RELATES TO:
KRS
205.520, 42 C.F.R. Part 435,
38 U.S.C.
5503,
42 U.S.C.
1396a, n
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 a requirement that may be
imposed or opportunity presented by federal law to qualify for federal Medicaid
funds. This administrative regulation establishes special income requirements
for 1915(c) home and community based waiver and hospice services, except for
individuals for whom a modified adjusted gross income is the Medicaid
eligibility income standard or former foster care individuals between the ages
of nineteen (19) and under twenty-six (26) who aged out of foster care while
receiving Medicaid coverage.
Section
1. Special Provisions for Recipients Participating in a 1915(c)
Home and Community Based Services Waiver Program.
(1) Medicaid eligibility for a recipient
receiving 1915(c) home and community based services 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:
(a) This
section; and
(2) Income protected for the basic
maintenance of a 1915(c) home and community based services waiver 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) A 1915(c) home and
community based services waiver program participant who participates in a
1915(c) home and community based services waiver 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
spend-down basis with the cost of SCL services projected.
(5) Institutional deeming rules shall apply
in accordance with
907 KAR 20:035.
(6)
(a) In
the posteligibility determination of available income, the basic maintenance
needs allowance shall include a mandatory withholding from income.
(b) Mandatory withholdings shall:
1. Include state and federal taxes;
and
2. 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 1915(c)
home and community based services waiver program and who is receiving a
Veterans Affairs benefit shall have ninety (90) dollars excluded from the
eligibility and posteligibility determination process.
(8) Veterans Affairs 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 20:030, Section 3(5),
shall not be excluded in the posteligibility determination.
Section 2. Special Provisions for Hospice
Recipients. Medicaid eligibility for a participant in the Medicaid Hospice
Program shall be determined in accordance with the provisions 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 medically needy standard established
in
907 KAR 20:020, Section 1, plus
the SSI general exclusion for a noninstitutionalized medically needy
participant, who shall spend-down 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 Veterans
Affairs benefit, ninety (90) dollars, which shall be excluded from the
eligibility and posteligibility determination process; or
(f) The amount of Veterans Affairs 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 or she 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 20:035 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 20:040 for a
noninstitutionalized hospice recipient who is:
(a) A medically needy individual, who shall
spend-down on a quarterly basis; and
(b) Not eligible under the special income
level.
(7)
(a) In the posteligibility determination of
available income, the basic maintenance needs allowance shall include a
mandatory withholding from income.
(b) Mandatory withholdings shall:
1. Include state and federal taxes;
and
2. 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 20:030, Section 3(5),
shall not be excluded in the posteligibility determination.
Section 3. Continuous Eligibility for
Children.
(1) An individual who is younger
than nineteen (19) shall receive continuous eligibility, consistent with
42 C.F.R.
435.926.
(2) The continuous eligibility period for a
child recipient shall be for a period of twelve (12) months.
(3) A child's eligibility during a continuous
eligibility period shall only be terminated under the following circumstances:
(a) The child becomes nineteen (19) during
the continuous eligibility period;
(b) The child, or representative, voluntarily
requests that the eligibility be terminated;
(c) The child ceases to be a resident of the
commonwealth;
(d) The agency
determines that the eligibility was granted due to:
1. Agency error; or
2. Fraud, abuse, or perjury attributed to the
child or representative; or
(e) The death of the child.
Section 4.
Applicability. The provisions and requirements of this administrative
regulation shall not apply to an individual whose Medicaid eligibility is
determined:
(1) Using the modified adjusted
gross income standard pursuant to
907 KAR 20:100; or