BASIC (11-02)

A. Policy -- general

Public Law 94-566, enacted October 20, 1976, and ef­fective with payment due for October 1976 and subse­quent months, changed the method for computing payments when only one member of an eligible couple is in a medical treatment facility throughout a month and the facility receives payment on this indi­vidual's behalf under a State plan approved under title XIX (Medicaid) covering more than 50 percent of the cost of the stay. The monthly rate of pay­ment to the institutionalized member of the couple is to be $25 reduced by that member's countable income. The monthly rate of payment to the member of the couple not in an institution is the appropriate FBR for his/her living arrangement less that member's countable income.

NOTE: If the $25 monthly FBR does not apply to either member of the couple, this method of computation is not used even though one member is in a facility. If both members of the have a $25 monthly FBR, follow the existing rules in SI 02009.010 for computation of payment. In any if these situations, the resource limitations for a couple (SI 01110.003) still apply until the couple has been living apart for more than 6 months.

B. Policy -- one member of an eligible couple is institutionalized throughout the quarter

When one member of an eligible couple is in a medical facility where Medicaid is paying more than 50 percent of the costs, and the other member of the couple is living in his/her own household or the household of another throughout the entire quarter, compute payment to each member of the couple as follows:

1. Determine the applicable quarterly FBR for the member of the couple not institutionalized (SI 02001.020). The quarterly FBR for the institution­alized member of the couple is $75. (See SI 02009.050C when there is an essential person(s)).

2. Determine the quarterly countable income for each member of the eligible couple as if each were an eli­gible individual without regard to any income of the spouse. Do not combine the incomes. Do not attribute unused exclusions by one member of the couple to the other member of the couple. (See SI 02009.050 when there is an essential person(s).)

3. Subtract the quarterly countable income of the member not institutionalized from the appropriate quarterly FBR. Subtract the quarterly countable income of the member of the couple in the institution from the quarterly FBR of $75. The results are the quarterly payments due each member of the couple.

4. Divide each result by 3 to find the monthly amount due each member of the couple.

Example:

Mr. and Mrs. Black are an aged eligible couple. On September 28, 1981, Mr. Black enters a nursing home and Medicaid pays more than 50 percent of his costs. Mrs. Black remains in their home and continues to operate a small business operating as a partnership. Each receives a Title II benefit of $130 a month. The small business had been netting the couple $1,020 a year and has been the basis for computing their benefits. Mrs. Black will contin­ue to run the business while her husband is in the nursing home. The couple has no other income.

Original Computation for October -December 1981 Before Report of Change

New Computation

Mr. Black

Mrs. Black

C. Policy -- monthly fbr for one member of an eligible couple is $25 for only one or two months of a quarter

When one member of an eligible couple is in a medical facility where Medicaid is paying more than 50 percent of the costs, and the other member of the couple is living in his/her own household or the household of another throughout the entire quarter, compute payments to each member of the couple as follows:

1. Determine the applicable quarterly FBR for the member of the couple not institutionalized (SI 02001.020). The quarterly FBR for the institutionalized member of the couple is $75. (See SI 02009.050 when there is an essential person(s)).

2. Determine the quarterly countable income for each member of the eligible couple as if each were an eligible individual without regard to any income of the spouse. Do not combine the incomes. Do not attribute unused exclusions by one member of the couple to the other member of the couple. (See SI 02009.050 when there is an essential person(s).)

3. Subtract each member's countable income for the period from the appropriate FBR for the same period. The results are the monthly payment amounts due each member of the couple (or the monthly payment amounts for 2 months which must be divided by 2 to find the amounts for each month).

4. For the short quarter prior to the effective month for which one member of the couple was institutionalized, re-compute the couples payment amounts as follows:

   1. Determine the applicable FBR for the couple (eligible individual with an eligible spouse) for the short quarter.

   2. Subtract from the FBR the couple's total countable income for the period involved. Determine the couple's countable income by com­bining the actual income received by each member of the couple for the short quarter.

      The result is the short quarter payment due the couple if the short quarter consists of 2 months, divide the payment amount by 2 to find the monthly amount payable to each member of the couple.

5. If only the first month or first and second months of a quarter are months for which one member of the couple was institutionalized in a medical facili­ty, compute payments by following steps 1 through 3 for the first month or first and second months of the quarter and apply the rules in 4 for the remaining month(s). (See SI 02009.035C.6. - examples 2 and 3.)

6. If the second month of a quarter is the only effective month for which one member of the coup­le is institutionalized, a determination of eligibility and calculation of payment amount applies which depends on the circumstances existing each month of the quarter. (In reality, three short quarters, see SI 02009.035C.6. - example 5.)

Example 1 - Income the Same All Months; Live in Same Household

Mr. and Mrs. Blue are an eligible and aged couple. Mr. Blue receives Title II benefits of $130.60 a month and Mrs. Blue receives wife's benefits of $65.30. On August 10, 1981, Mr. Blue enters a nursing home which reports it expects to receive Medicaid payments for more than 50 percent of Mr. Blue's costs. He remains in the home throughout the remainder of the quarter. Mrs. Blue maintains their home. The original and new computations for the quarter are shown below:

Original Computation Before Report of Change

New Computation

Mr. and Mrs. Blue

Mr. Blue

Mrs. Blue

Example 2- Monthly Income Varies: Spouse Changes Living Arrangement

Mr. and Mrs. Green an eligible couple, have each been re­ceiving monthly SSI payments of $101.84. Mr. Green re­ceives a pension payable the third month of each quarter in the amount of $640. On November 3, 1981, Mr. Green enters a nursing home where Medicaid pays for more than 50 percent of his costs. Several days later Mrs. Green goes to stay with her daughter while Mr. Green remains in the nursing home. She contributes nothing to the daughter's household expenses. Mr. Green stays in the nursing home throughout the month of December. The original and new computations for the quarter are shown below.

Original Computation Before Report of Change

New Computation

Mr. Green

Mrs. Green

Mr. and Mrs. Green

Example 3- Member of Couple Leaves Institution

On February 13, 1982, Mr. Green (from Example 2 above) leaves the nursing home. He and Mrs. Green resu­me living together in their own household. Mrs. Green stayed with her daughter until Mr. Green left the nursing home. The original and new computations for the March 1981 quarter are shown below:

Mr. Green

Mrs. Green

New Computation

Mr. Green

Mrs. Green

Mr. and Mrs. Green

Example 4 - Couple Lived in Household of Another

Mr. and Mrs. White have been living with their son for over one year and each has been receiving monthly SSI payments. Mr. White receives unearned income of $80.20 each month and during the second month of every quarter, he receives additional unearned income of $96. Mrs. White has no income. On November 2, 1981, Mr. White enters a nursing home where Medicaid pays for more than 50 percent of his costs. The original and new computations for the quarter are shown below:

Original Computation Before Report of Change

New, Computation-Short Quarter Computation (October­-November 1981)

Mr. and Mrs. White (October)

Mr. and Mrs. White (November)

Mr. White

Mrs. White

Short Quarter Computation (December 1981)

Mr. White

Mrs. White

Example 5 - Institutionalization Second Month of the Quarter

Mr. and Mrs. Gray live in their own household. On Octo­ber 15, 1981 Mr. Gray enters a medical facility which ex­pects Medicaid to pay for all the costs. It is expected that he will be in the facility indefinitely. Mr. Gray normally receives unearned income of $50 per month. Also, in the third month of each quarter, he receives additional unearned income of $90. Mrs. Gray receives unearned in­come of $40 per month. She remains in their home during Mr. Gray's medical confinement. The original and new computations for the quarter are shown below:

Original Computation Before Report of Change

New Computation

Mr. and Mrs. Gray

Mrs. Gray

Mr. Gray

On December 27, 1981, Mrs. Gray reports that Mr. Gray came home from the medical facility on December 24th and he is expected to stay at home. The new computation for the quarter is:

Mr. and Mrs. Gray

Mrs. Gray

Mr. Gray

Mr. and Mrs. Gray

D. Policy -- effect on state supplementation

For October 1976 and subsequent months, the changes in the Federal method of establishing payment rates and counting income also apply for computing federally ad­ministered State supplementary payments (both mandatory and optional) when only one member of an el­igible couple is in a medical facility and Medicaid is pay­ing more than 50 percent of the costs. Thus, the non-institutionalized member's payment level (combined FBR plus State supplement) is determined as for an indi­vidual rather than using 1/2 of the applicable State sup­plementary level for a couple. No Federally administered State supplement is payable for the institutionalized member (unless he or she is a mandatory supplement re­cipient converted in that living arrangement).

If countable income exceeds the FBR, the excess countable income reduces the supplement on a dollar for dollar basis (unless the State has additional income disre­gards). For Maine, which has additional income disre­gards, subtract the additional income disregards, where applicable, from countable income first to determine if there is any excess countable income to reduce the supplement.

For mandatory supplement computations processed using Federal countable income, substitute the minimum income level (MIL) for the State supplementary payment level. The total of the SSI benefits plus countable income is then subtracted from the MIL to determine the mandatory supplement.

Example-Computing a State optional supplementary payment for the non-institutionalized member of a couple.

Mr. and Mrs. Williams, an eligible aged couple, have been living in their own home and have each been receiv­ing monthly SSI payments of $227.60 which includes the State supplement. Mrs. Williams also receives monthly ti­tle II benefits of $140. On September 17, 1981, Mr. Wil­liams enters a nursing home in Springfield, Massachusetts. The home reports it expects him to stay indefinitely and total payment for his care to come from the State title XIX (Medicaid) program. Consequently, a monthly FBR of $25 is applicable begin­ning October 1981. Mrs. Williams continues to live in their home for which her monthly FBR beginning Octo­ber 1981 is $264~70. The State of Massachusetts provides the following total payment levels for individuals and couples:

Compute their monthly payments as follows:

Mrs. Williams

Since an SSI benefit is payable, the full $114.61 optional supplementary payment is payable. If countable income exceeded $264.70, the amount of the excess would have reduced the optional payment on a dollar for dollar basis.

Mr. Williams

No optional supplement is payable

E. Policy -- diaries

Diary the case for the sixth month after the eligible couple began living apart due to the medical confinement of one. When the diary matures, develop to see whether they are still separated and, if so, redetermine the eligibility status of each member of the couple as an eligi­ble individual. (See SI 02305.000ff.)