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Wisconsin Department of Health and Family Services Medicaid Eligibility Handbook |
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Wisconsin Department of Health and Family Services Medicaid Eligibility Handbook |
5.9.9.2.1 Personal Maintenance Allowance
5.9.9.2.2 Family Maintenance Allowance
5.9.9.2.3 Special Exempt Income
5.9.9.2.5 Medical/Remedial Expenses
Eligibility for Group A, B, and C Community Waivers cases are determined in CARES Client Assistance for Re-employment & Economic Support. Group A Katie Beckett cases are processed manually outside of CARES.
Care managers will determine and certify community waiver eligibility for children already eligible for Medicaid through the Katie Beckett program. In addition, care managers will determine if divestment of the child’s assets has taken place.
If so, a referral will be made to ES workers to determine manually if a penalty period exists. If a penalty period exists, the ES worker will notify the care manager, and the care manager will notify the applicant.
Katie Beckett waiver cases will now be considered “Group A”. The Katie Beckett medical status code will be retained. Because of the small number of these cases, the certification process will not be automated in CARES. Certification will be processed manually by care managers and Katie Beckett staff.
Complete the Waiver Eligibility and Cost Sharing Worksheet ( DDE-919 ) when an institutionalized client is going to be discharged, and enter the Community Waivers program.
When CARES screens are unavailable, use simulation or complete the DDE-919 as follows:
Fill out the identifying information at the top.
The MA
eligibility date is the date of most recent MA eligibility.
Fill out the financial information in Section I, Lines 1-4. When you have determined that the person is financially eligible, set the effective begin date of eligibility (5.9.8).
Read the descriptions of Groups A, B, and C below. After deciding which group the person is in, check the appropriate box in Section I. A person cannot be in more than one group at the same time.
Group A clients are defined as those waiver functionally eligible and MA eligible via SSI (including SSI-E and 1619A and B) or a full-benefit MA subprogram (7.1.2). This does not include someone solely eligible for any of the limited benefit MA subprograms (7.1.3).
Clients who have met a deductible are eligible for Community Waivers as a Group A. The client remains eligible as a Group A until the end of the deductible period. At the next review the client will be able to make a choice between meeting the deductible to receive MA (remaining a Group A) or becoming eligible for Community Waivers as a Group B with a potential cost share, or Group C with a potential spenddown/cost share.
Group A clients are financially eligible with no cost share. Put a check before Group A in Section I. Then complete Sections II and V on the worksheet.
Group B clients are defined as those not in Group A, but who have income Income is anything you receive in cash or in kind that you can use to meet your needs for food, clothing, and shelter. at or below the nursing home institutions categorically needy income limit. (8.1.5) Calculate a cost share based on the client’s income and allowable deductions.
Put a check before Group B in Section I. Then complete Sections III and V on the worksheet. Count only the income of each individual when you calculate that individual's cost share.
The personal maintenance allowance (Line 6 and Page 2 of the worksheet) is for room, board, and personal expenses. It is the total of:
Community Waivers Basic Needs Allowance (8.1.5.1).
$65 and ˝ earned income deduction (4.1.3.6).
Special housing amount. This
is an amount of the person's income set aside to help pay housing costs.
If the
waiver applicant's housing costs are over $350, add together
the following costs:
Rent.
Home or renters insurance.
Mortgage.
Property tax (including special assessments).
Utilities (heat, water, sewer, electricity).
“Room” amount for clients in a Community Based Residential Facility ( CBRF ), Residential Care Apartment Complex ( RCAC ) or an Adult Family/Foster Allowance.) Home ( AFH ). The case manager determines and provides this amount.
The total, minus $350, equals the special housing amount. The person can set this amount aside from his/her income.
If both spouses are applying and both have income, divide the special housing amount equally between them.
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Example: Two spouses applying with income: $600 rent - 350 = 250/2 spouses = $125 that each can set aside |
If only one spouse has income and both spouses are applying, allocate the full special housing amount to the spouse with income.
Do not give the special housing amount to waiver participants under age 18.
The total of 1, 2, and 3 must not be greater than the EBD
Maximum Personal Maintenance Allowance (8.1.5.1).
The family maintenance allowance is for the support of family members when spousal impoverishment policies do not apply. If the client is a disabled child, omit the family maintenance allowance.
Family Related - When the waiver
participant is the custodial parent of a minor child living in the home,
and there’s no spouse in the home, do the following:
Minor children’s gross earned income.
-$65 and ˝ of gross earned income (4.1.3.6).
=______________.
+ Minor Children’s total unearned income.
= __________Add (3) and (4).
AFDC Related med needy income limit _______ (8.1.4).
(Do not include the waiver applicant in the group size.)
If (5) is greater than (6), there’s no family maintenance allowance. If (5) is less than (6), the family maintenance allowance is the difference between (5) and (6).
EBD Related - If there are no minor children in the home, and spousal impoverishment policies do not apply, do the following:
Spouse’s gross earned income.
-$65 and ˝ of total gross earned income (4.1.3.6).
=__________.
+Spouse’s total unearned income.
=________________ (3)+(4).
-$20 disregard.
=_________________(6)-(5).
____________Enter the SSI Payment Level Plus the E Supplement for one person (8.1.5)
If (7) is greater than (8) there is no family maintenance allowance. If (7) is less than (8) the family maintenance allowance is the difference between (7) and (8).
Deduct special exempt income (4.1.3.2).
Include all health and dental insurance premiums covering the waiver person and for which s/he is responsible and pays. See 6.3.4 for a list of insurance types for which premium deductions are not allowed.
If the waiver participant is part of a covered group, but not responsible for the premium, find his/her proportionate share by dividing the premium by the number of people covered. If both members of a couple apply, but only one pays the premium, divide the premium equally. Prorate premiums over the months payment covers.
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Example: Sally pays a $600 premium quarterly for her Medicare supplement policy. $600 divided by three equals $200. Enter $200 as her monthly health insurance premium payment on AFMC. |
Obtain the dollar amount for medical and remedial expenses (Line 10) from the case manager. See 4.1.3.3 for definitions.
The waiver cost share amount (Line 12) is the monthly amount s/he must pay toward the cost of his/her waiver services.
Institutionalized Pace/Partnership or Family Care enrollees pay their cost share to the Managed Care Program instead of the institution.
Persons in Group C meet the medically needy income test for waiver clients.
Put a check before Group C in Section I. Complete
Sections IV and V.
Most Group C members have a monthly spenddown. They
must meet the spenddown each month to remain eligible. The
case manager monitors the monthly spenddown.
This page last updated in Release Number: 02-04
Release Date: 10/01/02
Effective Date: 10/01/02