Determining Eligibility for Medical Assistance

PURPOSE: This rule provides that the decision on the factor of disability shall be made by a qualified medical consultant employed by the division except in cases involving disability-based Social Security Income or Retirement, Survivor’s and Disability Insurance, and establishes the principles used by county staff in determining eligibility for Medical Assistance only on the basis of income. (1) The medical diagnosis and other medical information on Medical Assistance (MA), Supplemental Nursing Care (SNC), Aid to the Blind (AB) and Blind Pension (BP) cases shall be reviewed by a medical consultant employed by the Family Support Division, who shall certify eligibility or ineligibility on the basis of permanent and total disability or vision, except that this review will not be required to certify permanent and total disability when the claimant receives Supplemental Security Income (SSI) or Retirement, Survivor’s, and Disability Insurance (RSDI) based on his/her disability. In these cases, the verification of the receipt of disability-based SSI or RSDI benefits will be sufficient to establish permanent and total disability. (2) If a single individual has an adjusted gross income per month that does not exceed the income limit and meets the other eligibility requirements, s/he will be eligible for MA. If eligibility is based on AB provisions, the income limit is one hundred percent (100%) of the federal poverty level (FPL). If eligibility is based on MO HealthNet for Aged, Blind, and Disabled (MHABD) or Permanent and Total Disability (PTD) provisions, the income limit is eighty-five percent (85%) of the FPL. For a married couple living together, the adjusted gross income limitation will be one hundred percent (100%) of the FPL for two (2) persons, if eligibility is based on AB provisions. For a married couple living together, the adjusted gross income limitation will be eighty-five percent (85%) of the FPL for two (2) persons, if eligibility is based on MHABD or PTD provisions. In determining adjusted gross income, the following exemptions will be applied to the gross income: (A) If the income is earned or unearned, an amount of twenty dollars ($20) may be excluded from the gross. Payments for premiums for medical insurance, including Supplemental Medical Insurance (SMI) premium, may be excluded; (B) The full amount of any SSI payment will be excluded; and (C) If the income is earned, the twentydollar ($20) exclusion in subsection (2)(A) will be applied plus the first sixty-five dollars ($65) and one-half (1/2) of the remainder of all earned income will be excluded. If a person is a student and is under the age of twenty-two (22), the amount of the school expense will be excluded from any earned income. If eligibility is based on AB provisions, any work-related expenses also will be excluded from earned income. (3) If an individual qualifies for institutional vendor payments under the MA program, fifty dollars ($50) of the individual’s personal income shall be retained as his/her personal needs allowance. Federal regulation 42 CFR, Section 435.733 provides that there shall be a minimum amount available to meet the clothing and other personal needs of the individual. In order to meet other of the individual’s basic personal needs, this amount shall not be exhausted to satisfy any guardianship fees, court costs, attorney’s fees, or other related legal or court costs, or any combination of these, resulting from the administration of a guardianship or conservatorship, or both that has been sought on behalf of the Medicaid recipient. The claimant’s personal needs allowance shall not be used for the provision of any medical or remedial services, or both, that are covered through the Missouri Medical Exception Process. Institutionalized individuals who participate in sheltered workshops are allowed a personal needs allowance of fifty dollars ($50) plus the sheltered workshop income. (4) When an individual living in his/her home is assessed by Department of Health and Senior Services as needing both a nursing facility level-of-care as defined in 19 CSR 3081.030 and home- and community-based waiver services, his/her gross monthly income shall be compared to one thousand three hundred eleven dollars ($1,311) effective January 1, 2018, subject to adjustment by the Consumer Price Index beginning January 2019, if his/her gross monthly income is equal to or less than one thousand three hundred eleven dollars ($1,311), s/he shall be considered income eligible for Title XIX under the MA program. When his/her gross monthly income is greater than one thousand three hundred eleven dollars ($1,311), s/he must qualify for Title XIX in accordance with section (2) of this rule. (5) If an institutionalized spouse (as defined in 13 CSR 40-2.030) qualifies for institutional vendor payments under the MA program, in determining the amount the institutionalized spouse must pay to the medical institution or nursing facility for the cost of his/her care, the following amounts shall be disregarded: (A) A community spouse monthly income allowance which shall be determined as follows: 1. The amount by which— A. The applicable percentage of the Federal Poverty Level for two (2) persons; plus B. The amount by which the community spouse’s shelter expenses exceed thirty percent (30%) of the applicable percentage of the Federal Poverty Level for two (2) persons; exceeds C. The community spouse’s own income; 2. The amount determined in subparagraphs (5)(A)1.A. and B. may not exceed one thousand five hundred dollars ($1,500), subject to adjustment by the Consumer Price Index beginning January 1990; 3. The amount of court-ordered support, if higher, may be substituted for the amount determined in paragraph (5)(A)1.; 4. The applicable percentages of the Federal Poverty Level specified in paragraph (5)(A)1. shall be as follows: A. Effective September 30, 1989, one hundred twenty-two percent (122%); B. Effective July 1, 1991, one hundred thirty-three percent (133%); and C. Effective July 1, 1992, one hundred fifty percent (150%); 5. Allowable shelter expenses for the community spouse shall include the following expenses incurred at the principal place of residence of the community spouse: A. Mortgage payment or taxes, or both, and insurance; B. Rent; C. Maintenance fee for condominium or cooperative apartment; and D. The utility standard of the Food Stamp program in accordance with the Food Stamp Act of 1977, if the utility expenses are actually incurred and are not a part of the maintenance fee or rent previously allowed. If the community spouse’s only utility is telephone, the standard used shall be the telephone standard of the Food Stamp program. If the community spouse incurs any other type of utility, the standard used shall be the utility standard of the Food Stamp program; 6. If either spouse establishes in a fair hearing that the allowance as determined by the Family Support Division is insufficient (resulting in significant financial duress), an adequate amount may be substituted; and (B) An allowance for each family member equal to one-third (1/3) of the amount by which the amount described in subparagraph (5)(A)1.A. exceeds the monthly income of that family member. As used in this rule, the term family member shall mean minor or dependent children, dependent parents, or dependent siblings of either spouse who are residing with the community spouse. Dependent as used here means an individual who could be claimed as a dependent for federal income tax purposes. (6) Pursuant to the determination of the Health Care Financing Administration of the United States Department of Health and Human Services, no amounts charged as guardianship or conservatorship fees, court costs, attorney’s fees, or other related or similar legal or court costs are properly classified as necessary medical or remedial care. Therefore, no charges shall be recognized or allowed by this agency for the purpose of deducting those sums from an individual’s total income, when that individual qualifies for institutional vendor payments under the MA program established pursuant to Title XIX of the Social Security Act, 42 U.S.C. 1396. (7) Persons who are eligible for MA only must meet the eligibility requirements, other than income, for Old Age Assistance, Permanent and Total Disability or AB that was in effect in January 1972, except that the Homemaker provision will not be applied to the determination of disability in these cases. (8) Persons who receive SSI may receive MA if they meet the eligibility requirements, other than income, for General Relief that were in effect January 1972. However, in determining eligibility for MA, the eligibility requirements described in section (6) must be applied first. AUTHORITY: sections 207.022 and 660.017, RSMo 2016.* Original rule filed Sept. 26, 1951, effective Oct. 6, 1951. Amended: Filed Nov. 4, 1954, effective Nov. 14, 1954. Amended: Filed Feb. 27, 1974, effective March 9, 1974. Amended: Filed April 25, 1974, effective May 5, 1974. Amended: Filed June 3, 1974, effective June 13, 1974. Amended: Filed June 10, 1975, effective June 20, 1975. Amended: Filed July 8, 1977, effective Oct. 13, 1977. Amended: Filed March 13, 1978, effective June 11, 1978. Amended: Filed April 17, 1987, effective Sept. 11, 1987. Amended: Filed Sept. 6, 1988, effective Dec. 11, 1988. Emergency amendment filed Sept. 19, 1989, effective Oct. 1, 1989, expired Jan. 28, 1990. Amended: Filed Nov. 2, 1989, effective Jan. 26, 1990. Emergency amendment filed Dec. 18, 1992, effective Jan. 1, 1993, expired April 30, 1993. Emergency amendment filed Feb. 26, 1993, effective May 1, 1993, expired Aug. 28, 1993. Amended: Filed Dec. 18, 1992, effective June 7, 1993. Emergency amendment filed Dec. 13, 1993, effective Jan. 1, 1994, expired April 30, 1994. Amended: Filed Dec. 13, 1993, effective July 10, 1994. Emergency amendment filed Dec. 29, 1994, effective Jan. 8, 1995, expired May 7, 1995. Amended: Filed Jan. 12, 1995, effective July 30, 1995. Amended: Filed June 27, 2005, effective Jan. 30, 2006. Amended: Filed Sept. 18, 2018, effective May 30, 2019. *Original authority: 207.022, RSMo 2014 and 660.017, RSMo 1993, amended 1995. Bell v. Missouri State Division of Family Services, 597 SW2d 699 (Mo. App. 1980). 13 CSR 40-2.200, insofar as it makes the Medical Review Team report controlling upon the director upon appeal, is inconsistent with section 208.075, RSMo and to that extent is invalid.