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State of Wisconsin |
HISTORY |
The policy on this page is from a previous version of the handbook.
28.8.1 HCBWLTC Instructions Introduction
28.8.3.1 Personal Maintenance Allowance
28.8.3.2 Family Maintenance Allowance
28.8.3.3 Special Exempt Income
28.8.3.5 Medical/Remedial Expenses
Eligibility for Group A, B, and B Plus community waivers cases are determined in CARES.
Katie Beckett cases are Group A, and, because of the small number of these cases, are processed manually outside CARES by care managers and Katie Beckett staff.
Care managers will determine and certify community waiver eligibility for children already eligible for Medicaid through the Katie Beckett Program.
Group A members are waiver functionally eligible and Medicaid eligible via SSI (including SSI-E Supplement and 1619A and B) or a full-benefit Medicaid subprogram (see Section 21.2 Full-Benefit Medicaid). This does not include someone solely eligible for any of the limited benefit Medicaid subprograms (see Section 21.3 Limited Benefit Medicaid).
Note: Group A members do not have an asset limit if they are Group A eligible via Family Medicaid. Family Medicaid and it subprograms do not have an asset test.
Clients who have met a deductible are eligible for community waivers as a Group A. The member remains eligible as a Group A until the end of the deductible period. At the next review the member will be able to make a choice between meeting the deductible to receive Medicaid (remaining a Group A) or becoming eligible for community waivers as a Group B or B Plus with a potential cost share.
Group A members are financially eligible with no cost share. Put a check before Group A in Section I. Then complete Sections II and V on the worksheet.
Group B members are defined as those not in Group A, but who have gross income at or below the nursing home institutions categorically needy income limit (see Section 39.4 Elderly, Blind, or Disabled Assets and Income Tables).
Group B Plus members are defined as those not in Group A, who have gross income above the nursing home institutions categorically needy income limit, but whose income does not exceed the cost of the appropriate institutional care by more than the medically needy income limit (see Section 39.4 Elderly, Blind, or Disabled Assets and Income Tables).
For Group B and B Plus, calculate a cost share based on the member’s income and allowable deductions. Count only the income of each individual when you calculate that individual's cost share.
The personal maintenance allowance is an income deduction used when calculating a cost share for a Group B or B Plus waiver member.
The personal maintenance allowance (Line 6 and Page 2 of the worksheet) is for room, board, and personal expenses. It is the total of the following:
Community Waivers Basic Needs Allowance (see Section 39.4.2 Elderly, Blind, or Disabled Deductions and Allowances).
Sixty-five dollars and ½ earned income deduction (see Section 15.7.5 $65 and ½ Earned Income Deduction).
Special housing amount. This is an amount of the person's income set aside to help pay housing costs. If the waiver applicant's housing costs are over $350, add together the following costs:
Rent.
Home or renters insurance.
Mortgage.
Property tax (including special assessments).
Utilities (heat, water, sewer, electricity).
"Room” amount for members in a CBRF , Residential Care Apartment Complex, or an Adult Family/Foster Allowance Home. The case manager determines and provides this amount.
The total, minus $350, equals the special housing amount. The person can set this amount aside from his or her income.
If both spouses are applying and both have income, divide the special housing amount equally between them.
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Example 1: Two spouses applying with income: $600 rent - 350 = 250/2 spouses = $125 that each can set aside |
If only one spouse has income and both spouses are applying, allocate the full special housing amount to the spouse with income.
When one spouse has income and both are applying:
And they reside together in the same residence, allocate the full special housing amount to the spouse with income.
And they reside in separate rooms in a substitute care facility, but there is only one room and board contract for both, allocate the full housing amount to the spouse with income.
And they reside in separate rooms in a substitute care facility, but each has an individual room and board contract, only the spouse with income gets a deduction for the special housing amount, and it is based on their individual "rent” costs that are obtained from the care manager.
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Example 2: Emma and Herbert are living in the same residence. Herbert has income of $1,000 per month. Emma does not have any income. The total housing costs are $650 for both of them. Allocate the full special housing amount to Herbert ($650-$350 = $300 special housing amount). |
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Example 3: Bert and Ingrid live in separate rooms in a substitute care facility, but there is only one room and board contract for both. Bert has income of $1,000 per month. Ingrid does not have any income. The total rent amount is $650 for both of them. Allocate the full special housing amount to Bert ($650-$350 = $300 special housing amount). |
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Example 4: Ned and Maria live in separate rooms in a substitute care facility, and each of them has an individual room and board contract. Ned has income of $1,000 per month. Maria does not have any income. Ned’s "rent” from the room and board amount is $550 and Maria’s "rent” from the room and board amount is $400. Calculate Ned’s special housing amount ($550-$350 = $200 special housing amount). Do not consider Maria’s room and board amount when calculating Ned’s special housing amount. |
When both spouses have income and both are applying:
And they reside together in the same residence, divide the special housing amount equally between them.
And they reside in separate rooms in a substitute care facility, but there is only one room and board contract for both, divide the special housing amount equally between them.
And they reside in separate living arrangements (e.g., they reside in two different substitute care facilities OR they reside in the same substitute care facility but each has a private room and his or her own individual room and board contract) then calculate a separate special housing amount for each, based on their individual "rent" costs that are obtained from the care manager.
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Example 5: Emma and Herbert are living in the same residence. Herbert has income of $1,000 per month, and Emma has income of $500 per month. The total housing cost for both of them is $650. Divide the special housing amount equally between them ($650-$350 = $300 special housing amount, so the special housing amount for Emma and Herbert is $150 each). |
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Example 6: Bert and Ingrid live in separate rooms in a substitute care facility, but there is only one room and board contract for both. Bert has income of $1,000 per month, and Ingrid has income of $500 per month. The total "rent” from the room and board amount for both of them is $650. Divide the special housing amount equally between them ($650-$350 = $300 special housing amount, so the special housing amount for Bert and Ingrid is $150 each). |
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Example 7: Ned and Maria live in separate rooms in a substitute care facility, and each of them has an individual room and board contract. Ned has income of $1,000 per month, and Maria has income of $500 per month. Ned’s "rent” from the room and board amount is $550 and Maria’s "rent” from the room and board amount is $400. Calculate the special housing amounts separately. Ned’s is calculated as follows: $550-$350 = $200 special housing amount. Maria’s is calculated as follows: $400- $350= $50 special housing amount. |
Do not give the special housing amount to waiver participants under age 18.
The total of 1, 2, and 3 must not be greater than the EBD Maximum Personal Maintenance Allowance (see Section 39.4.2 Elderly, Blind, or Disabled Deductions and Allowances).
The family maintenance allowance is for the support of family members when spousal impoverishment policies do not apply. If the member is a disabled child, omit the family maintenance allowance.
Family Related - When the waiver participant is the custodial parent of a minor child living in the home, and there’s no spouse in the home, do the following:
1. Minor children’s gross earned income.
2. -$65 and ½ of gross earned income (see Section 15.7.5 $65 and ½ Earned Income Deduction).
3. =______________.
4. + Minor Children’s total unearned income.
5. = __________Add (3) and (4).
6. AFDC Related med needy income limit _______ (see Section 39.3 AFDC-Related Income Table). (Do not include the waiver applicant in the group size.)
If (5) is greater than (6), there’s no family maintenance allowance. If (5) is less than (6), the family maintenance allowance is the difference between (5) and (6).
EBD Related - If there are no minor children in the home, and spousal impoverishment policies do not apply, do the following:
1. Spouse’s gross earned income.
2. -$65 and ½ of total gross earned income (see Section 15.7.5 $65 and ½ Earned Income Deduction).
3. =__________.
4. +Spouse’s total unearned income.
5. =________________ (3)+(4).
6. -$20 disregard .
7. =_________________(6)-(5).
8. ____________Enter the SSI Payment Level Plus the E Supplement for one person (see Section 39.4 Elderly, Blind, or Disabled Assets and Income Tables).
If (7) is greater than (8), there is no family maintenance allowance. If (7) is less than (8), the family maintenance allowance is the difference between (7) and (8).
Deduct special exempt income (see Section 15.7.2 Special Exempt Income).
Include all health and dental insurance premiums covering the waiver person and for which he or she is responsible and pays a premium. This includes any Medicare Premium obligation including Medicare Part D. See Section 9.6.2 Policies Not To Report for a list of insurance types for which premium deductions are not allowed.
If the waiver participant is part of a covered group but not responsible for the premium, find his or her proportionate share by dividing the premium by the number of people covered. If both members of a couple apply, but only one pays the premium, divide the premium equally. Prorate premiums over the months payment covers.
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Example 8: Sally pays a $600 premium quarterly for her Medicare supplement policy. Six hundred dollars divided by three equals $200. Enter $200 as her monthly health insurance premium payment on the Medical Coverage page. |
Obtain the dollar amount for medical and remedial expenses from the care manager. See Section 15.7.3 Medical/Remedial Expenses.
Note: Care managers should refer to the limitations associated with allowable medical or remedial expenses that are described in Section 27.7.8 Medical/Remedial Expenses and Payments for Non-Covered Services.
The waiver cost share amount is the monthly amount he or she must pay toward the cost of his or her waiver services.
Institutionalized PACE /Partnership or Family Care members pay their cost share to the managed care program instead of the institution.
Effective July 1, 2015, Group C has been replaced with Group B Plus.
This page last updated in Release Number: 15-02
Release Date: 07/30/2015
Effective Date: 07/30/2015
The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.
Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.
Publication Number: P-10030