The community spouse must have income less than the minimum community spouse income standard to have the CSRA increased through the hearing process.

31 Stipulation: Usually, a formal hearing is not held. The participant s representative stipulates to the facts. The Department reviews the stipulation and agrees or disagrees. The hearing officer reviews the stipulations and gives his decision. The minimum Community Spouse Need Standard used to calculate spouse income is the same standard used in the patient liability computation. The minimum community spouse need standard for 1999 is $1,383 from through The standard changes to $1,407 on July 1, See AABD Reference Guide Sections , 744, 745 DETERMINE INITIAL RESOURCE ELIGIBILITY. Step 1: Total the couple's nonexcluded resources, as of the first day of the application month. Step 2: Calculate the Community Spouse Resource Allowance based on the assessment and spousal share. Step 3: Subtract the Community Spouse Resource Allowance from the couple's total nonexcluded resources. Compare the result to the single person resource limit. If there is a deficit, the nursing home spouse is resource eligible for Medicaid.

32 DETERMINE ONGOING RESOURCE ELIGIBILITY. Evaluate changes in resources as of the first day of the month following the month the participant gets the resource. If the participant has spent all or part of the resources by that date, do not count the amount spent. There is no overpayment. Changes in eligibility from the resource increase depend on the spouse owning the resource, as shown below. How to Treat an Increase in Resources. 1. Increase in Resources Owned Solely by Community Spouse. Do not count an increase in resources owned solely by the community spouse toward the nursing home spouse after eligibility starts. 2. Increase in Resources Owned Solely by Nursing Home Spouse. Add an increase in resources owned solely by the nursing home spouse to his other nonexcluded resources. The new resource amount counts the first day of the month after the new resource is received. Do not count resources the participant has spent by that date. 3. Increase in Community Resources. Count one-half share of an increase in community resources to each spouse. The onehalf share owned by the community spouse does not affect eligibility of the nursing home spouse. The nursing home spouse may transfer his share to the community spouse without a penalty. There is no limit on the amount of community or separate resources the nursing home spouse can transfer to the community spouse after eligibility starts. See AABD Reference Guide Sections

33 FSI RESOURCE ELIGIBILITY DETERMINATIONS IN RETROACTIVE MONTHS. For the three month Medicaid retroactive coverage period, use the same criteria for resource eligibility as used for the application month. The nursing home spouse is resource eligible in any of the three retroactive months when: The nursing home spouse has $2,000 or less in resources. The couple's current combined resources, minus the CSRA is $2,000 or less. OR The nursing home spouse has more than $2,000 in resources. He would be resource eligible if he transferred the excess resources to the community spouse. The transferred resources must be less than the difference between the CSRA and the resources the community spouse now owns. EXAMPLE: The Joneses requested an assessment in July, when Mr. Jones entered the nursing home. In July, the couple's resources totaled $35,000. The spousal share was $17,500. $17,500 was also Mrs. Jones CSRA. The couple s resources over $17,500 were attributed to Mr. Jones. With $17,500 in resources he was not resource eligible in July. Application Month. Mr. Jones applies for Medicaid on December 5. As of December 1, the Joneses spent down their resources to $17,000. Mrs. Jones CSRA is the $16,900 resource standard minimum. The $16,900 is protected for Mrs. Jones. Mrs. Jones owns separate resources of $2,000. The couple owns $15,000 in community property. Of the total $17,000 in resources Mrs. Jones actually owns $9,500. She owns $2,000 of separate resources. Plus Her $8,500 half of the community resources. Mr. Jones transfers $7,250 of his share of the community resources to Mrs. Jones. This brings her resources up to $16,750. This is less than her CSRA. Mr. Jones keeps $250 in countable resources. The transfer lowers Mr. Jones' resources under the $2,000 Medicaid limit. He is resource eligible in December. Retroactive Months. The potential retroactive coverage months for Mr. Jones are November, October and September.