550           ELIGIBILITY CATEGORIES FOR AN INDIVIDUAL LIVING IN AN INSTITUTION

550 A.      SSI Supplemental Security Income OR APA Adult Public Assistance RECIPIENT LIVING IN AN INSTITUTION

An individual who receives SSI Supplemental Security Income or APA Adult Public Assistance cash assistance while residing in a medical institution or nursing facility may remain eligible for cash assistance and Medicaid.  Some individuals may be eligible for cash assistance because they are living in an institution.  Because these individuals are eligible for Medicaid as a cash assistance recipient, they are not subject to Medicaid cost of care requirements.  See Section 570.  However, they may have their cash assistance grant reduced.  See APA Adult Public Assistance Manual Sections 450-5 and 452-5C.

Example 1:

Mr. Rice is a disabled man residing in the community with his employed wife.  He has no income of his own.  Because of his wife's income, Mr. Rice is not eligible for SSI Supplemental Security Income or APA Adult Public Assistance.  On March 5th, Mr. Rice enters a nursing facility.  SSI Supplemental Security Income rules require that the wife's income be considered as available to her husband through the month in which they cease to live together (March).  In April, his wife's income is no longer considered available to him since he is institutionalized, unless it is actually given to him.  Mr. Rice applies for SSI Supplemental Security Income and APA Adult Public Assistance and is found to be eligible as of April.  He is Medicaid-eligible as of April 1 based on the receipt of SSI Supplemental Security Income and APA Adult Public Assistance and is not required to contribute toward the cost of his care.  Mr. Rice is not Medicaid-eligible in March.

Example 2:

Mr. Bruce is a disabled man residing in the community and is receiving SSI Supplemental Security Income and APA Adult Public Assistance.  On March 5th, Mr. Bruce enters a nursing facility.  He is eligible for Medicaid based on receipt of his March SSI Supplemental Security Income and APA Adult Public Assistance cash assistance.  It is determined that Mr. Bruce will remain eligible for reduced SSI Supplemental Security Income and APA Adult Public Assistance cash assistance in the institution because he has no other source of income.  He is Medicaid-eligible and is not required to contribute toward the cost of his care.

550 B.      INDIVIDUAL ELIGIBLE FOR SSI Supplemental Security Income OR APA Adult Public Assistance CASH ASSISTANCE IF NOT IN AN INSTITUTION

An individual who would be eligible for SSI Supplemental Security Income or APA Adult Public Assistance cash assistance if he or she were not residing in an intermediate care or skilled nursing facility is Medicaid-eligible.  This individual cannot qualify for a cash assistance program because his or her needs are less in the institution than they would be if the individual were residing in the community.  First, establish eligibility and then establish the amount the individual must contribute toward the cost of care.  See Section 570 for policy on cost-of-care determinations.

550 C.      SPECIAL LONG TERM CARE ELIGIBILITY CATEGORY

Note:

Historically, this eligibility category was known as the Special Income 300% eligibility category because the income standard was 300% of the SSI Supplemental Security Income standard. In 2003, the income standard was frozen at the 2003 level of $1,656 and no longer reflected 300% of the current SSI Supplemental Security Income standard. As of September 1, 2010, the Long Term Care income limit again reflects 300% of the prevailing SSI Supplemental Security Income standard, which increases each year.  

Nursing Home:  An individual who resides in an intermediate care or skilled nursing facility is Medicaid-eligible if the individual:

1. Meets all requirements of the SSI or APA program except for income and the financial eligibility rules in Sections 553 - 555;
    

2. Has gross income equal to or below the Long Term Care Income Standard (no income disregard applies) See Addendum 1 for amount; and
    

3. Has resided in the institution for 30 consecutive calendar days.  Although the Medicaid determination cannot be made before the end of 30 full days, once eligibility is found to exist, the individual is eligible from the date of entry into the facility.  If the individual in the institution dies on or before the 30th day, the deceased individual is considered to have met the 30-day requirement.

HCB Home and Community-Based Waiver:  An individual who has been approved by DSDS Division of Senior and Disabilities Services to receive Home and Community Based ( HCB Home and Community-Based ) waiver services is Medicaid eligible if the individual:

1. Meets all requirements of the SSI or APA program except for income, age and the financial eligibility rules in Sections 553 - 555; and
    

2. Has gross income equal to or below the Long Term Care Income Standard (no income disregard applies) See Addendum 1 for amount. When determining eligibility for a disabled child who has a current DDS Disability Determination Service decision on file, the income and resources of the child’s parents are not counted, even if the child is living with his or her parents.  Individuals who can qualify for Medicaid under regular need standards are not subject to the Long Term Care income eligibility standard.

Because a recipient of HCB Home and Community-Based waiver services lives in his or her own home (or assisted living home), and not in an institution, the 30-day waiting period described above does not apply.