Section R9-28-408. Income Criteria for Eligibility

A.      The following Medicaid-eligible persons shall be deemed to meet the income requirements for ALTCS eligibility unless ineligible due to federal and state laws regarding trusts.

1.        A person receiving Supplemental Security Income (SSI);

2.        A person receiving Title IV-E Foster Care Maintenance Payments; or

3.        A person receiving Title IV-E Adoption Assistance.

B.       If the person is not included in subsection (A), the Administra- tion shall count the income described in 42 U.S.C. 1382a and 20 CFR 416 Subpart K to determine eligibility with the fol- lowing exceptions:

1.        Income types excluded by 42 U.S.C. 1382a(b) for deter- mining net income are also excluded in determining gross income to determine eligibility;

2.        Income of the parent or spouse of a minor child is counted as part of income under 42 CFR 435.602, except that the income of the parent or spouse is disregarded for the month beginning when the person is institutionalized;

3.        In-kind support and maintenance, under 42 U.S.C. 1382a(a)(2)(A), are excluded for both net and gross income tests;

4.        The income exceptions under A.A.C. R9-22-1503(B) apply to the net income test; and

5.        Income described in subsection (C) is excluded.

C.      The following are income exceptions:

1.        Disbursements from a trust are considered in accordance with federal and state law; and

2.        For an institutionalized spouse, a person defined in 42

U.S.C. 1396r-5(h)(1), income is calculated in accordance with 42 U.S.C. 1396r-5(b).

D.      Income eligibility. Except as provided in R9-28-406(B)(2)(b), countable income shall not exceed 300 percent of the FBR.

E.       The Administration shall determine the amount a person shall pay for the cost of ALTCS services and the post-eligibility treatment of income (share-of-cost) under A.R.S. § 36- 2932(L) and 42 CFR 435.725 or 42 CFR 435.726. The Admin- istration shall consider the following in determining the share- of-cost:

1.        Income types excluded by 42 U.S.C. 1382a(b) for deter- mining net income are excluded in determining share-of- cost.

2.        SSI benefits paid under 42 U.S.C. 1382(e)(1)(E) and (G) to a person who receives care in a hospital or nursing facility are not included in calculating the share-of-cost.

3.        The share-of-cost of a person with a spouse is calculated as follows:

a.         If an institutionalized person has a community spouse under 42 U.S.C. 1396r-5(h), share-of-cost is calculated under R9-28-410 and 42 U.S.C. 1396r- 5(b) and (d); and

b.        If an institutionalized person does not have a com- munity spouse, share of cost is calculated solely on the income of the institutionalized person.

4.        Income assigned to a trust is considered in accordance with federal and state law.

5.        The following expenses are deducted from the share-of- cost of an eligible person to calculate the person's share- of-cost:

a.         A personal-needs allowance equal to 15 percent of the FBR for a person residing in a medical institu- tion for a full calendar month. A personal-needs allowance equal to 300 percent of the FBR for a per- son who receives or intends to receive HCBS or who resides in a medical institution for less than the full calendar month;

b.        A spousal allowance, equal to the FBR minus the income of the spouse, if a spouse but no children remain at home;

c.         A household allowance equal to the standard speci- fied in Section 2 of the Aid for Families with Depen- dent Children (AFDC) State Plan as it existed on July 16, 1996 for the number of household members minus the income of the household members if a spouse and children remain at home;

d.        Expenses for the medical and remedial care services listed in subsection (6) if the expenses have not been paid or are not subject to payment by a third-party, the person still has the obligation to pay the expense, and one of the following conditions is met:

i.         The expense represents a payment made and reported to the Administration during the appli- cation period or a payment reported to the Administration no later than the end of the month following the month in which the pay- ment occurred and the expense has not previ- ously been allowed a share-of-cost deduction; or

ii.        The expense represents the unpaid balance of an allowed, noncovered medical or remedial expense, and the expense has not been previ- ously a share-of-cost deduction;

e.         An amount determined by the Director for the main- tenance of a single person's home for not longer than six months if a physician certifies that the person is likely to return home within that period; or

f.         An amount for Medicare and other health insurance premiums, deductibles, or coinsurance not subject to third-party reimbursement; and

6.        The deductible expense under subsection (5)(b) shall not include any amount for a service covered under the Title XIX State Plan. The deductible expense may include the TPL deductible, co-insurance, and co-payment charges for the following medically necessary services:

a.         Nonemergency dental services for a person who is age 21 or older;

b.        Hearing aids and hearing aid batteries for a person who is age 21 or older;

c.         Nonemergency eye care and prescriptive lenses for a person who is age 21 or older;

d.        Chiropractic services, including treatment for sub- luxation of the spine, demonstrated by x-ray;

e.         Orthognathic surgery for a person who is age 21 or older; or

f.         Co-payments for Medicare Part D prescriptions, if not paid by the State.

g.        On a case-by-case basis, other noncovered medi- cally necessary services that a person petitions the Administration for and the Director approves.

F.       A person shall provide information and verification of income under A.R.S. § 36-2934(G) and 20 CFR 416.203.

Historical Note

New Section adopted by final rulemaking at 5 A.A.R. 369, effective January 6, 1999 (Supp. 99-1). Amended by exempt rulemaking at 7 A.A.R. 4691, effective October 1, 2001 (Supp. 01-3). Amended by final rulemaking at 14

A.A.R. 2090, effective July 5, 2008 (Supp. 08-2). Amended by final rulemaking at 20 A.A.R. 234, effective

January 7, 2014 (Supp. 14-1).