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2000-2200-2400-2600 Florida Medicaid ESS Policy Manual

Chapter 2000. Coverage Groups.

2040.0801.Supplemental Security Income (SSI) Coverage Groups. Any Florida resident who is determined eligible for SSI benefits is automatically entitled to Florida Medicaid. However, there are additional Title XIX requirements in order to qualify for Medicaid’s institutional care program.

2040.0802.02 – 2040.0802.07.Discusses criteria which must be verified: age, disability/blindness,citizenship, Florida residence, and income.

2040.0804.02.Effective Date of Coverage. An individual can apply for up to three months of retroactive Medicaid based on the month of application.

2040.0812.01.Retroactive Medicaid.

2040.0812.02.Requirements for Retroactive Medicaid Coverage (RMAO).

·        Must file an application for ongoing assistance(RMAO can be made for a deceased individual)

·        In retroactive period, individual must have started receiving medical services which would be reimbursable by Medicaid.

·        A determination of eligibility must be made for each of the retroactive months requested.

2040.0812.03. Date of Entitlement for Retroactive Medicaid. If individual is determined eligible for any day in a month, they are eligible for that full calendar month.

2040.0814.01. Hospice.

2040.0814.02.Additional Criteria for Hospice Eligibility.   

2040.1814.03. Hospice for Institutionalized Individual.

2040.0815.01. Home and Community Based Services. HCBS programs are considered Medicaid Waiver Programs. Their purpose is to prevent institutionalization of the individual providing care in the community with specific providers.  See 0240.0111 for a list of Medicaid Waiver Programs. To be eligible, they must meet all SSI-Related criteria and have income and assets within limits of ICP program.

2040.0815.02 – 2040.0815.08.Additional Criteria for different HCBS Waiver Programs:

·        Cystic Fibrosis Waiver;

·        Familial Dysautonomia Waiver;

·        iBudget Florida (disabled or aged);

·        HCBS Model Waiver (under 21 with degenerative spinocerebellar disease);

·        Project AIDS;

·        HCBS Statewide Managed Medical Care Long Term Care (65 years old or older, meet level of care requirement by CARES, be enrolled in waiver with specific managed care provider as documented by form CF-ES 2515).

·        Traumatic Brain Injury (TBI) / Spinal Cord Injury Waiver.

2040.0822. Optional State Supplementation (OSS) Program. ALF.

2040.0823. Program of All-Inclusive Care for the Elderly (PACE).

Chapter 2200. Standard Filing Unit.

2240.0100. Standard Filing Unit. The standard filing unit (SFU) is the single individual or group of individuals whose income, assets or needs are considered in the eligibility determination.

2240.0612. Couple/One Requests Institutional Care Services. Applies to ICP, PACE, Hospice, and Long-Term Care Community Diversion Waiver (Note: HCBS is not listed).

Income: If an individual has a community spouse and only one spouse is requesting institutional services, the income standard for one is used. Only the institutionalized individual’s income is used to determine his income eligibility.

After eligibility is established, income may be allocated to the legal spouse, family member and dependents in accordance with Chapter 2600.

Assets: Total countable assets of both spouses are considered and am amount is allocated to the community spouse in accordance with the policies in Chapter 1600.

2240.0613. Eligible Couple / Both Request ICP, HCBS, or Hospice. Couple can choose whether to be considered as a couple or as individuals, whichever is to their advantage.

Income to dependents and family members must be allocated except in the HCBS Program (for which you do not allocate income to dependents or family members (see Chapter 2600 for allocation policies)

Chapter 2400. Budgeting Income.

2440.0100. Income Limits. See Appendix A-9 and Appendix A-12 for the standard income eligibility tables.

2440.0103. Income Limits. For ICP, HCBS or PACE, income may not exceed 300% of SSI Federal Benefit Rate (FBR) without establishing an incometrust.

2440.0110. Disabled Adult Children (DAC).

2440.0370. Ordinary and Necessary Expenses. Ordinary and necessary expenses deducted from unearned gross income are excluded (e.g. expenses incurred in obtaining or gaining access, such as attorney fees and costs and medical exam fees connected with the filing of a personal injury lawsuit, may be deducted from settlement proceeds).

2440.0371. Optional Deductions.Certain deductions are withheld at the source from an individual income that MUST BE INCLUDED in the amount of unearned income counted. Examples of optional deductions are: premium for Part B Medicare from a Social Security Benefit;premiums for health insurance or life insurance; federal and state income taxes.


2440.0502. When Income Should Be Averaged.

2440.0510. How to Count Income for Eligibility. Both earned and unearned income are treated the same for SSI-Related Medicaid Programs. All income is converted into a monthly amount for budget purposes.

Refer to Chapter 2600 for allowable income disregards and deductions.

2440.0512. How to Count Income for Patient Responsibility.

Chapter 2600. Calculating Benefits.

Once eligibility specialist has determined available income as per Chapters 1800 and 2400, the policy in this chapter must be used to determine eligibility for benefits and the actual benefit amount.

2640.0116.Eligibility Tests.

2640.0116 – 2640.0125.04 applies to ICP and HCBS.

2640.0117. Patient Responsibility Computation (ICP + HCBS Waivers Cystic Fibrosis, iBudget and Statewide Medicaid Managed Care Long-Term Care).

STEP (1) Deduct personal needs allowance (PNA) and ½ of gross therapeutic wages up to maximum of $111 for institutionalized individuals only, if applicable (see 2640.0118 for more info on personal needs allowance).

STEP (2) Deduct community spouse income allowance or dependent allowance, if applicable.

STEP (3) Consider protection of income policies for the month of admission.

STEP (4) Deduct uncovered medical expenses ad discussed in 2640.0125.01 – 2640.0125.04.

The balance is patient responsibility.

2640.0117.01. Home and Community Based Services Waiver Programs with no Patient Responsibility:familial dysautonomia, model, Project AIDS Care, Traumatic Brain Injury and Spinal Cord Injury.

2640.0118. Personal Needs Allowance. For ICP: $105.00

For Statewide Medicaid Managed Long-Term Care Program:

·        For individual residing in the community (not ALF): PNA is 300% of federal benefit rate

·        For individual residing in an ALF, PNA is a basic monthly rate (three meals per day and a semi-private room) + 20% of federal poverty level. The ALF basic monthly rate will vary depending on the facility's actual room and board charges.

·        For individual residing in nursing home: $105.00

2640.0119.01.Community Spouse Income Allowance (ICP, SMMC-LTC, PACE). If community spouse has gross income less than state’s minimum monthly maintenance needs allowance (MMMNA) plus CS excess shelter expense costs, a portion of MA's income may be allocated to meet the needs of the community spouse.

A community spouse who refuses to make his/her assets available to the MA spouse is not entitled to a community spouse income allowance.

2640.0119.03. Formulafor Community Spouse Income Allowance.

(MMMNA + Community Spouse’s Excess Shelter Costs) – (Community Spouse's Gross Income) = Community Spouse’s Income Allowance.

The CS Income Allowance is the total amount that can be allotted to the CS from the IS.

MMMNA + CS excess shelter cost cannot exceed state’s cap on CS Income Allowance (see Appendix A-9).

Institutionalized Spouse’s PNA and deduction for therapeutic wages is deducted prior to deducting the CS Income Allowance

If there is court ordered support against IS (for monthly support income for the CS) the CS monthly income allowance cannot be less than the amount ordered.

2640.0119.04.Determining Community Spouse’s Excess Shelter Costs.

STEP (1): Verify CS monthly expenses if questionable(rent/mortgage, taxes, homeowners or renters insurance, maintenance charges if condo and mandatory HOA fees). Do not include expenses paid by someone other than the CS. Add these all up.

STEP (2): Add current food stamp standard utility disregard(See Appendix A-1) of CS pays utility bills (water, sewage, gas and electric).

STEP (3): To determine what portion of shelter costs is excess, subtract 30% of state’s income allowance, from total costs. The difference is the CS’s excess shelter costs.

2640.0120.01. Family Allowance (for ICP, and SMMC LTC Programs). When eligible individual has dependent relatives living with the community spouse, each family member whose income is less than state’s MMMNA may receive a portion of individual’s monthly income.

If there is a CS, but the dependent family members do not live with CS, no family allowance may be authorized.

If institutionalized individual has a dependent child underage of 21 or disabled adult child living at home, but no community spouse,refer to Section 2640.0121, below.

2640.0120.02.Computation of Family Allowance.

STEP (1) – Subtract family member’s income from MMMNA.

STEP (2) – Divide total from above by three, and the result is the family member allowance.

Each dependent family member allowance must be separately computed and then added together to determine total family allowance.

2640.0121. Dependent Allowance. When eligible individual has no community spouse but has dependent unmarried children under 21 or disabled adult child living at home,the dependent child is entitled to a portion of MR’s equal to the TCA Consolidated Needs Standard minus the dependent’s income. (Refer to Appendix A-5 for the CNS).

2640.0122. Minimum Monthly Maintenance Needs Allowance (MMMNA). This income allowance is the basic monthly allowance the state recognizes for a community spouse whose spouse is institutionalized. Florida’s MMMNA is 150% of the poverty level for two individuals.

If either spouse establishes that the community spouse income allowance is inadequate due to exceptional circumstances of significant financial duress, the hearing officer may establish a higher income allowance(above established MMMNA) through the fair hearing process.

2640.0123. Protecting Income – month of Admission/Discharge.

2640.0125.01.Uncovered Medical Expenses. 2640.0125.01 – 2640.0125.05 is applied in considering post-eligibility treatment of income and uncovered medical expenses. An uncovered medial expense deduction is allowed for premiums,deductibles, co-insurance and health insurance payments from an institutionalized individual’s income to determine patient responsibility.

2640.0133. HCDA Eligibility Determinations (Home Care for Disabled Adults).  

2640.0200. DEEMING.Deeming of income refers to the portion of income of one individual’s income and sometimes assets as available to another individual even if the income and assets are not actually available based upon the assumption if a “legal obligation” of the first individual to the second. Examples are spouse to spouse and parent to child.

2640.0300. PRORATION.


2640.0415. Lump Sum Income.

2640.0418.Self-Employment Income.

2640.0423. ICP Therapeutic Wages (for ICP + HCBS Waiver Programs for computing patient responsibility).

Therapeutic wages are earned income and count in the budget when they become available. No earned income disregards are allowed. Refer to passage 2640.0118 and Chapter 1800 for a discussion of therapeutic wages and the personal needs allowance.

Other Medicaid Lawyer Summaries of ESS Policy Manual Sections

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