619.01 Cost of Care: Nursing Facility SR 94-04, 04/94 (AAM-A)

After the individual is determined to be eligible for nursing facility care, they are responsible for applying any available income toward the cost of care. The individual is allowed to keep a personal needs allowance each month. Use the following steps to determine the cost of care.

1. Add reduced SSI benefits to net income determined in Part 619. The result is available income to apply toward the cost of care.

2. Subtract one of the following:

- if entitled, the VA $90 Nursing Facility Pension or

- a $40 personal needs allowance. See Section 619.03, Supplemental Payments, for individuals with monthly income less than the $40 personal needs allowance.

3. Subtract the amount of income to be allocated. See Section 627, Allocation of Income.

4. Subtract the monthly cost incurred by the individual for their own:

- health insurance premiums (including Medicare Part B), coinsurance payments, and deductibles,

- necessary and remedial care that would be covered by medical assistance except that allowable payment limits have been exceeded,

- necessary and remedial care that is recognized by state law, but not covered by medical assistance per Item 902 of the Medical Assistance Manual, and

- currently obligated, unpaid prior medical debt.

 Exceptions: Do not subtract an amount for any medical expense that has been used to offset income or resources, e.g., expenses applied to meet an In and Out spenddown (Part 625, In and Out Medical Assistance) or expenses used to meet a Life Insurance Offset.

5. Add the VA Aid and Attendance Allowance. The result is the amount of income the individual must apply toward the cost of care.

6. Complete Form 273, Nursing Home Prior Authorization, or Form 278, Nursing Home Prior Authorization Update.