Code of Vermont Rules › Agency 13 - AGENCY OF HUMAN SERVICES › Sub-Agency 170 - DEPARTMENT FOR CHILDREN AND FAMILIES (DCF) › Chapter 440 - SPEND-DOWN, PATIENT SHARE, AND RESOURCE TRANSFER (4400) › Section 13 170 440 - SPEND-DOWN, PATIENT SHARE, AND RESOURCE TRANSFER (4400)

Current through June, 2024
Section 4400
				Spenddown, Patient Share, and Resource Transfer
The following spenddown, patient share and transfer of
				  resources provisions apply to individuals requesting SSI-related and
				  ANFC-related Medicaid depending on their living arrangement (M401-M401.2). They
				  are calculated using an accounting period of either one or six months,
				  depending on the type of Medicaid services requested (M402-M402.2).
When a Medicaid group's total countable income or resources
				  exceed the applicable income or resource standard for eligibility after
				  allocations are made, and exclusions and disregards are applied, a person
				  requesting Medicaid may use spenddown provisions to attain financial
				  eligibility (M410-M423).
The department requires individuals requesting long-term care
				  to apply their available income to the cost of their care through payment of a
				  patient share (M430-M433.3).
The department considers whether individuals otherwise
				  eligible for long-term care, including waiver and hospice services, have
				  transferred resources that should be subject to penalty period before
				  eligibility begins. The rules at M440 apply to transfer of resources after July
				  1, 2002 and the rules at M450 apply to transfers before July 2, 2002.
Section 4410 Living Arrangements
The length of the accounting period used to compute spenddown
				  requirements and patient share payments depends on the living arrangement of
				  the person requesting Medicaid. For the purposes of Medicaid eligibility, a
				  person may be in a community or long-term care living arrangement.
Section 4411 Community Living
				Arrangement
Community living arrangements include any residence, such as
				  a house, apartment, residential care facility, boarding house, rooming house.
				  Persons requesting Medicaid coverage of long-term care services, including
				  waiver and hospice services, are not considered to be in a community living
				  arrangement.
In a community living arrangement, the person requesting
				  Medicaid obtains and pays for basic maintenance items, such as food, shelter,
				  clothing, personal needs, separately from medical care. The person requesting
				  Medicaid may live alone, as a member of a family, or with non-relatives.
Section 4412 Long-Term Care Living
				Arrangement
Persons requesting Medicaid coverage of long-term care,
				  including waiver and hospice services, are considered to be in a long-term care
				  living arrangement. Medicaid eligibility and patient share payments are
				  determined according to long-term care rules for persons living in an
				  institution or receiving waiver or hospice services.
Institutional living arrangements include nursing facilities,
				  rehabilitation centers, and intermediate care facilities for the mentally
				  retarded.
Individuals receiving waiver services are considered to be in
				  a long-term care living arrangement. Individuals receiving Medicaid waiver
				  services would be eligible for Medicaid if they lived in an institution and
				  need enhanced residential care, home-and-community-based care, traumatic brain
				  injury services, developmental disability services, or children's mental health
				  services to live in the community.
Individuals receiving hospice services are considered to be
				  in a long-term care living arrangement. Individuals receiving Medicaid hospice
				  services are terminally ill and would be eligible for Medicaid if they live in
				  an institution and need additional interdisciplinary medical care and support
				  services to enable them and their families to maintain personal involvement and
				  quality of life in their choice of care setting and site of death.
Section 4420 Accounting Periods
Accounting period means the one-month or six-month span of
				  time the department uses to budget the income of a person requesting
				  Medicaid.
Section 4421
				Six-Month Spend-Down Period
The department uses a six-month accounting period to
				  determine spend-down requirements for persons in a community living
				  arrangement.
The six-month period begins with the first month for which
				  Medicaid coverage is requested, usually the month of application. If Medicaid
				  coverage is requested for expenses incurred during any one or more of the three
				  months preceding the month of application, the six-month period begins with the
				  earliest of these three months in which expenses were incurred and the
				  applicant met all other eligibility requirements.
To determine the amount of income a person must spend down,
				  the department shall make reasonable estimates of future income, subject to
				  review and adjustment if the applicant's circumstances change during the
				  remainder of the six-month period.
Section 4422 One-Month Patient Share Period
The department uses a one-month accounting period to
				  determine spend-down requirements and patient share payment amounts for persons
				  in waiver, hospice, or institutional living arrangements.
A one-month accounting period begins with the first calendar
				  month during which the person lives in long-term care for any part of the
				  month, applies for Medicaid coverage for that month, and meets the general and
				  categorical requirements for Medicaid eligibility.
A one-month accounting period ends with the last calendar
				  month during which the person lives in long-term care for any part of the month
				  and passes all other Medicaid eligibility tests.
Section 4430 Spenddown of Excess Resources
				and Income
Individuals who pass all nonfinancial eligibility tests may
				  qualify for Medicaid coverage by spending down the income or resources in
				  excess of applicable maximums. The department specifies the income and resource
				  maximums for each eligibility category in the benefit program descriptions
				  found at M200.2 and M300.2, as well as in the Medicaid procedures
				  manual.
Spending down is the process by which a Medicaid group incurs
				  allowable expenses to be deducted from its income or spends resources to meet
				  financial eligibility requirements, according to the rules in M410-M412.1 and
				  M420-M423.
Section 4431
				Spending Down Excess Resources
A resource spenddown is the amount a Medicaid group must
				  spend to reduce its excess resources to the resource standard applicable to the
				  appropriate Medicaid coverage category. The department determines that a person
				  requesting Medicaid with excess resources has passed the resource test upon
				  proof that the excess resources are no longer held as a resource and have
				  actually been spent or given away. A person with excess resources requesting
				  long-term care services, including waiver and hospice services, is subject to
				  the transfer of resource provisions specified in M440.
Medicaid may be granted for the month of application if the
				  resource test is passed at any point in the month and all other eligibility
				  criteria are met. A Medicaid group's resources may rise above the resource
				  maximum, for example, due to interest added to bank accounts or failure to use
				  the full monthly income amount protected for maintenance expenses during the
				  month it is received. The recipient may maintain Medicaid eligibility for any
				  month in which the Medicaid group's resources exceed the resource maximum by
				  taking any action that reduces the excess amount, including giving the excess
				  to the department to repay department expenditures on the individual's care. As
				  long as resources are reduced to the resource maximum before the end of the
				  month during which resources exceed the limit, Medicaid coverage continues
				  without interruption.
In addition, when a third party who handles any resources of
				  a member of the Medicaid group is unaware of a resource or its value, the
				  department will provide uninterrupted Medicaid coverage as long as the excess
				  amount is paid to the department as a recovery of Medicaid payments. Excess
				  resources reimbursed to the department in these situations will not result in
				  ineligibility.
Individuals seeking long-term care coverage may be subject to
				  a transfer penalty if they spend or give away excess resources within the
				  penalty period specified in M440.4 and its subsections.
Section 4432 Retroactive Coverage
One or more of the following actions may be taken to reduce
				  excess resources in order to qualify for Medicaid up to three months prior to
				  the month of application as long as all other eligibility test are
				  passed:
(a) Individuals may set up a
				burial fund that meets the requirements specified in M232.3 for an excluded
				resource.
(b) If the Medicaid
				group's countable income is less than the applicable PIL, they may spend
				resources on maintenance expenses, such as housing, food, clothing and fuel, up
				to a maximum per month of the difference between their countable income and the
				applicable PIL.
(c) Individuals may
				spend money on covered or noncovered medical expenses.