Correct Patient Responsibility
Defined
Once an individual is approved to receive Institutional Care Program benefits, the respondent determines the portion of the individual’s income that must be paid to the nursing facility, the patient responsibility. When there is a spouse in the community, some or all of the individual’s income can be diverted to help the spouse meet their needs- 09F-04274
Patient responsibility is zero where community spouse’s cost of living, including ALF and home maintenance exceeds income, Fla. Admin. Code 65A-1.712(4)(f)- 09F-04274
When calculating patient responsibility, it was within the rules for respondent to consider funds garnished for past-due child support payments as income even though that would create a monthly shortfall for Petitioner, Fla. Admin. Code 65A-1.701, F.A.C. 65A-1.713, F.A.C. 65A-1.714, 20 C.F.R. §416.1123, ACCESS Program Policy Manual s. 1840.0101, 1840.0102- 09F-02890
Respondent must consider the petitioner’s gross income, including the tax deduction from the Dept. of Labor’s pension as income, Fla. Admin. Code 65A-1.713, F.A.C. 65A-1.7141, Fla. Integrated Pub. Policy Manual passage 1840.0102- 09F-04203
In General
Termination of ICP benefits issue is moot because the Petitioner failed to fund the QIT, therefore benefits were correctly denied. However, the action to increase patient responsibility is reversed because, the Department failed to follow its policy in providing written notification of a change in benefits at least 10 days prior to the effective month of the action, 45 C.F.R. §205.10(a)(4), Fla. Admin. Code 65-2.048(1), F.A.C. 65-2.049, F.A.C. 65A-1.711, F.A.C. 65A-1.714(1), F.A.C. 65A-1.716(5)(c), Fla. Admin. Code 65-2.048(1), F.A.C. 65-2.049, F.A.C. 65A-1.702(15), F.A.C. 65A-1.713, Department of Children and Families Policy Manual 165-22 Appendix A-3.1, A-9 and A-10, DCF’s ACCESS Program Policy Manual, 165-22, section 1840.0110, 2640.0117 and 3440.0100, State Medicaid Manual, Part 03, Eligibility, Section 3700- 09F-06396
Patient responsibility was correct where each of petitioner’s income sources was considered and spousal maintenance need allowance was correctly calculated. Appeal denied, Fla. Admin. Code 65A-1.716(5)(c)- 09F-05772
Community Spouse Resource Allowance
Costs of the Assisted Living Facility must be considered in determining income diverted to the community spouse, The Minimum Monthly Maintenance Income Allowance may be increased if the community spouse can establish “exceptional circumstances resulting in significant financial duress,” such as, when spouse must maintain home until its sale. Fla. Admin. Code 65A-1.712(4)(f)- 09F-04274
Without proof of exceptional circumstances, community spouse allowance was correctly reduced and patient responsibility increased to reflect the additional SSA income which the Department failed to include in the original determination. Fla. Admin. Code 65A-1.712, F.A.C. 65A-1.7141, F.A.C. 65A-1.716, DCF Fla. Integrated Pub. Policy Manual, 165-22, passages 2640.0117, 2640.0119.01, 2640.0119.02, 2640.0119.03, Appendix A-9- 09F-02369
Request for a community spouse allowance to cover car payments and car insurance was denied for failure to meet the exceptional circumstances or unavoidable costs criteria necessary for hearing officer to override Department decision, Fla. Admin. Code 65A-1.712, F.A.C. 65A-1.716(5), Fla. Integrated Public Policy Manual, passages 2640.0119.02, 2640.0119.03, 2640.0119.04- 09F-05727
Increase in community spouse allowance denied where spouse’s allowable expenses do not exceed her income and no exceptional circumstances exist, 20 C.F.R. §416.1123, Fla. Admin. Code 65A-1.713(1)(d), F.A.C. 65A-1.712(4), F.A.C. 65A-1.716(5), Department of Children and Families Integrated Policy Manual, Passages 2640.0117, 2640.0119.01, 2640.0119.02, 2640.0119.03, 2640.0119.04, DCF Integrated Policy Manual, 165-22, Appendix A-9 and A-3.1- 09F-07534