Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 332 - MAINECARE ELIGIBILITY MANUAL › Part 14 - INDIVIDUALS IN MEDICAL INSTITUTIONS › Section 144-332-14-6 - COST OF CARE

Current through 2024-29, July 17, 2024
Institutionalized individuals are responsible for paying
					 toward their cost of care for stays of a full calendar month. This includes
					 those who may have paid privately for a portion of the month.
If an individual moves from one nursing facility to another
					 the payment goes to the facility where the individual was residing on the first
					 day of the month. If the individual moves from one facility to another on the
					 first day of the month, the facility to which the individual moves is paid the
					 cost of care.
If the individual was institutionalized on the first day of
					 the month for which eligibility is being requested, the cost of care begins
					 with that month.
If an individual was living in the community on the first
					 day of the month for which eligibility is being requested then the first cost
					 of care is owed for the following month.
If the individual was in acute status in a hospital for a
					 full calendar month the individual may not owe anything for hospital costs due
					 to payments from Medicare and/or other insurance. A cost of care is still
					 determined. The hospital will be responsible to collect any portion that is
					 actually owed.
When, after third party payments, the balance owed is less
					 than the individual's cost of care, the lesser amount will be collected by the
					 facility. This also applies when an individual is in a skilled nursing facility
					 and covered by Medicare and QMB. A cost of care will be established. Since QMB
					 covers the Medicare co-insurances and deductibles no cost of care will be
					 collected until the Medicare days end.
There is no cost of care for SSI recipients in a medical
					 institution if the Social Security Administration determines that the
					 individual will be returning home within three months of entering the
					 facility.
Individuals who receive SSI and whose total income is less
					 than $60.00 (based on being in a nursing facility) have no cost of care.
The amount of an individual's cost of care may be adjusted
					 without advance notice (See Section 6.2 of this Part).
Individuals who are no longer in a nursing facility are to
					 be refunded their cost of care for that month by the facility. If the
					 individual is entering a AFH, FRBH, CRBH, RCF, or AFCH (as defined in Part 1 2,
					 Section1), or receiving Home and Community Based Waiver services (see Part 13).
					 a cost of care may be owed to the new provider based on the eligibility
					 requirements for this new program.
Section
				  6.1:
Determining the Individual's Cost of Care
The individual's cost of care is what the individual is
					 expected to pay towards the cost of their care at the institution. The cost of
					 care is determined by considering the individual's income minus certain
					 expenses and the Community Spouse Monthly Income Allocation.
For individuals who are categorically eligible, there is
					 one determination process to follow. For those who are medically needy the
					 determination process varies, depending on the individual's income.
For any month that an individual is considered to be
					 institutionalized, a community spouse's income is never used in determining the
					 cost of care, including a partial month, except in determining the Community
					 Spouse Monthly Income Allocation.
Section
				  6.1.1:
Determining the Community Spouse Monthly Income
				  Allocation
At the time of application a determination is made of the
					 Community Spouse Monthly Income Allocation.
The Community Spouse Monthly Income Allocation is the
					 amount of income the institutionalized spouse is allowed to give to the
					 community spouse before paying the cost of care.
Definitions
Minimum Monthly Income Standard
- This is an
					 amount set by Federal law used in the formula to determine the Monthly Income
					 Allowance (See Chart 4.4).
Monthly Income Allowance
- This is the Minimum
					 Income Standard plus excess shelter costs.
Monthly Excess Shelter Standard
- This is an
					 amount set by Federal law. If the community spouse has shelter costs that
					 exceed this amount, the excess can be used in determining the Community Spouse
					 Monthly Income Allowance (See Chart 4.4).
Maximum Monthly Income Allocation
- This is an
					 amount set by Federal law that establishes the limit on income that can be
					 allocated to the community spouse.
Community Spouse Monthly Income Allocation
-
					 This is the Monthly Income Allowance minus the community spouse's
					 income.
The Community Spouse Monthly Income Allocation is
					 determined as follows:
I. Determine if
				  the community spouse has excess shelter costs:
Total the following shelter expenses for the community
					 spouse's primary residence:
A. rent or
				  mortgage payment (principal and interest);
B. taxes, homeowner's and renter's insurance
				  payments;
C. maintenance charges
				  for condominiums or cooperatives; and
D. the Standard Utility Allowance used by the
				  State in the Food Supplement Program. The utility standard will be reduced to
				  the extent it is included in cooperative or condominium maintenance fees (See
				  Appendix J for the computation of the utility standard).
1. If the countable monthly shelter expenses
				  are less than or equal to the Monthly Excess Shelter Standard (Chart 4.4), no
				  shelter costs are given in the allowance.
2. If the countable monthly shelter expenses
				  are greater than the Monthly Excess Shelter Standard, the difference is the
				  Excess Shelter Cost.