Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.18 - MEDICAID COST-SHARING › Section 16.03.18.400 - PARTICIPATION IN THE COST OF HOME AND COMMUNITY-BASED WAIVER SERVICES

Current through August 31, 2023
Medicaid participants required to participate in the cost of
				Home and Community-Based Waiver (HCBS) services as described in IDAPA 16.03.10,
				"Medicaid Enhanced Plan Benefits," must have their share of cost determined as
				described in Subsections
				400.01 through
				400.10 of this rule.
				(3-15-22)
01.
Excluded
			 Income
. Income excluded under the provisions of IDAPA 16.03.05,
			 "Eligibility for Aid to the Aged, Blind, and Disabled (AABD)," Sections
			 723 and
			 725, is excluded in determining
			 participation. (3-15-22)
02.
Base Participation
. Base participation is income available for
			 participation after subtracting all allowable deductions, except for the
			 incurred medical expense deduction in Subsection
			 400.07 of this rule. Base
			 participation is calculated by the participant's Self Reliance Specialist. The
			 incurred medical expense deduction is calculated by the Division of Welfare.
			 (3-15-22)
03.
Community
			 Spouse
. Except for the elderly or physically disabled participant's
			 personal needs allowance, base participation for a participant with a community
			 spouse is calculated under IDAPA 16.03.05, "Eligibility for Aid to the Aged,
			 Blind, and Disabled (AABD)," Section
			 725. A community spouse is the
			 spouse of an HCBS participant who is not an HCBS participant and is not
			 institutionalized. The HCBS personal needs allowance for a participant living
			 in adult residential care equals the federal Supplemental Security Income (SSI)
			 benefit rate for an individual living independently. (3-15-22)
04.
Home and Community Based Services
			 (HCBS) Spouse
. Except for the elderly or physically disabled
			 participant's personal needs allowance (PNA), base participation for a
			 participant with an HCBS spouse is calculated and specified under IDAPA
			 16.03.05, "Eligibility for Aid to the Aged, Blind, and Disabled (AABD),"
			 Section 723. An HCBS
			 spouse is the spouse of a participant who also receives HCBS.
			 (3-15-22)
05.
Personal Needs
			 Allowance
. The participant's personal needs allowance depends on whether
			 the participant has a legal obligation to pay rent or mortgage. The
			 participant's personal needs allowance is deducted from any countable income
			 after income exclusions and before other allowable deductions. To determine the
			 amount of the personal needs allowance, use Table 400.05 of this rule:
TABLE 400.05 - PERSONAL NEEDS
							 ALLOWANCE
Amount of Personal Needs
							 Allowance (PNA) for Participation
Not Responsible for Rent or
							 Mortgage
Responsible for Rent or
							 Mortgage
One hundred percent (100%) of the federal SSI benefit
							 for a person with no spouse
One hundred and eighty percent (180%) of the Federal
							 SSI benefit for a person with no spouse
(3-15-22)
06.
Developmentally Disabled
			 Participants
. These allowances are specified in IDAPA 16.03.05,
			 "Eligibility for Aid to the Aged, Blind, and Disabled (AABD)." The HCBS
			 personal needs allowance for adult participants receiving waiver services under
			 the Developmentally Disabled Waiver is three (3) times the federal SSI benefit
			 amount to an individual in his own home. (3-15-22)
07.
Incurred Medical Expenses
.
			 Amounts for certain limited medical or remedial services not covered by the
			 Idaho Medicaid Plan and not paid by a third party may be deducted from the base
			 participation amount. The Department must determine whether a participant's
			 incurred expenses for such limited services meet the criteria for deduction.
			 The participant must report such expenses and provide verification in order for
			 an expense to be considered for deduction. Costs for over-the-counter
			 medications are included in the personal needs allowance and will not be
			 considered a medical expense. Deductions for necessary medical or remedial
			 expenses approved by the Department will be deducted at application, and
			 changed, as necessary, based on changes reported to the Department by the
			 participant. (3-15-22)
08.
Remainder After Calculation
. Any remainder after the calculation in
			 Subsection 400.05 of this rule is the
			 maximum participation to be deducted from the participant's provider payments
			 to offset the cost of services. The participation amount will be collected from
			 the participant by the provider. The provider and the participant will be
			 notified by the Department of the amount to be collected. (3-15-22)
09.
Recalculation of
			 Participation
. The participant's participation amount must be
			 recalculated annually at redetermination or whenever a change in income or
			 deductions becomes known to the Department. (3-15-22)
10.
Adjustment of Participation
			 Overpayment or Underpayment Amounts
. The participant's participation
			 amount is reduced or increased the month following the month the participant
			 overpaid or underpaid the provider. (3-15-22)