Federal regulation 42 CFR 435.733 requires the reduction of the MO HealthNet Division (MHD) payment to a vendor facility by the amount that the FSD determines the participant can contribute to the cost of their institutional care. This is referred to as a surplus computation. This computation is completed in FAMIS:
NOTE: For months that have been approved in FAMIS for Spenddown or Non-spenddown coverage prior to authorizing vendor benefits, Worker Initiated Budget Calculation Area (WIBCA) must be completed. Comments must include verification of the income, expenses and the date of facility placement or payment start date, for each month of vendor coverage needed.
If a participant enters the vendor home after the first day of the month or leaves the vendor home before the last day of the month, multiple WIBCAs will need to be completed. The WIBCAs must be done to show the appropriate coverage type for the days when the participant was eligible for VENDOR NURSING CARE (VEND), and for the days either prior to entering and/or after leaving the facility when the participant would be eligible for another coverage type such as MA SPENDDOWN/NON-SPENDDOWN (SPNDN). Review the Medicaid Category History screen (MEDHIST) to determine if WIBCAs were authorized appropriately to provide coverage to the participant for the entire month.
The first step of the vendor surplus computation is to review and enter all gross income sources for the participant and members of the Eligibility Unit into FAMIS using the INCOME screen (SELINC or FMX2).
NOTE: Use gross eligibility amount for OASDI. For participants who participate in Medicare the gross OASDI amount includes the Supplemental Medical Insurance (SMI) premium.
NOTE: The Federal SSI benefit for any month is limited to a maximum of $30 for an eligible individual, less any non-SSI income, when the individual is a resident throughout a month in a vendor facility and Medicaid (MHN in Missouri) pays or is expected to pay over 50 percent of the cost of care for that month.
For participants receiving vendor benefits, SSI payments are reduced to zero ($.00) if they have other income that is equal to, or greater than, $30 per month. If their only income is SSI, SSI payments are reduced to $30.
EXAMPLE: Mrs. S has $600 Social Security and $74 SSI income. When she moves to a vendor facility she will continue to receive the $600 Social Security income but her SSI income will be reduced to $.00.
EXAMPLE: Mr. B only income is $674 SSI. When he moves to a vendor facility his SSI income will be reduced to $30.
NOTE: On-going payments by relatives, the Department of Mental Health (DMH), insurance policies, or other binding agreements intended to help meet the basic covered services must be counted as unearned income in the month received.
EXAMPLE: A participant has a long term care insurance policy which covers nursing facility care. According to the terms of the policy, the company will pay $15 per day for patient care while in the nursing facility. This payment will not be reduced if the participant's income increases or if the nursing home is also paid from another source. Therefore, in addition to any other income, the participant has $456.25 ($15 X 365 days divided by 12 months) which must be counted as unearned income in determining the vendor surplus. If the participant has not yet begun receiving the payment, set a reminder to adjust the surplus amount when the payment is expected to begin.
NOTE: Payments by relatives, etc. to cover the difference between a facility's semi-private and private room charge are not counted as income. MHN considers a private room a non-covered service, unless a private room is needed to isolate a recipient due to a medical or social condition.
The second step of the surplus computation is that FAMIS determines allowable deductions from gross income as follows:
With the exception of vendor participants receiving Supplemental Security Income (SSI), a personal needs allowance standard of $50 is allowed for vendor participants. This includes veterans receiving a reduced VA pension limited to $90.
NOTE: Participants receiving VA pension are entitled to receive the $50 personal needs standard in addition to their $90 reduced VA pension for personal needs.
NOTE: The personal needs allowance for vendor participants receiving Supplemental Security Income (SSI) is limited to $30 a month.
The personal needs allowance may be increased if a claimant is responsible to pay child support as defined in Section 0815.030.10.05.05, which follows.
If an applicant or participant is responsible for current child support payments and/or payments for child support arrearages, those payments may be used to increase the personal needs allowance when verification is received that the support is:
The institutionalized participant may make an allotment to the community spouse and certain dependents. The allotment is intended to help the participant's spouse and dependents meet their normal living expenses. (See ALLOTMENT INFORMATION SCREEN USER GUIDE)
Allotments may be made to the following persons:
The allotment is determined by FAMIS using data entered on the Allotment Information Screen (ALLOT or FMJ6). (See ALLOTMENT INFORMATION SCREEN USER GUIDE).
In certain circumstances, allotments may be made for minor children who do not live with the community spouse. See Section 0815.030.10.10.20.
Refer to Appendix B for information on maintenance standards used to compute allotments for a community spouse and dependents that live with a community spouse.
The institutionalized spouse can elect to make the maximum allotment or an amount less than the maximum allotment. For the maximum allotment to be allowed as a deduction, the institutionalized spouse must agree to make the maximum allotment available to his/her spouse.
The community spouse allotment information is entered on the Allotment Information (ALLOT/FMJ6) screen in FAMIS. FAMIS automatically calculates the community spouse's allotment based on the data entered. To calculate the community spouse's allotment:
Enter the community spouse's shelter expenses at his/her principal place of residence. Allowable expenses are:
If the institutionalized spouse indicates that s/he wishes to make the maximum allotment available to the community spouse, enter this in the Allotment Information (ALLOT or FMJ6) screen in FAMIS. FAMIS deducts this amount when determining the institutionalized spouse's surplus.
EXAMPLE: Ms. Smith is a resident in a nursing facility. She applies for vendor benefits. Mr. Smith, her spouse, still lives in their home in the community. Ms. Smith has income of $2000 per month. Mr. Smith has income of $1200 per month. His house payment, including taxes and insurance is $950 per month. He provides verification that he pays utility expenses for heat. Ms. Smith will make available to Mr. Smith the maximum income amount allowed.
|Total Shelter Expense:||$1330.00 ($950 + $380 utility standard)|
|Minus Shelter Standard:||$617|
|Excess Shelter Expense:||$713|
|Minimum Maintenance Standard:||$2058|
|Plus Excess Shelter Expense:||$704|
|Total Maintenance Standard:||$2771(< Maximum of $3161)|
|Minus Mr. Smith's Income:||$1200|
NOTE: Budget the allotment as unearned income on any IM or Food Stamp budget for Mr. Smith. This allotment is entered in the Income (FMX0) screen in FAMIS with Income Type UI and Source Type A2.
If the institutionalized spouse wishes to make the maximum allotment available but does not have sufficient income, the full amount of the maximum allotment must still be allowed as a deduction.
The amount of the actual allotment is calculated by subtracting the personal needs allowance and the SMI premium (if any) from the institutionalized spouse's income.
EXAMPLE: Mr. Jones is a resident in a nursing facility. He applies for vendor benefits. Mrs. Jones, his spouse, still lives in their home in the community. Mr. Jones has income of $952.50 per month. He pays an SMI premium of $134 per month. Mrs. Jones has income of $603 per month. Her house payment, including taxes and insurance, is $473.50 per month. She provides verification that she pays utility expenses for heating. Mr. Jones will make available to Mrs. Jones as much of his income as the FSD will allow.
|Total Shelter Expense:||$853.50 ($473.50 + $380 utility standard)|
|Minus Shelter Standard:||$617|
|Excess Shelter Expense:||$236.50|
|Minimum Maintenance Standard:||$2058|
|Plus Excess Shelter Expense:||$236.50|
|Total Maintenance Standard:||$2294.50 (< Maximum of $3161)|
|Minus Mrs. Jones' Income:||$603|
Because Mr. Jones wished to make the maximum allotment available to his spouse, an allotment amount of $1691.50 is shown as a deduction from his income, even though the allotment exceeds his income of $952.50 per month. When entering the community spouse allotment (A2) on the income amount (FMX3) screen in FAMIS, enter the actual amount of the allotment.
|Mr. Jones' Income:||$952.50|
|Minus Personal Needs Allowance:||$ 50|
|Minus SMI Premium:||$135.50|
NOTE: Budget the amount of the actual allotment as unearned income on any IM or Food Stamp budget for Mrs. Jones. Enter the allotment amount in the Income (FMx0) screen in FAMIS with Income Type UI and Source Type A2.
For more information on entering allotments in FAMIS refer to the Allotment Information Screen User Guide.
A hearing officer or court of law may set the amount of the allotment at a higher figure than the maximum allowed by this policy. If a hearing decision or court order sets a higher figure, use that amount in the surplus computation. See the FAMIS User Guide ALLOTMENT INFORMATION SCREEN. Retain a copy of the hearing decision or court order in the record.
In determining an allotment for a minor child, dependent child, dependent parent or dependent sibling who lives with the community spouse, use the Minimum Maintenance Standard. Do not deem the income of the parent or any other person who lives in the home. Minor and dependent allotment information is entered on the Allotment Information (FMJ6) screen in FAMIS
Allow these allotments after any allotment to the community spouse.
FAMIS deducts the minor or dependent allotment when determining the institutionalized spouse’s surplus. Each dependent's allotment is determined using the following process:
Allow the allotment amount as a deduction regardless of whether the institutionalized spouse makes it available to the minor or dependent.
EXAMPLE: Mr. Franks is a resident of a vendor nursing facility. He applies for vendor benefits. Mrs. Franks and their child, age 16, reside in the couple's home in the community. The child receives monthly Social Security of $157.00.
|Minimum Maintenance Standard:||$2058.00|
|Minus child's income:||$157.00|
|Divided by 3:||$633.66 = allotment to child|
In determining Mr. Franks' surplus, allow the amount of the child's allotment as a deduction (after any allotment for Mrs. Franks). FAMIS will deduct this amount when determining the institutionalized spouse's surplus after any community spouse allotment is deducted.
EXAMPLE: Mr. Stark is a resident of a vendor nursing facility. He applies for vendor benefits. Ms. Stark and their in-common child, Ben, age 16, live in the couple's home in the community. Also in the home is Mrs. Stark's 30 year old disabled child, Stan. Mrs. Stark claims Stan as a dependent for income tax purposes. Ben receives Social Security of $202.00 per month. Stan receives SSI of $607.00.
|Minimum Maintenance Standard:||$2058.00|
|Minus Ben's income:||$202.00|
|Divided by 3:||$618.66 = allotment to Ben|
|Minimum Maintenance Standard:||$2058.00|
|Minus Stan's Income:||$607.00|
|Divided by 3:||$483.66 = allotment to Stan|
In determining Mr. Stark's surplus, FAMIS allows the amount of each these allotments as a deduction on the Adult MO HealthNet Vendor Budget Summary (after any allotment for Mrs. Stark).
Enter dependent's allotment information into in FAMIS on the (FMJ6 or ALLOT) screen in FAMIS. The dependents must be included in the EU for cases in FAMIS. For more information on entering allotments in FAMIS refer to the Allotment Information Screen User Guide.
NOTE: Budget the amount of the actual allotment as unearned income on any IM or Food Stamp budget for dependents. Enter the allotment amount in the Income (FMX0) screen in FAMIS with Income Type UI and Source Type A2.
If the institutionalized participant has minor children who do not live with a community spouse, use the following method to determine the allotment amount.
Allow the allotment to the minor child after allotments to the community spouse and dependents who live with the community spouse.
Using MO HealthNet for Families (MHF) assistance group rules, determine the budget group for the minor child(ren). (See Section 0905.012.10.)
Using MHF income rules, determine the gross income of the minor child See Section 0905.012.60. Do not count any income excludable by MHF rules. (See Section 0905.012.75.)
Determine the adjusted gross income by subtracting any deductions allowable by MHF rules from the gross income. (See Section 0905.012.65 and Section 0905.012.70.)
Determine the deficit by subtracting the adjusted gross income of the minor child from the July 1996 AFDC percentage of need standard determined by the budget group. (See Appendix D).
The amount of the allotment may be up to but not exceed the amount of the deficit.
Medical expenses are entered into FAMIS on the Medical Expense (MEDEXP or FMXA) screen Allowable medical deductions for health insurance include:
Other allowable deductions include:
The effective date of the participant's surplus must always be the first day of a month.
EXAMPLE: Mr. B. was admitted to a MO HealthNet certified bed in a nursing facility on 7/5/06. He applied for MHABD vendor benefits on 7/10/06. He was determined eligible on all factors on 7/28/06. Mr. B's surplus will be effective 08/01/06; because he was not in the facility on 7/1/06 (the first day of the month of request). MO HealthNet will pay the nursing facility for the entire cost of care for 7/5 through 7/31. MO HealthNet will pay the nursing facility the cost of care minus the participant's surplus amount effective 8/1/06.
NOTE: If a participant enters the vendor home after the first day of the month, or leaves the vendor home before the last day of the month multiple WIBCAs will need to be completed. From the Select Worker Initiated Budget Calculation Area screen (SELWIBCA or FMXH) press F14=ADDWIBCA. The WIBCAs must be done to show the appropriate coverage type for the days when the participant was eligible for VEND VENDOR NURSING CARE, and for the days either prior to entering and/or after leaving the facility when the participant would be eligible for another coverage type such as SPNDN MA SPENDDOWN/NON-SPENDDOWN. Review the Medicaid Category History screen (MEDHIST or FM4L) to determine if WIBCAs were authorized appropriately to provide coverage to the participant for the entire month.
Increase in the surplus amount:
NOTE: If the participant requests a hearing during the advance notice period, no action may be taken to increase the surplus until the hearing decision is received and the agency is upheld. To prevent FAMIS from increasing the surplus update the Action Resolution screen( ACTRES or FM50) Status to HOL HOLD.
Decrease in the surplus amount: