10 CCR 2505-10
DEPARTMENT OF HEALTH CARE POLICY AND FINANCING Medical Services Board MEDICAL ASSISTANCE – SECTION 8.100 10 CCR 2505-10 8.100 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _____________________________________________________
8.100 MEDICAL ASSISTANCE ELIGIBILITY
8.100.1 Definitions
1619b is section 1619b of the Social Security Act which allows individuals who are eligible for Supplemental Security Income (SSI) to continue to be eligible for Medical Assistance coverage after they return to work.
1931 Medical Assistance is a Medical Assistance category for families, qualified pregnant women and children with limited income provided under section 1931 of Title XIX of the Social Security Act. AB - Aid to the Blind is a program which provides financial assistance to low-income blind persons. ABD - Aged, Blind and Disabled Medical Assistance is a group of Medical Assistance categories for individuals that have been deemed to be aged, blind, or disabled by the Social Security Administration or the Department.
AND - Aid to Needy Disabled is a program which provides financial assistance to low-income persons over age 18 who have a total disability which is expected to last six months or longer and prevents them from working.
AFDC - Aid to Families with Dependent Children is the Title IV federal assistance program in effect from 1935 to 1997 which was administered by the United States Department of Health and Human Services. This program provided financial assistance to children whose families had low or no income. AP-5615 is the form used to determine the patient payment for clients in nursing facilities receiving Long Term Care.
Alien is a person who was not born in the United States and who is not a naturalized citizen. Ambulatory Services is any medical care delivered on an outpatient basis. Annuity is an investment vehicle whereby an individual establishes a right to receive fixed for periodic payments, either for life or a term of years.
Applicant is a person who has submitted an application for public benefits. Application Date is the date the application is received and date-stamped by the eligibility site or the date the application was received and date-stamped by an Application Assistance site or Presumptive Eligibility site. In the absence of a date-stamp, the application date is the date that the application was signed by the client.
Application for Assistance is the designated application used to determine eligibility for financial assistance. It can also be used to determine eligibility for medical assistance. Blindness is defined in this volume as the total lack of vision or vision in the better eye of 20/200 or less with the use of a correcting lens and/or tunnel vision to the extent that the field of vision is no greater than 20 degrees.
Burial Spaces are burial plots, gravesites, crypts, mausoleums, urns, niches and other customary and traditional repositories for the deceased's bodily remains provided such spaces are owned by the individual or are held for his or her use, including necessary and reasonable improvements or additions to or upon such burial spaces such as: vaults, headstones, markers, plaques, or burial containers and arrangements for opening and closing the gravesite for burial of the deceased. Burial Trusts are irrevocable pre-need funeral agreements with a funeral director or other entity to meet the expenses associated with burial for Medical Assistance applicants/recipients. The agreement can include burial spaces as well as the services of the funeral director. Caretaker Relative is any relation by blood, marriage or adoption who is within the fifth degree of kinship to the dependent child, such as: a parent; a brother, sister, uncle, aunt, first cousin, first cousin once removed, nephew, niece, or persons of preceding generations denoted by prefixes of grand, great, great great, or great-great-great; a spouse of any person included in the above groups even after the marriage is terminated by death or divorce; or stepparent, stepbrother, stepsister, step-aunt, etc. Case management services are services provided by community mental health centers, clinics, community centered boards, and EPSDT case managers to assist in providing services to Medical Assistance clients in gaining access to needed medical, social, educational and other services. Cash surrender value is the amount the insurer will pay to the owner upon cancellation of the policy before the death of the insured or before maturity of the policy. Categorically eligible means persons who are eligible for Medical Assistance due to their eligibility for one or more Federal categories of public assistance.
CBMS - Colorado Benefits Management System is the computer system that determines an applicant’s eligibility for public assistance in the state of Colorado. CDHS -Colorado Department of Human Services is the state department responsible for administering the social service and financial assistance programs for Colorado. Child Support Services is a CDHS program that assures that all children receive financial and medical support from each parent. This is accomplished by locating each parent, establishing paternity and support obligations, and enforcing those obligations.
Citizen is a person who was born in the United States or who has been naturalized. Client is a person who is eligible for the Medical Assistance Program. "Client" is used interchangeably with "recipient" when the person is eligible for the program. CMS - Centers for Medicare and Medicaid Services is the Federal agency within the US Department of Health and Human Services that partners with the states to administer Medicaid and CHP+ via State Plans in effect for each State. Colorado is in Region VIII. CHP+ - Child Health Plan Plus is low-cost health insurance for Colorado's uninsured children and pregnant women. CHP+ is public health insurance for children and pregnant women who earn too much to qualify for The Medical Assistance Program, but cannot afford private health insurance. Colorado Medical Assistance application is the designated application for Medical Assistance Programs and the CHP+ Program.
COLA - Cost of Living Adjustment is an annual increase in the dollar value of benefits made automatically by the United States Department of Health and Human Services or the state in OASDI, SSI and OAP cases to account for rises in the cost of living due to inflation. Colorado State Plan is a written statement which describes the purpose, nature, and scope of the Colorado’s Medical Assistance Program. The Plan is submitted to the CMS and assures that the program is administered consistently within specific requirements set forth in both the Social Security Act and the Code of Federal Regulations (CFR) in order for a state to be eligible for Federal Financial Participation (FFP).
Common Law Marriage is legally recognized as a marriage in the State of Colorado under certain circumstances even though no legally recognized marriage ceremony is performed or civil marriage contract is executed. Individuals declaring or publicly holding themselves out as a married couple through verbal or written methods may be recognized as legally married under state law. C.R.S. 14-2-104(3) Community Spouse is a person who is legally married to an institutionalized spouse and is not in a medical institution or nursing facility. The community spouse remains in the community. Community Spouse Resource Allowance is the amount of resources that the Medical Assistance regulations permit the spouse staying at home to retain. Complete application means an application in which all questions have been answered, which is signed, and for which all required verifications have been submitted. The Department is defined in this volume as the Colorado Department of Health Care Policy and Financing which is responsible for administering the Colorado Medical Assistance Program and Child Health Plan Plus programs as well as other State-funded health care programs. Dependent child is defined in this volume as a child residing in the home under the age of 18 or between the ages of 18 and 19 who is a full time student in a secondary school or in the equivalent level of vocational or technical training and expected to complete the program before age 19. Dependent relative for purposes of this rule is defined as one who is claimed as a dependent by an applicant for federal income tax purposes.
Disability means the inability to do any substantial gainful activity (or, in the case of a child, having marked and severe functional limitations) by reason of a medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of l2 months or more.
Dual eligible clients are Medicare recipients who are also eligible for Medical Assistance. Earned Income is defined for purposes of this volume as any compensation from participation in a business, including wages, salary, tips, commissions and bonuses. Earned Income Disregards are the allowable deductions and exclusions subtracted from the gross earnings. Income disregards vary in amount and type, depending on the category of assistance. Eligibility site is defined in this volume as a location outside of the Department that has been deemed by the Department as eligible to accept applications and determine eligibility for applicants. EPSDT- Early Periodic Screening, Diagnosis and Treatment is the child health component of the Medical Assistance Program. It is required in every state and is designed to improve the health of low-income children by financing appropriate, medically necessary services and providing outreach and case management services for all eligible individuals.
Equity value is the fair market value of land or other asset less any encumbrances. Ex Parte Review is an administrative review of eligibility during a redetermination period in lieu of performing a redetermination from the client. This administrative review is performed by verifying current information obtained from another current aid program.
Face value of a life insurance policy is the basic death benefit of the policy exclusive of dividend additions or additional amounts payable because of accidental death or other special provisions. Fair market value is the average price a similar property will sell for on the open market to a private individual in the particular geographic area involved. Also, the price at which the property would change hands between a willing buyer and a willing seller, neither being under any pressure to buy or to sell and both having reasonable knowledge of relevant facts.
Family and Children’s Medical Assistance is a group of Medical Assistance categories that provides medical coverage for children, adults with dependent children, and pregnant women. FFP - Federal Financial Participation as defined in this volume is the amount or percentage of funds provided by the Federal Government to administer the Colorado Medical Assistance Program. FPL - Federal Poverty Level is a simplified version of the federal poverty thresholds used to determine financial eligibility for assistance programs. The thresholds are issued each year in the Federal Register by the Department of Health and Human Services (HHS).
Good Cause is the client’s justification for needing additional time due to extenuating circumstances, usually used when extending deadlines for submittal of required documentation. Good Cause for child support is the specific process and criteria that can be applied when a client is refusing to cooperate in the establishment of paternity or establishment and enforcement of a child support order due to extenuating circumstances.
HCBS are Home and Community Based Services are also referred to as “waiver programs” . HCBS provides services beyond those covered by the Medical Assistance Program that enable individuals to remain in a community setting rather than being admitted to a Long term care institution. Immediate family includes the individual's spouse, minor and adult children, stepchildren, adopted children, brothers, sisters, parents, adoptive parents, and the spouses of those persons, regardless of dependency or whether they are living in the applicant’s/client’s household. Inpatient is an individual who has been admitted to a medical institution on recommendation of a physician or dentist and who receives room, board and professional services for 24 hours or longer, or is expected to receive these services for 24 hours or longer. Institution is an establishment that furnishes, in single or multiple facilities, food, shelter and some treatment or services to four or more persons unrelated to the proprietor. Institutionalization is the commitment of a patient to a health care facility for treatment. Irrevocable means that the contract, trust, or other arrangement cannot be terminated, and that the funds cannot be used for any purpose other than outlined in the document. Legal Immigrant is an individual who is not a citizen or national of the United States and who was lawfully admitted to the United States by the immigration and naturalization service as an actual or prospective permanent resident or whose extended physical presence in the United States is known to and allowed by the immigration and naturalization service.
Legal Immigrant Prenatal is a medical program that provides medical coverage for pregnant legal immigrants who have been legal immigrants for less than five years. Long Term Care is a Medical Assistance category that provides nursing-home care, home-health care, personal or adult day care for individuals above the age of 65 or with a chronic or disabling condition that needs constant supervision.
Long Term Care institution means class I nursing facilities, intermediate care facilities for the mentally retarded (ICF/MR) and swing bed facilities. Long Term Care institutions can include hospitals. Managed care system is a system for providing health care services which integrates both the delivery and the financing of health care services in an attempt to provide access to medical services while containing the cost and use of medical care.
Medical Assistance is defined as all medical programs administered by the Department of Health Care Policy and Financing. Medical Assistance/Medicaid joint state/federal health benefits program for individuals and families with low income and resources. It is an entitlement program that is jointly funded by the states and federal government and administered by the state. This program provides for payment of all or part of the cost of care for medical services. Medical Assistance Required Household is defined for purposes of this volume as all parents or caretaker relatives, spouses, and dependent children residing in the same home. Minimal verification is defined in this volume as the minimum amount of information needed to process an application for benefits. No other verification can be requested from clients unless the information provided is questionable or inconsistent.
MMMNA - Minimum Monthly Maintenance Needs Allowance is the calculation used to determine the amount of institutionalized spouse’s income that the community spouse is allowed to retain to meet their monthly living needs.
MIA - Monthly Income Allowance is the amount of institutionalized spouse’s income that the community spouse is allowed to retain to meet their monthly living needs. MSP - Medicare Savings Program is a Medical Assistance Program to assist in the payment of Medicare premium, coinsurance and deductible amounts. There are four groups that are eligible for payment or part-payment of Medicare premiums, coinsurance and deductibles: Qualified Medicare Beneficiaries (QMBs), Specified Low-Income Medicare Beneficiaries (SLIMBs), Qualified Disabled and Working Individuals (QDWIs), and Qualifying Individuals – 1 (QI-1s). Nursing Facility is a facility or distinct part of a facility which is maintained primarily for the care and treatment of inpatients under the direction of a physician. The patients in such a facility require supportive, therapeutic, or compensating services and the availability of a licensed nurse for observation or treatment on a twenty-four-hour basis.
OAP - Old Age Pension is a financial assistance program for low income adults age 60 or older. OASDI - Old Age, Survivors and Disability insurance is the official term Social Security uses for Social Security Act Title II benefits including retirement, survivors, and disability. This does not include SSI payments.
Outpatient is a patient who is not hospitalized overnight but who visits a hospital, clinic, or associated facility for diagnosis or treatment. Is a patient who does not require admittance to a facility to receive medical services.
PACE - Program of All-inclusive Care for the Elderly is a unique, capitated managed care benefit for the frail elderly provided by a not-for-profit or public entity. The PACE program features a comprehensive medical and social service delivery system using an interdisciplinary team approach in an adult day health center that is supplemented by in-home and referral services in accordance with participants' needs. Patient is an individual who is receiving needed professional services that are directed by a licensed practitioner of the healing arts toward maintenance, improvement, or protection of health, or lessening of illness, disability, or pain.
PNA - Personal Needs Allowance means moneys received by any person admitted to a nursing care facility or Long Term Care Institution which are received by said person to purchase necessary clothing, incidentals, or other personal needs items which are not reimbursed by a Federal or state program. Proportionate Share is the income attributed to or counted for each individual member of a household based on the individual’s own income plus the equal share of income from the biological or adoptive parent or spouse as defined by the legal or biological relationship between members of a Family Medical Assistance household.
Provider is any person, public or private institution, agency, or business concern enrolled under the state Medical Assistance program to provide medical care, services, or goods and holding a current valid license or certificate to provide such services or to dispense such goods. Psychiatric facility is a facility that is licensed as a residential care facility or hospital and that provides inpatient psychiatric services for individuals under the direction of a licensed physician. Public Institution means an institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control.
Questionable is defined as inconsistent or contradictory tangible information, statements, documents, or file records.
Recipient is any person who has been determined eligible to receive benefits. Resident is any individual who is living within the state and considers the state as their place of residence. Residents include any unempancipated child whose parent or other person exercising custody lives within the state.
RRB - Railroad Retirement Benefits is a benefit program under Federal law 45 U.S.C.A. § 231 et seq that became effective in 1935. It provides retirement benefits to retired railroad workers and families from a special fund, which is separate from the social security fund. Secondary School is a school or educational program that provides instruction or training towards a high school diploma or an equivalent degree such as a GED.
Single Entry Point Agency means the organization selected to provide case management functions for persons in need of Long Term Care services within a Single Entry Point District. SISC- Supplemental Income Status Codes are system codes used to distinguish the different types of state supplementary benefits (such as OAP) a recipient may receive. Supplemental Income Status Codes determine the FFP for benefits paid on behalf of groups covered under the Medical Assistance program. SSA - Social Security Administration is an agency of the United States federal government that administers Social Security, a social insurance program consisting of retirement, disability, and survivors' benefits.
SSI - Supplemental Security Income is a Federal income supplement program funded by general tax revenues (not Social Security taxes) that provides income to aged, blind or disabled individuals with little or no income and resources.
SSI eligible means eligible to receive Supplemental Security Income under Title XVI of the Social Security Act, and may or may not be receiving the monetary payment. TANF - Temporary assistance to needy families is the Federal assistance program which provides supportive services and federal benefits to families with little or no income or resources. The program began on July 1, 1997, and succeeded the Aid to Families with Dependent Children program. It is the Block Grant that was established under the Personal Responsibility and Work Opportunity Reconciliation Act in Title IV of the Social Security Act.
Third Party is an individual, institution, corporation, or public or private agency which is or may be liable to pay all or any part of the medical cost of an injury, a disease, or the disability of an applicant for or recipient of medical assistance.
Title XIX is the portion of the federal Social Security Act which authorizes a joint federal/state Medicaid program. Title XIX contains federal regulations governing the Medicaid program. TMA - Transitional Medical Assistance is a Medical Assistance category for families that lost 1931 Medical Assistance coverage due to increased earned income or loss of earned income disregards. ULTC 100.2 is an assessment tool used to determine level of functional limitation and eligibility for Long Term Care services in Colorado.
Unearned Income is defined for purposes of this volume as any income received from sources other than employment.
VA - Veterans Affairs is The Department of Veterans Affairs which provides patient care and Federal benefits to veterans and their dependents.
8.100.2 Legal Basis [Eff. 03/30/2009]
Constitution of Colorado, Article XXIV, Old Age Pensions, section 7, established a health and medical care fund for persons who qualify to receive old age pensions. Colorado Revised Statutes, Title 26, Article 4, Colorado Medical Assistance Act, section 102, provides for a program of medical assistance for individuals and families, whose income and resources are insufficient to meet the costs of necessary medical care and services, to be administered in cooperation with the federal government.
The Social Security Act, Title XIX, Grants to States for Medical Assistance Programs, and the consequent Federal regulations, Title 42, CFR (Code of Federal Regulations), Chapter IV, Subchapter C, set forth the conditions for states to obtain Federal Financial Participation in medical assistance expenditures. Under the Colorado Medical Assistance Program, the Medicaid program provides coverage of certain groups specified in Title XIX of the Social Security Act. The OAP State Only Medical Assistance Program provides coverage to certain old age pension clients entitled to health and medical care under the Colorado Constitution.
The Department of Health Care Policy and Financing is the single State agency designated to administer the Colorado Medical Assistance Program under Title XIX of the Social Security Act and Colorado statutes. The Office of Medical Assistance of the Department is delegated the duties and responsibilities for administration of the Colorado Medical Assistance Program.
8.100.3 Medical Assistance General Eligibility Requirements [Eff. 03/30/2009]
8.100.3.A. Application Requirements 1. The eligibility site shall advise individuals concerning the benefits of the Medical Assistance Program and determine and redetermine eligibility for Medical Assistance in accordance with rules and regulations of the Department. A person who is applying for the Medical Assistance Program or a client who is determined ineligible for the Medical Assistance Program in one category shall be evaluated under all other categories of eligibility. There is no time limit for Medical Assistance coverage as long as the client remains categorically eligible.
2. Persons applying to the eligibility site for assistance need complete only one application form to apply for both Medical Assistance and Financial Assistance under the Federal or State Financial Assistance Programs administered in the county. The application will be the Application for Assistance.
3. The applicant must sign the application form in order to receive Medical Assistance.
4. If the applicant is not able to participate in the completion of the application forms due to physical or mental incapacity, the spouse, other relative, friend, or representative may complete the forms. When no such person is available to assist in these situations, the eligibility site shall assist the applicant in the completion of the necessary forms. This type of situation should be identified clearly in the case record and CBMS case comments.
5. For the purpose of Medical Assistance, when an applicant is incompetent or incapacitated and unable to sign an application, or in case of death of the applicant, the application shall be signed by someone acting responsibly on behalf of the applicant either:
a. a parent, or other specified relative, or legally appointed guardian or conservator, or b. for a person in a medical institution for whom none of the above in A are available, an authorized official of the institution may sign the application.
6. The eligibility site has the responsibility to assure that the specified relative or representative receives information regarding program benefits and requirements applicable to the family member(s), but the eligibility site can make no restrictions regarding which family member(s) on whose behalf the specified relative or representative may request assistance.
7. Application interviews or requested visits to the eligibility site for Medical Assistance shall not be required. All correspondence may be done by mail or telephone.
8. Eligibility sites shall not restrict the hours in which applicants may file an application. An applicant may file an application at any time during normal business hours. The eligibility site must afford any individual wishing to do so the opportunity to apply for Medical Assistance without delay.
9. If an applicant is found to be ineligible for a particular program, the Application for Assistance shall be reviewed and processed for other financial programs the household has requested on the Application for Assistance and all other Medical Assistance Programs. Referrals to other community agencies and organizations shall be made for the applicant whenever available or requested.
10. If the applicant applied for the Medical Assistance Program on the Colorado Medical Assistance application and was found ineligible, this application shall be reviewed for all other Medical Assistance eligibility programs and the Child Health Plan Plus (CHP+) program.
11. Persons required to be in the same Medical Assistance required household shall file for the Medical Assistance Program as one assistance unit. Each Medical Assistance Required Household shall be budgeted using the appropriate need standard/income level for that unit. See section 8.100.4.C for more information on required household members. 8.100.3.B. Residency Requirements 1. Individuals shall make application in the county in which they live. Individuals held in correctional facilities or who are held in community corrections programs shall apply for the Medical Assistance Program in the county specified as the county of residence upon release. Individuals who reside in a county but who do not reside in a permanent dwelling nor have a fixed mailing address shall be considered eligible for the Medical Assistance Program, provided all other eligibility requirements are met. In no instance shall there be a durational residency requirement imposed upon the applicant, nor shall there be a requirement for the applicant to reside in a permanent dwelling or have a fixed mailing address. If an individual without a permanent dwelling or fixed mailing address is hospitalized, the county where the hospital is located shall be responsible for processing the application to completion. If the individual moves prior to completion of the eligibility determination the origination eligibility site completes the determination and transfers the case as applicable.
For applicants in Long Term Care institutions The county of domicile for all Long Term Care clients is the county in which they are physically located and receiving services.
2. A resident of Colorado is defined as a person that is living within the state of Colorado and considers Colorado to be their place of residence at the time of application. For institutionalized individuals who are incapable of indicating intent as to their state of residence, the state of residence shall be where the institution is located unless that state determines that the individual is a resident of another state, by applying the following criteria:
a. for any institutionalized individual who is under age 21 or who is age 21 or older and incapable of indicating intent before age 21, the state of residence is that of the individual's parent(s) or legally appointed guardian at the time of placement;
b. for any institutionalized individual who became incapable of indicating intent at or after age 21,
c. upon placement in another state, the new state is the state of residence unless the current state of residence is involved in the placement. If a current state arranged for an individual to be placed in an institution located in another state, the current state shall be the individual's state of residence, irrespective of the individual's indicated intent or ability to indicate intent;
d. in the case of conflicting opinions between states, the state of residence is the state where the individual is physically located.
3. For purposes of this section on establishing an individual's state of residence, an individual is considered incapable of indicating intent if:
a. the person has an I.Q. of 49 or less or has a mental age of 7 or less, based on standardized tests as specified in the persons in medical facilities section of this volume;
b. the person is judged legally incompetent; or c. medical documentation, or other documentation acceptable to the eligibility site, supports a finding that the person is incapable of indicating intent.
4. Residence shall be retained until abandoned. A person temporarily absent from the state, inside or outside the United States, retains Colorado residence. Temporarily absent means that at the time he/she leaves, the person intends to return.
5. A non-resident shall mean a person who considers his/her place of residence to be other than Colorado. Any person who enters the state to receive Medical Assistance or for any other reason is a non-resident, so long as they consider their permanent place of residence to be outside of the state of Colorado.
8.100.3.C. Transferring Requirements 1. When a family or individual moves from one county to another within Colorado, the client shall report the change of address to the eligibility site responsible for the current active Medical Assistance Program case(s). If a household applies in the county in which they live and then moves out of that county during the application determination process, the originating eligibility site shall complete the processing of that application before transferring the case. The originating eligibility site shall electronically transfer the case to the new county of residence in CBMS.
2. The originating eligibility site must notify the receiving eligibility site of the client's transfer of Medical Assistance. The originating eligibility site may notify the receiving eligibility site by telephone that a client has moved to the receiving county. If the family or individual wishes to apply for other types of assistance, they shall submit a new application to the receiving eligibility site.
3. If the household is transferring the current Medical Assistance case, the receiving eligibility site cannot mandate a new application, verification, or an office visit to authorize the transfer. The receiving eligibility site can request copies of specific case documents to be forwarded from the originating eligibility site to verify the data contained in CBMS.
4. If the originating eligibility site closes a case for the discontinuation reason of "unable to locate," the applicant shall reapply at the receiving eligibility site for the Medical Assistance Program.
5. If a case is closed for any other discontinuation reason than "unable to locate" and the client provides appropriate information to overturn the discontinuation with the originating eligibility site, then, upon transfer, the receiving eligibility site shall reopen the case with case comments in CBMS. These actions shall be performed according to timeframes defined by the Department. Please review the Department User Reference Guide for timeframes.
6. When a recipient moves from his/her home to a nursing facility in another county or when a recipient moves from one nursing facility to another in a different county:
a. the initiating eligibility site will transfer the case electronically in the eligibility system to the eligibility site in which the nursing facility is located when the individual is determined eligible; and b. The following items shall be furnished by the initiating eligibility site to the new eligibility site in hard copy format:
7. When transferring a case, the initiating eligibility site will send an AP-5615 form to the nursing facility administrator of the new nursing facility showing the date of case closure and the current patient payment at the time of transfer. Should the Medical Assistance Program reimbursement be interrupted, the receiving eligibility site will have the responsibility to process the application and back date the Medical Assistance eligibility date to cover the period of ineligibility. 8.100.3.D. Processing Requirements 1. The eligibility site shall process an application for Medical Assistance Program benefits within the following deadlines:
a. 90 days for persons who apply for the Medical Assistance Program and a disability determination is required.
b. 45 days for all other Medical Assistance Program applicants.
c. The above deadlines cover the period from the date of receipt of a complete application to the date the eligibility site mails a notice of its decision to the applicant.
d. In unusual circumstances, documented in the case record and in CBMS case comments, the eligibility site may delay its decision on the application beyond the applicable deadline at its discretion. Examples of such unusual circumstances are a delay or failure by the applicant or an examining physician to take a required action such as submitting required documentation, or an administrative or other emergency beyond the agency's control.
2. Upon request, applicants will be given an extension of time within the application processing timeframe to submit requested verification. Applicants may request an extension of time beyond the application processing timeframe to obtain necessary verification. The extension may be granted at the eligibility site's discretion. The amount of time given should be determined on a case-by- case basis and should be based on the amount of time the individual needs to obtain the required documentation.
3. The eligibility site shall not use the above timeframes as a waiting period before determining eligibility or as a reason for denying eligibility.
4. For clients who apply for the Medical Assistance Program and a disability determination is required, the eligibility site shall send a notice informing the applicant of the reason for a delay beyond the applicable deadline, and of the applicant's right to appeal if dissatisfied with the delay. The eligibility site shall send this notice no later than 91 days following the application for the Medical Assistance Program.
5. For information regarding continuation of benefits during the pendency of an appeal to the Social Security Administration (SSA) based upon termination of disability benefits see section 8.057.5.C.
6. Effective July 1, 1997, as a condition of eligibility for the Medical Assistance Program, any legal immigrant who is applying for or receiving Medical Assistance shall agree in writing that, during the time period the client is receiving Medical Assistance, he or she will not sign an affidavit of support for the purpose of sponsoring an alien who is seeking permission from the United States Immigration and Citizenship Services to enter or remain in the United States. A legal immigrant's eligibility for Medical Assistance shall not be affected by the fact that he or she has signed an affidavit of support for an alien before July 1, 1997.
7. Eligibility sites at which an individual is able to apply for Medical Assistance benefits shall also provide the applicant the opportunity to register to vote.
a. The eligibility site shall provide to the applicant the prescribed voter registration application.
b. The eligibility site shall not:
c. The eligibility site shall ensure the confidentiality of individuals registering and declining to register to vote.
d. Records concerning registration and declination to register to vote shall be maintained for two years by the eligibility site. These records shall not be part of the public assistance case record.
e. A completed voter registration application shall be transmitted to the county clerk and recorder for the county in which the eligibility site is located not later than ten (10) days after the date of acceptance; except that if a registration application is accepted within five (5) days before the last day for registration to vote in an election, the application shall be transmitted to the county clerk and recorder for the county not later than five (5) days after the date of acceptance.
8. Individuals who transfer from one Colorado county to another shall be provided the same opportunity to register to vote in the new county of residence. The new county of residence shall follow the above procedure. The new county of residence shall notify its county clerk and recorder of the client's change in address within five (5) days of receiving the information from the client. 8.100.3.E. Retroactive Medical Assistance Coverage 1. An applicant for Medical Assistance shall be provided such assistance any time during the three months preceding the date of application, or as of the date the person became eligible for Medical Assistance, whichever is later. That person shall have received medical services at any time during that period and met all applicable eligibility requirements.
2. An explanation of the conditions for retroactive Medical Assistance shall be given to all applicants. Those applicants who within the three months period prior to the date of application or as of the date the person became eligible for Medical Assistance, whichever is later, have received medical services which would be a benefit under the Colorado State Plan, can request retroactive coverage on the application form. The determination of eligibility for retroactive Medical Assistance shall be made as part of the application process. An applicant does not have to be eligible in the month of application to be eligible for retroactive Medical Assistance. The applicant or client may verbally request retroactive coverage at any time following the completion of an application. Verification required to determine Medical Assistance Program eligibility for the retroactive period shall be secured by the eligibility site to determine retroactive eligibility. Proof of the declared medical service shall not be required.
8.100.3.F. Groups Assisted Under the Program 1. The Medical Assistance Program provides benefits to the following persons who meet the federal definition of categorically needy at the time they apply for benefits:
a. Families and children as defined under the Family and Children’s Medical Assistance section 8.100.4.
b. Persons who meet legal immigrant requirements as outlined in this volume, who were or would have been eligible for SSI but for their alien status, if such persons meet the resource, income and disability requirements for SSI eligibility.
c. Persons who are receiving financial assistance; and who are eligible for a SISC Code of A or
d. Persons who are eligible for financial assistance under Old Age Pension (OAP) and SSI, but are not receiving the money payment.
e. Persons who would be eligible for financial assistance from OAP or SSI, except for the receipt of Social Security Cost of Living Adjustment (COLA) increases, or other retirement, survivors, or disability benefit increases to their own or a spouse's income. This group also includes persons who lost OAP or SSI due to the receipt of Social Security Benefits and who would still be eligible for the Medical Assistance Program except for the cost of living adjustments (COLA's) received. These populations are referenced as Pickle and Disabled Widow(er)s.
f. Persons who are blind, disabled, or aged individuals residing in the medical institution or Long Term Care Institution whose income does not exceed 300% of SSI.
g. Persons who are blind, disabled or aged receiving HCBS whose income does not exceed 300% of the SSI benefit level and who, except for the level of their income, would be eligible for an SSI payment.
h. A disabled adult child who is at least 18 years of age and who was receiving SSI as a disabled child prior to the age of 22, and for whom SSI was discontinued on or after May 1, 1987, due to having received of OASDI drawn from a parent(s) Social Security Number, and who would continue to be eligible for SSI if the above OASDI and all subsequent cost of living adjustments were disregarded. This population is referenced as Disabled Adult Child (DAC).
i. Children age 18 and under who would otherwise require institutionalization in an Long Term Care Institution, Nursing Facility (NF), or a hospital but for which it is appropriate to provide care outside of an institution as described in 1902(e)(3) of the Act Public Law No. 97-248 (Section 134).
j. Persons receiving OAP-A, OAP-B, and OAP Refugees who do not meet SSI eligibility criteria but do meet the state eligibility criteria for the OAP State Only Medical Assistance Program. These persons qualify for a SISC Code C.
k. Persons who apply for and meet the criteria for one of the categorical Medical Assistance programs, but do not meet the criteria of citizenship shall receive Medical Assistance benefits for emergencies only.
8.100.3.G. General and Citizenship Eligibility Requirements 1. To be eligible to receive Medical Assistance, an eligible person shall:
a. Be a resident of Colorado;
b. Not be an inmate of a public institution, except as a patient in a public medical institution or as a resident of an Long Term Care Institution or as a resident of a publicly operated community residence which serves no more than 16 residents;
c. Not be a patient in an institution for tuberculosis or mental disease, unless the person is under 21 years of age or has attained 65 years of age and is eligible for the Medical Assistance Program and is receiving active treatment as an inpatient in a psychiatric facility eligible for Medical Assistance reimbursement. See section 8.100.4.H for special provisions extending Medical Assistance coverage for certain patients who attain age 21 while receiving such inpatient psychiatric services;
d. Meet all financial eligibility requirements of the Medical Assistance Program for which application is being made;
e. Meet the definition of disability or blindness, when applicable. Those definitions appear in this volume at 8.100.1 under Definitions;
f. Meet all other requirements of the Medical Assistance Program for which application is being made; and g. Fall into one of the following categories:
An emergency medical condition (including labor and delivery) which manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
8.100.3.H. Citizenship and Identity Documentation Requirements 1. For determinations of initial eligibility and redeterminations of eligibility for Medical Assistance made on or after July 1, 2006, citizenship or nationality and identity status must be verified unless such satisfactory documentary evidence has already been provided, as described in 8.100.3.H.4.b. This requirement applies to an individual who declares or who has previously declared that he or she is a citizen or national of the United States.
a. The following electronic interfaces shall be accepted as proof of citizenship and/or identity as listed and should be used prior to requesting documentary evidence from applicants/clients:
b. This requirement does not apply to the following groups: i). Individuals who are entitled to or who are enrolled in any part of Medicare. ii). Individuals who receive Supplemental Security Income (SSI). iii). Individuals who receive child welfare services under Title IV-B of the Social Security Act on the basis of being a child in foster care.
v). Individuals who receive Social Security Disability Insurance (SSDI). vi). Children born to a woman who has applied for, has been determined eligible, and is receiving Medical Assistance on the date of the child's birth, as described in 8.100.4.G.5. This includes instances where the labor and delivery services were provided before the date of application and were covered by the Medical Assistance Program as an emergency service based on retroactive eligibility.
vii). Individuals receiving Medical Assistance during a period of presumptive eligibility.
2. Satisfactory documentary evidence of citizenship or nationality includes the following:
a. Primary Evidence of Citizenship and Identity. The following evidence shall be accepted as satisfactory documentary evidence of both identity and citizenship:
b. Secondary Evidence of Citizenship. If primary evidence from the list in 8.100.3.H.2.a. is unavailable, an applicant or recipient shall provide satisfactory documentary evidence of citizenship from the list specified in this section to establish citizenship AND satisfactory documentary evidence from the documents listed in section 8.100.3.H. 3. to establish identity. Secondary evidence of citizenship includes:
viii) A final adoption decree that:
c. Third Level Evidence of U.S. Citizenship. Third level evidence of U.S. citizenship is documentary evidence of satisfactory reliability that is used when neither primary nor secondary evidence is available. Third level evidence shall be used only when primary evidence cannot be obtained within 10 business days, secondary evidence does not exist or cannot be obtained, and the applicant or recipient alleges being born in the U.S. A second document from the list in 8.100.3.H.3. to establish identity shall also be presented.
d. Fourth Level Evidence of Citizenship. Fourth level evidence of citizenship is documentary evidence of the lowest reliability. Fourth level evidence shall only be used in the rarest of circumstances. This level of evidence is used only when primary evidence is unavailable, both secondary and third level evidence do not exist or cannot be obtained within 10 business days, and the applicant alleges U.S. citizenship. The affidavit process described in 8.100.3.H.2.d.ii.5. may be used by U.S. citizens or nationals born inside or outside the U.S. In addition, a second document establishing identity shall be presented as described in 8.100.3.H.3.
e. Evidence of Citizenship for Collectively Naturalized Individuals. If a document shows the individual was born in Puerto Rico, the Virgin Islands of the U.S., or the Northern Mariana Islands before these areas became part of the U.S., the individual may be a collectively naturalized citizen. A second document from 8.100.3.H.3.. to establish identity shall also be presented.
f) Referrals for Colorado Birth Certificates
3. The following documents shall be accepted as proof of identity and shall accompany a document establishing citizenship from the groups of documentary evidence outlined in 8.100.3.H.2.b. through e.
a) A driver's license issued by a State or Territory either with a photograph of the individual or other identifying information such as name, age, sex, race, height, weight, or eye color;
b) School identification card with a photograph of the individual;
c) U.S. military card or draft record;
d) Identification card issued by the Federal, State, or local government with the same information included on driver's licenses;
e) Military dependent's identification card;
f) U.S. Coast Guard Merchant Mariner card;
g) Certificate of Degree of Indian Blood, or other U.S. American Indian/Alaska Native Tribal document with a photograph or other personal identifying information relating to the individual. The document is acceptable if it carries a photograph of the individual or has other personal identifying information relating to the individual such as age, weight, height, race, sex, and eye color; or h) Three or more documents that together reasonably corroborate the identity of an individual provided such documents have not been used to establish the individual's citizenship and the individual submitted evidence of citizenship listed under 8.100.3.H.2.b. or 8.100.3.H.2.c. The following requirements must be met:
i) Special identity rules for children. For children under 16, the following records are acceptable:
j) Special identity rules for disabled individuals in institutional care facilities.
k) Expired identity documents.
l) Referrals for Colorado Identification Cards
4. Documentation Requirements a. Effective January 1, 2008, all citizenship and identity documents must either be originals or copies certified by the issuing agency, except as provided in 8.100.3.H.4.b. Uncertified copies, including notarized copies, are not acceptable.
b. Individuals who submitted notarized copies of citizenship and identity documents as part of an application or redetermination before January 1, 2008 shall not be required to submit originals or copies certified by the issuing agency for any application or redetermination processed on or after January 1, 2008.
c. All citizenship and identity documents shall be presumed to be genuine unless the authenticity of the document is questionable.
d. Individuals shall not be required to submit citizenship and identity documentation in person. Documents shall be accepted from a Medical Assistance applicant or client or from his or her guardian or authorized representative in person or by mail.
e. Individuals may present original citizenship and identity documents or copies certified by the issuing agency to Medical Assistance (MA) sites, School-based Medical Assistance sites, Presumptive Eligibility (PE) sites, Federally Qualified Health Centers (FQHCs), Disproportionate Share Hospitals (DSHs), or any other location designated by the Department by published agency letter.
f. Counties shall accept photocopies of citizenship and identity documents from any location described in 8.100.3.H.4.e provided the photocopies include the form, stamp, or verification described in 8.100.3.H.4.e.i).
g. Counties shall develop procedures for handling original citizenship and identity documents to ensure that these documents are not lost, damaged, or destroyed.
h. Once an individual has provided the required citizenship and identity documentation, he or she shall not be required to submit the documentation again unless:
5. Record Retention Requirements a. The eligibility site shall retain a paper or electronically scanned copy of an individual's citizenship and identity documentation, including any verification described in 8.100.3.H.4.e.i), for at least five years from the ending date of the individual's last period of Medical Assistance eligibility.
6. Name Change Provisions a. An individual who has changed his or her last name for reasons including, but not limited to, marriage, divorce, or court order shall not be required to produce any additional documentation concerning the name change unless:
7. Reasonable Level of Assistance a. The eligibility site shall provide a reasonable level of assistance to applicants and clients in obtaining the required citizenship and identity documentation.
b. Examples of a reasonable level of assistance include, but are not limited to:
c. The eligibility site shall not be required to pay for the cost of obtaining required documentation.
8. Individuals Requiring Additional Assistance a. The eligibility site shall provide additional assistance beyond the level described in 8.100.3.H.7 to applicants and clients in obtaining the required citizenship and identity documentation if the client or applicant:
b. Examples of additional assistance include, but are not limited to:
c. The eligibility site shall document its efforts to provide additional assistance to the client or applicant. Such documentation shall be subject to the record retention requirements described in 8.100.3.H.5.a.
9. Reasonable Opportunity Period a. If a Medical Assistance applicant or recipient does not have the required documentation, he or she must be given a reasonable opportunity period to provide the required documentation. If the applicant or recipient does not provide the required documentation within the reasonable opportunity period, then:
b. The reasonable opportunity period for Family Programs covered under 8.100.3.H is 14 calendar days. For the purpose of this section, Family Programs are defined as the following:
Commonly Used Program Rule Citation Name 1931 Medical Assistance 8.100.4.G.2 Transitional Medical 8.100.4.I.1-7 Assistance Four Month Extended 8.100.4.I.8 Medical Assistance Institutionalized under 8.100.4.H.1.a age 21 Parents Plus Program 8.100.4.G.8 Qualified Child 8.100.4.G.6 Expanded Child 8.100.4.G.6 Ribicoff Child 8.100.4.G.7 Qualified Pregnant 8.100.4.G.9 Expanded Pregnant 8.100.4.G.9 c. The reasonable opportunity period for Adult Programs covered under 8.100.3.F. is 70 calendar days. For the purpose of this rule, Adult Programs are defined as the following: Commonly Used Program Rule Citation Name Old Age Pension A 8.100.3.F.1.c (OAP-A)
Old Age Pension B 8.100.3.F.1.c (OAP-B)
Qualified Disabled 8.100.3.F.1.e Widow/Widower Pickle 8.100.3.F.1.e Long-Term Care 8.100.3.F.1.f-h Breast and Cervical 8.715 Cancer Program (BCCP)
10. Good Faith Effort a. In some cases, a Medical Assistance client or applicant may not be able to obtain the required documentation within the applicable reasonable opportunity period. If the client or applicant is making a good faith effort to obtain the required documentation, then the reasonable opportunity period should be extended. The amount of time given should be determined on a case-by-case basis and should be based on the amount of time the individual needs to obtain the required documentation.
An individual’s verbal statement describing his or her efforts at securing the required documentation should be accepted without further verification unless the accuracy or truthfulness of the statement is questionable. The individual’s good faith efforts should be documented in the case file and are subject to all record retention requirements. 8.100.3.I. Additional General Eligibility Requirements
1. Each person for whom Medical Assistance is being requested shall furnish a Social Security Number (SSN); or, if one has not been issued or is unknown, shall apply for the number and submit verification of the application. The application for an SSN shall be documented in the case record by the eligibility site. Upon receipt of the assigned SSN, the client shall provide the number to the eligibility site. This requirement does not apply to those individuals who are not requesting Medical Assistance yet appear on the application, nor does it apply to individuals applying for emergency medical services or eligible newborns born to a Medical Assistance eligible mother.
a. An applicant's or client's refusal to furnish or apply for a Social Security Number affects the family's eligibility for assistance as follows:
2. A person who is applying for or receiving Medical Assistance shall assign to the State all rights against any other person (including but not limited to the sponsor of an alien) for medical support or payments for medical expenses paid on the applicant's or client's behalf or on the behalf of any other person for whom application is made or assistance is received. All appropriate clients of the Medical Assistance Program shall have the option to be referred for child support enforcement services using the form as specified by the Department.
3. A person who is applying for or receiving Medical Assistance shall provide information regarding any third party resources available to any member of the assistance unit. Third party resources are any health coverage or insurance other than the Medical Assistance Program. A client’s refusal to supply information regarding third party resources may result in loss of Medical Assistance Program eligibility.
4. A person who is eligible for Medical Assistance shall be free to choose any qualified and approved participating institution, agency, or person offering care and services which are benefits of the program unless that person is enrolled in a managed care program operating under Federal waiver authority.
8.100.3.J. Supplemental Security Income (SSI) And Aid To The Needy Disabled (AND) Recipients 1. Persons who may be eligible for benefits under either Family and Children’s Medical Assistance or SSI:
a. shall be advised of the benefits available under each program;
b. may apply for a determination of eligibility under either or both programs, and c. have the option to receive benefits under the program of their choice, but may not receive benefits under both programs at the same time;
d. may change their selection if their circumstances change or if they decide later that it would be more advantageous to receive benefits from the other program.
2. Any family member who is receiving financial assistance from SSI or OAP-A is not considered a member of the Medical Assistance required household, is not counted as a member of the household, and the individual's income and resources are disregarded in making the determination of need for Medical Assistance.
3. An individual receiving AND may also receive Family and Children’s Medical Assistance. An AND recipient shall be eligible for Family and Children’s Medical Assistance, if the recipient meets all the requirements of Family and Children’s Medical Assistance. For these individuals, eligibility sites shall include the applicant’s AND payment as unearned income to the Medical Assistance required household along with all other income. If the AND individual's AND payment and other income makes the Medical Assistance required household ineligible, eligibility sites shall disregard the AND individual and give the remaining members Family and Children’s Medical Assistance as long as they meet the income requirements for the appropriate Family and Children’s Medical Assistance category.
8.100.3.K. Consideration of Income 1. In determining eligibility for Medical Assistance for household members, financial responsibility is limited to spouse being responsible for spouse, and parent being responsible for a dependent child. Financial responsibility of parents for a dependent child is not changed by the fact that the child may be pregnant or that she is a mother and caretaker of her own child.
2. Income of parents of minor parents under the age of 18 living in the same household shall be attributed to the minor parent unless the minor parent is married or legally separated from marriage.
3. A declared common law spouse retains the same financial responsibility as a legally married spouse. Once declared as common law, financial responsibility remains unless legal separation or divorce occurs. If two persons live together, but are not married to each other, neither one has the legal responsibility to support the other. This is not changed by the fact that the unmarried individuals may share a common child.
4. Income for the Medical Assistance Program eligibility is income which is received by an individual or family in the month in which they are applying for or receiving Medical Assistance or the previous month if income for the current month is not yet available to determine eligibility.
5. Income or resources of an alien sponsor or an alien sponsor’s spouse shall be countable to the sponsored alien effective December 19, 1997. Forms used prior to December 19, 1997, including but not limited to forms I-134 or I-136 are legally unenforceable affidavits of support. The attribution of the income and resources of the sponsor and the sponsor's spouse to the alien will continue until the alien becomes a U.S. citizen or has worked or can be credited with 40 qualifying quarters of work, provided that an alien crediting the quarters to the applicant/client has not received any public benefit during any creditable quarter for any period after December 31, 1996.
6. Income, in general, is the receipt by an individual of a gain or benefit in cash or in kind during a calendar month. Income means any cash, payments, wages, in-kind receipt, inheritance, gift, prize, rents, dividends, interest, etc., that are received by an individual or family.
7. Earned income is payment in cash or in kind for services performed as an employee or from self- employment.
8. Earned in kind income shall be income produced as a result of the performance of services by the applicant/client, for which he/she is compensated in shelter or other items in lieu of wages.
9. Received means "actually" received or legally becomes available, whichever occurs first; the point at which the income first is available to the individual for use. For example, interest income on a savings account is counted when it is credited to the account.
10. Compensation received from the Crime Victims Compensation Act shall be considered as income to the extent that it exceeds the expenses for which it was designated, i.e., medical and/or burial expenses.
11. All Home Care Allowance (HCA) income paid to a Medical Assistance applicant/client by the HCA recipient to provide home care services is countable earned income.
12. Participation in the Workforce Investment Act (WIA) affects eligibility for Medical Assistance as follows:
a. Wages derived from participation in a program carried out under WIA (work experience or on- the-job training) and paid to a caretaker relative is considered countable earned income.
b. Training allowances granted by WIA to a dependent child or a caretaker relative of a dependent child to participate in a training program is exempt.
c. Wages derived from participation in a program carried out the under Workforce Investment Act
13. An individual involved in a profit making activity as a sole proprietor, partner in a partnership, independent contractor, or consultant shall be classified as self-employed.
a. To determine the net profit of a self-employed applicant/client deduct the cost of doing business from the gross income. These business expenses include, but are not limited to:
b. The following are not allowed as business expenses:
c. Appropriate allowances for cost of doing business for Medical Assistance clients who are licensed, certified or approved day care providers are (1) $ 55 for the first child for whom day care is provided, and (2) $ 22 for each additional child. If the client can document a cost of doing business which is greater than the amounts above set forth, the procedure described in A, shall be used.
d. When determining self employment expenses and distinguishing personal expenses from business expenses it is a requirement to only allow the percentage of the expense that is business related.
14. Self-employment income includes, but is not limited to, the following:
a. Farm income - shall be considered as income in the month it is received. When an individual ceases to farm the land, the self-employment deductions are no longer allowable.
b. Rental income - shall be considered as self-employment income only if the Medical Assistance client actively manages the property at least an average of 20 hours per week.
c. Board (to provide a person with regular meals only) payment shall be considered earned income in the month received to the extent that the board payment exceeds the maximum food stamp allotment for one-person household per boarder and other documentable expenses directly related to the provision of board.
d. Room (to provide a person with lodging only) payments shall be considered earned income in the month received to the extent that the room payment exceeds documentable expenses directly related to the provision of the room.
e. Room and board payments shall be considered earned income in the month received to the extent that the payment for room and board exceeds the food stamp allotment for a one- person household per room and boarder and documentable expenses directly related to the provision of room and board.
15. Unearned income is the gross amount received in cash or kind that is not earned from employment or self-employment. Unearned income includes, but is not limited to, the following:
a. Pensions and other period payments, such as:
a. A bona fide loan. Bona fide loans are loans, either private or commercial, which have a repayment agreement. Declaration of such loans is sufficient verification.
b. Benefits received under Title VII, Nutrition Program for the Elderly, of the Older Americans Act.
c. Title XVI (SSI) or Title II (Retirement Survivors or Disability Insurance) retroactive payments (lump sum) for nine months following receipt and the remainder countable as a resource thereafter.
d. The value of supplemental food assistance received under the special food services program for children provided for in the National School Lunch Act and under the Child Nutrition Act, including benefits received from the special supplemental food program for women, infants and children (WIC).
e. Home produce utilized for personal consumption.
f. Payments received under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act; relocation payments to a displaced homeowner toward the purchase of a replacement dwelling are considered exempt for up to 6 months.
g. Experimental Housing Allowance Program (EHAP) payments made by HUD under section 23 of the U.S. Housing Act.
h. Payments made from Indian judgment funds and tribal funds held in trust by the Secretary of the Interior and/or distributed per capita; and initial purchases made with such funds. (Public Law No 98-64 and Public Law No. 97-458).
i. Distributions from a native corporation formed pursuant to the Alaska Native Claims Settlement Act (ANCSA) which are in the form of: cash payments up to an amount not to exceed $ 2000 per individual per calendar year; stock; a partnership interest; or an interest in a settlement trust. Cash payments, up to $ 2000, received by a client in one calendar year which is retained into subsequent years is excluded as income and resources; however, cash payments up to $ 2000 received in the subsequent year would be excluded from income in the month(s) received but counted as a resource if retained beyond that month(s).
j. Assistance from other agencies and organizations.
k. Major disaster and emergency assistance provided to individuals and families, and comparable disaster assistance provided to states, local governments and disaster assistance organizations shall be exempt as income and resources in determining eligibility for Medical Assistance.
l. Payments received for providing foster care.
m. Payments to volunteers serving as foster grandparents, senior health aids, or senior companions, and to persons serving in the Service Corps of Retired Executives (SCORE) and Active Corps of Executives (ACE) and any other program under Title I (VISTA) when the value of all such payments adjusted to reflect the number of hours such volunteers are serving is not equivalent to or greater than the minimum wage, and Title II and Title III of the Domestic Volunteer Services Act.
o. The benefits provided to eligible persons or households through the Low Income Energy Assistance (LEAP) Program.
p. Training allowances granted by the Workforce Investment Act (WIA) to enable any individual whether dependent child or caretaker relative, to participate in a training program q. Payments received from the youth incentive entitlement pilot projects, the youth community conservation and improvement projects, and the youth employment and training programs under the Youth Employment and Demonstration Project Act.
r. Social Security benefit payments and the accrued amount thereof to a client when an individual plan for self-care and/or self-support has been developed. In order to disregard such income and resources, it shall be determined that (1) SSI permits such disregard under such developed plan for self-care-support goal, and (2) assurance exists that the funds involved will not be for purposes other than those intended.
s. Monies received pursuant to the "Civil Liberties Act of 1988" P.L. No. 100-383, (by eligible persons of Japanese ancestry or certain specified survivors, and certain eligible Aleuts).
t. Effective January 1, 1989, payments made from the Agent Orange Settlement Fund or any fund established pursuant to the settlement in the In Re Agent Orange product liability litigation, M.D.L. No 381 (E.D.N.Y).
u. A child receiving subsidized adoption funds shall be excluded from the Medical Assistance budget unit and his income shall be exempt from consideration in determining eligibility, unless such exclusion results in ineligibility for the other members of the household.
v. Effective January 1, 1991, the Earned Income Tax Credit (EIC). EIC shall also be exempt as resources for the month it is received and for the following month.
w. Any money received from the Radiation Exposure Compensation Trust Fund, pursuant to P.L.
x. Reimbursement or restoration of out-of-pocket expenses. Out-of-pocket expenses are actual expenses for food, housing, medical items, clothing, transportation, or personal needs items.
y. Effective 8/1/1994, payments to individuals because of their status as victims of Nazi persecution pursuant to Public Law No. 103-286.
z. General Assistance, SSI, OAP-A and cash assistance under the Temporary Assistance to Needy Families (TANF) funds.
aa. All wages paid by the United States Census Bureau for temporary employment related to the decennial Census.
bb. Any grant or loan to an undergraduate student for educational purposes made or insured under any programs administered by the Commissioner of Education (Basic Education Opportunity Grants, Supplementary Education Opportunity Grants, National Direct Student Loans and Guaranteed Student Loans), Pell Grant Program, the PLUS Program, the BYRD Honor Scholarship programs and the College Work Study Program.
cc. Any portion of educational loans and grants obtained and used under conditions that preclude their use for current living cost (need-based).
dd. Financial assistance received under the Carl D. Perkins Vocational and Applied Technology Education Act that is made available for attendance cost shall not be considered as income or resources. Attendance cost includes tuition, fees, rental or purchase of equipment, materials or supplies required of all students in the same course of study, books, supplies, transportation, dependent care and miscellaneous personal expenses of students attending the institution on at least a half-time basis, as determined by the institution.
ee. The additional unemployment compensation of $25 a week enacted through the American Recovery and Reinvestment Act of 2009.
2. Income of a Medical Assistance applicant/client who is attending school (student in a secondary education or undergraduate degree program) shall be treated as follows:
a. Income received from a college work-study program grant shall be exempt when it is part of a "need-based package" administered by the U.S. Commission of Education.
b. Scholarships given to individuals for education and training are exempt.
c. Income received by the Medical Assistance client which exceeds the work study grant specified in the need-based package shall be considered earned income.
d. All earned income that is received by a dependent child who is a full-time student or a part- time student who is not a full-time employee shall be disregarded for the eligibility determination as long as they remain a student.
e. All earned income of dependent children who are not students (except income from WIA for up to six months in each calendar year) shall be considered in determining eligibility for Medical Assistance. All disregards from the earned income shall apply as listed in the Family and Children’s Medical Assistance Program portion of this volume. 8.100.3.M. Consideration of Resources 1. Resources are counted in determining eligibility for the Aged, Blind and Disabled, and Long Term Care institutionalized and Home and Community Based Services categories of Medical Assistance. Resources are not counted in determining eligibility for the Family and Children’s Medical Assistance programs. See section 8.100.5 for rules regarding consideration of resources. 8.100.3.N. Federal Financial Participation (FFP)
1. The state is entitled to claim federal financial participation (FFP) for benefits paid on behalf of groups covered under the Colorado Medical Assistance Program and also for the Medicare supplementary medical insurance benefits (SMIB) premium payments made on behalf of certain groups of categorically needy persons.
2. The SISC codes are as follows:
a. Code A - for institutionalized persons whose income is under 300% of the SSI benefit level and who, except for the level of their income, would be eligible for an SSI payment; and non- institutionalized persons receiving Home and Community Based Services, whose income does not exceed 300% of the SSI benefit level and who, except for the level of their income, would be eligible for an SSI payment; code A signifies that FFP is available in expenditures for medical care and services which are benefits of the Medical Assistance program but not for SMIB premium payments;
b. Code B - for persons eligible to receive financial assistance under SSI; persons eligible to receive financial assistance under OAP "A" who, except for the level of their income, would be eligible for an SSI payment; persons who are receiving mandatory State supplementary payments; and persons who continue to be eligible for Medical Assistance after disregarding certain Social Security increases; code B signifies that FFP is available in expenditures for medical care and services which are benefits of the Medical Assistance program and also for SMIB premium payments;
c. Code C - for persons eligible to receive assistance under OAP "A", OAP "B", or OAP Refugee Assistance for financial assistance only; who do not receive SSI payment and do not otherwise qualify under SISC code B as described in item B. above; code C signifies that no FFP is available in Medical Assistance program expenditures.
3. Recipients of financial assistance under State AND, State AB, or OAP "C" are not eligible for Medical Assistance and the SISC code which shall be entered on the eligibility reporting form is C. 8.100.3.O. Confidentiality 1. All information obtained by the eligibility site concerning an applicant for or a recipient of Medical Assistance is confidential information.
2. A signature on the Colorado Medical Assistance application and the Application for Assistance allows an eligibility site worker to consult banks, employers, or any other agency or person to obtain information or verification to determine eligibility. The identification of the worker as an eligibility site employee will, in itself, disclose that an application for the Medical Assistance Program has been made by an individual. In this type of contact, as well as other community contacts, the eligibility site should strive to maintain confidentiality. The signature on the Colorado Medical Assistance application and the Application for Assistance also provides permission for the release of the client's medical information to be provided by health care providers to the State and its agents for purpose of administration of the Medical Assistance Program.
3. Eligibility site staff may release a client's Medical Assistance state identification number and approval eligibility spans to a Medical Assistance provider for billing purposes. Eligibility site staff may inform a Medical Assistance provider that an application has been denied but may not inform them of the reason why.
4. Access to information concerning applicants or recipients must be restricted to persons or agency representatives who are subject to standards of confidentiality that are comparable to those of the State and the eligibility site.
5. The eligibility site must obtain permission from a family, individual, or authorized representative, whenever possible, before responding to a request for information from an outside source, unless the information is to be used to verify income, eligibility and the amount of Medical Assistance payment. This permission must be obtained unless the request is from State authorities, federal authorities, or State contractors acting within the scope of their contract. If, because of an emergency situation, time does not permit obtaining consent before release, the eligibility site must notify the family or individual immediately after supplying the information.
6. The eligibility site policies must apply to all requests for information from outside sources, including government bodies, the courts, or law enforcement officials. If a court issues a subpoena for a case record or for any eligibility site representative to testify concerning an applicant or recipient, the eligibility site must inform the court of the applicable statutory provisions, policies, and regulations restricting disclosure of information.
7. The following types of information are confidential and shall be safeguarded:
a. Names and addresses of applicants for and recipients of the Medical Assistance Program;
b. Medical services provided;
c. Social and economic conditions or circumstances;
d. Agency evaluation of personal information;
e. Medical data, including diagnosis and past history of disease or disability;
f. All information obtained through the Income and Eligibility Verification System (IEVS), Colorado Department of Labor and Employment, SSA or Internal Revenue Service;
g. Any information received in connection with third party resources;
h. Any information received for verifying income and resources if applicable, or other eligibility and the amount of Medical Assistance payments.
8. The confidential information listed above may be released to persons outside the eligibility site only as follows:
a. In response to a valid subpoena or court order;
b. To State or Federal auditors, investigators or others designated by the Federal or State departments on a need-to-know basis;
c. To individuals executing Income and Eligibility Verification System;
d. Child Support enforcement officials;
e. To a recipient or applicant themselves or their designated representative.
f. To a Long Term Care institution on the AP-5615 form.
9. The applicant/recipient may give a formal written release for disclosure of information to other agencies, such as hospitals, or the permission may be implied by the action of the other agency in rendering service to the client. Before information is released, the eligibility site should be reasonably certain the confidential nature of information will be preserved, the information will be used only for purposes related to the function of the inquiring agency, and the standards of protection established by the inquiring agency are equal to those established by the State Department. If the standards for protection of information are unknown, a written consent from the recipient shall be obtained.
8.100.3.P. Protection Against Discrimination 1. Eligibility sites are to administer the Medical Assistance Program in such a manner that no person will, on the basis of race, color, sex, age, religion, political belief, national origin, or handicap, be excluded from participation, be denied any aid, care, services, or other benefits of, or be otherwise subjected to discrimination in such program.
2. The eligibility site shall not, directly or through contractual or other arrangements, on the grounds of race, color, sex, age, religion, political belief, national origin, or handicap:
a. Provide aid, care, services, or other benefits to an individual which is different, or provided in a different manner, from that of others;
b. Subject an individual to segregation barriers or separate treatment in any manner related to access to or receipt of assistance, care services, or other benefits;
c. Restrict an individual in any way in the enjoyment or any advantage or privilege enjoyed by others receiving aid, care, services, or other benefits provided under the Medical Assistance Program;
d. Treat an individual differently from others in determining whether he/she satisfies any eligibility or other requirements or conditions which individuals shall meet in order to receive aid, care, services, or other benefits provided under the Medical Assistance Programs;
e. Deny an individual an opportunity to participate in programs of assistance through the provision of services or otherwise, or afford him/her an opportunity to do so which is different from that afforded others under the Medical Assistance Program.
3. No distinction on the grounds of race, color, sex, age, religion, political belief, national origin, or handicap is permitted in relation to the use of physical facilities, intake and application procedures, caseload assignments, determination of eligibility, and the amount and type of benefits extended by the eligibility site to Medical Assistance recipients.
4. An individual who believes he/she is being discriminated against may file a complaint with the eligibility site, the Department, or directly with the Federal government. When a complaint is filed with the eligibility site, the county director is responsible for an immediate investigation of the matter and taking necessary corrective action to eliminate any discriminatory activities found. If such activities are not found, the individual is given an explanation. If the person is not satisfied, he/she is requested to direct his/her complaint, in writing, to the State Department, Complaint Section, which will be responsible for further investigation and other necessary action consistent with the provisions of Title VI of the 1963 Civil Rights Act, as amended 42 U.S.C. §2000e et seq. and section 504 of the Rehabilitation Act of 1973, as amended 29 U.S.C. §791. 8.100.3.Q. Redetermination of Eligibility 1. A redetermination of eligibility shall mean a case review and necessary verification to determine whether the Medical Assistance Program client continues to be eligible to receive Medical Assistance. Beginning as of the case approval date, a redetermination shall be accomplished each 12 months for Title XIX Medical Assistance only cases. An eligibility site may redetermine eligibility through telephone, mail, or electronic means. The use of telephone or electronic redeterminations should be noted in the case record and in CBMS case comments.
2. The eligibility site shall promptly redetermine eligibility when:
a. it receives and verifies information which indicates a change in a client's circumstances which may affect continued eligibility for Medical Assistance; or b. it receives direction to do so from the Department.
The eligibility site shall redetermine eligibility according to timelines defined by the Department. Please review the Department User Reference Guide for timeframes.
3. A redetermination form is not required to be sent to the client if all current eligibility requirements can be verified by reviewing information from another assistance program, verification system, and/or CBMS. When applicable, the eligibility site shall redetermine eligibility based solely on information already available. If verification or information is available for any of the three months prior to redetermination month, no request shall be made of the client and a notice of the findings of the review will go to the client. If not all verification or information is available, the eligibility site shall only request the additional minimum verification from the client. This procedure is referenced as Ex Parte Review.
4. A redetermination form, approved by the Department, shall be mailed to the person at least 30 days prior to the first of the month in which completion of eligibility redetermination is due. The redetermination form shall be used to inform the client of the redetermination and verification needed, but the form itself cannot be required to be returned. The only verification that can be required at redetermination is the minimum verification needed to complete a redetermination of eligibility. If no documentation is required, a written declaration from the client is sufficient verification for redetermination. If the redetermination is performed by phone and no documentation is required, a verbal statement from the client is sufficient verification for redetermination and should be noted in the case record and in CBMS case comments. The following procedures relate to mail-out redetermination:
a. A Redetermination Form shall be mailed to the client together with any other forms to be completed;
b. Required verification shall be returned by the client to the eligibility site no later than ten working days after receipt of request;
c. When the individual is unable to complete the forms due to physical, mental or emotional disabilities, or other good cause, and has no one to help him/her, the eligibility site shall either assist the client or refer him/her to a legal or other resource. When initial arrangements or a change in arrangements are being made, an extension of up to thirty days shall be allowed. The action of the eligibility site in assistance or referral shall be recorded in the case record and CBMS case comments.
d. The redetermination form shall require that a recipient and community spouse of a recipient of HCBS, PACE or institutional services disclose a description of any interest the individual or community spouse has in an annuity or similar financial instrument regardless of whether the annuity is irrevocable or treated as an asset. The redetermination form shall include a statement that the Department shall be a remainder beneficiary for any annuity or similar financial instrument purchased on or after February 8, 2006 for the total amount of Medical Assistance provided to the individual.
e. The eligibility site shall notify in writing the issuer of any annuity or financial instrument that the Department is a preferred remainder beneficiary in the annuity or similar financial instrument for the total amount of Medical Assistance provided to the individual. This notice shall require the issuer to notify the eligibility site when there is a change in the amount of income or principal that is being withdrawn from the annuity.
5. When the redetermination information is not returned within the 4.b ten-working-day time period:
a. A second request form shall be mailed to the client;
b. A State approved notice of proposed action taken shall be mailed with the forms notifying the client of termination of Medical Assistance eligibility, but such action will not be taken if the completed and signed forms are returned before the end of the month in which the redetermination information is due, or the client can show good cause as to why the forms cannot be returned timely.
c. If no response is received by the end of the time period contained in the notice listed in b., action to terminate shall be taken.
6. When the redetermination verification information is received by the eligibility site, it shall be date stamped. Within ten working days, the verification information shall be thoroughly reviewed for completeness, accuracy, and consistency. All factors shall be evaluated as to their effect on eligibility at that time. Verifications shall be documented in the case file and CBMS case comments. The case file shall be used as a checklist in the redetermination process, and shall be used to keep track of matters requiring further action. When additional information is needed:
a. due to incomplete information, the request form shall be mailed back to the client with a letter specifying the items that require completion;
b. due to incomplete, inaccurate or inconsistent data, the Medical Assistance client shall be contacted by telephone or in writing so that the worker may secure the proper information according to timelines defined by the Department. Please review the Department User Reference Guide for timeframes.
8.100.4 Family and Children’s Medical Assistance Eligibility [Eff. 03/30/2009]
8.100.4.A. Family and Children’s Application Requirements 1. Persons requesting Family and Children’s Medical Assistance need only to complete the Colorado Medical Assistance application 2. Pregnant women and children may apply for Family and Children’s Medical Assistance at eligibility sites other than the County Department of Social Services. These sites shall be approved by the Department to receive and initially process these applications. The application used shall be the Colorado Medical Assistance application. The eligibility site shall determine eligibility.
3. The eligibility sites shall refer Medical Assistance clients who are pregnant and/or age 20 and under to EPSDT offices by copying the page of the Colorado Medical Assistance application that includes the EPSDT benefit questions. The eligibility site will then forward this page to the EPSDT office within five working days from the date of application approval. 8.100.4.B. Family and Children’s Minimal Verification Requirements 1. The particular circumstances of a family will dictate the appropriate documentation needed for a complete application. Documentation to establish that a situational requirement is met is needed only when inadequate or inconsistent information supplied by the caretaker relative warrants securing verification to clarify a question of eligibility.
2. Minimal Verification - The following items shall be verified for all families applying for medical assistance:
a. A Social Security Number shall be provided for each individual on the application for whom Medical Assistance is being requested, or proof shall be submitted that an application for a Social Security Number has been made. Members of religious groups whose faith will not permit them to obtain Social Security Numbers shall be exempt from providing a Social Security Number.
b. Verification of citizenship and identity as outlined in section 8.100.3 under Citizenship and Identity Requirements.
c. Earned income may be self-declared by an individual and verified by the Income and Eligibility Verification System (IEVS). Individuals who provide self-declaration of earned income must also provide a Social Security Number for wage verification purposes. If a discrepancy occurs between self-declared income and IEVS wage data reports, IEVS wage data will be used to determine eligibility. An individual may dispute IEVS wage data by submitting all wage verification for all months in which there is a wage discrepancy. If the applicant is self employed, ledgers are sufficient for verification of earnings, if a ledger is not available, receipts are acceptable. The ledger included in the Medical Assistance application is sufficient verification of earnings, unless questionable. If an individual cannot provide verification through self-declaration, income shall be verified by wage stubs, written documentation from the employer stating the employees' gross income or a telephone call to an employer. Applicants may request that communication with their employers be made in writing.
d. Immigrant registration cards or papers, if applicable, to determine if the client is eligible for full Medical Assistance benefits. If an applicant does not provide this, he/she shall only be eligible for emergency Medical Assistance if they meet all other eligibility requirements.
e. Pregnancy verification, if applicable, and if the pregnancy is not observable. The verification shall be documented according to 8.100.4.G.9.a.
f. Unearned income may be declared by the client verbally or in writing on the application.
3. Additional Verification - No other verification shall be required of the client unless information is found to be questionable on the basis of fact.
4. The determination that information is questionable shall be documented in the applicant's case file and CBMS case comments.
5. Information that exists in another case record or in CBMS shall be used by the eligibility site to verify those factors that are not subject to change, if the information is reasonably accessible.
6. The criteria of age, school attendance, and relationship can be declared by the client unless questionable. If questionable, these criteria can be established with information provided from:
a. official papers such as: a birth certificate, order of adoption, marriage license, immigration or naturalization papers; or, b. records or statements from sources such as: a court, school, government agency, hospital, or physician.
7. Establishing that a dependent child meets the eligibility criterion of:
a. age, if questionable requires (1) viewing the birth certificate or comparably reliable document at eligibility site discretion, and (2) documenting the source of verification in the case file and CBMS case comments;
b. school attendance, if questionable requires (1) obtaining confirmation from the school by phone or in writing, and (2) documenting the means of verification in the case file and CBMS case comments;
c. living in the home of the caretaker relative, if questionable requires (1) viewing the appropriate documents which identify the relationship, (2) documenting these sources of verification in the case file and CBMS case comments.
8.100.4.C. Family and Children’s Household Requirements 1. Only certain family members residing in the same household shall be included in the same Medical Assistance required household:
a. dependent children;
b. parent(s) or caretaker relative;
c. married individuals.
2. Parent means only a natural (including expectant) or adoptive parent.
3. Household size for all Medical Assistance categories shall include the unborn child(ren) as a child(ren) living in the home for the purposes of determining eligibility. However, medical assistance is not available to the unborn child, but only to the pregnant mother.
4. Medical assistance is not available to the father of an unborn child when there are no other children in the household.
5. Dependent children between the ages of 18 and 19 who are full time students in a secondary school or in the equivalent level of vocational or technical training and expected to complete the program before age 19 are eligible through the month of completion.
6. A dependent child is considered to be living in the home of the caretaker relative as long as the parent or specified relative exercises responsibility for the care and control of the child even though:
a. the child is under the jurisdiction of the court (for example, receiving probation services);
b. legal custody is held by an agency that does not have physical possession of the child;
c. the child is in regular attendance at a school away from home;
d. either the child or the relative is away from the home to receive medical treatment;
e. either the child or the relative is temporarily absent from the home;
f. the child is in voluntary foster care placement for a period not expected to exceed three months. Should the foster care plan change within the three months and the placement become court ordered, the child is no longer considered to be living in the home as of the time the foster care plan is changed.
8.100.4.D. 1931 Medical Assistance Specific Requirements 1. Application for 1931 Medical Assistance shall be made by a caretaker relative with whom the dependent child is living.
2. There is no age requirement for the caretaker nor is the status of emancipation a requirement in regard to the caretaker relative. The caretaker relative is a specified relative who exercises responsibility for the care and control of the dependent child.
3. For 1931 Medical Assistance, include all the family members for whom 1931 Medical Assistance would be considered.
4. 1931 Medical assistance shall be provided to needy families who would have been eligible for Aid to Families with Dependent Children(AFDC) under regulations in effect on July 16, 1996. No other TANF/Colorado Works criterion applies to this group. Eligibility sites shall not require that a Medical Assistance applicant/recipient comply with any TANF/Colorado Works requirements. All references to the 1931 Medical Assistance Program apply to AFDC rules effective on July 16, 1996.
5. To receive medical assistance under 1931 Medical Assistance, a person shall meet general requirements for Medical Assistance outlined in this volume, and not be receiving Medical Assistance from another category due to financial assistance from AFDC foster care, OAP-A or SSI.
8.100.4.E. Family and Children’s Income Disregards 1. The earned income disregards described in this section shall be applied to the gross wages of each individual who is employed in the following order:
a. deduct the employment expense disregard of $90; and b. deduct dependent care disregard.
For purposes of this section, a dependent is defined as a dependent child or adult included in the Medical Assistance household. The employed person is allowed a dependent care deduction of the actual amount of the dependent care expenses of up to $175 per month per each dependent two years and older; up to $200 per month per dependent less than two years old. In order to receive a dependent care deduction, declaration from the client is acceptable. The declaration, verbal, or written on the application, shall include the total dependent care costs paid per dependent for the month(s) Medical Assistance eligibility is being determined. The client may also present receipts or other documentation of paid costs for dependent care for these months.
2. The unearned income disregard described in this section shall be applied to the total amount received for each individual:
a. The first $50 per household per month of any current monthly support obligation shall be disregarded. Monthly support includes child support, and/or maintenance, and/or alimony. The disregard shall be divided among each person that receives the month support. 8.100.4.F. Family and Children’s Presumptive Eligibility 1. A pregnant applicant may apply for presumptive eligibility for ambulatory services through Medical Assistance presumptive eligibility sites. A child under the age of nineteen may apply or have an adult apply on their behalf for presumptive eligibility for State Plan approved medical services through presumptive eligibility sites.
2. To be eligible for presumptive eligibility:
a. an applicant shall have a verified pregnancy, declare that her household's income shall not exceed 133% of federal poverty level and declare that she is a United States citizen or a documented immigrant.
b. a child under the age of 19 shall have a declared household income that does not exceed 100% of federal poverty level for a child age 6-18 or 133% of federal poverty level for a child under the age of 6 and declare that the child is a United States citizen or a documented immigrant of at least five years.
3. Presumptive eligibility sites shall be certified by the Department to make presumptive eligibility determinations. Sites shall be re-certified by the Department every 2 years to remain approved presumptive eligibility sites.
4. The presumptive eligibility sites shall attempt to obtain all necessary documentation to complete the application within fourteen calendar days of application.
5. The presumptive eligibility site shall forward the application to the county within five business days of being completed. If the application is not completed within fourteen calendar days, on the fifteenth calendar day following application, the presumptive eligibility sites shall forward the application to the appropriate county.
6. The presumptive eligibility period shall be no less than 45 days. The presumptive eligibility period ends on the last day of the month following the completion of the 45 day Presumptive Eligibility period. The county department shall make a Medical Assistance eligibility determination within 45 days from receipt of the application. The effective date of Medical Assistance eligibility shall be the date of application.
7. A Presumptive eligible client may not appeal the end of a presumptive eligibility period.
8. Presumptively eligible women and Medical Assistance clients may appeal the county department's failure to act on an application within 45 days from date of application or the denial of an application. Appeal procedures are outlined in the State Hearings section of this volume. 8.100.4.G. Family and Children’s Covered Groups 1. For Family and Children’s Medical Assistance, any person who is determined to be eligible for Medical Assistance at any time during a calendar month shall be eligible for benefits during the entire month.
2. Families whose total income does not exceed 100% of the federal poverty level Parents or caretaker relatives eligible for this category shall have a dependent child in the household receiving Medical Assistance. This population is referenced as 1931 Medical Assistance.
3. Medical assistance shall be furnished to any person who is residing in a participating Medicaid facility and who would be eligible for section 1931 Medical assistance if that person resided outside a facility.
4. Persons who would be eligible for 1931 Medical Assistance except for the inclusion in the assistance unit of a relative not included as financially responsible whose income makes the unit ineligible. This procedure is referenced as the 113 rule.
5. A child born to a woman receiving Medical Assistance at the time of the child's birth is continuously eligible for one year as long as the child remains a member of the mother’s household. This provision also applies in instances when the woman received Medical Assistance to cover the child’s birth through retroactive Medical Assistance. To receive Medical Assistance under this category, the family need not file an application nor provide a social security number or proof of application for a social security number for the newborn. Anyone can report the birth of the baby verbally or in writing. Information provided shall include the baby's name, date of birth, and mother's name or Medical Assistance number. A newborn can be reported at any time. Once reported, a newborn meeting the above criteria shall be added to the Medical Assistance case according to timelines defined by the Department. Please review the Department User Reference Guide for timeframes. This population is referenced as Eligible Needy Newborn.
6. Children up to age six whose income does not exceed their proportionate share of 133% of the federal poverty level or whose total family income does not exceed 133% of the federal poverty level. This population is referenced as Expanded Child.
7. Children up to age 19 whose income does not exceed their proportionate share of 100% of the federal poverty level or whose total family income does not exceed 100% of the federal poverty level. This population is referenced as Ribicoff.
8. Medical assistance shall be provided to a woman:
a. whose pregnancy is medically verified in writing by a medical professional (a certified medical assistant or higher level position supervised by a registered nurse or doctor) confirming the pregnancy and the estimated date of delivery, if pregnancy is not observable ; and b. whose income does not exceed her proportionate share of 133% of the federal poverty level or whose total family income does not exceed 133% of federal poverty level.
c. For a period beginning with the date of application for medical assistance through the last day of the month following 60 days from the date the pregnancy ends. Once eligibility has been approved, Medical Assistance coverage must be provided regardless of changes in the woman's financial circumstances. This population is referenced as Expanded Pregnant.
9. A pregnant legal immigrant who has been a legal immigrant for less than five years is eligible for medical care if she meets the eligibility requirements for expectant mothers listed in 8.100.4.G.9. This population is referenced as Legal Immigrant Prenatal.
10. If an individual is found ineligible because their income exceeds their proportionate share of the federal poverty level, a recalculation shall be performed to look at the Medical Assistance required household as a whole. The household's total income, after the allowable Medical Assistance deductions, shall be compared to the maximum federal poverty level. If the individual is then eligible under this process, they shall be eligible under the same category for which they originally were determined ineligible. This procedure is referenced as the Boatwright rule. 8.100.4.H. Needy Persons Under 21 1. Medical assistance shall be provided to certain needy persons under 21 years of age, including the following:
a. Those receiving care in a Long Term Care Institution eligible for Medical Assistance reimbursement or receiving active treatment as inpatients in a psychiatric facility eligible for Medical Assistance reimbursement and whose family income is less than the AFDC needs standard for his/her family size when the client applies for assistance. Clients that are receiving benefits under this category and are still receiving active inpatient treatment in the facility at age 21 shall be eligible to age 22. This population is referenced as Psych < 21.
b. Those for whom the Department of Human Services is assuming full or partial financial responsibility and who are in foster care, in homes or private institutions or in subsidized adoptive homes. See Colorado Department of Human Services “Social Services Staff Manual” section 7 for specific eligibility requirements (12 CCR 2599). A child shall be the responsibility of the county, even if the child may be in a medical institution at that time.
c. Those for whom the Department of Human Services is assuming full or partial financial responsibility and who are in independent living situations subsequent to being in foster care.
d. Those for whom the Department of Human Services is assuming full or partial responsibility and who are receiving services under the state’s Alternatives to Foster Care Program and would be in foster care except for this program and whose family income is less than the AFDC needs standard for his/her family size.
e. Those for whom the Department of Human Services is assuming full or partial responsibility and who are removed from their home either with or without (court ordered) parental consent, placed in the custody of the county and residing in a county approved foster home.
f. Those for whom the Department of Human Services is assuming full or partial responsibility and who are receiving services under the state’s subsidized adoption program, including a clause in the subsidized adoption agreement to provide Medical Assistance for the child.
g. Those for whom the Department of Human Services is assuming full or partial financial responsibility on their 18th birthday or at the time of emancipation. These individuals also must have received foster care maintenance payments or subsidized adoption payments from the State of Colorado pursuant to article 7 of title 26, C.R.S. immediately prior to the date the individual attained 18 years of age or was emancipated. Eligibility will be extended until the individual’s 21st birthday.
8.100.4.I. Transitional Medical Assistance and 4 Month Extended Medical Assistance 1. Eligibility for Transitional Medical Assistance shall be granted for twelve months (beginning with the first month of ineligibility) to families who would otherwise become ineligible for Medical Assistance under 1931 Medical Assistance. The extension shall be applied for a family who is eligible and receiving assistance under 1931 Medical Assistance in at least 3 of the 6 months immediately preceding the month in which the family would have become ineligible for 1931 Medical Assistance, and a. who becomes ineligible for 1931 Medical Assistance solely because of new or increased income from employment, or hours of employment, provided an employed member of the family continues to be employed.
2. Required members of the Medical Assistance required household who come into the household after the unit is receiving transitional Medical Assistance are eligible for the remaining months of Transitional Medical Assistance. Transitional Medical Assistance applies to the members of the Medical Assistance required household.
3 . To remain eligible for Transitional Medical Assistance:
a. The employed member of the Assistance Unit cannot terminate employment without good cause.
b. The household must include a dependent child. If it is determined that the household no longer has a child living in the home, Transitional Medicaid Assistance shall discontinue at the end of the month in which the household does not include a dependent child.
c. If health insurance is available from the employer to the employee, at no cost to the 1931 Medical Assistance recipient, the client shall enroll in the insurance program.
4. When Transitional Medical Assistance ends, the eligibility site shall review the file for all other categories of Medical Assistance for which the family members may be eligible. A new application shall not be required for this process.
5. Eligibility for medical assistance shall be extended for four months (beginning with the first month of ineligibility) for certain families who become ineligible for 1931 Medical Assistance due solely or partially to the receipt of support income. Support income may be child support, maintenance, or alimony. The extension shall be applied for a family which receives assistance under 1931 Medical Assistance in at least three of the six months immediately preceding the month in which the family becomes ineligible for assistance. To be eligible for the four month Medical Assistance extension, the family shall be eligible for 1931 Medical Assistance in all respects before the support income is applied. The support recipient shall be included in the 1931 Medical Assistance calculation for the extension to apply.
8.100.5 Aged, Blind, and Disabled Medical Assistance General Eligibility
8.100.5.A. Application Requirements 1. When an individual applies for Medical Assistance on the basis of disability or blindness, the eligibility sites shall take the application and determine whether the individual is eligible for Long Term Care or any of the categories of assistance described in section 8.100.6 under Qualified Disabled and Working Individuals. If the applicant does not qualify for Medical Assistance on one of those bases, he/she shall be referred to the local Social Security office to apply for SSI.
2. Applicants who apply for Long Term Care Medical Assistance on the basis of disability or blindness shall complete a Medical Assistance disability determination application in addition to the required Medical Assistance application. The Medical Assistance disability determination application shall be collected by a designated eligibility site representative and shall be forwarded the state disability determination contractor upon completion. The state disability determination contractor shall conduct a client disability determination and shall forward the determination to the designated eligibility site representative.
The disability determination application is not required for individuals that have already been determined disabled by the Social Security Administration.
3. Persons requesting Aged, Blind, and Disabled Medical Assistance need only to complete the Colorado Medical Assistance application.
8.100.5.B. Verification Requirements 1. The particular circumstances of an applicant will dictate the appropriate documentation needed for a complete application. The following items shall be verified for individuals applying for Medical Assistance:
a. A Social Security Number shall be provided for each individual on the application for whom Medical Assistance is being requested, or proof shall be submitted that an application for a Social Security Number has been made. Members of religious groups whose faith will not permit them to obtain Social Security Numbers shall be exempt from providing a Social Security Number.
b. Verification of citizenship and identity as outlined in the section 8.100.3 under Citizenship and Identity Eligibility Requirements.
c. Earned income may be self-declared by an individual and verified by the Income and Eligibility Verification System (IEVS). Individuals who provide self-declaration of earned income must also provide a Social Security Number for wage verification purposes. If a discrepancy occurs between self-declared income and IEVS wage data reports, IEVS wage data will be used to determine eligibility. An individual may dispute IEVS wage data by submitting all wage verification for all months in which there is a wage discrepancy. If the applicant is self employed, ledgers are sufficient for verification of earnings, if a ledger is not available, receipts are acceptable. The ledger included in the Medical Assistance application is sufficient verification of earnings, unless questionable. If an individual cannot provide verification through self-declaration, income shall be verified by wage stubs, written documentation from the employer stating the employees' gross income or a telephone call to an employer. Applicants may request that communication with their employers be made in writing.
d. Verification of all unearned income shall be provided if the unearned income was received in the month for which eligibility is being determined or during the previous month. If available, information that exists in another case record or verification system shall be used to verify unearned income.
e. Verification of all resources shall be provided if the resources were available to the applicant in the month for which eligibility is being determined.
f. Immigrant registration cards or papers, if applicable, to determine if the client is eligible for full Medical Assistance benefits. If an applicant does not provide this, he/she shall only be eligible for emergency Medical Assistance if they meet all other eligibility requirements.
g. Pregnancy verification, if applicable, and if the pregnancy is not observable. The verification shall be documented according to 8.100.4.G.9.a.
h. Additional verification-If the requested verification is submitted by the applicant, no other additional verification shall be required unless the submitted verification is found to be questionable on the basis of fact.
i. The determination that information is questionable shall be documented in the applicant's case file and CBMS case comments.
8.100.5.C. Effective Date Of Eligibility 1. Medical Assistance shall be approved effective as of the date of application for Medical Assistance, or as of the date the person becomes eligible for Medical Assistance, whichever is later. Individuals held in correctional facilities or who are held in community corrections programs that are determined eligible for Medical Assistance shall be approved effective as of the individual’s date of release.
2. To be eligible for retroactive Medical Assistance, the categorically needy disabled or blind person shall either:
a. have received SSI money payment or Social Security disability insurance (DIB) for that month, or b. be determined to have met the SSI definition of disability or blindness at that month through the procedure for processing applicant/client determinations as described in the chapter on AID TO NEEDY DISABLED OR BLIND PERSONS in the Colorado Department of Human Services Income Maintenance Staff Manual (9 CCR 2503-1). 8.100.5.D. Medical Assistance Estate Recovery Program 1. The eligibility site shall provide written information from the Department to the following people explaining the provisions of the Medical Assistance Estate Recovery Program and how those provisions may pertain to the applicant/client:
a. Applicants age 55 and older who are institutionalized.
b. Applicants/clients who will turn age 55 before their next eligibility re-determination who are institutionalized.
c. Clients age 55 and older, and approved for admittance to an institution 8.100.5.E. Availability Of Resources and Income 1. Income, which includes earned and unearned income, shall be calculated on a monthly basis regardless of whether it is received annually, semi-annually, quarterly or weekly.
2. For married couples, the income and resources of both spouses are counted in determining eligibility for either or both spouses. Refer to section 8.100.7 for exceptions.
3. Resources and income shall be considered available both when actually available and when the applicant or client has a legal interest in a sum (including cash or equity value of a resource) and has the legal ability to make such sum available for support and maintenance.
4. If the applicant or client demonstrates with written documentation that appropriate steps are being taken to secure the resources, Medical Assistance shall not be delayed or terminated. Verification of efforts to secure the resources must be provided at regular intervals as requested by the eligibility site.
5. Resources will be considered available and Medical Assistance shall be denied or terminated if the applicant or client refuses or fails to make a reasonable effort to secure a potential resources or income.
6. Timely and adequate notice must be given regarding a proposed action to deny, reduce or terminate assistance due to failure to make reasonable efforts to secure resources or income. If upon receipt of the prior notice, the individual acts to secure the potential resource, the proposed action to deny, reduce, or terminate assistance must be withdrawn, and assistance must be approved or continued until the resource or income is, in fact, available.
7. If the resources or income has been transferred to a trust, the trust shall be submitted for review to the Department to determine the effect of the trust on eligibility in accordance with section 8.100.7.E. 8.100.5.F. Income Requirements 1. This section reviews how income is looked at for the ABD Medical Programs. For more general income information and income types refer to the General Medical Assistance General Eligibility Requirements section 8.100.3.
2. Earned income is countable as income in the month received and a countable resource the following month. Earned Income includes the following:
a. Wages, which include salaries, commissions, bonuses, severance pay, and any other special payments received because of employment.
b. Net earnings from self-employment c. Payments for services performed in a sheltered workshop d. Royalties and honoraria 3. Unearned income is countable as income in the month received and a countable resource the following month. Unearned income includes, but is not limited to, the following:
a. Death benefits, reduced by the cost of last illness and burial b. Prizes and rewards c. Gifts and inheritances d. Interest payments on promissory notes established on or after March 1, 2007.
e. Interest or dividend payments received from any resources f. lump sum payments from SSA/SSI, workman’s compensation, insurance settlements g. Dividends, royalties or other payments from mineral rights or other resources listed for sale within the resource limits h. Income from annuities that meet requirements for exclusion as a resource 8.100.5.G. Deeming Of Income And Resources For The OAP Program All aliens who apply for OAP on or after April 16, 1988, for three years after the date of admission into the United States, shall have the income and resources of their sponsors other than relatives deemed for their care. Refer to the Medical Assistance General Eligibility Requirements section 8.100.3.K for specific information on deeming of income and resources.
8.100.5.H. Income Disregards 1. The following income disregards are only applicable to SSI related, OAP, and Medicare Savings Programs (MSP). These disregards are not applicable to the HCBS waivers or the LTC programs.
2. The gross amount of earned and unearned income is countable toward eligibility with the following exclusions:
a. the first $20 of total available unearned income (except for SSI income) must be disregarded;
b. an additional $65 plus 1/2 of the remainder of earned income must be disregarded;
c. income of spouses living together is considered mutually available and must be compared to the current SSI benefit level for a couple; net income of a non recipient spouse must be reduced by an amount up to one half the individual SSI benefit level for unmet needs of each non recipient child in the family;
d. income of single persons must be compared to the current SSI benefit level for an individual (a one third reduction applies to a person living in the household of another);
e. unemancipated children are not subject to a one-third reduction, an amount of parental income equal to the individual or couple SSI benefit level must be allowed for the needs of the parent or parents, up to one half the individual SSI benefit level must be allowed for the unmet needs of each non recipient child in the family, and the remainder must be considered as income available to the applicant or recipient child. For the purposes of this rule, "unemancipated child" means (1) a child under age 18 who is living in the same household with a parent or spouse of a parent, or (2) a child under age 21 who is living in the same household with a parent or spouse of a parent, if the child is regularly attending a school, college, or university, or is receiving technical training designed to prepare the child for gainful employment;
f. one third of child support for the applicant/recipient child from an absent parent must be disregarded;
g. the first $400 of gross monthly earnings, not to exceed $1620 in a calendar year, shall be exempt from consideration as earned income of a disabled or blind child who is a student regularly attending school.
h. any other applicable exemptions in 20 CFR 416.1112. 20 CFR 416.1112 is incorporated herein by reference. No amendments or later editions are incorporated. Copies are available for inspection from the following person at the following address: Custodian of Records, Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO 80203. Any material that has been incorporated by reference in this rule may be examined at any state publications repository library.
8.100.5.I. Determining Ownership of Income 1. If payment is made solely to one individual, the income shall be considered available income to that individual.
2. If payment is made to more than one individual, the income shall be considered available to each individual in proportion to their interests.
3. In case of a married couple in which there is no document establishing specific ownership interests, one-half of the income shall be considered available to each spouse.
4. Income from the Community Spouse's Resource Allowance, as defined in the spousal protection rules in this volume, is income to the community spouse.
8.100.5.J. Income-Producing Property 1. Net rental income from an exempt home or a life estate interest in an exempt home is countable after the following allowable deductions:
a. Property taxes and insurance b. Necessary reasonable routine maintenance expenses c. Reasonable management fee for a professional property manager.
d. Non-business property that is necessary to produce goods or services essential to self support is excluded up to $6000 for applicants who are not applying for long-term care in a Long Term Care institution.
e. Property used in a trade or business which is essential to self-support is excluded up to a limit of $6000 if it produces 6% return of the excluded value. This exclusion does not apply to applicants for Long Term Care in a Long Term Care institution. 8.100.5.K. Department of Veterans Affairs (VA) Payments 1. Payments for aid and attendance (A&A) and unreimbursed medical expenses (UME) shall not be considered as income and should not be paid as patient payment for the following:
a. Veteran in a medical facility that is not a state veteran's medical facility.
b. Veteran or spouse of a veteran in a state veteran's medical facility who has a spouse or child at home.
2. Payments for aid and attendance (A&A) and unreimbursed medical expenses (UME) to a veteran or spouse of a veteran in a state veteran's medical facility with no spouse or child at home shall be treated as follows:
a. Payments shall not be considered as income.
b. Payments shall be used as patient payment to the medical facility. 8.100.5.L. Reverse Mortgages 1. In accordance with C.R.S. 11-38-110, reverse mortgages payments made to a borrower shall not be treated as income for eligibility purposes.
2. Funds remaining the following month after the payment is made will be countable as a resource.
3. Any payments from a reverse mortgage that are transferred to another individual without fair consideration shall be analyzed in accordance with the rules on transfers without fair consideration in the Long Term Care section and may result in a penalty period of ineligibility. 8.100.5.M. Resource Requirements 1. Consideration of resources: Resources are defined as cash or other assets or any real or personal property that an individual or spouse owns. The resource limit for an individual is $2000. For a married couple, the resource limit is $3000. The resource limits for the QMB, SLMB, and QI programs are $8,100 for a single individual and $12,910 for a married individual living with a spouse and no other dependents. If one spouse is institutionalized, refer to Spousal Protection- Treatment of Income and Resources for Institutionalized Spouses.
2. The following resources are exempt in determining eligibility:
a. The principal place of residence, which is owned by the applicant or applicant's spouse, including the home in which the individual resides, the land on which the home is located and related out-buildings.
b. If an individual or spouse moves out of his or her home without the intent to return, the home becomes a countable resource because it is no longer the individual's principal place of residence.
c. If an individual leaves his or her home to live in an institution, the home will still be considered the principal place of residence, irrespective of the individual's intent to return as long as the individual's spouse or dependent relative continues to live there. Dependent relative is defined as one who is claimed as a dependent for federal income tax purposes.
d. The individual's equity in the former home becomes a countable resource effective with the first day of the month following the month it is no longer his or her principal place of residence.
e. The home will still be considered the individual's principal place of residence and retain the exemption if all of the following conditions apply:
f. The principal place of residence, which is subject to estate recovery, becomes a countable resource upon the execution and recording of a beneficiary deed. The exemption can be regained if a revocation of the beneficiary deed is executed and recorded. For applications filed on or after January 1, 2006, an individual’s home if:
g. Excess real property will not be included in countable resources as long as reasonable efforts to sell it have been unsuccessful. Reasonable efforts to sell means:
h. One automobile is totally excluded regardless of its value if it is used for transportation for the individual or a member of the individual's household. An automobile includes, in addition to passenger cars, other vehicles used to provide necessary transportation.
i. Household goods are not counted as a resource to an individual (and spouse, if any) if they are:
j. Personal effects are not counted as a resource to an individual (and spouse, if any) if they are:
k. The cash surrender value of all life insurance policies owned by an individual and spouse, if any, is a countable resource. However, if the total face value of all life insurance policies does not exceed $1500 on any person, the cash surrender value of those policies will be excluded.
l. Term life insurance having no cash surrender value, and burial insurance, the proceeds of which can be used only for burial expenses, are not countable toward the resource limit.
m. The total value of burial spaces for the applicant/recipient, his/her spouse and any other members of his/her immediate family is exempt as a resource. If any interest is earned on the value of an agreement for the purchase of a burial space, such interest is also exempt.
n. An applicant or recipient may own burial funds through an irrevocable trust or other irrevocable arrangement which are available for burial and are held in an irrevocable burial contract, an irrevocable burial trust, or in an irrevocable trust which is specifically identified as available for burial expenses without such funds affecting the person's eligibility for assistance.
o. An applicant or recipient may also own up to $1,500 in burial funds through a revocable account, trust, or other arrangement for burial expenses, without such funds affecting the person's eligibility for assistance. This exclusion only applies if the funds set aside for burial expenses are kept separate from all other resources not intended for burial of the individual or spouse's burial expenses. Interest on the burial funds is also excluded if left to accumulate in the burial fund. For a married couple, a separate $1500 exemption applies to each spouse.
3. Countable resources include the following:
a. Cash;
b. Funds held by a financial institution in a checking or savings account, certificate of deposit or money market account;
c. Current market value of stocks, bonds, and mutual funds;
d. All funds in a joint account are presumed to be a resource of the applicant or client. If there is more than one applicant or client account holder, it is presumed that the funds in the account belong to those individuals in equal shares. To rebut this presumption, evidence must be furnished that proves that some or all of the funds in a jointly held account do not belong to him or her. To rebut the sole ownership presumption, the following procedure must be followed:
e. Any real property that is subject to a recorded beneficiary deed and on which an estate recovery claim can be made.
f. For applications filed on or after January 1, 2006, an individual’s home if the individual’s equity interest in the home exceeds $500,000 and the individual’s spouse, dependent child under the age of 21, or blind or disabled child does not reside in the home.
g. Real property not exempt as the principal place of residence and not exempt as income producing property with a value of $6000 or less, as described in this section.
h. When the applicant alleges that the sale of real property would cause undue hardship to the co-owner due to loss of housing, all of the following information must be obtained:
i. There is no other readily available residence because there is no other affordable housing available or no other housing with the necessary modifications for the co-owner if he is a person with disabilities.
j. Personal property such as a mobile home or trailer or the like, that is not exempt as a principal place of residence or that is not income producing.
k. Personal effects acquired or held for their value or as an investment. Such items can include but are not limited to: gems, jewelry that is not worn or held for family significance, or collectibles.
l. The equity value of all automobiles that are in addition to one exempt vehicle.
m. The cash surrender value of life insurance policies if the face value exceeds $1500.
n. Promissory notes established before April 1, 2006 are treated as follows:
o. Promissory notes established on or after April 1, 2006 are treated as follows:
p. Promissory notes established on or after March 1, 2007 are treated as follows:
4. Treatment of Property Owned by Native Americans a. Effective July 1, 2009, notwithstanding any other requirement in 10 C.C.R. 2505-10, Section 8, the following property shall be considered exempt for the purpose of determining Medicaid resource eligibility for a Native American:
1. The following regulations apply to self-funded retirement accounts such as an Individual Retirement Account (IRA), Keogh Plan, 401(k), 403(b) and any other self-funded retirement account.
2. Self-funded retirement accounts in the name of the applicant are countable as a resource to the applicant.
3. Self-funded retirement accounts in the name of the applicant's spouse who is living with the applicant are exempt in determining eligibility for the applicant, except as set forth in 4. below.
4. Self-funded retirement accounts in the name of a community spouse who is married to an applicant who is applying for Long Term Care in a Long Term Care institution, HCBS or PACE, are countable as a resource to the applicant and may be included in the Community Spouse Resource Allowance (CSRA) up to the maximum amount allowable. The terms community spouse and CSRA are further defined in the regulations on Spousal Protection in this volume.
5. The value of a self-funded retirement account is determined as follows:
a. The gross value of the account, less any taxes due, is the amount that is countable as a resource, regardless of whether any monthly income is being received from the account.
b. If the applicant is not able to provide the amount of taxes that are due, the value shall be determined by deducting 20% from the gross value of the account. 8.100.5.O. Treatment of Proceeds from Disposition of Resources Treatment of proceeds from disposition of resources is determined as follows:
1. The net proceeds from the sale of exempt or non-exempt resources are considered available resources.
2. The net proceeds are the selling price less any valid encumbrances and costs of sale.
3. After deducting any amount necessary to raise the individual's and spouse's resources to the applicable limits, the balance of the net proceeds shall be considered available resources. In lieu of terminating eligibility due to excess resources, the client may request that the proceeds be used to reimburse the Medical Assistance Program for previous payments for Medical Assistance.
4. The proceeds from the sale of an exempt home will be excluded to the extent they are intended to be used and are, in fact, used to purchase another home in which the individual, a spouse or dependent child resides, within three months of the date of the sale of the home.
8.100.6 Aged, Blind, and Disabled Medical Assistance Eligibility [Eff. 03/30/2009] 8.100.6.A. Aged, Blind, and Disabled (ABD) General Information Medical Assistance for ABD includes SSI eligible individuals, OAP recipients, and the Medicare Savings Program (MSP) individuals. Refer to section 8.100.5 of this volume for income and resource criteria for these categories of assistance.
8.100.6.B. Disability Determinations 1. Beginning on July 1, 2001, the Department or its contractor shall determine whether the client is disabled or blind in accordance with the requirements and procedures set forth elsewhere in this volume and according to Federal regulations regarding disability determinations.
2. A client who disagrees with the decision on disability or blindness shall have the right to appeal that decision to a state-level fair hearing in accordance with the procedures at 8.058. 8.100.6.C. SSI Eligibles 1. Benefits of the Colorado Medical Assistance Program must be provided to the following:
a. persons receiving financial assistance under SSI;
b. persons who are eligible for financial assistance under SSI, but are not receiving SSI;
c. persons receiving SSI payments based on presumptive eligibility for SSI pending final determination of disability or blindness; and persons receiving SSI payments based on conditional eligibility for SSI pending disposal of excess resources.
2. The Department has entered into an agreement with SSA in which SSA shall determine Medical Assistance for all SSI applicants. Medical Assistance shall be provided to all individuals receiving SSI benefits as determined by SSA to be eligible for Medical Assistance.
3. The eligibility sites shall have access to a weekly unmatched listing of all individuals newly approved and a weekly SSI-Cases Denied or Discontinued listing. These lists shall include the necessary information for the eligibility site to authorize Medical Assistance.
4. Medical Assistance shall not be delayed due to the necessity to contact the SSI recipient and obtain third party medical resources.
5. Notification shall be sent to the SSI recipient advising him/her of the approval of Medical Assistance.
6. The SISC Code for this type of assistance is B.
7. Denied or terminated Medical Assistance based on a denial or termination of SSI which is later overturned, must be approved from the original SSI eligibility date.
8. Individuals who remain eligible as SSI recipients but are not receiving SSI payments shall receive Medical Assistance benefits. This group includes persons whose SSI payments are being withheld as a means of recovering an overpayment, whose checks are undeliverable due to change of address or representative payee, and persons who lost SSI financial assistance due to earned income.
9. If the eligibility site obtains information affecting the eligibility of these SSI recipients, they shall forward such information to the local Social Security office.
8.100.6.D. Pickle Amendment 1. Beginning July 1977, medical assistance must be provided to an individual if their countable income is below the current years SSI standard after a cost of living adjustment (COLA) disregard is applied to their OASDI (excluding Railroad Retirement Benefits) and they meet all other eligibility criteria. This is referred to as Pickle Disregard.
2. The Pickle Disregard applies to an individual who:
a. lost SSI and/or OAP because of a cost of living adjustment to his/her own OASDI benefits.
b. lost SSI and/or OAP because a cost of living adjustment to OASDI income deemed from a parent or spouse.
c. lost OAP and/or SSI due to the receipt of, or increase to, OASDI, and would be eligible for OAP and/or SSI if all COLA’S on the amount that caused them to lose eligibility is disregarded from their current OASDI amount.
8.100.6.E. Pickle Determination 1. To determine eligibility of Medical Assistance recipients to whom the Pickle disregards apply, the eligibility site must:
a. establish whether the person was eligible for SSI or OAP and, for the same month, was entitled to OASDI;
b. determine the previous amount of the OASDI that caused them to lose SSI and/or OAP;
c. determine the current OASDI income;
d. subtract the previous OASDI income from the current OASDI income to find the cumulative OASDI COLAs since SSI and/or OAP was lost. This is the Pickle Disregard amount;
e. subtract the Pickle Disregard amount from the current OASDI income to get the countable OASDI income.
2. If the countable OASDI income and all other countable income is less than the current SSI or OAP standard, and the individual meets all other eligibility criteria then medical eligibility must continue or be reinstated.
3. This disregard must also be applied to any OASDI cost of living increases paid to any financially responsible individual such as a parent or spouse whose income is considered in determining the person's continued eligibility for Medical Assistance.
4. The cost of living increase disregard specified in the preceding action must continue to be applied at each eligibility redetermination.
5. An SSI medical only individual who loses SSI due to an OASDI cost-of-living increase shall be contacted by the eligibility site to determine if the individual would continue to remain eligible for Medical Assistance under the provisions for SSI related cases. The individual must complete an application for assistance to continue receiving benefits. 8.100.6.F. 1972 Disregard Individuals 1. Medical Assistance must be provided to a person who was receiving financial assistance under AND or Aid to the Blind (AB) for August 1972 and who – except for the October 1972 Social Security (includes RRB) 20% increase amount would currently be eligible for financial assistance. This disregard must also be applied to a person receiving Medical Assistance in August 1972 who was eligible for financial assistance but was not receiving the money payment and to a person receiving Medical Assistance as a resident in a medical institution in August 1972.
2. To redetermine the eligibility of Medical Assistance recipients to whom the 1972 disregard applies, the eligibility site must:
a. review the case against the current applicable program definitions and requirements;
b. apply the resource and income criteria specified in section 8.100.5;
c. subtract the 1972 disregard amount from the income;
d. consider the remainder against the current appropriate SSI benefit level. 8.100.6.G. Individuals Eligible in 1973 1. Medical Assistance must be provided to ABD persons who are receiving mandatory state supplementary payments (SSP). Such persons are those with income below their December 1973 minimum income level (MIL).
2. Medical Assistance must be provided to a person who was eligible for medical assistance in December 1973 as an inpatient of a medical facility, who continues to meet the December 1973 eligibility criteria for institutionalized persons and who remains institutionalized.
3. Medical Assistance must be provided to a person who was eligible for Medical Assistance in December 1973 as an "essential spouse" of an AND or AB financial assistance recipient, and who continues to be in the grant and continues to meet the December 1973 eligibility criteria. Except for such persons who were grandfathered-in for continued assistance, essential spouses included in assistance grants after December 1973 are not eligible for Medical Assistance. 8.100.6.H. Eligibility for Certain Disabled Widow(er)s 1. Medical Assistance shall be provided retroactive to July 1, 1986, to qualified disabled widow(er)s who lost SSI and/or state supplementation due to the 1983 change in the actuarial reduction formula prescribed in section 134 of P.L. No. 98 21.
In order for these widow(er)s to qualify, these individuals must:
a. have been continuously entitled to Title II benefits since December 1983;
b. have been disabled widow(er)s in January 1984;
c. have established entitlement to Title II benefits prior to age 60;
d. have been eligible for SSI/SSP benefits prior to application of the revised actuarial reduction formula;
e. have subsequently lost eligibility for SSI/SSP as a result of the change in the actuarial table; and f.. reapply for assistance prior to July 1, 1987.
8.100.6.I. Eligibility for Disabled Widow(er)s 1. Effective January 1, 1991, Medical Assistance shall be provided to disabled widow(er)s age 50 through 64 who lost SSI and/or OAP due to the receipt of Social Security benefits as a disabled widow(er). The individual shall remain eligible for Medical Assistance until he/she becomes eligible for Part A of Medicare (hospital insurance).
To qualify these individuals must:
a. be a widow(er);
b. have received SSI in the past;
c. be at least 50 years old but not 65 years old;
d. no longer receive SSI payments because of Social Security payments;
e. not have hospital insurance under Medicare; and, f. meet all other Medical Assistance requirements.
8.100.6.J. Old Age Pension (OAP) Eligibles 1. Individuals that are 65 and over are defined as the OAP-A category. Individuals who attain the age of 60 but not yet 65 are defined as the OAP-B category.
2. Medical Assistance must be provided to persons receiving OAP-A or OAP-B and SSI (SISC B).
3. Medical Assistance must be provided to all OAP-A and OAP-B persons who also meet SSI eligibility criteria but are not receiving a money payment (SISC-B).
4. Medical Assistance must be provided to all OAP-A and OAP-B persons who also meet SSI eligibility criteria except for the level of their income (SISC-B).
5. Medical Assistance must be provided to persons in a facility eligible for Medical Assistance reimbursement whose income is under 300% of the SSI benefit level and who, but for the level of their income, would be eligible for OAP “A” or OAP “B” and SSI financial assistance. This group includes persons 65 years of age or older receiving active treatment as inpatients in a psychiatric facility eligible for Medical Assistance reimbursement (SISC A). This population is referenced as Psych >65.
6. The OAP B individual included in AFDC assistance unit shall receive Medical Assistance as a member of the AFDC household (SISC B).
7. The OAP State Only Medical Assistance Program provides Medical Assistance to OAP-A, OAP-B or OAP Refugees who lost their OAP financial assistance because of a cost of living adjustment other than OASDI. Examples of other sources of income are VA, RRB, PERA, etc. (SISC C).
8. For the purpose of identifying the proper SISC code for persons receiving assistance under OAP "A" or OAP "B", if the person:
a. receives an SSI payment (SISC B);
b. does not receive an SSI payment but is receiving assistance under OAP "A", a second evaluation of resources must be made using the same resource criteria as specified in section 8.100.5.M for those who meet this criteria the SISC code is B for money payment and "disregard" case, A for institutional cases;
c. does not receive an SSI payment and does not otherwise qualify under SISC code B or A as described in item b. above (SISC C).
8.100.6.K. Qualified Medicare Beneficiaries (QMB)
1. Medical Assistance coverage for QMB clients is payment of Medicare part B premiums, co-insurance and deductibles.
2. Effective July 1, 1989, a Qualified Medicare Beneficiary is an individual who:
a. is entitled to Part A Medicare; and b. for an individual, who has resources at or below twice the SSI individual resource limit, or for a couple who has resources at or below three times the SSI individual resource limit, as described in section 8.100.5; and c. has income at or below the percentage of the federal poverty level for the size family as mandated for QMB by federal regulations. Poverty level is established by the Executive Office of Management and Budget.
3. For QMB purposes, couples shall have their income compared against the federal poverty level couples income maximum. This procedure shall be applied whether one or both members apply for QMB.
4. For QMB purposes, income of the applicant and/or the spouse shall be determined as described under Income Requirements in section 8.100.5. If two or more individuals have earned income, the income of all the individuals shall be added together and the 65 plus 1/2 earned income disregard shall be applied to the total amount of earned income.
5. Medicare cost sharing expenses must be provided to qualified Medicare beneficiaries. This limited Medical Assistance package of Medicare cost sharing expenses only includes:
a. payment of Part A Medicare premiums where applicable; and, b. payment of Part B Medicare premiums; and, c. payment of coinsurance and deductibles for Medicare services whether or not a benefit of Medical Assistance up to the full Medicare rate or reasonable rates as established in the State Plan.
6. Individuals may be QMB recipients only or the individual may be classified as a dual eligible. A dual eligible is a Medicare recipient who is otherwise eligible for Medical Assistance.
7. A QMB-only recipient is an individual who is not eligible for other categorical assistance program due to their income and/or resources but who meets the eligibility criteria for QMB described above.
8. Individuals who apply for QMB assistance have the right to have their eligibility determined under all categories of assistance for which they may qualify.
9. All other general non-financial requirements or conditions of eligibility must also be met such as age, citizenship, residency requirements as well as reporting and redetermination requirements. These criteria are defined in section 8.100.3 of this volume.
10. Eligibility for QMB benefits shall be effective the month following the month of determination. Beneficiaries who submit and complete an application within the 45-day standard shall be eligible for benefits no later than the first of the month following the 45th day of application. Administrative delays shall not postpone the effective date of eligibility.
11. QMB benefits are not retroactive and the three month retroactive Medical Assistance rule does not apply to QMB benefits.
12. Clients who would lose their QMB entitlement due to annual social security COLA will remain eligible for QMB coverage under Medical Assistance, as income disregard cases, until the next year's federal poverty guidelines are published.
8.100.6.L. Special Low Income Medicare Beneficiaries 1. Medical Assistance coverage for SLMB clients is limited to payment of monthly Medicare Part B (Supplemental Medical Insurance Benefits) premiums.
2. Effective January 1, 1993, a Special Low Income Medicare Beneficiary (SLMB) is an individual who:
a. is entitled to Medicare Part A;
b. for an individual who has resources at or below twice the SSI individual resource limit, or for a couple who has resources at or below three times the SSI individual resource limit, as described in section 8.100.3 of this volume.
c. has income at or below a percentage of the federal poverty level for the family size as mandated by federal regulations for SLMB. Income limits have been defined through CY 1995, as follows: CY 1993 and 1994 100-110% of FPL, CY 1995 100-120% of FPL.
3. For SLMB purposes, couples shall have their income compared against the federal poverty level couples income maximum. This procedure shall be applied whether one or both members apply for SLMB.
4. For SLMB purposes, income of the applicant and/or the spouse shall be determined as described under Income Requirements in section 8.100.5. If two or more individuals have earned income, the income of all the individuals shall be added together and the 65 plus 1/2 earned income disregard shall be applied to the total amount of earned income.
5. SLMB eligibility starts on the date of application or up to three month prior to the application date for retroactive Medical Assistance.
6. Eligibility may be made retroactive up to 90 days, but may not be effective prior to 1/1/93.
7. Clients who would lose their SLMB entitlement due to annual SSA COLA will remain eligible for SLMB coverage, as income disregard cases, through the month following the month in which the annual federal poverty levels (FPL) update is published.
8.100.6.M. Medicare Qualifying Individuals 1 (QI1)
1. Medical Assistance coverage is limited to monthly payment of Medicare Part B premiums. Payment of the premium shall be made by the Department on behalf of the individual.
2. Eligibility for this benefit is limited by the availability of the allocation set by CMS. Once the state allocation is met, no further benefits under this category shall be paid and a waiting list of eligible individuals shall be maintained.
3. Eligibility for QI1 benefits shall be effective the month in which application is made and the individual is eligible for benefits. Eligibility may be retroactive up to three months from the date of application, but not prior to January 1, 1998.
4. In order to qualify as a Medicare Qualifying Individual 1, the individual must meet the following:
a. be entitled to Part A of Medicare, b. income of at least 120%, but less than 135% of the FPL.
c. resources may not exceed twice the SSI limit, and d. he/she cannot otherwise be eligible for Medical Assistance.
5. For QI1 purposes, income of the applicant and/or the spouse shall be determined as described under Income Requirements in section 8.100.5. If two or more individuals have earned income, the income of all the individuals shall be added together and the 65 plus 1/2 earned income disregard shall be applied to the total amount of earned income.
6. Clients who would lose QI-1 entitlement due to annual social security COLA will remain eligible for QI- 1 coverage under Medical Assistance, as an income disregard case, until the next year’s federal poverty guidelines are published.
8.100.6.N. Qualified Disabled And Working Individuals 1. Medical Assistance coverage is limited to monthly payment of Medicare Part A premiums, and any other Medicare cost sharing expenses determined necessary by CMS.
2. Effective July 1, 1990, a Qualified Disabled and Working Individual (QDWI) is an individual who:
a. was a recipient of federal Social Security Disability Insurance (SSDI) benefits, who continues to be disabled but lost SSDI entitlement due to earned income in excess of the Social Security Administration's Substantial Gainful Activity (SGA) threshold, and;
b. has exhausted SSA's allowed extension of "premium free" Medicare Part A coverage under SSDI, and;
c. has resources at or below twice the SSI resource limit as described in section 8.100.5.
d. has income less than 200% of FPL.
3. For QDWI purposes, income of the applicant and/or the spouse shall be determined as described under Income Requirements in section 8.100.5. If two or more individuals have earned income, the income of all the individuals shall be added together and the 65 plus 1/2 earned income disregard shall be applied to the total amount of earned income.
4. An individual may be eligible under this section only if he/she is not otherwise eligible under another Medical Assistance category of eligibility.
5. Eligibility for QDWI benefits shall be effective the month of determination of entitlement.
6. Eligibility may be retroactive only to the date as of which SSA approves an individual's application for coverage as a "Qualified Disabled and Working Individual". However, eligibility may not begin prior to 07/01/90.
8.100.7 Long Term Care Medical Assistance Eligibility
8.100.7.A. Persons in Long-Term Care Institutions or Other Residential Placement 1. For Long–Term Care services to be covered in a Long-Term Care institution, a client must be determined eligible under the Institutionalized 300% Special Income category. If the client is already Medicaid eligible, a new application is not required but a redetermination must be performed.
For a client entering a Long-Term Care Institution from the community, the Eligibility Site must notify the Single Entry Point/Case Management Agency, upon receipt of the application or client request, to schedule the institutional level of care assessment. This is not applicable to a client being discharged from a hospital, nursing facility or Long-Term Home Health. For purposes of applying the special income standard for the aged, disabled or blind persons in Long-Term Care Institutions, gross income means income before application of deductions, exemptions or disregards appropriate to the SSI program. Medical Assistance will be provided beginning the first day of the month following the month during which a child under the age of 18 ceases to live with his or her parent(s). Once determined to meet the institutional requirement, parental income and resources will cease to be deemed available to the child because the child is institutionalized and not living in the parents' home.
2. Eligibility under the Institutionalized 300% Special Income category will be provided to applicants who:
a. Have attained the age of 65 years or;
b. Have met the requirements according to the definition of disability or blindness applicable to the Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) c. Have been institutionalized for at least 30 consecutive days in a Long–Term Care institution. The 30 day consecutive stay may be a combination of days in a hospital, Long–Term Care institution, or receiving services from a Home and Community Based Services
Once the 30 consecutive days of institutionalization requirement has been met, Medical Assistance benefits start as of the first day when institutionalization began if all other eligibility requirements were met as of that date.
d. Are in a facility eligible for Medical Assistance Program reimbursement if the individual is in a hospital or Long Term Care institution; and e. Have gross income that does not exceed 300% of the current individual SSI benefit level or; Are in a Long-Term Care institution (excluding hospital) whose gross income exceeds the 300% level and who establishes an income trust in accordance with the rules on income trusts in section 8.100.7 of this volume;
g. Have resources that conform with the regulations regarding resource limits and exemptions set forth in section 8.100.5 of this volume; and h. If married, Income and resources conform to rules set forth at 8.100.7.C and 8.100.7.K; and i. Have not transferred assets for less than fair market value on or after the look-back date defined in section 8.100.7.F.2.d. which would incur a penalty period of ineligibility in accordance with the regulations on transfers without fair consideration in section 8.100.7 of this volume; and j. Have submitted trust documents to the Department if the individual or the individual's spouse has transferred assets into a trust or is a beneficiary of trust. The Department shall determine the effect of the trust on Medical Assistance Program eligibility.
3. An appeal process is available to children identified by C.R.S. 27-10.3-101 to 108, The Child Mental Health Treatment Act, who are denied residential treatment. The appeal process is outlined in the Income Maintenance Staff Manual of the Department of Human Services (9 CCR 2503-1). A determination made in connection with this appeal shall not be the final agency action with regard to Medical Assistance eligibility 8.100.7.B. Persons Requesting Long-term Care through Home And Community Based Services (HCBS) or the Program of All Inclusive Care for the Elderly (PACE) 1. HCBS or PACE shall be provided to persons who:
a. are SSI or OAP Medicaid eligible; or b. are eligible under the Institutionalized 300% Special Income category described at 8.100.7.A; and c. have been assessed by the Single Entry Point/Case Management Agency to have met the functional level of care and will remain in the community by receiving HCBS or the PACE.
2. A client who is already Medicaid eligible does not need to submit a new application. The client must request the need for Long–Term Care services and the Eligibility Site must redetermine the client’s eligibility.
3. For individuals served in Alternative Care Facilities (ACF), income in excess of the personal needs allowance and room and board amount for the ACF shall be applied to the Medical Assistance charges for ACF services. The total amount allowed for personal need and room and board cannot exceed the State's Old Age Pension Standard.
8.100.7.C. Treatment of Income and Resources for Married Couples 1. The income of a community spouse is not deemed to the institutionalized spouse in determining eligibility. If both spouses are institutionalized, their individual income is counted in determining their own eligibility. The income of one institutionalized spouse is not deemed to the other institutionalized spouse when determining eligibility.
2. The income and resources of both spouses are counted in determining eligibility for either or both spouses with the following exceptions:
a. If spouses share the same room in an institution, the income of the individual spouse is counted in determining his or her eligibility, and each spouse is allowed the $2000 limit for resources.
b. Beginning the first month following the month the couple ceases to live together, only the income of the individual spouse is counted in determining his or her eligibility.
c. If one spouse is applying for Long-Term Care in a Long-Term Care institution or Home and Community Based Services (HCBS), refer to the rules on Treatment of Income and Resources for Institutionalized Spouses.
3. Long term care insurance benefits are not countable as income, but are payable as part of the patient payment to the Long-Term Care institution.
4. For living expense purposes, income and resources of spouses living in the same household for a full calendar month or more must be considered as available to each other, whether or not they are actually contributed, and must be evaluated in accordance with rules contained in 8.100.7.Q. Long–Term Care 8.100.7.D. Other Medical Assistance Clients Requesting Long-Term Care in an Institution or through HCBS or PACE Clients who need Long-Term Care services who are eligible for the State Only Health Care Program shall submit an application because they are not already Medicaid eligible. 8.100.7.E Consideration of Trusts in Determining Medical Assistance Eligibility 1. Trusts established before August 11, 1993:
a. Medical Assistance Qualifying Trust (MQT)
b. This provision does not apply to any trust or initial decrees established before April 7, 1986, solely for the benefit of a developmentally disabled individual who resides in an Long Term Care Institution for the developmentally disabled.
c. This provision does not apply to individuals who are receiving SSI.
2. Trusts established on or after July 1, 1994:
Assets include all income and resources of the individual and the individual's spouse, including all income and resources which the individual or the individual's spouse is entitled to but does not receive because of action by any of the following:
a. The individual or the individual's spouse, b. A person, including a court or administrative body, with legal authority to act in place of or on behalf of the individual or the individual’s spouse, or c. Any person court or administrative body acting at the direction of or upon the request of the individual or the individual's spouse.
3. In determining an individual's eligibility for Medical Assistance, the following regulations apply to a trust established by an individual:
a. An individual shall be considered to have established a trust if assets of the individual were used to form all or part of the corpus of the trust, and if any of the following individuals established the trust, other than by will:
b. In the case of a trust, the corpus of which includes assets of an individual and the assets of any other person(s), this regulation shall apply to the portion of the trust attributable to the assets of the individual.
c. These regulations apply without regard to the following:
4. Revocable Trusts are considered as follows:
a. The corpus of the trust shall be considered resources available to the individual.
b. Payments from the trust to or for the benefit of the individual shall be considered income to the individual, and c. Any other payments from the trust shall be considered assets transferred by the individual for less than fair market value and are subject to a 60 month look back period and a penalty period of ineligibility as set forth in the regulations on transfers without fair consideration in this volume.
5. Irrevocable Trusts If there are any circumstances under which payments from the trust could be made to or for the benefit of the individual, the following shall apply:
a) The portion of the corpus of the trust, or the income on the corpus, from which payment to the individual could be made, shall be considered as resources available to the individual.
b) Payments from that portion of the corpus, or income to or for the benefit of the individual, shall be considered income to the individual.
c) Payments from that portion of the corpus or income for any other purpose shall be considered as a transfer of assets by the individual for less than fair market value and are subject to a 60 month look back period and a penalty period of ineligibility as set forth in the regulations on transfers without fair consideration in this volume.
d) Any portion of the trust from which, or any income on the corpus from which no payment could be made to the individual under any circumstances, shall be considered as a transfer of assets for less than fair market value and shall be subject to a 60 month look back period and penalty period of ineligibility as set forth in the regulations on transfers without fair consideration in this volume. The transfer will be effective as of the date of the establishment of the trust, or the date on which payment to the individual from the trust was foreclosed, if later. The value of the trust shall be determined by including the amount of any payments made from such portion of the trust after such date.
6. The preceding regulations for trusts established on or after July 1, 1994, do not apply to the following:
a. Income Trusts
REGION III: (Alamosa, Baca, Bent, Chaffee, Conejos, Costilla, Crowley, Custer, El Paso, Fremont, Huerfano, Kiowa, Lake, Las Animas, Lincoln, Mineral, Otero, Prowers, Pueblo, Rio Grande, Saguache, Teller)
REGION IV: (Archuleta, Delta, Dolores, Eagle, Garfield, Gunnison, Hinsdale, La Plata, Mesa, Moffat, Montezuma, Montrose, Ouray, Pitkin, Rio Blanco, Routt, San Juan, San Miguel)
b. Disability Trusts
c. Pooled Trusts
d. Third Party Trusts
e. Federally Approved Trusts
7. Submission of Trust Documents and Records a. The trustee of a trust which was established by or which benefits a Medical Assistance Applicant or client shall submit trust documents and records to the eligibility site and to the Department.
b. This requirement includes documents and records for income trusts, disability trusts and the joinder agreement for each pooled trust account.
c. The eligibility site shall submit any trust which is submitted with an application or at redetermination to The Department. The eligibility site shall determine Medical Assistance eligibility based on the determination of The Department as to the effect of the trust on eligibility.
8.100.7.F. Transfers of Assets Without Fair Consideration 1. If an institutionalized individual or the spouse of such individual disposes of assets for less than fair market value on or after the look-back date, the individual shall be subject to a period of period of ineligibility for Long Term Care services, including Long Term Care institution care, Home and Community Based Services (HCBS), and the Program of All Inclusive Care for the Elderly (PACE).
2. The following definitions apply to transfers of assets without fair considerations:
a. Assets include all income and resources of the individual and such individual's spouse, including all income or resources which the individual or such individual's spouse is entitled to but does not receive because of action by any of the following:
b. Fair market value is the value of the asset if sold at the prevailing price at the time it was transferred.
c. Fair consideration is the amount the individual receives in exchange for the asset that is transferred, which is equal to or greater than the value of the transferred asset.
d. For transfers made before February 8, 2006, the look-back date is 36 months prior to the date of application. For transfers made on or after February 8, 2006, the look-back date is 60 months prior to the date of application.
e. An institutionalized individual is one who is institutionalized in a medical facility, a Long Term Care institution, or applying for or receiving Home and Community Based Services
3. If an institutionalized individual or such individual's spouse transfers assets without fair consideration on or after the look-back date, the transfer shall be evaluated as follows:
a. The fair market value of the transferred asset, less the actual amount received, if any, shall be divided by the average monthly private pay cost for Long Term Care institution care in the state of Colorado at the time of application.
b. The resulting number is the number of months that the individual shall be ineligible for Medical Assistance. For transfers made before February 8, 2006, the period of ineligibility shall begin with the first day of the month following the month in which the transfer occurred. For transfers made on or after February 8, 2006, the period of ineligibility shall begin on the later of the following dates:
4. The period of ineligibility shall also include partial months, which shall be calculated by multiplying 30 days by the decimal fractional share of the partial month. The result is the number of days of ineligibility. For transfers occurring on or after April 1, 2006, the result should be rounded up to the nearest whole number.
5. There is no maximum period of ineligibility.
6. For transfers prior to February 8, 2006, the total amount of all of the transfers are added together and the period of ineligibility begins the first day of the month following the month in which the resources are transferred.
a. If the previous penalty period has completely expired, the transfers are not added together.
b. If the previous penalty period has not completely expired and the first day of the month following the month in which the resources are transferred is part of a prior penalty period, the new penalty period begins the first day after the prior penalty period expires.
7. For transfers on or after February 8, 2006, the total amount of all of the transfers are added together and the penalty period is assessed as outlined in section 8.100.7.F.4 above.
a. If the previous penalty period has completely expired, the transfers are not added together.
b. If the previous penalty period has not completely expired and the first day of the month following the month in which the resources are transferred is part of a prior penalty period, the new penalty period begins the first day after the prior penalty period expires.
8. The institutionalized individual may continue to be eligible for Supplemental Security Income (SSI) and basic Medical Assistance services, but shall not be eligible for Medical Assistance for Long Term Care institution services, Home and Community Based Services or the Program of All Inclusive Care for the Elderly due to the transfer without fair consideration.
9. If a transfer without fair consideration is made during a period of eligibility, a period of ineligibility shall be assessed in the same manner as stated above.
10. Actions that prevent income or resources from being received, as set forth on the following list, which is not exclusive, shall create a rebuttable presumption that the transfer was without fair consideration:
a. Waiving pension income.
b. Waiving a right to receive an inheritance.
c. Preventing access to assets to which an individual is entitled by diverting them to a trust or similar device. This is not applicable to valid income trusts, disability trusts and pooled trusts for individuals under the age of 65 years.
d. Failure of a surviving spouse to elect a share of a spouse's estate.
e. Failure to obtain a family allowance or exempt property from an estate of a deceased spouse or parent.
f. Not accepting or accessing a personal injury settlement.
g. Transferring assets into an irrevocable private annuity which was not purchased from a commercial company.
h. Transferring assets into an irrevocable entity such as a Family Limited Partnership which eliminates or restricts the individual's access to the assets.
i. Refusal to take legal action to obtain a court ordered payment that is not being paid, such as child support or alimony, if the benefit outweighs the cost.
j. Failure to exercise rights in a Dissolution of Marriage case, which insure an equitable distribution of marital property and income.
8.100.7.G. Treatment of Certain Assets as Transfers Without Fair Consideration 1. Promissory notes established before April 1, 2006:
a. The fair market value of promissory notes are a countable resource and must be evaluated in accordance with the regulations on consideration of resources in this volume.
b. Promissory notes with one or more of the following provisions, indicating they have little or no market value, shall create a rebuttable presumption of a transfer without fair consideration:
c. Promissory notes which have been appraised by a note broker as having little or no value shall create a rebuttable presumption of a transfer without fair consideration.
2. Promissory notes established on or after April 1, 2006 a. Subject to the look-back date described in section 8.100.7.F.2.d for the purpose of calculating the penalty period of ineligibility for a transfer without fair consideration, the value of a promissory note, loan or mortgage which does not meet the criteria in section 8.100.7.G.1. is the outstanding balance due as of the date of the individual’s application for Medical Assistance for services, described in section 8.100.7.F.4.
3. Promissory notes established on or after March 1, 2007 a. Subject to the look-back date described in section 8.100.7.F.2.d, for the purpose of calculating the penalty period of ineligibility for a transfer without fair consideration, the value of a promissory note, loan or mortgage which does not meet the criteria in section 8.100.7.G.1 is the outstanding balance due as of the date of the individual’s application for Medical Assistance for services, described in section 8.100.7.F.4.
4. Personal care services a. Effective for agreements that were signed and notarized prior to March 1, 2007, family members who provide assistance or services are presumed to do so for love and affection, and compensation for past assistance or services shall create a rebuttable presumption of a transfer without fair consideration unless the compensation is in accordance with the following:
b. Effective for agreements that are signed and notarized on or after March 1, 2007, compensation under personal service agreements will be deemed to be a transfer without fair consideration unless the following requirements are met:
c. Payment for services, which were rendered previously and for which no compensation was made, shall be considered as a transfer without fair consideration.
d. Assets transferred in exchange for a contract for personal services for future assistance after the date of application are considered available resources.
e. A care agreement must be entered into, signed, and notarized prior to providing any services for which a beneficiary will be compensated.
5. Transfers of real property into joint tenancy without fair consideration a. If real property is transferred into joint tenancy with right of survivorship with one or more joint tenants, the amount transferred depends on the number of joint tenants to whom the property is transferred. The following are examples:
b. If the transfer is completed with two deeds or transactions, the first of which transfers a fractional share of the property into tenancy in common, and the second into joint tenancy, the amount transferred shall be determined in the same manner as set forth above.
6. No period of ineligibility will be imposed if the individual transferred the assets under any of following circumstances:
a. The asset transferred was a home and title to the home was transferred to:
b. The assets were transferred:
7. Definition of the term "for the sole benefit of," as used in the preceding exceptions to the transfer penalty rules:
a. A transfer or a trust is considered to be for the sole benefit of the spouse, blind or disabled child, or a disabled individual if the transfer is arranged in such a way that no individual or entity except the spouse, blind or disabled child, or disabled individual can benefit from the assets transferred in any way, whether at the time of the transfer or at any time in the future.
b. To insure that the asset transferred is for the sole benefit of the spouse, blind or disabled child or disabled individual, the following criteria must be met:
c. The written instrument must provide for the spending of funds or use of the transferred assets for the benefit of the individual on a basis that is actuarially sound based on the life expectancy of the individual.
d. Disability trusts and income trusts, which designate the Colorado Department of Health Care Policy and Financing as the remainder beneficiary up to the amount of Medical Assistance paid on behalf of the individual are exempt from this requirement.
e. A community spouse to whom a Community Spouse Resource Allowance has been transferred does not have to provide a written document or comply with the requirement that the transfer is actuarially sound. However, the Community Spouse Resource Allowance must be for the sole benefit of the community spouse to whom it is transferred. Upon the death of the community spouse, those resources shall be made available to the surviving spouse, at least up to the amount of the elective share of the augmented estate, the family allowance and the exempt property allowance.
f. There is a rebuttable presumption the transfer without fair consideration was made for purposes of Medical Assistance eligibility.
8. The transfer is presumed to have been made for the purpose of obtaining eligibility or remaining eligible unless the individual provides convincing, objective evidence that the transfer was exclusively for some other purpose and the reason for the transfer did not include Medical Assistance eligibility. Transfers that are made to avoid the Medical Assistance lien or the Medical Assistance estate recovery program shall be included in the definition of Medical Assistance eligibility.
9. A subjective statement of intent or ignorance of the transfer penalty or verbal assurances that the individual was not considering Medical Assistance eligibility when the transfer was made are not sufficient.
10. There is a rebuttable presumption that transfers without fair consideration were made for the purpose of Medical Assistance eligibility in the following cases:
a. In any case in which the individual's assets and the assets of the individual's spouse remaining after the transfer total an amount insufficient to meet all living expenses and medical expenses reasonably expected to be incurred by the individual or the individual's spouse in the thirty-six months following the transfer. Medical expenses include the cost of Long Term Care unless the future necessity of such care could have been absolutely precluded because of the particular circumstances.
b. In any case where the transfer was made on behalf of the individual or the individual's spouse, by a guardian, conservator, or agent under a power of attorney to any spouse, child, grandchild, brother, sister, niece, nephew, parent, grandparent, by birth, adoption, or marriage of the guardian, conservator, or agent under a power of attorney.
11. Convincing evidence may include, but is not limited to, verification which establishes:
a. That at the time of the transfer the individual could not have anticipated needing long term Medical Assistance due to the existence of other circumstances which would have precluded the need.
b. Other assets were available at the time of the transfer to meet current and future needs of the individual, including the cost of Long Term Care institution or other institutionalized care for a period of thirty-six months.
c. The specific purpose for which the assets were transferred and the reason the transfer was necessary and the reason there was no alternative but to transfer the assets for less than fair market value. The presumption cannot be rebutted successfully by stating it was done for estate planning purposes or to avoid probate.
d. When the individual had some other purpose for transferring the assets, but any expectation of establishing eligibility could reasonably be inferred to be a factor in the decision to transfer the asset, the presumption cannot be successfully rebutted.
12. Apportionment of penalty period between spouses a. If a transfer results in a period of ineligibility for an individual, and the individual's spouse becomes institutionalized and is otherwise eligible for Medical Assistance, the period of ineligibility shall be apportioned equally between the spouses.
b. If one spouse dies or is no longer institutionalized, any months remaining in the period of ineligibility shall be assigned to the spouse who remains institutionalized.
13. If the individual or the individual's spouse has transferred assets into a trust or is a beneficiary of a trust, the trust document shall be submitted to the Colorado Department of Health Care Policy and Financing to determine the effect of the trust on Medical Assistance eligibility.
14. Notice a. The Colorado Department of Health Care Policy and Financing is an interested person according to 15-14-406, C.R.S. or a successor statute.
b. As an interested party, the department shall be given notice of a hearing in cases in which Medical Assistance planning or Medical Assistance eligibility is set forth in the petition as a factor for requesting court authority to transfer property.
15. Undue Hardship a. The period of ineligibility resulting from the imposition of the transfer or the trust provisions may be waived if denial of eligibility would create an undue hardship. Undue hardship can be established only if all of the following conditions are met:
b. Undue hardship shall not exist when the application of the trust or transfer rules merely causes the individual inconvenience or when such application might restrict his or her lifestyle but would not put him or her at risk of serious deprivation.
c. Notice of an undue hardship exception shall be given to the applicant or client, and a determination of whether an undue hardship waiver will be granted shall be given in a timely manner. An adverse determination may be appealed in accordance with the appeal process as set forth in RECIPIENT APPEALS PROTOCOLS/PROCESS in this volume.
d. The facility in which an institutionalized individual is residing may file an undue hardship waiver application on behalf of the individual with the individual's or his or her personal representative's consent.
16. No period of ineligibility shall be assessed in any of the following circumstances:
a. Convincing and objective evidence is provided that the individual intended to dispose of the resources either at fair market value or for other valuable consideration.
b. Convincing and objective evidence is presented proving that the resources were transferred exclusively for a purpose other than to qualify or remain eligible for Medical Assistance.
c. All of the resources transferred for less than fair market value have been returned to the individual.
d. For assets transferred before February 8, 2006, the assets were transferred more than 36 months prior to the date of application.
e. For assets transferred before February 8, 2006, the penalty period has expired based on the following formula: The fair market value of the transferred asset is divided by the average cost of Long Term Care institution care in the state at the time of application and the resulting number of months of ineligibility has ended prior to the date of application. 8.100.7.H. Treatment of Life Estates 1. Effective July 1, 1995, for an applicant/recipient of Medical Assistance, and/or his/her spouse, who established a life estate on his/her residence, a transfer of assets without fair consideration may occur. A transfer of assets without fair consideration occurs when a life estate was established on the residence by the applicant/recipient of Medical Assistance, and/or their spouse, on or after the look-back date. However, in no event shall these regulations apply to a life estate established before July 1, 1995.
The amount to be considered as a transfer of assets without fair consideration shall be computed by using equity value of the property and applying it to the life estate table contained in these rules as follows:
a. Determine the equity value of the property at the time the life estate was established. The equity value of the residential property shall be determined by obtaining the actual value and subtracting encumbrances. The actual value shall be obtained by using the actual value reported by a county assessor or from the most recent property assessment notice. If the actual value is not shown on the property assessment notice, the assessed value shall be divided by the appropriate percentage value for residential property as established by state law to obtain the actual value.
b. Multiply the equity value by the "Remainder" factor from the Life Estate Remainder Interest Table contained in these rules that corresponds to the person's age at the time the life estate was established. The result is the amount to be considered as a transfer of assets without fair consideration.
2. Effective April 1, 2006, the purchase of a life estate interest in an individual’s home is a transfer without fair consideration unless the purchaser resides in the home for a period of at least one year after the date of purchase.
Once the transfer of asset amount is computed, the penalty period for transfer of assets without fair consideration is determined by using the steps as explained in subsection "G" of this section. LIFE ESTATE REMAINDER INTEREST TABLE AGE REMAINDER AGE REMAINDER 0 .02812 55 .19954 1 .01012 56 .20994 2 .00983 57 .22069 3 .00992 58 .23178 4 .01019 59 .24325 5 .01062 60 .25509 6 .01116 61 .26733 7 .01178 62 .27998 8 .01252 63 .29304 9 .01337 64 .30648 10 .01435 65 .32030 11 .01547 66 .33449 12 .01671 67 .34902 13 .01802 68 .36390 14 .01934 69 .37914 15 .02063 70 .39478 16 .02185 71 .41086 17 .02300 72 .42739 18 .02410 73 .44429 19 .02520 74 .46138 20 .02635 75 .47851 21 .02755 76 .49559 22 .02880 77 .51258 23 .03014 78 .52951 24 .03159 79 .54643 25 .03322 80 .56341 26 .03505 81 .58033 27 .03710 82 .59705 28 .03938 83 .61358 29 .04187 84 .63002 30 .04457 85 .64641 31 .04746 86 .66236 32 .05058 87 .67738 33 .05392 88 .69141 34 .05750 89 .70474 35 .06132 90 .71779 36 .06540 91 .73045 37 .06974 92 .74229 38 .07433 93 .75308 39 .07917 94 .76272 40 .08429 95 .77113 41 .08970 96 .77819 42 .09543 97 .78450 43 .10145 98 .79000 44 .10779 99 .79514 45 .11442 100 .80025 46 .12137 101 .80468 47 .12863 102 .80946 48 .13626 103 .81563 49 .14422 104 .82144 50 .15257 105 .83038 51 .16126 106 .84512 52 .17031 107 .86591 53 .17972 108 .89932 54 .18946 109 .95455 8.100.7.I. Annuities 1. An annuity is a contract between an individual and a commercial company in which the individual invests funds and in return is guaranteed fixed substantially equal installments for life or a specified number of years.
2. Treatment of annuities purchased prior to July 1, 1995:
a. An annuity purchased prior to July 1, 1995 is not an available resource if it is annuitized and regular returns are being received by the annuitant. The funds received are income in the month received.
b. If the annuity purchased by the applicant/ client or his/her spouse has not been annuitized it shall be considered an available resource regardless of the irrevocable status.
3. Treatment of annuities purchased on or after July 1, 1995.
a. The purchase of an annuity shall be considered as a transfer of assets without fair consideration unless the following criteria are met:
4. Treatment of annuities purchased on or after April 1, 1998.
a. The eligibility site shall determine the MMMNA of the community spouse, if applicable. If the monthly payment amount provided by the annuity to the community spouse exceeds the MMMNA, the amount of the annuity which causes the monthly annuity payment to exceed the MMMNA shall be considered a transfer without fair consideration in determining the institutionalized spouse’s eligibility. This subsection applies only to the extent that the transferred amount causes the CSRA to exceed the maximum.
b. The eligibility site shall determine if the applicant/client is receiving substantially equal installments from the annuity for the period of the annuity. If the annuity is not paid in substantially equal installments, the original purchase price of the annuity shall be considered as a transfer without fair consideration.
c. For annuities purchased before February 8, 2006, if an annuity was purchased more than 36 months prior to the date of application, the penalty period for a transfer without fair consideration has expired. Any income received from the annuity shall be considered as income in the month received.
5. Provisions for annuities purchased on or after February 8, 2006. These provisions are in addition to those listed in 8.100.7.I.4.
a. An applicant for HCBS, PACE or institutional services shall disclose a description of any interest the individual or his or her community spouse has in an annuity or similar financial instrument, regardless of whether the annuity or financial instrument is irrevocable or is treated as an asset.
b. By providing HCBS, PACE or institutional services, the Department shall be a remainder beneficiary of the annuity or similar financial instrument.
c. The eligibility site shall notify the issuer of the annuity that the Department is a preferred remainder beneficiary in the annuity for Medical Assistance provided to the individual. This notice shall include a statement requiring the issuer to notify the eligibility site when there is a change in the amount of income or principal that is being withdrawn from the annuity.
d. The purchase of an annuity shall be treated as a transfer without fair consideration unless:
1. To determine if a transfer of assets without fair consideration has occurred in the purchase of an annuity, the eligibility technician must review the annuity and determine the length of time of the return the annuity exceeds the reasonable life expectancy of the annuitant. The amount to be considered as a transfer of assets without fair consideration for this type of annuity shall be computed by using the Life Expectancy Tables contained in these regulations. This procedure includes:
a. Determine the date on which the annuity was purchased.
b. Determine the amount of money used to purchase the annuity and the time period of return to the annuitant.
c. Determine the age of the annuitant at the time the annuity was purchased.
d. Determine the life expectancy of the annuitant at the time the annuity was purchased from the table contained in this section of these regulations. The appropriate table for male or female must be used.
e. If the return from the annuity exceeds the life expectancy of the annuitant, a transfer of assets without fair consideration exists for the portion of the annuity return that exceeds the life expectancy of the annuitant.
f. If the return of the annuity over its lifetime is less than the original purchase price, the difference shall be considered a transfer without fair consideration.
g. For annuities purchased before February 8, 2006, if the annuity was purchased more than 36 months prior to the date of application, the transfer period has expired and any income shall be considered as income in the month received.
h. If the return is equal to or more than the original purchase price, the annuity is not a transfer without fair consideration and the money received by the annuitant from the annuity is considered as income in the month received.
2. If an irrevocable annuity is purchased by an applicant/client of Medical Assistance, or their his/her spouse, and the return or benefit from the annuity is transferred to a third party, a transfer of assets without fair consideration exists for the total amount of the annuity.
3. If a revocable annuity is purchased by an applicant/client of Medical Assistance, or his/her spouse, the total amount invested in the annuity is considered as a countable resource.
4. Once it has been determined that a transfer of assets without fair consideration exists, the penalty period shall be calculated by using the steps in accordance with the rules at 8.100.7.F.3. LIFE EXPECTANCY TABLE – MALES FOR ANNUITIES PURCHASED BEFORE FEBRUARY 8, 2006 Age Life Expectancy Age Life Expectancy 0 71.80 30 44.06 1 71.53 31 43.15 2 70.58 32 42.24 3 69.62 33 41.33 4 68.65 34 40.23 5 67.67 35 39.52 6 66.69 36 38.62 7 65.71 37 37.73 8 64.73 38 36.83 9 63.74 39 35.94 10 62.75 40 35.05 11 61.76 41 34.15 12 60.78 42 33.26 13 59.79 43 32.37 14 58.82 44 31.49 15 57.85 45 30.61 16 56.91 46 29.74 17 55.97 47 28.88 18 55.05 48 28.02 19 54.13 49 27.17 20 53.21 50 26.32 21 52.29 51 25.48 22 51.38 52 24.65 23 50.46 53 23.82 24 45.55 54 23.01 25 48.63 55 22.21 26 47.73 56 21.43 27 46.80 57 20.66 28 45.88 58 19.90 29 44.97 59 19.15 LIFE EXPECTANCY TABLE – MALES FOR ANNUITIES PURCHASED ON OR AFTER FEBRUARY 8, Age Life Expectancy Age Life Expectancy 0 74.14 30 45.90 1 73.70 31 44.96 2 72.74 32 44.03 3 71.77 33 43.09 4 70.79 34 42.16 5 69.81 35 41.23 6 68.82 36 40.30 7 67.83 37 39.38 8 66.84 38 38.46 9 65.85 39 37.55 10 64.86 40 36.64 11 63.87 41 35.73 12 62.88 42 34.83 13 61.89 43 33.94 14 60.91 44 33.05 15 59.93 45 32.16 16 58.97 46 31.29 17 58.02 47 30.42 18 57.07 48 29.56 19 56.14 49 28.70 20 55.20 50 27.85 21 54.27 51 27.00 22 53.35 52 26.16 23 52.42 53 25.32 24 51.50 54 24.50 25 50.57 55 23.68 26 49.64 56 22.86 27 48.71 57 22.06 28 47.77 58 21.27 29 46.84 59 20.49 LIFE EXPECTANCY TABLE – FEMALES FOR ANNUITIES PURCHASED BEFORE FEBRUARY 8, Age Life Expectancy Age Life Expectancy 0 78.79 30 50.15 1 78.42 31 49.19 2 77.48 32 48.23 3 76.51 33 47.27 4 75.54 34 46.31 5 74.56 35 45.35 6 73.57 36 44.40 7 72.59 37 43.45 8 71.60 38 42.50 9 70.61 39 41.55 10 69.62 40 40.61 11 68.63 41 39.66 12 67.64 42 38.72 13 66.65 43 37.78 14 65.67 44 36.85 15 64.68 45 35.92 16 63.71 46 35.00 17 62.74 47 34.08 18 61.77 48 33.17 19 60.80 49 32.27 20 59.83 50 31.37 21 58.86 51 30.48 22 57.89 52 29.60 23 56.92 53 28.72 24 55.95 54 27.86 25 54.98 55 27.00 26 54.02 56 26.15 27 53.05 57 25.31 28 52.08 58 24.48 29 51.12 59 23.67 LIFE EXPECTANCY TABLE – FEMALES FOR ANNUITIES PURCHASED ON OR AFTER FEBRUARY 8, 2006 Age Life Expectancy Age Life Expectancy 0 79.45 30 50.53 1 78.94 31 49.56 2 77.97 32 48.60 3 77.00 33 47.63 4 76.01 34 46.67 5 75.03 35 45.71 6 74.04 36 44.76 7 73.05 37 43.80 8 72.06 38 42.86 9 71.07 39 41.91 10 70.08 40 40.97 11 69.09 41 40.03 12 68.09 42 39.09 13 67.10 43 38.16 14 66.11 44 37.23 15 65.13 45 36.31 16 64.15 46 35.39 17 63.17 47 34.47 18 62.20 48 33.56 19 61.22 49 32.65 20 60.25 50 31.75 21 59.28 51 30.85 22 58.30 52 29.95 23 57.33 53 29.07 24 56.36 54 28.18 25 55.39 55 27.31 26 54.41 56 26.44 27 53.44 57 25.58 28 52.47 5 24.73 29 51.50 59 23.89 8.100.7.K. Spousal Protection - Treatment of Income and Resources for Institutionalized Spouses 1. The spousal protection regulations apply to married couples where one spouse is institutionalized or likely to be institutionalized for at least 30 consecutive days and the other spouse remains in the community.
2. For purposes of spousal protection, an institutionalized spouse is an individual who:
a. Begins a stay in a medical institution or Long Term Care institution on or after September 30, 1989, or b. Is first enrolled as a Medical Assistance client in the Program of All Inclusive Care for the Elderly (PACE) on or after October 10, 1997, or c. Receives Home and Community Based Services on or after July 1, 1999.
3. A person is considered likely to remain in a medical institution, Long Term Care institution, enrolled in the PACE program, or receiving HCBS when, at the beginning of the institutionalization there is a reasonable expectation, based on medical evidence, that he/she will remain institutionalized for at least 30 consecutive days.
4. A community spouse is defined as a spouse who:
a. Is not in a medical institution or Long Term Care institution, b. Is not enrolled as a Medical Assistance client in the Program of All Inclusive Care for the Elderly (PACE), c. Is not receiving Home and Community Based Services (HCBS).
d. Is not in receipt of Medical Assistance other than coverage under a Medicare cost-sharing program such as QMB, SLMB, QI-1, or QI-2.
8.100.7.L. Assessment and Documentation of The Couple's Resources An assessment of the total value of the couple’s resources shall be completed at the time of initial Medical Assistance application or when requested by either spouse of a married couple. All non-exempt resources owned by a married couple are counted, whether owned jointly or individually. There are no exceptions for legal separation, pre-nuptial, or post-nuptial agreements. Once the applicant is approved, the Community Spouses’ resources are not reviewed again unless the Community Spouse applies for Medical Assistance.
8.100.7.M. Calculation of the Community Spouse Resource Allowance 1. A Community Spouse Resource Allowance (CSRA) shall be allocated based on the total resources owned by the couple as of the time of Medical Assistance application. The CSRA is established at intake only, and; once approved the community spouse’s resources are not considered again until the community spouse applies for Medical Assistance. This is true even if the community spouse becomes institutionalized but does not apply for Medical Assistance. In calculating the amount of the CSRA, resources shall not be attributed to the community spouse based upon state laws relating to community property or the division of marital property. For persons whose Medical Assistance application is for an individual who meets the definition of an institutionalized spouse, the CSRA is the largest of the following amounts:
a. The total resources of the couple but no more than the current maximum allowance which, changes each year beginning January 1st.; or b. The increased CSRA calculated pursuant to section 8.100.7.S; or c. The amount a court has ordered the institutionalized spouse to transfer to the community spouse for monthly support of the community spouse or a dependent family member.
2. The resources allotted to the community spouse as the CSRA shall be transferred into the name of the community spouse and shall not be considered available to the institutionalized spouse. After the transfer of the CSRA to the community spouse, the income from these resources shall be attributed to the community spouse.
3. The transfer of the CSRA shall be completed as soon as possible, but no later than the next redetermination when the community spouse becomes institutionalizes; whichever is earlier. If the transfer is not completed within this time period, the resources shall be attributed to the institutionalized spouse and shall affect his/her Medical Assistance eligibility. Verification of the transfer of assets to the community spouse shall be provided to the eligibility site. The institutionalized spouse may transfer the resources allotted to the community spouse as the CSRA to another person for the sole benefit of the community spouse.
4. If the community spouse is in control of resources attributed to the institutionalized spouse, but fails to make such resources available for his/her cost of care, this fact shall not make the institutionalized spouse ineligible for Medical Assistance, where:
a. The institutionalized spouse has assigned The Department any rights to support from the community spouse; or b. The institutionalized spouse lacks the ability to execute an assignment due to physical or mental impairment but The Department has the right to bring a support proceeding against the community spouse without such assignment; or c. The eligibility site determines that the denial of eligibility would work an undue hardship upon the institutionalized spouse. For the purposes of this subparagraph, undue hardship means that an institutionalized spouse, who meets all the Medical Assistance eligibility criteria except for resource eligibility, has no alternative living arrangement other than the medical institution or Long Term Care institution.
8.100.7.N. Treatment of the Home and Other Exempt Resources The CSRA shall not include the value of exempt resources including the home. It is not necessary for the home to be transferred to the community spouse. The rules regarding countable and exempt resources can be found in the section 8.100.5. However, for Spousal Protection there is no limit to the value of household goods and personal effects and one automobile. 8.100.7.O. Determination of the Institutionalized Spouse’s Income and Resource Eligibility 1. The institutionalized spouse is resource eligible for Medical Assistance when the total resources owned by the couple are at or below the amount of the Community Spouse Resource Allowance plus the Medical Assistance resource allowance for an individual of $2,000.
2. The eligibility site shall determine whether the institutionalized spouse is income eligible for Medical Assistance. The institutionalized spouse shall be income eligible if his/her gross income is at or below the Medical Assistance income limit for recipients of long-term care. If an income trust is used the trust must be established before the MIA is calculated. 8.100.7.P. Attribution of Income During any month in which a spouse is institutionalized, the income of the community spouse shall not be deemed available to the institutionalized spouse except as follows:
1. If payment of income from resources is made solely in the name of either the institutionalized spouse or the community spouse, the income shall be considered available only to the named spouse.
2. If payment of income from resources is made in the names of both the institutionalized spouse and the community spouse, one-half of the income shall be considered available to each spouse.
3. If payment of income is made in the names of the institutionalized spouse or the community spouse, or both, and to another person or persons, the income shall be considered available to each spouse in proportion to the spouse’s interest.
4. The above regulations of attribution of income are superseded if the institutionalized spouse can establish by a preponderance of the evidence that the ownership interests in the income are other than that provided in the regulations.
8.100.7.Q. Calculating the Community Spouse’s Monthly Income Needs 1. The community spouse's total minimum monthly needs shall be determined as follows:
a. The current minimum monthly maintenance needs allowance (MMMNA), which is equal to 150% of the federal poverty level for a family of two and is adjusted in July of each year;
b. An excess shelter allowance, in cases where the community spouse's expenses for shelter exceed 30% of the MMMNA. The excess shelter allowance is computed by adding (a) and (b) together:
2. An additional amount may be approved for the following expenses:
a. Medical expenses of the community spouse or dependent family member for necessary medical or remedial care. Each medical or remedial care expense claimed for deduction must be documented in a manner that describes the service, the date of the service, the amount of the cost incurred, and the name of the service provider. An expense may be deducted only if it is:
b. The cost of Medicare, Long Term Care insurance, and health insurance premiums. A health insurance premium may be allowed in the month the premium is paid or may be prorated and allowed for the months the premium covers. This allowance does not include payments made for coverage which is:
3. If either spouse establishes that the community spouse needs income above the level provided by the minimum monthly maintenance needs allowance due to exceptional circumstances, which result in significant financial duress, such as loss of home and possessions due to fire, flood, or tornado, an additional amount may be substituted for the MMMNA if established through a fair hearing.
4. The total that results from adding the current MMMNA and the excess shelter allowance shall not exceed the current maximum MMMNA which is $2,175.00 for the year 2001 and is adjusted by the Health Care Financing Administration in January of each year. 8.100.7.R. Calculating the Amount of Income to be Contributed by the Institutionalized Spouse for the Community Spouse's Monthly Needs 1. The Monthly Income Allowance (MIA) is the amount of money necessary to raise the community spouse's income to the level of his/her monthly needs, and shall be obtained from the monthly income of the institutionalized spouse. For individuals who become institutionalized on or after February 8, 2006, all income of the institutionalized spouse that could be made available to the community spouse must be considered to have been made available to the community spouse before an MIA is allocated to the community spouse.
2. The MIA shall be the amount by which the community spouse's minimum monthly needs, which is the MMMNA, exceed his/her income from sources other than the institutionalized spouse. The community spouse’s income shall be calculated by using the gross income less mandatory deduct ions for FICA and Medicare tax.
3. If a court has entered an order against the institutionalized spouse for monthly support of the community spouse, the MIA shall not be less than the monthly amount ordered by the court.
4. The eligibility site shall make adjustments to the MMMNA and/or the MIA on a monthly basis for any continuing change in circumstances that exceeds $50 a month. Continuing changes of less than $50 in a month, and any infrequent or irregular changes, shall be considered at redetermination. 8.100.7.S. Increasing the Community Spouse Resource Allowance 1. The CSRA shall be increased above the maximum amount if additional resources are needed to raise the community spouse's monthly income to the level of the Minimum Monthly Maintenance Needs Allowance (MMMNA). In making this determination the items listed below are calculated in the following order:
a. The community spouse's MMMNA;
b. The community spouse’s own income; and c. The Monthly Income Allowance (MIA) contribution that the community spouse is eligible to receive from the institutionalized spouse.
d. If the community spouse’s own income, and the Monthly Income Allowance contribution from the institutionalized spouse’s income is less than the Minimum Monthly Maintenance Needs Allowance, additional available resources shall be shifted to the community spouse to bring his/her income up to the level of the MMMNA. The additional resources necessary to raise the community spouse’s monthly income to the level of the MMMNA shall be based upon the cost of a single-premium lifetime annuity with monthly payments equal to the difference between the MMMNA and the community spouse’s income. The following steps shall be followed to determine the amount of resources to be shifted:
e. The CSRA shall not be increased if the institutionalized spouse refuses to make the monthly income allowance (MIA) available to the community spouse. 8.100.7.T. Deductions from Monthly Income of the Institutionalized Spouse 1. During each month after the institutionalized spouse becomes Medical Assistance eligible, deductions shall be made from the institutionalized spouse's monthly income in the following order.
a. A personal needs allowance or the client maintenance allowance as allowed by program eligibility.
b. A Monthly Income Allowance (MIA) for the community spouse, but only to the extent that income of the institutionalized spouse is actually made available to, or for the benefit of, the community spouse;
c. A family allowance for each dependent family member who lives with the community spouse.
d. Allowable deductions identified in section 8.100.7.V.
e. If the institutionalized spouse fails to make his/her income available to the community spouse or eligible dependent family members in accordance with these regulations, that income shall be applied to the cost of care for the institutionalized spouse.
f. No other deductions shall be allowed.
8.100.7.U. Right to Appeal 1. Both spouses shall be informed of the following:
a. The amount and method by which the eligibility site calculated the community spouse resource allowance (CSRA), community spouse monthly income allowance (MIA), and any family allowance;
b. The spouses' right to a fair hearing concerning these calculations;
c. The eligibility site conclusions with respect to the spouses' ownership and availability of income and resources, and the spouses' right to a fair hearing concerning these conclusions.
2. If either spouse establishes that the community spouse needs income above the level provided by the minimum monthly maintenance needs allowance due to exceptional circumstances, which result in significant financial duress, such as loss of home and possessions due to fire, flood, or tornado, an additional amount may be substituted for the MMMNA if established through a fair hearing.
3. Appeals from decisions made by the eligibility site shall be governed by the provisions under Recipient Appeals Protocols/Process at 8.058.
8.100.7.V. Long Term Care Institution Recipient Income 1. Determination of Income and Communication between the Long term care institution and the Eligibility Site Using the AP-5615 Form for Patient Payment a. Sections I, II and IV of the AP-5615 form is to be completed by the Long Term Care institution for all admissions, readmissions, transfers to and from another payer source, including private pay and Medicare, discharges, deaths, changes in income and/or patient payment, and medical leaves of absence and non-medical/programmatic leave in excess of 42 days combined per calendar year.
b. The initial determination of resident income for patient payment shall be made by the Eligibility Site. The Eligibility Site shall notify the Long Term Care institution of current resident income.
c. On receipt of AP-5615 form, the Eligibility Site will, within five working days:
d. For change in patient payment with respect to changes in resident income:
e. For change in patient payment with respect to the post-eligibility treatment of income, the Eligibility Site shall:
f. For resident leave of absence:
g. For change in payer status:
h. For discharge or death of resident:
i. Failure to provide a correct and timely AP-5615 to the Long Term Care institution may result in the refusal of the Department to reimburse such Long Term Care institution care. The AP- 5615 form is required in order for a Prior Authorization Request (PAR) to be issued for Long Term Care institution claim reimbursement.
j. General Instructions:
k. The Department may deduct excess payments from the county administrative reimbursement as stated in the Colorado Department of Human Services Finance Staff Manual, Volume 5 if the Eligibility Site fails to:
2. Collection of Patient Payment a. It shall be the responsibility of the Long Term Care institution to collect from the client, or from the client's family, conservator or administrator, the patient payment, which is to be applied to the cost of client care. The Department is not responsible for any deficiency in patient payment accounts, due to failure of the Long Term Care institution to collect such income.
b. If, however, the Long Term Care institution is unable to collect such funds, through refusal of the resident or the resident's family, conservator, administrator or responsible party to release such income, the Long Term Care institution shall immediately notify the eligibility site.
c. When notified by the Long Term Care institution of the refusal of the client or the client's family, conservator administrator or responsible party to pay the patient payment due, the Eligibility Site shall immediately contact the refusing party. If, after such contact, the party still refuses to release such income, the action shall be deemed a failure to cooperate, and the Eligibility Site shall proceed to discontinue Medicaid benefits for the resident.
3. Calculation of Patient Payment a. Specific instructions for computing the patient payment amount are contained in this volume under The "Status of Long term care institution Care" Form, AP-5615 b. Once an applicant for Nursing Facility Medical Assistance has been determined eligible for Medical Assistance, the Eligibility Site shall determine the patient payment due to the Nursing Facility which is to be applied to the Medicaid reimbursement for the cost of care. That patient payment is calculated by:
b. The amount to be reserved for personal needs is $50 per month with the following exceptions:
c. The reserve specified in section 8.100.7.V.3.b.ii. of this volume shall apply to Long Term Care institution residents who are engaged in income-producing activities on a regular basis. Types of income-producing activities include:
d. In determining the personal needs reserve amount for Long Term Care institution residents engaged in income-producing activities:
e. Other Deductions Reserved from Recipient's Income:
f. The necessity for the deduction from a recipient's income specified in section 8.100.7.V.3 shall be fully explained in the case record. Such additional reserve amount must be entered on the eligibility reporting form.
g. As of July 1, 1988, an SSI cash recipient may continue to receive SSI benefits when he/she is expected to be institutionalized for three months or less. This provision is intended to allow temporarily institutionalized recipients to pay the necessary expenses to maintain the principal place of residence.
h. When a nursing facility resident’s SSI is reduced due to institutionalization, the difference between the reduced SSI payment and the personal needs allowance amount shall be provided through the Adult Financial program so that the resident receives the full personal needs allowance.
4. Reduction of the Patient Payment a. Patient payment may be reduced only under the following conditions:
b. Patient payment may not be waived in the following instances:
c. The Eligibility Site shall verify and approve partial month patient payments due to transfers, discharges or death when calculated by the nursing facility based upon the nursing facility’s per diem rate.
d. The amount of SSI benefits received by a person who is institutionalized is not considered when calculating patient payment.
5. Responsibilities of the Eligibility Site Regarding the Personal Needs Fund a. It shall be the responsibility of the Eligibility Site to explain to the resident the various options for handling the personal needs monies, as well as the resident's rights to such funds. The resident has the option to allow the Long Term Care institution to hold such funds in trust.
b. It shall be the responsibility of the Eligibility Site to assure that the Long Term Care institution properly transfers or disposes of the resident's personal needs funds within 30 days of discharge from the Long Term Care institution, or transfer to another Long Term Care institution.
c. The Eligibility Site shall notify the State Department if they become aware that a Long Term Care institution has retained personal needs funds more than 30 days after the death of a resident.
6. For rules regarding post eligibility treatment of income, see the section in this volume titled “Post Eligibility Treatment of Income”
8.130 PROVIDER PARTICIPATION
8.130.1 DEFINITION [Eff. 12/30/2008]
Requesting Agency means the United States Department of Health and Human Services, the Department or its designees, Department of Human Services, or the Medicaid Fraud Control Unit, acting through their representatives who have written or de facto designation as such.
8.130.2 MAINTENANCE OF RECORDS [Eff. 12/30/2008]
8.130.2.A. Each provider shall:
1. Maintain legible records necessary to disclose the nature and extent of goods and services provided to clients including but not limited to:
2. Maintain legible records, which fully substantiate or verify claims submitted for payment.
8.130.2.F. Each entry in a medical record must be signed and dated by the individual providing the medical service. Stamped signatures are not acceptable. 8.130.2.G. Providers utilizing electronic record-keeping may apply computerized signatures and dates to the medical record if their record-keeping systems guarantee the following security measures:
1. Restrict application of an electronic signature to the specific individual identified by the signature. System security must prevent one person from signing another person's name.
2. Prevent alterations to authenticated (signed and dated) reports. If the provider chooses to supplement a previous entry, the system must only allow a new entry that explains the supplement. The provider must not be allowed to change the initial entry.
3. Printed or displayed electronic records must note that signatures and dates have been applied electronically.
8.130.2.H. At the discretion of the requesting agency, record verification may include but not be limited to interviews with providers, employees of providers, billing services that bill on behalf of providers, and any member of a corporate structure that includes the provider as a member. 8.130.2.I. Nothing in Section 8.130 shall negate or modify any specific record keeping requirements contained in 10 C.C.R. 2505-10, Sections 8.000 et seq. or in individual provider agreements.
8.130.3 ADVANCE DIRECTIVES [Eff. 12/30/2008]
8.130.3.A. Advanced Directive means a written instruction, such as a Living Will or Durable Power of Attorney for health care, recognized under state law, whether statutory or as recognized by the courts of the state, that relates to the provision of medical care when the individual is incapacitated.
8.130.3.B. Providers shall provide adult Medical Assistance program clients with written information about the individual's rights under state law to accept or refuse medical treatment, the right to formulate advance directives and the providers' policies regarding the implementation of such rights as follows:
1. Hospitals, at the time of the individual's admission as an inpatient.
2. Nursing facilities, at the time of the individual's admission as a resident.
3. Providers of home health care or personal care services, in advance of the individual coming under the care of the provider.
4. Hospice programs, at the time of initial receipt of hospice care by the individual from the program.
5. Health maintenance organizations, at the time of enrollment of the individual with the organization.
8.130.3.C. The provider shall maintain written policies and procedures with respect to all adult individuals receiving medical or personal care by or through the provider organization which shall include:
1. Documentation in the individual's medical records indicating whether the individual has executed an advance directive.
2. Documentation that the individual will not be discriminated against, nor will the provision of care be conditioned on whether he/she has executed an advance directive.
3. Documentation ensuring compliance with requirements of state law respecting advanced directives.
4. Documentation in the individual's medical record substantiating the provider's reason(s) for non-compliance with an advance directive based on conscience or professional ethics. 8.130.3.D. Providers shall provide education for staff and the patient/client community on issues concerning advance directives.
8.130.35 SCREENING FOR EXCLUDED EMPLOYEES AND CONTRACTORS
A. As a condition of enrollment in the medical assistance program, each provider shall comply with the following requirements for screening for employees and contractors who have been excluded from participation in Medicaid and Medicare by the US Department of Health & Human Services Office of Inspector General:
1. Each provider shall utilize the US Department of Health & Human Services Office of Inspector General’s List of Excluded Individuals/Entities (www.oig.hhs.gov) to determine if a prospective employee or newly signed contractor has been excluded from participation in Medicaid.
2. Each provider shall screen its employees and contractors against the List of Excluded Individuals/Entities at least monthly to capture any exclusions or reinstatements that have occurred since the last search of the database.
3. If a provider determines that an employee or contractor of the provider has been excluded, then the provider shall report this to the Department within five (5) business days of the date of discovery.
B. Except as otherwise provided in federal law, if the Medical Assistance program pays for any goods or services furnished, ordered, or prescribed by an excluded individual or entity that is employed by or has contracted with a provider, such payment shall constitute an overpayment, as defined at 8.076.1.8. and shall be subject to the overpayment recovery provisions of 8.076.3. Such provider may also be subject to sanctions by the Department including the termination of the provider agreement, as described at 8.076.5., if the provider knew or should have known of the exclusion. The provider may also be subject to civil and monetary penalties imposed by the Department of Health and Human Services.
1. To the extent that such amount can be traced, the amount of the overpayment shall include any funds expended by the Medical Assistance program to pay the excluded individual’s or contractor’s salary, expenses, or fringe benefits.
C. Subject to federal law and the Department’s discretion, failure of provider to comply with the screening requirements listed at 8.130.35.A. may constitute good cause sufficient to justify termination of the provider agreement, as described at 8.076.5.
8.130.4 TERMINATION
Existing contracts shall be terminated if the provider fails to disclose requested information or if any person who has an ownership or control interest in the entity, or who is an agent or managing employee of the entity, has been convicted of a criminal offense related to that person's involvement in any program established under Medicare, Medicare, or the Title XX services program. Person with an Ownership or Control Interest means a person, corporation, partnership, joint venture or other legal entity that:
A. Has an ownership interest equal to five percent or more in a Disclosing Entity, or B. Has an indirect ownership interest equal to five percent or more in a Disclosing Entity, or C. Has a combination of direct and indirect ownership interests equal to five percent or more in a Disclosing Entity, or D. Owns an interest of five percent or more in any mortgage, deed of trust, note, or other obligation secured by the Disclosing Entity if that interest equals at least five percent of the value of the property or assets of the Disclosing Entity, or E. Is an officer or director of a Disclosing Entity that is organized as a corporation, or F. Is a partner in a Disclosing Entity that is organized as a partnership. Convicted means that a federal, state, or local court, regardless of whether an appeal from that judgment is pending, has entered a judgment of conviction.
8.170 STATE IDENTIFICATION NUMBER
.10 As medical assistance is administered on an individual recipient basis, rather than on a household basis, the individual recipient is uniquely identified. A state assigned number is used for this purpose. This state identification number consists of an alpha (letter) prefix, followed by a six-digit number. When an individual is approved for medical assistance, the state identification number is assigned. This number is transmitted to the county department via the automated system. .20 The State Identification Number is the only numeric designation medical assistance providers will have, other than the name, to identify individuals. This number is required to be entered on all billing transactions.
In order to carry out this responsibility for facilitating provision of medical benefits to recipients, to properly respond to inquiries from providers, to secure benefits of medical resources other than Medicaid (see 8.061 et seq.), and for other administrative purposes, county departments are to maintain cross reference files of household and medical identification numbers.
8.180 MEDICAL IDENTIFICATION CARDS AND DURATION OF ELIGIBILITY
8.181 IDENTIFICATION
.10 The state department will issue identification cards directly to clients who are eligible for benefits under a medical assistance program.
.20 The providers of benefits in the Department's medical assistance programs are instructed to use the identifying information to access an automated eligibility database to obtain the client's current or previous eligibility for medical assistance for a given date of service.
8.182 MEDICAL IDENTIFICATION CARD
Each eligible client shall have a medical identification card issued from the state department's office to obtain medical services.
8.183 INSTRUCTIONS FOR HANDLING UNDELIVERED MEDICAL IDENTIFICATION CARDS
The Post Office returns all undelivered Medical Identification Cards to the county departments when recipients are deceased, no longer at that address, etc. The following steps will be taken to assure delivery of cards to the recipient.
A. If the address shown in the envelope window is incorrect or no longer valid, the county departments are not to make the address change for remailing on the returned envelope. Counties are to open the envelope, paste a white sticker over the incorrect address, type in the correct address, use a separate envelope with the corrected address, insert the Medical Identification Card Mailer, and remail the card and its carrier to the client's new (correct) address. (This includes out-of-state moves if the client remains eligible.) B. Counties shall immediately correct the address on the automated system.
C. If the recipient is deceased, the county shall destroy the identification card and make appropriate change in the eligibility system.
8.190 ACUTE MEDICAL BENEFITS DETERMINATION
8.190.1 A client or provider may request a coverage determination for new acute medical benefits or services by submitting a written request to the Department. 8.190.1.A. Written requests shall include documentation on all the following criteria regarding the benefit or service:
1. Prescribed by a doctor of medicine or osteopathy, or an optometrist, dentist or podiatrist acting within the scope of their respective licenses;
2. A reasonable, appropriate and effective method for meeting the medical need;
3. The expected use is in accordance with current medical standards or practices;
4. Proven cost effective method of treatment;
5. Does not result in an unsafe environment or situation;
6. Not experimental, investigational and is accepted by the medical community as standard practice;
7. Primary purpose is not to enhance personal comfort or convenience; and 8. Considered to be medically necessary for the diagnosis.
8.190.2 The requestor shall be notified in writing of the Department's decision regarding coverage. ___________________________________________________ Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 3/4/07, Statements of Basis and Purpose, and rule history are located in the first section, 10 CCR 2505-10. Prior versions can be accessed from the History link that appears above the text in 10 CCR 2505-10. To view versions effective on or after 3/4/07, select the desired section of the rule, for example 10 CCR 2505-10 8.100, or 10 CCR 2505-10 8.500.
History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10 ]