619.01 Cost of Care: Nursing Facility (MAM) |
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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. Determine the individual's gross earned income.
2. Subtract the employment expense disregard from the individual's gross earned income to obtain net income. SeeSection 603.03, Employment Expense Disregard (EED).
3. Add the individual's total unearned income, including SSI benefits. The result is available income to apply toward the cost of care.
4. Subtract one of the following:
- if entitled, the VA $90 Nursing Facility Pension; or
- a $74 personal needs allowance.
5. Subtract the amount of income to be allocated. See PART 627, ALLOCATION OF INCOME.
6. 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. For a list of covered and non-covered services, refer to NH administrative rules PART He-W 530, SERVICE LIMITS, CO-PAYMENTS, AND NON-COVERED SERVICES (http://gencourt.state.nh.us/rules/state_agencies/he-w500.html); and
- currently obligated, unpaid prior medical debt. For nursing facility debts use the Medicaid provider payment rate for the facility, not the actual rate billed by the facility. See BEAS'Appendix A of the Medicaid Manual, "Nursing Facility Rates" for Medicaid provider payment rates.
Note: The following do not count as "currently obligated, unpaid prior medical debts:"
. cost of care liability from prior months that have not been paid; and
. nursing facility debt incurred while an individual is in a transfer of assets penalty period.
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.
Examples
Mary's cost of care effective in January is $1,000. In March, Mary's authorized representative reports that Mary did not pay the $1,000 liability for either January or February and would like to use the $2,000 that Mary owes to the nursing facility as a "currently obligated, unpaid prior medical debt." In this case, the $2,000 is not a "medical debt," because it is a "cost of care liability" that Mary was supposed to pay in January and February. It cannot be subtracted again when determining the current cost of care liability for March or any future months.
Joe resides in a nursing home and sells his house to his cousin for $10. He is penalized for 4 months for transferring assets for less than fair market value. During those 4 months, Joe is not eligible for assistance and accumulates nursing home bills. In the fifth month, Joe applies for assistance and wants to use his bills incurred during the penalty period as "currently obligated, unpaid prior medical debts." These debts are not subtracted when determining cost of care, as they are not "prior medical debts", but rather debts he was responsible for during the penalty period.
Ralph applies for nursing facility assistance on September 1. He has $5,000 in counted resources and had more resources in previous months. Ralph has currently obligated, unpaid nursing facility debts for June, July, and August. Although Ralph's resources exceeded the resource limit in June, July, and August, and Ralph was therefore ineligible for nursing facility care, the nursing facility bills owed for those months can be used as "currently obligated, unpaid prior medical debts" to offset Ralph's current cost of care liability, once he is eligible for assistance.
7. Subtract continuing SSI benefits.
8. Add the VA Aid and Attendance Allowance. The result is the amount of income the individual must apply toward the cost of care.
9. Complete Form 273, Nursing Home Prior Authorization, or Form 278, Nursing Home Prior Authorization Update.
Nursing facility residents are allowed to adjust the cost of care liability amount on a monthly basis to pay:
. a current out of pocket medical expense; or
. a currently obligated prior medical expense.
The Nursing Facility:
. reports the medical expense on DFA Form 295, Request to Adjust Patient Liability; and
. provides documentation verifying the expense reported.
Adjust the amount of the cost of care liability, determined in steps 1 through 9 above, for as many months necessary to allow the nursing facility resident to pay the medical expense. Do not make any adjustments until all documentation is received.
References: He-W 854.17, He-W 854.18(a), RSA 167:27-a, 42 CFR 435.733(c), 42 CFR 435.832(c), 38 USC 5503