627.04 Criteria for Increased Income Allocation Due to Significant Financial Duress (MAM)

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If either spouse verifies at an administrative appeal that the community spouse needs a higher income allowance than is determined according to policy and procedures in 627.03, Allocation to a Community Spouse, the Appeals Officer may allocate an additional sum from the institutionalized individual's income available for allocation to provide for unmet needs due to exceptional circumstances resulting in significant financial duress.

The following is an all-inclusive list of exceptional circumstances resulting in significant financial duress:

. costs of medical, remedial, or other support services, including medical insurance, necessary for community spouses to maintain themselves in the community;

. cost of repairs which are necessary to maintain the home in a livable condition;

. cost of repairs to appliances within the home;

. cost of repairs or maintenance of one vehicle, including insurance and registration;

. costs associated with unforeseen circumstances such as fire or flood which result in loss of housing, clothing, household goods or other necessities; and

. costs for items or services which have been certified in writing by a physician as being medically necessary to maintain the community spouse in the community.

Acceptable documentation of the above costs is a currently dated bill or written estimate from the provider which indicates the amount of the expense.

When the Appeals Officer determines that significant financial duress exists as a result of one or more of the costs described, the community spouse's income allowance must be adjusted by the District Office as follows:

. If the cost is a one time expense and the institutionalized individual has sufficient monthly income to allocate to the community spouse to cover the cost, the allowance is adjusted only in the month that the expense is approved.

. If the cost is a one time expense and the institutionalized individual has insufficient monthly income to allocate to the community spouse to cover the cost, the cost is prorated and the allowance adjusted for the specific number of months required to accommodate the expense.

. If the cost is an ongoing expense, the allowance is adjusted for the specific number of months for which the ongoing expense exists, if known, or until a change is reported or at the next regularly scheduled redetermination, whichever occurs first.

The Appeals Officer may also, under certain circumstances, increase the community spouse resource allowance to generate additional income to the community spouse. See Section 419.03, Determining the Protected Resource Amount.