PROPOSED RULEMAKING
DEPARTMENT OF
PUBLIC WELFARE
[55 PA CODE CHS. 178 AND 181]
Resource Provisions for Categorically NMP-MA and MNO-MA; Income Provisions for Categorically Needy NMP-MA and MNO-MA
[32 Pa.B. 4854] The Department of Public Welfare (Department) proposes to amend Chapters 178 and 181 (relating to resource provisions for categorically NMP-MA and MNO-MA; and income provisions for categorically needy NMP-MA and MNO-MA) under the authority of sections 201(2), 403(b), 441.1 and 442.1 of the Public Welfare Code (62 P. S. §§ 201(2), 403(b), 441.1 and 442.1); sections 1917(c) and 1924 of Title XIX of the Social Security Act (42 U.S.C.A. §§ 1396p(c) and 1396r-5); and Federal regulations for posteligibility treatment of income of institutionalized individuals found in 42 CFR 435.725(c)(4)(ii) and (d) and 435.832(c)(4)(ii) and (d) (relating to post-eligibility treatment of income of institutionalized individuals in SSI States: application of patient income to the cost of care; and post-eligibility treatment of income of institutionalized individuals: application of patient income to the cost of care).
Purpose
The purpose of this proposed rulemaking is to codify rules that revise the Medical Assistance (MA) eligibility requirements for applicants and recipients in need of long-term care (LTC) services both in the community and in an institutional setting. This proposed rulemaking revises the financial requirements to qualify for MA payment for LTC services and posteligibility calculation of the amount of income the MA recipient in LTC facilities is required to contribute toward the cost of institutional care.
Background
The Department is committed to administering an efficient and effective MA program. The Department wants to ensure access to quality health care for its most vulnerable citizens, including those who require LTC services.
Over the past year, the Commonwealth, as well as many other states, has experienced a significant increase in costs under the MA Program. No immediate relief is in sight. This fiscal pressure has required states to examine closely all expenditures and evaluate and prioritize what programs can continue to be fully funded.
The Department has taken steps to contain costs in past years through the implementation of managed care and the institution of management controls to avoid payments for services not medically necessary. Despite these changes, expenses in the MA Program continue to grow.
MA is a means-tested Federal-State funded program designed to provide health care benefits to individuals with limited income and resources. While the Federal government provides a baseline of what eligibility groups must be covered and what benefits must be provided in order for states to receive Federal financial participation, states may choose to expand eligibility to additional groups as well as provide additional services. Historically, the Commonwealth has adopted most of the eligibility and service options under Federal law and exercised various options to use less restrictive methodologies to determine eligibility. As a result, the Commonwealth is administering one of the most generous MA Programs in the country.
In reviewing program areas to help reduce the significant growth in expenditures, the Department has compared its current MA Program requirements with the requirements the Federal government mandates as well as what other states provide. As a result of this comparison, options were identified that would bring Pennsylvania's program more in line with the Federal baseline as well as closer to what other states provide.
Despite the increasing costs, the Department, unlike its counterparts in other states, has not limited service coverage. Instead, the Commonwealth's approach has been to try to protect benefits for those in greatest financial need while looking at those areas of the program where individuals have some existing income or resources to pay for at least part of their care.
Current escalating cost in the MA Program compels the Department to make changes that will control costs without compromising access to LTC services. While taking steps to reduce coverage causes concern, taking less drastic action at this point to minimize growth now will hopefully mitigate the need to limit coverage or eliminate entire eligibility groups. These revisions target eligibility rules that are more generous than required by Federal statute or regulation. Under current policy, some individuals are able to divert available resources to avoid paying for LTC. This proposed rulemaking will help maintain the current level of coverage for current recipients and require those with available resources to assume greater financial responsibility for their care.
This proposed rulemaking implements four changes to current policy related to eligibility for services for LTC under the MA Program. The first revision changes the method of computing available income and resources between spouses by implementing the Income-First Rule. This includes an expansion of the definitions to delineate the terms used to implement the Income-First Rule. (See §§ 178.2 and 178.124(b)(2) (relating to definitions; and resource eligibility for the institutionalized spouse.) The second revision expands the circumstances when the ineligibility period for services for LTC under the MA Program when an applicant or recipient transfers a resource and fair market value is not received. (See §§ 178.104(d) and 178.174(d) (relating to disposition of assets and fair consideration provisions for transfers on or after July 30, 1994; and disposition of assets and fair consideration provisions for transfers on or after July 30, 1994).) The third revision limits the amount of unpaid medical expenses owed by an MA recipient that is allowed as an income deduction when determining contribution toward the cost of LTC services. (See § 181.452(d)(5)(iii) (relating to posteligibility determination of income available from an MA eligible person toward the cost of care).) The final revision eliminates an optional income deduction that is currently provided for maintenance of a home when the LTC recipient's stay in the LTC facility is expected to be less than 6 months. (See § 181.452(d)(6).)
Income-First Rule
Background
The Medicare Catastrophic Coverage Act of 1988 (MCCA) (42 U.S.C.A. § 1396r-5) included provisions that protect the spouse living at home (called the community spouse (CS)) from having her resources depleted when the other spouse (called the institutionalized spouse (IS)) is admitted to an LTC facility. Until the MCCA, Federal standards often left a spouse living at home destitute, the couple's assets drained to qualify the spouse in the institution for MA. The provisions in MCCA responded to this problem. MCCA added section 1924 to Title XIX of the Social Security Act (42 U.S.C.A. § 1396r-5), revising the MA statutory standards for providing the CS with additional income to bring her up to the protected level. These requirements are known as the ''spousal impoverishment'' provisions. These provisions govern the treatment of assets (income and resources) of the couple for determining MA eligibility and allow for the provision of additional income to the CS.
The provisions of 42 U.S.C.A. § 1396r-5 require that a resource assessment be completed when one spouse is admitted to an LTC facility. The total available resources owned by the couple, both jointly and individually, on the date of admission are determined. A determination is made of the CS's share of the couple's total resources, generally one-half of the total subject to the minimum and maximum resource standards consistent with section 1924(c) of the Social Security Act. The remaining resources are considered available to the IS.
In addition to preserving resources for the CS, the requirements of MCCA were designed to ensure that the CS has sufficient income to meet basic monthly needs. Section 1924(d) of the Social Security Act requires the establishment of a minimum monthly maintenance needs allowance for the CS. The minimum monthly maintenance needs allowance is an annually updated figure set to a level that is 1/12th of 150% of the official Federal poverty level for a family of two. If the CS's income is less than the minimum monthly maintenance needs allowance, states may adopt a method to permit the amount of the shortfall to be met from the income or resources of the IS in accordance with section 1924(d)(1)(B) and (f)(2)(A)(iii) of the Social Security Act.
The Department's current regulations provide that the income-first method is to be used for providing the CS with additional income to bring her up to the protected level. (See 55 Pa. Code §§ 178.124(b) and 181.452.) This income transfer must occur before additional resources can be protected to provide the CS with income. Current regulations, however, do not conform to current practice which is based on the provisions of a settlement agreement in Hurly v. Houstoun, C. A. No. 93-3666 (U. S. Dist. Ct. E. D. Pa.) In Hurly, plaintiffs challenged the Department's regulations implementing section 1924(d) of the Social Security Act, contending that the income-first rule did not comply with Federal law. As a result of a settlement reached between plaintiffs and the Department in June 1996, the Department revised its procedures. The Department uses an ''annuity rule'' which permits the couple to use resources to purchase an annuity that will provide the CS with the additional income that she is permitted. At the time the Hurly settlement was reached, there were no Federal regulations to interpret the Federal statute.
On September 7, 2001, the United States Department of Health and Human Services issued a notice of proposed rulemaking allowing states to choose either the income-first or resource-first method to determine how the CS will be provided with additional income. (See 66 FR 4676.) Thereafter, the United States Supreme Court decided that the income-first rule was a reasonable interpretation of section 1924(d) of the Social Security Act. See Wisconsin Department of Health and Family Services v. Blumer, 534 U. S. 952 (2002). Based upon these developments, the Department will restore the income-first policy which is set forth in the current regulations including certain technical amendments to improve clarity.
Proposed Rulemaking
This proposed rulemaking eliminates the Commonwealth's Annuity Rule procedure and implements the income-first method when determining how the CS is provided with additional income--the Federal term is the ''CS monthly income allowance.'' Using the income-first rule takes into account the anticipated monthly contribution of income from the IS to the CS to bring the CS's income up to the protected income level. The monthly contribution of income from the IS to the CS is considered before any additional resources can be allocated to the CS for the purpose of generating income. These resources are intended to be used to help pay for the cost of LTC services until the IS is eligible for MA. This method eliminates the option for a couple to automatically preserve additional resources to purchase an annuity to generate monthly income for the CS.
Partial Month of Ineligibility
Background
Section 1917(c) of the Social Security Act (42 U.S.C.A. § 1396p(c)) requires a period of ineligibility for MA coverage of LTC services when the applicant or recipient or his spouse transfers resources for less than fair market value within a specified look-back period. The period of ineligibility is called the penalty period or disqualification period. The length of the penalty period is calculated by dividing the uncompensated value of all transferred assets by the current average monthly rate for private nursing facility care (NFC) at the time of application for MA. States have the choice of not imposing a penalty period for transfers of less than a full month. Pennsylvania is using full months and rounding down when the calculation results in a fraction.
Proposed Amendment
This proposal expands the circumstances in which an MA ineligibility period for payment of LTC services will result from a transfer of an asset that occurs when fair market value has not been received. Currently, existing regulations do not require a penalty period for a transfer of an asset that is less than the average monthly rate for private NFC and for a partial penalty period of less than 1 month when the calculation of the period of ineligibility for payment of LTC services results in a fraction of a month. A penalty will be imposed under these proposed amendments for a transfer of asset that is less than the average monthly rate and for a partial penalty period. This proposal will require that an individual be responsible for paying for LTC services equal to the entire amount of the asset that was transferred for less than fair market value if a penalty is imposed due to failure to receive fair market value. Any transfer of assets, regardless of the amount, will be evaluated to determine if an individual will be denied payment of LTC services.
Limit on Unpaid Medical Expenses
Background
An MA recipient who is residing in an LTC facility is required to contribute to the cost of LTC by using monthly income after deductions in accordance with 42 CFR 435.725(c)(4)(ii) and 435.832(c)(4)(ii). Deductions include expenses for medical or remedial care recognized under state law but not covered under the state's MA plan. These deductions are subject to allowable limits the state may establish. Current regulations in § 181.452(d)(5)(ii) permit these deductions regardless of the amount of the expense when determining the amount of income an MA recipient must contribute toward the cost of LTC services. The medical expense is deducted from the MA recipient's income in the calendar month the medical expense is paid by the MA recipient.
Proposed Amendment
This proposal sets a limit of $10,000 for an outstanding unpaid medical expense that can be used as an allowable medical expense deduction when calculating an MA recipient's contribution toward cost of care. The $10,000 limit is a reasonable limit approximately equal to 3 months of NFC at the MA rate. The limit is intended to encourage individuals who are potentially eligible for MA to apply for MA on a timely basis to prevent a medical expense debt to a LTC facility at the private rate.
Elimination of the Home Maintenance Deduction
Background
States have the option of providing a home maintenance allowance deduction when determining contribution toward cost of NFC in accordance with 42 CFR 435.725(d) and 435.832(d). This deduction is allowed if a physician has certified that the resident will likely return home within 6 months.
Proposed Amendment
This proposal eliminates the home maintenance allowance as an allowable deduction when determining an MA recipient's contribution toward cost of NFC. It is estimated that these proposed amendments will affect approximately 3,794 individuals applying for or receiving LTC under the MA Program.
Need for Proposed Rulemaking
This proposed rulemaking is necessary to revise the MA eligibility requirements for applicants and recipients requesting LTC MA to address the significant growth in costs in the MA Program.
Summary of Requirements
I. The following are regulations that apply to applicants and recipients for LTC services both in the community and in an institutional setting:
Sections 178.104(d) and 178.174(d). These subsections are proposed to expand the circumstances in which there could be a period of MA ineligibility for LTC services due to a transfer of assets without receiving fair market value and increase the disqualification period. In accordance with 42 U.S.C.A. § 1396p(c), an applicant or recipient of MA or spouse of an applicant who transfers an asset without receiving fair market value could be subject to a period of ineligibility for payment of LTC services under the MA Program.
Currently, there is no disqualification or penalty period of less than 1 month. Consequently, a transfer of assets with a value at less than the average monthly pay rate for private NFC without receiving fair market value does not result in a penalty period for payment of LTC services. This revision expands the circumstances for a penalty period. Under the proposed change, a partial month penalty period may be imposed for an asset transfer that is less than the average monthly pay rate for private NFC.
In addition, the change extends the penalty period to include a partial month when the calculation to determine the penalty period yields a fraction. This revision will make applicants and recipients responsible for more of the cost of their LTC services both in institutional settings and for those LTC services received in a residential setting. Applicants and recipients will be responsible for paying toward the cost of LTC services the amount equivalent to the cost of the asset that was transferred without receiving fair market value.
II. The following are regulations that apply to applicants and recipients for LTC services in an institutional setting:
A. Section 178.2. This section has been expanded to include additional terms that are used to define various income standards and allowance amounts. These standards/amounts are applied to the provisions that govern the treatment of assets (income and resources) of a couple when one spouse is admitted to a LTC facility.
B. Section 178.124(b)(2). This paragraph is modified to incorporate the change in the method of providing the CS with additional income to bring her up to the protected level when one spouse is admitted to a LTC facility. Currently, the couple has the option to use available resources to purchase an annuity that will generate monthly income for the CS if the CS's monthly income is less than the protected income level established by Federal law. This revision will require that if the CS's own monthly income which includes interest income generated by the resources that are protected for the CS is less than the protected income level, a contribution of monthly income can be provided from the IS. This revision does not eliminate the provision that protects the CS's income level; it is changing how the CS will receive that monthly income. If the CS's monthly income including the determined contribution of monthly income from the IS is less than the protected income level, the IS can continue to use available resources to purchase an annuity to generate monthly income for the CS.
C. Section 181.452(d)(5). This paragraph is revised to include a limitation on the total amount that is allowable as a medical and remedial expense deduction when determining an MA recipient's contribution toward cost of care. Currently, any medical or remedial expense, regardless of the amount, is an allowable deduction when determining an MA recipient's contribution toward cost of care. This change will limit the total deduction allowed for outstanding medical and remedial expenses to $10,000. See 42 CFR 435.725(f) and 435.832(f).
D. Section 181.452(d)(6). This paragraph is deleted to remove the income deduction that is given for maintenance of an MA recipient's home for short-term stays in an LTC facility when determining contribution toward cost of care. See 42 CFR 435.725(d) and 435.832(d).
Affected Individuals and Organizations
This proposed rulemaking will affect applicants and recipients who are requesting or receiving LTC services, both in the community and in an institutional setting. Applicants and recipients will be responsible for paying more toward the cost of LTC.
Accomplishments/Benefits
This proposed rulemaking will continue to allow the Department to provide MA benefits to the Commonwealth's Federally-mandated eligibility groups, while providing sound fiscal management of the Commonwealth's limited resources.
Fiscal Impact
Commonwealth. The Department estimates the Fiscal Year 2002-2003 savings to be $7.001 million ($3.171 million in State funds).
Public Sector. There is a potential cost to county LTC facilities with residents who incur an outstanding unpaid medical expense for LTC services.
Private Sector. There is a potential cost to private LTC facilities with residents who incur outstanding medical expense for LTC services in excess of $10,000 before becoming eligible for MA. Individuals may be responsible to pay more for LTC services under the income-first rule.
Paperwork Requirements
No additional forms or paperwork will be required to implement this change in the regulations. Current forms and workbook pages will continue to be used.
Effective Dates
This proposed rulemaking will be effective upon publication in the Pennsylvania Bulletin as final-form rulemaking.
Sunset Date
There is no sunset date. The Department monitors regulations through its Quality Control and Corrective Action agencies.
Public Comment Period
Interested persons are invited to submit written comments, suggestions or objections regarding the proposed amendments to the Department of Public Welfare, Edward J. Zogby, Director, Bureau of Policy, Room 431, Health and Welfare Building, Harrisburg, PA 17120, (717) 787-4081, within 30 days after the publication in the Pennsylvania Bulletin. Comments received within the 30 calendar days will be reviewed and considered in the preparation of the final-form regulations. Comments received after the 30-day comment period will be considered for subsequent revisions of these regulations.
Persons with a disability may use the AT&T Relay Service by calling (800) 654-5984 (TDD users) or (800) 654-5988 (Voice Users).
Regulatory Review Act
Under section 5(a) of the Regulatory Review Act (71 P. S. § 745.5(a)), on September 25, 2002, the Department submitted a copy of these proposed amendments to the Independent Regulatory Review Commission (IRRC) and to the Chairpersons of the House Committee on Health and Human Services and the Senate Committee on Public Health and Welfare. In addition to submitting the proposed rulemaking, the Department has provided IRRC and the Committees with a copy of a detailed Regulatory Analysis Form prepared by the Department in compliance with Executive Order 1996-1, ''Regulatory Review and Promulgation.'' A copy of this material is available to the public upon request.
Under section 5(g) of the Regulatory Review Act, if the Commission has any objections to any portion of the proposed amendments, it will notify the Department within ten days of the close of the Committees' review period. The notification shall specify the regulatory review criteria which have not been met by that portion. The Act specifies detailed procedures for review, prior to final publication of the final-form regulations, of objections raised by the Department, the General Assembly and the Governor.
FEATHER O. HOUSTOUN,
SecretaryFiscal Note: 14-478. No fiscal impact; (8) recommends adoption. These proposed revisions will result in savings totaling $3.171 million to the 2002-2003 Medical Assistance--Long Term, Inpatient and Outpatient appropriations.
Annex A
TITLE 55. PUBLIC WELFARE
PART II. PUBLIC ASSISTANCE MANUAL
Subpart D. DETERMINATION OF NEED
AND AMOUNT OF ASSISTANCE
CHAPTER 178. RESOURCE PROVISIONS FOR CATEGORICALLY NMP-MA AND MNO-MA
Subchapter A. GENERAL PROVISIONS FOR
MA RESOURCES COMMON TO ALL
CATEGORIES OF MA
GENERAL PROVISIONS FOR MA RESOURCES § 178.2. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
* * * * * CSMMNA--Community Spouse Monthly Maintenance Needs Amount--The income needed by the community spouse to prevent the community spouse from being impoverished according to Federal standards. This figure is based on the community spouse's monthly shelter expense and the minimum and maximum monthly maintenance need allowances.
* * * * * Excess shelter amount--The resulting amount of the community spouse's monthly shelter expense that exceeds the shelter expense allowance.
* * * * * MAMMNA--Maximum Monthly Maintenance Need Allowance--The maximum amount of income permitted to be protected to prevent the community spouse from being impoverished, as established under section 1924(a)(3)(c) of the Social Security Act (42 U.S.C.A. § 1396r-5(d)(3)(c)). A revision to the amount required by Federal law and regulations is published annually as a notice in the Pennsylvania Bulletin.
* * * * * MIMMNA--Minimum Monthly Maintenance Need Allowance--The minimum amount of income permitted to be protected to prevent the community spouse from being impoverished, as established under section 1924(d)(3)(A) and (B), which is 1/12th of 150% of the official income poverty limit for a family of two. A revision to the amount required by Federal law and regulations is published annually as a notice in the Pennsylvania Bulletin.
MMNA--Monthly Maintenance Need Allowance--The amount of income that the institutionalized spouse can contribute to the community spouse.
Monthly shelter expense--The monthly cost for housing, including:
(i) Rent, mortgage payment, including principal and interest, property taxes and property insurance.
(ii) Maintenance charge for a condominium or cooperative less the utility allowance described in subparagraph (iii).
(iii) One of the two standard utility allowances (SUAs) specified in § 501.7(a)(1) and (2) (relating to treatment of income).
(iv) Telephone allowance specified in § 501.7(a)(3).
(v) Homeless shelter allowance specified in § 501.7(a)(4).
* * * * * Shelter expense allowance--Thirty percent of the minimum monthly maintenance need allowance. A revision to the amount required by Federal law and regulations is published annually as a notice in the Pennsylvania Bulletin.
* * * * *
Subchapter B. AGED-, BLIND- AND DISABLED-RELATED CATEGORIES OF MA
DISPOSITION OF PROPERTY AND FAIR CONSIDERATION PROVISIONS FOR THE AGED-, BLIND- AND DISABLED-RELATED CATEGORIES OF MA § 178.104. Disposition of assets and fair consideration provisions for transfers on or after July 30, 1994.
* * * * * (d) The [number of months] period of ineligibility for [the institutionalized] an individual who is applying for, or receiving MA for NFC as defined in § 178.2, including services in an ICF/MR facility, or a level of care in an institution equivalent to NFC, or home or community-based waiver services furnished under a Title XIX waiver and who disposes of assets for less than FMV begins in the month of transfer if the date does not occur during an existing period of ineligibility. The period of ineligibility shall be [equal to the]:
(1) The number of months, including partial months, arrived at by dividing the total cumulative UV of all assets transferred by the individual or the individual's spouse on or after the look-back date divided by the average monthly cost to a private patient of NFC in effect in [the] this Commonwealth at the time of application.
(2) A partial month if the total cumulative UV of all assets transferred by the individual or the individual's spouse on or after the look-back date, divided by the average monthly cost to a private patient of NFC in effect in this Commonwealth at the time of application results in a fraction.
* * * * *
RESOURCE ELIGIBILITY REQUIREMENTS FOR AN INSTITUTIONALIZED SPOUSE WITH A COMMUNITY SPOUSE § 178.124. Resource eligibility for the institutionalized spouse.
* * * * * (b) Allowance revision. The community spouse resource allowance may be revised if either spouse establishes at a Departmental hearing, based on evidence acceptable to the Department, that:
* * * * * (2) [Income generated by the community spouse resource allowance is not sufficient to raise the community spouse's income to the monthly standard community spouse maintenance need allowance amount described in § 181.452(c)(2)(ii) (relating to posteligibility determination of income available from an MA eligible person toward his cost of care). The Department hearing officer will establish a resource amount adequate to assure that the community spouse has income up to the community spouse maintenance need allowance amount. This applies only if the institutionalized spouse actually gives the community spouse maintenance need allowance to the community spouse.] Additional monthly income is needed for the community spouse and is calculated as follows:
(i) The community spouse's total gross monthly income is calculated by adding the following:
(A) The total gross monthly earned income includes earned income specified in §§ 181.91--181.96 (relating to types of earned income counted for the aged, blind and disabled categories).
(B) The total gross monthly unearned income includes unearned income specified in §§ 181.101--181.109 (relating to types of unearned income counted for the aged, blind and disabled categories). Interest and other income generated by the community spouse resource determined under § 178.123 are included as unearned income of the community spouse.
(ii) The monthly shelter costs of the community spouse are added together to arrive at a total monthly shelter expense.
(iii) If the total monthly shelter expense exceeds the shelter expense allowance, the excess shelter amount is added to the MIMMNA to arrive at the CSMMNA. The excess shelter amount plus the MIMMNA cannot exceed the MAMMNA except as provided in subparagraph (vii).
(iv) If the total monthly shelter expense is equal to or less than the shelter expense allowance, the MIMMNA is the CSMMNA.
(v) If the community spouse's total gross monthly income determined in subparagraph (i) is equal to or greater than the CSMMNA determined in subparagraph (iii) or (iv), the community spouse is not in need of an MMNA unless subparagraph (vii) applies.
(vi) If the community spouse's total monthly income determined in subparagraph (i) is less than the CSMMNA determined in subparagraph (iii) or (iv), the difference is the MMNA, unless subparagraph (vii) applies.
(vii) The MMNA may exceed the CSMMNA determined in subparagraph (iii) or (iv) if one of the following applies:
(A) A greater amount is ordered through a court order under section 1924(d)(5) of the Social Security Act (42 U.S.C.A. § 1396r-5(d)(5)).
(B) A greater amount is determined as a result of a Department hearing decision in which either spouse establishes that the community spouse needs income greater than the MMNA due to exceptional circumstances resulting in significant financial duress.
(viii) If the institutionalized spouse's total gross monthly income as described in § 181.452(a) (relating to posteligibility determination of income available from an MA eligible person toward cost of care) less allowable deductions in § 181.452(d) is not sufficient to raise the community spouse's income to the MMNA described in subparagraph (vi), or unless subparagraph (vii) applies, the resource allowance as determined under § 178.123 may be revised as follows:
(A) Through the fair hearing process, if the Department hearing officer establishes a resource amount adequate to assure that the community spouse has income up to the MMNA.
(B) If the institutionalized spouse actually gives the MMNA to the community spouse.
* * * * *
Subchapter C. TANF-RELATED AND
GA-RELATED CATEGORIES OF MA
DISPOSITION OF PROPERTY AND FAIR CONSIDERATION PROVISIONS FOR THE [AFDC] TANF- AND GA-RELATED CATEGORIES OF MA § 178.174. Disposition of assets and fair consideration provisions for transfers on or after July 30, 1994.
* * * * * (d) The [number of months] period of ineligibility for [the institutionalized] an individual who is applying for, or receiving MA for NFC as defined in § 178.2, including services in an ICF/MR facility, or a level of care in an institution equivalent to NFC, or home or community-based waiver services furnished under a Title XIX waiver and who disposes of assets for less than FMV begins in the month of transfer provided that the date does not occur during an existing period of ineligibility. The period of ineligibility shall be [equal to the]:
(1) The number of months, including partial months, arrived at by dividing the total, cumulative [uncompensated value] UV of the assets transferred by the individual or the individual's spouse, on or after the look-back date, divided by the average monthly cost to a private patient of [nursing facility services] NFC in effect in this Commonwealth at the time of application.
(2) A partial month if the total cumulative UV of all assets transferred by the individual or the individual's spouse on or after the look-back date, divided by the average monthly cost to a private patient of NFC in effect in this Commonwealth at the time of application results in a fraction.
* * * * *
CHAPTER 181. INCOME PROVISIONS FOR CATEGORICALLY NEEDY NMP-MA AND MNO-MA
Subchapter D. POSTELIGIBILITY DETERMINATION OF ELIGIBILITY FOR MA PAYMENT TOWARD COST OF CARE IN INSTITUTIONS
POSTELIGIBILITY DETERMINATION PROVISIONS § 181.452. Posteligibility determination of income available from an MA eligible person toward the cost of care.
* * * * * (d) The following amounts are deducted from the MA eligible person's total gross income identified in subsection (a) for persons in the aged, blind and disabled-related categories, or subsection (b) for persons in the TANF-related or GA-related categories and adjusted as applicable by the treatment of Veterans Administration benefits under subsection (c) for all MA eligible persons in the following order:
* * * * * (5) The following medical expenses which are not subject to payment by a third party are deducted in the calendar month the medical expenses are paid[.]:
* * * * * (iii) [Expenses paid by the MA eligible person for necessary] Necessary medical or remedial care recognized under State statutes or regulations but not covered under the MA Program, subject to a total deduction limit of $10,000.
[(6) An amount for maintenance of a single MA eligible person's home if a physician has certified that he is likely to return to his home within a 6-month period from the date he entered the facility. When this deduction is given, it may not be deducted for more than one 6-consecutive month period. The maintenance need amount for the single person is the MA income limit for one person in Appendix A. A home is defined as the residence maintained by the MA eligible person before he entered the facility and to which he plans to return. If a person is discharged and subsequently returns to a facility, the single MA eligible person is eligible for a new 6 consecutive month period for this deduction if a physician certifies that the person is likely to return to his home within a 6-month period from the date of admittance to the facility.]
* * * * *
[Pa.B. Doc. No. 02-1735. Filed for public inspection October 4, 2002, 9:00 a.m.]
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