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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 29. PUBLIC WELFARE |
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Chapter 29-98. FINANCIAL ELIGIBILITY FOR LONG TERM CARE SERVICES |
Section 29-9804. POST-ELIGIBILITY TREATMENT OF INCOME
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9804.1The Department shall determine how much monthly income a beneficiary must contribute toward the cost of LTCSS after an initial eligibility determination.
9804.2The Department shall project the beneficiary’s gross countable monthly income for a six (6) month prospective period to determine a beneficiary’s contribution to the cost of care.
9804.3Gross countable monthly income shall be calculated as follows:
(a)Income received on a yearly basis or less often than monthly shall be converted to a monthly amount or prorated;
(b)If the amount or frequency of regularly received income is known, the Department shall average the income over the period between payments; or
(c)If neither the amount nor the frequency of income is predictable, the Department shall not average the income but count income only for the month in which it is received.
9804.4The Department shall subtract the following types of deductions from the beneficiary’s gross countable monthly income:
(a)A Personal Needs Allowance equal to:
(1)Seventy dollars ($70) for a beneficiary in a nursing facility who does not receive a pension from the Department of Veterans Affairs;
(2)Ninety dollars ($90) for a beneficiary in a nursing facility who receives a pension from the Department of Veterans Affairs;
(3)One hundred and forty dollars ($140) for a couple if both spouses are institutionalized in a nursing facility and neither spouse receives a pension from the Department of Veterans Affairs;
(4)One hundred dollars ($100) for a beneficiary who receives waiver funded residential supports through the District Department on Disability Services (DDS) and receives social security benefits;
(5)Seventy dollars ($70) for a beneficiary in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) who receives Supplemental Security Income (SSI); and
(6)One hundred dollars ($100) for a beneficiary in an ICF/IID who receives Social Security Disability Income (SSDI).
(b)A Community Maintenance Needs Allowance, for a beneficiary enrolled in an HCBS Waiver program only, equal to the Special Income Standard (SIS);
(c)A Community Spouse Allowance, for a beneficiary who has a community spouse only;
(d)A Dependent Family Allowance, equal to the annual MNIL, for a beneficiary who has:
(1)Minor or dependent children, including disabled adult children of the beneficiary or community spouse, who reside in the personal home with the community spouse;
(2)Dependent parents of the beneficiary or community spouse who reside in the personal home with the community spouse; or
(3)Dependent siblings of the beneficiary or community spouse who reside in the personal home with the community spouse;
(e)Incurred Medical Expenses, if the expenses are not subject to payment by a third party, including incurred medical expenses used to meet a spend down obligation;
(f)Remedial Care Expenses, equal to the amount of fees paid to a guardian, conservator, or representative payee;
(g)A Home Maintenance Deduction equal to the MNIL for a beneficiary residing in an institutional facility. A home maintenance deduction may be deducted only:
(1)For up to six (6) months;
(2)When a community spouse does not reside in the home; and
(3)If a physician certifies that the beneficiary is likely to return to the home within six (6) months; and
(h)The full amount of SSI or State Supplementary Payment Benefits for a beneficiary who resides in a long term care facility.
9804.5The amount of the beneficiary’s gross countable income that remains after allowable deductions and spousal impoverishment protections for income and resources (if applicable) have been applied is the amount of the beneficiary’s contribution to the cost of care.
9804.6The Department shall reduce its payment for LTCSS by the amount of the beneficiary’s contribution to the cost of care.
9804.7The Department shall reconcile the beneficiary’s projected income with the beneficiary’s actual income at the end of every six (6) month period in which a beneficiary receives Medicaid coverage of LTCSS, or whenever any significant change in the beneficiary’s income or circumstances occurs.
9804.8The reconciliation may include a period of up to six (6) months prior to the month in which the reconciliation is done.
9804.9The Department may redetermine the beneficiary’s contribution to the cost of care:
(a) After the reconciliation process;
(b) At annual renewals; and
(c) When a beneficiary reports a significant change of income or other circumstances.
9804.10Any redetermination of or adjustment to the beneficiary’s contribution to the cost of care resulting from the reconciliation shall not be applied until timely and adequate notice of the redetermination or adjustment is provided to the beneficiary.
9804.11The Department shall adjust the beneficiary’s contribution to the cost of care prospectively when the income actually received by the beneficiary during the six (6) month reconciliation period differs from the beneficiary’s projected income for that period.
9804.12If the income actually received by the beneficiary during the six (6) month period exceeds the beneficiary’s projected income for that period, an adjustment shall be added to the beneficiary’s contribution to the cost of care in a future month or months to reflect the amount that should have been contributed during the six (6) month period.
9804.13If an income change or change in circumstances renders a beneficiary ineligible for Medicaid coverage of LTCSS, a prospective adjustment cannot be added to the former beneficiary’s contribution to the cost of care. Under these circumstances, the Department may seek to recover the full amount of the adjustment by requesting voluntary repayment from the former beneficiary.
9804.14The Department may pursue recovery by appropriate action, pursuant to District law, against the income or resources of the former beneficiary if the Department is unable to recover the full amount of the adjustment through voluntary repayment from the former beneficiary.
9804.15If the income actually received by the beneficiary during the six (6) month period is less than the beneficiary’s projected income for that period, the beneficiary’s contribution to the cost of care shall be reduced in a future month or months to reflect the amount that should not have been contributed during the six (6) month period.