Purpose: This section describes resource eligibility for institutional medicaid programs including HCBS Waiver programs.
Worker Responsibilities - Resources of a Couple
When the current period of institutional status began before October 1, 1989:
- Consider resources in both spouses’ names as community resources (jointly owned).
- Do not count separate resources of each spouse as a community resource. In order to be considered separate, these resources must belong to one spouse and be maintained separately from community resources.
- Count one-half of the community resources and one-half of the resources owned by the institutionalized spouse toward the Medicaid resource standard for one person of $2,000 to determine resource eligibility.
When the current period of institutional status began on or after October 1, 1989:
- Determine the value of the community resources as of the first day of the month of application. Include all nonexcluded resources of both spouses. Do not consider whether or not the resources are separate or jointly owned.
- Allocate nonexcluded community resources to the community spouse up to:
- The maximum amount if the client’s institutional status onset was before 8/1/03;
- The state spousal resource standard or the spousal share up to the federal maximum if the client’s institutional status onset was on or after 8/1/03; or
- An amount ordered by the court or ALJ
- Count the remaining resources toward the Medicaid resource standard for one person.
- If below the standard, the institutionalized spouse is resource eligible
- If above the standard, consider whether the excess amount can be used to satisfy any spenddown liability for the cost of care in the initial month
- If you deny the application for excess resources and the individual disputes the value assigned to the resources, send the individual a letter to gain verification of the value of the couples’ resources. Allow ten days, and send a confirmation of denial, if the individual does not respond or provide the information requested. If the information is provided and the individual is ineligible, send a confirmation of denial that itemizes resources and their values.
- If the institutionalized spouse is eligible after allocating resources to the community spouse, inform the individual that the names must be changed to that of the community spouse on documents of ownership for the allocated resources by the end of one year. Start this protected period on the date you open LTC services and end this period on the last day of the month in which the first eligibility review is due.
- When completing the first eligibility review, determine if the resources have been transferred to the community spouse.
- If the transfer has been completed, the institutionalized spouse remains eligible.
- If the transfer has not been completed, determine if legal proceedings to transfer the resources have begun. If not, terminate the case after giving the client advance and adequate notice. Do not allow an additional protected period if the individual reapplies unless there is a 30 day break in services. A reapplication after a 30 day break is treated like a new application.
- If legal proceedings are under way, tickle the case to review the status of the resources based on the expected date of transfer.
- Do not reassess community resources unless the institutionalized spouse has a break of at least thirty consecutive days in the current period of institutional status or acquires resources above the program standard.
- When both spouses are institutionalized during the same month, count all nonexcluded resources during the first month of separation. Consider all resources as available to both and compare total resources to the couple institutional standard. If resources are above this standard, both are ineligible for that month. For the month following the month of separation, refer to number 9.
- When eligibility has already been established for one spouse, and the other spouse becomes institutionalized in a following month, consider one-half of all community resources jointly held as available to both spouses. Add to that amount the separate resources of each spouse when determining eligibility for each of them. Establish eligibility for each spouses as you do for a single individual. If resources of a spouse are above the standard for one person, that spouse is ineligible.
Use the following guidelines when completing an evaluation of the community resources when the individual becomes institutionalized on or after 8/1/03:
- Resource evaluations can be completed prior to the application or at the same time as the application.
- An evaluation is not necessary if the individual’s community resources do not exceed the state spousal resource standard plus the resource standard for a single individual (total of $42,000 for time period 8/1/03 through 6/30/05. Effective 7/1/2005, total increased to $43,943).
- Determine the value of the community resources as of the first day of the month that institutionalization began.
- Obtain verification of the resource values. Allow 10 days for a response.
- If the individual does not provide requested verification when completing evaluations prior to the application, send a letter that explains we cannot determine the spousal share without this verification. A letter template is available to DSHS staff from the ADSA home page.
- When completing evaluations prior to the application, send the individual and spouse the results. In addition, inform the couple that the spousal share determination may change if there is a break in institutional status of 30 or more consecutive days. A letter template is available to DSHS staff from the ADSA home page.
- A new evaluation is needed only if there has been a break in institutional status of 30 or more consecutive days prior to the Medicaid application. If needed, this evaluation can be completed in conjunction with the Medicaid application.
- After completing the evaluation, do not require married couples to report changes in institutional status prior to applying for Medicaid. However, when the institutional individual applies, always confirm that there has not been a break in institutional status since completing the evaluation.
- If a Community Resource evaluation was completed prior to the Medicaid application, determine if there has been a break in the institutional status of 30 or more consecutive days since the onset of the current period of institutionalization.
- When the individual applies, a new evaluation will be needed If there was a break in the individual’s institutional status of 30 or more consecutive days and the individual’s current community resources exceed the state spousal resource standard plus the resource standard for a single person.
- When processing the long term care application, if the individual does not provide verification of resources to determine the spousal share:
- Use the state spousal resource standard to determine eligibility;
- Do not deny the application for failure to provide this information; and
- If the individual is over the resource limit after allowing the state spousal resource standard and applying excess resources towards the cost of care, deny the application and explain in the ACES denial letter that we cannot determine the spousal share without the missing verification.
A married individual applies for nursing home care on 8/15/03. The individual first entered the hospital on 7/2/03 and discharged to the nursing home on 8/14/03. Because the individual became institutionalized before 8/1/03, use the Federal Community Spouse Resource Allocation maximum standard.
A married individual applies for LTC on 3/15/04. The individual first became institutionalized 8/1/03 and has remained institutionalized without a break. Because the individual first became institutionalized on or after 5/1/03, use the State Spousal Resource Standard of $40,000 for the time period 8/1/03 through 6/30/05. (Effective July 1, 2013 State Spousal Resource shared increase to $53,016.) unless the individual or the individual's spouse requests an evaluation of the community resources.
If the individual or the individual's spouse requests an evaluation of the community resources, determine the amount of the spousal share as of the first day of the month the individual became institutionalized.
The individual and spouse had a total of $90,000 of nonexcluded resources on 8/01/03 (the first day of the month that the individual became institutionalized) One-half of the total was $45,000. This is the spousal share. For this individual we would use the spousal share of $45,000 as the Community Spouse Resource allocation because it is higher than the State Spousal Resource Standard and less than the Federal Community Spouse Resource Allocation maximum
The most we can allow is the Federal Community Spouse Resource Allocation maximum. As of 8/1/03 $90,660. If we evaluated the couple's resources and found they had a total of $200,000 in nonexcluded resources as of 8/1/03, then we would use the Federal Community Spouse Allocation maximum in place at the time of application. This is because the spousal share of $100,000 is greater than both the State Spousal Resource Allocation standard and the Federal Community Resource Allocation maximum.