The CAO will use the countable monthly gross income according to Chapter 450, Income. The income may be actual or expected.
The CAO must:
Count the individual’s actual income.
Count income the individual received or expects to receive in the calendar month.
The CAO must not allow deductions from gross income.
NOTE: Alimony payments, even if ordered by a court, are not an allowable income deduction.
Exception: The CAO must not count the Aid and Attendance portion of a VA benefit as income.
The CAO must not allow deductions for medical expenses, including medical insurance payments or premiums.
The CAO must compare the gross monthly countable income to the NMP special income limit in Appendix A. This NMP special income limit is 300% of the Federal Benefit Rate (FBR).
If an individual applying for HCBS has income exceeding 300% of the FBR he or she may choose to spend-down income in order to be eligible for MA and payment of HCBS. (See Section 468.23, HCBS Spend-Down Procedures).
For individuals with income exceeding the NMP special income limit who are applying for or receiving LTC facility services the CAO must review for MNO eligibility. When determining eligibility in a MNO LTC facility category the CAO must count an individual’s income that is expected or received in a calendar month.
Count income the individual received in the calendar month and add income the person expects to receive in the rest of the six-month period.
Count income the individual received in the past 30 days to estimate income for the six-month period.
NOTE: The CAO must apply deductions according to the Medical Assistance Handbook, Section 361.3.
The CAO must compare the individual’s six-month net income to the MNO limit found in Appendix A. If the income remaining after deductions is equal to or less than the six-month MNO limit, the CAO must authorize payment for LTC facility services. If the income remaining after deductions is more than the six-month limit, the CAO must project the private pay rate for LTC facility services costs as a medical expense deduction. The deduction is the cost for LTC facility services that the person expects to receive or the lowest rate in the county if an LTC facility has not been identified. The CAO will determine the monthly MA LTC rate by multiplying the MA LTC per diem rate by 180 days.
NOTE: The CAO must not authorize MNO using the projected MA LTC rate as a medical expense until the person is admitted to the LTC facility.
Medical expenses include the following:
Health insurance premiums, including enrollment fees, deductibles, or co-insurance charges, such as Medicare or Blue Cross premiums.
Copayments required by the DHS’s copayment program. See Medical Assistance Handbook, Chapter 338, Appendix D.
Expenses that are allowed but are not covered by the MNO program. See Appendix C.
The CAO can deduct an unpaid medical expense incurred during the retroactive period or expected to be incurred during the six-month period if:
It will not be paid by anyone else.
It will not be paid under the MNO program if MNO is authorized.
It is the legal obligation of the individual.
The date and amount are verified.
It was not already used as a deduction for approval of MA.
The CAO can deduct a paid medical expense if it was paid in the month of application or in any of the retroactive months if:
It was paid by the individual.
The individual was required to pay it by law.
The date and amount are verified.
It was not already used as a deduction for approval of MA.
55 Pa. Code § 181.13 55 Pa. Code § 181.14(d)
When an individual applying for HCBS has gross monthly income that exceeds the NMP special income limit found in Appendix A, the individual is not eligible for payment of HCBS in a waiver category. Unlike LTC facility services, a person with excess income applying for HCBS cannot be determined eligible for payment of HCBS in a MNO waiver category. However, an individual may agree to spend-down income in a non-LTC, SSI-related category of MA.
55 Pa. Code § 181.13 55 Pa. Code § 181.11(c)
If an individual has a functional need for HCBS and has income exceeding the NMP special income limit, the CAO will explain the spend-down procedures found in MA Handbook Chapters 368.4, NMP Spend-Down; MA Handbook Chapter 369.331 Spend-Down and MA Handbook Chapter 369.431 Continuing MNO Spend-Down to the individual or his representative. The CAO will also verify that resources are within the appropriate MA spend-down limits found in MA Handbook Chapter 340 Appendix A..
NOTE: The standard $6000 NMP disregard and a protected share of resources are not applicable when determining eligibility in a MA spend-down category.
An individual applying for HCBS in any HCBS Program other than the Living Independence for the Elderly (LIFE) Program will have the spend-down options listed below. See Section 468.231 for spend-down options for individuals applying for the LIFE Program.
A single individual applying for HCBS may choose to spend-down to a monthly NMP spend-down category or may choose to spend-down in an ongoing MNO category. The individual must decide which option is best for him. If the individual needs prescription coverage he may benefit from NMP spend-down; however, MNO spend-down categories have a higher resource limit.
A married individual applying for HCBS may choose to spend-down to a monthly NMP spend-down category or may choose to spend-down in an ongoing MNO category.
In the NMP monthly spend-down category, the CAO must count the income and the resources of the community spouse (CS) when determining eligibility for the institutionalized spouse (IS). The CAO will compare the income and resources to the two-person income and resource limits.
In the MNO ongoing spend-down category, the CAO will NOT count the income or resources of the CS when determining eligibility of the IS. Only the income and resources of the IS will be compared to the one-person income and resource limits.
See MA Handbook Chapter 368 Appendix B for the SSI-related NMP income limits; MA Handbook Chapter 369 Appendix A for the MNO income limits; and MA Handbook Chapter 340 Appendix A. for the SSI-related NMP and MNO resource limits.
The individual must first incur enough medical expenses to spend-down excess income before the CAO will authorize MA and HCBS. If the individual chooses to spend-down income and has incurred enough medical expenses, the CAO will authorize in a spend-down category following the procedures outlined in MA Handbook Chapter 340 Appendix A. or MA Handbook Chapter 369.331 Spend-Down and MA Handbook Chapter 369.431, Continuing MNO Spend-Down for MNO Spend-Down. In order to ensure proper billing of waiver services and proper notice of eligibility the CAO must also follow the procedures identified below:
Delete the system generated eligibility notice.
Enter the appropriate waiver code and the waiver begin date in the case record.
Enter the waiver information by accessing the authorized case through maintenance mode. Enter a 'Y' for waiver services on the Individual Non-Financial Questions screen. Enter the appropriate waiver information on the Waiver and Long Term Living screens. When eligibility is run the category will not change to a waiver category.
NOTE: The wavier code must be entered after authorizing the case in the spend-down category. If the waiver code is entered while authorizing the case, the case will fail the waiver category due to income.
Create a manual notice of spend-down and HCBS eligibility:
See Appendix E for appropriate notice text and citations.
Use the spend-down information found in CIS on CQBURD, the MA Budget Result screen, and CQMETR, the Medical Expenses Tracking screen to complete the spend-down portion of the notice. In eCIS the same information is found on the Income Eligibility Results screen.
Send proper notice of spend-down and HCBS eligibility to:
The HCBS applicant and any MA representatives.
Assessing agency or Maximus.
NOTE: Fair consideration and spousal impoverishment procedures do not apply when an individual is authorized for payment of HCBS in a non-LTC related category of MA. Only individuals applying for a HCBS Waiver Program with gross monthly income that exceeds the NMP special income limit are to be authorized for MA in a spend-down category. Should these individuals later enter a LTC facility, the CAO would authorize in a MNO LTC facility category. Once authorized in a MNO LTC facility category, fair consideration and spousal impoverishment provisions would apply.
Exception: If it is more beneficial for the family to include the HCBS recipient in the eligibility determination for the family then the HCBS recipient may be authorized in a category that does not end in a ‘W’. A waiver code must be added to the case record to ensure proper billing of HCBS. (See LTC Handbook 405.31)
PMN18478489 - Capitated Rates Paid to LIFE Program Providers, May 10, 2017
PMN17655468 - LIFE Participants Transitioning from Facility to Community
Since the LIFE Program involves a set monthly payment to the LIFE provider, an individual applying for MA and payment of HCBS in the LIFE Program may be evaluated for eligibility in a NMP-related ongoing spend-down category. The capitated rate may be used as a medical expense in order to spend-down income.
A single individual applying for HCBS in the LIFE Program may choose to spend-down to either an ongoing NMP or an ongoing MNO spend-down category. As with other HCBS Programs the applicant must decide which category is more beneficial to his circumstances.
A married individual applying for HCBS in the LIFE Program may choose to spend-down to either an ongoing NMP or an ongoing MNO spend-down category.
In the NMP ongoing spend-down category, the CAO must count the income and resources of the CS when determining eligibility for the IS. The CAO will compare the income and resources to the two-person income and resource limits.
In the MNO ongoing spend-down category, the CAO will not count the income or resources of the CS when determining eligibility of the IS. Only the income and resources of the IS will be compared to the one-person income and resource limits.
See MA Handbook Chapter 368 Appendix B for the SSI-related NMP income limits; MA Handbook Chapter 369, Appendix A for the MNO income limits; and MA Handbook Chapter 340 Appendix A. for the SSI-related NMP and MNO resource limits.
NOTE: The standard $6000 NMP disregard and a protected share of resources are not applicable when determining eligibility in a MA spend-down category.
If the individual chooses to spend-down income, the CAO will authorize in a spend-down category following the procedures outlined in MA Handbook Chapter 368.5 for NMP Spend-Down or MA Handbook Chapter 369.331 Spend-Down and MA Handbook Chapter 369.431 Continuing MNO Spend-Down. The CAO will ensure all medical expenses are entered on the Medical Expenses screen in eCIS, including the Medicare B premiums, private insurance premiums, and the amount of the LIFE monthly capitated rate. The LIFE monthly capitated rate can be found in Long Term Care Handbook 468 Appendix A. In order to ensure proper billing of waiver services and proper notice of eligibility the CAO must also follow the procedures identified below:
Delete the system generated MA spend-down eligibility notice.
Enter the LIFE waiver code 96 and the waiver begin date in the case record.
Enter the waiver information by accessing the authorized case through maintenance mode. Enter a 'Y' for waiver services on the Individual Non-Financial Questions screen. Enter the appropriate waiver information on the Waiver and Long-Term Living screens. When eligibility is run the category will not change to a waiver category.
NOTE: The LIFE wavier code must be entered after authorizing the case in the spend-down category. If the waiver code is entered while authorizing the case, the case will fail the waiver category due to income.
Determine the correct cost of care. eCIS will not automatically create a 902Z TPL for an individual receiving MA in a spend-down category. To determine the correct cost of care, deduct the following deductions that are applicable to the individual from gross income (see MA Handbook Chapter 368 for more information):
Unearned income expenses
The $20 unearned income deduction
Earned income work incentive
The $10 NMP income deduction
Paid medical expenses to include Medicare B and private insurance premiums
Unpaid medical expenses to include the LIFE capitated payment.
Example: In 2021 Alex is requesting MA and payment of HCBS in the LIFE Program. Alex has gross Railroad Retirement Benefits of $3,000/month. Alex agrees to spend down his income to the one-person SSI income limit. Alex is responsible to pay his $148.50/month Medicare B premium and his $100/month Capital Blue Cross premium.
To determine the 902Z cost-of-care TPL, the CAO will deduct the $20 unearned income deduction, $10 NMP deduction, $148.50 Medicare B premium and $100 Capital Blue Cross premium from his $3,000 monthly income. The CAO will then compare the resulting $2,721.50 to the 2021 SSI one-person income limit of $816.10. Alex needs to pay the LIFE provider $1,905.40 each month in order to spend down his income. Alex has a cost of care of $1,905.40/month.
Enter the 902Z TPL following the instructions found in the Standalone TPL Summary section in eCIStance.
Create a manual notice of spend-down and LIFE Program eligibility:
See Appendix E for appropriate notice text and citations.
Use the spend-down information found in CIS on CQBURD, the MA Budget Result screen, and CQMETR, the Medical Expenses Tracking screen to complete the spend-down portion of the notice. In eCIS the same information is found on the Income Eligibility Results screen.
Send proper notice of spend-down and LIFE Program eligibility to:
The LIFE applicant and his representative.
The LIFE provider.
Office of Long-Term Living:
LIFE/Forum Place 6th Floor
PO BOX 8025
Harrisburg, PA 17105-8025
NOTE: Fair consideration and spousal impoverishment procedures do not apply when an individual is authorized for payment of HCBS in a non-LTC related category of MA. Only individuals applying for a HCBS Waiver Program with gross monthly income that exceeds the NMP special income limit are to be authorized for MA in a spend-down category. Should these individuals later enter a LTC facility, the CAO would authorize in a MNO LTC facility category. Once authorized in a MNO LTC facility category, fair consideration and spousal impoverishment provisions would apply.
Updated August 29, 2022, Replacing August 30, 2021