Medi-Cal Handbook Long Term Care (LTC) 29. Long Term …29. Long Term Care (LTC) When a Medi-Cal...

Medi-Cal Handbook page 29-1Long Term Care (LTC)

29. Long Term Care (LTC)

When a Medi-Cal applicant or recipient enters a skilled nursing facility, LTC rules apply to determine the month of LTC status, who is in the MFBU, and how to treat the income and property, and budgeting.

For married couples with one spouse in LTC, there are two sets of rules: the Medicare Catastrophic Coverage Act (MCCA) and the Community Property/Income rules. Which rules apply depends on the date the married individual entered the LTC facility and applied for Medi-Cal. MCCA rules apply if the individual entered the facility on or after September 30, 1989 and applied for Medi-Cal on or after 1/1/1990. These regulations define new terms such as community spouse, institutionalized spouse, continuous period of institutionalization and allow the institutionalized spouse to allocate income and property to the community spouse at home without considering the State’s community property and income laws. Assembly Bill (AB) 641 allows counties to implement MCCA rules to same-sex spouses and Registered Domestic Partners (RDP) effective January 1, 2012.

Married Medi-Cal applicants or recipients who entered a LTC facility prior to September 30, 1989, fall under the State’s equal division of community property/income rules. Under these rules, terms such as LTC status, separate and community property, spouse at home, apply. Community property/income rules do not consider same-sex spouses or RDPs.

This chapter contains all applicable Medi-Cal policies, regulations, processes and procedures specifically applicable to individuals who are in LTC whether they are married, single, or in a registered domestic partner relationship. Other rules and regulations not specific to LTC remain in their respective chapter, although they are also applicable to persons in LTC.

Note:Persons in LTC are not eligible for In Home Supportive Services (IHSS) [Refer to “In-Home Supportive Services Payment for Intake,” page 51-8] and the CalFresh Handbook [Refer to “HH Composition,” page 29-12]

29.1 Definitions

For a list of complete definitions refer to the Medi-Cal Handbook, [Refer to “Definitions, Abbreviations and Program Terms,” page 1-1]

Update # 13--07 Revised: 07/24/13

2 Medi-Cal HandbookLong Term Care (LTC)

29.1.1 Common Law Marriage

[Refer to “Common-Law Marriage,” page 60-5]

29.1.2 Community Spouse [50031.5]

A person who is NOT an inpatient in a medical or nursing facility and who is married to an institutionalized spouse or for income purposes, married to a person with LTC status. Registered Domestic Partners (RDP) and same-sex spouse meet the definition of community spouse.

Note:A community spouse may be a resident in a board and care facility, assisted living facility or other nonmedical living arrangement.

29.1.3 Community Spouse Monthly Income Allowance (CSMIA)

This is also referred to as MMMNA.

29.1.4 Community Spouse Resource Allowance (CSRA)[50031.7]

The CSRA is the amount of combined nonexempt community and separate property, belonging to either or both the institutionalized and community spouse/same-sex spouse/RDP, which the community spouse/same-sex spouse/RDP is allowed to retain when the institutionalized spouse/same-sex spouse/RDP applies for Medi-Cal.

29.1.5 Competent [50032]

Competent means being able to act on one's own behalf in business and personal matters.

[Refer to “LTC and Incompetent Persons,” page 29-9]

Revised: 07/24/13 Update # 13--07


29.1.6 Continuous Period of Institutionalization [50033.5]

A “Continuous Period of Institutionalization” is 30 or more consecutive days of inpatient medical care in a medical institution or nursing facility. A “Continuous Period of Institutionalization” begins when an institutionalized person is expected to remain an inpatient for 30 consecutive days and ends when the institutionalized person is no longer an inpatient for a full calendar month.

“Continuous Period of Institutionalization” applies only to LTC individuals who have a community spouse/same-sex spouse/RDP. [Refer to “Long Term Care Status [50056],” page 29-4], if the LTC individual does not have a community spouse/same-sex spouse/RDP.]

Note:Persons are considered “expected to remain” even though they do not actually stay in an institution, when it was determined at the beginning of the period of institutionalization that he/she was “expected to remain.”

29.1.7 Institution - LTC Medical Facilities

A medical institution is any public or private medical facility licensed by an officially designated state standard setting authority. LTC medical facilities include the following:

• Acute care hospitals• Acute psychiatric hospitals• Intermediate care facilities• Skilled nursing facilities

Note:Board and Care, Residential Care Facility or Assisted Living Facility are not considered Nursing Facilities for purposes of LTC status.

29.1.8 Institutionalized Spouse [50046.5]

Beginning with the date of admission into the nursing facility or medical institution, an institutionalized spouse is one who is all of the following:

• Is applying for Medi-Cal on or after 1/1/1990

• Is beginning a “Continuous Period of Institutionalization” on or after 9/30/1989 as an impatient in a medical institution or a nursing facility.

Update # 13--07 Revised: 07/24/13


• Is expected to remain in the medical institution or nursing facility for a continuous period of at least 30 consecutive days as evidenced by a statement, signed and dated by his/her physician.

• Is married to a community spouse/same-sex spouse/RDP.

• Is NOT AFDC-MN.

Note:Couples with AFDC-MN (linkage to Cash Aid) are eligible for the AFDC-MN Medi-Cal Program. Spousal allocation and CSRA are not applicable. They are in the same MFBU.

Note:If MI couples meet the definition of “institutionalized spouse/same-sex spouse/RDP” above, Spousal allocation and CSRA rules apply. They are separate MFBUs beginning in the month of institutionalization.

29.1.9 Long Term Care Status [50056]

Long Term Care (LTC) status means inpatient medical care which lasts for more than the month of admission and is expected to last for a least one full calendar month after the month of admission. LTC status starts the first day of the month following the month of admission. LTC status terminates the first day of the month in which the client is discharged from a medical facility

[Refer to “Long Term Care Eligibility,” page 29-5]

29.1.10 Minimum Monthly Maintenance Need Allowance (MMMNA)

This is term generally used in court orders to refer to the CSMIA.

29.1.11 Nursing Facility [50064.71]

A nursing facility is a skilled nursing or an intermediate care facility.

Note:Board and Care, Residential Care Facility or Assisted Living Facility are not considered Nursing Facilities for purposes of LTC status.

Revised: 07/24/13 Update # 13--07


29.1.12 Nursing Facility Level of Care [50064.9]

Nursing facility level of care is received by inpatients in skilled nursing facilities, in intermediate care facilities, in subacute care facilities, in the distinct-part of distinct part facilities and when an inpatient is receiving either skilled nursing or intermediate care in swing-bed hospital. Nursing facility level of care is commonly known to Medi-Cal providers as “long term care.”

29.1.13 Nursing Facility Level of Care During the Period of Ineligibility

If found ineligible due to a disqualifying transfer, the institutionalized person is only ineligible for nursing facility level of care. He/she will receive a “restricted” card (950 restriction code in MEDS) which covers other types of medical services.

29.1.14 Registered Domestic Partners and Same Sex Marriage [Refer to “Registered Domestic Partners (RDP) /Same Sex Spouse in Long Term Care,” page 29-23]

29.1.15 Skilled Nursing Care/Facility

A health facility or a distinct part of a hospital which provides skilled nursing care and supportive care to patients whose primary need is for skilled nursing care on an extended basis. It provides 24-hour care and, as a minimum, includes nursing, dietary, pharmaceutical services, and an activity program.

29.2 Long Term Care Eligibility

There are three LTC situations:

• A single person with linkage (ABD) in a LTC medical facility; • A person in LTC with a spouse/same-sex spouse/RDP at home, regardless of

linkage; and • A single person with no linkage (MIA aid code 53) in LTC.

Update # 13--07 Revised: 07/24/13


A person with linkage (ABD) in a LTC medical facility:

In the example of Abel below, LTC status applies.

Example:Abel, ABD single person, enters a nursing home on February 25 and is expected to stay until April 6. LTC status starts in March as he is expected to stay at least the full month after the month of admission

Example:Hilda, ABD, a widow, enters a hospital on February 25 and is expected to be released on March 28. This is NOT considered LTC status as Hilda will not be hospitalized for at least one full month (March) after the month of admission. Process regular Medi-Cal eligibility.

A person in LTC with a spouse/same-sex spouse/RDP at home,

The definition of LTC status does not apply for a married couple with one member in LTC and the spouse/same-sex spouse/RDP at home or board and care. LTC eligibility starts the month of institutionalization (first of the month) and ends at the end of the month in which the person is discharged from the LTC facility. This rule applies regardless of linkage, i.e., ABD, MIA.

Example:Jose, married person, in LTC with a spouse/same-sex spouse/RDP at home, enters the facility September 20 and is expected to remain in the facility. LTC eligibility starts September 1. Jose is discharged home on December 12. LTC eligibility ends December 31.

A person with no linkage (MIA aid code 53) in LTC

For a single person in LTC without linkage to Medi-Cal, LTC eligibility starts the month of institutionalization (first of the month) and ends at the end of the month in which the person leaves the LTC facility.

Example:Maria, 45 years old, MIA, enters the hospital August 10. She is transferred to a LTC facility on October 1. Her LTC eligibility starts the month of admission to the hospital (August 1). Her LTC eligibility (aid code 53) continues after Maria transfers to LTC.

Revised: 07/24/13 Update # 13--07


Example:Boris, 27 year old MIA, enters the hospital August 10. He is transferred to LTC on August 25 and is expected to remain in LTC for at least 30 days. LTC eligibility starts the month of admission to the hospital (August 1) and continues when he is transferred to LTC.

Example:Maggie,55 years old MIA, enters the hospital August 10 and remains in the hospital for several months. Her LTC eligibility (aid code 53) starts August 1 and continues.

Note:Explore disability and possible DDSD referral for all MIA situations.

[Refer to “Federally Disabled Persons [50167, Proc. 22C],” page 27-1]

29.3 Institution for Mental Diseases (IMD)

IMD is defined as a hospital, nursing facility, or other institution of more than 16 beds, AND provides the following to individuals with mental diseases:

• Diagnosis,

• Treatment,

• Care including medical attention, nursing care and related services.

Individuals who are residents of IMD are eligible for either full scope or restricted Medi-Cal depending on their situations, if other Medi-Cal eligibility requirements are met.

Note:An institution for the mentally retarded is not an IMD because mental retardation is considered a mental deficiency and not a mental disease.

Update # 13--07 Revised: 07/24/13


29.3.1 Individuals Under 21

An individual under the age of 21 who is a patient in an IMD is eligible for Medi-Cal. Use the appropriate aid code based on the linkage factor.

If the disability has...

Then...

Not yet been determined,

Request a determination for disability (refer to DDSD referral criteria and requirements, Chapter 27).

Determine the share of cost. In determining the share of cost for these individuals, the EW must only allow a $35 maintenance need.

Activate the individual on MEDS and use the appropriate aid code based on the linkage factor, until disability has been determined.

Been Approved,


Place the individual in Aid Code 63-0.

Medi-Cal eligibility continues up to age 22 for individuals institutionalized in an IMD prior to their 21st birthday as long as they have:

• Remained continuously institutionalized, and• Continued to receive inpatient psychiatric care.

When the individual turns 22 years of age, eligibility for Medi-Cal must be redetermined. If still eligible, place in the appropriate aid code.

29.3.2 Individuals Between Age 21-65

The EW must determine Medi-Cal eligibility of an individual who is between age 21-65 and admitted to an IMD or who is a resident of an IMD as follows:

If the disability has... Then...

Not yet been determined, Request a determination for disability (refer to DDSD referral requirements, Chapter 27).


Activate the individual on MEDS in Aid Code 53-0 or 53-1 until disability has been determined.

(Chart page 1 of 2)

Revised: 07/24/13 Update # 13--07


29.4 Application

Many individuals who are in LTC may have a designated authorized representative (AR). [Refer to “Persons Who May Represent the Client,” page 5-15]

29.4.1 LTC and Incompetent Persons

Some individuals in long-term care (LTC) may be incompetent or are unable to handle their affairs. This section contains Medi-Cal regulations regarding which persons may file a Medi-Cal application and complete the application process on behalf of these persons.

Determination of Competency

EWs must determine if the LTC applicant is able to act on his/her own behalf in business and personal matters. Is the LTC patient mentally able to complete all documents, to provide all necessary information and verifications?

An EW may use one of the following methods to determine whether an individual is able to complete the application process:

• Call the LTC facility and inquire as to the patient's ability to handle his/her affairs; or

• Make a “home visit” to the facility to communicate with the applicant; or

Been Approved, Determine the share of cost. In determining the share of cost for these individuals, the EW must only allow a $35 maintenance need.

Place the individual in Aid Code 63-0.

If the disability has... Then...

(Chart page 2 of 2)

Update # 13--07 Revised: 07/24/13


• Obtain satisfactory evidence from family members which would provide sufficient reason to believe that the LTC individual is incapable of handling his/her affairs (for example, conservatorship documents or a written statement from a family member stating the client is unable to complete the application process without assistance); or

• Obtain a statement from the patient's physician.

Note:Medi-Cal does not require a formal certification, such as a doctor's statement, regarding competency. A physician statement is just one example of how the EW may determine the client's ability to complete the application process.

Who May Apply [50143]

If a LTC patient is not mentally competent to complete the application process, anyone knowing the need of the person to obtain Medi-Cal benefits may complete and file the SAWS 1 application form. This person may be a spouse, a friend, a nursing home staff member or anyone else.

Who May Complete the Application [50077, 50163]

The persons listed below, in the order indicated, may complete and sign the Application/Statement of Facts for Medi-Cal for an applicant who is not mentally able to complete the required forms or fulfill any other eligibility requirements:

If... Then...

The applicant has a spouse, The spouse must complete and sign the application for Medi-Cal.

The applicant has a conservator, guardian or executor,

The conservator, guardian or executor must complete and sign the application for Medi-Cal.

Revised: 07/24/13 Update # 13--07


Knowledge of Client's Circumstances

EWs are to interpret “a person who has knowledge of the applicant's circumstances” broadly. The office manager, administrator or social worker of a nursing facility may have sufficient information and knowledge of the client's circumstances if the client's income and property are known to them.

Many nursing facilities maintain a trust account for their patients in which the patient's income is automatically deposited and funds dispersed by the facility. In these instances, if no other family member is involved in the application process and protective services are not needed, the nursing staff person may complete the eligibility forms for the patient.

In addition to the above, any other person who “has knowledge of the applicant's circumstances” may act on behalf of an incompetent person. EWs must ensure, however, that the person does, in fact, have specific knowledge to handle the client's application.

DHCS 7068

Completion of the “Responsibilities of Public Guardian/Conservators or Applicant/Beneficiary Representative” (DHCS 7068) form is required when an applicant has a public guardian, conservator or a representative acting in his/her behalf, due to the incompetence of the client.The DHCS 7068:

• Defines the responsibilities of the court appointed or volunteer representative.

There is no spouse, conservator, guardian or executor,

The EW must determine if there is a need for protective services.

If there is no need for protective services, then the application for Medi-Cal may be completed and signed by:

• A relative, • A person who has knowledge of the

applicant's circumstances, or • A representative of a public agency or the

county department.

Note: A Regional Center for Developmentally Disabled (for example, the San Andreas Regional Center) is regarded as a “public agency”.

If... Then...

Update # 13--07 Revised: 07/24/13


• Must be completed at application and redetermination.

• Must be given to the representative (one copy) and a copy scanned into IDM.

Incompetent Persons Cannot Designate an AR

An applicant who is incompetent does not have the required knowledge and ability to designate an authorized representative. A written authorization would not be appropriate in these situations. A written authorization from an incompetent person is not required in order for a representative to assist in the application process.

For information on other types of representation refer to MC sections:

• [Refer to “Authorized Representatives,” page 5-15]• [Refer to “Public Guardian,” page 5-17]• [Refer to “MC 306 and Other Written Authorization,” page 5-17] • [Refer to “Family Members,” page 5-20] • [Refer to “Representative Payees,” page 5-21]• [Refer to “Durable Powers of Attorney,” page 5-21]

29.5 Resources

29.5.1 LTC Ombudsman Program

The long-term care Ombudsman works to resolve any problem or complaint involving resident of a nursing home or board and care facility.

(408) 944-0567

29.5.2 Probate/Estate Recovery

[Refer to “Probate/Estate Recovery,” page 3-12]

29.5.3 Managed Care Disenrollment When Entering LTC

When a recipient enters LTC and is already enrolled in a Managed Care Plan, instruct the facility to contact Health Care Options contractor requesting an LTC waiver. For disenrollment procedures refer to [Refer to “Disenrollment,” page 15-9].

Revised: 07/24/13 Update # 13--07


Note:The State may want to see the LTC aid code in MEDS prior to removing the Managed Care coding.

29.5.4 Voluntary Repayment of Benefits by Beneficiaries

[Refer to “Voluntary Repayment of Benefits by Beneficiaries,” page 3-16]

29.6 County of Responsibility

[Refer to “County of Responsibility [50135],” page 19-22]

29.6.1 Long Term Care Clients

If the family member or authorized representative (AR) of an incompetent LTC client lives in another county, counties shall allow the family member or AR the flexibility of working with a local Medi-Cal office. If family member or AR requests that the case remain in his/her county of residence, counties shall be flexible and honor this request. The LTC client’s MEDS record must reflect the LTC facility’s address and county code (in the Residence County field) where it is located.

LONG TERM CARE CLIENTS

Situation County of Responsibility

community spouse/same-sex spouse/RDP or family member of an incompetent LTC client resides in another county.

The county where the community spouse/same-sex spouse/RDP resides is the county of responsibility. The county of responsibility is not determined by the county residence/location of the authorized representative appointed by a competent community spouse/same-sex spouse/RDP, responsible relative or other knowledgeable representative.

Authorized representative of an incompetent LTC client resides in another county.

The county where the authorized representative (if there is no community spouse/same-sex spouse/RDP) resides is the county of responsibility.

Competent individual in LTC. The county of responsibility is the county where the LTC individual resides.

Update # 13--07 Revised: 07/24/13


Example 1:

community spouse/same-sex spouse/RDP resides and maintains a home in Santa Clara County. He/she applies in Santa Clara County for his/her incompetent spouse/same-sex spouse/RDP who is in a LTC facility in San Mateo County. The Santa Clara County EW must accept and process the application for the institutionalized spouse/same-sex spouse/RDP. Santa Clara County, where the community spouse/same-sex spouse/RDP resides, may retain the continuing case for ongoing eligibility since the institutionalized spouse/same-sex spouse/RDP is incompetent and unable to provide information.

Example 2:

An incompetent individual is in a LTC facility in Santa Clara County. The individual’s adult child, who lives in Monterey County, applies for benefits in Monterey County on behalf of the LTC parent. Monterey County must accept and process the Medi-Cal application for the LTC applicant. Monterey County must retain the active Medi-Cal case because the adult child is the beneficiary’s representative acting on the beneficiary’s behalf, and reporting changes to Monterey County.

In the above example, if the LTC individual were to be competent but incapacitated, Monterey County would accept the application from the adult child, contact Santa Clara and forward the application/information to Santa Clara. Santa Clara Social Services staff will assist the LTC applicant with completing the Statement of Facts, (MC210), conduct the face-to-face interview (if necessary), review the rights and responsibilities, and determine initial eligibility for the LTC applicant.

Example 3:

The client resides in a LTC facility in Santa Clara County. He/she has family members in Santa Clara County assisting with his/her personal/financial affairs. After three months, the family finds an LTC facility in Napa County that would better serve the needs of the client and moves the client to that facility. The family requests that the client’s Medi-Cal case remain in Santa Clara County. Santa Clara County must honor the family’s request.

Note:This third example illustrates that there are situations when a client’s representative would move a LTC beneficiary from one facility to another within a short period. Keeping the case in the original county as specified would eliminate the excessive paper work involved with multiple intercounty transfers when county staff are working with a representative who handles the affairs of an incompetent beneficiary.

Revised: 07/24/13 Update # 13--07


For LTC cases with a Public Guardian, refer to [Refer to “Person with a Guardian,” page 19-25]

CalWIN System

To ensure the correct county code is on MEDS, enter the facility address in the Home Address field of the Individual Demographics window and the spouse/same-sex spouse/RDP’s or AR’s address in the mailing address field.

29.7 Redetermination

29.7.1 MC 262

The “Redetermination for Medi-Cal Beneficiary -Long Term Care in own MFBU” (MC 262) must be used for beneficiaries in Long Term Care. LTC beneficiaries are in their own Medi-Cal Family Budget Unit (MFBU) with income, property, and needs allocations that are computed differently from other Medi-Cal cases.

[Refer to “PRUCOL Redeterminations,” page 41-25]

29.8 Medicare

29.8.1 Medicare Buy-In

Effective April 1, 2011, as a result of 2010/2011 budget trailer bill, SB 853, the Department of Health Care Services (DHCS) stopped paying Medicare Part B premiums for Medicare eligible Medi-Cal beneficiaries who have a share of cost (SOC) unless the SOC is met on a monthly basis.

Share of cost individuals in long term care facilities are certified on the first of the month. That means, all LTC individuals regardless of SOC will continue to be eligible for Part B premium buy-in and are not impacted by this change.

Update # 13--07 Revised: 07/24/13


29.9 Notices of Action (NOA)

29.9.1 LTC Medi-Cal NOA’s

Long Term Care (LTC) Medi-Cal NOAs

When issuing a NOA to an applicant/beneficiary in LTC, the EW must:

• Mail the original NOA to the applicant/beneficiary at the nursing facility.• Mail a copy of the NOA to the individual’s representative, if another person is

acting on his/her behalf.• Mail a copy of the NOA to the administrator of the facility, if requested by the

family.• Scan a copy of the NOA into IDM.

Note:Speedletters and other “conditional notices” are not required to be sent to the administrator.

29.9.2 NOA’s and AR’s for Competent Clients

An applicant/beneficiary may designate another person or organization to act as his/her “authorized representative” (AR). The AR is not automatically entitled to receive a copy of all NOAs. ARs are entitled to receive only the notices which the applicant/beneficiary specifically requests to be sent to the AR.

[Refer to “Subject: Authorized Representative with Durable Power of Attorney Chapter: 5 Date: 10-01-2012,” page -1]

Exception:When there is a hearing request or hearing issue, the county is required to provide copies to the AR of all NOAs or other correspondence that the county has sent to an applicant/beneficiary regarding that hearing request or hearing issue if the county has received notification from the applicant/beneficiary that the AR is authorized to represent him/her.

Revised: 07/24/13 Update # 13--07


29.10Former SSI/SSP Recipient

Clients under age 65 who are discontinued from SSI/SSP for reasons other than “cessation of disability” (e.g. excess income or resources) and who are Not receiving Social Security Disability benefits must be referred to DDSD to determine if the disability established by SSA still exists. (This also includes persons who are in LTC.) [Refer to “Referral for Former SSI/SSP Recipient - Discontinued for Reasons Other than “Cessation of Disability”,” page 31-3]

29.11California Residency

Persons who are in long-term nursing home care may not have one of the “specified documents” (such as a mortgage or rent receipt, a current California DMV license, etc.) However, receipt of California “public assistance” is one of “specified documents” which may be used for residency verification. For purposes of residency verification only, the term “public assistance” includes any government benefits or pensions, from federal, state, county or city sources, except unemployment insurance or Medi-Cal.

Most LTC persons receive Social Security benefits. Receipt of Social Security at a California address can be used to satisfy the residency verification requirement for most persons in LTC, unless there is other conflicting information.

However, the MC 214 must also be completed if one of the specified documents is not available, for example, the client receives no government pensions/benefits. (The LTC admissions record can be used as proof of residency, but it would also require completion of the MC 214, as it is not a specified document.)

Note:Many people have direct deposit of their Social Security and pension checks. Therefore, if the check is a direct deposit, and the name and address on the bank statement is the client at a California address, the residency verification requirement is met.

Update # 13--07 Revised: 07/24/13


29.12Citizenship/Immigration Status

Most noncitizens who apply for full-scope benefits have documentation of their legal status. However, for those noncitizens who declare they have satisfactory immigration status (SIS), but who do not have formal USCIS documents, PRUCOL status can be sought. As a result of the court-ordered permanent injunction issued in the Ruiz v. Kizer lawsuit, PRUCOL procedures must be initiated by the EW for those noncitizens who have declared and provided adequate documentation of SIS or who claim PRUCOL by completion of the MC 13. Full-scope benefits are granted to otherwise eligible noncitizens during the time PRUCOL status is being determined by USCIS.

29.12.1 PRUCOL for Undocumented Individuals in LTC or Receiving Renal Dialysis

Senate Bill 175 mandated the Department of Health Services (DHCS) and counties to continue to provide full scope benefits to undocumented noncitizens receiving Medi-Cal who were in long term care (LTC) services on October 1, 1988.

The Ruiz v. Kizer and Crespin v. Kizer court injunctions expanded the application of PRUCOL to noncitizens in LTC who applied for Medi-Cal after October 1, 1988.

The following PRUCOL procedures shall be followed only for undocumented noncitizens who apply for or receive full or restricted benefits because they are in LTC.

Do NOT request these special PRUCOL procedures for:

• Undocumented noncitizens who are not currently in LTC.

• Undocumented noncitizens who check the last PRUCOL category 16, Section B #5 of the MC 13.

Note:The client must already be in an LTC facility, not waiting to get in. The client’s situation must be considered whether the client has already met the LTC status and is already in LTC facility. LTC status is defined as inpatient medical care which lasts for more than the month of admission and is expected to last for at least one full calendar month after the month of

Revised: 07/24/13 Update # 13--07


admission. An LTC facility is defined as a medical institution or nursing facility, including: acute care hospitals (like VMC), psychiatric hospitals, intermediate care facilities and skilled nursing facilities. Important: Transfers from one nursing home or medical institution to another do not affect long-term care status, as long as the patient does not go home or to board and care. (e.g. patient admitted to VMC 0n 2/17 and discharged to nursing home on 3/4 and is expected to remain through 3/31 or longer.) That means, PRUCOL can be granted as soon as the client has met the LTC status and is in LTC facility (like VMC hospitals) per above definitions. Again, transfers from one nursing home or medical institution to another do not affect long-term care status, as long as the patient does not go home or to board and care.

• Non-linked noncitizens eligible for State-Only LTC Aid Code 53 benefits.

• Noncitizens who claim to have citizenship or lawful resident status, but who do not have documentation. They shall be treated according to PRUCOL procedures [Refer to “Presumptive Eligibility,” page 41-5].

Prucol Procedures for Undocumented Individuals in LTC

The following procedures apply to undocumented individuals who check any box from 1 - 15 in Section B5 of the MC 13.

New Applicants

Step Action

1 Have the applicant read the “Applicant PRUCOL Notification Letter” SC 1627, prior to completion of the MC 13.

2 The applicant must complete the MC 13 as follows:

• Request full benefits. • Claim PRUCOL status by checking any box from 1 - 15 in Section B 5.

3 The applicant (or representative) must complete the “G-845 Supplement - PRUCOL” (MC 845).

Update # 13--07 Revised: 07/24/13


Continuing Cases

Persons who are receiving restricted benefits and who are in LTC shall be changed to full benefits:

• Effective the first of the month that SIS status based on PRUCOL is claimed. The noncitizen must:

• Complete an MC 13 requesting full benefits, and• Check the last PRUCOL box Section B, #5 on the MC 13.

• Follow procedural requirements for completion and referral of the MC 845 and G-845S to USCIS as discussed in “New Applicants Procedures.” if one of the boxes 1-15 is checked on Section B 5 of the MC 13.

4 Allow the applicant 30 days, or the period of time it takes to clear eligibility, whichever is longer, for the return of the MC 845.

• Review MC 845 to ensure the beneficiary/representative supplied requested information and documents (if any). No sections can be let blank. “Information unknown not available

• If the MC 845 is completed and returned within 30 days, and Medi-Cal is subsequently approved, establish full benefits once eligibility is cleared.

• If the MC 845 is not returned within 30 days, nor by the time eligibility is cleared after 30 days, establish restricted benefits.

• Notify the applicant that the MC 845 must be completed and returned so that full benefits can be granted.

• If the MC 845 is completed and returned after the 30 days, or after eligibility is cleared after 30 days, change to full scope benefits effective the first of the month that the MC 845 is received.

• Spltr 484 is available for used when the MC 845 must be returned to the client for more information.

5 Submit the completed MC 845 to USCIS with the Document Verification Request, (G-845).

• Check “other” in Box 8 of the G-845S and write PRUCOL REQUEST” in the open space.

• Do not check any other square within Box #8. • Send the original forms to USCIS, following the standard secondary SAVE

procedures.

6 Scan a copy of the MC 845 and G-845S in IDM. Set a case alert for a 30-day follow up.

Step Action

Revised: 07/24/13 Update # 13--07


29.12.2 PRUCOL Redeterminations

[Refer to “PRUCOL Redeterminations,” page 41-25]

29.12.3 PRUCOL Response/Approval

[Refer to “USCIS Responses on the G 845,” page 41-26]

29.12.4 PRUCOL Denied aid code 55

In rare instances when the G845S is returned by USCIS and box #17 of the G-845S is checked, the statement “USCIS actively pursues the expulsion of a noncitizen in this class/category” means that the beneficiary is NOT PRUCOL.

General

When an undocumented person applies for PRUCOL status, he/she is established on full-scope benefits pending the USCIS decision.When USCIS denies PRUCOL status to the undocumented noncitizen in LTC, the level of Medi-Cal benefits must be reduced, changing the client to aid code 55. aid code 55 entitles the recipient:

• To receive all LTC services (at state-only expense), and • Restricted benefits, which are emergency and pregnancy-related services.

Undocumented noncitizens in LTC who:

• Have gone through the special PRUCOL-seeking procedures, and• Are determined NOT to have PRUCOL status are the only Medi-Cal recipients

who can be placed in aid code 55.

Note:These applicants/beneficiaries will remain in aid code 55 even if they leave LTC.

Update # 13--07 Revised: 07/24/13


29.13MFBU Determination [50060]

29.13.1 Responsible Relative

In determining Medi-Cal eligibility and share of cost, relative responsibility shall be determined in accordance with the following:

If... Then...

One or both spouse/same-sex spouse/RDPs is in LTC,

Both spouse/same-sex spouse/RDP’s income and property is considered available in determining each others eligibility and share of cost.

Neither spouse/same-sex spouse/RDP is in LTC, the spouse/same-sex spouse/RDPs live apart, and it is known that the separation will not be temporary.

The spouse/same-sex spouse/RDPs shall have their eligibility and share of cost determined as single persons the day following the separation.

29.13.2 Registered Domestic Partners (RDP)

Federal law does not recognize RDP relationships. However, RDP rights and responsibilities under AB 204 apply for State-only funded Medi-Cal programs that are not based on federal law. The same-sex spouse/RDP may be eligible for certain state-funded Medi-Cal programs because he/she is treated as a spouse/same-sex spouse/RDP under state law: These state only programs include the Medically Indigent Adults in Long-Term Care program - LTC for individuals who have no linkage to federal programs (aid code 53).

In June 2011 the Center for Medicare and Medicaid Services issued guidance permitting the states to expand the determination of undue hardship to allow transfers of property and income between same-sex spouse or RDPs. California’s AB 641 was passed effective January 1, 2012 which extends the full array of spousal protections now available to married, opposite-sex couples, to same-sex spouses and RDPs. In other words, individuals eligible for federal Medi-Cal benefits under the ABD-MN program who are or become institutionalized and who have a same-sex spouse or an RDP can have CSRA property rules and spousal income allocation applied to them.

Revised: 07/24/13 Update # 13--07


For more information refer to the following handbook sections:

• “Transfers of Property on or After 1/1/90 [50408, 50411],” page 29-56• “Income Allocations, ABD-MN Person with LTC Status Who Has a Community

Spouse/Same-Sex Spouse/RDP [50563],” page 29-76• “Community Spouse Resource Allowance (CSRA)[50031.7],” page 29-2• 60.2.4 Registered Domestic Partners and Same-Sex Spouse/RDPs

29.13.3 Registered Domestic Partners (RDP) /Same Sex Spouse in Long Term Care

The policy for eligibility determinations for same-sex spouse/RDPs is as follows:

• If one same-sex spouse/RDP is applying for Medi-Cal and is in an LTC facility and is not federally eligible (i.e., ABD), then he/she must be placed in the State-only LTC program for Medically Indigent Adults with or without a share-of-cost if otherwise eligible (aid code 53).

• If his/her same-sex spouse/RDP is not an inpatient in a medical institution or nursing facility, then the EW shall apply the spousal impoverishment provisions as if the same-sex spouse/RDP is a “community spouse”.

Note:Two same-sex spouses or RDPs in Board and Care would not be eligible under state-only LTC. State-only LTC provides coverage only when the individual is in an intermediate or skilled nursing facility, not Board and Care. Therefore, EWs must determine eligibility for two RDPs in Board and Care as individuals under federal law or determine whether eligibility might exist for one of the other state-only programs

• If the institutionalized RDP later turns 65 or is determined disabled, then he/she is no longer eligible under the State-only LTC program. Transfer to the appropriate federal program (aid code 13, 23, or 63) and continue to apply Spousal Impoverishment rules.

• All Spousal Impoverishment rules apply to institutionalized same-sex spouses/RDPs.

Verification of the property transferred to the same-sex spouse/RDP at home is required. At their option, either same-sex spouse/RDP may provide a copy of the marriage license or registered domestic partner certificate; otherwise, their statement on the Statement of Facts is sufficient

Update # 13--07 Revised: 07/24/13


29.13.4 Adults in LTC [50377, PROC 8-B]

LTC Person with a Community Spouse/Same-Sex Spouse/RDP

An institutionalized spouse/same-sex spouse/RDP or, for income purposes, an LTC spouse/same-sex spouse/RDP, shall be considered to be in his/her own MFBU at the beginning of the “Continuous Period of Institutionalization.” “Continuous Period of Institutionalization [50033.5],” page 29-3]

• The LTC spouse/same-sex spouse/RDP may provide the community spouse/same-sex spouse/RDP Resource Allowance (CSRA) and an income allocation to the community spouse/same-sex spouse/RDP beginning with the month of admission to the long term care facility.

Note:The CSRA and the Maximum Base Allocation may be increased by a court order.

• The spouse/same-sex spouse/RDPs are in separate budget units beginning with the month of admission,

• The Maintenance Need for the LTC spouse/same-sex spouse/RDP shall be $35 (the personal needs allowance) beginning with the month of admission.

• When the institutionalized spouse/same-sex spouse/RDP and the community spouse/same-sex spouse/RDP are both beneficiaries and their budgets are being revised at the beginning of the “Continuous Period of Institutionalization”, there can be no increase in the share of cost until a ten day notice of action is issued, even though an allocation to the community spouse/same-sex spouse/RDP has been given.

ABD Couple

ABD spouse in the same medical facility, or sharing the same room in LTC, shall have their eligibility and share of cost determined as two separate MFBUs the month after the month of admission

ABD, No Community Spouse

An aged, blind or disabled (ABD) person in Long Term Care with no community spouse shall be in his/her own separate MFBU when “LTC Status” is attained (the month after the month of admission).

Revised: 07/24/13 Update # 13--07


• The Maintenance Need for the LTC individual shall be $35 (the personal needs allowance) the month after the month of admission.

Non-ABD Persons

A non-ABD person in LTC married to a non-ABD spouse shall be included in the MFBU with his/her spouse and/or children or, if the person is a child, with his/her parents.

29.13.5 Children in LTC [50377, PROC 8-B]

Blind/Disabled LTC Child

Beginning the first of the month following the month of admission to LTC, a blind or disabled child shall be in his own MFBU.

• Only the child's separate and available property/income may be used to determine his eligibility and share of cost.

• The resources and income of the child's family may NOT be used in determining the child's Medi-Cal eligibility and share of cost.

Non-Blind/Disabled LTC Child

[“Children in LTC [50377, PROC 8-B],” page 29-25]

Children in LTC who are Not determined to be blind or disabled must be in the MFBU with their parents.

Reminder:A DDSD and SSA disability referral must be initiated.

Note:Explore the Waiver Programs when the parents’ income and property are over the limits.

Exception:A child who was NOT living with his parents immediately prior to entering LTC shall be in his own MFBU.

Disabled Newborns

Update # 13--07 Revised: 07/24/13


A disabled or a presumptively disabled “Presumptive Eligibility (PD),” page 27-17] premature newborn who is born in a facility and remains an inpatient for the remainder of the month is in his/her own MFBU beginning with the month of birth rather than in the following month.

Example:A premature baby girl is born April 15 and weighs 2 lbs., thus she meets “presumptive disability” criteria. She remains in the hospital through July 17 when she is discharged to her home. From April-July she is in her own MFBU. The EW would use only the baby's own income and resources to determine eligibility. Beginning in August, she is in the same MFBU as her parent(s) or caretaker and their income and resources are counted.

A newborn who is not disabled (or presumptively disabled) or who is released to the home and is later hospitalized during the month of birth, must be included in the parents’ MFBU in the month of admission.

Placements

A child who is a ward of the court, or a child who is the responsibility of a public agency due to a voluntary placement by a parent or guardian, and who is a patient in a medical facility, shall be in his/her own MFBU.

29.13.6 Medically Indigent Adults in LTC

Background

The State discontinued the Medically Indigent Adult (MIA) category, from the Medi-Cal program, with a few exceptions, effective 1/1/1983. One of the exceptions is the category of MIAs residing in a skilled nursing facility (SNF) or intermediate care facility (ICF) (including an intermediate care/developmentally disabled).

Note:These facilities are all licensed as medical facilities and are different from board and care homes, which are only licensed to give personal care.

Aid code and Benefits

MIA persons in SNF/ICF are identified by aid code 53. A MIA residing in a SNF/ICF is entitled to all benefits normally covered by Medi-Cal. However, should that MIA person become an inpatient at an acute care hospital, any services provided during that hospital stay will not be covered by the Medi-Cal program.

Revised: 07/24/13 Update # 13--07


MFBU Determination

A MIA in LTC who is a single person shall be in a MFBU of one (1). Long term care status shall begin with the date of LTC entry. He/she must be expected to stay a full calendar month after the month of LTC admission.

Adults

A MIA in LTC whose spouse/same-sex spouse/RDP is not ABD shall be included in the MFBU with his/her spouse/same-sex spouse/RDP and/or children. However a MIA in LTC can be considered an “institutionalized spouse/same-sex spouse/RDP” as long as there is no AFDC-MN linkage, (e.g. there is no temporary absence from the home) [“Institutionalized Spouse [50046.5],” page 29-3]. The at-home spouse/same-sex spouse/RDP (community spouse/same-sex spouse/RDP/RDP) would be entitled to the CSRA and the spousal income allocation if all criteria are met.

Temporary absence for AFDC means the person leaves and returns to the home in the same month or the following month.

Example:Brad (47 years old) and Angelina (48 years old) have six children. Angelina is hospitalized and expected to remain more than 30 days. Because this is an intact family, the EW needs to explore AFDC-MN linkage for purposes of MCCA rules. The question the EW must ask is whether Angelina will return to the home within the same month of hospitalization or the following month. If Angelina returns within these months, this family is considered linked to AFDC-MN and MCCA rules do not apply. If Angelina will stay longer than the month following the month of hospitalization, MCCA rules apply. Angelina will be in her own MFBU beginning the month of hospitalization. Spousal/children allocation and CSRA rules apply.

EW Responsibilities

APD ProgramIf acute care is needed, it may be provided through the Ability to Pay Determination (APD) program at Valley Medical Center. The EW must refer any aid type 53 MIA person to the APD program when that person becomes an inpatient at an acute care facility. DO NOT refer client to the VMC Medi-Cal Unit.

Note:The aid type 53 person who goes to an acute care hospital other than VMC will usually be referred to VMC if he/she has no other health coverage.

Update # 13--07 Revised: 07/24/13


A client may have concurrent Aid Code 53 Medi-Cal coverage and county medical assistance in any month medical services were received in both an SNF/ICF and an acute care facility.

29.13.7 Medically Indigent Children in LTC

The Medically Indigent Child in LTC shall be included in the MFBU with his/her parents. “Children in LTC [50377, PROC 8-B],” page 29-25]

Exception:The child who was not living with parent(s) immediately prior to entering LTC shall be in his/her own MFBU.

Children in LTC

When one or more children are in an LTC facility the following chart applies. An LTC facility is defined as a medical institution or nursing facility. [50056.5]

Table 29-1:

One or Both ABD Parents in the Home

Only Parent is ABD in LTC or B&C

One or Both AFDC Parents in the Home

Only Parent is MI in the Home

Only Parent is MI in LTC or B&C

AFDC-MN Child in LTC Living with Parent Immed. Preceding Entry

Same MFBU Separate MFBUs

Same MFBU Same MFBU Same MFBU

AFDC-MN Child in LTC not living with parent imm. preceding entry

Separate MFBUs

Separate MFBUs

Separate MFBUs

Separate MFBUs

Separate MFBUs

B/D Child in LTC

Separate MFBUs

Separate MFBUs

Separate MFBUs

Separate MFBUs

Separate MFBUs

Revised: 07/24/13 Update # 13--07


Note:1. Where the chart indicates that the child is in the “Same MFBU” this means that the child is in the same MFBU with the parent in the home when at least one of the parents is in the home.

2. An unborn is considered to be living with the parent immediately preceding entry.

MI Child in LTC living with parent immed. preceding entry

Same MFBU Separate MFBUs

Same MFBU Same MFBU Same MFBU

MI child in LTC not living with parent immd. preceding entry

Separate MFBUs

Separate MFBUs

Separate MFBUs

Separate MFBUs

Separate MFBUs

Table 29-1:

Update # 13--07 Revised: 07/24/13


PERSONS UNDER AGE 21 LIVING AWAY FROM PARENT’S HOME

Living SituationPerson’s Characteristics

StatusAdult/ Child

Who Completes Statement of Facts

Whose Income and Property is Counted

Contact with Parent

4. Long-term care (LTC).

Disabled, 18-to-21-year-old.

X 18-to-21-year-old. 18-to-21-year-old’s. No

Disabled, under 18.

X Parent or person or agency responsible for

child. 1

Disabled child’s. yes

Living with parents prior to LTC status, not

disabled. 2

X Parent. Parent’s, LTC child’s, other MFBU member’s.

Yes

Independent living, attending school, out-of-home care prior to LTC status, not

disabled. 2

Determine as in 1 through 4, [“Adult/Child Status Chart,” page 60-43]

No

Aid Code 45 or in foster care prior to LTC status, not

disabled. 3

X Person or agency responsible for child.

Child’s 3 No

1. If the disabled child was 14 to 18 years old and met the criteria in 2B of the chart in “Adult/Child Status Chart,” page 60-43 prior to LTC status, the disabled 14-to-18-year-old would completes Statement of Facts. Likewise, if the conditions of 2B are not met and no person or agency will accept responsibility or the child is under 14 and no person or agency will accept responsibility, the child may complete the Statement of Facts.

2. A child who was AFDC-MN prior to LTC status retains this linkage as he/she is still considered to be living in the parent’s home.

3. These children would lose their status as Aid Code 45 and would be MI children, Aid Code 82 or 83, with one exception. If the public agency which assumes financial responsibility for the Aid Code 45 child continues to pay for his/her person (nonmedical) needs in whole or in part, the child would continue to be considered an Aid Code 45 child and the MC 250 would be the appropriate Statement of Facts.

Revised: 07/24/13 Update # 13--07


29.14Treatment of MIA Residents of Skilled Nursing/Intermediate Care Facilities

While an MI person is a resident of an SNF/ICF, he/she will receive a limited Medi-Cal services under aid code 53 and will receive all Medi-Cal benefits except for services rendered during an acute stay in an inpatient hospital. If eligible, eligibility begins the date the client enters the SNF/ICF. These persons receive the Long Term Care Maintenance Need for the month(s) they are in the SNF/ICF.

A person with a “53” aid code Medi-Cal card is eligible to receive whatever outpatient treatment that is not available to them at the facility in which they reside.

Aid code 53 identifies a client as eligible for Medi-Cal benefits limited to services received while residing in an SNF/ICF. It is not necessary to input any special code to indicate eligibility to limited services. The Medi-Cal identification card for aid code 53 contains the following restriction message: “Services to acute hospital inpatients are not covered.”

Note:Aid code 53 can be granted as long as the SNF/ICF verifies (verbal is acceptable) that arrangements have been made to accommodate the client’s admission to their facility. Most SNF/ICF do not accept clients without a 53 card upon admission. Document in the [Maintain Case Comments] window.

For acute care facilities with SNF beds:

• Phone the facility and verify the level of care patient is receiving with Administrator, nursing station or billing clerk. Document in narrative, or

• Request the applicant/representative for a signed statement on the facility's letterhead concerning the level of care the patient is receiving.

Retroactive Eligibility

These MIA-X's (exceptions) may be eligible for retroactive eligibility if both of the following conditions are met:

• The MIA resided in an SNF/ICF for one day or more during the month of application, and

Update # 13--07 Revised: 07/24/13


• The MIA resided in an SNF/ICF for one day or more during the retroactive month(s) for which Medi-Cal coverage is requested.

The retroactive month(s) (up to three) are also coded with aid code 53, and the same services are covered in the retroactive month(s) as in the current month of eligibility.

Medi-Cal Identification Card

Aid Code 53 identifies a client as eligible for Medi-Cal benefits limited to services received while residing in an SNF/ICF. It is not necessary to input any special code to indicate eligibility to limited services. The Medi-Cal identification card for Aid Code 53 contains the following restriction message: “Services to acute hospital inpatients are not covered.”

Health Care Coverage Assistance Program: If acute care is needed, it may be provided through the Health Care Coverage Assistance Program at Valley Medical Center.

Note:The aid code 53 person who goes to an acute care hospital other than VMC will usually be referred to VMC if he/she has no other health coverage.

A client may have concurrent aid code 53 Medi-Cal coverage and county medical assistance in any month medical services were received in an SNF/ICF and an acute care facility.

DDSD Approvals: Should a disability evaluation subsequently be approved, aid code 53 must be changed to a disabled aid type category (e.g. 63, 64, 67) the disability onset date.

Terminating Benefits: If the client is subsequently released from the LTC facility, he/she is no longer eligible for Medi-Cal as aid code 53. A 10-day notice shall be required to discontinue Medi-Cal under this aid category.

Status Reports: A Midyear Status Reports (MSR) are required for MIAs in LTC. MSRs are generated for aid code 53.

Revised: 07/24/13 Update # 13--07


29.15Long-Term Care Admission and Discharge Procedures

Medi-Cal recipients, including Supplemental Security Income/State Supplementary Payment (SSI/SSP) recipients, have a responsibility to report changes to the appropriate Agency, either the Social Services or Social Security Administration (SSA) within 10 (ten) days. The “Medi-Cal Long-Term Care Facility Admission and Discharge Notification” (MC 171) was developed as a means to notify SSA and Social Services on a more timely basis of SSI and Medi-Cal recipients who enter or leave a LTC facility.

WHO ACTION

Client Enters LTC facility and informs the facility of the SSI/Medi-Cal status.

LTC Facility Provides a “Medi-Cal Long-Term Care Facility Admission and Discharge Notification” (MC 171) to the recipient

Client Completes Part I and II of the MC 171

LTC Facility Sends the original or copy of MC 171 to the appropriate Agency

Social Services

Takes appropriate action:

If the client. . .

Then the EW. . .

is active on Medi-Cal,

• Re-computes the budget with the appropriate maintenance need for the appropriate month.

• Sends a timely NOA• Ensures MEDS has correct information

is an SSI recipient,

• Contacts the LTC facility to inform them to send the MC 171 to SSA. Note: SSA reduces the client’s SSI/SSP to $50 and retains the SSI aid code in MEDS.

• Updates the address and/or other information, as appropriate, if an SSI/QMB MC case is open.

is not active,

• Contacts the LTC facility to advise to apply for MC and/or SSI/SSP as appropriate.

Update # 13--07 Revised: 07/24/13


29.16Property

Treatment of property for long term care applicants is the same as written in the following chapters:

• Chapter 45 e.g., Property Spenddown, including Principe Exemption, and other topics, “Treatment of Property,” page 45-1

• Chapter 46 e.g. burial items, life insurance, reverse mortgages, etc. [“Personal Property,” page 46-1]

• Chapter 47 for Trusts and Annuities e.g. special needs trusts,“Trusts and Annuities [Article 9J],” page 47-1]

• Chapter 48 for Principal Residence “Principal Residence,” page 48-1”

with the following variations:

29.16.1 Do Not Include in the Property Consideration

• The separate property and the share of community property of the spouse at home (who is not included in the LTC MFBU) when the LTC spouse entered LTC prior to September 30, 1989.

Note:The owner of any property is the person who holds legal title to the property.

• California Partnership-approved LTC policies as these are not counted as property. At any given time, the total cumulative benefit payments issued under the California Partnership-approved LTC insurance policy equal the amount of assets that must be excluded in property determination.

• A former home is exempt even if the applicant/recipient is absent from the home for any reason, including a person in LTC, as long as they intend to return. [“General Rules,” page 48-2]

29.16.2 MFBU Determination for Property

All treatment of property rules applicable to other Medi-Cal applicants and recipients also apply to persons who are in long term care.

Revised: 07/24/13 Update # 13--07


[“Treatment of Property,” page 45-1]

An institutionalized spouse/same-sex spouse/RDP, for purposes of establishing the CSRA, shall be in his/her own MFBU at the beginning of a “Continuous Period of Institutionalization” in a nursing facility or medical institution

MFBU Determination: Couples-No Children-Living Together Prior to Entry Into a Long-Term Care Facility.

Family Composition

Separate MFBUs Month Following Entry

Separate MFBUs Month Following 6 Full Calendar Months of LTC Status/B&C

Same MFBU

ABD-MN spouse/same-sex spouse/RDP in LTC Status; MI spouse/same-sex spouse/RDP at home

X

MI spouse/same-sex spouse/RDP in LTC Status; ABD-MN spouse/same-sex spouse/RDP at home

X

ABD-MN spouse/same-sex spouse/RDP in LTC Status; ABD spouse/same-sex spouse/RDP at home who does not apply or is not eligible

X

One ABD-MN spouse/same-sex spouse/RDP in LTC Status; one ABD-MN spouse/same-sex spouse/RDP at home

X

One ABD-MN spouse/same-sex spouse/RDP in LTC Status; MI spouse/same-sex spouse/RDP in LTC Status/B&C; spouse/same-sex spouse/RDPs share a room or are in separate rooms

X

Both spouse/same-sex spouse/RDPs ABD-MN in LTC Status; sharing a room or in separate rooms, both applying and eligible

*X

Both spouse/same-sex spouse/RDPs MI; both in LTC, or one in B&C and one in LTC.

X

*Same MFBU for property evaluations only.

Update # 13--07 Revised: 07/24/13


MFBU Determination (Property): Families—One Parent with Child(ren) Together Prior to Entry into a Long-Term Facility

Family Composition

Separate MFBUs Month Following Entry

Same MFBU

ABD-MN parent in LTC Status; AFDC-MN child(ren) at home X

ABD-MN parent in home; AFDC-MN child in LTC Status X

ABD-MN parent in home; AFDC-MN child in LTC Status but child was not living with parent immediately prior to entering LTC

X

ABD-MN parent in LTC Status; BD-MN child(ren) at home X

ABD-MN parent at home; BD-MN child(ren) in LTC Status X

AFDC-MN parent in LTC Status; BD-MN child(ren) at home X

AFDC-MN parent in LTC Status; AFDC-MN child(ren) at home X

AFDC-MN parent at home; AFDC-MN child(ren) in LTC Status X

AFDC-MN parent at home; BD-MN child(ren) in LTC Status X

Revised: 07/24/13 Update # 13--07


MFBU Determination (Property): Families—Two Parents with Child(ren)—Living Together Prior to Entry into Long-Term Care Facility

Family Composition

Separate MFBUs Month FollowingEntry

Separate MFBUs Month Following 6 Months of LTC Status

Same MFBU

One ABD-MN parent in LTC Status; one AFDC-MN/MI parent at home; any category Medi-Cal Only child(ren) at home

X

ABD-MN parent in home; AFDC-MN/MI parent in LTC Status; any category Medi-Cal Only child(ren) at home

X

One ABD-MN parent in LTC Status; one ABD parent at home who chooses not to apply or is not eligible; child(ren) at home not applying

X

One ABD-MN parent in LTC Status; one ABD-MN parent at home; any category Medi-Cal Only child(ren) at home

X

One AFDC-MN/MI parent in LTC Status; one AFDC-MN/MI parent at home; any category Medi-Cal Only child(ren) at home

X

Both parents (any category Medi-Cal Only) at home; AFDC-MN/MI child(ren) in LTC Status

X

Both parents (any category Medi-Cal only) at home; BD-MN child(ren) in LTC Status

X

.

29.16.3 Voluntary Payment Program - Persons in Long Term Care (LTC) Facilities

Voluntary payment of excess cash property may be made to the Department of Health Care Services (DHCS) Recovery Section to avoid discontinuance. Payment cannot exceed LTC expenditures. This procedure does not limit the beneficiary's right to spend personal property in any way wished.

Note:Real property, sales contracts or deeds of trust cannot be transferred directly to DHCS.DHCS

Voluntary payment of excess property for medical services received is only appropriate when ALL of the following apply:

Update # 13--07 Revised: 07/24/13


• The person is a current Medi-Cal beneficiary.• The person is in LTC.• The property exceeds or will exceed the property limit in the month.• The beneficiary or the person acting on his/her behalf wishes to participate in the

voluntary program.

If a beneficiary, the authorized representative or the LTC facility contacts the EW, stating that the beneficiary wishes to make a voluntary payment, the EW shall:

Step Action

1 Advise the beneficiary, his/her representative or the LTC facility that the process must be completed within 30 days, and that the request to make a voluntary payment should be in writing, if possible.

2 Notify the beneficiary or his/her representative and the LTC facility of the amount which must be paid voluntarily to reduce property within the property limit.

3 Advise the beneficiary, the representative or LTC facility to send the payment to the Department of Health Care Services, Recovery Section - Overpayments Unit. [“Third-Party Liability,” page 3-15]

4 Advise the person sending in the payment to include the following information:

• Beneficiary’s name • Beneficiary’s date of birth• Beneficiary’s Social Security Number • LTC facility name and address • Medi-Cal County ID Number (14 digit) • Name and address of the person acting in beneficiary’s behalf, if any • The amount of excess property to be paid• The reason for excess property • Persons who shall receive the State's acknowledgment of payment (the beneficiary or

representative and the EW).

Upon receipt of the voluntary payment, DHCS will send a letter acknowledging receipt to the beneficiary or person acting on their behalf and will also send a copy to the county department.

When the EW is notified by the Recovery Section that payment has been made, the EW shall recompute the property status of the beneficiary. The effective date of the payment is the date it was sent (postmarked) to the State.

If the beneficiary informs the EW that payment has been made but the acknowledgment letter has not been received, the EW must contact the DHCS Recovery Section.

Revised: 07/24/13 Update # 13--07


If the beneficiary does not make the payment as agreed within 60 days, DHCS will notify the EW an overpayment exists for all months in which the property exceeds the property reserve limits. The case shall be discontinued.

Note:If a beneficiary is discontinued due to excess property, voluntary payment to DHCS cannot be made. Eligibility can only be reestablished in the month the property is brought within the property limit.

29.16.4 LTC Insurance Exemption

“LTC Insurance Exemption,” page 45-12

29.16.5 California Partnership-Approved LTC Insurance Policy or Certificate

29.16.6 Overview

Title 22, California Code of Regulations provides Medi-Cal Asset Protection for Medi-Cal applicants/recipients. The State of California “Department of Health and Services” (DHCS) has formed a partnership with private insurance companies issuing long-term care coverage policies or certificates. These policies and certificates potentially reduce federal and state Medicaid costs and provide Medi-Cal applicants/recipients “lifetime asset protection.” The Partnership’s mission is to provide affordable long-term care insurance protection, so that individuals will not be forced to spend everything they have worked for on long-term care. Additionally, the Partnership protects beneficiaries from having to spend down their assets, should they use their long-term care benefits and need to apply for Medi-Cal later.

29.16.7 Policy

The California Partnership for Long-Term Care guarantees a dollar’s worth of “asset protection” for every dollar amount of benefits paid under a Partnership-approved LTC insurance policy. At any given time, the total cumulative benefit payments made by the LTC insurance policy equals the amount of assets that must be excluded in property determination.

Update # 13--07 Revised: 07/24/13


Note:All benefits paid under the Partnership-approved LTC policies BEFORE or AFTER Medi-Cal application qualify for the Medi-Cal property exemption. The Partnership-approved LTC insurance exemption applies to different types of Medi-Cal application including but not limited to AFDC-MN, ABD-MN, MIA, MIC, or LTC.

29.16.8 Qualification

To qualify for this property exemption, the applicant/recipient must provide verification of the amount of benefits paid under the Partnership-approved LTC policy or certificate. The Medi-Cal LTC insurance exemption is limited to insurance policies or certificates of companies that have been approved by DHCS for participation in the California Partnership for Long-Term Care. The insurance companies that are authorized to sell state-certified LTC insurance policies and certificates are limited to:

• Bankers Life and Casualty• John Hancock Mutual Life• CNA Insurance*• Met Life• Transamerica Occidental Life Insurance*• Genworth Financial (formerly GE Financial)• New York Life Insurance• CalPERS Long-Term Care Program.

Note:At this time, CNA and Transamerica are not marketing a Partnership policy. If a client previously purchased one from either of these two companies, they still retain the same rights and benefits as outlined in their policy.

These companies have agreed to offer high quality policies that must meet stringent requirements set by the Partnership and the State of California. The sale of Partnership-approved LTC insurance policies and certificates began July 29,1994.

29.16.9 Verification

The applicant/recipient must provide a “Service Summary” from the insurance company to the EW. The “Service Summary” verifies that the insurance policy or certificate is Partnership-approved and indicates the amount of benefits paid under the Partnership-approved LTC insurance policy or certificate. The “Service Summary” must be on company letterhead with the company seal and list the

Revised: 07/24/13 Update # 13--07


insured’s name, date of birth, social security number, address, policy number, policy issuance date and the total amount of qualifying benefits that have been paid to date.

Each Partnership-approved LTC insurance policy or certificate holder will receive a “Service Summary” report from the insurance company, at least quarterly when payments have been paid in that quarter. The report will include the cumulative amount of:

• Benefits paid prior to the current reporting period• Benefits paid during the current reporting period• Benefits paid to date• Remaining unpaid benefits

The total cumulative benefits paid to date must be used.

29.16.10 Property Exemption

The Medi-Cal property exemption is equal to the amount of benefits paid under a Partnership-approved LTC insurance policy. This LTC insurance exemption is over and above the property that Medi-Cal normally exempts. The amount paid out by a Partnership-approved LTC insurance policy or certificate is used to reduce the countable real and personal property of the Medi-Cal applicant/recipient. Nonexempt real and personal property equal to the amount of benefits paid on behalf of the Medi-Cal applicant/recipient is exempt.

The exemption continues for as long as the applicant/recipient is alive AND regardless of whether the person is currently in LTC or not.

Note:Individuals who acquire additional property after establishing eligibility for Medi-Cal such as the sale of his/her former principal residence, inheritance, lotto winnings, etc., must have their case reviewed again for the LTC exemption. The amount of additional benefits paid under a Partnership-approved LTC insurance policy must be verified again to determine if the LTC insurance exemption may be increased to exempt all or some of the net market value of newly acquired nonexempt property.

29.16.11 Duration of Property Exemption

The LTC insurance exemption applies as long as the person is alive and is applied regardless of whether he/she is in LTC. It’s a “lifetime asset protection.”

Update # 13--07 Revised: 07/24/13


A person may have had a serious accident or illness which required the type of care provided under a certified LTC insurance policy or certificate. He/she may not have needed to apply for Medi-Cal. At some point later, the individual may require acute hospitalization or some other benefit not covered under his/her LTC insurance and may need to apply for Medi-Cal. In that case, the individual is eligible to receive an LTC insurance exemption equal to the amount of benefits paid out under the Partnership-approved LTC insurance up to the date of application for Medi-Cal. The individual will have to spend down any additional excess property before Medi-Cal eligibility may be established.

29.16.12 Additional Information

For additional information regarding the California Partnership for Long Term Care, please contact the Partnership Office at (916) 323-4253, or visit the web site at www.DHCS.ca.gov/cpltc.

29.16.13 Examples

The following examples clarifies the treatment of property under the Partnership Medi-Cal Asset Protection.

Situation #1

Husband and wife apply for Medi-Cal. The Medi-Cal application is for the husband who is in LTC facility. The couple have an exempt principal residence, a savings account of $90,000, other real property with a net market value of $130,000 (currently meeting utilization requirements,) and stock certificates valued at $125,000. The husband owns a Partnership-approved LTC insurance policy and has provided the “Service Summary” which verifies that $225,000 has been paid out under the policy. After applying the LTC insurance exemption, the applicants’ total nonexempt property is $0.

Note:CSRA is subject to change annually. See Chart Book for MC for current amounts.

Revised: 07/24/13 Update # 13--07

www.dhs.ca.gov/cpltc


Calculation:

Savings Account $90,000

Other Real Property

Net market value $130,000

Less Utilization Exemption -$6,000

Net Countable Other Real Property $124,000

Stock Certificates $125,000

Net Countable Property $339,000

Less payments from a Partnership-approved LTC Insurance policy

$-225,000

Less “community spouse/same-sex spouse/RDP/RDP Resource Allowance” (CSRA) as of 1/1/12

-$113,640

Less Property Limit for One -$2,000

Total Net Nonexempt Property (Total property reserve) $0

Situation #2

Using the previous example, but this time the wife needs LTC while her husband is still alive (in LTC). State law exempts the $225,000 from Medi-Cal eligibility and estate recovery. The $225,000 would remain exempt property if the wife applies for Medi-Cal during her husband’s lifetime.

When the husband applied for Medi-Cal, a CSRA in the amount of $113,640 was allowed. The property in the CSRA was transferred into the wife’s name. An additional $2,000 (the property limit for one) remained in the name of the institutionalized individual. Since the wife was allowed a CSRA of $113,640 at the time of her husband’s approval for Medi-Cal, she would be required to spend down the CSRA and any separate property she had subsequently acquired to bring her nonexempt property to below the $2,000 limit (property limit for one).

Situation #3

The husband purchases a Partnership-approved LTC insurance policy worth $225,000 and the policy pays out $225,000. The husband recovers and never applies for Medi-Cal. The wife then enters LTC and applies for Medi-Cal. The couple has the same property as described in situation #1.

Update # 13--07 Revised: 07/24/13


Question: Can the benefits paid out under the Partnership-approved LTC insurance policy be used to reduce the property limits for the wife?

Answer: Yes. As long as the husband is alive, the couple receives the benefit of the $225,000 LTC insurance exemption since the property of both spouse/same-sex spouse/RDPs is used in the Medi-Cal eligibility determination.

Note:Once her husband dies, the LTC insurance exemption is eliminated. The $225,000 exemption would no longer exist. The wife would not be eligible for Medi-Cal until she spent down all of her nonexempt property below the $2,000 limit.

Situation #4

Using the same example: situation #1, after applying the LTC insurance exemption, the applicant’s total net nonexempt property is $0 and the husband is determined eligible for Medi-Cal. Later the husband transfers ALL of his interest in the property to his wife as her sole AND separate property. While the husband remains in LTC, his wife enters LTC and applies for Medi-Cal.

Question: Is the wife eligible to a Medi-Cal LTC insurance exemption?

Answer: No.The wife now has separate property amounting to $309,000. The husband received benefits under the Partnership-approved policy but has no property to apply the exemption against. All of his interest in the property was transferred to his wife as her sole and separate property. The $225,000 LTC insurance exemption is allowed ONLY for the individual who received services under the policy. In this case, it is the husband who has no property. Spousal impoverishment provisions DO NOT apply since there is no community spouse/same-sex spouse/RDP/RDP. The wife is in a “Medi-Cal Family Budget Unit” (MFBU) of one. All of her separate property ($309,000) is countable and compared against the $2,000 property limit for one.

29.16.14 Community Property Rules for the Treatment of Property for Couples With One Spouse in LTC

California's “division of community property” rules were implemented in order to protect the spouse at home from impoverishment when the other spouse requires costly LTC. However, the Medicare Catastrophic Coverage Act (MCCA) overrides

Revised: 07/24/13 Update # 13--07


any existing provisions for protecting the at-home spouse/same-sex spouse/RDP, and provides a new method, the community spouse/same-sex spouse/RDP/RDP Resource Allowance (CSRA), for preventing “spousal impoverishment.”

MCCA allows states to continue their prior treatment of property until the effective date of the new MCCA provisions. Therefore, the “division of community property” rules will continue to apply to couples (one spouse in LTC, the other spouse at home) who are applying and eligible before 1/1/90, or to those where a spouse was admitted to an LTC facility prior to 9/30/89, regardless of when they apply for Medi-Cal.

Furthermore, LTC patients (and their spouse) receive information about Medi-Cal property and income rules when they are admitted to a nursing facility. Therefore, those who received information about the division of community property will still be subject to those rules.

29.16.15 Overlapping Property Regulations:

1. Certain cases will continue to be subject to the “division of community property” regulations indefinitely.

• Document in the [Maintain Case Comments] window if the division of community property regulations apply to a case.

• Set a case alert to notify the Continuing EW that the case is a “division of community property” case.

2. Some couples will want the new rules to apply, the community spouse/same-sex spouse/RDP/RDP resource allowance (CSRA), even though they are subject to the division of community property regulations based on the date of entry into LTC.

a. To establish eligibility under the new CSRA provisions, the individual must be discharged from the LTC facility for at least one full calendar day.

b. When considering new applications, look at the most recent date of institutionalization if it was preceded by at least one full calendar day of residence outside of a nursing facility or medical institution, and that the individual is expected to remain institutionalized for 30 consecutive days.

Example:Mr. Jones went into a nursing home on 9/1/89 and is in the process of spending down his 1/2 of the community property, which is $30,000. The spouse/same-sex spouse/RDP at home also has her 1/2, $30,000. Under the

Update # 13--07 Revised: 07/24/13


new rules, Mr. Jones would be allowed to give up to $62,580 to the spouse/same-sex spouse/RDP at home, yet he is still subject to the division of community property rules due to his LTC admission date. If he is discharged and returns to his residence for one full calendar day, and is then readmitted to LTC and applies for Medi-Cal on or after the readmission date, he can take advantage of the new CSRA provisions. (He is discharged 1/10/90 and is readmitted 1/12/90, then applies for Medi-Cal on or after 1/12/90.) If otherwise eligible, he is eligible for January as the EW considers the most recent date of admission.

Note:If the discharge date is 1/10/90 and the date of readmission is 1/11/90, there is no break in institutionalization and the old property rules will still apply.

3. Transfers from one nursing home or medical institution to another do not affect the “Continuous Period of Institutionalization”.

4. Once the CSRA has been established and the case is in continuing status, the couple's property is recombined only if the institutionalized spouse/same-sex spouse/RDP returns to the home for a full calendar month.

5. The law regarding transfers of nonexempt property has changed with transfers occurring on or after 1/1/90. Therefore, an LTC spouse/same-sex spouse/RDP who has an automatic division or an inter spousal agreement dividing the couple's community property (for whom the CSRA does not apply) can transfer his/her remaining 1/2 to the at-home spouse/same-sex spouse/RDP. As long as the transfer of the LTC spouse/same-sex spouse/RDP's 1/2 occurs on or after 1/1/90 and it is transferred to the at-home spouse/same-sex spouse/RDP, this would not be a disqualifying transfer. If all other eligibility criteria are met, he/she would be eligible.

Chart - Which Property Rules Apply?

Property rules for couples, one spouse/same-sex spouse/RDP in LTC the other spouse/same-sex spouse/RDP at home.

Situation Property Rules

LTC spouse/same-sex spouse/RDP on Medi-Cal before 9/30/89.

Continue to use Division of Community Property rules.

Spouse/rdp was admitted to LTC before 9/30/89, regardless of when they eventually apply.

Use Division of Community Property rules.

Revised: 07/24/13 Update # 13--07


EWs MUST NEVER, UNDER ANY CIRCUMSTANCES, ADVISE ANYONE TO LEAVE A MEDICAL FACILITY IN ORDER TO QUALIFY UNDER THE MCCA PROVISIONS.

(This could result in grave medical consequences. There is also the possibility that the EW could be held personally liable for giving such advice.)

29.16.16 Community Spouse/Same-Sex Spouse/RDP/RDP Resource Allowance (CSRA) [Section 50490.5]

The following CSRA rules apply to persons in LTC with a community spouse/same-sex spouse/RDP/RDP. Once the spouse/same-sex spouse/RDP leaves the LTC facility, the CSRA rules no longer apply and property must be re-evaluated. Refer to “Personal Property,” page 46-1]

CSRA rules also apply to Registered Domestic Partners. “Registered Domestic Partners and Same Sex Marriage [Refer to “Registered Domestic Partners (RDP) /Same Sex Spouse in Long Term Care,” page 29-23],” page 29-5]

29.16.17 Definitions

• Community spouse/same-sex spouse/RDP/RDP - Refer to [“Community Spouse [50031.5],” page 1-6]

• Institutionalized spouse/same-sex spouse/RDP - Refer to [“Institutionalized Spouse [50046.5],” page 1-11] Note: A physician's statement is not required when, at the time of the eligibility determination, the individual has already been institutionalized for at least 30 consecutive days. The EW must verify this (e.g., phone the nursing home) and document in the [Maintain Case Comments] window.

• Continuous Period of Institutionalization

Spouse/rdp was admitted to LTC, applied and was determined eligible for Medi-Cal between 9/30/89 and 12/31/89.

Use Division of Community Property rules.

Spouse/rdp is admitted to LTC on or after 9/30/89 and applies on or after 1/1/90.

Determine community spouse/same-sex spouse/RDP/RDP Resource Allowance.

Update # 13--07 Revised: 07/24/13


A “Continuous Period of Institutionalization” is 30 or more consecutive days of inpatient medical care in a medical institution or nursing facility. A “Continuous Period of Institutionalization” begins when an institutionalized person is expected to remain an inpatient for 30 consecutive days and ends when the institutionalized person is no longer an inpatient for a full calendar month.

• Persons are considered “expected to remain,” even though they do not actually remain in the facility as long as the physician determined at the beginning of the stay that he/she was “expected to remain” for 30 consecutive days.

• Only the patient's physician can make the 30 day determination.

• As long as the date of the physician's determination that the person is “expected to remain” precedes the date of discharge, the applicant shall be considered an “institutionalized spouse/same-sex spouse/RDP.”

• Once eligibility has been established, the continuous period ends only when the institutionalized person is no longer an inpatient for a full calendar month.

The “Continuous Period of Institutionalization” determination is only used in regard to couples covered by the spousal impoverishment rules. The “Continuous Period of Institutionalization” determines the effective date of CSRA and the $35 LTC Maintenance Need.

Note:For a singe person in LTC, a “Continuous Period of Institutionalization is not required. “LTC Status” determines when the $35 LTC Maintenance Need is used. Refer to [Refer to “Long Term Care Status [50056],” page 29-4 for additional information.

29.16.18 Calculation of the CSRA

General

The CSRA is calculated by combining the net nonexempt separate and community property, belonging to either or both the institutionalized and community spouse/same-sex spouse/RDP/RDP:

• As of the date the institutionalized spouse/same-sex spouse/RDP applies or re-applies for Medi-Cal (new applicants or if there is a break in aid and client re-applies), OR

Revised: 07/24/13 Update # 13--07


Note:The CSRA can be applied to 3-month retro Medi-Cal as long as the couple meets the definitions of community spouse/same-sex spouse/RDP and institutionalized spouse/same-sex spouse/RDP in the retroactive months; and, their combined net nonexempt property does not exceed the CSRA, plus the property limit for one person, for at least one day in each of the retroactive months.

• As of the date a spouse/same-sex spouse/RDP is institutionalized and expected to remain 30 consecutive days, for continuing beneficiaries.

The community spouse/same-sex spouse/RDP must only be able to keep the CSRA, regardless of state community and separate property laws.

Maximum CSRA

The maximum CSRA is the greatest of:

• The CSRA amount issued by the state each year, which is adjusted annually by the Consumer Price Index, or

• An amount established by a court order, or

• An amount awarded through a fair hearing.

Chart Value

Refer to Chart Book [Refer to “Community Spouse Resource Allowance (CSRA),” page 5-2.

Court Order

The CSRA can be an amount established by a court order as of the date of, or specified in the court order if the order is “against the spouse/same-sex spouse/RDP in long-term care” for the support of the community spouse/same-sex spouse/RDP or family member.

• If the maximum CSRA is established by a court order, use the value of the property as of the date of the order. Disregard any increases in the value of such property when determining eligibility.

Update # 13--07 Revised: 07/24/13


• Do not use the court ordered amount if the net market value of the property has since decreased and is now worth less than the other two CSRA options (it is less than the maximum CSRA or the fair hearing amount).

• An application shall remain pending if a court order for support is being sought and the couple provides verification that an order is being sought.

Fair Hearing

A fair hearing Administrative Law Judge (ALJ) will only increase the CSRA amount when additional property is needed to produce income up to the Minimum Monthly Maintenance Need Allowance (MMMNA). When calculating the necessary CSRA increase, the ALJ must first consider the total income available to the community spouse/same-sex spouse/RDP prior to determining the amount of property adequate to provide the difference between the MMMNA and all income available to the community spouse/same-sex spouse/RDP. Total income available includes the net non-exempt income of the institutionalized spouse/same-sex spouse/RDP that can be allocated to the community spouse/same-sex spouse/RDP and the community spouse/same-sex spouse/RDP’s own separate income.

Example:

The 2006 CSRA amount is $99,540 and the MMMNA is $2,489. Assume the couple has $350,000 in property and filed for a State hearing to increase the CSRA amount to $350,000 in order for the institutionalized spouse/same-sex spouse/RDP to qualify for Medi-Cal. The institutionalized spouse/same-sex spouse/RDP has net non-exempt income of $1400 ($35 LTC maintenance need already deducted) that can be allocated to the community spouse/same-sex spouse/RDP. The community spouse/same-sex spouse/RDP receives $1000 per month in social security income. The couple who sought to increase the CSRA to $350,000 would have to establish that investing $350,000 would generate $89 or less (since MMMNA is $2489 - 2400 [community spouse/same-sex spouse/RDP’s own income $1000 plus allocation from institutionalized spouse/same-sex spouse/RDP of $1400].) Otherwise, the couple’s request to increase the CSRA would be denied.

Total Property

In order for the institutionalized spouse/same-sex spouse/RDP to be eligible, the couple's net nonexempt property must not exceed the maximum CSRA amount plus the property limit for one.

• If their total property is less than or equal to the maximum CSRA, then that amount is the CSRA.

Revised: 07/24/13 Update # 13--07


• If their total property exceeds the maximum CSRA, then:

• The community spouse/same-sex spouse/RDP receives the maximum CSRA, and

• The remaining excess is included in the property reserve of the institutionalized spouse/same-sex spouse/RDP.

• The institutionalized spouse/same-sex spouse/RDP is not eligible until his/her property is less than or equal to the property reserve for one.

A CSRA Approval or Denial NOA must be issued which explains what property was counted, how the CSRA was determined, and defines the transfer period.

29.16.19 Transfer of the CSRA to the Community Spouse/Same-Sex Spouse/RDP/RDP

Rule

The institutionalized spouse/same-sex spouse/RDP must actually transfer into the community spouse/same-sex spouse/RDP's name, all or any portion of the CSRA which:

• Is not already the separate property of the community spouse/same-sex spouse/RDP, or

• Community property which is not already held solely in the name of the community spouse/same-sex spouse/RDP.

Transfer Period

The transfer period begins on the date of the initial determination of eligibility and continues through whichever comes first:

• The end of the month in which the transfer(s) occur, OR

• The end of the month in which the 90 days ends, OR

• The transfer period may be extended to the end of the month in which a court enters an order which is necessary to accomplish the transfer. (A probate court order may be needed to accomplish the transfer.)

Update # 13--07 Revised: 07/24/13


The property which is included in the CSRA shall not be considered available to the institutionalized spouse/same-sex spouse/RDP during the transfer period.

Note:At the initial determination of eligibility i.e., Intake, the EW must create a case alert in CalWIN for the 90-day follow up to ensure the transfer of property has occurred.

At the end of the transfer period, all of the net nonexempt property still remaining in the name of the institutionalized spouse/same-sex spouse/RDP, or property which is still in the name of both spouse/same-sex spouse/RDPs, shall be considered 100% available to the institutionalized spouse/same-sex spouse/RDP and included in the property reserve.

Note:Discontinue the institutionalized spouse/same-sex spouse/RDP with a proper 10-day NOA if there is excess property, unless there is undue hardship.

29.16.20 Adding to the CSRA

Once the separate CSRA has been established at application, the community spouse/same-sex spouse/RDP can continue to add to the CSRA with no impact to the institutionalized spouse/same-sex spouse/RDP. New nonexempt property acquired by the community spouse/same-sex spouse/RDP and held in his/her name only is not to be considered available to the institutionalized spouse/same-sex spouse/RDP.

Exception:If there is a break in aid and the institutionalized spouse/same-sex spouse/RDP reapplies for Medi-Cal, then a new CSRA determination would include all of the couple’s property (including the new non-exempt property acquired by the community spouse/same-sex spouse/RDP) as of the date of the re-application month.

29.16.21 Undue Hardship for Establishing CSRA

“Undue hardship” may exist for purposes of establishing the CSRA. When establishing eligibility for the institutionalized spouse/same-sex spouse/RDP, if property is considered to be legally unavailable without the signature of the community spouse/same-sex spouse/RDP, then undue hardship exists.

Revised: 07/24/13 Update # 13--07


Important:

Evidence is required; e.g., statement from financial institution. Completion of affidavit or CSF 2 alone is not sufficient.

Undue hardship exists when:

• The institutionalized spouse/same-sex spouse/RDP is otherwise eligible except for the excess property, AND

• He/she is unable to obtain medical care without Medi-Cal, AND

• The whereabouts of the community spouse/same-sex spouse/RDP is unknown, OR

• There has been a break in marital ties and the community spouse/same-sex spouse/RDP refuses to cooperate. (There must be some evidence of refusal to cooperate; for example, copies of letters written to or from the community spouse/same-sex spouse/RDP.)

29.16.22 Married v Separated for Purposes of Applying CSRA

For purposes of applying the CSRA and community spouse/same-sex spouse/RDP income only, a couple is considered to be married until the marriage is dissolved or annulled. A legal separation means that the two spouse/same-sex spouse/RDPs are still married and entitled to the CSRA plus the property limit for one. In addition, the LTC spouse/same-sex spouse/RDP may still provide the income allocation to the community spouse/same-sex spouse/RDP. However, the EW must use the criteria listed above to document when “undue hardship” exists.

Update # 13--07 Revised: 07/24/13


29.16.23 EW Actions in Deeming CSRA

When determining the CSRA the EW shall:

Step Action

1. Verify the “Continuous Period of Institutionalization”.

• Obtain the physician's statement.

• The statement must be signed and dated and indicate the person is “expected to remain” at least 30 consecutive days.

EXCEPTION: Physician's statement is NOT required when, at the time of the eligibility determination, the individual has already been institutionalized for at least 30 consecutive days. The EW must verify this (e.g., phone the nursing home), and carefully document in the [Maintain Case Comments] window.

2. Verify property and calculate the CSRA and explain it to the applicant and spouse/same-sex spouse/RDP, advising them that the property must be transferred to the community spouse/same-sex spouse/RDP within 90 days.

3. Set a case alert in CalWIN and document in the [Maintain Case Comments] window indicating the end of the 90th day for follow-up.

4. Send a specific CSRA Property NOA whenever Medi-Cal is:

• Approved, or

• Denied due to net nonexempt property in excess of the CSRA plus the property limit for one, or

• Discontinued because the transfer has not occurred by the end of the transfer period, and the beneficiary has not submitted evidence of undue hardship.

29.16.24 CRSA Examples

Example 1: CSRA Includes Separate Property of Community Spouse/Same-Sex Spouse/RDP

Betty Johnson is applying for Medi-Cal on 2/1/06 on behalf of her husband. He has been in a nursing home since 10/16/05. The couple had a total of $132,000 in assets at the time he went into a nursing home. Of this amount, $80,800 is Mrs. Johnson's inheritance from her mother, which she has always maintained separately. To date, the couple has used $31,200 (for nursing home care and a new car).

Revised: 07/24/13 Update # 13--07


All available net nonexempt property on 2/1/06 is combined:

$80,800 Savings (separate property of Mrs. Johnson)

+ 20,000 Community property

$100,800 Total NET NONEXEMPT PROPERTY

- 99,540 Maximum CSRA, effective 1/1/06

$1,260 (Under property limit for one, NO excess property)

Mr. Johnson is eligible and the couple has 90 days to remove his name from $18,740. ($99,540 CSRA - $80,800 which is already in Betty's name.)

Example 2: Court Order

The Stuarts divided their property pursuant to a court order for the support of Mr. Stuart when Mrs. Stuart went into a nursing home due to Alzheimer's disease on 1/10/04. The court order states that each is to receive $100,000 of their community property plus their own separate property. Mr. Stuart had $50,000 in IRAs which he purchased prior to their marriage. Mrs. Stuart has $10,000 from a prior marriage, maintained in a separate account. On 3/15/06 he is applying for Medi-Cal on behalf of his wife as her property is now down to $2,000. Mr. Stuart still has his separate property as awarded by the court, ($100,000 + $50,000 in IRAs) and he has an additional $10,000 which he has accrued on his portion of the property through investment. Mrs. Stuart is eligible. In this example the maximum CSRA is the court-ordered amount as of the date of the court order, regardless of increases in the market value of the property awarded. The additional property was accrued as the result of investment of property originally awarded by the court, and therefore it is disregarded. It is not included in the determination of the CSRA nor the property reserve for the institutionalized spouse/same-sex spouse/RDP.

Example 3: Undue Hardship Exists

Mrs. Groves is admitted to a nursing home on 7/1/06 and her sister applies for Medi-Cal on her behalf on 7/15/06. Mrs. Groves had $10,000 and used $8,000 to pay off the mortgage of her exempt home. IEVS reveals that there is interest income from a 20 year C.D. which is in the name of Mr. and Mrs. Groves. Mr. Groves has been absent for four years and she doesn't know where he is now. The bank provides verification that the C.D. cannot be liquidated without both signatures.

Update # 13--07 Revised: 07/24/13


Mrs. Groves is eligible as there has been a break in marital ties. There is undue hardship as Mr. Groves' whereabouts are unknown.

29.16.25 Transfers of Property on or After 1/1/90 [50408, 50411]

29.16.26 Institutionalized Persons

Effective 1/1/90, only transfers of assets made by institutionalized persons may result in ineligibility. If found ineligible due to a disqualifying transfer, the institutionalized person is only ineligible for nursing facility level of care. He/she will receive a “restricted” card which covers other types of medical services.

• Effective 1/1/90, the “look back” period for applicants who are in LTC is anytime during the 30 months immediately preceding the application.

• For continuing beneficiaries who later enter a nursing home, look back 30 months from the date of institutionalization to see if a disqualifying transfer has occurred.

• Effective 1/1/90, a period of ineligibility (POI) cannot exceed 30 months.

• Effective 1/1/97, an individual who knowingly and willfully makes a disqualifying transfer on or after 1/1/97 which results in a POI may be subject to criminal penalties.

29.16.27 General

EWs must carefully document in [Maintain Case Comments] window all of the circumstances pertaining to a transfer and why. If the EW is not establishing a period of ineligibility for LTC services, then the reason must be clearly documented (e.g., not in LTC, or “non-disqualifying transfer because...”).

Sometimes the transferee may be willing to give back the asset.

If it appears that a person in LTC is being exploited and there is no other relative to contact, the EW should make a referral to Adult Protective Services (APS) and contact the LTC Ombudsman. Refer to [Refer to “Inquiries and Resources,” page 3-1 for phone number. Occasionally, the Public Guardian will handle an LTC case

Revised: 07/24/13 Update # 13--07


29.16.28 Non-Disqualifying Transfers

The following transfers, before or after admission to an LTC facility, DO NOT result in a period of ineligibility for LTC services:

Exempt Property

A transfer of exempt property does NOT result in ineligibility for LTC services.

CSRA

The transfer of the community spouse/same-sex spouse/RDP Resource Allowance (CSRA) to the community spouse/same-sex spouse/RDP.

Other Reasons

It must always be presumed that property transferred without adequate consideration was for the purpose of establishing eligibility for Medi-Cal. The evidences or situations (e.g., sequence of events) must be sufficient and convincing enough to prove that the above assumption is not true. If the applicant/beneficiary can satisfactorily show that the nonexempt resources were transferred exclusively for a purpose other than to qualify for Medi-Cal, there is no ineligibility for LTC services.

Example:Adequate resources were left available at the time of transfer for the support and medical care of the LTC individual considering his/her age, health, life expectancy and ability to understand extent of resources.

Intent to Get Full Value

If the client can establish that he/she intended to dispose of the assets for fair market value or other equally valuable consideration, then no period of ineligibility for LTC services shall be imposed. Additionally, there is no penalty if full value was received when the asset was transferred.

Certain Transfers to spouse/same-sex spouse/RDP or Child

There is no period of ineligibility for LTC services if nonexempt property was transferred to:

Update # 13--07 Revised: 07/24/13


• The community spouse/same-sex spouse/RDP (or, as of the date of the transfer to another for the sole benefit of the community spouse/same-sex spouse/RDP), or

• A blind, or permanently or totally disabled son or daughter of the institutionalized person (verify), or

• Prior to the admission to an LTC facility, to the spouse/same-sex spouse/RDP (or as of the date of the transfer, to another for the sole benefit of the spouse/same-sex spouse/RDP), provided that the spouse/same-sex spouse/RDP did not transfer the property to another person for less than its fair market value.

Principal Residence

If the resource is a nonexempt principal residence, no period of ineligibility is assessed if the former home was transferred to:

• A spouse/same-sex spouse/RDP, or

• A son or daughter under 21, or

• A son or daughter who is blind, totally or permanently disabled, or

• A sibling who has equity interest and who lived in the home for one year immediately preceding the institutionalization of the individual, or

• An adult son/daughter who lived in the home for two years immediately preceding the date of institutionalization of the individual and who provided care which permitted him/her to remain in the home, rather than going to a nursing home.

Revised: 07/24/13 Update # 13--07


Undue Hardship

No period of ineligibility for LTC services results from a transfer of property if the denial would cause an UNDUE HARDSHIP. Undue Hardship, for purposes of whether or not to impose a period of ineligibility for LTC services exists when the following criteria are met:

IF the person is... AND... THEN...

Otherwise eligible for Medi-Cal and is unable to obtain medical care without Medi-Cal

The person was incompetent at the time of the transfer (as evidenced by his/her physician)

Undue Hardship exists.


The person was competent but unduly influenced to transfer property



All of the following conditions exist:

• The person is being threatened with eviction from the LTC facility, and

• Eviction would increase his/her medical problems or decrease physical health (doctor's statement required), and

• Satisfying proof is provided which establishes that the person who received the transferred property no longer has it and cannot obtain it; and, he/she does not have sufficient funds to pay for institutionalized care (both past due and for the remaining period of ineligibility).


Hospice Care

An applicant for or beneficiary of a hospice program must not be made ineligible for nursing facility level of care due to a disqualifying transfer, even though he/she may be receiving hospice program benefits in a nursing facility. That means, POI rules do not apply for individuals in a hospice program.

Note:A terminally ill person may choose to receive hospice care instead of treatment directed at curing the illness. The patient signs a contract directly with the hospice provider and the information is immediately sent to the State. The State changes the person's MEDS record to restricted so that the card states

Update # 13--07 Revised: 07/24/13


“Primary diagnosis care limited to hospice svs.” The special card covers additional hospice related services, while the patient is foregoing aggressive medical treatment.

29.16.29 Disqualifying Transfers

A disqualifying transfer exists when:

• The EW cannot establish a basis for exempting the transfer, or• When there is no basis for undue hardship, or• The LTC individual has given the property as a gift, or• The LTC individual did not receive fair market value (FMV) or other equally

valuable consideration for the transferred property.

Once a disqualifying transfer exists, the EW must:

• Determine the period of ineligibility (POI) for LTC services,• Determine if there is a resulting overpayment, and• Send the POI documentation to the Medi-Cal Program Coordinator for review.

The POI information will then be referred to the Department of Health Services (DHCS) for review and referral to the federal authorities.

29.16.30 Period of Ineligibility (POI)

A period of ineligibility for LTC services begins in the month in which the property was transferred.

General Rule

• It does not start and stop when an individual goes in and out of a nursing home.• The period of ineligibility stops if the property is transferred back or is reduced if

a portion of the property is transferred back.

CalWIN and MC 176 PI

Properties that meet the criteria must be reviewed on the [Display Liquid Asset Summary] window. The EW enters the type of disposition. CalWIN automatically computes the POI based on the information entered in the [Collect Disposition Detail] window. POI results can be viewed in the [Display Period of Ineligibility - Resource] window in the Wrap Up Subsystem. The “Period of Ineligibility Worksheet” (MC 176 PI) is used.

Revised: 07/24/13 Update # 13--07


The MC 176 PI is completed as follows:

Section Action

A. Determine if the property transferred was exempt at the time of transfer.

• If yes, no POI exists. No further action is needed.• If no, continue to Step B.

B. Determine the uncompensated value of the transferred property:

• Establish the Net Market Value of the nonexempt property transferred, and• Subtract the amount received (if any), after deducting encumbrances and closing

costs.

C. Determine if the uncompensated value of the transferred property (from Step B) is less than the Average Private Pay Rate (APPR). (Use the APPR for whichever is most recent, the date of application or the date of institutionalization.)

• If yes, no POI exists. No further action is needed.• If no, continue to Step D.

D. Determine if there is a potential POI:

• Divide the uncompensated value (from Step B) by the APPR,• Round down to the nearest whole number (Total should be no more than 30), and• Subtract the number of months since the date of transfer (include the month of

transfer, but exclude the month of application).

If the total is less than or equal to zero, no POI exists. No further action is needed.

If the total is more than zero, continue to Step E.

E. Determine if the institutionalized individual was within the property limits at the time of transfer:

• Determine the value of all other nonexempt resources owned by the institutionalized person (and spouse/same-sex spouse/RDP) at the time of the transfer.

• Add the uncompensated value of property transferred (from Step B).• Subtract the property limit for one (and the CSRA if there is a community

spouse/same-sex spouse/RDP) which was in effect at the time of the transfer. • The remainder is the uncompensated value transferred to establish eligibility.

If the total is less than or equal to zero, no POI exists. No further action is needed.

If the total is more than zero, continue to Step F.

Update # 13--07 Revised: 07/24/13


Average Private Pay Rate (APPR)

Use the statewide Average Private Pay Rate (APPR) for nursing facility level of care according to whichever is most recent: [“Statewide Average Private Pay Rate (APPR),” page 5-4]

• The date of application, or• The date of institutionalization.

The APPR amount changes annually; however, Periods of Ineligibility (POI) are NOT recalculated each year.

Period of Ineligibility (POI) Referral Procedures

F. Determine the number of months remaining for which the person is ineligible for nursing home level of care.

• Divide the uncompensated value of property transferred to establish eligibility (Step E) by the APPR.

• Round down to the nearest whole number. (Total should be no more than 30.)• Subtract the number of months since the date of transfer.

For applicants, include the month of transfer, but exclude the month of application. For beneficiaries, include the month of transfer, but exclude the current month.

• The total is the number of months of ineligibility remaining.• Determine the date on which the POI will expire.

G. For Beneficiaries Only:

If Medi-Cal for Nursing Facility Level of Care was received in a month throughout which the POI should have existed, there is an overpayment for nursing facility level of care only. Complete an overpayment referral.

Section Action

Revised: 07/24/13 Update # 13--07


After the EW has determined that a POI exists, a POI referral must be completed.

Stage Who Action

1 EW Send a POI referral to the Medi-Cal Program Coordinator, which includes: - Documentation of the disqualifying transfer

- Screen prints of [Collect Disposition Detail], [Collect Sanction/POI/Penalty Detail], and [Display Period of Ineligibility]

- “Period of Ineligibility for Nursing Facility Level of Care Worksheet” (MC 176 PI)

- Screen print of MEDS INQM.

At this point, the EW MUST NOT:

• Authorize the case in CalWIN• Enter the “950” restriction code in MEDS• Issue a NOA informing the beneficiary of the reduction in Medi-Cal

benefits

NOTE: During the POI referral process, the EW must NOT impose the POI. Since CalWIN automatically sends the restriction code “950” on MEDS when POI exists, the EW must not authorize the case in CalWIN until the final POI decision is received from the State.

2 MC Program Coordinator

Review the POI referral packet and forwards the information to the Department of Health Services (DHCS) if criteria are met.

3 DHCS Review the POI referral to review for accuracy and penalty criteria.

Notify the Medi-Cal Program Coordinator of:

• Any modifications required in the POI determination, and• Whether or not the NOA for restricted benefits may be issued.

4 MC Program Coordinator

Forward this information to the EW.

Update # 13--07 Revised: 07/24/13


29.16.31 Period of Ineligibility (POI) Example

Walter Brooks, age 73, entered a nursing home on December 11, 2008. He applies for Medi-Cal on January 8, 2009.

He and his spouse/same-sex spouse/RDP (who is not applying for Medi-Cal) currently have $78,000 net nonexempt community property and no separate property. In November 2008, they gifted $130,000 to their grandson.

Note:The 2009 CSRA limit ($109,560) and the 2009 APPR limit is ($5,698). EWs must use the CSRA which was in effect at the time of the application.

The EW has determined that Walter is eligible for Medi-Cal but, due to disqualifying transfer of property (i.e., gifted $130,000 to grandson,) has a 23-month period of ineligibility ($78,000 plus $130, 000 = $208,000 total property; less CSRA $95,100 and property limit for one $2,000 = $110,900 uncompensated value; divide by

5 EW • Review the POI period in CalWIN and authorizes the case if the POI period matches the State’s POI decision.

• Issue the appropriate NOA to grant restricted services or change the level of Medi-Cal to restricted services for the institutionalized individual. Note: A 10-day NOA is required for continuing recipients.

• Review MEDS INQM to ensure that the restriction code “950” is in the [RESTRICT] field. Otherwise, submit an SC 1296 to the MEDS Terminal Operator (MTO) to restrict the level of benefits on MEDS via an EW30 (Change) transaction.

Reminder: For continuing recipients, complete an overpayment referral if a potential overpayment exists.

6 MTO Generate an EW 30 (Change) transaction to add the’950’ restriction code for the affected POI months (for intake applicants) or future MEDS month (for recipients) in the [RESTRICT] field.

7 DHCS Forward the POI documentation to the appropriate federal authorities, after the period of time for requesting an appeal has passed.

NOTE: If an Appeal or re-hearing is requested, DHCS will not forward the case until the results are known.

8 Federal Authorities

Determine whether or not to prosecute specific individuals.

Stage Who Action

Revised: 07/24/13 Update # 13--07


APPR $4,812 = 23 months) for nursing facility level-of-care which will expire on 09/30/06. Prior to taking action to reduce the level of Medi-Cal benefits, the EW refers the case to the Medi-Cal Program Coordinator for a final POI decision.

29.16.32 Consecutive Transfers

Each transfer is treated separately beginning with the month of transfer as long as it meets the criteria stated in the note below. However, periods of ineligibility may run concurrently, reducing the total number of months of ineligibility for nursing home level of care.

Note:If the date of transfer, recipient of the property and account number/source are the same, it is considered one transaction of transfer. If at least one variable is different, then each transfer is considered separately.

If consecutive transfers are claimed, EWs must be careful to verify the date that each transfer occurred; for example, view bank statements.

Example:In 2006, the Average Private Pay Rate is $5,031. Therefore, if an individual makes a disqualifying transfer of $50,530 in one lump sum, it will result in ten months of ineligibility. However, if the same amount is transferred in consecutive months, the period of ineligibility is reduced to four months:

Amount and Date of Transfer

Ineligible Month(s)

4/06 5/06 6/06 7/06

$20,164 (4/1/06) X X X X

$15,193 (5/1/06) X X X

$10,082 (6/1/06) X X

$5,091 (7/1/06) X

TOTAL $50,530 transferred.

Update # 13--07 Revised: 07/24/13


Example:consecutive months, the period of ineligibility is reduced to four months:

Amount and Date of Transfer

Ineligible Month(s)

4/06 5/06 6/06 7/06

$20,164 (4/1/06) X X X X

$15,193 (5/1/06) X X X

$10,082 (6/1/06) X X

$5,091 (7/1/06) X

TOTAL $50,530 transferred.

29.16.33 MEDS Restriction Coding

General

Institutionalized persons who have made a disqualifying transfer are only ineligible for nursing facility level of care. They will receive a restricted Medi-Cal card with a long-term care restriction message on the MOPI screen.

CalWIN automatically sends the restriction code “950” to MEDS via interface (entries made in the Display Sanction Summary window) when POI exists in CalWIN. If (for whatever reason) the restriction code was not successfully posted on MEDS, the EW must complete an SC 1296 requesting an EW 30 (Change) transaction to add the’950’ restriction code to the [RESTRICT] field in the affected months (for intake) or future MEDS month (for continuing recipients.)

Once the POI period is over, CalWIN will interface with MEDS to “remove the LTC restriction code” at the end of the period of ineligibility.

Reminder:Prior to authorizing restricted coding on MEDS, the EW must have:

• Completed the POI Referral to the Medi-Cal Program Coordinator, and• Received instructions from the State via the Medi-Cal Program Coordinator

to proceed with the POI.

Revised: 07/24/13 Update # 13--07


29.16.34 Division of Community Property

Division of community property rules were established as of 9/1/85 to protect the spouse/same-sex spouse/RDP at home from impoverishment when the other spouse/same-sex spouse/RDP enters long-term care. An automatic division of all nonexempt community property takes place as of the date one spouse/same-sex spouse/RDP enters any medical facility.

DIVISION OF COMMUNITY PROPERTY SHALL BE APPLIED TO CASES WHEN:

• The spouse/same-sex spouse/RDP was admitted to LTC before 9/30/89, regardless of when they actually apply.

• The LTC spouse/same-sex spouse/RDP is already on Medi-Cal prior to 9/30/89, the division of community property rules continue to apply.

• The spouse/same-sex spouse/RDP was admitted to LTC, applied for Medi-Cal, and was determined eligible for Medi-Cal between 9/30/89 and 12/31/89.

Note:Document the detailed information regarding the division of community property in the [Maintain Case Comments] window.

29.16.35 Separate Property [50075, 50403]

Separate property means any item that is considered separate property under California Property Law. Generally, separate property is:

• Property acquired by either spouse/same-sex spouse/RDP prior to marriage.

• Property held as separate property in a separate property state.

• Property acquired by either spouse/same-sex spouse/RDP separately during the marriage as a gift or an inheritance.

• Property acquired during marriage if purchased with funds which are the separate property of the owner, e.g.:

• Funds received from the sale of separate property.• Funds received by gift or inheritance.

Update # 13--07 Revised: 07/24/13


29.16.36 Community Property [50072, 50403]

Community property, real or personal, is acquired by the husband and/or wife during the marriage (unless acquired as separate property). Included are:

• Property purchased with community funds (may include earnings of the spouse/same-sex spouse/RDPs while married and living together).

• Income derived from community property.

• Funds received from the sale of community property.

Note:Property purchased with funds which cannot be identified as separate shall be presumed to be community property, unless rebutted by documentation which shows the property to be separate.

29.16.37 Automatic Division Rules

Important:

These rules do not apply to couples when one spouse/same-sex spouse/RDP entered LTC on or after 9/30/89 and applies on or after 1/1/90.

The nonexempt community property (both real and personal) of a married couple, is automatically divided into equal shares as of the date one spouse/same-sex spouse/RDP enters any medical (either acute or non-acute care) facility.

Note:Evidence can be provided by the applicant/beneficiary to rebut (oppose) the automatic division rule, e.g., proof of separate ownership prior to marriage, inheritance, etc.

• The division will only affect the eligibility of those spouse/same-sex spouse/RDPs who are in their own MFBUs. As long as spouse/same-sex spouse/RDPs remain in the same MFBU, all their separate and community property must be taken into account in any Medi-Cal eligibility determination.

• Individual members of a couple with one spouse/same-sex spouse/RDP residing in a medical facility will have their property eligibility determined for Medi-Cal according to the automatic division of property, unless they are both MI or AFDC-MN.

Revised: 07/24/13 Update # 13--07


• Any part of this separate share of property which is made available to the other spouse/same-sex spouse/RDP must be considered in determining each spouse/same-sex spouse/RDP's eligibility.

• The division of community property upon entry to medical facility is automatic and meets the requirements of adequate consideration. The transfer of nonexempt separate property must be evaluated.

• If one spouse/same-sex spouse/RDP's share of property, and their own separate property exceeds the property limit, any resulting spenddown must be done solely for that spouse/same-sex spouse/RDP's benefit. This includes all medical expenses.

Important:

There is no “own benefit” requirement after 1/1/90, although a period of ineligibility may result if property has been inappropriately transferred. The LTC spouse/same-sex spouse/RDP may only spenddown property up to his/her “proportionate share” of an expense. - EXAMPLE: A spouse/same-sex spouse/RDP in LTC owns 1/2 of the interest in his home with his spouse/same-sex spouse/RDP. Therefore, he may opt to spenddown his excess property by paying up to 1/2 of the remaining mortgage. Or, he may choose to pay up to 1/2 of the balance owing on an exempt car that he owns jointly with his spouse/same-sex spouse/RDP.

• As soon as the spouse/same-sex spouse/RDP is discharged from the medical facility to return home, “separate property” reverts back to community property effective the first day of the following month.

• A transfer from one medical facility to another does not affect this division of property.

• The LTC spouse/same-sex spouse/RDP shall receive 1/2 of any interest income which accumulates on the at home spouse/same-sex spouse/RDP's share of community property which is subject to the “automatic division”, unless there is an inter spousal agreement which has transmuted the at-home spouse/same-sex spouse/RDP's community property to his/her separate property. Refer to [Refer to “Limitations of the Inter spousal Agreement [50408, 50409],” page 29-71.

Update # 13--07 Revised: 07/24/13


29.16.38 Inter spousal Agreements

An inter spousal agreement is still necessary in order to separate the community property of couples who are informally separated due to any circumstances other than admission to a medical facility.

If a couple separated and completed an valid inter spousal agreement prior to an admission to a medical facility, the separation of property is effective as of the date of the agreement, not the admission.

An inter spousal agreement is only effective when spouse/same-sex spouse/RDPs are in separate MFBUs.

Inter spousal Agreement Requirements

A valid inter spousal agreement must meet the requirements listed below. It must:

• Be in writing and signed by both parties.

• The agreement does not need to be prepared by an attorney.

• If one member of the couple is incompetent or otherwise incapable of giving his/her consent, one of the following third parties (not including the person's spouse/same-sex spouse/RDP) shall act on his/her behalf in completing the agreement:

• A public guardian• A court appointed conservator• A person who has a durable power of attorney.

Note:A durable power of attorney is one that is entered into while the applicant/beneficiary is capable of handling his/her own affairs and makes provision for maintaining the power of attorney in the eventuality the client becomes incapable or incompetent. The document must specifically state that the person is empowered to enter into an agreement to separate community property.

• Provide an accounting of the value of each asset divided. (A spouse/same-sex spouse/RDP's share of community property is always 1/2 of the total community property.)

Revised: 07/24/13 Update # 13--07


• Specify how the assets are divided, i.e., the actual divided amounts must be indicated or a fifty percent division of the amounts identified must be specified.

• Provide a clear division of nonexempt resources into equal shares.

Important:

If the inter spousal agreement does not divide the couple's nonexempt community resources into equal shares, then the EW must evaluate the “transfer of property” to determine if the transfer was not for adequate consideration. The applicant's spouse/same-sex spouse/RDP then has the option of reconveying property to his/her spouse/same-sex spouse/RDP to provide him/her with an equal share, or a period of ineligibility may be imposed. a. spouse/same-sex spouse/RDPs may choose to divide some or all of their community property. b. Exempt property may be included in the inter spousal agreement; however, it need not be divided into equal shares. c. An actual physical division of community property is not required as long as the legal division is satisfactorily documented in the agreement.

Limitations of the Inter spousal Agreement [50408, 50409]

• Individual members of a couple who have completed a valid inter spousal agreement will have their eligibility for Medi-Cal determined using only their share of community property, as stipulated in the agreement, and any separate property they may have.

• This law provides for the transfer (division) of community property only. Any transfer of nonexempt separate property by one spouse/same-sex spouse/RDP to the other must be evaluated for adequate consideration.

• An inter spousal agreement executed after the date of entry into LTC, which ratifies an existing automatic division of community property calculated by the county shall be accepted, even if it appears to be an unequal division because the spouse/same-sex spouse/RDP in LTC has already spent down all or a portion of his/her 1/2 share of the community property.

• The property given to the spouse/same-sex spouse/RDP at home through an inter spousal agreement which ratifies the county's automatic division shall be treated as his/her separate property.

Update # 13--07 Revised: 07/24/13


• Any interest income that accumulates on the separate property of the spouse/same-sex spouse/RDP in the home shall be considered the separate income of the spouse/same-sex spouse/RDP at home and shall not be considered in computing the share of cost of the LTC spouse/same-sex spouse/RDP.

Filing the Inter spousal Agreement

A copy of the inter spousal agreement must be filed or scanned into the IDM system fastener one (bottom) of the case record.

Division of Community Property Documentation

Appropriate CalWIN Property windows must be completed:

• In all situations where an inter spousal agreement is used in the Medi-Cal eligibility process.

• Using the share of community property and any separate property of each beneficiary.

Advising Applicants/Beneficiaries

Eligibility workers are responsible for issuing Medi-Cal Information Notice 005 at intake and RD to all applicants and beneficiaries who are subject to the division of community property rules.

29.16.39 Principal Residence

All regulations as written in Chapter 48 apply to persons in LTC with the following variation:

An applicant/beneficiary's home, interest in a home or life estate, will continue to be the exempt principal residence (PR) if any of the following circumstances exists:

29.16.40 Intent to Return

During any absence, a principal residence is exempt based on a person’s SUBJECTIVE intent to return. The intent to return is indicated by the individual or their representative marking the appropriate box on the “Application for Medi-Cal” (MC 210). Verification of the individual’s ability to return to the principal residence

Revised: 07/24/13 Update # 13--07


must not be required unless the individual or his/her authorized representative requests the income deduction for upkeep and repair of the home. [Refer to “Upkeep of Home,” page 29-83 .].

Note:Intent to return must be explored at the annual redetermination (MC 262).

Note:A person’s physical ability to return to the principal residence is not considered when determining principal residence.

Example: Long Term Care

An individual in a nursing home declares “intent to return” to her former home in Oregon. She has no other real property. The EW determines, based on the statements made by her representative and nursing home staff, that the client is not likely to leave the nursing facility. The home is an exempt principal residence and California residence is established.

29.16.41 Client in LTC, Sibling or Child Over Age 21 in Home

If during the applicant/beneficiary's stay in a intermediate care or LTC facility, the applicant/beneficiary's sibling or child 21 years of age or older lives in the principal residence AND has done so for at least one year prior to the time the applicant/beneficiary entered the facility, it is exempt.

Verifications required include but are not limited to:

• Mail addressed to the sibling or child at the principal residence address.• Cancelled personal checks from the account of the sibling or child showing the

residence address and a date at least one year prior to the date of admission.

Note:For the purpose of exempting the principal residence, it is not necessary for the sibling/child over 21 years of age to have made contributions to the LTC beneficiary's personal needs.

Update # 13--07 Revised: 07/24/13


29.16.42 List Property for Sale - Persons in Long-Term Care” (MC 239 Y)

When an LTC applicant/beneficiary has an interest in a principal residence which must be listed for sale, or, which the client chooses to list for sale, the EW must send an MC 239 Y. This NOA tells the applicant/beneficiary that:

• In order for Medi-Cal to be established or continued, the property must be listed for sale at its fair market value with a licensed real estate broker, and

Note:Fair Market Value means the price an item would sell for, in the open market, in the particular geographic area it is located. Market value is the same as the assessed value, and is not the same as the Fair Market Value.

• A copy of the listing contract from the real estate agent and a copy of a written appraisal from a qualified real estate appraiser must be provided by the applicant/beneficiary, and

• Verification of this listing and appraisal must be received within 30 days of the date of the NOA, and

• A lien will be recorded against the property to recover the cost of medical care received under the Medi-Cal program while in LTC, and

• The applicant/beneficiary has a right to a County Legal Review (CLR) and/or a State Hearing.

29.16.43 Client in LTC with List and Lien

If during any LTC absence, the applicant/beneficiary does not intend to return, and no specified relative resides in the residence, but a verified effort is being made to sell the property at Fair Market Value, and a lien has been filed by the County to recover the cost of medical services paid for the Medi-Cal, it is exempt.

Progress of the sale must be checked quarterly.

Revised: 07/24/13 Update # 13--07


29.16.44 List and Lien Requirements (LTC)

If during any LTC absence or upon discharged from the LTC facility, the applicant/beneficiary does not intend to return and no specified relative resides in the residence, the property must be listed for sale at Fair Market Value AND a lien recorded.

Exception:Client's with homes whose market value is less than $6,000 must be offered the choice of listing the property for sale or meeting utilization requirements. Applicants/beneficiaries with property whose market value is more than $6,000 must list the property for sale and provide a copy of the deed.

Note:Liens are recorded on property of all LTC clients regardless of age.

[Refer to“Lien Procedures,” page 48-12]

29.16.45 Transfer of Nonexempt Principal Residence by Institutionalized Persons

A nonexempt principal residence can be transferred from an institutionalized person to the following persons without determining a POI:

• The spouse/same-sex spouse/RDP.

• A son or daughter under age 21.

• A blind or disabled son or daughter.

• A sibling with equity interest in the home and who lived in the home for one year immediately preceding the date of institutionalization.

• A son or daughter who lived in the home and provided care for 2 years prior to the institutionalization.

Update # 13--07 Revised: 07/24/13


29.17Income

Persons who are aged and disabled whose income is below the FPL limit and who are in LTC are not eligible for the ABD-FPL Progams. [Refer to “Eligibility Criteria,” page 38-8]

29.17.1 Ownership of Income

Background [50512]

The Medicare Catastrophic Coverage Act (MCCA) of 1988 amended the federal Social Security Act regarding rules for the treatment and protection of income of the community spouse/same-sex spouse/RDP at home, when the other spouse/same-sex spouse/RDP is institutionalized. MCCA specifically prohibits consideration of state community property laws when determining income.

“Ownership of Income,” page 53-1

29.17.2 Income Allocations, ABD-MN Person with LTC Status Who Has a Community Spouse/Same-Sex Spouse/RDP [50563]

29.17.3 Rule

Effective 1/1/90, an institutionalized spouse/same-sex spouse/RDP, or a person with LTC status, can choose to allocate income to:

• The community spouse/same-sex spouse/RDP who is residing in the home.• Minor children who are residing with the community spouse/same-sex

spouse/RDP.• Certain dependent family members who are residing in the home with the

community spouse/same-sex spouse/RDP.

Revised: 07/24/13 Update # 13--07


29.17.4 Dependent Family Members

A dependent family member is limited to minor or dependent children, parent(s) or sibling(s) of either spouse/same-sex spouse/RDP, provided that the individual resides in the home with the community spouse/same-sex spouse/RDP. Dependency can be physical, emotional or financial.

Exception:An unborn is not eligible for a family member allocation.

29.17.5 Proof of Dependency

Dependency must be documented by obtaining a written statement from the person with LTC status. If dependency is questionable, the EW must require:

• A statement from his/her physician which verifies the knowledge of medical or emotional support of the individual upon the person with LTC status, or

• An affidavit (CSF 2) from the at-home spouse/same-sex spouse/RDP verifying the family member's financial dependency. (If the person with LTC status is incompetent, the spouse/same-sex spouse/RDP or the person completing the Statement of Facts can complete the affidavit.)

No written statement is required when the dependent family member is a blind or disabled son or daughter; however, the EW must document this dependency in the case file.

No written statement is required for a child, through age 18.

Update # 13--07 Revised: 07/24/13


29.17.6 Maximum Allocation to Community Spouse/Same-Sex Spouse/RDP

The maximum allocations from an ABD-MN LTC spouse/same-sex spouse/RDP to the community spouse/same-sex spouse/RDP and/or to dependent family members are adjusted annually based on the Consumer Price Index. “Community Spouse Allocation,” page 5-2 for current amounts.

The community spouse/same-sex spouse/RDP Allowance (Maintenance Need) is the greater of:

• The base allocation, or• The amount established by a court order, or• The amount ordered by a fair hearing decision.

Court Order

A court order must be the result of an order against the spouse/same-sex spouse/RDP with LTC status for the support of the community spouse/same-sex spouse/RDP. It must not be the result of a request by the institutionalized spouse/same-sex spouse/RDP for permission to give money to the community spouse/same-sex spouse/RDP or, an “authorization to pay. “

It can be a preexisting court order.

If the applicant has requested a court order but chooses not to delay the application while waiting for the order, the share of cost must be computed allowing the base allocation amount. The higher amount ordered by the court applies from the date of the order forward.

Note:Inter spousal agreements do not affect income, they only affect property.

Fair Hearing

A fair hearing judge (aka Admisistrative Law Judge (ALJ)) will only allow additional income to be kept by the spouse/same-sex spouse/RDP at home due to exceptional circumstances which will result in financial duress, (e.g., special health care needs, the necessity of home repairs, increased utility costs due to special medical needs or equipment, etc.)

Revised: 07/24/13 Update # 13--07


Note:A court order or fair hearing decision may be temporary or for an indefinite period.

29.17.7 Verification of Community Spouse/Same-Sex Spouse/RDP Allocation

The Community Spouse/Same-Sex Spouse/RDP Allowance shall only be deducted from the income of the ABD-MN (or MI) LTC spouse/same-sex spouse/RDP if it is actually made available to the community spouse/same-sex spouse/RDP.

Complete a General Affidavit, CSF 2, as verification of the amount of income actually being transferred to the spouse/same-sex spouse/RDP at home. Either the LTC spouse/same-sex spouse/RDP or the spouse/same-sex spouse/RDP at home can sign the affidavit stating that the income is being transferred.

Example:“This is to certify that I...will contribute the maximum allowable amount of my income to my spouse/RDP at home for her/his living expenses.” Or, the spouse/same-sex spouse/RDP with LTC status may specify an amount.

Note:Usually, the spouse/same-sex spouse/RDP at home has control of the income, so that availability is not an issue.

Verify the community spouse/same-sex spouse/RDP allocation at intake and redetermination by a cancelled check written from the LTC spouse/same-sex spouse/RDP to the community spouse/same-sex spouse/RDP, checking or savings account statement, etc.

Verify the income of the spouse/same-sex spouse/RDP at-home at intake and redetermination.

29.17.8 Verification of Dependent: Family Member Maximum Base Allocation

The Family Member Maximum Base Allocation (FMMBA) amount for dependent family members is updated annually in July. [Refer to Chart Book, “Family Member Maximum Base Allocation,” page 5-3 for current allocation amount.]

The dependent family member must:

Update # 13--07 Revised: 07/24/13


• Be residing with the at-home spouse/same-sex spouse/RDP• Verify his/her income.

Note:Dependent family members are NOT required to apply for other income.

The family member allocation shall be deducted from the income of the ABD-MN LTC spouse/same-sex spouse/RDP, regardless of whether or not it is actually transferred to the family members.

29.17.9 Total Allocation

The total amount allocated from the LTC spouse/same-sex spouse/RDP to the spouse/same-sex spouse/RDP at home and to dependent family members cannot exceed the LTC spouse/same-sex spouse/RDP's actual available income. When the maximum allocation allowance exceeds the available income of the LTC spouse/same-sex spouse/RDP, the LTC spouse/same-sex spouse/RDP must designate which family members will receive an income allocation, and how much will be given to each person.

29.17.10 Income Allowances, Persons With LTC Status [50605]

29.17.11 Maintenance Needs

A person who has (LTC) long-term care status is allowed $35 for personal and incidental needs when they will remain in LTC the entire calendar month.

The maintenance need for persons living in the home shall be used when the client is in LTC for only a portion of the month.

Exception:An institutionalized spouse/same-sex spouse/RDP, or, for income purposes, an LTC spouse/same-sex spouse/RDP, shall be in his/her own MFBU at the beginning of the continuous period of institutionalization. The LTC spouse/same-sex spouse/RDP may provide an income allocation to the community spouse/same-sex spouse/RDP beginning with the month of admission. The Maintenance Needs for the LTC spouse/same-sex spouse/RDP beginning with the first month of admission shall be $35.

Revised: 07/24/13 Update # 13--07


29.17.12 Medicare

When determining the amount that is actually available for allocation, the EW must consider if Buy-In is in effect. Persons who actually pay Medicare premium are allowed these deductions in the budget computation.

Only the Medicare premium of the LTC spouse/same-sex spouse/RDP can be deducted from the budget of the LTC spouse/same-sex spouse/RDP when Buy-In is not yet in effect. However, if the community spouse/same-sex spouse/RDP later applies for Medi-Cal, then his/her Medicare premium would be allowable deduction on the budget for the spouse/same-sex spouse/RDP at-home.

“Contacting Medicare Buy In Unit,” page 16-22 when there are Medicare problems.

29.17.13 Other Health Insurance Premiums

The premiums for private health insurance for family members are to be deducted from the budget of the person who actually pays it. The LTC spouse/same-sex spouse/RDP may be allowed a deduction for the premium paid for the private coverage for himself and his spouse/same-sex spouse/RDP, even though the community spouse/same-sex spouse/RDP is not requesting or receiving Medi-Cal, as long as it is paid with the LTC person's income.

When the OHC premium is paid by the community spouse/same-sex spouse/RDP and reimbursed by the LTC spouse/same-sex spouse/RDP, the OHC premium deduction can be allowed in the LTC spouse/same-sex spouse/RDP’s budget as long as this situation is clearly documented in Maintain Case Comments window in CalWIN.

Example:A case consists of a married couple. The husband (LTC spouse/same-sex spouse/RDP) is in along term care facility and his wife (community spouse/same-sex spouse/RDP) lives at home and is not requesting Medi-Cal. The community spouse/same-sex spouse/RDP maintains OHC for both of them and the monthly premium is being deducted automatically from her retirement/payroll check. Per clients’ statement, the LTC spouse/same-sex spouse/RDP reimburses his wife for the full cost of the OHC

Update # 13--07 Revised: 07/24/13


29.17.14 Therapeutic Wages

Certain Medi-Cal beneficiaries who live and work in LTC facilities may retain a portion of their therapeutic wages in excess of the LTC maintenance need level. Therapeutic wages are wages earned by the individual when ALL the following conditions are met:

(1) The physician who prescribes the work as therapy:

• Has no financial interest in the LTC facility, and• Is in charge of the individual's case, and

(2) The individual is employed within the same LTC facility where residing, and

(3) The individual's employment does not displace any existing employees, and

(4) The individual has resided in a LTC facility for a continuous period commencing at least five years prior to September, 1984 (i.e.September, 1979, or earlier).

c. The amount of earned income the LTC individual shall be allowed to retain shall be the LESSER of:

(1) 70% of the gross therapeutic wages, or

(2) 70% of the maintenance need level for a non-institutionalized person, or if the LTC beneficiary is included in their spouse/same-sex spouse/RDPs MFBU, the maintenance need for a family of corresponding size.

Note:The 70% disregard amount shall NOT be treated as exempt income or a deduction. It must be added to the maintenance need when completing the MC 176-M (LTC). Document the computation on the MC 176-M (LTC).

Verification

Therapeutic wages of a person in long-term care (LTC) shall be verified by obtaining:

• A statement from the individual physician which states that:

Revised: 07/24/13 Update # 13--07


• He/she has no financial interest in the LTC facility in which the beneficiary resided, and

• The work has been prescribed as therapy for the beneficiary.

• A statement from the LTC facility verifying:

• The amount and frequency of therapeutic wage payment, and• That such employment does not displace any existing employee.

• A statement(s) from the facility(ies) verifying that the beneficiary has been an LTC resident continuously since September 1979.

• Prior to allowing the therapeutic disregard the statement listed above must be obtained.

At each subsequent redetermination statements listed above must be obtained.

29.17.15 Upkeep of Home

In addition to personal needs, an allowance for the upkeep of a home shall be allowed when all of the following conditions are met:

Criteria

• The spouse/same-sex spouse/RDP or family of the person who has LTC status is not living in the home, and

• The home, whether rented or owned by the person who has LTC status, is actually being maintained for the return of the person with LTC status, and

• There is a verified medical determination that the person who has LTC status will return home within six months of the date LTC patient status was established. Set up a case alert for the six-month follow up.

The amounts allowed for upkeep of home shall be the lesser of actual cost, or:

Allowances

If the beneficiary has been living alone in the home, $209 effective 7/1/89.

• If the home is shared with persons for whom the beneficiary has no legal responsibility for support, $138 effective 7/1/89.

Update # 13--07 Revised: 07/24/13


• If the beneficiary and spouse/same-sex spouse/RDP have been living together and both have become persons with LTC status and will return home within 6 months, $138 effective 7/1/89.

Unavailabe Income

Unavailable income may be such income as levies to the recipient’s Social Security benefits due to overpayments. [Refer to “Unavailable Income [50515],” page 53-5]

29.17.16 Support of a Disabled Relative

The person who has LTC status shall be allowed to retain an amount of income to pay for the support of a disabled relative if all of the following conditions are met:

Criteria

• The disabled relative is not the LTC patient's spouse/same-sex spouse/RDP or child (as defined in Section 50030).

• The LTC person has contributed and will continue to contribute to the support of the disabled relative on a regular basis.

Allowance

The amount allowed for support shall be the lesser of:

• The actual amount contributed, or• The Medi-Cal Maintenance Need Level for one person, minus the disabled

relative's net income.

29.17.17 Exempt Income

Refer to chapter 54 and for exempt income. Treat a LTC persons income as specified in chapter 54 unless specifically mentioned in this LTC chapter.

29.17.18 Veterans’ Aid and Attendance - In LTC

Veterans’ benefits must be verified using the CW 5 or the actual VA award letter. [“Veterans’ Benefits,” page 57-13]

A & A cash benefits received by a veteran in LTC are:

Revised: 07/24/13 Update # 13--07


• NOT included in the division of community income.• Exempt, if the veteran has a spouse/same-sex spouse/RDP and/or minor

child(ren) at home.• Partially exempt (first $90 only), if the veteran does NOT have a

spouse/same-sex spouse/RDP and/or minor child(ren) at home.• Included in the share of cost determination if not otherwise exempt.

Note:When the Veterans Administration (VA) is paying the cost of the LTC facility, the beneficiary’s resources may not exceed $1,500 or the VA benefits will be suspended until the resource level falls below $500. If the VA is not paying the cost of the LTC facility, then the Va benefits are not subject to the $1,500 limit.

29.17.19 Retroactive Payments

Veteran’s lump sum retroactive payment is treated as follows:

• Determine the number of months the veteran was at home and the number of months the veteran was in LTC and on Medi-Cal during the retroactive period. Determine the countable A&A portion of the lump sum by muliplying the rate times full months in LTC.

• For the months the veteran was at home, the A&A portion should be disregarded as income in the month of receipt and treated as property thereafter.

• For the months the veteran was in LTC and on Medi-Cal, the A&A payment should apply to the cost of LTC services and is subject to repayment. Increase the share of cost by an amount equal to the A&A received while the beneficiary was in LTC.

Example:In July, assume a veteran (at home or in LTC) received a lump sum VA payment of $3,000 total for March, april and May; and the amount of the A&A award is $300 per month. Assume the veteran was at home in March and in LTC in April and May. The $900 ($300x3) A&A lump sum is allocated as follows: The $300 is reimbursement of A&A payments for March, the month when the veteran was at home. It is not treated as income nor property for July but is property thereafter. The $600 is reimbursement for April and May when the veteran was in LTC. It is not treated as income nor property for July. The veteran must be added to the client’s share of cost in a future month. The remaining $2100 ($3000 - $900) is a lump sum social insurance payment and treated as property.

Update # 13--07 Revised: 07/24/13


29.17.20 Institutionalized Veteran with NO spouse/same-sex spouse/RDP and/or Minor Child(ren)

The first $90 of Aid and Attendance (A&A) payments received by a veteran in LTC who does NOT have a spouse/same-sex spouse/RDP and/or minor child(ren) at home is exempt. If the A&A payments exceeds $90, the portion of the payment in excess of $90 is counted when determining the Share of Cost.

29.17.21 Institutionalized Veteran with a spouse/same-sex spouse/RDP and/or Minor Child(ren)

The entire Aid and Attendance (A&A) payment received by a veteran in LTC who DOES have a spouse/same-sex spouse/RDP and/or minor child(ren) at home is exempt. In addition, the A&A payment received by an institutionalized widow of a veteran who has a minor child(ren) at home is exempt.

29.17.22 $90 VA Pension, Veteran in LTC

The $90 flat VA pension of veterans in long-term care (LTC) who have no spouse/same-sex spouse/RDP or children in the home is exempt. In addition, the flat $90 VA pension of a surviving spouse/same-sex spouse/RDP in LTC is exempt.

29.18Budgeting

The earned and unearned income deductions shall be allowed to persons in LTC per handbook Chapters 56 and 57 and budget principals apply as written in Chapter 61with the following variations for persons in LTC.

Completion of the budget form is optional as CalWIN automatically computes the budget based on the information entered, or mandated when outside of the CalWIN EDBC period

References to completion of budget forms only apply when a manual computation is necessary (i.e., outside of EDBC period).

Revised: 07/24/13 Update # 13--07


LTC Person with a Community Spouse

An institutionalized spouse/same-sex spouse/RDP, or, for income purposes, an LTC spouse/same-sex spouse/RDP shall be in his/her own MFBU at the beginning of the continuous period of institutionalization.

• The LTC spouse/same-sex spouse/RDP may provide an income allocation to the community spouse/same-sex spouse/RDP beginning with the month of admission to the long term care facility.

• The spouse/same-sex spouse/RDPs are in separate budget units beginning with the month of admission.

• The Maintenance Need for the LTC spouse/same-sex spouse/RDP shall be $35 (the personal needs allowance) beginning with the first month of admission.

• When the institutionalized spouse/same-sex spouse/RDP or the LTC spouse/same-sex spouse/RDP and the community spouse/same-sex spouse/RDP are both beneficiaries and their budgets are being revised at the beginning of the continuous period of institutionalization, there can be no increase in the share of cost until a ten-day notice of action (NOA) is issued, even though an allocation to the community spouse/same-sex spouse/RDP has been given.

Maintenantce Need - No Community Spouse

• The Maintenance Need of the LTC individual shall be $35 (the personal needs allowance) beginning with the month after the month of entry.

29.18.1 MC 176 M-LTC

Form MC 176 M-LTC, Share of Cost Determination MFBUs With LTC Person Included LTC, is used in computing the SOC for all MFBUs which include person in LTC for months outside of the EDBC period.

Update # 13--07 Revised: 07/24/13


29.18.2 MC 176W Allocation/Special Deduction Worksheet

MC 176 W, Worksheet A

Part III. Allocation from Board and Care Person to spouse/same-sex spouse/RDP and/or Children at Home, or from LTC Person with No Community Spouse/Same-Sex Spouse/RDP to Children at Home

This portion of the form is completed when:

1. The ABD-MN person with LTC status has children but no community spouse/same-sex spouse/RDP, or

2. An MI person has LTC status and has a spouse/same-sex spouse/RDP and/or children living in the home, but no “community spouse/same-sex spouse/RDP.”

This section applies when the spouse/same-sex spouse/RDP and/or children of the board and care person or the children of the person with LTC status (and no spouse/same-sex spouse/RDP) are in separate MFBUs.

Do not complete this section for family members who receive Public Assistance. Do not complete this section when the ABD-MN person has a community spouse/same-sex spouse/RDP. Complete the MC 176WB, Parts VII through X if the ABD-MN person with LTC status has a community spouse/same-sex spouse/RDP.

Any Income Deduction

When the $20 Any Income Deduction has been allowed for an MFBU which includes a person in LTC, the $20 must be added back prior to computing the Share of Cost. (50653)

29.18.3 Use of the MC 176W, Allocation Special Deduction Worksheet-B

Form MC 176W, Allocation/Special Deduction Worksheet B is used for when there is an ABD-MN spouse with long term care (LTC) status and a community spouse/same-sex spouse/RDP resides in the home.]

• Subtract the gross income of the community spouse from the community spouse maintenance need which is the greater of:

• The community spouse allowance, or • The amount awarded by a fair hearing, or

Revised: 07/24/13 Update # 13--07


• A court ordered amount.

• Verify community spouse income. Include PA (e.g., SSI, AFDC).

• The lesser of the amount actually paid by the LTC spouse or the maximum allocation is allowed as a deduction to the LTC spouse.

Part VIIIIncome of LTC Spouse Available for Allocation.

Subtract the Personal Needs Allowance (PNA) and the allocation to the community spouse from the total gross income of the LTC spouse to determine if there is income remaining to allocate to other dependent family members.

Part IXAllocation to Family Members Residing with Community Spouse.

• Compute a separate allocation for each dependent family member. Additional space is available on back.

• Total allocations from the LTC spouse cannot exceed actual available income. If the allowable allocations exceed the available income, the LTC spouse must choose who receives an allocation.

• The family member must be residing with the community spouse.

Part X:

• Use this section to compute the total allocation from the LTC spouse to the community spouse at home and, if applicable, to each additional family member.

• Enter any notes which will clarify the income used to determine the calculation, and any other clarifications.

29.18.4 The “Allocation/ Special Deduction Worksheet” (MC 176W, Worksheet B), is used to compute the allocation from the ABD (or MI) spouse/same-sex spouse/RDP to the community spouse/same-sex spouse/RDP. Follow

Update # 13--07 Revised: 07/24/13


these steps to compute the allocation from the LTC spouse/RDP/same-sex spouse:[

Step Action

1 Subtract the Personal Needs Allowance (PNA) $35 (effective 1/1/90) from the gross income of the LTC spouse/same-sex spouse/RDP to determine the maximum income of the LTC spouse/same-sex spouse/RDP which is available for allocation. (MC 176W- Worksheet B, Part VIII, lines 1 - 3)

Note:Veterans Aid and Attendance (A & A) payments are considered to be a “third party payment”, and shall not be treated as income when determining the income which is available for allocation budget (MC 176 W). When received by the LTC spouse/same-sex spouse/RDP, the A & A portion must be included in the LTC spouse/RDP's SOC budget determination (MC 176 M-LTC).

Revised: 07/24/13 Update # 13--07


2 Determine the community spouse/same-sex spouse/RDP Allowance (either the community spouse/same-sex spouse/RDP Allocation for a community spouse/same-sex spouse/RDP; or, the amount ordered by a fair hearing or a court order), MC 176 W - Worksheet B Part VII, and subtract the gross monthly income of the community spouse/same-sex spouse/RDP.

Example:LTC spouse/same-sex spouse/RDP with a spouse/same-sex spouse/RDP at home: LTC spouse/same-sex spouse/RDP has gross income of $1000 RSDI. spouse/same-sex spouse/RDP at home earns $700 gross each month. LTC spouse/same-sex spouse/RDP or representative states he wants to allocate the maximum amount. When completing Worksheet B, Part VII, first complete lines 1-3. On line 4 enter the amount from Part VIII, line 3. The actual allocation from the LTC spouse/same-sex spouse/RDP is the lesser of lines 3 or 4. That amount is transferred to Part VII, line 5. The amount on line 5 is transferred to Part X, line 1 [“Budgeting Examples:,” page 29-93]

Consider the following rules:

• Determine the community spouse/same-sex spouse/RDP Allocation for current amount.[“Maximum Base Allocations - LTC Cases,” page 5-2]

• This figure on Part VII line 3 is the maximum amount of income that can be allocated to the at-home spouse/same-sex spouse/RDP.

• However, the LTC spouse/same-sex spouse/RDP is not required to allocate the maximum amount. The income of the at-home spouse/same-sex spouse/RDP must be verified.

• Include any PA (e.g., SSI, AFDC) received by the community spouse/same-sex spouse/RDP. If the community spouse/same-sex spouse/RDP has SSI, advise him/her in writing that this increase in income must be reported to the Social Security Administration because allocations are unearned income.

• Medicare expense is allowed prior to Buy-In being in effect (in Intake). Include the Medicare expense on Part VIII, line 2 with the PNA.

• The community spouse/same-sex spouse/RDP Allowance can only be deducted from the income of the LTC spouse/same-sex spouse/RDP if it is actually paid to the community spouse/same-sex spouse/RDP. (Obtain affidavit and verify by obtaining a cancelled check, bank statement, etc.)

• If the at-home spouse/same-sex spouse/RDP has income and is receiving Medi-Cal, he/she may have an increased share of cost due to the new allocation. A ten day NOA is required.

Step Action

Update # 13--07 Revised: 07/24/13


3 If there are dependent family members residing with the community spouse/same-sex spouse/RDP, complete Part VIII and Part IX, Allocation to Family Members Residing with community spouse/same-sex spouse/RDP.

Example:LTC spouse/same-sex spouse/RDP with a spouse/same-sex spouse/RDP at home and two minor children. LTC spouse/same-sex spouse/RDP has gross income of $2000 RSDI. spouse/same-sex spouse/RDP at home pension of $1500 and RSDI of $1500 each month. The children each receive $900 RSDI. The LTC spouse/same-sex spouse/RDP or representative states he wants to allocate the maximum amount. When completing Worksheet B, Part VII, first complete lines 1-3. On line 4 enter the amount from Part VIII, line 3. The actual allocation from the LTC spouse/same-sex spouse/RDP is the lesser of lines 3 or 4. That amount is transferred to Part VII, line 5. The amount on line 5 is transferred to Part X, line 1. Part IX A and B are used to compute the allocation to the children. [“Budgeting Examples:,” page 29-93]

Consider the following rules:

• There must be a community spouse/same-sex spouse/RDP in the home in order to allow an allocation.

• Determine the Maximum Allocation Base for each family member for current amount.“Maximum Base Allocations - LTC Cases,” page 5-2

• Verify the income of the dependent family member.

• Deduct from the maximum allocation base of each family member his/her gross income. Do not apportion income for dependent family members; use actual.

• Include any PA (e.g., SSI, AFDC) received by the dependent family member. Advise the family (in writing) to report the additional income. Allocations are unearned income.

• One-third (1/3) of the remainder is the family member allowance for that individual.

• A family member allocation can be allowed, even if it is not actually paid.

• IEVS does not apply to family members.

Step Action

Revised: 07/24/13 Update # 13--07


29.19Budgeting Examples:

Below are step-by-step examples on an MC 176 W, Part B of Spousal Allocation and Family Allocation:

4 Compute the total allocation from the LTC person to the community spouse/same-sex spouse/RDP and family members on Part X.

• The LTC spouse/RDP can only allocate up to the maximum income he/she has available for allocation.

• The Personal Needs Allowance must be retained by the LTC spouse/same-sex spouse/RDP.

• If the allowable allocations exceed the actual available income to allocate, the LTC person, his/her spouse/same-sex spouse/RDP or their representative must choose who to allocate the income to, and how much.

• Evaluate the amount of income that the LTC spouse/same-sex spouse/RDP actually has available to allocate. Use the “Notes” Section of the MC 176W, Part B to document the actual allocation.

• If a relative refuses to verify his/her income, document carefully and do not allow the allocation.

Step Action

Update # 13--07 Revised: 07/24/13


Step 1. Complete lines VIII 1 - 3

Revised: 07/24/13 Update # 13--07


Step 2: Complete lines VII 1 - 3

Update # 13--07 Revised: 07/24/13


Step 3: Complete line VII 4 (standard practice is to allocate all from line VIII 3.)

Revised: 07/24/13 Update # 13--07


Step 4: Complete line VII 5.

Update # 13--07 Revised: 07/24/13


Step 5: Complete line VIII 4 (from line VII 5).

Revised: 07/24/13 Update # 13--07


Step 6: Complete X 1 (from line VII 5, step 4)

Update # 13--07 Revised: 07/24/13


Step 7: Complete line VIII 5 (any remaining amount).

Revised: 07/24/13 Update # 13--07


Step 8: Complete Line X 7 (this is the total spousal allocation).

Update # 13--07 Revised: 07/24/13


Family Allocation Step 1: Complete lines VIII 1 - 3 (above)

Revised: 07/24/13 Update # 13--07


Family Allocation Step 2: Complete lines VII 1 - 3. (above)

Update # 13--07 Revised: 07/24/13


Family Allocation Step 3: Complete line VII 4 (allocate all) (above)

Revised: 07/24/13 Update # 13--07


Family Allocation Step 4: Complete line VII 5 (above)

Update # 13--07 Revised: 07/24/13


Family Allocation Step 5: Complete line VIII 4 (from line VII 5)

Revised: 07/24/13 Update # 13--07


Family Allocation step 6: Complete X 1 from line VII 5, step 5.

Update # 13--07 Revised: 07/24/13


Family Allocation Step 7: Complete Line VIII 5 ( any remaining amout) above.

Family Allocation Step 8: Complete IX A 1(enter family member information).

Family Allocation Step 9: Complete IX A 2 - 5 above.

Family Allocation Step 10: Complete line X 2 (from IX A 5 in step 9).

Revised: 07/24/13 Update # 13--07


Family Allocation Step 11: Complete line X 7 (this is total family allocation).

29.19.1 Long-Term Care (LTC) SOC Recomputation [50659]

When an LTC beneficiary is discharged from a long term care facility, a recomputation of the SOC must be completed using the appropriate non-LTC maintenance need level.

The EW must verify that the beneficiary is no longer in LTC.

When the SOC is recomputed, send the original “SOC Medi-Cal Provider Letter” (MC 1054) to the provider, i.e. nursing facility, hospital. Refer to [Refer to “Processing Cases When the SOC is Retroactively Reduced,” page 62-5]

Update # 13--07 Revised: 07/24/13


29.19.2 Super-Liability Cases

If the EW believes an applicant may have a super liability, contact the Medi-Cal Coordinator for procedures.

Definition

An LTC person whose SOC exceeds the monthly cost of care at the Medi-Cal reimbursement rate shall have a “super-liability.”

If the client was in the nursing facility for the... Then Super-Liability...

Full calendar month, Exists.

Partial calendar month, Does not exist.

Super-Liability Determination

To determine the monthly reimbursement rate, the EW must multiply the specific county per diem rate by the number of days in the month. If the client’s SOC exceeds the monthly rate, the client has a super-liability.

The EW needs to contact the nursing facility (NF) to determine the level of care that the client receives and the per diem rate.

Note:These rates change every year. For current rates and more information, contact the Program Coordinator via the Medi-Cal Liaison.

Per Diem Chart Rates

The following charts are provided for informational purposes only. The NF/LTC per diem rates Levels A and B, effective 08/01/05 are as follows:

1. LEVEL A per diem rates

a. Daily Rates

Facility Size (Beds)

Santa Clara, Alameda, Contra Costa, Marin, San Francisco, and San Mateo Counties

Los Angeles County

All Other Counties

1-99 $87.18 $87.18 $67.94

Revised: 07/24/13 Update # 13--07


b. Monthly Rates - Santa Clara County

Bedsize 1-99 Daily Rate $87.18

Bedsize 100+ Daily Rate $89.54

28 Day Month $2,441.04 $2,507.12

30 Day Month $2,615.40 $2,686.20

31 Day Month $2,702.58 $2,775.74

2. LEVEL B per diem rates

a. Daily Rates

Facility Size (Beds)

Santa Clara, Alameda, Contra Costa, Marin, San Francisco, and San Mateo Counties

Los Angeles County

All Other Counties

1-59 $141.19 $114.02 $122.68

60+ $148.40 $114.17 $127.37

b. Monthly Rates - Santa Clara County

Bedsize 1-59 Daily Rate $141.19

Bedsize 60+ Daily Rate $148.40

28 Day Month $3,953.32 $4,155.20

30 Day Month $4,235.70 $4,452.00

31 Day Month $4,376.89 $4,600.40

Example:In the month of September 2005, in Santa Clara County, Mr. Jones was in a nursing facility (NF) and had a SOC of $5,000. According to the NF, the facility consists of less than 60 beds and Mr. Jones was provided with a LEVEL B of care. The reimbursement rate is computed as follows:

Santa Clara County per diem rate (NF 1-59 Beds) $141.19

Multiply by the number of days in the month of September (September is a 30-day month)

X 30

September monthly reimbursement rate $4,235.70

Mr. Jones SOC in September 2005 $5,000.00

100+ $89.54 $89.54 $89.54

Update # 13--07 Revised: 07/24/13


In this situation, since Mr. Jones had a SOC of $5,000 which is higher than the monthly reimbursement rate of $4,235.70, Mr. Jones is determined to have a Super-liability case.

29.20Benefits Identification Card (BIC)

Please refer to Chapter 64 for more detailed information regarding the BIC. The following applies specifically to persons in Long Term Care (LTC)

• The BIC may be given/mailed to the spouse/same-sex spouse/RDP of an eligible person residing in LTC, if that spouse/same-sex spouse/RDP is acting as Authorized Representative; or to the AR when the beneficiary is comatose, amnesiac, or incompetent. Similar situations must be approved by an EW Supervisor.

Note:MEDS screen BIC-ID CROSS REFERENCE REPORT [INXB] shows the full BIC card number.

For Letter of Authorization (LOA) “Letter of Authorization,” page 64-13

29.21Court Orders

29.21.1 Craig v. Bonta

Refer to 67.2

29.21.2 Public Guardian Referral for Incompetent Clients

According to the lawsuit, a referral to the Public Guardian Office must be completed for clients discontinued from SSI/SSP who are receiving nursing facility services and who are eligible for Medi-Cal under the Craig lawsuit. Many of these clients may be in these facilities without representatives or Public Guardians.

Revised: 07/24/13 Update # 13--07


Note:The laws governing referrals to the Public Guardian’s Office are very complex and require a number of forms to be completed. Among the required forms is a “Capacity Declaration” from a medical doctor or psychiatrist declaring the person to be in need of a conservator and a request for a court hearing to determine capacity. Due to the complexity of the referral process, the social workers at the hospitals initiate these referrals. Our Agency will no longer refer individuals to the Public Guardian’s Office for conservatorship

Note:When there is a valid reason to believe that a client is being abused or neglected, then the EW must complete an “Adult Protected Services” (APS) referral.

Long Term Care (LTC) Beneficiaries

Discontinued SSI/SSP beneficiaries who have entered into a LTC facility must receive PRIORITY to minimize their accumulation of nonexempt resources resulting from receiving Medi-Cal eligibility at no share-of-cost. A new code of “L” will be placed in the [Pickle Status] field on MEDS to identify beneficiaries who are discontinued from SSI/SSP due to entering LTC.

29.21.3 Hunt v Kizer

Applicants who are in LTC many times have old unpaid medical bills that may qualify to be used to reduce the current or future SOC.

• The EW may use the SCD 1596 as a tool to organize and record submitted bills.• IDM both bills and SCD 1596.• Private medical insurance and medicare must first be billed prior to using the

balance on the bill.• If bills are incurred during the retro months, the client may be advised to apply

for Retro Medi-Cal to pay the bills.• The EW must contact the provider to clarify any discrepancies on the bill.

[“Hunt v. Kizer (Applying Old Medical Bills to the Share of Cost),” page 63-1]

Update # 13--07 Revised: 07/24/13


29.21.4 Johnson v Rank

29.21.5 Issue

A federal court lawsuit, Johnson v Rank, specified that LTC beneficiaries shall be able to use medical items or services which are not covered by Medi-Cal to help meet their SOC.

1. LTC beneficiaries will receive their Medi-Cal cards on the first of the month.

2. The LTC facility will bill the beneficiary on the first of each month for the total SOC indicated on the card.

3. The LTC facility must pay for necessary non covered medical services from the total SOC collected.

Note:Medi-Cal cards are no longer issued on a monthly basis and SOC is not indicated on the card.

29.21.6 Decision

Effective October 1, 1989, all Medi-Cal recipients in LTC facilities must obtain a physician's prescription or order for any non covered medical or remedial drug or service, when the cost is to be applied toward their share-of-cost amounts. [Refer to “Follow these steps when a SOC has already been certified on MEDS and the date of service is more than 12 months ago:,” page 62-15, for instructions.]

29.21.7 Johnson v. Rank (Noncovered Medical Expenses of Persons in Long-Term Care)

The Johnson v Rank court decision specifies that LTC clients must be able to use medical items services which are not covered by Medi-Cal to help meet their SOC.

• Effective October 1, 1989, all Medi-Cal recipients in LTC facilities must obtain a physician's prescription or order for any non covered medical or remedial drug or service, when the cost is to be applied toward their share-of-cost amounts.

• The LTC facility must ensure that a copy of the prescription or order is in the beneficiary's medical record.

Revised: 07/24/13 Update # 13--07


Note:This court order is different than Hunt v Kizer. Hunt v Kizer is for medical expenses incurred prior to establishing Medi-Cal eligibility.

Necessary Noncovered Services

Necessary non-covered services are defined as “Medical and remedial drugs, services, supplies, and other items which are not paid for by Medi-Cal or any other third party, and which are prescribed or ordered by attending physicians.”

Examples of non covered medical services include, but are not limited to:

• Podiatry services• Chiropractic services• Hearing aid batteries.

Payment for Necessary Noncovered Services

Payment for non covered services will be accomplished in the following manner:

• For services arranged through the LTC facility, payment will be made by the facility.

• For services arranged and paid by the beneficiary or their authorized representative, the bills or receipts must be submitted to the nursing home no later than two months after receipt of the service, supplies or drugs.

• Bills/receipts provided to the nursing home at the beginning of the month (when the LTC SOC is normally paid) may be deducted from the current month's share of cost before paying the remaining SOC to the nursing home.

• If the bill/receipt is submitted after the current month's SOC has been paid, it will be deducted from the SOC during the following month.

“Important Notice About Your Medi-Cal Benefits”

The MC 18 (formerly ID-104) “Important Notice About Your Medi-Cal Benefits”, shall be issued and explained to all LTC beneficiaries.

• The notice explains the LTC/SOC billing procedure which enables the client to pay for necessary medical expenses that are not paid by Medi-Cal.

• The EW shall issue the MC 18 to:

Update # 13--07 Revised: 07/24/13


• New LTC beneficiaries or to persons acting on their behalf.• LTC beneficiaries at the time of redetermination.

Johnson v. Rank Payments to Beneficiary

Payments received as a result of the Johnson v. Rank Court Order are exempt as income and exempt as a resource for six months from (and including) the month of receipt.

Note:The “Request for SOCO (Share of Cost Obligation) Transaction (SCD 1296 SOCO) is used when the Medi-Cal recipient has paid medical expenses not covered by Medi-Cal. The EW completes the form and submits it to the MTO to apply the amount toward the SOC in MEDS.

29.21.8 Pickle v. Rank

Persons in long term care are not eligible for Pickle or DAC. [“Court Orders: Lynch v. Rank - Pickle Amendment,” page 68-1]

29.21.9 Reese v Kizer

Note:Due to MCCA rules effective 1/1/1990, community property share of income no longer applies. The information regarding Reese v Kizer is only for historical purposes.

29.21.10 Issue

Whether the community property share of income of a spouse/same-sex spouse/RDP in an LTC facility should be made available to the spouse/same-sex spouse/RDP at home.

29.21.11 Decision

This court order took effect in part on April 29, 1985, to the extent that the counties were ordered to divide community income only if requested to do so by the applicant/beneficiary.

Revised: 07/24/13 Update # 13--07


AB 987 was subsequently enacted in September 1985. It required counties to automatically divide community income as of the date one spouse/same-sex spouse/RDP entered LTC or any medical facility. The first month that counties were required to use the new income amounts was December 1985.

29.21.12 LTC Prejudice Cases

Note:Due to MCCA rules effective 1/1/1990, community property share of income no longer applies to married spouses when one spouse enters LTC. The information regarding LTC Prejudice Cases is only for historical purposes.

29.21.13 Issue

AB 987 established the “automatic” division of community property when one spouse enters long-term care (LTC). The law became effective September 29, 1985 and required the Department of Health Services (DHCS) to immediately issue a notice to all LTC patients informing them of the new law. However, DHCS did not publish this notice until March, 1986.

1. Certain persons may have been eligible for retroactive Medi-Cal for the period September, 1985 through April, 1986 if the division of community property regulations had been applied.

2. On April 18, 1988, DHCS mailed a notice to all LTC patients known to MEDS from September, 1985 through 1986 which informed them that they may apply for retroactive Medi-Cal for this period, as they may have been disadvantaged by the delay.

3. EWs were required to review LTC cases in order to identify potentially eligible persons for retroactive Medi-Cal for the period September, 1985 through April, 1986. The case review period was 8/1/88 through 8/31/89.

Update # 13--07 Revised: 07/24/13


Revised: 07/24/13 Update # 13--07

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