55 Pa. Code § 181.452 - Posteligibility determination of income available from an MA eligible person toward his cost of care
(a) The total gross
income of an aged, blind or disabled MA eligible person's income includes:
(3)
Aged, blind and disabled
categories. Some income that is identified as excluded in Subchapter B
(relating to aged, blind and disabled categories) is not excluded under this
subchapter and is counted when determining the MA eligible person's total gross
income. This includes:
(i) The income
exclusion as specified in §
181.122 (relating to earned income
exclusion).
(ii) The income
exclusions as specified in §
181.123 (relating to unearned
income exclusions).
(4)
Income from nontrust property. Unless the instrument
specifically provides otherwise as follows:
(i) Payment of income made solely in the name
of the institutionalized spouse or the community spouse is considered only
available to that spouse.
(ii)
Payment of income made in the names of both spouses is considered available in
equal shares to each of them.
(iii)
Payment of income made in the names of the institutionalized spouse or the
community spouse, or both, and to another person is considered available to
each spouse in proportion to the spouse's interest, or if payment is made with
respect to both spouses and no interest is specified, one-half of the joint
interest is considered available to each spouse.
(5)
Income from trust
property.
(i) Income is considered
available to each spouse as provided for in the trust.
(ii) In the absence of a specific provision
in the trust, if payment of income is made solely to the institutionalized
spouse or the community spouse, the income is considered available only to that
spouse.
(iii) In the absence of a
specific provision in the trust, if payment of income is made to both the
institutionalized spouse and the community spouse, one-half of the income is
considered available to each spouse.
(iv) In the absence of a specific provision
in the trust, if payment of income is made to the institutionalized spouse or
the community spouse, or both, and to another person, the income is considered
available to each spouse in proportion to the spouse's interest or, if payment
is made with respect to both spouses and no interest is specified, one-half of
the joint interest is considered available to each spouse.
(6)
Income from property with no
instrument. In the case of income not from a trust in which there is
no instrument establishing ownership, subject to the requirements in paragraph
(7), one-half of the income is considered available to the institutionalized
spouse and one-half to the community spouse.
(7)
Rebutting income
ownership. The requirements in paragraphs (4) and (6) are superseded
to the extent that an institutionalized spouse can establish, by a
preponderance of evidence, that the ownership interests in income are other
than as provided under those paragraphs.
(b) The total gross income of an TANF-related
category and a GA-related category MA eligible person's total income includes:
(1) The total earned income as specified in
§§
181.271 and
181.272 (relating to gross earned
income; and profit from self-employment).
(3) Income that is identified as a type of
income that is not counted when determining MA eligibility is counted when
determining the MA eligible person's total gross income. This includes income
specified in §
181.263 (relating to other types
of income not counted for the TANF and GA categories).
(4) Income from nontrust property, unless the
instrument specifically provides otherwise, as follows:
(i) Payment of income made solely in the name
of the institutionalized spouse or the community spouse is considered only
available to that spouse.
(ii)
Payment of income made in the names of both spouses is considered available in
equal shares to each of them.
(iii)
Payment of income made in the names of the institutionalized spouse or the
community spouse, or both, and to another person is considered available to
each spouse in proportion to the spouse's interest, or if payment is made with
respect to both spouses and no interest is specified, one-half of the joint
interest is considered available to each spouse.
(5) Income from trust property.
(i) Income is considered available to each
spouse as provided for in the trust.
(ii) In the absence of a specific provision
in the trust, if payment of income is made solely to the institutionalized
spouse or the community spouse, the income is considered available only to that
spouse.
(iii) In the absence of a
specific provision in the trust, if payment of income is made to both the
institutionalized spouse and the community spouse, one-half of the income is
considered available to each spouse.
(iv) In the absence of a specific provision
in the trust, if payment of income is made to the institutionalized spouse or
the community spouse, or both, and to another person, the income is considered
available to each spouse in proportion to the spouse's interest or, if payment
is made with respect to both spouses and no interest is specified, one-half of
the joint interest is considered available to each spouse.
(6) Income from property with no instrument.
In the case of income not from a trust in which there is no instrument
establishing ownership, subject to the requirements in paragraph (7), one-half
of the income is considered available to the institutionalized spouse and
one-half to the community spouse.
(7) Rebutting income ownership. The
requirements in paragraphs (4) and (6) are superseded to the extent that an
institutionalized spouse can establish, by a preponderance of evidence, that
the ownership interests in income are other than as provided under those
paragraphs.
(c) For an MA
eligible person in the aged, blind or disabled related categories or an MA
eligible person in the TANF-related or GA-related categories, the veterans aid
and attendance and housebound allowance portion of the Veterans Affairs pension
as specified in §
181.81(9)
(relating to items that are not income) is excluded and is not counted when
determining the MA eligible person's total gross income unless if the Veterans
Administration states, in writing, that the benefit is for an incompetent
veteran or incompetent spouse or child of a deceased veteran who is determined
incompetent by the Veterans Administration and that the benefit shall be
counted toward cost of care.
(d) The
following amounts are deducted from the MA eligible person's total gross income
identified in subsection (a) for persons in the aged, blind and
disabled-related categories, or subsection (b) for persons in the TANF-related
or GA-related categories and adjusted as applicable by the treatment of
Veterans Administration benefits under subsection (c) for all MA eligible
persons in the following order:
(1) A
personal needs allowance deduction for clothing and other personal needs while
in the institution.
(i) A personal needs
allowance deduction of $30 a month for one person, except for those persons as
specified in subparagraphs (ii)-(v) who are in intermediate care facilities for
the mentally retarded-ICF/MR-and have sheltered workshop earnings or other
earnings from therapeutic activities arranged by the institution.
(ii) A personal needs allowance deduction of
$50 a month for a person in an ICF/MR who has sheltered workshop earnings or
other earnings from therapeutic activities arranged by the institution which do
not exceed $50 gross per month.
(iii) A personal needs allowance deduction of
$70 a month for a person in an ICF/MR who has sheltered workshop earnings or
other earnings from therapeutic activities arranged by the institution which
are more than $50 gross per month but do not exceed $90 gross per
month.
(iv) A personal needs
allowance deduction of $110 a month for a person in an ICF/MR who has sheltered
workshop earnings or other earnings from therapeutic activities arranged by the
institution which are more than $90 gross per month but do not exceed $150
gross per month.
(v) A personal
needs allowance deduction of $110 a month plus 50% of the difference between
the actual gross earnings and $150.01, subject to a maximum personal needs
allowance deduction equal to the one person NMP-MA income limit in Appendix A
if the person in an ICF/MR has sheltered workshop earnings or other earnings
from therapeutic activities arranged by the institution which are more than
$150 gross per month.
(2)
If the MA-eligible person's spouse remains at home, an amount for the
maintenance needs of the spouse.
(i) The
maintenance need for the spouse in the community is reduced by the community
spouse's available income. The available income is obtained by determining the
community spouse's total gross earned income as specified in §§
181.91-181.96 (relating to types of
earned income counted for the aged, blind and disabled categories); the total
gross unearned income as specified in §§
181.101-181.109.
(ii) The amount of the community spouse's
monthly available income is then compared to the monthly standard community
spouse maintenance need allowance under
42 U.S.C.A. §
1396r-5(d)(3)(A) and
(B) plus an excess shelter allowance for the
couple's principal residence. The excess monthly shelter allowance is the
amount by which the actual monthly verified shelter expenses specified in
subparagraph (iii) exceed the excess shelter standard in
42 U.S.C.A. §
1396r-5(d)(4)(A) and
(B). The monthly standard community spouse
maintenance need allowance and the excess monthly shelter standard will be
changed effective July of each year based on
42 U.S.C.A. §
1396r-5(d)(3)(B).
Revisions required by Federal law and regulations to the amounts will be
published as a notice in the Pennsylvania Bulletin and will be
made available upon request at the CAOs.
(iii) Actual verified monthly shelter
expenses include rent, mortgage payment, including principal and interest,
taxes and insurance, and the maintenance charge for a condominium or
cooperative and an amount for utilities. The amount for utilities is one of the
two standard utility allowances (SUAs) or the telephone cost only rate
contained in the Department's Food Stamp Handbook, Chapter 560, Income
Deductions. The two SUAs are based on the standard utility allowance specified
in section 5(e) of the Food Stamp Act of 1977 (Pub. L. 95-400, 92 Stat. 856)
(September 30, 1978) and 7
CFR 273.9(d)(6) (relating to
income and deductions) and are set forth in a waiver request approved by the
United States Department of Agriculture, Food and Nutrition Service, under
7 CFR
272.3(c)(1)(ii) (relating to
operating guidelines and forms). If all utility expenses including the
telephone are included in the rent or the maintenance charge for a condominium
or cooperative, no utility amount is deducted from the total determined in this
subparagraph. Annual payments for items such as taxes and insurance shall be
converted to a monthly figure.
(iv)
The monthly payment of the community spouse maintenance need allowance may not
exceed the maximum monthly community spouse maintenance need amount specified
in 42 U.S.C.A. §
1396r-5(d)(3)(C)
subject to adjustment under 42 U.S.C.A. §
1396r-5(g) unless the
requirements in subparagraphs (ix) or (x) apply. Revisions required by Federal
law and regulations to the amounts will be published as a notice in the
Pennsylvania Bulletin and will be made available upon request
at the CAOs.
(v) If the community
spouse's net monthly income is equal to, or exceeds, the amount determined in
subparagraph (ii), no community spouse maintenance need allowance deduction is
provided.
(vi) If the community
spouse's net monthly income is less than the amount determined in subparagraph
(ii), the community spouse's net monthly income is subtracted from the amount
in subparagraph (ii) to determine the monthly community spouse maintenance need
allowance. Only the amount actually provided to, or for the benefit of, the
community spouse by the institutionalized spouse is deducted. The CAO is
responsible for obtaining verification from the institutionalized spouse or
someone acting on his behalf, in writing, of the amount the institutionalized
spouse intends to give to the community spouse. The amount shall be verified by
the CAO, in writing, at each application/reapplication or whenever the
institutionalized spouse or someone acting on his behalf indicates, in writing,
that the amount has changed.
(vii)
The requirements in this paragraph no longer apply beginning the first full
calendar month following changes in the couple's circumstances which end the
community spouse/institutionalized spouse relationship.
(viii) The community spouse maintenance need
allowance may exceed the amount determined in subparagraph (ii) and the amount
specified in subparagraph (iv) if a greater amount is ordered through a court
support order under 42
U.S.C.A. §
1396r-5(d)(5).
(ix) The community spouse maintenance need
allowance may exceed the amount determined in subparagraph (ii) and the amount
specified in subparagraph (iv) if a greater amount is determined as a result of
a Departmental hearing decision in which either spouse establishes that the
community spouse needs income above the standard due to exceptional
circumstances resulting in significant financial duress. The CAO shall review
the increased income need established by the Departmental hearing decision at
each application/reapplication or whenever a change in the circumstances that
warranted the increase no longer exist.
(x) A written notice of the monthly community
spouse maintenance need allowance and the right to appeal the amount shall be
provided to both members of the couple.
(3) If the MA-eligible person has a community
spouse and dependent children, dependent parents or dependent siblings of
either member of the couple living at home with the community spouse, an amount
for the maintenance needs of the other family members.
(i) A dependent child of either member of the
couple who lives with the community spouse is a child of any age who is or may
be claimed as a dependent by either member of the couple for tax purposes under
the IRC.
(ii) A dependent parent is
the parent of either member of the couple who lives with the community spouse
and who is or may be claimed as a dependent by either member of the couple for
tax purposes under the IRC.
(iii) A
dependent sibling of either member of a couple which includes half-brothers,
half-sisters and siblings by adoption who lives with the community spouse and
who is or may be claimed as a dependent by either member of the couple for tax
purposes under the IRC.
(iv) The
family member maintenance need amount is reduced by the family member's
available income. The available income is obtained by determining the family
member's total gross earned income as specified in §§
181.91-181.96; the total gross unearned
income as specified in §§
181.101-181.109. The income of a dependent
child or a child regardless of age who is blind or disabled who does not
receive SSI minus the exemptions specified in §
181.110(c)
(relating to income deemed available from the spouse) shall also be
obtained.
(v) In addition, if the
child is a student, the child's earned income up to $1,200 a calendar quarter,
but not more than $1,620 per year is excluded.
(vi) The net amount of the dependent family
member's income is then compared to the standard monthly dependent family
member maintenance allowance under
42 U.S.C.A. §
1396r-5(d)(1)(C) and
(3)(A)(i). Revisions required by Federal law
and regulations to the amounts will be published as a notice in the
Pennsylvania Bulletin and will be made available upon request
at the CAOs.
(vii) If the dependent
family member's income equals, or exceeds, the standard, no dependent family
member maintenance need allowance deduction is provided.
(viii) If the dependent family member's
income is less than the standard, the dependent family member's income is
subtracted from the standard. The dependent family member's maintenance need
allowance deduction is 1/3 of the remaining amount.
(ix) The dependent family member's
maintenance need allowance deduction, which may not exceed the
institutionalized spouse's remaining available income, shall be deducted from
the institutionalized spouse's income even if the amount is not actually given
to the family member by the institutionalized spouse.
(x) A written notice of the family member
maintenance need allowance and the right to appeal the amount deducted shall be
provided to both members of the couple.
(xi) The requirements in this paragraph no
longer apply beginning the first full calendar month following changes in the
dependent family member's or the institutionalized spouse's circumstances which
end the dependent family member's/institutionalized spouse's
relationship.
(4) If the
MA-eligible person has no spouse in the community with whom he lived before
being institutionalized but does have a dependent child or a disabled child, a
dependent child maintenance need allowance is determined.
(i) A dependent child for this subsection is
a child who is not married, not the head of a household, and is either 17 years
of age or younger, or if a student, 21 years of age or younger and is or may be
claimed as a dependent by the institutionalized person for tax purposes under
the IRC.
(ii) A disabled child is a
child who meets the eligibility conditions as a disabled person and is claimed
as a dependent by the institutionalized person for tax purposes under the
IRC.
(iii) The dependent child
maintenance need allowance is reduced by the dependent/disabled child's
available income. The available income is obtained by determining the
dependent/disabled child's total gross earned income as specified in §§
181.91-181.96 and the total gross
unearned income as specified in §§
181.101-181.109. The available income is
also obtained by determining the income of a dependent child or a child
regardless of age who is blind or disabled who does not receive SSI minus the
exemptions specified in §
181.110(c). In
addition, if the dependent child is a student, the child's earned income up to
$1,200 a calendar quarter, but not more than $1,620 per year, is
excluded.
(iv) The net income of
the dependent child is then compared to the one person MA income limit in
Appendix C for the county in which the dependent child resides. If the
dependent child resides out-of-State, the amount listed in Schedule No. 2 in
Appendix C for one person is used.
(v) The net income of the disabled child is
then compared to the one person MA income limit in Appendix A.
(vi) If the dependent or disabled child's net
income is less than the amount in subparagraph (iv) or (v), the
dependent/disabled child's maintenance need allowance is the difference between
the net income and the amount in subparagraph (iv) or (v).
(vii) This amount, which may not exceed the
institutionalized person's remaining available income, is deducted from the
institutionalized person's income only if the amount is given to the
dependent/disabled child. The CAO is responsible for obtaining verification
from the institutionalized spouse or someone acting on his behalf, in writing,
of the amount the institutionalized person intends to give to the dependent or
disabled child. The amount shall be verified by the CAO, in writing, at each
application/reapplication or whenever the institutionalized person or someone
acting on the person's behalf indicates, in writing, that the amount has
changed.
(viii) A written notice of
the dependent/disabled child maintenance need allowance and the right to appeal
the amount shall be provided to the institutionalized person.
(ix) The requirements in this paragraph no
longer apply beginning the first full calendar month following changes in the
dependent/ disabled child's or the institutionalized person's circumstances
which end the dependent/disabled child's or institutionalized person's
relationship.
(5) The
following medical expenses which are not subject to payment by a third party
are deducted in the calendar month the medical expenses are paid.
(i) Medicare and other health insurance
premiums, including enrollment fees, deductibles or coinsurance charges
incurred by the MA eligible person.
(ii) Copayments or deductibles, including the
amount an applicant/recipient participating in the Copayment Program is
required to pay by the Department subject to the Department's established
copayment limit.
(iii) Expenses
paid by the MA eligible person for necessary medical or remedial care
recognized under State statutes or regulations but not covered under the MA
Program.
(6) An amount
for maintenance of a single MA eligible person's home if a physician has
certified that he is likely to return to his home within a 6-month period from
the date he entered the facility. When this deduction is given, it may not be
deducted for more than one 6-consecutive month period. The maintenance need
amount for the single person is the MA income limit for one person in Appendix
A. A home is defined as the residence maintained by the MA eligible person
before he entered the facility and to which he plans to return. If a person is
discharged and subsequently returns to a facility, the single MA eligible
person is eligible for a new 6 consecutive month period for this deduction if a
physician certifies that the person is likely to return to his home within a
6-month period from the date of admittance to the facility.
(e) The amount that the MA eligible
person is expected to pay toward the cost of care is the amount that remains
and as adjusted under subsection (c), if applicable, and after the deductions
in subsection (d) are applied to the person's total gross income as determined
under subsections (a) and (b).
Notes
The provisions of this § 181.452 issued under section 403(b) of the Public Welfare Code (62 P. S. § 403(b)); amended under sections 201, 403 and 443.1 of the Public Welfare Code (62 P. S. §§ 201, 403 and 443.1).
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