Florida Administrative Code › 65 - DEPARTMENT OF CHILDREN AND FAMILIES › 65A - Economic Self-Sufficiency Program › Chapter 65A-1 - PUBLIC ASSISTANCE PROGRAMS › Section 65A-1.7141 - SSI-Related Medicaid Post Eligibility Treatment of Income

Current through Reg. 50, No. 138; July 16, 2024
After an individual is determined eligible for Hospice,
				  Institutional Care Program (ICP), Program of All-Inclusive Care for the Elderly
				  (PACE), Individual Budgeting (iBudget), or Statewide Medicaid Managed Care
				  Long-Term Care (SMMC-LTC) Program, the Department determines the individual's
				  patient responsibility. "Patient responsibility" is the amount the Agency for
				  Health Care Administration (AHCA) must reduce its payments to a medical
				  institution and intermediate care facility or payments for home and community
				  based services provided to an individual towards their cost of care. Patient
				  responsibility is based on the amount of income remaining after the following
				  deductions are applied pursuant to
				  42 CFR §
										435.725 and
				  42 CFR §
										435.726. This process is called "post
				  eligibility treatment of income."
(1)
				For institutional care services and Hospice, the following deductions are
				applied to the individual's income to determine patient responsibility in the
				following order:
(a) A Personal Needs
				Allowance (PNA) of $130. Individuals residing in medical institutions and
				intermediate care facilities shall have $130 of their monthly income protected
				for their personal need allowance.
(b) A PNA for individuals residing in the
				community. Individuals electing hospice services shall have an amount equal to
				the federal poverty level (FPL) protected as their personal needs
				allowance.
(c) An additional PNA
				for therapeutic wages. If the institutionalized individual earns therapeutic
				wages, an additional deduction from income equal to one-half of the monthly
				therapeutic wages, up to a maximum of $111, shall be applied and treated as an
				additional PNA protected for personal need.
(d) An additional PNA for court ordered child
				support. If the institutionalized individual is court ordered to pay child
				support an additional PNA is deducted in an amount equal to the court ordered
				support paid by the individual to meet their court ordered obligation. The
				additional PNA is applied only if a court ordered deduction was not made under
				another provision under the post eligibility process.
(e) The community spouse income allowance.
				The Department applies the formula and policies under §1924 of the
				Social-Security Act, and Rule
				 65A-1.716, F.A.C., to compute
				the community spouse income allowance after the institutionalized spouse is
				determined eligible for institutional care benefits.
(f) The community spouse's excess shelter and
				utility expenses. The amount by which the sum of the spouse's expenses for rent
				or mortgage payment (including principal and interest), taxes and insurance
				and, in the case of a homeowner's association, condominium or cooperative,
				required maintenance charge, for the community spouse's principal residence and
				utility expense exceeds thirty percent of the amount of the Minimum Monthly
				Maintenance Needs Allowance (MMMNA) is allowed. The utility expense is based on
				the current Food Assistance Program's standard utility allowance as referenced
				in subsection  65A-1.603(2),
				F.A.C.
(g) For community hospice,
				spousal allowance. This allowance is equal to the Supplemental Security Income
				(SSI) Federal Benefit Rate (FBR), minus the spouse's monthly income. A portion
				of the individual's income equal to 100% of the Federal Poverty Level (FPL),
				minus the spouse and dependent's income, if the individual has a spouse and
				dependent child in the community. (For FPL criteria, refer to subsection
				 65A-1.716(1),
				F.A.C.)
(h) For ICP or
				institutional Hospice, income is protected for the month of admission and
				discharge, if the individual's income for that month is obligated to directly
				pay for their cost of food or shelter outside of the facility.
(i) Uncovered medical expense deduction. The
				following policy will be applied in considering medical deductions for
				institutionalized individuals and individuals receiving HCBS services to
				calculate the amount allowed for the uncovered medical expense deduction:
1. For institutionalized persons or residents
				of medical institutions and intermediate care facilities, the deduction
				includes:
a. Any premium, deductible, or
				coinsurance charges or payments for health insurance coverage.
b. For other incurred medical expenses, the
				expense must be for a medical or remedial care service and be medically
				necessary as specified in the Florida Medicaid Definitions Policy, incorporated
				by reference in subsection
				 59G-1.010(2),
				F.A.C., and be recognized in state law. For medically necessary care, services
				and items not paid for under the Medicaid State Plan, the actual billed amount
				will be the amount of the deduction, not to exceed the maximum payment or fee
				recognized by Medicare, commercial payors, or any other third party payor, for
				the same or similar item, care, or service.
2. The expense must have been incurred no
				earlier than the three month period preceding the month of application
				providing eligibility.
3. The
				expense must not have been paid for under the Medicaid State Plan.
4. Other health insurance policies, including
				long term care insurance, are considered to be the first payor for medical
				items, care, or services covered by such policies and the remaining items can
				be used as an uncovered medical expense deduction. Therefore, to be deducted
				from the individual's income, the individual must demonstrate that other
				insurance does not cover such medical items, care, or services.
5. The medical and remedial care expenses
				that were incurred as the result of imposition of a transfer of asset penalty
				is limited to zero.