65A-1.707: Family-Related Medicaid Income and Resource Criteria
65A-1.713: SSI-Related Medicaid Income Eligibility Criteria
PURPOSE AND EFFECT: Amendments to the rules clarify language for the Medically Needy Program, allowing medical expenses paid prior to the month for which eligibility is being requested, to be used to meet the share of cost. Technical and non-substantive changes in the rule language are included.
SUMMARY: Proposed amendments revise the language regarding the treatment of paid medical expenses in the Medically Needy Program.
SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS: No Statement of Estimated Regulatory Cost was prepared.
Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.
SPECIFIC AUTHORITY: 409.919 FS.
LAW IMPLEMENTED: 409.902, 409.903, 409.904, 409.906, 409.918, 409.919 FS.
IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE HELD AT THE DATE,TIME AND PLACE SHOWN BELOW(IF NOT REQUESTED, THIS HEARING WILL NOT BE HELD):
DATE AND TIME: March 3, 2008, 1:30 p.m.
PLACE: 1317 Winewood Boulevard, Building 3, Room 455, Tallahassee, FL 32399
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Pat Whitford, Economic Self-Sufficiency Services, Telephone (850)410-3479
THE FULL TEXT OF THE PROPOSED RULE IS:
65A-1.707 Family-Related Medicaid Income and Resource Criteria.
(1) No change.
(2) The department considers income in excess of the medically needy income level available to pay for medical care and services. Available income from a one month period is used to determine the amount of excess countable income available to meet medical care and services. To be allowable, a paid expense may not have been previously deducted from countable income during a period of eligibility. The department deducts allowable medical expenses which are not subject to third party payment while unpaid and still owed, or paid during the current month, or incurred and paid during the three previous calendar months to the month for which eligibility is being determined but no earlier than the three retroactive application months from countable income that exceeds the medically needy income level, as follows:
(a) Allowable health insurance costs such as medical premiums, other health insurance premiums, deductibles and co-insurance charges; and
(b) Allowable medical services such as the cost of public transportation to obtain allowable medical services; medical services provided or prescribed by a recognized member of the medical community; and personal care services in the home prescribed by a recognized member of the medical community.
Specific Authority 409.919 FS. Law Implemented 409.903, 409.918, 409.919 FS. History–New 10-8-97, Amended 2-15-01, 11-23-04, 2-20-07,_________.
65A-1.713 SSI-Related Medicaid Income Eligibility Criteria.
(1) Income limits. An individual’s income must be within limits established by federal or state law and the Medicaid State Plan. The income limits are as follows:
(a) through (d) No change.
(e) For HCBS, gross income cannot exceed 300 percent of the SSI federal benefit rate after consideration of allowable deductions set forth in subsection 65A-1.713(2), F.A.C. Individuals with income over this limit may qualify for HCBS services by establishing a qualified income trust which meet criteria set forth in subsection 65A-1.702(15), F.A.C.
(f) For hospice services, income cannot exceed 300 percent of the SSI federal benefit rate or income must meet Medically Needy eligibility criteria, including the share of cost requirement. Effective October 1, 1998, institutionalized individuals with income over this limit may qualify for institutional hospice services by establishing an income trust which meets criteria set forth in subsection paragraph 65A-1.702(15)(14)(a), F.A.C.
(g) For SLMB, income must be greater than 100 percent of the federal poverty level but equal to or less than 120 percent of the federal poverty level.
(h) For Medically Needy, income must be less than or equal to the Medically Needy income standard after deduction of allowable medical expenses.
(i) For Protected Medicaid, income cannot exceed the limits established in accordance with 42 U.S.C. § 1383c (incorporated by reference).
(j) No change.
(k) For the Traumatic Brain Injury and Spinal Cord Injury Waiver Program an individual cannot have income that exceeds 300% of the federal benefit rate as defined in subsection 65A-1.701(13), F.A.C. An income trust may be established to qualify for this assistance.
(2) Included and Excluded Income. For all SSI-related coverage groups the department follows the SSI policy specified in 20 C.F.R. 416.1100 (incorporated by reference), et seq., including exclusionary policies regarding Veterans Administration benefits such as VA Aid and Attendance, unreimbursed Medical Expenses, and reduced VA Improved pensions, to determine what counts as income and what is excluded as income with the following exceptions:
(a) through (e) No change.
(3) No change.
(4) Income Budgeting Methodologies. To determine eligibility SSI budgeting methodologies are applied except where expressly prohibited by 42 U.S.C. § 1396 (incorporated by reference), or another less restrictive option is elected by the state under 42 U.S.C. § 1396a(r)(2) (incorporated by reference). When averaging income, all income from the most recent consecutive four weeks shall used if it is representative of future earnings. A longer period of past time may be used if necessary to provide a more accurate indication of anticipated fluctuations in future income.
(a) For MEDS-AD Demonstration Waiver, Protected Medicaid, Medically Needy, Qualified Working Disabled Individual, QMB, SLMB, QI1, and to compute the community spouse income allocation for spouses of ICP individuals, the following less restrictive methodology for determining gross monthly income is followed:
1. through 3. No change.
(b) No change.
(c) Medically Needy. The amount by which the individual’s countable income exceeds the Medically Needy income level, called the “share of cost”, shall be considered available for payment of medical care and services. The department computes available income for each month eligibility is requested to determine the amount of excess countable income available to meet medical costs. If countable income exceeds the Medically Needy income level the department shall deduct allowable medical expenses in chronological order, by day of service. Countable income is determined in accordance with subsection 65A-1.713(2), F.A.C. To be deducted the expenses must be unpaid, or if paid, must have been paid in the month for which eligibility is being determined or incurred and paid during the three previous calendar months to the month for which eligibility is being determined but no earlier than the three retroactive application months. The paid expense may not have been previously deducted from countable income during a period of eligibility. Medical expenses reimbursed by a state or local government not funded in full by federal funds, excluding Medicaid program payments, are allowable deductions. Any other expenses reimbursable by a third party are not allowable deductions. Examples of recognized medical expenses include:
1. Allowable health insurance costs such as medical premiums, other health insurance premiums, deductibles and co-insurance charges; and,
2. Allowable medical services such as the cost of public transportation to obtain allowable medical services; medical services provided or prescribed by a recognized member of the medical community; and personal care services in the home prescribed by a recognized member of the medical community.
Specific Authority 409.919 FS. Law Implemented 409.902, 409.903, 409.904, 409.906, 409.919 FS. History–New 10-8-97, Amended 1-27-99, 4-1-03, 6-13-04, 8-10-06(1), (4), 8-10-06(1), 2-20-07, 10-16-07,________.