463-1 Determine Total Income and Cost-of-Care Contribution

Effective Date: June 1, 2020

Previous Policy Determining Total Income (414-1)

Previous Policy for Short-Term Stay (414-2)

A. Total Income

1. For the process of determining the member’s cost of care contribution for long-term care services, consider only the member’s income 413-4. Do not deem income from a spouse or parent. This includes residents of nursing facilities and HCB waiver recipients in the Special Income coverage group. (Sec 381 through 389 for waiver deductions.)

Use the member's total income excluding only the following types of income:

· SSI and SSP benefits paid under 1611(e)(1)(E) and (G) of the Act to individuals who receive care in a hospital, nursing home, SNF, or ICF.

· Austrian Reparation Payments

· German Reparations Payments made by the Federal Republic of Germany.

· Japanese and Aleutian Restitution Payments.

· Netherlands Reparation Payments based on Nazi, but not Japanese, persecution during World War II.

· Payments from the Agent Orange Settlement Fund or any other fund established pursuant to the settlement regarding Agent Orange product liability litigation.

· Radiation Exposure Compensation.

· VA pensions limited to $90 per month under 38 U.S.C. 5503.

· Federal tax refunds, including tax credits included in the refund amount .

· Payments received by an American Indian/Alaska Native under the Individual Indian Money Account Litigation Settlement as required by Pub. L. 111-291 (403-16 and 417-14).

· Amounts an American Indian/Alaska Native receives from the conversion of protected assets under the American Recovery and Reinvestment Act of 2009 (ARRA). (521-5)

· Payments made to American Indians/Alaska Natives under various federal laws as defined in Sec. 417-14.

2. The member’s total income includes all other income, even income that is not counted for other programs.

B. How to Count SSI and SSP

1. Do not count SSI payments for the first three calendar months after the member enters the nursing home. After 3 months, count any SSI and SSP (661) received by the member to determine the member's contribution to the cost of care.

2. If the payment is not reduced to $30 after the first three months do not count the money if you verify the member has returned the money to SSI. If necessary, help the member return the money to SSI. If the member refuses to return the money to SSI, count it as income. If, after counting the payment, SSI contacts the member or nursing home and requests a refund, adjust the payment system to reimburse the nursing home after you have received verification the check has been returned.

C. Deductions From Total Income

Long Term Stay Members

1. Deduct these amounts from the member’s total income in the following order to determine the member’s contribution to the cost of care:

a. Earned income deduction (431-4).

b. Personal Needs Allowance (PNA) (431-8) or the BMS, see 'Short Term Stay for Unmarried members' below .

c. Spousal Needs Allowance (SNA) (431-9).

d. Deduction for Dependent Family Members (431-10).

e. Health Insurance Premiums (431-1.3).

f. Medical Expenses (463-3).

2. If the member's contribution to the cost of care is equal to or less than what the nursing home would charge a private pay resident, open the case for nursing home care.

3. If the member’s contribution to the cost of care is more than the nursing home private pay rate, determine if the case should be opened for ancillary services (833).

Short Term Stay for Unmarried Members

1. An unmarried member or a person whose spouse resides in a medical institution is allowed to keep more income if the doctor verifies that he expects the member will stay in a medical institution for 6 months or less. A member in a medical institution for a short-term stay gets a personal needs allowance of the one-person BMS ($382).

· Do not count the month the member enters a nursing home as one of the six months when allowing this deduction.

· Deduct health insurance premiums (431-1.3)

· Allow deductions for medical bills the member owes (463-3)

2. If the diagnosis changes during the first six-months, change the individual’s status effective the month after the change.

· Example: The member enters a nursing home in May. The doctor originally indicated the stay would be long-term, but in August the doctor provides a statement saying the stay will now be short-term. Change the case for September-November to short-term and allow the BMS as the personal needs allowance.

Making Payments

If the member is a resident of a nursing home, Utah State Developmental Center, or Utah State Hospital the member must pay the contribution towards cost of care to the facility they live in.

If the member is a resident of a medical institution OTHER THAN Utah State Developmental Center, Utah State Hospital, or a nursing home, the member must may the contribution towards cost of care to the Department of Workforce Services.