907 KAR 20:045. Special income requirements for hospice and home and community based services (HCBS).

 

      RELATES TO: KRS 205.520, 42 C.F.R. Part 435, 38 U.S.C. 5503, 42 U.S.C. 1396a, n

      STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), EO 2004-726

      NECESSITY, FUNCTION, AND CONFORMITY: EO 2004-726, effective July 9, 2004, reorganized the Cabinet for Health Services and placed the Department for Medicaid Services and the Medicaid Program under the Cabinet for Health and Family Services. The Cabinet for Health and Family Services has responsibility to administer the Medicaid Program. KRS 205.520(3) authorizes the cabinet, by administrative regulation, to comply with a requirement that may be imposed or opportunity presented by federal law for the provision of medical assistance to Kentucky's indigent citizenry. This administrative regulation establishes special income requirements for home and community based waiver and hospice services.

 

      Section 1. Definitions. (1) "Basic maintenance" means the amount of income that may be retained by the applicant for living and personal expenses.

      (2) "Categorically needy" means an individual with income below 300 percent of the supplemental security income (SSI) standard who has been receiving hospice or HCBS for thirty (30) consecutive days.

      (3) "HCBS" means home and community based services.

      (4) "Institutionalized" means residing in a nursing facility or receiving hospice or HCBS benefits.

      (5) "Special income level" means the amount which is 300 percent of the SSI standard.

      (6) "SSI" means the Social Security Administration Program called supplemental security income.

      (7) "SSI general exclusion" means the twenty (20) dollars disregard from income allowed by the Social Security Administration in an SSI determination.

      (8) "SSI standard" means the amount designated by the Social Security Administration as the federal benefit rate.

 

      Section 2. Special Provisions for Recipients Participating in the HCBS Waiver Program. (1) Medicaid eligibility for a participant under HCBS shall be determined if necessary to establish eligibility for Medicaid benefits for a case with income in excess of the basic maintenance standard taking into consideration the special provisions established in this section and in 907 KAR 1:655.

      (2) Income protected for the basic maintenance of an HCBS Program participant who is eligible as medically needy or under the special income level established in this section shall be the standard used for an individual in the federal SSI Program in additional to the SSI general exclusion from income.

      (3) An HCBS Program participant who participates in the HCBS Program for thirty (30) consecutive days, including the actual days of institutionalization within that period, and who has income which does not exceed the special income level shall be determined to be eligible as categorically needy under the special income level.

      (4) If a Supports for Community Living (SCL) Program participant has income in excess of the special income level, eligibility of the participant shall be determined on a monthly spenddown basis with the cost of SCL services projected.

      (5) Institutional deeming rules shall apply in accordance with 907 KAR 1:655.

      (6) In the posteligibility determination of available income, the basic maintenance needs allowance shall include a mandatory withholding from income. Mandatory withholdings shall:

      (a) Include state and federal taxes; and

      (b) Not include child support, alimony, or a similar payment resulting from an action by the recipient.

      (7) A veteran or the spouse of a veteran who is receiving services in a home and community based waiver program and who is receiving a Veteran's Administration (VA) benefit shall have ninety (90) dollars excluded from the eligibility and posteligibility determination process.

      (8) Veterans Administration payments for unmet medical expenses (UME) and aid and attendance (A&A) shall be excluded in a Medicaid eligibility and posteligibility determination for a veteran or the spouse of a veteran receiving services from a home and community based waiver program.

      (9) Income placed in a qualifying income trust established in accordance with 42 U.S.C. 1396p(d)(4) and 907 KAR 1:650, Section 3(5), shall not be excluded in the posteligibility determination.

 

      Section 3. Special Provisions for Hospice Recipients. Medicaid eligibility for a participant in the Medicaid Hospice Program shall be determined by taking into consideration the special provisions contained in this section.

      (1) Income protected for basic maintenance shall be:

      (a) The SSI standard and the SSI general exclusion from income for the hospice participant in the posteligibility determination for a noninstitutionalized individual eligible on the basis of the special income level;

      (b) The usual medically needy standard established in 907 KAR 1:640, Section 2, plus the SSI general exclusion for a noninstitutionalized medically needy participant, who shall spenddown on a quarterly basis;

      (c) The medically-needy standard for the appropriate family size plus the SSI general exclusion for the institutionalized medically needy;

      (d) Forty (40) dollars per month for the hospice participant institutionalized in a long-term care facility;

      (e) For a veteran or the spouse of a veteran who is receiving services from a hospice and who is receiving a Veteran's Administration (VA) benefit, ninety (90) dollars, which shall be excluded from the eligibility and posteligibility determination process; or

      (f) The amount of Veterans Administration payments for unmet medical expenses (UME) and aid and attendance (A&A), which shall be excluded in a Medicaid eligibility and posteligibility determination for a veteran or the spouse of a veteran receiving services from a hospice.

      (2) If eligibility is determined for an institutionalized spenddown case, the attributed cost of care against which available income of the hospice participant shall be applied shall be the hospice routine home care per diem for the hospice providing care as established by 42 U.S.C. 1395f(i) plus the private pay rate for the nursing facility.

      (3) Eligibility shall continue on the same monthly basis as for an institutionalized individual if the recipient is eligible based on the special income level.

      (4) A hospice participant shall be eligible for a benefit based on this section if he has elected coverage under the Medicaid Hospice Program rather than the regular Medicaid Program.

      (5) Institutional deeming rules shall apply in accordance with 907 KAR 1:655 with regard to the categorically needy including a participant eligible on the basis of the special income level.

      (6) Community deeming procedures shall be used in accordance with 907 KAR 1:660 for a noninstitutionalized hospice recipient who is:

      (a) A medically needy individual, who shall spenddown on a quarterly basis; and

      (b) Not eligible under the special income level.

      (7) In the posteligibility determination of available income, the basic maintenance needs allowance shall include a mandatory withholding from income. Mandatory withholdings shall:

      (a) Include state and federal taxes; and

      (b) Not include child support, alimony, or a similar payment resulting from an action by the recipient.

      (8) Income placed in a qualifying income trust established in accordance with 42 U.S.C. 1396p(d)(4) and 907 KAR 1:650, Section 3(5), shall not be excluded in the posteligibility determination. (30 Ky.R. 1125; Am. 1540; eff. 1-5-2004; Recodified from 907 KAR 1:665, 9-30-2013.)