13 CSR 40-2.200 - Determining Eligibility for Medical Assistance
(1) The medical diagnosis and other medical
information on Medical Assistance (MA), Supplemental Nursing Care (SNC), Aid to
the Blind (AB) and Blind Pension (BP) cases shall be reviewed by a medical
consultant employed by the Family Support Division, who shall certify
eligibility or ineligibility on the basis of permanent and total disability or
vision, except that this review will not be required to certify permanent and
total disability when the claimant receives Supplemental Security Income (SSI)
or Retirement, Survivor's, and Disability Insurance (RSDI) based on his/her
disability. In these cases, the verification of the receipt of disability-based
SSI or RSDI benefits will be sufficient to establish permanent and total
disability.
(2) If a single
individual has an adjusted gross income per month that does not exceed the
income limit and meets the other eligibility requirements, s/he will be
eligible for MA. If eligibility is based on AB provisions, the income limit is
one hundred percent (100%) of the federal poverty level (FPL). If eligibility
is based on MO HealthNet for Aged, Blind, and Disabled (MHABD) or Permanent and
Total Disability (PTD) provisions, the income limit is eighty-five percent
(85%) of the FPL. For a married couple living together, the adjusted gross
income limitation will be one hundred percent (100%) of the FPL for two (2)
persons, if eligibility is based on AB provisions. For a married couple living
together, the adjusted gross income limitation will be eighty-five percent
(85%) of the FPL for two (2) persons, if eligibility is based on MHABD or PTD
provisions. In determining adjusted gross income, the following exemptions will
be applied to the gross income:
(A) If the
income is earned or unearned, an amount of twenty dollars ($20) may be excluded
from the gross. Payments for premiums for medical insurance, including
Supplemental Medical Insurance (SMI) premium, may be excluded;
(B) The full amount of any SSI payment will
be excluded; and
(C) If the income
is earned, the twenty-dollar ($20) exclusion in subsection (2)(A) will be
applied plus the first sixty-five dollars ($65) and one-half (1/2) of the
remainder of all earned income will be excluded. If a person is a student and
is under the age of twenty-two (22), the amount of the school expense will be
excluded from any earned income. If eligibility is based on AB provisions, any
work-related expenses also will be excluded from earned income.
(3) If an individual qualifies for
institutional vendor payments under the MA program, fifty dollars ($50) of the
individual's personal income shall be retained as his/her personal needs
allowance. Federal regulation
42 CFR, Section
435.733 provides that there shall be a
minimum amount available to meet the clothing and other personal needs of the
individual. In order to meet other of the individual's basic personal needs,
this amount shall not be exhausted to satisfy any guardianship fees, court
costs, attorney's fees, or other related legal or court costs, or any
combination of these, resulting from the administration of a guardianship or
conservatorship, or both that has been sought on behalf of the Medicaid
recipient. The claimant's personal needs allowance shall not be used for the
provision of any medical or remedial services, or both, that are covered
through the Missouri Medical Exception Process. Institutionalized individuals
who participate in sheltered workshops are allowed a personal needs allowance
of fifty dollars ($50) plus the sheltered workshop income.
(4) When an individual living in his/her home
is assessed by Department of Health and Senior Services as needing both a
nursing facility level-of-care as defined in
19 CSR
30-81.030 and home- and community-based waiver
services, his/her gross monthly income shall be compared to one thousand three
hundred eleven dollars ($1,311) effective January 1, 2018, subject to
adjustment by the Consumer Price Index beginning January 2019, if his/her gross
monthly income is equal to or less than one thousand three hundred eleven
dollars ($1,311), s/he shall be considered income eligible for Title XIX under
the MA program. When his/her gross monthly income is greater than one thousand
three hundred eleven dollars ($1,311), s/he must qualify for Title XIX in
accordance with section (2) of this rule.
(5) If an institutionalized spouse (as
defined in 13 CSR 40-2.030) qualifies for
institutional vendor payments under the MA program, in determining the amount
the institutionalized spouse must pay to the medical institution or nursing
facility for the cost of his/her care, the following amounts shall be
disregarded:
(A) A community spouse monthly
income allowance which shall be determined as follows:
1. The amount by which-
A. The applicable percentage of the Federal
Poverty Level for two (2) persons; plus
B. The amount by which the community spouse's
shelter expenses exceed thirty percent (30%) of the applicable percentage of
the Federal Poverty Level for two (2) persons; exceeds
C. The community spouse's own
income;
2. The amount
determined in subparagraphs (5)(A)1.A. and B. may not exceed one thousand five
hundred dollars ($1,500), subject to adjustment by the Consumer Price Index
beginning January 1990;
3. The
amount of court-ordered support, if higher, may be substituted for the amount
determined in paragraph (5)(A)1.;
4. The applicable percentages of the Federal
Poverty Level specified in paragraph (5)(A)1. shall be as follows:
A. Effective September 30, 1989, one hundred
twenty-two percent (122%);
B.
Effective July 1, 1991, one hundred thirty-three percent (133%); and
C. Effective July 1, 1992, one hundred fifty
percent (150%);
5.
Allowable shelter expenses for the community spouse shall include the following
expenses incurred at the principal place of residence of the community spouse:
A. Mortgage payment or taxes, or both, and
insurance;
B. Rent;
C. Maintenance fee for condominium or
cooperative apartment; and
D. The
utility standard of the Food Stamp program in accordance with the Food Stamp
Act of 1977, if the utility expenses are actually incurred and are not a part
of the maintenance fee or rent previously allowed. If the community spouse's
only utility is telephone, the standard used shall be the telephone standard of
the Food Stamp program. If the community spouse incurs any other type of
utility, the standard used shall be the utility standard of the Food Stamp
program;
6. If either
spouse establishes in a fair hearing that the allowance as determined by the
Family Support Division is insufficient (resulting in significant financial
duress), an adequate amount may be substituted; and
(B) An allowance for each family member equal
to one-third (1/3) of the amount by which the amount described in subparagraph
(5)(A)1.A. exceeds the monthly income of that family member. As used in this
rule, the term family member shall mean minor or dependent children, dependent
parents, or dependent siblings of either spouse who are residing with the
community spouse. Dependent as used here means an individual who could be
claimed as a dependent for federal income tax purposes.
(6) Pursuant to the determination of the
Health Care Financing Administration of the United States Department of Health
and Human Services, no amounts charged as guardianship or conservatorship fees,
court costs, attorney's fees, or other related or similar legal or court costs
are properly classified as necessary medical or remedial care. Therefore, no
charges shall be recognized or allowed by this agency for the purpose of
deducting those sums from an individual's total income, when that individual
qualifies for institutional vendor payments under the MA program established
pursuant to Title XIX of the Social Security Act,
42 U.S.C.
1396.
(7) Persons who are eligible for MA only must
meet the eligibility requirements, other than income, for Old Age Assistance,
Permanent and Total Disability or AB that was in effect in January 1972, except
that the Homemaker provision will not be applied to the determination of
disability in these cases.
(8)
Persons who receive SSI may receive MA if they meet the eligibility
requirements, other than income, for General Relief that were in effect January
1972. However, in determining eligibility for MA, the eligibility requirements
described in section (6) must be applied first.
Notes
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