Ch. 332: Chapter 301. Standard Utility Allowance values can also be found at www.maine.gov/dhhs/ofi/fs-standards.shtml or by consulting www.fns.usda.gov/snap and search for Standard Utility Allowance Charts for the current values

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Code of Maine Rules › -144 Department of Health and Human Services Rules › Ch. 332

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section. If the individual or couple would be eligible for SSI after disregarding the increase in Social Security, the individual or couple is eligible for coverage as Categorically Needy.

INDIVIDUALS WHO WERE ELIGIBLE AS "ESSENTIAL SPOUSES" IN DECEMBER 1973

The individual must have been living with a recipient of the Aid to the Aged, Blind or Disabled (AABD) program in 12/73 and receiving Medicaid at that time. "Essential Spouse's needs must have been used to determine the amount of the AABD grant." In order to continue Medicaid for the "essential spouse,” the former AABD recipient must continue to be eligible for an SSI payment and the needs of the "essential spouse" must continue to be included in determining the payment to the SSI recipient.

INSTITUTIONALIZED INDIVIDUALS WHO WERE ELIGIBLE IN DECEMBER 1973

The individuals must have been eligible for Medicaid in 12/73 as inpatients of medical institutions or intermediate care facilities that were participating in the Medicaid program. The individual must continue to meet Medicaid eligibility requirements in effect in 12/73, continue to reside in the institution and be classified as needing institutionalized care.

BLIND AND DISABLED INDIVIDUALS WHO WERE ELIGIBLE IN DECEMBER 1973

The individuals must meet all current Medicaid eligibility criteria except those for blindness or disability and must have continued to meet all criteria for Medicaid, including blindness and disability, in effect in 12/73.

Appendix E

Life Estate and Remainder Interest Tables

STATE OF MAINE

DEPARTMENT OF HEALTH AND HUMAN SERVICES

To: Case No:

CONSENT DECISION

On or about a hearing was requested on behalf of (applicant) _____ to appeal the allocation of spousal assets.

Both (applicant & spouse) and the Department agree to the following:

(applicant) resides in a nursing facility and applied for Medicaid on ___________. (applicant's spouse) is the community spouse

DEPARTMENT OF HEALTH AND HUMAN SERVICES

To: Case No:

CONSENT DECISION

On or about a hearing was requested on behalf of (applicant) _____ to appeal the allocation of spousal assets.

Both (applicant & spouse) and the Department agree to the following:

(applicant) resides in a nursing facility and applied for Medicaid on ___________. (applicant's spouse) is the community spouse.

As indicated below, (applicant’s spouse) can keep $__________ of the couple’s countable assets effective ___________.

INCOME ALLOWANCE

$ ____________ Monthly mortgage/rent

+ ____________ Real estate taxes

+ ____________ Condo fees

+ ____________ Home owners insurance

+ ____________ Utility standard

$ ____________ Total shelter expenses

- ______ 582.00 (30% of Chart 4.4)

$ ____________ Excess Shelter Expense

+ _____1,939.00 Minimum Monthly Income Standard (Chart 4.4)

$ ____________ May not exceed Monthly Income Allowance (Chart 4.4)

- ____________ Community spouse's gross income

- ____________ Community spouse monthly income allocation

= ____________ Deficit in meeting Monthly Income Allowance

Average cost of an annuity to generate $__________ per month income is $__________.

Dated Signed ( Supervisor)

for the Department of Health and Human Services

Dated Signed

Institutionalized spouse or representative

Based upon the agreement between the parties, this CONSENT DECISION to the hearing requested in this matter is the final agency action on the appeal.

Dated Signed

Hearing Officer

Appendix G

Supplies Provided to Recipients in a Nursing Facility

Below is a list of Supplies and Equipment provided to recipients by a Nursing Facility as part of regular rate of reimbursement:

The following items may not be billed by either the facility or supplier. Facilities which service a special group of the disabled are expected to furnish that equipment which is normally used in their care (e.g. children's wheelchairs) as a part of their reasonable cost

Below is a list of Supplies and Equipment provided to recipients by a Nursing Facility as part of regular rate of reimbursement:

Routine supplies and personal care items which are provided by the Nursing Facility under 67.05-11(A), may not be purchased by a resident and then deducted from their cost of care. The Nursing Facility must provide any brand name item to the resident as part of the Nursing Facility regular rate of reimbursement if the resident has a therapeutic need as documented by the physician.

Alcohol, swabs and rubbing

Analgesics: (non-prescription): 1) Acetaminophen: tablets, 325 mg, 500 mg; liquid; suppositories, 325 mg, 650 mg. 2) Aspirin: tablets, 325 mg, plain, buffered, coated; suppositories, 325 mg, 650 mg.

Antacids: aluminum hydroxide, magnesium hydroxide: gel and tablets (ex. Maalox). 2) Aluminum/magnesium hydroxide with simethicone (ex. Mylanta, Maalox Plus). 3) Calcium carbonate tablets (ex. Tums). 4) Calcium carbonate/magnesium hydroxide tablets (ex. Rolaids).

Alternating pressure pads, air mattresses, "Egg crate" mattresses, gel mattresses

Applicators

Bandages

Band-Aids

Basins

Beds (standard hospital type, not therapy beds)

Bed pans

Bed rails

Blood pressure equipment

Bottles (water)

Canes

Calcium supplements: 1) Calcium carbonate (ex. Tums). 2) Calcium carbonate with vitamin D (ex. Oscal).

Catheters

Catheter trays (disposable)

Chairs (standard, geriatric)

Combs

Commodes

Corner chair

Cotton

Cough syrup & expectorants: (non prescription) 1)Guaifenesin (ex. Robitussin). 2)Guaifenesin - DM (ex. Robitussin DM) 3) Ammonium chloride/diphenhydramine (ex. Benylin)

ment

Bottles (water)

Canes

Calcium supplements: 1) Calcium carbonate (ex. Tums). 2) Calcium carbonate with vitamin D (ex. Oscal).

Catheters

Catheter trays (disposable)

Chairs (standard, geriatric)

Combs

Commodes

Corner chair

Cotton

Cough syrup & expectorants: (non prescription) 1)Guaifenesin (ex. Robitussin). 2)Guaifenesin - DM (ex. Robitussin DM) 3) Ammonium chloride/diphenhydramine (ex. Benylin).

Crutches

Cushions (e.g., comfort rings)

Dietary supplements

Disinfectants

Douche trays (disposable)

Dressings

Enema equipment

Enteral feedings, supplies and equipment

Facility deodorants

Gauze bandages (sterile & unsterile)

Glucometers

General services such as administration of oxygen and related medications, hand feeding, incontinency care, tray service and enemas

Gloves (sterile)

Gloves (unsterile)

Gowns

Hemorrhoidal preparations

Ice bags

Incontinent supplies full brief - all sizes; bed pans; undergarment liners, disposable or reusable; under pads.

Iron supplements (oral: ferrous sulfate; ferrous gluconate; liquid and/or tablet

Irrigation trays

Laundry services, personal (including supplies and equipment)

Laxatives: Stool softeners: docusate sodium liquid or capsule. Bulk: psyllium. Stimulants: Bisacodyl tablets and suppositories; docusate casanthranol, liquid and/or capsule. Enemas: saline; phosphate types (ex. Fleets); oil retention. Misc.: Milk of Magnesia; glycerin suppositories; lactulose and analogs (when used as a laxative); mineral oil

y services, personal (including supplies and equipment)

Lotions (emollient) and Lubricants (skin, bath oil)

Mouth wash

Ointments and creams ( over the counter), including petroleum jelly and hydrocortisone 0.5%

Ophthalmic lubricants: tears, ointments

Oxygen, for emergency and prn use only

Parenteral solutions, supplies and equipment

Pillows

Pitchers (water)

Powders (medicated and baby)

Prone boards

Rectal medicated wipes

Restraints (posey, thoracic chest supports, tilt in space chairs, wedge pillows, etc.)

Shampoo: three types: 1) regular; 2) medicated; and 3) no tears - baby shampoo

Sheepskin

Shower chairs/ Tub seats

Soap: include one hypoallergenic type

Special dietary supplements

Specimen containers

Sterile I.V. or irrigation solution

Stethoscope

Sunscreen - level 30

Supplies (non-prescription) necessary for the treatment of decubiti

Suture sets

Swabs, medicated or unmedicated

Syringes and needles

Tapes

Testing materials to be used by staff or facility

Thermometers

Tissues

Toothbrush

Toothpaste - two types accepted by AFA; and a denture cleaner

Towels, washcloths

Tongue depressors

Traction equipment

Trapezes

Tubes (gavage, lavage, etc.)

Urinals

Urinary drainage equipment and supplies (disposable)

Vitamins: two brands acceptable to pharmacy and dietary

Walkers

Wheelchairs - standard, including those with removable arms and leg rests, pediatric, "hemi" chairs, reclining wheelchairs

Routine personal hygiene and grooming to include, but not limited to: shave, shampoo, bathing, nail clipping (unless specified as a covered service by a podiatrist in the MaineCare Benefits Manual), unless the services of a barber or hairdresser are requested by and paid for by the resident

Rout

ard, including those with removable arms and leg rests, pediatric, "hemi" chairs, reclining wheelchairs

Routine transportation of residents or laboratory specimens to hospital or doctors offices

Appendix H

Transfers Prior to January 1, 1994 and Trusts Prior to August 11, 1993

These rules apply to trusts that are set up prior to 8/11/93.

TRUSTS

Trust funds are available assets unless the terms of the trust make them unavailable.

If the trust is irrevocable, that is, no member of the assistance unit or any responsible relative residing in the home has the power to revoke the trust arrangement or change the name of the beneficiary, what is available to the client is what is made available according to the terms of the trust.

The terms of the trust may specify the amount/frequency and/or purposes for which the funds may be used or this may be left to the discretion of the trustee(s). The terms of the trust may use a combination of both trustee discretion and specific fund usage.

Of the funds left to trustee discretion, what is available to the client is whatever the trustee makes available.

Funds made available are considered as income or assets in accordance with applicable Medicaid eligibility rules for the situation.

If the terms of the trust restrict withdrawal by written approval of a judge of the courts, regular withdrawals will be treated as any other income. Irregular withdrawals, in order to be disregarded, must be used to supplement the needs of the person for whom the trust is drawn up.

Examples

awals will be treated as any other income. Irregular withdrawals, in order to be disregarded, must be used to supplement the needs of the person for whom the trust is drawn up.

Examples

An individual has a trust fund that was established upon the death of his parents based on their will. From this he is to receive $500 from the interest each month and $10,000 every three years to buy a new vehicle. The monthly payments are income. The $10,000 is used to purchase an excluded asset (the old vehicle is traded in to purchase the new one). This trust is irrevocable in accordance with the provisions above. The terms of the trust specify the amount, frequency and for part of the payments (the $10,000) the purpose. Medicaid policy treats interest payments as income and excludes the vehicle as an asset.

A trust was set up for the individual by his father who is deceased. The individual is to receive $200 per month for as long as the fund lasts. The fund currently has $140,000. The individual can get all the funds in the trust if there is an emergency. The $200 per month is considered income as long as this represents interest income. The remainder of the fund is considered an asset (currently $140,000) since it can be accessed by the individual.

A trust is set up for the individual by her grandmother. It is irrevocable and the trustee has full discretion in disbursement of the funds (totaling $75,000) based on the needs of the individual. Since the trust is irrevocable, what is considered available to the individual is whatever the trustee, in her discretion, makes available.

Medicaid Qualifying Trusts

Even if a trust is irrevocable, it may be considered as an available asset if it meets certain conditions listed below. These are called Medicaid Qualifying Trusts. This is a type of trust or other legal device which:

is established by the individual or individual's spouse (other than by will)

to the individual is whatever the trustee, in her discretion, makes available.

Medicaid Qualifying Trusts

is established by the individual or individual's spouse (other than by will). It may be irrevocable or established for purposes other than to enable the grantor to qualify for Medicaid;

the individual is the beneficiary of all or part of the payments from the trust;

the distribution of such payments is determined by one or more trustees who are permitted to exercise discretion with respect to the distribution to the applicant; or

when established by the individual's or spouse's legal guardian or power of attorney, the trust is considered to have been established by the individual or spouse whom they represent.

The amount of this trust that is counted as an asset is the total undistributed amount that is permitted under the terms of the trust that the trustee could disburse if he, as trustee, exercised his full discretion.

Because Medicaid is the payer of last resort, it is expected that individuals (and their spouses) access available trust income and assets before turning to Medicaid. The assets and income from trusts that contain provisions that purport to limit the trustee's discretion to disburse funds in situations related to the individual's application for Medicaid are to be considered without regard to such provisions. For example, the assets and income of a trust are to be considered without regard to any provisions that purport to limit the trustee's discretion to disburse funds when the individual applies for Medicaid or enters a nursing home.

Example

Mary establishes a trust under which she is a beneficiary. The trustee has discretion to distribute all of the assets of the trust to Mary except if she applies for Medicaid or enters a nursing home

a trust are to be considered without regard to any provisions that purport to limit the trustee's discretion to disburse funds when the individual applies for Medicaid or enters a nursing home.

Example

Mary establishes a trust under which she is a beneficiary. The trustee has discretion to distribute all of the assets of the trust to Mary except if she applies for Medicaid or enters a nursing home. In those circumstances, the trust states that the trustee does not have discretion to disburse the funds to Mary. At the time Mary applies for Medicaid, the trust is valued at $200,000. All of the $200,000 is considered available to Mary.

Amounts actually distributed are counted as income and/or assets using applicable eligibility rules for the situation.

When determining eligibility for Nursing care assistance, the value of an irrevocable trust may constitute an uncompensated transfer of assets. See Part 15.

If the Department determines that denial of eligibility would constitute undue hardship, these provisions may be waived. The consequence of being denied Medicaid coverage by itself does not constitute undue hardship.

Exceptions

When the beneficiary of a trust is an Individual with an Intellectual Disability who resides in an Intermediate Care Facility - IID the trust is not considered a Medicaid qualifying trust provided the trust or initial decree was established prior to 4/7/86 and is solely for the benefit of the Individual with an Intellectual Disability.

Trusts that are set up with retroactive SSI benefits awarded under the Zebley vs. Sullivan decision are exempted from the provisions of the Medicaid Qualifying Trust and transfer of assets rules.

Examples

Sullivan decision are exempted from the provisions of the Medicaid Qualifying Trust and transfer of assets rules.

Examples

The individual's wife set up a trust fund for him before she died. The trust is irrevocable. The individual receives monthly payments of $100.00 from interest accrued on the principal and the trustee may disburse the remaining funds (currently $150,000) to meet living expenses. This is a Medicaid Qualifying Trust because it was set up by the individual's wife (not by will). Therefore, the total amount of the trust ($150,000) is a countable asset. This is the total undistributed amount of the trust that the trustee could disburse if she exercised her full discretion.

Same as Example 1 except: Added to the monthly interest income of $100.00, the remaining funds are disbursed in $3,000 semi-annual payments for the life of the individual. Any funds remaining at his death are passed to the individual's daughter. The trustee has no discretion in the disbursement of funds. Here, both the $100.00 per month and the $3,000 semi-annual payment are income. Since the trustee has no discretion in disbursement of funds, nothing else is countable.

The individual sets up a trust fund for himself that is irrevocable. He receives $500.00 per month from interest. The principal will be donated to the Save the Whale Foundation at his death. The trustee has no discretion in disbursement of funds. This is not a Medicaid Qualifying Trust even though it was set up by the individual other than by will for his benefit because the trustee has no discretion in distribution of the trust funds. The disbursement of $500.00 per month are counted as income under the general rules applying to trusts.

Couples Residing in a Nursing Facility

has no discretion in distribution of the trust funds. The disbursement of $500.00 per month are counted as income under the general rules applying to trusts.

Couples Residing in a Nursing Facility

If the total assets of a couple in the same room in a nursing facility exceed the standard for a couple, one of the individuals may reapply for assistance. This results in one being an ineligible spouse. Beginning the first of the month after being denied, only the assets remaining in the name of the eligible spouse are considered when determining eligibility.

If the couple resides in different rooms in the same facility or in different facilities, then each is treated as an individual when determining the asset limit. Since there is no penalty for transfer of assets between spouses, they can decide who will retain the assets.

No spousal allowance of income or assets is determined since the ineligible spouse is not living in the community.

Transfer of Assets

"Assets" are defined as cash or other liquid assets or real or personal property.

When determining eligibility for Home and Community Based Services Waivers and nursing care services, the following applies to transfers to individuals by the applicant or the applicant’s spouse. Transfers between spouses do not incur a penalty. Although an individual or couple may be eligible in the community, once a request is made for waiver or nursing care services all assets must be checked back thirty months from date of application to determine if a transfer has occurred.

Transfers only affect nursing and waiver services, all other Medicaid services may still be covered

nt’s spouse. Transfers between spouses do not incur a penalty. Although an individual or couple may be eligible in the community, once a request is made for waiver or nursing care services all assets must be checked back thirty months from date of application to determine if a transfer has occurred.

Transfers only affect nursing and waiver services, all other Medicaid services may still be covered.

To determine the effect that the transfer has on eligibility several questions must be answered:

What was transferred?

Who was the transfer made to?

When was the transfer made?

What did the individual or couple receive in exchange?

Why was the transfer made?

Exempt Transfers

The following may be transferred without penalty:

The home if it is transferred to

a child who is under age 21 or who does or would meet SSI criteria of total and permanent disability or blindness.

a sibling who has an equity interest in the home and was residing in the home for at least one year prior to the individual going to the medical institution.

Example

A brother and sister have joint ownership of a home in which they both lived for the last five years prior to the brother going into a nursing facility. The brother may transfer his interest in the home to his sister without penalty.

A penalty would be established if:

the sister was not a joint owner or had no equity interest in the home, or

the sister had not lived in the home one year prior to the institutionalization of her brother.

a child over age 21 who does not meet the SSI criteria of blindness or disability if the child was residing in the home for at least two years prior to the individual's entering the medical institution and was providing care which enabled the institutionalized individual to live at home rather than a medical institution for this time.

a spouse.

Any asset transferred to the individual's child who does or would meet SSI criteria of total and permanent disability or blindness

ity if the child was residing in the home for at least two years prior to the individual's entering the medical institution and was providing care which enabled the institutionalized individual to live at home rather than a medical institution for this time.

a spouse.

Any asset transferred to the individual's child who does or would meet SSI criteria of total and permanent disability or blindness.

Assets which the owner intended to dispose of at fair market value or for other valuable consideration but, without being at fault, the owner did not obtain full fair market value.

Assets, exempt or non-exempt, transferred to (or for the sole benefit of) the community spouse.

Assets transferred thirty months prior to the date of application.

Assets transferred for Fair Market value:

Fair Market Value

A transfer for fair market value incurs no penalty. Fair market value may be received in cash. It may also be in the form of past support for basic necessities or past medical expenses and debts, if measurable and verifiable. A reasonable value must be placed on the support provided or medical costs and the specific time period for which it is given substantiated. Past support for basic necessities does not include such items as gifts, clothing, transportation or personal care provided by relatives unless these were provided as part of a legally enforceable agreement whereby the individual would transfer the asset or otherwise pay for such items.

Examples of transfer for fair market value

An individual transfers ownership of a life insurance policy to a funeral home.

An individual's sister pays all household expenses while he waits for an insurance settlement of $5000. He verifies that his rent, utilities and food came to $4500. He may transfer the $4500 to his sister without penalty because these are basic necessities which are measurable and verifiable.

Examples of transfers for less than fair market value

A couple sells their home to their son for $40,000. The assessed value is $70,000. A $30,000 transfer has occurred

its for an insurance settlement of $5000. He verifies that his rent, utilities and food came to $4500. He may transfer the $4500 to his sister without penalty because these are basic necessities which are measurable and verifiable.

Examples of transfers for less than fair market value

A couple sells their home to their son for $40,000. The assessed value is $70,000. A $30,000 transfer has occurred.

An individual has help from her daughter with shopping, cleaning and preparing meals. The daughter spends four to eight hours a week providing these services. When the individual enters a nursing facility she transfers $25,000 to her daughter to compensate for these services. Since these were not provided as part of a legally enforceable agreement to pay for these services, the transfer does result in a penalty.

A neighbor comes in for an hour a day to help a couple prepare meals and do laundry. Two years later the couple give the neighbor $50,000. Two months later they enter a nursing facility. Based on the average cost for homemaker services in the area a value of $10.00 per hour is placed on these services and $7280 of the transfer is allowed. The remaining $42,720 would be a transfer for less than fair market value.

Disproving the Presumed Transfer

Any transfer taking place will be presumed to have been made for the purpose of becoming or remaining eligible for Medicaid, unless the individual furnishes clear and convincing evidence that the transaction was for some other purpose and that there was no intent at the time to apply for Medicaid within the foreseeable future. It is the Department's responsibility to demonstrate that a transfer took place and to establish the date of the transfer. It is the individual's responsibility to prove that the transfer took place for reasons other than to gain eligibility for Medicaid.

If the individual wants to disprove the presumption that the transfer was made to establish Medicaid eligibility, the burden of proof rests with the individual

tment's responsibility to demonstrate that a transfer took place and to establish the date of the transfer. It is the individual's responsibility to prove that the transfer took place for reasons other than to gain eligibility for Medicaid.

If the individual wants to disprove the presumption that the transfer was made to establish Medicaid eligibility, the burden of proof rests with the individual. The individual must demonstrate that the transfer was specifically and solely for some other purpose than to receive Medicaid. Statements and evidence to disprove the transfer must be contained in the individual's record.

The statement should cover, but not necessarily be limited to the individual's:

purpose for transferring the asset;

attempts to dispose of the asset for fair market value;

reasons for accepting less than the fair market value for the asset;

plans for and ability to provide financial support after the transfer;

relationship, if any, to the persons to whom the asset was transferred; and

belief that the fair market value was received.

In addition to the individual having to prove that the transfer was made specifically and solely for a purpose other than to be Medicaid eligible, other factors to be considered include:

a sudden onset of a disability or blindness after the asset was transferred;

the diagnosis of a previously undetected disabling condition after the transfer occurred;

unexpected loss of other assets following the transfer;

unexpected loss of income after the transfer occurs; and

court ordered transfers.

Establishing Date and Value of a Transfer

Assets other than bank accounts. A transfer of assets occurs on the date when:

title (ownership) or legal interest to property has passed from the individual or spouse to another individual;

title to property has been given by establishing joint ownership, such as adding a name to stocks, bonds, real property;

The value of the transfer is the value of the asset or the part of the asset that is transferred

her than bank accounts. A transfer of assets occurs on the date when:

title (ownership) or legal interest to property has passed from the individual or spouse to another individual;

title to property has been given by establishing joint ownership, such as adding a name to stocks, bonds, real property;

The value of the transfer is the value of the asset or the part of the asset that is transferred. For example:

Sole ownership of a home valued at $100,000 is transferred to another. The value of the transfer is $100,000.

Sole ownership of a home valued at $100,000 becomes jointly owned with another person. The value of the transfer is $50,000.

a document has been signed and delivered by the individual or spouse to another individual to transfer title at some future date. This concept does not include a will but does include a signed but unregistered deed;

the asset is converted from an accessible to an inaccessible asset. An example is when assets are placed in an irrevocable trust or a name is removed from a jointly owned asset; or

the individual or spouse refuses to accept items which would be countable assets.

With bank accounts, a transfer of funds in an account is determined to take place when:

funds, owned by the individual, are withdrawn by the other joint owner(s) from an account and used for other that the sole benefit of the individual; or

another person's name is added to the individual's account, the money in the account is owned by the individual, and the intent of the individual in giving access is to convey ownership of those funds.

If the individual maintains that there was an intent to transfer funds in the bank account at the time a joint name was added, this intent must be documented.

Documentation consists of a clearly written statement of intent to transfer the funds in the account to the joint owner

ount is owned by the individual, and the intent of the individual in giving access is to convey ownership of those funds.

If the individual maintains that there was an intent to transfer funds in the bank account at the time a joint name was added, this intent must be documented.

Documentation consists of a clearly written statement of intent to transfer the funds in the account to the joint owner. This statement must be:

a notarized statement; or

signed by the individual at the time the account was made joint or within a reasonable period of time, usually one week but maybe longer due to circumstances beyond the control of the client.

Note: Evidence of an intent to transfer the funds in the account at the time that the name was added to the account will be rebutted by evidence that the individual continued to use the funds.

Examples

George adds his son Larry's name to a $50,000 bank account in 8/91. In 6/92 Larry withdraws $50,000 which he used to make renovations on his (Larry's) home. George is applying for nursing care services 9/92.

Whose money is the $50,000? The money in the account is made up of deposits by George. This is George's money and there is a potential transfer.

What was George's intent of adding son's name? If the intent was to convey ownership of the funds in the account, this must be documented with a notarized statement by George. In this situation, there is no statement from George. No transfer occurred when Larry's name was added as a joint owner.

The 6/92 withdrawal is then examined as a transfer. Since Larry used the $50,000 that was withdrawn for other than the sole benefit of George, a transfer has occurred. Unless the transfer is exempted (4120.01), the penalty is assessed for $50,000 as of 6/92.

rawn for other than the sole benefit of George, a transfer has occurred. Unless the transfer is exempted (4120.01), the penalty is assessed for $50,000 as of 6/92.

Sally adds her son's name (Sam) to her bank account in 12/88. At that time there was $70,000 in her account. At the time of adding her son's name to the account she signs a statement that she intends to transfer the funds in the account. Subsequently, Sally cashes a check for $10,000 from the account. Also during the transfer penalty period, Sam cashes a check for $20,000 from the joint account. At the time Sally applies for nursing care services in 9/92, there is $40,000 in the account.

The $20,000 spent by Sam was a transfer subject to penalty. This is because Sally's continued use of the funds in the account rebuts her written statement saying she intended to transfer the funds to her son at the earlier time. Since the funds were Sally's when Sam cashed the check for $20,000, this is a transfer subject to penalty.

The $40,000 remaining in the account is considered an available asset for Sally.

Butch adds his nephew's name (Charles), to his (Butch's) solely owned bank account in 1/89. The $70,000 in the account was owned by Butch. There is documentation that Butch intended to transfer the funds in the account at that time. In 5/92, Butch sells a piece of his solely owned property for $20,000 and deposits this money in the joint account. Charles cashes a $20,000 check from the account in 6/92. The account totals $70,000 at the time Butch applies for nursing care services in 9/92.

The $20,000 withdrawn by Charles in 6/92 is considered to be part of the $70,000 that Butch intended to give his nephew in 1/89. Therefore, this $20,000 may not be subject to transfer penalty.

Of the remaining $70,000 in the account:

$20,000 is a countable asset for Butch since this $20,000 was deposited by him from his funds.

$50,000 is owned by Charles due to the 1/89 transfer of funds

in 9/92.

The $20,000 withdrawn by Charles in 6/92 is considered to be part of the $70,000 that Butch intended to give his nephew in 1/89. Therefore, this $20,000 may not be subject to transfer penalty.

Of the remaining $70,000 in the account:

$20,000 is a countable asset for Butch since this $20,000 was deposited by him from his funds.

$50,000 is owned by Charles due to the 1/89 transfer of funds.

Establishing a Penalty

A period of ineligibility is imposed on the individual in a nursing care status if the individual or spouse disposes of an asset for less than Fair Market Value.

When a penalty is imposed, it is only the nursing care services that cannot be paid. The individual may be eligible for all other Medicaid services.

Once it has been determined that a transfer of assets has occurred for less than fair market value, the penalty period must be determined.

A special determination must be made for each transfer.

Determine the date that each transfer occurred.

Determine the amount of the transfer.

Divide the amount of the initial transfer by the current average monthly private rate at the time of application for a semiprivate room rate for a nursing facility (see Chart 4.3).

This determines the number of months of ineligibility based on the initial transfer. Any remaining fraction is to be disregarded. The penalty period may not exceed thirty months. The penalty period begins with the month in which the uncompensated transfer occurred. If there had been more than one transfer and a penalty is already in effect for that month, the penalty period will begin with the next non-penalty month.

Examples

An individual adds her daughter's name to her savings account on 4/14. A transfer for the entire balance has taken place. Based on the amount of funds in the account at the time of transfer she is ineligible for 7.3 months. Eligibility potentially begins 11/1.

An individual has a solely owned savings account with $60,000 in it. In 10/92 he transfers $60,000 to his daughter

-penalty month.

Examples

An individual has a solely owned savings account with $60,000 in it. In 10/92 he transfers $60,000 to his daughter. He also owns stocks worth $40,000 which he transfers to his son in 12/92.

10/92 $60,000 $3619 = 16.5 months, potentially eligible 2/94

12/92 $40,000 $3619 = 11 months, potentially eligible 1/95

The penalty on the 12/92 transfer does not start until 2/94. This is the first non-penalty month after the 12/92 transfer

In this case the individual is potentially eligible as of 1/95.

Appendix I

Preparation for and Participation in the Administrative Hearing Process

The purpose of a hearing is to review whether the Agency acted in accord with defined policy and procedural requirements in carrying out its actions. The review is usually requested in relation to proposed closings, denials, decreases in the level of coverage, and changes in deductible amounts. The hearing may also include questions of medical eligibility, classification for nursing care status and eligibility for retroactive coverage.

Hearings are not formal in the sense that there are oaths given, set formal procedures of addressing individuals concerned, or required procedures for entering objections or questioning at a particular time. Hearings are not casual conversations or arguments, however.

In addition to reviewing the decision itself, the Hearing Officer has the responsibility, at the hearing, to review whether appropriate procedures were followed in carrying out the action.

The Hearing Report

The agency representative has the responsibility to be prepared to give a report and to answer questions that may be asked by the Hearing Officer of other participants in the hearing

however.

In addition to reviewing the decision itself, the Hearing Officer has the responsibility, at the hearing, to review whether appropriate procedures were followed in carrying out the action.

The Hearing Report

The agency representative has the responsibility to be prepared to give a report and to answer questions that may be asked by the Hearing Officer of other participants in the hearing. The Eligibility Specialist must make sure that proper written notice, with an advance notice period, if applicable, was forwarded to the applicant or recipient. The notice must cite the manual section on which the decision to deny or reduce benefits is based. It is not sufficient to state: “You have excess assets,” or “You have excess income.” The amount of assets or income should be given. In addition, the agency limit on assets or income should be cited. It might be necessary to cite more than one manual reference. If so, this should be done.

If the action results in a request for a hearing the Eligibility Specialist should submit a copy of the notice which was sent to the applicant or recipient to the Hearing Officer. The copy of the notice and other pertinent documents will become a permanent part of the Hearing Record.

When notified of a request for a hearing, the Eligibility Specialist must prepare a detailed report outlining what was done and why it was done. The report should indicate how the decision was made. If income is an issue, the Eligibility Specialist must elaborate on how net income was determined. If assets are an issue, the Eligibility Specialist must show what was considered as an asset. If medical eligibility is an issue, specifics should be given as to what went into the decision that the individual no longer is considered incapacitated or disabled in accord with agency policy. If the decision involved the Medical Review Team, contact must be made with that unit, The MRT will provide medical information if necessary

igibility Specialist must show what was considered as an asset. If medical eligibility is an issue, specifics should be given as to what went into the decision that the individual no longer is considered incapacitated or disabled in accord with agency policy. If the decision involved the Medical Review Team, contact must be made with that unit, The MRT will provide medical information if necessary.

If negative action is taken because information is incomplete, inconclusive or conflicting, the Eligibility Specialist must show what is inconclusive and why more information is needed. The Eligibility Specialist also has responsibility to show that specific information was requested and that the individual was given the opportunity to resolve questions before action was taken.

A copy of the report is sent to the individual requesting the hearing by the Division of Administrative Hearings prior to the hearing. If the agency is informed that the individual has a representative for the hearing, a copy of the report is also sent to the representative.

To the extent that the report is complete and concise, it will assist the Hearing Officer in conducting the hearing and will assist the applicant or recipient in understanding or questioning information.

The Hearing - The Hearing Officer will begin the hearing by giving an opening statement. In the opening statement, the Hearing Officer will:

cite the case name and basis purpose of the hearing;

request the names of all present;

remind all persons that the hearing is being recorded and that individuals should follow procedures by:

identifying themselves and referring to each other by name during the hearing;

make an effort to speak loud enough to be heard by all participants and face the recording equipment while talking.

Note that exhibits will be presented during the hearing.

After an opening statement by the Hearing Officer, the Eligibility Specialist will be asked to present a copy of the notice which was sent to the applicant or recipient

s and referring to each other by name during the hearing;

make an effort to speak loud enough to be heard by all participants and face the recording equipment while talking.

Note that exhibits will be presented during the hearing.

After an opening statement by the Hearing Officer, the Eligibility Specialist will be asked to present a copy of the notice which was sent to the applicant or recipient.

The Hearing Officer will request a verbal report outlining the actions taken and the basis of the action. The report submitted by the Eligibility Specialist may be read or used as the basis for the verbal report. The Hearing Officer may ask additional questions if there areas which are unclear. In addition, copies of documents such as medical statements, budgets, lists of assets or medical bills may be requested by the Hearing Officer. When requested, copies of these items should be given to the Hearing Officer and the individual requesting the hearing.

The individual or the representative may question the decision of the Eligibility Specialist. Questions should be made through the Hearing Officer and not between the persons involved.

The individual requesting the hearing will be given the opportunity to:

question any information;

refute any information;

present any additional information or make any comments.

In situations where additional information is presented, the Hearing Officer will decide whether the information had a bearing on the decision in question at the time of the decision or whether the information relates to a period of time subsequent to the decision. If the latter is the situation, the information should only be considered in a re-application or in carrying out a subsequent review.

After both parties have presented information and entered any questions and the Hearing Officer is satisfied that pertinent data has been presented, the Officer will summarize the issue as much as possible

tion relates to a period of time subsequent to the decision. If the latter is the situation, the information should only be considered in a re-application or in carrying out a subsequent review.

A continuance of the hearing may be determined by the Hearing Officer if additional date is needed, obtainable, and not available at the hearing. If the applicant or recipient requests a continuance, the Hearing Officer will determine if it would be appropriate.

The agency representative should always have manual material at the hearing and be prepared to cite necessary data from the manual.

Appeal

When the above procedures are followed and there is further appeal through the courts, those persons responsible for representing the agency have issues that are clearly defined. In addition, procedures such as adequate and specific notice may be raised in court even if not mentioned at a hearing. Thus, it is necessary that procedures taken, as well as the decision made, be reviewed at the hearing.

Appendix J

Computation of Utility Standard

Standard Utility Allowances are approved through the Food and Nutrition Service of the United States Department of Agriculture and are included in the rules for Maine’s Food Supplement Program at 10-144 CMR Chapter 301. Standard Utility Allowance values can also be found at www.maine.gov/dhhs/ofi/fs-standards.shtml or by consulting www.fns.usda.gov/snap and search for Standard Utility Allowance Charts for the current values.

Utility Expenses

d search for Standard Utility Allowance Charts for the current values.

Utility Expenses

The community spouse has the option of using the full standard utility allowance (FSUA or actual utility expenses as deductions. They must incur expenses for heating or air conditioning bills which are separate and apart from rent/mortgage or receive assistance from HEAP or ECIP in order to qualify for the FSUA. At the time of redetermination, and one additional time during each twelve month period, the community spouse may change the option between actual expenses and the FSUA.

Standard Utility Allowance

When expenses are incurred on an irregular basis, use the FSUA between billing periods. The FSUA cannot be used for a community spouse who lives in a public or private rental unit, which has central utility meters and charges the residents only for excess heating or air conditioning costs. If someone outside of the household is paying the entire cost of heating/cooling, and the payment is excluded as a vendor payment, the utility allowance is not allowed.

Note: Assistance from HEAP or ECIP automatically entitles the community spouse to the FSUA.

The FSUA is not allowed when utility expenses are included in the rent unless the community spouse receives assistance from HEAP or ECIP, the residence is metered separately, or the community spouse can otherwise provide verification that there are separate charges for heat and/or air conditioning.

Actual Utility Costs

If the community spouse resides in public housing, which has central utility meters and is charged only for excess utility costs, the excess amount incurred is allowed.

Whenever the FSUA is not permitted, the community spouse may claim the actual expenses or elect to use the individual standard:

Shared Residence

To determine the utility allowance when the residence is shared by the community spouse and other persons, divide the appropriate utility allowance equally among the parties who pay for the cost. This prorated share is the utility allowance

ed is allowed.

Whenever the FSUA is not permitted, the community spouse may claim the actual expenses or elect to use the individual standard:

Shared Residence

Home Temporarily Vacated

Shelter expenses can be allowed if the principle residence is temporarily vacated due to employment or training, illness, natural disaster or casualty loss only if:

the community spouse intends to return

the home is not leased or rented while the community spouse is absent.

Note: Verification of actual utility cost for an unoccupied home is required if a deduction will be used. The SUA is not allowed for unoccupied homes.

Handling of Expenses Other Than Mortgage, Residence Insurance

Except when an expense is averaged, a deduction is allowed only in the month the expense is billed or otherwise becomes due, regardless when the community spouse expects to pay the expense. Amounts from past billing periods are not deductible.

For an expense to be deductible, it must be payable to someone outside the household.

Fluctuating expenses may be averaged. Expenses, which are billed less often then monthly, may be averaged forward over the interval between scheduled billings or if there is no schedule, over the period the expense is intended to cover. Interest, carrying charges, insurance, or penalties are not allowance expenses. Interest portions on mortgage payments are allowable.

That portion of the household shelter expenses associated with a business or trade is not considered as a deductible shelter expense.

That portion of the shelter expenses paid by an excluded vendor payment shall not be allowed as a deduction. Shelter expenses paid via a countable vendor payment shall be allowed.

Shelter expenses shall be computed based upon expected expenses to be billed

lowable.

That portion of the household shelter expenses associated with a business or trade is not considered as a deductible shelter expense.

That portion of the shelter expenses paid by an excluded vendor payment shall not be allowed as a deduction. Shelter expenses paid via a countable vendor payment shall be allowed.

Shelter expenses shall be computed based upon expected expenses to be billed. Anticipation of the expense shall be based upon the most recent month's bills unless it is reasonably certain that a change will occur.

Expenses billed weekly are converted by multiplying by 4.333 and those billed biweekly by 2.167 to obtain monthly figures.

III. Verification

Utility expenses must be verified if the amounts claimed are in excess of the SUA and a deduction would result.

A move to a new residence requires reassessment of all shelter expenses.

Chart 1

ITEMS INCLUDED IN THE BASIC COST CHART

Housing: includes either a payment for rent or home ownership costs (which include taxes, mortgage payments, insurance and property maintenance), heating fuel, water, electricity, gas, refuse disposal, household textiles such as sheets and towels, furniture and appliance replacement, house wares, laundry and cleaning supplies, paper products, services and telephone at the basic rate.

Food: includes all food eaten at home, meals eaten at work or school and snacks.

Clothing: includes basic inner and outer clothing, undergarments, footwear, dress and work clothing, cleaning and pressing services and shoe repair.

Personal Care: includes haircuts, hair dressing, and such items as toothpaste, shaving cream, and shampoo.

Other Family Consumption: includes newspapers, magazines, entertainment expenses and allowances for participation in sports, hobbies and other recreation.

Chart 2

DEPENDENT ALLOCATIONS USING AFDC RELATED LIMITS

The amounts below are used for income allocations for dependents in Home and Community Based Waivers and dependents of nursing home residents when there is no community spouse

and shampoo.

Other Family Consumption: includes newspapers, magazines, entertainment expenses and allowances for participation in sports, hobbies and other recreation.

Chart 2

DEPENDENT ALLOCATIONS USING AFDC RELATED LIMITS

The amounts below are used for income allocations for dependents in Home and Community Based Waivers and dependents of nursing home residents when there is no community spouse. They are based on the Full Need Standard in the AFDC Program as of 8/96.

Add $142 to Full Need for each additional person.

Chart 3

SSI - RELATED INCOME STANDARDS, ALLOCATIONS AND DISREGARDS

Chart 3.1 - Disregards (eff. 7/1/87)

$20.00 Federal disregard

$55.00 State disregard for Individual

$80.00 State disregard for Couple

Chart 3.2 - Maximum Allocations

Ineligible child living allowance Maximum Federal Supplemental Security Income (SSI) payment amount for an eligible individual, divided by 2.

One parent - living in the household Maximum Federal Supplemental Security Income (SSI) payment amount for an eligible individual.

Two parents living in the household Maximum Federal Supplemental Security Income (SSI) payment amount for an eligible couple.

Chart 3.3 - Maximum Income-in-Kind

Individual living alone or with others Maximum Federal Supplemental Security Income (SSI) payment amount for an eligible individual, divided by 3, plus $20.

Individual living in the household of another Maximum Federal Supplemental Security Income (SSI) payment amount for an eligible individual, divided by 3.

Couple Living alone or with others Maximum Federal Supplemental Security Income (SSI) payment amount for an eligible couple, divided by 3, plus $20.

Couple living in the household of another Maximum Federal Supplemental Security Income (SSI) payment amount for an eligible couple, divided by 3.

Chart 3.4 - Maximum Countable Income

Individual living alone or with others Maximum Federal Supplemental Security Income (SSI) payment amount for an eligible individual, plus $10

Income (SSI) payment amount for an eligible couple, divided by 3, plus $20.

Couple living in the household of another Maximum Federal Supplemental Security Income (SSI) payment amount for an eligible couple, divided by 3.

Chart 3.4 - Maximum Countable Income

Individual living alone or with others Maximum Federal Supplemental Security Income (SSI) payment amount for an eligible individual, plus $10.

Individual living in the household of another Maximum Federal Supplemental Security Income (SSI) payment amount for an eligible individual, plus $8.

Couple living alone or with others Maximum Federal Supplemental Security Income (SSI) payment amount for an eligible couple, plus $15.

Couple living in the household of another Maximum Federal Supplemental Security Income (SSI) payment amount for an eligible couple, plus $12.

Chart 3.5 - Ineligible Spouse Standard

Ineligible spouse in the deeming process Maximum Federal Supplemental Security Income (SSI) payment amounts for an eligible individual, divided by 2.

Chart 3.6 - SSI and State Supplement Maximum Income and Payment Amounts

SSI Countable Income Limit & Maximum Benefit for an Individual:

Living Arrangement A, D, E, F, G, I: Maximum Federal Supplemental Security Income (SSI) payment amount for an eligible individual

Living Arrangement C: Divide the Maximum Federal Supplemental Security Income (SSI) payment amount for an eligible individual by 3. Multiply the result by 2.

SSI Countable Income Limit & Maximum Benefit for a Couple:

Living Arrangement A, D, E, F, G, I: Maximum Federal Supplemental Security Income (SSI) payment amount for an eligible couple

Living Arrangement C: Divide the Maximum Federal Supplemental Security Income (SSI) payment amount for an eligible couple by 3. Multiply the quotient by 2.

If countable income is less than the SSI limit plus $20.00 for a particular “Living Arrangement,” the individual should apply for SSI in order to get the SSI benefit and State Supplement

urity Income (SSI) payment amount for an eligible couple

Living Arrangement C: Divide the Maximum Federal Supplemental Security Income (SSI) payment amount for an eligible couple by 3. Multiply the quotient by 2.

If countable income is less than the SSI limit plus $20.00 for a particular “Living Arrangement,” the individual should apply for SSI in order to get the SSI benefit and State Supplement. If more, but less than the “State Supplement Income Limit” (plus $75 for living arrangements A and C), the individual can apply at Department of Health and Human Services for the State Supplement only.

Chart 3.7 - Income Limit for Adult Family Care Homes

This rate is set by the Office of MaineCare Sevices.

Previous year’s rate plus the product of the previous year’s rate multiplied by the current Social Security Administration’s Cost of Living Adjustment (COLA) percentage increase.

Chart 3.8 - Premiums for Special Benefits Waiver [Maine Section 1115 Health Care Reform Demonstration for Individuals with HIV/AIDS]

These premiums are set by the Office of MaineCare Services under the 1115 Health Care Reform Demonstration for Individuals with HIV/AIDS. This is a waiver agreement with the Centers for Medicare and Medicaid Services, and is set to expire December 31, 2028. There is an annual 5% increase in premium amounts.

Chart 3.9 - Spousal Living Allowance for SSI Recipients

The difference between 100% of the Federal Poverty Level for a single individual and the Federal Supplemental Security Income (SSI) payment amount for an eligible individual, plus $55.

Note: For non-SSI recipients the amount of the Living Allowance is the difference between countable income and 100% federal poverty level.

Chart 3.10 - Premiums for MaineCare Katie Beckett Coverage Group

Chart 4

NURSING CARE LIMITS

Chart 4.1 Categorically Needy Nursing Care Status Income Limits

Maximum Federal Supplemental Security Income (SSI) payment amounts for an eligible individual multiplied by 3

For non-SSI recipients the amount of the Living Allowance is the difference between countable income and 100% federal poverty level.

Chart 3.10 - Premiums for MaineCare Katie Beckett Coverage Group

Chart 4

NURSING CARE LIMITS

Chart 4.1 Categorically Needy Nursing Care Status Income Limits

Maximum Federal Supplemental Security Income (SSI) payment amounts for an eligible individual multiplied by 3.

This is used as the income limit for:

Categorically Needy Nursing Care Status

Home and Community Based Waivers

Katie Beckett coverage

SSI - Related or Family - Related coverage group in a hospital for thirty consecutive days

Chart 4.2 Maximum Waiver Allowances

The amounts below are used as the maximum spousal allowance for Home and Community Based Waivers:

Maximum Federal Supplemental Security Income (SSI) payment amounts for an eligible individual.

Chart 4.3 Nursing Care Private Rate

The average nursing care private rate is the annual average monthly cost for a private patient to receive nursing facility care in the State of Maine as determined by the Department. This amount is used to calculate penalty periods for disposing of assets for less than fair market value on or after the look-back period.

$3917.00 eff. 8/1/1994

$6255.00 eff. 1/1/2006

$6778.00 eff. 1/1/2008

$7258.00 eff. 1/1/2009

$7667.00 eff. 9/1/2011

$8476.00 eff. 10/19/2014

Effective 6/1/2023 the average nursing care private rate is calculated using the previous year’s average rate as reported by nursing facilities on their most recent MaineCare Cost Report provided to the Division of Audit. To calculate the average nursing care private rate the Department shall add the total of all reported nursing facility daily rates and divide that sum by the total number of reported Nursing Facility rates. The average daily rates is multiplied by 31 to establish the average nursing care private rate

y nursing facilities on their most recent MaineCare Cost Report provided to the Division of Audit. To calculate the average nursing care private rate the Department shall add the total of all reported nursing facility daily rates and divide that sum by the total number of reported Nursing Facility rates. The average daily rates is multiplied by 31 to establish the average nursing care private rate. The average nursing care private rate is redetermined annually, with effective dates of June 1st, and posted online at https://www.maine.gov/dhhs/ofi/programs-services/health-care-assistance.

Chart 4.4 Spousal Impoverishment

Community Spouse Asset Allowance Maximum

$60,000 increased by the same percentage as the percentage increase in the consumer price index for all urban consumers (all items; U.S. city average) between September 1988 and the September before the calendar year involved.

Minimum Monthly Income Standard

150% of the Federal Poverty Level for a household of 2.

Monthly Excess Shelter Standard

30% of the Minimum Monthly Income Standard [above].

Maximum Monthly Income Allocation

$1500 increased by the same percentage as the percentage increase in the consumer price index for all urban consumers (all items; U.S. city average) between September 1988 and the September before the calendar year involved.

Chart 5

Protected Income Level

The following levels are effective 11/91:

Add $116 for each additional person.

Chart 6

Fee Schedule for QDWI

Countable income is determined using SSI - Related rules.

Chart 7

CUB CARE

(Repealed by adoption filing 2023-123 effective August 15, 2023.)

NONSUBSTANTIVE CORRECTIONS (terminology updates):

May 20, 2026

| Payment of

Part A | Payment of Part B | Payment of

Medicare Deductible &

Co-Ins

The following levels are effective 11/91:

Add $116 for each additional person.

Chart 6

Fee Schedule for QDWI

Countable income is determined using SSI - Related rules.

Chart 7

CUB CARE

(Repealed by adoption filing 2023-123 effective August 15, 2023.)

NONSUBSTANTIVE CORRECTIONS (terminology updates):

May 20, 2026

| Payment of

Part A | Payment of Part B | Payment of

Medicare Deductible &

Co-Ins.

SSI and State Supplement Recipients | | X | X

Pickle Amendment | | X | X

Qualified Medicare Beneficiaries (QMB) | X | X | X

Qualified Disabled and Working Individual (QDWI) | X | |

Specified Low Income Medicare Beneficiaries (SLMB) | | X |

Qualifying Individuals (QI) Part 1 | | X |

0 | 0.97188 | 0.02812 | | 53 | 0.82028 | 0.17972

1 | 0.98988 | 0.01012 | | 54 | 0.81054 | 0.18946

2 | 0.99017 | 0.00983 | | 55 | 0.80046 | 0.19954

3 | 0.99008 | 0.00992 | | 56 | 0.79006 | 0.20994

4 | 0.98981 | 0.01019 | | 57 | 0.77931 | 0.22069

5 | 0.98938 | 0.01062 | | 58 | 0.76822 | 0.23178

6 | 0.98884 | 0.01116 | | 59 | 0.75675 | 0.24325

7 | 0.98882 | 0.01118 | | 60 | 0.74491 | 0.25509

8 | 0.98748 | 0.01252 | | 61 | 0.73267 | 0.26733

9 | 0.98663 | 0.01337 | | 62 | 0.72002 | 0.27998

10 | 0.98565 | 0.01435 | | 63 | 0.70696 | 0.29304

11 | 0.98453 | 0.01547 | | 64 | 0.69352 | 0.30648

12 | 0.98329 | 0.01671 | | 65 | 0.67970 | 0.32030

13 | 0.98198 | 0.01802 | | 66 | 0.66551 | 0.33449

14 | 0.98066 | 0.01934 | | 67 | 0.65098 | 0.34902

15 | 0.97937 | 0.02063 | | 68 | 0.63610 | 0.36390

16 | 0.97815 | 0.02185 | | 69 | 0.62086 | 0.37914

17 | 0.97700 | 0.02300 | | 70 | 0.60522 | 0.39478

18 | 0.97590 | 0.02410 | | 71 | 0.58914 | 0.41086

19 | 0.97480 | 0.02520 | | 72 | 0.57261 | 0.42739

20 | 0.97365 | 0.02635 | | 73 | 0.55571 | 0.44429

21 | 0.97245 | 0.02755 | | 74 | 0.53862 | 0.46138

22 | 0.97120 | 0.02880 | | 75 | 0.52149 | 0.47851

23 | 0.96986 | 0.03014 | | 76 | 0.50441 | 0.49559

24 | 0.96841 | 0.03159 | | 77 | 0.48742 | 0.51258

25 | 0.96678 | 0.03322 | |

0522 | 0.39478

18 | 0.97590 | 0.02410 | | 71 | 0.58914 | 0.41086

19 | 0.97480 | 0.02520 | | 72 | 0.57261 | 0.42739

20 | 0.97365 | 0.02635 | | 73 | 0.55571 | 0.44429

21 | 0.97245 | 0.02755 | | 74 | 0.53862 | 0.46138

22 | 0.97120 | 0.02880 | | 75 | 0.52149 | 0.47851

23 | 0.96986 | 0.03014 | | 76 | 0.50441 | 0.49559

24 | 0.96841 | 0.03159 | | 77 | 0.48742 | 0.51258

25 | 0.96678 | 0.03322 | | 78 | 0.47049 | 0.52951

26 | 0.96495 | 0.03505 | | 79 | 0.45357 | 0.54643

27 | 0.96290 | 0.03710 | | 80 | 0.43659 | 0.56341

28 | 0.96062 | 0.03938 | | 81 | 0.41967 | 0.58033

29 | 0.95813 | 0.04187 | | 82 | 0.40295 | 0.59705

30 | 0.95543 | 0.04457 | | 83 | 0.38642 | 0.61358

31 | 0.95254 | 0.04746 | | 84 | 0.36998 | 0.63002

32 | 0.94942 | 0.05058 | | 85 | 0.35359 | 0.64641

33 | 0.94608 | 0.05392 | | 86 | 0.33764 | 0.66236

34 | 0.94250 | 0.05750 | | 87 | 0.32262 | 0.67738

35 | 0.93868 | 0.06132 | | 88 | 0.30859 | 0.69141

36 | 0.93460 | 0.06540 | | 89 | 0.29526 | 0.70474

37 | 0.93026 | 0.06974 | | 90 | 0.28221 | 0.71779

38 | 0.92567 | 0.07433 | | 91 | 0.26955 | 0.73045

39 | 0.92083 | 0.07917 | | 92 | 0.25771 | 0.74229

40 | 0.91571 | 0.08429 | | 93 | 0.24692 | 0.75308

41 | 0.91030 | 0.08970 | | 94 | 0.23728 | 0.76272

42 | 0.90457 | 0.09543 | | 95 | 0.22887 | 0.77113

43 | 0.89855 | 0.10145 | | 96 | 0.22181 | 0.77819

44 | 0.89221 | 0.10779 | | 97 | 0.21550 | 0.78450

45 | 0.88558 | 0.11442 | | 98 | 0.21000 | 0.79000

46 | 0.87863 | 0.12137 | | 99 | 0.20486 | 0.79514

47 | 0.87137 | 0.12863 | | 100 | 0.19975 | 0.80025

48 | 0.86374 | 0.13626 | | 101 | 0.19532 | 0.80468

49 | 0.85578 | 0.14422 | | 102 | 0.19054 | 0.80946

50 | 0.84743 | 0.15257 | | 103 | 0.18437 | 0.81563

51 | 0.83674 | 0.16326 | | 104 | 0.17856 | 0.82144

52 | 0.82969 | 0.17031 | | 105 | 0.16962 | 0.83038

ADULTS INCLUDED | ADULTS INCLUDED | ADULTS NOT INCLUDED | ADULTS NOT INCLUDED | ADULTS NOT INCLUDED

Unit Size | Full Need | | Full Need |

1 | 262 | | 154 |

2 | 412 | | 295 |

3 | 553 | | 437 |

4 | 695 | | 579 |

5 | 837 | | 721 |

6 | 979

50 | 0.84743 | 0.15257 | | 103 | 0.18437 | 0.81563

51 | 0.83674 | 0.16326 | | 104 | 0.17856 | 0.82144

52 | 0.82969 | 0.17031 | | 105 | 0.16962 | 0.83038

ADULTS INCLUDED | ADULTS INCLUDED | ADULTS NOT INCLUDED | ADULTS NOT INCLUDED | ADULTS NOT INCLUDED

Unit Size | Full Need | | Full Need |

1 | 262 | | 154 |

2 | 412 | | 295 |

3 | 553 | | 437 |

4 | 695 | | 579 |

5 | 837 | | 721 |

6 | 979 | | 863 |

7 | 1120 | | 1005 |

8 | 1262 | | 1146 |

Living Arrangements from Part 11 | | State Supplement Benefit | State Supplement

Countable Income Limit | | State Supplement Benefit | State Supplement

Countable Income Limit

A | | $10.00 | Sum of Column B and C | | $15.00 | Sum of Column E and F

C | | $8.00 | Sum of Column B and C | | $12.00 | Sum of Column E and F

D | | $49.00 | Sum of Column B and C | | $273.00 | Sum of Column E and F

E | | $217.00 | Sum of Column B and C | | $590.00 | Sum of Column E and F

F | | $234.00 | Sum of Column B and C | | $636.00 | Sum of Column E and F

G | | $234.00 | Sum of Column B and C | | $636.00 | Sum of Column E and F

H | | $10.00 | Sum of Column B and C | | $20.00 | Sum of Column E and F

I | | $10.00 | Sum of Column B and C | | $15.00 | Sum of Column E and F

Demonstration Year (DY) | Actual Premium, Income Level <150% FPL | Actual Premium, Income Level 150-200% FPL | Actual Premium, Income Level 200-250% FPL

DY17 1/2019 – 12/2019 | $0 | $35.93 | $71.85

DY18 1/2020 – 12/2020 | $0 | $37.73 | $75.44

DY19 1/2021 – 12/2021 | $0 | $39.61 | $79.22

DY20 1/2022 – 12/2022 | $0 | $41.59 | $83.18

DY21 1/2023 – 12/2023 | $0 | $43.67 | $87.34

DY22 1/2024 – 12/2024 | $0 | $45.85 | $91.71

DY23 1/2025 – 12/2025 | $0 | $48.14 | $96.30

DY24 1/2026 – 12/2026 | $0 | $50.55 | $101.12

DY25 1/2027 – 12/2027 | $0 | $53.08 | $106.18

DY26 1/2028 – 12/2028 | $0 | $55.73 | $111.49

Family Income as a % of FPL

Federal Poverty Level | Monthly Premium with Private Insurance | Monthly Premium without Private insurance

150 – 200% |

3 | $0 | $43.67 | $87.34

DY22 1/2024 – 12/2024 | $0 | $45.85 | $91.71

DY23 1/2025 – 12/2025 | $0 | $48.14 | $96.30

DY24 1/2026 – 12/2026 | $0 | $50.55 | $101.12

DY25 1/2027 – 12/2027 | $0 | $53.08 | $106.18

DY26 1/2028 – 12/2028 | $0 | $55.73 | $111.49

Family Income as a % of FPL

Federal Poverty Level | Monthly Premium with Private Insurance | Monthly Premium without Private insurance

150 – 200% | $ 11 | $ 30

201 – 250% | $ 14 | $ 40

251 - 300% | $ 18 | $ 50

301 - 350% | $ 21 | $60

351 - 400% | $ 25 | $70

401 - 450% | $30 | $85

451 - 500% | $35 | $100

501 - 550% | $ 40 | $115

551 - 600% | $ 46 | $130

601 - 700% | $51 | $145

701 - 800% | $61 | $175

801 - 900% | $72 | $205

901 – 1000% | $84 | $240

1001-1200% | $96 | $275

1201-1400% | $117 | $335

1401-1600% | $138 | $395

1601-1800% | $159 | $455

1801-2000% | $182 | $520

2001-2500% | $207 | $590

2501%+ | $263 | $750

Unit Size | Protected Income Level

1 | $315

2 | $341

3 | $458

4 | $575

5 | $691

6 | $808

7 | $925

8 | $1033

9 | $1150

10 | $1266

If Monthly Countable Income is | Monthly Payment Required

Is This % of the Current

Medicare Part A Premium

150% FPL - 160% FPL | 10%

160.01% - 170% | 20%

170.01% - 180% | 30%

180.01% - 190% | 40%

190.01% - 200% | 50%

Over 200% | Not Eligible

This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.