Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part V - Married Institutionalized Individuals' Eligibility and Patient Pay › Subpart I - Definitions › Section 12VAC30-110-720 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
Subpart I
Definitions
The following words and terms when used in this part
						shall have the following meanings unless the context clearly indicates
						otherwise:
"Acceptable medical evidence" means either (i)
						certification by a nursing home preadmission screening committee; or (ii)
						certification by the individual's attending physician.
"Actual monthly expenses" means the total of:
1. Rent or mortgage, including interest and
					 principal;
2. Taxes and
					 insurance;
3. Any maintenance
					 charge for a condominium or cooperative; and
4. The utility standard deduction under the
					 Food Stamp Program that would be appropriate to the number of persons living in
					 the community spouse's household, if utilities are not included in the rent or
					 maintenance charge.
"Applicable percent" means that percentage as defined in
						§ 1924(d)(3)(B) of the Social Security Act.
"As soon as practicable" (as it relates to transfer of
						resources from the institutionalized spouse to the community spouse for the
						purpose of the community spouse resource allowance) means within 90 days from
						the date the local agency takes action to approve the institutionalized
						spouse's initial eligibility for medical assistance long-term care services
						when the institutionalized spouse agrees to transfer resources to the community
						spouse.
"At the beginning of the first continuous period of
						institutionalization" means the first calendar month of a continuous period of
						institutionalization in a medical institution or of receipt of a Medicaid
						community-based care waiver service or hospice.
"Community spouse" means a person who is married to an
						institutionalized spouse and is not himself an inpatient at a medical
						institution or nursing facility.
"Community spouse monthly income allowance" means an
						amount by which the minimum monthly maintenance needs allowance exceeds the
						amount of monthly income otherwise available to the community spouse.
"Community spouse resource allowance" means the amount of
						the resources in the institutionalized spouse's name that can be transferred to
						the community spouse to bring the resources in the community spouse's name up
						to the protected resource amount.
"Continuous period of institutionalization" means 30
						consecutive days of institutional care in a medical institution or nursing
						facility, or 30 consecutive days of receipt of Medicaid waiver or hospice
						services, or 30 consecutive days of a combination of institutional care and
						waiver and hospice services. Continuity is broken only by 30 or more days
						absence from a medical institution or 30 or more days of nonreceipt of waiver
						services.
"Couple's countable resources" means all of the couple's
						nonexcluded resources regardless of state laws relating to community property
						or division of marital property. For purposes of determining the combined and
						separate resources of the institutionalized and community spouses when
						determining the institutionalized spouse's eligibility, the couple's home,
						contiguous property, household goods and one automobile are excluded.
"Department" means the Department of Medical Assistance
						Services.
"Dependent child" means a child under age 21 and a child
						age 21 years old or older, of either spouse, who lives with the community
						spouse and who may be claimed as a dependent by either member of the couple for
						tax purposes pursuant to the Internal Revenue Code.
"Dependent family member" means a parent, minor child,
						dependent child, or dependent sibling, including half brothers and half sisters
						and siblings gained through adoption, of either member of a couple who resides
						with the community spouse and who may be claimed as a dependent by either
						member of the couple for tax purposes pursuant to the Internal Revenue
						Code.
"Exceptional circumstances resulting in significant
						financial duress" means circumstances other than those taken into account in
						establishing the spousal maintenance allowance for which the community spouse
						incurs expenses in amounts that he cannot be expected to pay from the spousal
						maintenance allowance or from amounts held in the community spouse resource
						allowance.
"Excess shelter allowance" means the amount by which the
						actual monthly expense of maintaining the community spouse's residence plus the
						standard utility allowance exceeds the excess shelter standard.
"Excess shelter standard" means 30% of the monthly
						maintenance needs standard.
"Family member's income allowance" means an allowance for
						each dependent family member residing with the community spouse. The family
						member's income allowance is equal to 1/3 of the amount by which the monthly
						maintenance needs standard exceeds the family member's income.
"Federal Poverty Level" or "FPL" means the annual Federal
						Poverty Level as computed by the Office of Management and Budget and published
						in the Federal Register.
"First continuous period of institutionalization" means
						the first day of the first month of the first continuous period of
						institutionalization, which began on or after September 30, 1989.
"Initial eligibility determination" means:
1. An eligibility determination made in
					 conjunction with a medical assistance application filed during an individual's
					 most recent continuous period of institutionalization; or
2. The initial redetermination of eligibility
					 for a medical assistance eligible institutionalized spouse after being admitted
					 to an institution or receiving medical assistance community-based care waiver
					 services.
"Initial redetermination" means the first redetermination
						of eligibility for a medical assistance eligible spouse which is regularly
						scheduled, or which is made necessary by a change in the individual's
						circumstances.
"Institutionalized spouse" means an individual who is an
						inpatient at a medical institution, who is receiving medical assistance
						community-based care waiver services, or who has elected hospice services, and
						who is likely to remain in such facility or to receive waiver or hospice
						services for at least 30 consecutive days, and who has a spouse who is not in a
						medical institution or nursing facility.
"Likely to remain in an institution" means a reasonable
						expectation based on acceptable medical evidence that an individual will be in
						a medical institution or will receive medical assistance waiver or hospice
						services for 30 consecutive days, even if receipt of institutional care or
						waiver or hospice services actually terminates in less than 30 days.
						Individuals who have been screened and approved for medical assistance
						community-based waiver services or who have elected hospice services shall be
						considered likely to remain in an institution.
"Maximum monthly maintenance needs standard" is the upper
						limit, i.e., cap established under § 1924(d)(3)(C) of the Social Security
						Act.
"Maximum spousal resource standard" means the maximum
						amount of the couple's combined countable resources established for a community
						spouse to maintain himself in the community calculated in accordance with
						§ 1924(f)(2)(A)(ii)(II) of the Social Security Act. This amount increases
						annually by the same percentage as the percentage increase in the Consumer
						Price Index for all urban consumers between September 1988 and the September
						before the calendar year involved as required in § 1924(g) of the Social
						Security Act.
"Medical institution" or "nursing facility" means
						hospitals and nursing facilities, including an intermediate care facility for
						the mentally retarded (ICF/MR), consistent with the definitions of such
						institutions found in the Code of Federal Regulations at
						42 CFR
						435.1009,
						42 CFR
						435.1010,
						42 CFR
						440.40 and 42 CFR 440.150 and which are
						authorized under Virginia law to provide medical care.
"Minimum monthly maintenance needs allowance" means the
						monthly maintenance needs standard, plus an excess shelter allowance, if
						applicable, not to exceed the maximum monthly maintenance needs standard. The
						minimum monthly maintenance needs allowance is the amount to which a community
						spouse's income is compared in order to determine the community spouse's
						monthly income allowance.
"Minor" means a child under age 21, of either spouse, who
						lives with the community spouse.
"Monthly maintenance needs standard" means an amount no
						less than 150% of 1/12 of the Federal Poverty Level for a family of two in
						effect on July 1 of each year.
"Other family members" means dependent children and
						dependent parents and siblings of either member of a couple who reside with the
						community spouse.
"Otherwise available income or resources" means income
						and resources which are legally available to the community spouse and to which
						the community spouse has access and control.
"Promptly assess resources" means within 45 days of the
						request for resource assessment unless the delay is due to nonreceipt of
						documentation or verification, if required, from the applicant or from a third
						party.
"Protected period" means a period of time, not to exceed
						90 days after an initial determination of medical assistance eligibility.
						During the protected period, the amount of the community spouse resource
						allowance will be excluded from the institutionalized spouse's countable
						resources if the institutionalized spouse expressly indicates his intention to
						transfer resources to the community spouse.
"Resource assessment" means a computation, completed by
						request or upon medical assistance application, of a couple's combined
						countable resources at the beginning of the first continuous period of
						institutionalization of the institutionalized spouse beginning on or after
						September 30, 1989.
"Resources" means real and personal property owned by a
						medical assistance applicant or his spouse. Resources do not include resources
						excluded under subsection (a) or (d) of § 1613 of the Social Security Act
						and resources that would be excluded under § 1613(a)(2)(A) but for the
						limitation on total value described in such section.
"Significant financial duress" means, but is not limited
						to, threatened loss of basic shelter, food or medically necessary health care
						or the financial burden of caring for a disabled child, sibling or other
						immediate relative.
"Spousal protected resource amount" means (at the time of
						medical assistance application as an institutionalized spouse) the greater of:
(i) the spousal resource standard in
					 effect at the time of application;
(ii) the spousal share, not to exceed the
					 maximum spousal resource standard in effect at the time of application;
(iii) the amount actually
					 transferred to the community spouse by the institutionalized spouse pursuant to
					 a court spousal support order; or
(iv) the amount of resources designated by a
					 department hearing officer.
"Spousal resource standard" means the minimum amount of a
						couple's combined countable resources calculated in accordance with §
						1924(f)(2)(A)(i) of the Social Security Act necessary for the community spouse
						to maintain himself in the community. The amount increases each calendar year
						after 1989 by the same percentage increase as in the Consumer Price Index as
						required by § 1924(g) of the Social Security Act.
"Spousal share" means 1/2 of the couple's total countable
						resources at the beginning of the first continuous period of
						institutionalization as determined by a resource assessment.
"Spouse" means a person who is legally married to another
						person under Virginia law.
"State Plan" means the State Plan for Medical
						Assistance.
"Undue hardship" means that the provisions listed under
						12VAC30-110-831 have been met. The
						absence of an undue hardship provision would result in the institutionalized
						spouse being ineligible for Medicaid payment of long-term care services and
						unable to purchase life-sustaining medical care.
"Waiver services" means medical assistance reimbursed
						home or community-based services covered under a § 1915(c) waiver approved
						by the Secretary of the United States Department of Health and Human
						Services.