New DOH Directive Requires Most Favorable Eligibility Budgeting Methodology for Married Individuals
The Department of Health (DOH) issued a General Information System (GIS) message (GIS 14 MA/025) to local social services districts on Nov. 3, rescinding an August GIS message (GIS 14 MA/015) and reinstating GIS 12 MA/013, "Spousal Impoverishment Budgeting with Post-Eligibility Rules for Individuals Participating in a Home and Community-Based Waiver Program" and NYS DOH GIS 13 MA/018, "Spousal Impoverishment and Transfer of Assets Rules for Certain Individuals Enrolled in Managed Long Term Care."
The rescinded GIS message required districts to apply spousal impoverishment budgeting with post-eligibility rules to any married individual applying for or receiving Medicaid for long term care services under a 1915(c) waiver or under New York's managed long term care program. The reinstated GIS messages require spousal impoverishment budgeting with post-eligibility rules only when it is more advantageous to the applicant. The Nov. 3 GIS message (GIS 14 MA/015) notes, however, that this policy is to be applied, "[p]ending the issuance of further guidance from the Centers for Medicare and Medicaid Services regarding Section 2404 of the Affordable Care Act."
The rescission of the August GIS message corrects a problem arising out of DOH's interpretation of that Affordable Care Act (ACA) provision, which requires spousal impoverishment budgeting with post-eligibility rules, when reviewing the income and resources of a spouse who is applying for or receiving managed long term care or HCBS waiver services. Spousal impoverishment budgeting is usually more favorable for married individuals, but can be unfavorable if the individual has a high spend-down after the spousal needs allowance and other allowances and deductions are applied.
Prior to the August GIS message (GIS 14 MA/015), such individuals would establish a supplemental needs trust to reduce their spend-down amounts. However, DOH interpreted the ACA provision to require spousal impoverishment budgeting under HCBS waivers and managed long term care to be conducted in the same manner as nursing home budgeting. As a result, a married individual's spend-down amount was to be treated like the NAMI and could not be reduced through the use of a supplemental needs trust. The August GIS message resulted in higher spend-down amounts for some married individuals receiving Medicaid for long term care services.
Under the new GIS message, spousal impoverishment budgeting with post-eligibility rules must be applied only if it is more advantageous to the applicant or recipient. The GIS message directs local districts to identify anyone whose case was "negatively impacted due to the requirement to use spousal impoverishment budgeting with post-eligibility rules," and redetermine eligibility. The redetermination must be effective retroactive to the month the eligibility was determined according to the rescinded August GIS message (GIS 14 MA/15).
Contact: Karen Lipson, klipson@leadingageny.org, 518-867-8383 ext. 124.