Opinion ID: 2653500
Heading Depth: 1
Heading Rank: 1

Heading: General Background Law

Text: ¶ 2. Choices is a state-administered program funded through a Medicaid waiver that, in relevant part, provides home-based long-term-care services to eligible elderly or physically disabled Vermont adults. See Choices for Care 1115 Long-Term Care Medicaid Waiver Regulations § I( A), 4 Code of Vt. Rules 13 110 008-1, available at http://www.lexisnexis.com/hottopics/codeofvtrules [CFC Regulations]. The Choices waiver is subject to approval by the Centers for Medicare and Medicaid Services (CMS), the federal agency charged with providing program oversight, and is managed in compliance with CMS terms and conditions of participation. Id . ¶ 3. Applicants for services through the Choices program must satisfy both clinical and financial criteria. Id . § IV( A)(1). On the financial side, applicants are sometimes required to “spend down” their available income before they are eligible to participate in the program. See id . § IV( D) (discussing financial eligibility standards). Based on various clinical criteria, eligible individuals are classified into the highest-needs group, the high-needs group and the moderate-needs group. Id . § IV( B). The services available under the program vary based on the individual’s classification. Id . § VIII. DAIL and the Department for Children and Families (DCF) jointly administer Choices, with DAIL determining clinical eligibility and category of clinical needs and DCF determining financial eligibility for those in the high- and highest-needs categories. Id . § VI( B)-(C). ¶ 4. Among the personal care services covered by Choices are assistance with activities of daily living (ADLs)—which are categorized into discrete units such as dressing, eating, bathing, bed mobility, and toilet use—and assistance with instrumental activities of daily living (IADLs)—which are also categorized into discrete units such as meal preparation, medication management, household maintenance, and transportation. Id . § III( 1), (28), (37). The number of hours of personal care services available through Choices for assistance with various specified needs are capped. Id . § VIII. However, an individual may request services above the cap by seeking a variance. Id . § XI. ¶ 5. People eligible for Medicaid programs, including Choices, are required, depending on their income, to pay a share of the costs of their care. Spend-down, Patient Share, and Resource Transfer Regulations § 4400, 5 Code of Vt. Rules 13 170-1, available at http//www.lexisnexis.com/hottopics/codeofvtrules [Patient Share Regulations]. The patient share is calculated by determining a person’s gross monthly income and then subtracting federally mandated deductions, including a personal needs allowance, home-upkeep expenses, family maintenance, and reasonable medical expenses. Id . § 4460. In the closely related context of spend-downs in connection with an applicant’s initial eligibility, a deduction “is allowed for necessary medical and remedial expenses recognized by state law but not covered by Medicaid,” id . § 4452, including “ noncovered personal care services provided in an individual’s own home . . . when they are medically necessary in relation to an individual’s medical condition,” id . § 4452.3, and “[c] overed medical expenses . . . that exceed limitations on amount, duration, or scope of services covered,” id . § 4442(c). Deductions for “general supervision” of a beneficiary’s well-being may be allowed where that care is required due to a specific diagnosis of certain debilitating diseases like Alzheimer’s disease or dementia. Id . § 4452.3(a). ¶ 6. A beneficiary claiming a deduction for the cost of personal services as a necessary medical expense submits to DAIL a Statement of Cost for Personal Care Services (form 288C) and a Statement of Need for Personal Care Services (form 288B) from a treating physician. DAIL reviews the forms and determines whether to provide the requested services under the Choices program. DCF determines the amount of the patient share. Services that are medically necessary and not covered by Choices are deducted from the beneficiary’s income for purposes of calculating the patient share. See 42 C.F.R. § 435.735(c )( 4)(ii) (federal regulation governing application of patient income to the cost of care); see also Patient Share Regulations § 4442 (listing deduction sequence for spend-down purposes).