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If a Florida Nursing Home Medicaid applicant is applying for ICP Medicaid (nursing home Medicaid), then there a patient responsibility. Patient responsibility is the amount of money per month that a Medicaid applicant must contribute to pay for his or her share of the nursing home. The Agency for Health Care Administration sets the rates that a nursing home can charge for Medicaid patients. The patient responsibility will be paid towards whatever the rate that the Agency for Health Care Administration sets for how much a nursing home can charge.
So how is the patient responsibility calculated? The patient responsibility is calculated by taking the applicant’s gross monthly income and then deducting the patient needs allowance, health insurance premiums, and whether there is a spouse who needs additional monies at home (spousal diversion).
Example: John is unmarried and is receiving ICP Medicaid because he is currently in a nursing home. John’s gross monthly income is $3,000 per month, so his daughter acting as power of attorney establishes a Qualified Income Trust on his behalf so that John qualifies for Medicaid income wise. Each month John’s $3,000 of gross income is placed into the QIT. Since John is not married, his patient responsibility is calculated as follows:
$3,000 (John’s gross income) – $130 (patient needs allowance) – $300 (health insurance premiums) = $2,570.
This means that on a monthly basis $2,570 of John’s income must be paid to the nursing home to fulfill John’s patient responsibility requirement under Medicaid.
Caution: Before an application is approved by Medicaid be careful before paying the patient responsibility without approval from your elder law attorney. Often times a nursing home facility will try and force you to pay a patient responsibility higher than what you might actually owe.
Once a Medicaid applicant is approved for Medicaid—and if the type of Medicaid is nursing home Medicaid—Florida Department of Children and Families will specify the exact amount for the patient responsibility. This is the amount that must be paid on a monthly basis from the Medicaid applicant’s gross income to the nursing home.
Just like with anything else, DCF makes mistakes when calculating the patient responsibility. The mistake in the patient responsibility calculation could be due to a number of factors—miscalculation of the applicant’s gross income, missing health care insurance premiums, or a miscalculation of the spousal diversion.
If the patient responsibility is incorrect then you should speak with your elder law attorney. The elder law attorney will then look at the documents to confirm whether there is an error with the patient responsibility. If there is an error, then the elder law attorney will need to file a fair hearing with DCF.
Tip: calculating patient responsibility can be very difficult. If you have any questions, consult a qualified elder law attorney.
A common concern for married couples is what will happen if one spouse ends up in the nursing home and that spouse’s income goes to the nursing home. Many elderly couples rely on their shared gross monthly income to pay for bills, food, and keep a roof over their head. The majority of one spouse’s gross monthly income going to pay for the nursing home would cause many community spouses (the spouse who stays in the home) to not be able to make ends meet.
Thankfully, Medicaid allows for spousal diversion. Spousal diversion allows monthly income from the spouse in the nursing home to be diverted to the community spouse (the spouse at home). The total amount of spousal diversion depends on a calculation that takes into account both the spouse who is in the nursing home and the spouse at home’s income.
The calculation then looks at both the minimum and a maximum monthly amount that the community spouse can have. If the calculation is below the minimum—what we call the Minimum Monthly Maintenance Income Allowance (MMMIA)—then the difference between the calculation and the MMMIA would be the amount that can be diverted from the ill spouse to the community spouse.
Example: Jimbo is in the nursing home and his spouse Delilah still lives in the home that they both lived in for the past thirty years. Jimbo’s monthly income is significantly higher than Delilah’s monthly income and Delilah is struggling to pay the bills and the upkeep of the home. When taking into account Jimbo and Delilah’s monthly income, their calculated income under the Minimum Monthly Maintenance Income Allowance (MMMIA) is $1,800 per month, which is well below the MMMIA of $2,113.75 (2019). This means that a minimum of $313.75 ($2,113.75 – $1,800 = $313.75) of Jimbo’s monthly income will be diverted to Delilah to help pay bills.
Tip: The MMMIA of $2,113.75 (2019) is just the minimum. There is also a maximum of $3,160.50 (2019). This means that it is likely that more than just $313.75 of Jimbo’s income in the example above will be diverted to Delilah on a monthly basis.
Calculating the MMMIA can be quite complex. First, you figure out the gross monthly income of the Medicaid applicant and the community spouse. Then you factor in the community spouse’s monthly shelter costs. These monthly shelter costs are only for the mortgage (includes principal and interest) or rent, real estate taxes, homeowner’s insurance or renter’s insurance, condo maintenance fee or HOA fee, and the standard utility allowance (water, sewer, gas, and electric). The standard utility allowance is set at $347.00 for 2019.
Once the community spouse’s monthly shelter costs are calculated, then the excess shelter standard is deducted from the monthly shelter costs. The excess shelter standard is $617.00 for 2019. The resulting number is what is called the excess shelter cost.
Once you have the excess shelter cost, you add the MMMIA of $2,113.75 (2019). This number is the gross monthly income entitlement that the community spouse may be entitled to for spousal diversion. If the number exceeds the maximum MMMIA of $3,160.50 (2019), then for the next calculation you will just use $3,160.50 (2019).
You will then take the gross monthly income entitlement for the community spouse and then subtract the community spouse’s gross income. This number is what we call the Community Spouse Income Allowance (CSIA). The CSIA is the amount that can be diverted from the Medicaid applicant’s gross income to the community spouse each month.
Tip: Remember, gross income includes tax deductions and healthcare insurance premiums that are paid. This is very important when calculating the MMMIA since even a few hundred dollars in deductions can determine whether a community spouse receives any spousal diversion.
The short answer is no. The community spouse can have an unlimited amount of income and their income does not affect the Medicaid applicant’s eligibility. The community spouse’s income would only affect how much the community spouse can receive from the Medicaid applicant’s income per month.
Example: Jimbo is in a nursing home and his gross monthly income is $2,100 per month. His wife Delilah won the lottery after Jimbo was placed into a nursing home and she invested all of her winnings into annuities that produce income on a monthly basis. Her monthly income is $10,000 per month. Even though her income is way above the $2,313 (2019) allowed by Medicaid per month, she is the community spouse and her income does not affect her husband’s nursing home eligibility.
It is very common that DCF will give the community spouse a lower Community Spouse Income Allowance (CSIA). This is often due to poor training or a miscalculation on the part of the DCF case worker. If the community spouse receives a lower than expected CSIA, then the community spouse can file a notice and request a fair hearing.
A fair hearing gives the community spouse—or the community spouse’s representative—the ability to present evidence, provide testimony, and provide witnesses to a hearing officer. If the CSIA calculation was incorrect due to a miscalculation, then the community spouse would simply provide evidence showing that the case worker’s calculation of the CSIA was incorrect.
Fair hearings can be quite stressful. We recommend you speak with a qualified elder law attorney before requesting or attending a fair hearing.
Tip: If the CSIA was calculated correctly by the case worker, then the community spouse can still request a hearing to adjust the CSIA if the community spouse presents proof that exception circumstances provide that the CSIA should be higher due to a low CSIA causing significant inadequacy to meet the community spouse’s needs.
Example: DCF determined that Delilah’s CSIA would be $2,300 per month. Delilah has serious health issues requiring expensive daily home health care. Delilah also needs to do significant remodeling to her and Jimbo’s home so that she can stay in the home for a longer time period.
Delilah should request a fair hearing and she should provide evidence, witnesses, and she should provide testimony to the fair hearing officer that there are exceptional circumstances due to her health and rising costs so that the fair hearing officer should raise her CSIA.
If the community spouse receives a low CSIA and the community spouse is unsuccessful in obtaining a larger CSIA from the hearing officer, the community spouse can potentially obtain a Qualified Domestic Relations Order (QDRO), or the community spouse can sue for alimony under Florida Statute 61.09. Both are mechanisms for a Judge to divert a higher amount of income from the spouse in the nursing home to the community spouse.
When this happens, the community spouse is represented by their attorney, and the spouse in the nursing home is represented by another attorney from a different law firm. A QDRO is typically used for pension funds, and Florida Statute 61.09 is used as a way for a spouse to obtain alimony without a divorce.
Note: Suing a spouse for a QDRO or for alimony can be complicated. Speak to a competent elder law attorney who is familiar with these procedures before proceeding.
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