Eligibility Online Manual

M906 Completing Medical Assistance Computations

Purpose: This section will assist in completing medical assistance computations.


Current Policy Effective Date: April 1, 2021

Date Last Reviewed: April 1, 2021

Previous Policy: November 1, 2019

POL M906: COMPLETING MEDICAL ASSISTANCE COMPUTATIONS

1. Employed Individuals With Disabilities (EID) Premium

The EID program requires a monthly premium to be paid by the client based on gross monthly income. The premium must be recalculated when there is an increase or decrease in income.

Refer to Section M1003 for information on how to calculate the premium.

2. Certain Clients May Pay Patient Contribution Toward Cost Of Care

A client in ICF-ID (Wyoming Life Resource Center), Geriatric Hall at the State Hospital in Evanston, Inpatient Hospital, or Nursing Home/Swing Bed must pay a patient contribution toward their cost of care.

The following programs do not require a patient contribution:

    • Acquired Brain Injury Waiver

    • Comprehensive and Support Waivers

    • Children’s Mental Health Waiver

    • Hospice Care

    • Community Choices Home & Community Based Waivers

3. Patient Contribution May Be Required For Partial Month

ICF-ID (Wyoming Life Resource Center), Geriatric Hall at the State Hospital in Evanston, Inpatient Hospital, or Nursing Home/Swing Bed client must private pay toward their cost of care when a partial month penalty is imposed from an uncompensated resource transfer. Refer to Medicaid Table 9 for additional information.

4. Clients May Pay Prorated Patient Contribution

A client may pay a prorated amount toward the cost of care, based on the number of days in the facility, when any of the following occur:

    • Client enters or is discharged from a facility after the first of the month.

    • Medicare is no longer paying room and board in full and the facility has notified you of the end date.

    • Client passes away.

5. Clients With A Long Term Care (LTC) Insurance Policy May Pay A Reduced Patient Contribution

An LTC Insurance policy that pays directly to the facility, provider or the Wyoming Department of Health (WDH) reduces the amount the client pays toward their cost of care.

6. Clients May Not Pay An Initial Patient Contribution

Clients, who are already Medicaid eligible when they enter the nursing home, are not required to pay a patient contribution for the first 30 days in a facility. After 30 days pass, a patient contribution is required for the next full month.

Clients who are eligible for the Medicare Savings program are required to pay a patient contribution beginning with the month of entry into a nursing home.

7. Child Support May Be Deducted

The actual court ordered liability for child support may be deducted, against gross countable income, when calculating the patient contribution.

8. Deduction For Dependent Child

Dependent deduction may be allowed, against gross countable income, for each dependent child. Refer to Medicaid Table 1A for the dependent deduction amount.

9. Spousal Maintenance Allowance May Be Deducted

Spousal maintenance allowance may be deducted, against gross countable income, when there is a community spouse and his or her spouse is Medicaid eligible in a nursing home. Refer to Medicaid Table 1A for spousal maintenance allowance amount.

Community spouses should be informed the receipt of the spousal maintenance allowance could cause the loss of SSI, Medicaid, and/or MSP benefits.

Clients may refuse to make an allowance available or allow a partial allowance by writing a statement.

10. Spousal Maintenance Allowance May Increase

A spousal maintenance allowance may increase if the community spouse is found to have exceptional circumstances resulting in extreme financial duress.

11. Medical Expenses May Be Deducted From Patient Contribution

Medical expenses not covered by Medicaid, Medicare, private insurance, or a third party may be deducted, against gross countable income, when calculating the patient contribution.

Do not allow a deduction when a transfer penalty has been assessed on the case.

Medical expenses may be deducted from income, when calculating the patient contribution, until the medical expense is paid in full.

12. Medical Care Items Included In Daily Rates Must Not Be Deducted

Medical care items provided by an institution and included in the daily rate must be excluded from deductions. These include:

    • Wheelchairs, ice bags, bed rails, canes, crutches, walkers, or repair/replacement of such items

    • Influenza or pneumococcal vaccines

    • Oxygen or surgical supplies

    • Over-the-counter items

13. Medicare Premium May Be Deducted From Patient Contribution

Allow a medical deduction, for Medicare premium(s) when calculating the patient contribution, as follows:

    • Nursing Home/QMB Medical deduction for the Medicare Premium(s) in the first month.

    • Nursing Home/QI - Medical deduction for the Medicare Premium(s) for the first two months.

    • Nursing Home/SLMB - Monthly medical deduction for the portion of the Medicare Part C and D Premium(s), when the premium exceeds the amount allowed by Medicaid.

14. Health Insurance Premiums May Be Deducted From Patient Contribution

Allow a deduction, against gross countable income, for a health insurance premium and increase the deduction in any month the premium changes, when calculating the patient contribution.

      • Allow a deduction when the client has a single health insurance policy and pays a premium.

      • Allow a deduction for the portion of the premium, applicable to the client, when there is a joint health insurance policy.

      • Allow a deduction for the portion of the premium, applicable to the client, when the spouse pays the health insurance premium.

15. Home Maintenance Expense May Be Deducted From Patient Contribution

Allow a monthly deduction of $150, against gross countable income, to cover home maintenance for an individual or couple who are temporarily in an institution for six months or less.

Clients must provide a written statement from a physician to verify the temporary stay.

Expenses may not be deducted if the client has a community spouse.

16. Guardianship Costs May Be Deducted From Patient Contribution

Allow a deduction of $500, against gross countable income, to help with the cost of establishing a guardianship. An additional $75 per month may be deducted for guardianship fees.

17. Personal Needs Allowance Of $50 May Be Deducted Monthly

18. Wyoming Life Resource Center Individuals May Be Allowed A Working Deduction

Allow a deduction of $65 plus one-half of the remaining earned income, not to exceed $300, against gross countable income, for each working individual in the Wyoming Life Resource Center.

19. Income Trust Distributions For Nursing Home

For income trusts established on or after October 17, 2017

Allow the following distributions from an Income Trust:

    • Monthly distribution for each dependent child. Refer to Medicaid Table 1A.

    • Monthly distribution for Trustee Fees not to exceed $20 per month.

    • Yearly distribution for Income Tax, when taxes are required by law and owed to the Internal Revenue Service (IRS).

    • One-time distribution of no more than $100 for actual verified expenses related to the establishment of the Income Trust.

    • Distribution of $500 to help with the cost of establishing a guardianship.

    • Monthly distribution of $75 for guardianship fees.

    • Monthly spousal maintenance allowance. Figure by taking the spousal maintenance allowance minus the income of the community spouse. Refer to Medicaid Table 1A (F). The balance is the amount that can be distributed to the community spouse from the trust.

For income trusts established after September 1, 1998:

    • Allow all deductions listed above. In addition, allow the following distributions from the Income Trust:

      • Administrative fees of the trust, not to exceed $20 per month.

      • Income tax owed on the income within the trust.

      • Attorney fees the trust is obligated to pay.

20. Income Trust Distributions For HCBS Waivers

For Income Trusts set up on or after October 17, 2017:

Allow the following distributions from an Income Trust:

    • Monthly distribution to the client, of the maximum income standard to the client. Refer to Medicaid Table 1A.

    • Monthly distribution for each dependent child. Refer to Medicaid Table 1A.

    • Monthly distribution for Trustee Fees, not to exceed $20 per month.

    • Yearly distribution for Income Tax, when taxes are required by law and owed to the Internal Revenue Service (IRS).

    • One-time distribution of no more than $100 for actual verified expenses related to the establishment of the Income Trust.

    • Distribution of $500 to help with the cost of establishing a guardianship.

    • Monthly distribution of $75 for guardianship fees.

    • Monthly spousal maintenance allowance. Figure by taking the spousal maintenance allowance minus the income of the community spouse. Refer to Medicaid Table 1A (F). The balance is the amount that can be distributed to the community spouse from the trust.

The following may be distributed from an Income Trust established before October 17, 2018:

    • A monthly payment of the maximum income standard. Refer to Medicaid Table 1A (A).

    • Administrative fees of the trust, not to exceed $20 per month.

    • Income tax owed by the trust.

    • Attorney fees the trust is obligated to pay.

    • Spousal maintenance allowance.

      • Figure by taking the spousal maintenance allowance minus the income of the community spouse. Refer to Medicaid Table 1A (F). The balance is the amount that can be distributed to the community spouse from the trust.

    • Monthly distribution for each dependent child. Refer to Medicaid Table 1A.

    • Distribution of $500 to help with the cost of establishing a guardianship.

    • Monthly distribution of $75 for guardianship fees.

Reference:

Defining Requirement: 20 CFR 416, Subpart K

42 CFR Subpart I

Clarifying Information:

Worker Responsibilities:

Calculating Income And Converting To Monthly Amount

1. Paid weekly - Multiply gross income by 4.3 for monthly amount.

2. Paid bi-weekly - Multiply gross income by 2.15 for monthly amount.

3. Paid semi-monthly - Multiply gross income by 2 for monthly amount.

Allow applicants to anticipate income on a month-to-month basis rather than using the 4.3, 2.15, or 2 conversions, when advantageous to the assistance unit.

Determining Patient Contribution

1. Prorate the patient contribution when a client resides in nursing home for a partial month.

Example:

Prorating Income

Client enters nursing home on 3/19.

Monthly income is $1307.90.

$1307.90 - $304.90 (allowable deductions) divided by 31 days = $32.25 x 9 days = $291.15 patient contribution.

2. Calculate the patient contribution when an individual has a long term care insurance policy in the following manner:

Example:

Long Term Care Insurance Policy

Example 1

STEP 1

Nursing Home Daily Rate: $143.10

Times # of days in month x 30

Total monthly Medicaid rate $4,293.00

LTC insurance payment $140.00

Times # of days in month x 30

Total monthly LTC Insurance payment - $4,200.00

Subtract monthly Medicaid rate from the monthly LTC Insurance payment

Total Amount Owed to Facility $ 93.00

STEP 2

Clients Gross Income: $400.00

Minus Allowable deductions: - $ 50.00

Clients Countable income $ 350.00

STEP 3 Patient Contribution

Patient contribution is $93.00

The patient contribution will be whichever is less, the total amount owed to the facility or the client’s countable income after deductions.

Example 2

STEP 1 – Total Amount Owed to Facility

Nursing Home Daily Rate: $187.00

Times # of days in month x 31

Total monthly Medicaid rate $5,797.00

LTC insurance payment $125.00

Times # of days in month x 31

Total monthly LTC Insurance payment - $3,875.00

Subtract monthly Medicaid rate from the monthly LTC Insurance payment

Total Amount Owed to Facility $1,922.00

STEP 2 Client’s Countable Income

Clients Gross Income: $600.00

Allowable Deductions: - $ 50.00

Clients Countable Income $ 550.00

STEP 3 Patient Contribution

Patient contribution is $550.00

* The patient contribution will be whichever is less, the total amount owed to the facility or the client’s countable income after deductions.