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State of Wisconsin |
HISTORY |
The policy on this page is from a previous version of the handbook.
27.7.1 ILTC Cost of Care Calculation Introduction
27.7.3.2 Community and Nursing Home
27.7.4 Transfers Between Institutions
27.7.5 Retroactive Cost of Care
27.7.6 Personal Needs Allowance
27.7.7 Medical/Remedial Expenses and Payments for Non-Covered Services
After an institutionalized person has been determined eligible for Medicaid, his or her cost of care must be calculated. Cost of care is the amount he or she will pay each month to partially offset the cost of his or her Medicaid services. It is called the patient liability amount when applied to a resident of a medical institution and cost share when applied to a community waivers client, Pace/ Partnership, or Family Care client. The institutionalized member will be expected to pay their patient liability to the institution that they are residing in as of the first day of the month.
Calculate the cost of care in the following way:
For a Medicaid member in a medical institution who does not have a community spouse , subtract the following from the person’s monthly income:
$65 and ½ earned income disregard (15.7.5 $65 and ½ Earned Income Deduction).
Monthly cost for health insurance (27.6.4 Health Insurance).
Support payments (15.7.2.1 Support Payments).
Personal needs allowance (39.4 EBD Assets and Income Tables).
Home maintenance costs, if applicable (15.7.1 Maintaining Home or Apartment).
Expenses for establishing and maintaining a court-ordered guardianship or protective placement, including court-ordered attorney and/or guardian fees (27.6.6 Fees to Guardians or Attorneys).
Medical Remedial Expenses. See 27.7.8 Payment for Non-Covered Services.
For a Medicaid member in a medical institution who has a community spouse , follow the directions in 18.6 Spousal Impoverishment Income Allocation.
For a community waivers member with or without a community spouse, follow the directions in 28.5 HCBWLTC Cost Sharing.
There is no cost of care for SSI recipients.
For a Medicaid member who was or could have been certified through a deductible before entering the institution, there is no cost of care until the deductible period ends.
If the cost of care amount is equal to or more than the medical institution ’s Medicaid rate, the individual is responsible for the entire cost of his or her institutional care. He or she would be entitled to keep any overage without restriction. He or she would remain eligible for the Medicaid program and have no further financial obligation to the Medicaid program for that month.
Effective December 1st, 2008, hospitalized individuals will be responsible for paying a patient liability. See 27.7.5 Transfers Between Institutions for information about patient liability calculations when a person transfers between a hospital and nursing home(s).
If a member is not Medicaid eligible and residing in an institution (27.1 Institutions) as of the first of the month, there is no patient liability for that month.
Exception: There is a patient liability if the reason why the person didn't reside in the institution for the entire month was due to death or being on Therapeutic leave.
If the patient liability amount in the month of death is greater than the nursing home’s cost of care for that month send a completed F-10110 (formerly DES 3070) form to:
Mail:
HP Enterprise Services
P.O. Box 7636
Madison, WI 53707
Fax: (608) 221-8815
Indicate the patient liability amount as equal to the nursing home charges for the month. This is done for potential retroactive nursing home rate adjustments. The nursing home will notify the Estate Recovery Program ( ERP ) of who received the excess income. ERP will attempt recovery even if the money goes to the heir directly. ERP uses the same process to recover this excess income as it does for recovering patient fund accounts (22.1.5.7 Patient Fund Account).
There is no patient liability in a month a member moves from:
The community into a nursing home after the first of the month, or
From a nursing home to the community before the end of the month. This includes members moving from the nursing home to the community on the last day of the month.
Effective 12/01/08:
When an institutionalized individual transfers between institutions (nursing homes, hospitals, hospices) in the same month, you will no longer pro rate the patient liability between the various institutions that they resided in during that month. The client/member will pay their patient liability to the institution that they were residing in on the first day of the month. ForwardHealth will automatically deduct the appropriate patient liability amount from the first nursing home, hospice, or long term inpatient hospital claim received for the member. If the amount of the patient liability exceeds the reimbursement amount of the first claim, the remaining liability amount will be deducted from the next claim(s) received for services provided in the month that patient liability is owed. Patient liability amounts deducted from claims will appear in the provider’s remittance information. Nursing home, hospice, and inpatient hospital providers may have to occasionally transfer a patient liability amount that they collected from a client/member, on the first day of a month, to the appropriate provider who ultimately had their claim adjusted to reflect the required patient liability amount.
Occasionally a nursing home or community waivers applicant becomes retroactively eligible. This might happen, for example, when a person, having been denied eligibility, goes to a fair hearing. If the fair hearing determines the person was eligible at the time of application, the agency must retroactively certify him or her and compute retroactive cost of care. The directions are the same as for current cost of care (27.7.1 ILTC Cost of Care Calculation Introduction).
Deduct the personal needs allowance (39.4.2 EBD Deductions and Allowances) for all institutionalized members in both the eligibility test and the patient liability calculation.
An institutionalized person's personal needs allowance may accumulate to where he or she may lose eligibility due to excess assets. To prevent this, he or she can spend money on personal needs or make a refund to Medicaid. See Voluntary Recovery 22.1.10.
Medicaid members in nursing homes are allowed to pay for some medically necessary non-covered services out of their patient liability. They are not required to use their personal needs allowance for these services.
Effective January 4, 2008, allowable payments that an institutionalized person is actually making for all medical/remedial expenses they have incurred and are legally obligated to pay, are used as a need item when determining their eligibility for MA. These actual payments are also allowed as an income deduction to reduce the cost share amount. This includes payments for medical/remedial expenses that the person is currently incurring as well as payments for certain previously incurred medical/remedial expenses.
In order to use the medical/remedial expense as a need item and as an income deduction in the cost share calculation, the expense must meet the following criteria:
The institutionalized individual must be legally liable for payment of the incurred medical/remedial expense. Any portion that will be paid by a legally liable third party such as private health insurance, Medicare, Medicaid, etc. cannot be allowed as a deduction; and
The institutionalized individual must provide verification of the allowable expense. See 27.7.8.2 Disallowed Expenses
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Example 1: In February, Al had a root canal performed by a dentist who is not an MA provider. He is responsible for paying $600 for the procedure. Al began making payments of $100 per month on this medical bill in March. On April 1st, Al became institutionalized and eligible for MA. The $100 payment that Al is making on a previously incurred medical expense should be used as a need item when determining Al’s institutional MA eligibility. The expense should also be used as in income deduction when calculating Al’s cost share obligation. The $100 payment can be used as an income deduction in the cost share calculation until it is fully paid in August. Since Al will no longer be making payments in September, the expense should be decreased to zero prior to adverse action in August. |
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Example 2: In April, Edna applied for Institutional MA and requested a one-month backdate. Her request for eligibility in March was denied because her assets exceeded program limits, but was approved effective April 1st. Edna used her excess assets to make a partial payment to the nursing home for March costs, but still has an outstanding balance of $1,800. Edna agrees to make payments to the nursing home of $500 per month until the expense is paid in full. The $500 payment to the nursing home should be used as an income deduction when calculating her cost share for the months of April through June. In July she will only owe $300 to the nursing home so the deduction for July should be decreased to $300 prior to adverse action in June. Edna will no longer be making payments in August so the expense should be decreased to zero prior to adverse action in July. |
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Example 3: Jack has been an institutionalized MA member since January. In March, he had a tooth extracted. The procedure was performed by a dentist who is not an MA provider, so it was a non-covered service. Jack contacts the agency in April to request a deduction from his cost share so that he can pay the expense. The cost of the extraction was $209. Since this was a one-time expense and his patient liability exceeds this amount, the agency enters the expense in CWW to reduce the May cost share by $209. |
Do not allow payments that an institutionalized person is making, or requests to make, as a need item, or as a cost share adjustment if the medical or remedial expense meets any of the following exception reasons:
Remains unpaid, but was previously used to meet a Medicaid deductible.
Were incurred as the result of imposition of a divestment penalty period.
A patient liability or cost share from a previous budget period, whether paid or unpaid, cannot be used as an incurred medical or remedial care expense in a subsequent budget period.
Incurred medical and remedial care expenses deducted from income to determine patient liability or cost share in a month cannot be used to determine patient liability or cost share in a subsequent month.
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Example 4: On September 17, Alice was hospitalized for injuries she sustained in a fall. Alice was uninsured at the time and incurred a $2,000 hospital bill. Before leaving the hospital, she set up a payment agreement to pay $100 per month until the debt was paid. Alice used the outstanding expense to satisfy a deductible in the amount of $1,800 and was determined MA eligible from September through February.
In May, Alice was determined to be functionally eligible for Home and Community Based Waivers and was determined eligible for MA under Group B waiver rules. Without a medical/remedial expense, Alice’s cost share would be $100. Alice’s Care Manager verified that Alice still owes $1,200, but only $200 of the expense is allowable because $1,800 was already used to satisfy a deductible. Her Care Manager will include the $100 payment in the medical/remedial expense amount submitted to the IM worker for determining her cost share, but will reevaluate Alice’s medical/remedial expense amount in two months. |
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Example 5: On August 1, Alice moved to a nursing home. Her eligibility for Home and Community Based Waiver ended and she was determined eligible for Nursing Home MA beginning August 1st. She is still making the $100 payments to the hospital, and has an outstanding balance of $900. However, Alice used $1,800 to meet a deductible and already received a deduction of $200 from her community waiver cost share. The payment cannot be used as a medical expense deduction from her income when calculating the monthly patient liability. |
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Example 6: In January, Lyle was institutionalized and applied for MA. Due to a previous divestment, Lyle has a three-month divestment penalty period, beginning in December. During this three month period, MA will not cover the cost of Lyle’s institutional care, but will only cover his card services. In March, the divestment penalty period expired, and Lyle is eligible for MA payment of his institutional cost share. He would like to use $2,000 of his monthly income to pay for the nursing home bills that he incurred in January and February and deduct this amount from his cost share. The request to allow an adjustment in Lyle’s cost share must be denied because the medical expense that he wants deducted from his income is to pay for the cost of institutional care incurred during a prior MA divestment penalty period. |
CARES Process
Until changes in CARES can be made to accommodate this policy and process change for institutional cases, enter the allowable medical and remedial expenses as a court ordered support payment on the Support Obligations/Payments page in CWW. Be sure to document detailed information about the expense and cost share calculations in case comments.
Remember, Medical/remedial expenses for group B waiver cases are still entered on the Medical Expense page. There are no CARES processing changes/overrides required for community waiver/Family Care cases.
This page last updated in Release Number: 15-01
Release Date: 06/10/2015
Effective Date: 06/10/2015
The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.
Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.
Publication Number: P-10030