Tenn. Comp. R. & Regs. 1240-03-03-.04

Current through October 22, 2024

Section 1240-03-03-.04 - INCOME LIMITATIONS FOR THE CATEGORICALLY NEEDY

(1) Applicants and recipients for medical assistance as Categorically Needy in an AFDC-MO (Section 1931 of the Social Security Act [ 42 U.S.C. § 1396u-1 ]) coverage group are subject to the Centers for Medicare and Medicaid Services (CMS) approved earned income deduction. To calculate the deduction, select the Families First Consolidated Need Standard (CNS) for the appropriate Aid Group (AG) size and subtract ninety dollars ($90) plus thirty dollars ($30) or one hundred and twenty dollars ($120) from the Families First CNS for the AG size. After deducting one hundred and twenty dollars ($120) from the CNS, subtract one-third (1/3) of the balance of the CNS. In addition, subtract the entire amount of the current Families First standard earned income disregard to arrive at the AFDC-MO earned income deduction.

Example: Current CNS for Aid Group size one (1) is $658.

Step 1: Subtract ninety ($90) plus thirty ($30) or $120 from $658. $658 minus $120 is $538.

Step 2: One third (1/3) of $538 is $179. $538 minus $179 is $359.

Step 3: $359 minus $250 (Families First standard earned income disregard) is $109. $109 is the AFDC-MO earned income disregard for a 1 person AG size.

Eligible AFDC-MO applicants and recipients with earned income receive the Families First standard earned income disregard plus the AFDC-MO earned income disregard. In the example above, the AFDC-MO individual would receive a combined earned income deduction of $359.00 ($250 Families First standard earned disregard and $109 AFDC-MO earned income disregard).

(2) Except as otherwise provided in paragraph (3) of this rule, SSI-related coverage groups are subject to income definitions and exclusions from income and policies as provided in 42 C.F.R. § 435.725, 42 C.F.R. 435.1005, 42 U.S.C. § 1382a and at 20 C.F.R. Part 416, Subpart K Income.

(a) Any aged, blind or disabled individual confined to long term nursing care in a facility must be likely to be continuously confined for at least thirty (30) consecutive days, as evidenced by an approved NF Preadmission Evaluation eligibility segment which, when combined with the days already confined, total at least 30 days, prior to attaining Medicaid eligibility or if enrolled in a HCBS waiver program offered either through the CHOICES Program or through a Section 1915(c) HCBS waiver program and likely to receive HCBS services for at least 30 consecutive days going forward, may have countable income equal to or less than 300% of the SSI/FBR beginning the month of admission.

(b) The otherwise eligible individual confined to a long-term care facility is required to assume some of his/her cost of care.

1. Personal Needs Allowance: $50 for an individual. The personal needs allowance for each person receiving Medicaid in a Nursing Facility or an Intermediate Care Facility for persons with Mental Retardation is $50.

(i) The maximum personal needs allowance for persons participating in CHOICES Group 2 is 300% of the SSI Federal Benefit Rate.

(ii) The maximum personal needs allowance for persons participating in one of the State's Section 1915(c) HCBS waivers is as follows:

(I) The Statewide HCBS E/D Waiver: 200% of the SSI Federal Benefit Rate.

(II) The Statewide MR Waiver: 200% of the SSI Federal Benefit Rate.

(III) The Arlington MR Waiver: 200% of the SSI Federal Benefit Rate.

(IV) The Self-Determination MR Waiver: 300% of the SSI Federal Benefit Rate.

2. Effective April 1, 2009, spousal dependent allocation not to exceed two thousand seven hundred thirty-nine dollars ($2,739) per family, and adjusted annually per federal law, which includes:

(i) the spousal allocation using a standard maintenance amount (SMA) based upon one hundred fifty percent (150%) of the federal poverty level for two (2) persons for one (1) year divided by twelve (12) months, minus the community spouse's available countable income in addition to excess shelter expenses that exceed thirty percent (30%) of the SMA, in addition to

(ii) The dependent allocation which equals the SMA minus each dependent's gross countable income divided by three. Department relatives include all individuals who can be or are claimed for Federal income tax purposes by either spouse; and

(iii) The Medically Needy Income Standard (MNIS) will be used to determine the dependent allocation when there is no community spouse.

(c) Qualified Medicare Beneficiaries may be income eligible if such an individual's total income does not exceed one hundred percent (100%) of Federal Poverty Guidelines.

(d) The otherwise eligible individual confined to a long-term care facility is required to assume some of his/her cost of care.

The following deductions are made from the total income available for the cost of long-term nursing home care in the following order:

1. Personal Needs Allowance: $50 for an individual.

2. Allocation to eligible dependent(s) at home reduced by the amount of the dependent's own income.

3. Monthly costs for health insurance premium(s) paid by the eligible individual.

4. Payments for medical or remedial care recognized under state law, but not encompassed within the State's Medicaid plan subject to the following criteria.

Non-Covered Medical Expenses

(i) Reserved for future use.

(ii) Eyeglasses and necessary related services. Deductions can only be made for the following services and must be the lesser of the provider's usual and customary charges, billed charges, or the amounts indicated in the TennCare fee schedule.

Examination and refraction

Frame

Lenses (bifocal)

Lenses (single)

(iii) Hearing aids and necessary related services. Deductions can only be made for the following services and must be the lesser of the provider's usual and customary charges, billed charges, or the amounts indicated in the TennCare fee schedule.

Audiogram

Ear mold

Hearing aid

Batteries

Hearing aid orientation

(iv) Dental services.

(I) In addition to the deductions from the total income available for the cost of long-term nursing home care authorized by rules and regulations of the Department of Human Services, Division of Medical Services for an eligible individual confined to a long-term care facility, a deduction shall also be authorized and made from such total income available for the costs of routine and emergency dental services paid by the eligible individual.

(II) Deductions for such routine and emergency dental services, as defined by the Bureau of TennCare, shall only be made for those purposes and in such amounts as determined annually by the Bureau of TennCare's dental fee listing, whether such services are provided at a dental office, on-site at the long-term care facility, or through a mobile dental services provider that contracts with the long-term care facility.

(v) Specialized chairs such as electric wheelchairs. Deductions will be restricted to the lesser of the Medicare prevailing charges or the Medicaid established fee.

(vi) Charges for nursing home days incurred as the result of bed-holds or therapeutic leave days when the recipient is away from the nursing facility are not allowable deductions. These charges are allowed only when the individual is in an Intermediate Care Facility for the Mentally Retarded (ICF/MR). (TennCare allows a ten (10) day bed hold).

(vii) Charges incurred by the nursing facility for failure to timely submit or renew a previously submitted Pre-Admission Evaluation (PAE) are not allowable deductions.

5. Patient liability overcharges adjustment.

(e) Qualified Disabled Working Individual may be income eligible, if the individual income does not exceed 200% of the Federal Poverty Guidelines.

(f) Specified Low-Income Medicare Beneficiaries (SLMB) may be income eligible, if the individual's income does not exceed 120% of Federal Poverty Guidelines.

(g) Qualified Individuals 1 (QI-1) may be income eligible if the individual's income does not exceed one hundred thirty-five percent (135%) of Federal Poverty Guidelines.

(h) Reserved.

(3) Post-eligibility treatment of income for individuals participating in Home and Community Based Services (HCBS) offered either through CHOICES Program or through a Section 1915(c) of the Social Security Act HCBS waiver program will be determined as follows:

(a) Total gross income will consist of the eligible individual's own income after deduction of the personal needs allowance (maintenance need based on the SSI/FBR for an individual living in the home) has been made for the participating individual and spouse, if applicable.

(b) An allocation will be made to the community spouse and/or dependents as indicated in Paragraph (2)(b)2. herein.

(c) Deductions cited in 1240-03-03-.04(2)(d) will be made from the total gross income with the exception of the personal needs allowance.

Tenn. Comp. R. & Regs. 1240-03-03-.04

Repeal and new rule filed June 14, 1976; effective July 14, 1976. Repeal and new rule filed August 17, 1982; effective September 16, 1982. Amendment filed June 27, 1985; effective July 27, 1985. Amendment filed July 31, 1987; effective September 13, 1987. Amendment filed August 5, 1988; effective November 29, 1988. Amendment filed November 30, 1988; effective January 14, 1989. Amendment filed August 9, 1989; effective September 23, 1989. Amendment filed May 1, 1991; effective June 15, 1991. Amendment filed April 23, 1997; effective July 7, 1997. Amendment filed October 26, 2001; effective January 9, 2002. Amendment filed May 1, 2003; effective July 15, 2003. Public necessity rule filed July 2, 2007; expires December 14, 2007. Amendment filed September 25, 2007; effective December 9, 2007. Amendment filed April 22, 2008; effective July 6, 2008. Amendments filed August 5, 2009; effective November 3, 2009. Emergency rule filed March 1, 2010; effective through August 28, 2010. Amendments filed May 25, 2010; effective August 23, 2010.

Authority: T.C.A. §§ 4-5-201 et seq., 4-5-202, 4-5-208, 71-1-105(12), 71-5-101, 71-5-102, 71-5-103, 71-5-106, 71-5-111, 71-5-140, 71-5-147 and 71-5-1401 et seq.; Acts 2008, Chapter 1190; 42 U.S.C. § 1302, 42 U.S.C. § 1382a, 42 U.S.C. § 1382b, 42 U.S.C. §§ 1396 et seq., 42 U.S.C. §§ 1396a(a)(10), 1396a(a)(50) and (51), and 1396a(1), (q) and (r); 42 U.S.C. § 1396d(p) and (s), 42 U.S.C. § 1396a(q), 42 U.S.C. § 1396r-5, 42 U.S.C. §§ 1396r-5(b) and 5(d)(3)(B) and (C); 42 C.F.R. §§ 435.700, 435.725, 435.726, 435.735, and 435.845; PL 99-272, PL 100-360§ 301, and PL 100-360§ 303.