Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 332 - MAINECARE ELIGIBILITY MANUAL › Appendix 144-332-B - Calculation for Substantial Gainful Activities (SGA) and Impairment Related Work Expenses (IRWE)

Current through 2024-29, July 17, 2024
To compute SGA earnings and costs of certain items and
				  services needed to work and related to medical impairment will be deducted from
				  the monthly average gross earnings. These costs are allowable even though the
				  items and services are also used for daily living needs in addition to work,
				  unless otherwise stated below. The costs for each item must be the
				  responsibility of the disabled individual. Actual or potential reimbursements
				  from another source will reduce the allowable deduction.
Example:
Individual purchases crutches for
$80.00
Reimbursement from another source
- $64.00
____________
Allowable cost
$16.00
I.
Allowable Expenses for Consideration
A.
Attendant Care Services
- Only that portion
				  of cost associated with assistance:
1. traveling to and from work:
2. with personal functions while at work (such as eating and
				  toileting):
3. with work related functions (such as reading,
				  communicating): and
4. with personal functions at home for work (such as
				  dressing, administering medications).
Note:
Attendant care services may be paid to a
				  family member only if that person suffered an economic loss by ending this job
				  or other employment in order to perform these services. The family member can
				  be related by blood, marriage, or adoption, and need not live with the disabled
				  person.
B.
Medical Devices
- This item includes durable
				  equipment (such as canes, wheelchairs, crutches).
C.
Prosthetic Devices
(such as artificial
				  limbs).
D.
Work Related Equipment
specifically designed
				  to accommodate an impairment (such as typewriters and telecommunication devices
				  for deafness).
E.
Residential Modifications
:
1.
Outside
- For individuals employed away from
				  home, changes may be made to the outside of the home to permit transportation
				  to work (such as the installation of an exterior ramp for a wheelchair confined
				  person or special railing or pathways for a person requiring crutches).
2.
Inside
- If an individual is employed at
				  home, costs of modifying the inside of the home is allowed to create a work
				  space to accommodate the individual's impairment. Only those expenses
				  associated directly with the work area will be allowed, (such as the
				  enlargement of the doorway leading to the work area).
Note:
If the cost can be deducted as a business
				  expense for the IRS, then it cannot be deducted in this calculation.
F.
Non-medical Appliances and Equipment
-
				  Appliances and equipment specifically prescribed by a physician as essential
				  for control of the impairment. Essential means the item must be one that if not
				  available would cause immediate adverse impact on the individual's ability to
				  function in work activity. (such as the need for an electric air cleaner for an
				  individual who has severe respiratory disease and must work in a purified air
				  environment).
G.
Drugs and Medical Services
- including
				  diagnostic procedures to control medical impairments. These items must be
				  prescribed or utilized to reduce or eliminate symptoms of the impairment or to
				  slow down its progression. The diagnostic procedures must be performed to
				  ascertain how the impairment is progressing or to determine what type of
				  treatment is needed (such as anticonsulsant drugs for epilepsy, antidepressant
				  drugs for mental disorders, radiation treatments or chemotherapy for cancer
				  patients). Items or services not directly related to the impairment are not
				  allowable deductions (such as routine annual physical exams, optician services
				  when the impairment is not visual and dental checkups).
H.
Medical Supplies
- Medical items utilized for
				  work and directly related to the impairment. (such as catheters, bandages,
				  irrigating kits and face masks).
I.
Transportation
- Payments for transportation
				  are limited to the following:
1.
Own Vehicle
a. If the individual's impairment necessitates a modified
				  vehicle needed for travel to work, modifications must be critical to the
				  individual's operation or use of the vehicle and directly related to the
				  impairment. The cost of the modifications is deductible but not the cost of the
				  vehicle.
b. If the impairment prevents use of public transportation to
				  and from work, a physician must verify that the need to drive is caused by the
				  impairment and not the lack of public transportation.
c. The standard IRS mileage rate will be given for the trip
				  to and from work and also, if needed, the cost to hire a driver.
2.
Hired Transportation
- Actual payments made
				  to hire a driver will be allowed but not a mileage allowance.
Exception:
Except for mileage and modifications, costs for the operation
				  of any vehicle are not allowable.
J.
Installation, Maintenance and Repairs
- Costs
				  directly associated with these services for all appliances or devices, which
				  qualify as a deduction in this appendix.
II.
Limits on Deductions
Payments for allowable expenses must be made during a month
				  when the individual was working. An individual is considered working even if
				  absent from work temporarily to receive medical treatment.
In addition, a portion of payments for certain items made in
				  any of the eleven (11) months preceding a month of work can be used.
Note:
Allowable deductions in anticipation of
				  work are limited to durable items such as medical devices, prosthesis, work
				  related equipment, residential modifications, non-medical appliances and
				  vehicle modifications, as defined in Section A above. Payments for services and
				  expendable items such as drugs, oxygen, diagnostic procedures, medical
				  supplies, and vehicle operating costs are not deductible for purposes of
				  determining payments in anticipation of work.
For recurring expenses, payments made on a regular periodic
				  basis, on credit and paid in installments, or rental, may be used.
For non-recurring expenses the one time payment may be
				  deducted in one month or over a twelve consecutive month period beginning with
				  the month of payment.
For down payments a separate deduction process is possible
				  which may be prorated for up to a year. The proration may be for a shorter time
				  period if the regular monthly payments are extended over a period of less than
				  twelve months. When this happens, the proration time period for the down
				  payment and duration of the regular monthly payments will be the same.
Example:
Individual begins to work on 3/1/07 and at the same time
				  purchases special equipment which costs $4800, giving $1200 down. The balance
				  of $3600, plus interest of $540.00, is to be repaid in thirty-six installments
				  of $115 per month beginning 4/1/07
$ 1200.00 Down payment 3/07
+ $ 1265.00 Monthly payments
_____________
$ 2465.00
÷12 Months
= $ 205.42 Monthly deduction
A monthly deduction of $205.42 would be allowed. Beginning
				  3/08, the deduction changes to the regular monthly payment of $115.00 per
				  month.
Before any payments are used as deductions against SGA, the
				  amounts must be determined reasonable.
Amounts up to the prevailing charges for durable medical
				  equipment, prosthetic devices, medical services, and similar medically-related
				  items and services as set by Medicare will be allowed. If the individual pays
				  more than the prevailing charge allowed under Medicare it will be allowed if he
				  or she can establish that the average is consistent with normal charges within
				  their community.
Example:
Mr. Adams applies for Medicaid based on his disability. His
				  assets are below $2000. His income consists of Social Security benefits of
				  $132.90 gross and part time earnings of $530.00 gross a month.
After determining that the job was not created out of
				  sympathy, a hobby, or part of therapy or Vocational Rehabilitation training,
				  the presence and value of impairment related work expenses must be
				  considered.
Mr. Adams is currently paying for a special shoe made from a
				  mold and which costs $682.00. He has been making $50.00 payments monthly after
				  an initial $100.00 down payment in 3/08 when he also found employment.
Using the policy under down payments, the calculation for the
				  pretest is:
$ 100.00 Down payment +
$582.00
$ 682.00
÷ 12Months
_______________
$ 56.83 Monthly payments over one year
As an allowable Impairment Related-Work Expense:
$ 530.00 Gross wages
- $ 56.83 IRWE
_______________
$ 473.17 Compare to earnings allowable
							 standard.
(see example to calculate eligibility).