RELATES TO:
KRS
205.520(3)
NECESSITY, FUNCTION, AND CONFORMITY: 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 any requirement that may
be imposed or opportunity presented by federal law to qualify for federal
Medicaid funds. This administrative regulation establishes resource and income
considerations regarding relatives by which Medicaid eligibility is determined,
except for individuals whose eligibility is determined based on modified gross
adjusted income or former foster care individuals between the ages of nineteen
(19) and twenty-six (26) who aged out of foster care while receiving Medicaid
benefits.
Section 1. Treatment of
Income and Resources for a Parent, Dependent Child, ABD Applicant, or
Recipient.
(1) A married individual shall be
considered responsible for that person's spouse.
(2) A parent shall be considered responsible
for a dependent minor child.
(3)
Excluding a child who is at least eighteen (18) years of age and who is blind
or disabled and for purposes of deeming income and resources, an individual
under age twenty-one (21) years living with a parent shall be considered a
dependent minor even if the individual is emancipated under state
law.
(4) Responsibility regarding
income and resources shall be determined as established in this subsection.
(a)
1. For
an ABD applicant or a recipient living with a spouse who is eligible for
Medicaid, total resources and adjusted income of the couple shall be considered
in relation to the resource and income limitations for a family size of two (2)
unless a dependent lives with the couple.
2. If any dependent lives with a couple, the
appropriate family size shall include any dependent living with the
couple.
(b) For an ABD
applicant or a recipient living with an ineligible spouse, income from the
ineligible spouse shall be deemed as available to the eligible spouse as
outlined in this paragraph.
1. Determine the
potential spend-down amount of the eligible individual by comparing the
countable income, as determined in accordance with
907
KAR 20:020, to the income level for one (1) as shown
in
907
KAR 20:020, Section 1(1).
2. Allocate to other dependents in the
household from the ineligible spouse's income an amount equal to one-half (1/2)
of the MNIL for a family size of one (1) for each dependent.
3.
a. If the
ineligible spouse's income is more than the difference between the MNIL for one
(1) and MNIL for two (2), combine the income of the ineligible spouse with that
of the eligible individual and compare that figure with the MNIL for one (1) to
determine continuing eligibility or the spend-down amount in accordance with
clause b. of this subparagraph.
b.
If the ineligible spouse's income is less than the difference between MNIL for
one (1) and MNIL for two (2), the income shall be disregarded and the income of
the eligible individual shall be compared with the MNIL for a family size of
one (1).
4. Compare the
amount resulting from subparagraph 1 of this paragraph with the result of
sub-paragraph 3 of this paragraph and determine eligibility using the
spend-down amount, if any, which is greater.
5. Resources shall be considered in the same
manner as for an eligible spouse.
(c)
1. For
an ABD couple living apart for any reason and both of whom are concurrently
applying for or receiving Medicaid only, income and resources shall be
considered in relation to resource and income limitations for a family size of
one (1) after the month of separation, or if any other dependent lives with
either spouse, the family size shall include any dependent in the month
following the month of separation.
2. Eligibility shall be determined on a
couple basis for the month of separation.
(d) For an ABD individual living apart from a
spouse who is not a recipient of Medicaid only, eligibility shall be determined
on a couple basis for the month of separation and on an individual basis after
the month of separation.
(e) The
following shall be considered a resource for an individual considered to be
single in accordance with paragraphs (c) or (d) of this section and who has a
jointly-held checking or savings account with his or her spouse:
1. The entire jointly-held checking or
savings account if it may be accessed independently of the spouse; or
2. One-half (1/2) of the jointly-held
checking or savings account if it shall not be accessed independently of the
spouse.
(f) Resources
and income of an SSI essential person, spouse or nonspouse, whose Medicaid
eligibility is not based on inclusion in the SSI case shall be
considered.
(g) For a child who is
blind or disabled and under eighteen (18) years of age living with a parent
(including a stepparent, if applicable), total resources and adjusted income of
the parent shall be related to limitations for family size, including the
applicant or recipient child and any other dependent child of the parent using
the adult scale.
(h)
1. For comparison with the resource and
income limitations, a child's individual resources and income shall be
considered in relation to a family size of one (1).
2. The following criteria shall be used to
determine whether an AFDC-related Medicaid child who has been living with a
parent and is institutionalized in a psychiatric facility (mental hospital or
psychiatric residential treatment facility) shall be considered as living apart
from his or her parents:
a. Unless he or she
has been in a psychiatric facility for thirty (30) or more days, a child shall
be considered as living with a parent. Beginning with the 31st day in a
facility, a child shall be considered living apart from his or her
parent.
b. A child who is
institutionalized in a psychiatric facility but is legally committed to or in
the custody of the Cabinet for Health and Family Services shall not be
considered as living with a parent.
(i) Excluding a child, if an AFDC-related
Medicaid recipient has income and resources considered in relation to family
size and enters a nursing facility, his or her income and resources shall be
considered in the case for up to one (1) year with the individual allowed the
basic maintenance standard as established in
907
KAR 20:035, Section 3(2).
(j)
1. If a
child in an AFDC-related Medicaid case is in a nursing facility, eligibility of
the child shall continue in the case for up to a year but his or her liability
for the cost of care shall be determined by:
a. Allowing to the child from his or her own
income the basic maintenance standard as established in
907
KAR 20:035, Section 3(2); and
b. Considering the remainder available for
the cost of care.
2. A
welfare payment made to a child under subparagraph 1 of this paragraph shall be
disregarded when determining liability for cost of care.
3. The eligibility of the child, with regard
to income and resources, shall be determined on the basis of living apart from
the other family members if it becomes apparent that the separation will last
for more than one (1) year.
Section 2. Companion Cases.
(1) If a spouse or parent and child living in
the same household apply separately for assistance, relative responsibility
shall be taken into consideration.
(2) For a spouse, income and resources of
both spouses shall be combined and compared against the medically-needy income
and resources limits for a family size of two (2) even though a separate
determination of eligibility shall be made for each individual.
(3) Income disregards, and needs of siblings
in the other case may also be included in budgeting for the spend-down case if
that works to the advantage of the technically excluded child for whom
eligibility is being determined in the spend-down case.
Section 3. Applicability. The provisions and
requirements of this administrative regulation shall not apply to:
(1) A qualified Medicare
beneficiary;
(2) A qualified
disabled and working individual;
(3) A Medicare qualified individual group 1
(QI-1) individual;
(4) A specified
low-income Medicare beneficiary; or
(5) An individual whose Medicaid eligibility
is determined:
(a) Using the modified adjusted
gross income standard pursuant to
907
KAR 20:100; or
Section 4. Appeals. An appeal of a negative
action taken by the Department for Medicaid Services regarding Medicaid
eligibility of an individual shall be in accordance with
907
KAR 1:560.