J-1100, Texas Administrative Code Rules

Revision 10-3; Effective September 1, 2010

The following rules are taken from Subchapter C, Financial Requirements, Division 5, Spousal Impoverishment.

§358.411. Purpose and Application.

(a) This division establishes the criteria under which income and resources are protected for a community spouse, in accordance with 42 U.S.C. §1396r-5.

(b) This division applies to an institutionalized spouse whose continuous period in an institutional setting begins on or after September 30, 1989. For this division only, a reference to an institutional setting includes the receipt of services under the Program of All-Inclusive Care for the Elderly (PACE).

(c) This division applies to a person who is in an institutional setting and has a community spouse. It is not necessary for the community spouse to meet citizenship and residency requirements.

(d) This division does not apply to a couple with a void or annulled marriage.

(e) In the case of a divorce, the provisions of this division apply through the end of the calendar month of the court order granting the divorce.

§358.412. Definitions.

In this division, the following words and terms have the following meanings, unless the context clearly indicates otherwise.

(1) Community spouse—The spouse of an institutionalized spouse who is not living in a setting that provides medical care and services.

(2) Dependent family member—A minor or dependent child, dependent parent, or dependent sibling of an institutionalized spouse or a community spouse who resides with the community spouse. [Note: A dependent family member can be either spouse's minor or dependent children, dependent parents and dependent siblings (including half brothers, half sisters and siblings gained through adoption) who were living in an institutionalized client's home before the client's institutionalization, and who are unable to support themselves outside the client's home because of medical, social or other reasons.]

(3) Institutional setting—In this division only, a living arrangement in which a person applying for or receiving Medicaid:

(A) lives in a Medicaid-certified long-term care facility;

(B) receives services under a §1915(c) waiver program; or

(C) receives services under the Program of All-Inclusive Care for the Elderly (PACE).

(4) Institutionalized spouse—A person who:

(A) receives care in an institutional setting;

(B) has met or is likely to meet the criterion in subparagraph (A) of this paragraph for at least 30 consecutive days; and

(C) is married to a spouse who does not meet the criterion in subparagraph (A) of this paragraph.

(5) Spousal protected resource amount (SPRA)—That portion of a couple's combined countable resources reserved for the community spouse and deducted from the couple's combined countable resources in determining eligibility.

§358.413. Spousal Impoverishment Treatment of Income and Resources.

The Texas Health and Human Services Commission follows §1924 of the Social Security Act (42 U.S.C. §1396r-5), regarding the treatment of income and resources for certain institutionalized spouses in institutional settings.

§358.414. Assessment of Resources to Determine a Spousal Protected Resource Amount.

(a) Assessment. Upon request of either the institutionalized spouse or the community spouse, or either spouse's authorized representative, the Texas Health and Human Services Commission (HHSC) assesses the couple's resources to determine the spousal protected resource amount (SPRA). The request and assessment may be made any time from the beginning of the continuous period in an institutional setting to the date of application for Medicaid.

(b) Assessment request. If the request described in subsection (a) of this section is not part of an application for Medicaid, the couple must provide information on their resources and verification as required by HHSC. If the couple does not provide the verification within the time frame requested by HHSC, HHSC does not complete the assessment and takes no further action.

(c) Assessment date. HHSC assesses the couple's combined countable resources as of 12:01 a.m. on the first day of the month in which the first continuous period in an institutional setting began. When determining the first day of the month in an institutional setting for the SPRA, HHSC may count days the person spent in a hospital if the person admits directly from the hospital to an institutional setting. After the continuous period begins, hospital stays and therapeutic home visits are not considered as breaks in the 30-consecutive-day period.

§358.415. Calculation of the Spousal Protected Resource Amount.

(a) The Texas Health and Human Services Commission (HHSC) calculates the spousal protected resource amount (SPRA) as of the assessment date described in §358.414(c) of this division (relating to Assessment of Resources to Determine a Spousal Protected Resource Amount).

(b) When determining the SPRA, HHSC excludes the following resources regardless of value:

(1) one automobile; and

(2) a home, if:

(A) the community spouse or dependent family member continues to live in the home while the person is in the institutional setting;

(B) the community spouse lives in another state on out-of-state property, whether or not the institutionalized spouse has ownership interest; or

(C) the community spouse had been living in the out-of-state property as a home but is not residing there during the assessment and initial eligibility period and the community spouse signs a statement of intent to return to the home.

(c) The SPRA is the greater of:

(1) one-half of the couple's combined countable resources, not to exceed the maximum resource amount set by federal law; or

(2) the minimum resource amount set by federal law.

(d) HHSC calculates the SPRA as described in this section whether the SPRA is calculated at the time of application for Medicaid or before an application for Medicaid is filed. After HHSC determines the SPRA, the SPRA does not change unless:

(1) the SPRA was based on incomplete or inaccurate information, as described in §358.416(f)(1) of this division (relating to Initial Application and the Spousal Protected Resource Amount); or

(2) the SPRA is expanded as described in §358.420 of this division (relating to Expanding the Spousal Protected Resource Amount).

(e) The couple may not appeal the SPRA at the time of the assessment. The couple may appeal the SPRA after an application for Medicaid is filed.

§358.416. Initial Application and the Spousal Protected Resource Amount.

(a) Upon receiving an application for Medicaid, the Texas Health and Human Services Commission (HHSC) calculates the couple's combined countable resources, without regard to community or separate property laws or the spouses' respective ownership interests, as of 12:01 a.m. on the first day of the month in which eligibility is being determined. HHSC follows the resource exclusions for an automobile and a home, regardless of value, as described in §358.415 of this division (relating to Calculation of the Spousal Protected Resource Amount).

(b) If an assessment of resources to determine the spousal protected resource amount (SPRA) has not previously been completed, HHSC determines the SPRA at initial application, in accordance with §358.415 of this division.

(c) HHSC deducts the SPRA from the couple's combined countable resources calculated in subsection (a) of this section. HHSC follows §1924(a)(3) and §1924(c)(2) of the Social Security Act (42 U.S.C. §1396r-5(a)(3) and 42 U.S.C. §1396r-5(c)(2)) when determining resource eligibility of the institutionalized spouse at the initial eligibility determination.

(d) If the SPRA determined at assessment is either the federal minimum or maximum resource amount, and the federal minimum or maximum resource amount increases before completion of the initial application for Medicaid, HHSC uses the federal minimum and maximum resource amounts in effect at the time of completion of the initial application.

(e) If the institutionalized spouse is found ineligible for Medicaid at the initial application and reapplies, HHSC deducts the same SPRA for subsequent applications.

(f) If an institutionalized spouse, after having been certified, is subsequently denied and reapplies for Medicaid:

(1) if the institutionalized spouse should never have been certified and was denied because of unreported resources, HHSC calculates a new SPRA at reapplication, taking into account the previously unreported resources; and

(2) if the institutionalized spouse was denied for any other reason, HHSC does not deduct the SPRA and counts only the institutionalized spouse's resources at reapplication.

(g) After eligibility is established for the institutionalized spouse, HHSC follows §1924(c)(4) of the Social Security Act (42 U.S.C. §1396r-5(c)(4)) in the separate treatment of resources.

§358.417. Treatment of Resources of the Institutionalized Spouse after the Initial Eligibility Period.

After the initial eligibility period of the institutionalized spouse, the Texas Health and Human Services Commission does not apply the spousal protected resource amount and counts only the institutionalized spouse's resources for the purpose of eligibility redetermination, in accordance with Division 2 of this subchapter (relating to Resources).

§358.418. Refusal of a Community Spouse to Cooperate.

(a) If a community spouse refuses to cooperate in providing information to establish a spousal protected resource amount (SPRA) during an assessment as described in §358.414(b) of this division (relating to Assessment of Resources to Determine a Spousal Protected Resource Amount), the Texas Health and Human Services Commission (HHSC) does not complete the assessment and takes no further action.

(b) If an assessment is undertaken in conjunction with an eligibility determination at the initial application, and a community spouse refuses to furnish information, HHSC determines the living arrangement before the continuous period in an institutional setting began.

(1) If the couple was living in the same household, HHSC denies the application based on the couple's failure to furnish information. Living in the same household includes temporary separations.

(2) If the couple was not living in the same household, HHSC determines the purpose of separation, the length of separation, and resources or income commingled or managed jointly by one spouse or a third party.

(c) If the community spouse refuses to cooperate in providing information, and circumstances indicate possible abuse or neglect by the community spouse, HHSC considers the institutionalized spouse as an individual for purposes of determining eligibility and calculating the co-payment.

§358.419. Separation to Circumvent Medicaid Policy.

(a) The Texas Health and Human Services Commission (HHSC) evaluates the information provided by a couple to determine if a couple separated before the continuous period in an institutional setting began to avoid the pooling of resources under Medicaid spousal impoverishment provisions, if:

(1) the separation occurred after a change in the health of the institutionalized spouse;

(2) the community spouse potentially owns separate resources; or

(3) the ownership of commingled resources was changed recently.

(b) A couple has the right to rebut HHSC's determination that a separation occurred to circumvent Medicaid policy. To rebut HHSC's determination, either spouse or either spouse's authorized representative must provide a written statement or evidence to HHSC to substantiate the separation as directed on the written notification of HHSC's determination that a separation occurred to circumvent Medicaid policy.

(c) If HHSC determines that circumstances indicate there was no intent to circumvent Medicaid policy, HHSC treats the institutionalized spouse as an individual for purposes of determining Medicaid eligibility and calculating the co-payment.

§358.420. Expanding the Spousal Protected Resource Amount.

(a) This section applies to an institutionalized spouse whose continuous period in an institutional setting begins on or after September 1, 2004.

(b) An institutionalized spouse may request that HHSC expand the spousal protected resource amount (SPRA) to produce additional income for the community spouse. To determine whether to expand the SPRA, HHSC considers the countable amount of non-resource-produced and non-investment income of the community spouse and compares the countable amount of non-resource-produced and non-investment income to the minimum monthly maintenance needs allowance (MMMNA). The MMMNA is the minimum income level for a community spouse set by the Centers for Medicare and Medicaid Services.

(1) If the community spouse's countable non-resource-produced and non-investment income is less than the MMMNA, HHSC considers the available income (countable non-resource-produced income minus the personal needs allowance) of the institutionalized spouse and adds the institutional spouse's available income to the community spouse's countable non-resource-produced and non-investment income and compares the combined incomes to the MMMNA.

(2) If the total amount of the community spouse's own income plus the amount of available income diverted from the institutionalized spouse is equal to or greater than the MMMNA, then HHSC does not expand the SPRA.

(3) If the total amount of the community spouse's own income plus the amount of available income diverted from the institutionalized spouse is less than the MMMNA, then HHSC determines an expanded SPRA as described in subsections (c) - (e) of this section.

(c) If, after the diversion of the institutionalized spouse's available income, the community spouse's total income is less than the MMMNA, the couple can protect an amount of resources equal to the dollar amount that must be deposited in a one-year certificate of deposit (CD), at current interest rates, to produce interest income equal to the difference between the MMMNA in effect at the time of the request and other countable income not generated by either spouse's countable resources. The couple is not required to invest in the CD as a condition of eligibility.

(d) To determine the amount of the expanded SPRA, HHSC determines the current interest rate of a one-year CD as published in the local newspaper or provided by a local bank. HHSC then determines the amount of resources required to produce income, at the specified interest rate, that would increase the community spouse's income to the MMMNA.

(e) The amount of resources to be protected is determined by using the methodology described in paragraphs (1) - (4) of this subsection. This methodology is to be used to determine the maximum amount of resources to be protected regardless of the actual income the couple's resource may or may not be producing.

(1) Subtract from the amount of the MMMNA the community spouse's monthly income from all sources other than resources of the couple (including any income that must first be diverted by the institutionalized spouse as required by subsection (b) of this section). The result is the additional monthly income needed by the community spouse.

(2) Multiply by 12 the additional monthly income needed by the community spouse (from paragraph (1) of this subsection). The product equals the annual income needed by the community spouse.

(3) Divide the product from paragraph (2) of this subsection by the interest rate described in subsection (d) of this section. The result is the expanded SPRA, subject to paragraph (4) of this subsection.

(4) The expanded SPRA must not exceed the value of the couple's combined countable resources as of the first month of the continuous period in an institutional setting.

§358.421. Treatment of Income for Eligibility and Co-payment.

(a) To be eligible for Medicaid, an institutionalized spouse must have countable income that does not exceed the special income limit for an individual and meet all other eligibility criteria.

(b) In determining the income of an institutionalized spouse or community spouse for purposes of determining a co-payment, the Texas Health and Human Services Commission follows §1924(b)(2) and (d) of the Social Security Act (42 U.S.C. §1396r-5(b)(2) and (d)). See also Division 6 of this subchapter (relating to Budgeting for Eligibility and Co-payment).

§358.422. Notice and Fair Hearing.

The Texas Health and Human Services Commission follows §1924(e) of the Social Security Act (42 U.S.C. §1396r-5(e)) concerning notices and fair hearings for matters relating to spousal impoverishment.

§358.423. Transfer of Assets and Spousal Impoverishment.

See Division 4 of this subchapter (relating to Transfer of Assets) for requirements governing a transfer of assets under spousal impoverishment circumstances.

J-1200, Spousal Impoverishment Purpose

Revision 15-3; Effective September 1, 2015

Effective September 30, 1989, Public Law 100–360 provides for the protection of income for the community spouse and certain dependent family members when the other spouse is institutionalized. Use the spousal impoverishment policies to determine Medicaid eligibility for individuals who:

  • are likely to be in an institutional setting for a continuous period, or
  • are eligible for Home and Community-Based Services and likely to need such services for at least 30 consecutive days, and
  • have a spouse living in the community.

Spousal impoverishment requires a valid existing marriage. In Texas, there are three ways to terminate a marriage:

  • Void Marriages — A determination that the marriage could not have existed because of one of the following legal impediments: the parties married within a prohibited degree of consanguinity (for example, nephew or niece), or at least one party has a previous marriage that has not been resolved. Void marriages do not require a lawsuit, and the marriage may be declared void in a collateral action (for example, contest of will). A legal marriage between parties never existed.
  • Annulments — Also called voidable marriages. Grounds for annulment include, but are not limited to, marrying under the influence of drugs/alcohol, at least one party being incapacitated or the marriage being coerced. Annulments require court action, but under common law, an annulment is retroactive to the date of marriage.
  • Divorce — Requires court action, and the marriage is dissolved effective the date of the divorce decree.

Spousal impoverishment provisions do not apply in the case of void or annulled marriages. If there is a void marriage or a court annulment of the marriage, always treat the person as an individual. In the case of a divorce, spousal impoverishment provisions apply through the end of the calendar month in which the divorce is issued.

Spousal impoverishment provisions do not apply when determining Medicare Savings Programs (MSP) eligibility for either spouse. When determining resource eligibility for MSP, consider resources in the institutionalized spouse's name even if they are protected for the community spouse.

A resource assessment is part of the spousal impoverishment process. The purpose of the resource assessment is to determine a protected resource amount, which is the portion of the total resources that is reserved for the community spouse and deducted from the couple's combined resources in determining eligibility.

An institutionalized spouse is a spouse who is either (1) likely to reside in an institutional setting (for example, a medical institution and/or nursing facility) for a continuous period of institutionalization, or (2) eligible for Home and Community-Based Services and likely to need such services for at least 30 consecutive days. For spousal impoverishment policy, when determining the first continuous period of institutionalization, a medical care facility includes any of the following:

  • Hospital, including a U.S. Department of Veterans Affairs (VA) hospital
  • Nursing facility, whether private-pay or Medicaid
  • Intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID)
  • Institution for mental diseases (IMD)
  • Rehabilitation facility

A community spouse is a spouse who is not living in a medical institution or nursing facility. An incarcerated spouse is not considered a community spouse for spousal impoverishment purposes.

The community spouse could be living in any of the following settings and still be considered a community spouse:

  • Personal care setting
  • Adult foster care setting
  • Supervised living setting
  • Residential care facility setting

However, if the community spouse is living in a personal care facility, check the bill to see if the spouse is actually living in a medical facility. If the personal care facility is billing for room and board only, the spouse meets the definition of a community spouse. If the personal care facility is billing for the services of any medical professional (such as a registered nurse [RN], licensed vocational nurse [LVN], doctor, etc.), the spouse does not meet the definition of a community spouse and spousal impoverishment polices do not apply.

See Section J-1500, Change in Martial Status.

J-1300, Spousal Definitions

Revision 15-3; Effective September 1, 2015

Community spouse — A person who is not living in a setting that provides medical care/services and who is married to:

  • an institutionalized person, or
  • a person who has been determined eligible for a Home and Community-Based Services waiver program.

Note: The community spouse of an institutionalized person may receive services under a Home and Community-Based Services waiver program, which will not affect the spousal diversion.

Dependent family member — Either spouses' minor or dependent children, dependent parents or dependent siblings (including half brothers, half sisters and siblings gained through adoption) who were:

  • living in an institutionalized recipient's home before the recipient's institutionalization; or
  • living with a recipient of a Home and Community-Based Services waiver program; and
  • who are unable to support themselves outside the recipient's home because of medical, social or other reasons.

First continuous period of institutionalization — A spouse who is likely to reside in one or more of the following medical care facilities for a continuous period of institutionalization:

  • Hospital, including a VA hospital
  • Nursing facility, whether private-pay or Medicaid
  • ICF/IID
  • IMD
  • Rehabilitation facility

Institutional setting — In this chapter only, a living arrangement in which a person applying for or receiving Medicaid:

  • lives in a Medicaid-certified long-term care facility,
  • receives services under a Home and Community-Based Services waiver program, or
  • receives services under the Program of All-Inclusive Care for the Elderly (PACE).

Institutionalized spouse — A person who is married to a spouse residing in the community and who:

  • receives care in an institutional setting, and
  • has met or is likely to meet the continuous period of institutionalization for at least 30 consecutive days.

or

  • is eligible for a Home and Community-Based Services waiver program, and
  • is likely to need such services for at least 30 consecutive days.

Spousal protected resource amount (SPRA) — The portion of a couple's combined countable resources that is reserved for the community spouse and deducted from the couple's combined countable resources in determining eligibility.

J-1400, Community Spouse Cooperation

J-1410 Refusal of a Community Spouse to Cooperate

Revision 09-4; Effective December 1, 2009

If a community spouse refuses to cooperate in providing information to establish a spousal protected resource amount (SPRA) during an assessment HHSC does not complete the assessment and takes no further action. See Section J-4000, Assessment and SPRA.

If an assessment is started in conjunction with an eligibility determination at the initial application, and a community spouse refuses to furnish information, HHSC determines the living arrangement before the continuous period in an institutional setting began and takes the following action:

  • If the couple was living in the same household, HHSC denies the application based on the couple's failure to furnish information. Living in the same household includes temporary separations.
  • If the couple was not living in the same household, HHSC determines the purpose of separation, the length of separation, and resources or income commingled or managed jointly by one spouse or a third party.
  • If the community spouse refuses to cooperate in providing information, and circumstances indicate possible abuse or neglect by the community spouse, HHSC considers the institutionalized spouse as an individual for purposes of determining eligibility and calculating the co-payment.

 

J-1420 Separation to Circumvent Medicaid Policy

Revision 09-4; Effective December 1, 2009

Evaluate the information provided by a couple to determine if a couple separated before the continuous period in an institutional setting began to avoid the pooling of resources under Medicaid spousal impoverishment provisions, if:

  • the separation occurred after a change in the health of the institutionalized spouse;
  • the community spouse potentially owns separate resources; or
  • the ownership of commingled resources was changed recently.

A couple has the right to rebut HHSC's determination that a separation occurred to circumvent Medicaid policy. To rebut HHSC's determination, either spouse or either spouse's authorized representative must provide a written statement or evidence to HHSC to substantiate the separation as directed on the written notification of HHSC's determination that a separation occurred to circumvent Medicaid policy.

If HHSC determines that circumstances indicate there was no intent to circumvent Medicaid policy, HHSC treats the institutionalized spouse as an individual for purposes of determining Medicaid eligibility and calculating the co-payment.

The rebuttal period is five workdays after oral notification (by HHSC to either spouse) and seven workdays after written notification. The institutionalized spouse, community spouse or responsible party must provide written statements or evidence to substantiate the separation.

Obtain supervisory approval of this evaluation of additional evidence. If circumstances indicate there was no intent to circumvent Medicaid policy, HHSC treats the institutionalized spouse as an individual for consideration of resources, income and co-payment.

J-1500, Change in Marital Status

Revision 10-2; Effective June 1, 2010

Spousal impoverishment requires both:

  • an institutional spouse, and
  • a spouse living in the community.

When there is a reported change to the status of the community spouse, the situation must be evaluated. Evaluation of any dependent family member situation would also be required when there is a change to the status of the community spouse or dependent family member.

The dependent allowance changes to the SSI FBR when there is no community spouse.

 

J-1510 Community Spouse Dies

Revision 12-1; Effective March 1, 2012

If the marriage ends by death in the same month it began, treat the marriage as if it had never existed. Otherwise, the end of marriage is effective the month after the month of death.

If the community spouse dies, the SPRA and income diversion are allowed through the month in which the community spouse dies. Beginning the month after the death of the community spouse, consider the surviving spouse as an individual.

Things to Consider

With the death of the community spouse, determine if there is a change in the authorized representative who signed the application/redetermination under penalty of perjury. See Section B-3220, Who May Sign an Application for Assistance.

Re-evaluate available assets due to the death of a spouse. For example:

  • pensions could adjust;
  • available resource exclusions could change; and
  • resources could change due to inheritance.

Co-payment Changes

Enter the information concerning the community spouse's date of death on the Individual Information screen. Ensure notice is sent for any co-payment change.

The community spouse was eligible for the income diversion the month of death, but restitution is applicable for subsequent months until the co-payment is corrected. Do not seek restitution for the month the community spouse died. Do restitute for subsequent months until the co-payment is changed in the system of record.

The dependent allowance changes to the SSI FBR when there is no community spouse.

 

J-1520 Before Certification the Community Spouse Enters an Institutional Setting

Revision 15-4; Effective December 1, 2015

If the community spouse moves into an institutional setting (e.g., a medical institution or nursing facility) before certification of the first institutionalized spouse, determine if the spouses can be considered a couple.

Prepare a couple budget if a person is living with an eligible spouse (i.e., a spouse who is aged or has a disability) and they are:

  • presenting themselves to the community as a married couple,
  • determined to be married for purposes of receiving Social Security benefits, or
  • recognized as married under state law.

To qualify for the special income limit, a person or couple must:

  • have countable income that exceeds the reduced SSI FBR,
  • reside in a Medicaid-certified long-term care facility for 30 consecutive days or be determined eligible for Home and Community-Based Services and be likely to need such services for at least 30 consecutive days, and
  • receive a level of care or medical necessity determination that qualifies the person or couple for Medicaid.

If the spouses can be considered a couple, consider the incomes of both spouses against the special income limit standard for a couple.

If the spouses cannot be considered a couple or are not eligible as a couple, consider each spouse as an individual.

Notes:

  • Use the special income limit if the person is age 65 or older and in a Medicaid-certified institution for mental diseases for 30 consecutive days. The dependent allowance is the SSI FBR when there is no community spouse.
  • HHSC allows spousal diversions to a community spouse who is receiving services under a Home and Community-Based Services waiver program. Count the diversion as income to the community spouse in the waiver budget.

 

J-1530 After Certification the Community Spouse Enters an Institutional Setting

Revision 15-4; Effective December 1, 2015

After certification of the institutional spouse, the SPRA and diversion of income stops when the former community spouse moves to an institutional setting either:

  • during the initial 12-month eligibility period, or
  • after the initial 12-month eligibility period.

When determining income for each spouse, allow the income diversion through the month in which the former community spouse moves to an institutional setting and consider it as income to the former community spouse. For the month following the move to an institutional setting, budget the former community spouse’s income without the diversion. The diversion becomes part of the co-payment budget for the first institutional spouse effective the month after the former community spouse moves to an institutional setting.

If the community spouse moves into an institutional setting (e.g., a medical institution or nursing facility) after certification of the first institutionalized spouse, determine if both spouses can be considered a couple. See Section G-6000, Institutional Eligibility Budget Types.

A couple budget is prepared if a person is living with an eligible spouse (i.e., a spouse who is aged or has a disability) and they are:

  • presenting themselves to the community as a married couple,
  • determined to be married for purposes of receiving Social Security benefits, or
  • recognized as married under state law.

To qualify for the special income limit, a person or couple must:

  • have countable income that exceeds the reduced SSI FBR,
  • reside in a Medicaid-certified long-term care facility for 30 consecutive days, and
  • receive a level of care or medical necessity determination that qualifies the person or couple for Medicaid.

If they can be considered a couple, the incomes of both spouses are considered against the special income limit standard for a couple.

If both spouses cannot be considered a couple or are not eligible as a couple, budget each spouse as an individual.

Note: The special income limit is used if the person is age 65 or older and in a Medicaid-certified institution for mental diseases for 30 consecutive days.

Things to Consider

If the spouses are eligible as a couple, a new application may not be required unless it is time for the annual redetermination. See Section B-3220, Who May Sign an Application for Assistance, if there has been a change in the authorized representative, power of attorney or legal guardian.

Verify resources as of 12:01 a.m. the month in which the former community spouse's medical effective date falls. When determining resources and transfers, see the information in Section I-3000, Exceptions to the Transfer of Assets, and Section I-5600, Apportioning Penalty Period Between Spouses.

Co-payment Changes

Enter the information concerning the community spouse's change in living arrangement to an institutional setting. Ensure notice is sent for any co-payment change.

Do not seek restitution for the month the former community spouse moved to an institutional setting. Do restitute for subsequent months until the co-payment is changed in the system of record.

The dependent allowance changes to the SSI FBR when there is no community spouse.

Example 1:

Spouse 1 entered the nursing facility in February of last year. Spouse 2 remained in the community. Combined countable resources as of 12:01 a.m. on Feb. 1 of last year were $50,000. An SPRA of $25,000 was determined at assessment. After spending down assets on the nursing facility and outstanding debts, spouse 1 filed an application this month. Two months ago, spouse 2 entered the same nursing facility. Treat as a couple case. If the spouses are not eligible as a couple, test their eligibility as individuals.

Example 2:

Spouse 1 entered the nursing facility on Feb. 2 of this year. Spouse 2 continued to live in their home. Combined countable assets for the month of entry were $14,000. The minimum SPRA was determined and the case certified in March. The couple's only income was their Social Security of $650 for spouse 1 and $900 for spouse 2, so the applied income was $0. Form H1279, Spousal Impoverishment Notification, was sent.Spouse 2 entered the same facility in April. Resources at 12:01 a.m. on April 1 totaled $9,000 in spouse 2’s name. Spouse 2 is no longer a community spouse. Spousal impoverishment policy no longer applies. Spouse 2 is not resource-eligible.

  • Complete the appropriate screens in the system of record to reflect that the community spouse is now in an institutional setting.
  • Restitute for the month after spouse 2's entry if these changes do not process before cutoff.

 

J-1540 Spouses Divorce

Revision 12-1; Effective March 1, 2012

If the marriage ends by divorce or annulment in the same month it began, treat the marriage as if it never existed. Otherwise, the end of marriage is effective the month after the month of divorce or annulment.

The SPRA and income diversion are allowed through the month in which the marriage ended. Beginning the month after the marriage ended, consider the institutional spouse as an individual.

Things to Consider

With the end of the marriage, determine if there is a change in the authorized representative who signed the application/redetermination under penalty of perjury. See Section B-3220, Who May Sign an Application for Assistance.

Re-evaluate available assets due to the divorce or annulment. For example:

  • pensions could adjust;
  • available resource exclusions could change; and
  • resources could change due to judges orders.

Co-payment Changes

Complete the appropriate screens in the system of record to reflect the community spouse's change in status. Ensure notice is sent for any co-payment change.

The community spouse was eligible for the income diversion the month of divorce or annulment, but restitution is applicable for subsequent months until the co-payment is corrected. Do not seek restitution for the month the marriage ended. Do restitute for subsequent months until the co-payment is changed in the system of record.

The dependent allowance changes to the SSI FBR when there is no community spouse.

J-2000, Spousal Treatment of Income and Resources

Revision 10-2; Effective June 1, 2010

Spousal impoverishment policy does not change the determination of what constitutes income or resources, or the methodology and standards for determining and evaluating income and resources.

J-2100, Spousal Treatment of Income

Revision 09-4; Effective December 1, 2009

Spousal impoverishment policy does not change the determination of what constitutes income or the methodology and standards for determining and evaluating income. See Chapter E, General Income. For spousal impoverishment, do not consider Section E-7000, Deeming Income, or Section E-8000, Support and Maintenance.

 

J-2110 Income Eligibility Test for the Institutional Spouse

Revision 09-4; Effective December 1, 2009

For the income eligibility test, separate treatment of income is required. During any month in which an institutionalized spouse is in an institutional setting, no income of the community spouse is used to determine the eligibility of the institutionalized spouse. When totaling countable income for the institutional spouse, consider the following.

If payment of income is made:

  • solely in the name of the institutionalized spouse or the community spouse, the income shall be considered available only to that respective spouse;
  • in the names of the institutionalized spouse and the community spouse, one-half of the income shall be considered available to each of them; and
  • 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 (or, if payment is made with respect to both spouses and no such interest is specified, one-half of the joint interest shall be considered available to each spouse).

An institutionalized spouse can rebut the treatment of the income based on the assumed ownership interest by establishing a preponderance of evidence that the ownership interests in income are different.

 

J-2111 Treatment of Interest from a Joint Account

Revision 09-4; Effective December 1, 2009

For treatment of jointly owned accounts with liquid assets such as a joint bank account, follow Appendix XXV, Accessibility to Income and Resources in Joint Bank Accounts, in determining how to treat the interest. Also refer to the policy for treatment of interest in the following items:

 

J-2112 Treatment of Income from a Trust

Revision 09-4; Effective December 1, 2009

If income from a trust is countable, the income is considered available to each spouse as provided in the trust. If the trust does not specifically address how the income is to be distributed and payment of income is made:

  • solely to the institutionalized spouse or the community spouse, the income shall be considered available only to that respective spouse;
  • to both the institutionalized spouse and the community spouse, one-half of the income shall be considered available to each of them; and
  • to 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 (or, if payment is made with respect to both spouses and no such interest is specified, one-half of the joint interest shall be considered available to each spouse).

 

J-2113 Other Treatment of Income

Revision 09-4; Effective December 1, 2009

When income is received, but there is no instrument establishing ownership, one-half of the income shall be considered to be available to the institutionalized spouse and one-half to the community spouse.

An institutionalized spouse can rebut the treatment of the income based on the assumed ownership interest by establishing a preponderance of evidence that the ownership interests in income are different.

J-2200, Spousal Treatment of Resources

Revision 10-2; Effective June 1, 2010

For the resource eligibility test, combined treatment of resources is required by federal regulations. In determining the resources of an institutionalized spouse, regardless of any state laws relating to community property or the division of marital resources, all the resources held by either the institutionalized spouse, community spouse or both shall be considered to be available to the institutionalized spouse.

When totaling countable resources for the institutional spouse consider the total value of the resources to the extent either the institutionalized spouse or the community spouse has an ownership interest.

Use Chapter F, Resources, for treatment of resources to determine countable value. Apply exclusions, as appropriate, keeping in mind the federal requirement to use the combined resources regardless of any state laws relating to community property or the division of marital resources.

For the assessment and the initial eligibility period, follow these exceptions to the resource exclusions in Chapter F and do not consider in the countable value the following resources:

  • one automobile; and
  • a home, if:
    • the community spouse or dependent family member continues to live in the home while the person is in the institutional setting;
    • the community spouse lives in another state on out-of-state property, whether or not the institutionalized spouse has ownership interest; or
    • the community spouse had been living in the out-of-state property as a home but is not residing there during the assessment and initial eligibility period and the community spouse signs a statement of intent to return to the home.
  • household goods and personal effects (see Section F-4222, Household Goods and Personal Effects).

Determine countable resources based on resources of the couple beginning with the first month for which eligibility is being tested (including prior months). Follow standard resource requirements to verify the resources as of 12:01 a.m. on the first day of the month.

Countable resources can be reduced by the amount of funds encumbered before 12:01 a.m. on the first day of the month by any checks written before that time that have not yet been processed by the financial institution. For further information about encumbered funds, see Section F-1311, Encumbered Funds, and Section F-1312, Nursing Facility Refunds.

At application, resource eligibility will be determined from the countable resource. See Section J-5000, Spousal Initial Application.

 

J-2210 Out-of-State Home and Spousal Impoverishment

Revision 09-4; Effective December 1, 2009

With the following exceptions, a person who applies for and receives Medicaid benefits in Texas is not allowed to exclude a home in another state. Otherwise, if the person considers his home in another state to be his principal place of residence, he is not a Texas resident, and he must apply for assistance in his home state.

  • If the community spouse lives in another state in a house that the institutional spouse claims is not his homestead, to determine the protected resource amount and initial eligibility, exclude the out-of-state property as a part of resources totally excluded regardless of value. If the institutional spouse still has an ownership interest in the property at the first annual redetermination, HHSC considers the value of the property a countable resource that is real property. This situation does not affect residency requirements. As long as the institutionalized spouse intends to remain in the state where he is institutionalized, he is considered a resident.
  • If the community spouse lives in another state in a house that is the institutional spouse’s homestead, the home is excluded in the resource assessment and throughout the initial eligibility period of 12 months. If the institutional spouse still has an ownership interest in the property at the first annual redetermination, the home is a countable resource. If the community spouse is not living in the out-of-state home, the community spouse must sign a statement of intent to return for the home to be excluded for the resource assessment and initial eligibility period of 12 months.

See Section F-3000, Home, and Section F-3500, Out-of-State Home Property.

J-3100, Spousal Transfer of Resources

Revision 09-4; Effective December 1, 2009

There are no restrictions on interspousal transfers occurring from the date of institutionalization to the date of the MEPD application; the reason is that at application and throughout the initial eligibility period (first annual redetermination date set by the automated system), the combined countable resources of the couple are considered in determining eligibility. For the same reason, interspousal transfers are also permitted before institutionalization. A penalty can result when the community spouse transfers assets to a third party, not for the sole benefit of either spouse.

To remain eligible at the end of the initial eligibility period, the institutionalized spouse must reduce resources to which he has access at least to the resource limit. If the institutionalized spouse chooses, he may, during the initial eligibility period, transfer resources from his name to the community spouse's name with no penalty applied to the transfer. The transfer-of-assets policy applies only to transfer of assets for less than fair market value to individuals other than the community spouse, if not for the sole benefit of that spouse.

Transfer penalties apply when the community spouse transfers his separate property before institutionalization, or after institutionalization but before the MEPD certification. Transfer penalties apply when the community spouse transfers community property both before and after institutionalization, if not for the sole benefit of the spouse.

 

J-3110 Spousal Resource Transfer Examples

Revision 12-1; Effective March 1, 2012

  • When the institutionalized spouse enters a nursing facility, the couple's combined countable resources are $100,000, and the resources are all in the institutionalized spouse's name. The spousal protected resource amount (SPRA) is $50,000.

    Before application, the institutionalized spouse transfers the entire $100,000 to the community spouse. No transfer of assets penalty applies when eligibility is established.
  • When the institutionalized spouse enters a nursing facility, the couple's combined countable resources are $100,000, all in the institutionalized spouse's name. The SPRA is $50,000. The institutionalized spouse transfers all resources to the community spouse without penalty.

    A Medicaid application is filed two and one-half years later. The couple's combined countable resources are $30,000 as of 12:01 a.m. on the first day of the month of application, and the resources are all in the community spouse's name.
     
    • $30,000 Combined countable resources
    • – $50,000 SPRA
    • = $0 Compared to appropriate resource standard for an individual
  • If the institutionalized spouse inherits $20,000 after Medicaid certification, the institutionalized spouse may transfer the entire amount of that inheritance to the community spouse without penalty during the initial eligibility period. However, this $20,000 is treated as income for the month of receipt, and restitution of the full vendor payment for that month is requested. This brings the community spouse's resources to $50,000, the full protected amount.

  • If more than $22,000 is inherited, the person would be ineligible based on resources ($22,001 + $30,000 = $52,001 combined resources).
     
    • $52,001 Combined resources
    • – $50,000 SPRA
    • = $2,001 > $2,000 and ineligible
  • When the person enters the nursing facility, the couple's combined countable resources are $100,000 ($90,000 in person's name and $10,000 in the community spouse's name). The protected resource amount is $50,000.

    A Medicaid application is filed eight months later. Before application, the person transferred $80,000 to the community spouse and spent $10,000 on nursing facility bills. The community spouse then transferred $50,000 to her daughter before the Medicaid application was filed. The couple's combined countable resources are now $40,000 as of 12:01 a.m. on the first day of the month of application, and the resources are all in the community spouse's name.
     
    • $40,000 Combined countable resources
    • – $50,000 SPRA
    • = $0 Compared to appropriate resource standard for an individual

    The applicant is eligible for Medicaid but does not receive nursing facility services. The penalty period for vendor payment is imposed based on the $50,000 uncompensated value of the transfer to the daughter. Note: If the institutional spouse has a level of care or medical necessity determination and meets all eligibility criteria except for the transfer of assets provisions, the institutional spouse may be eligible to receive Your Texas Benefits Medicaid card but not assistance in paying for the cost of care in the long-term care facility. Follow procedures in Appendix XXIII, Procedure for Designated Vendor Number to Withhold Vendor Payment, to put the vendor payment on hold.

  • When the institutional spouse entered the nursing facility (June 17), the couple's combined countable resources were $30,000. The institutionalized spouse had transferred $10,000 in April, with no compensation to a son. The uncompensated value is not included when calculating the protected resource amount, and the SPRA is one-half of $30,000, which would be $15,000. However, $15,000 is less than the current minimum SPRA amount; thus, the SPRA would be the current minimum SPRA amount.

    Under post-DRA transfer of assets policy, a penalty is imposed should a Medicaid application be filed and the transfer is within the look-back period, but the penalty would not start until the medical effective date. (If under pre-DRA transfer of assets policy, a penalty is imposed should a MEPD application be filed before the 85-day penalty [based on $117.08] has expired.)

The transfer of assets divisor used for all of the above illustrations may not reflect the most recent average private-pay cost per day amount.

J-3200, Spousal Transfer of Income

Revision 09-4; Effective December 1, 2009

A person potentially incurs a transfer penalty by transferring income. Transfers of income include:

  • waiving the right to receive an inheritance even in the month of receipt;
  • giving away a lump sum payment even in the month of receipt; or
  • irrevocably waiving all or part of federal, state or private pensions or annuities.

The date of transfer is the date of the actual change in income, if within the look-back period or during an ongoing month.

Interspousal transfers of income are permitted (for example, obtaining a court order to have community property pension income paid to a community spouse).

J-4000, Assessment and SPRA

Revision 14-2; Effective June 1, 2014

The purpose of the assessment is to determine a protected resource amount, which is that portion of total resources reserved for the community spouse and deducted from the couple's combined resources in determining eligibility.

J-4100, Time Frame to Request the Assessment

Revision 09-4; Effective December 1, 2009

Upon request of either the institutionalized spouse or the community spouse, or either spouse's authorized representative, assess the couple's resources to determine the spousal protected resource amount. The request and assessment may be made any time from the beginning of the continuous period in an institutional setting to the date of application for Medicaid.

 

J-4110 Automatic SPRA

Revision 09-4; Effective December 1, 2009

An automatic SPRA occurs when a community Medicaid recipient requests a program transfer to an institutional setting; use minimum SPRA at the time of the request.

J-4200, Assessment Request

Revision 09-4; Effective December 1, 2009

If the request for the assessment of resources to determine the SPRA is not part of an application for Medicaid, the couple must provide information on their resources and verification as required by HHSC.

Inform the couple and/or representative of the verifications required to complete an assessment and the time frame to return the verification(s). The couple must provide requested verification of resources within 30 days of the request for assessment, or the request is void. Complete the assessment within 45 days after receipt of verification requested.

If the couple does not provide the verification(s) within the time frame requested by HHSC, HHSC does not complete the assessment and takes no further action.

Note: The couple may not appeal the SPRA at the time of the assessment. The couple may appeal the SPRA after an application for Medicaid is filed.

 

J-4210 Procedures for Processing the Assessment Request

Revision 09-4; Effective December 1, 2009

Step Procedure
1 Assessment is requested.
2 Send Form H1272, Declaration of Resources.

Note: Form H1272 is not used as an application. If the assessment and application are requested at the same time, only an HHSC application for MEPD Medicaid is needed.
3 If all necessary documentation is not received within 15 calendar days of return of completed Form H1272, send Form H1273, Request for Assessment Information. If the needed documentation is not received by the 30th calendar day, discontinue the assessment.
4 If all necessary documentation is received by the 30th calendar day, the assessment must be completed by the 45th calendar day from the receipt of the signed Form H1272.
5 When the assessment is complete, send Form H1274, Medicaid Eligibility Resource Assessment Notification, showing the protected resource amount.

Note: This form must be sent whether or not the assessment is completed at the same time as an application.

J-4300, Assessment Date

Revision 09-4; Effective December 1, 2009

HHSC assesses the couple's combined countable resources as of 12:01 a.m. on the first day of the month in which the first continuous period in an institutional setting began. When determining the first day of the month in an institutional setting for the SPRA, HHSC may count days the person spent in a hospital if the person is admitted directly from the hospital to an institutional setting. After the continuous period begins, hospital stays and therapeutic home visits are not considered as breaks in the 30-consecutive-day period. See Section G-6210, 30 Consecutive Days and the Special Income Limit.

Note: When determining the first day of month of institutionalization for the SPRA, institutionalization can be based on hospitalization if the individual is admitted directly to the nursing facility from the hospital stay.

 

J-4310 Determining the Assessment Date for a Home and Community-Based Services Waiver

Revision 09-4; Effective December 1, 2009

The SPRA is assessed as of 12:01 a.m. on the first day of the month that the application was received for the financial Medicaid eligibility component. See Chapter O, Waiver Programs, Demonstration Projects and All-Inclusive Care.

  • If the waiver application is certified, the SPRA assessment date does not change unless it was based on incomplete or inaccurate information.
  • If the waiver application is not certified and the individual reapplies, the SPRA assessment date is 12:01 a.m. on the first day of the month of the re-application month.

 

J-4311 Examples of the Assessment Date

Revision 09-4; Effective December 1, 2009

If spousal impoverishment is applicable and:

an institutionalized Medicaid recipient requests a program transfer to a waiver,

use the established SPRA.

This is considered an institutional SPRA.

a community applicant applies for a waiver,

assess resources as of 12:01 a.m. on the first day of the month of the MEPD application.

This is considered a waiver SPRA if the waiver application is certified.

an institutionalized applicant applies for Medicaid and then a waiver before being certified,

assess resources as of 12:01 a.m. on the first day of the month of institutionalization.

Institutionalization can be based on hospitalization if the individual is admitted directly to the facility from the hospital stay.

This is considered an institutional SPRA.
Note: When determining the 30-day stay requirement, consider both the days in a medical facility and the days in the waiver setting.

a community applicant applies for a waiver and then enters a medical facility before being certified,

assess resources as of 12:01 a.m. on the first day of the month of institutionalization from a medical facility regardless if the applicant remains in the medical facility or returns to community waiver services before certification.

This is considered an institutional SPRA. Note: When determining the 30-day stay requirement, consider both the days in a medical facility and the days in the waiver setting.

Note: When determining the first day of month of institutionalization for the SPRA, institutionalization can be based on hospitalization if the individual is admitted directly to the nursing facility from the hospital stay.

J-4400, SPRA Calculation

Revision 14-2; Effective June 1, 2014

Use the following for the calculation of the SPRA at the time of the assessment request without an application or with the receipt of the MEPD application.

Calculate the SPRA as of the assessment date described in Section J-4300, Assessment Date. When determining the SPRA, determine countable resources using policy in Section J-2200, Spousal Treatment of Resources. To determine the amount of the SPRA, divide the countable resources by two and the result will be the amount to compare to the maximum and minimum SPRA amount set by federal law.

The SPRA is the greater of:

  • one-half of the couple's combined countable resources, not to exceed the maximum resource amount set by federal law; or
  • the minimum resource amount set by federal law.

Calculate the SPRA as described above whether the SPRA is calculated at the time of application for Medicaid or before an application for Medicaid is filed.

Resource exclusions determined in the SPRA are the same exclusions used in the eligibility determination at application.

Note: The equity value of the home does not impact spousal impoverishment policy and treatment of the home during the assessment process. If the person’s community spouse, child or disabled adult child is living in the home, substantial home equity policy does not apply. See Section F-3600, Substantial Home Equity.

J-4500, Changing the Assessment Amount

Revision 09-4; Effective December 1, 2009

With an automatic SPRA, no additional verification is necessary to establish the amount of the SPRA. Send Form H1274, Medicaid Eligibility Resource Assessment Notification, indicating the minimum SPRA and the right to appeal. See Section J-4110, Automatic SPRA.

See Section J-4311, Examples of the Assessment Date, for information about an institutional SPRA or Home and Community-Based Services waiver SPRA.

With an institutional SPRA, the SPRA assessment date and amount do not change unless they are based on incomplete or inaccurate information.

With a Home and Community-Based Services waiver SPRA, if the application is certified, the SPRA assessment date and amount do not change unless they are based on incomplete or inaccurate information. If the application is not certified, the SPRA assessment date is re-established if the individual reapplies.

The SPRA amount must not be deducted from resources for an individual who is found eligible, who is certified, or who is subsequently denied and then reapplies. Only those resources in the name of the Home and Community-Based Services waiver (institutionalized) spouse are considered at reapplication.

If an institutional spouse was certified incorrectly because of unreported resources and the case is subsequently denied, the original SPRA amount is not used when the institutional spouse reapplies for Medicaid. A new SPRA amount that includes the previously unreported resources must be calculated.

The SPRA can change if it is expanded as described in Section J-6000, SPRA Expansion.

J-5000, Spousal Initial Application

Revision 13-3; Effective September 1, 2013

Upon receiving an application for Medicaid, calculate the couple's combined countable resources, without regard to community or separate property laws or the spouses' respective ownership interests, as of 12:01 a.m. on the first day of the month in which eligibility is being determined.

See Section J-2200, Spousal Treatment of Resources.

If an assessment of resources to determine the spousal protected resource amount (SPRA) has not previously been completed, determine the SPRA at initial application, using Section J-4000, Assessment and SPRA.

When the assessment is complete, send Form H1274, Medicaid Eligibility Resource Assessment Notification. If the institutionalized spouse is found eligible for Medicaid, ensure Form H1279, Spousal Impoverishment Notification, is sent at certification along with the eligibility notice.

If the SPRA determined at assessment is either the federal minimum or maximum resource amount, and the federal minimum or maximum resource amount increases before completion of the initial application for Medicaid, use the federal minimum and maximum resource amounts in effect at the time of completion of the initial application.

If the institutionalized spouse is found ineligible for Medicaid at the initial application and reapplies, deduct the same SPRA for subsequent applications.

If an institutionalized spouse, after having been certified (even if there are ineligible months within the three months prior, month of application and any months through certification), is subsequently denied and reapplies for Medicaid:

  • if the institutionalized spouse should never have been certified and was denied because of unreported resources, calculate a new SPRA at reapplication, taking into account the previously unreported resources; and
  • if the institutionalized spouse was denied for any other reason, do not deduct the SPRA and count only the institutionalized spouse's resources at reapplication.

Note: A case is not considered “certified” until a decision or certification has taken place and there may be both ineligible as well as eligible months within this certification decision. The total countable combined resources of the couple are considered within the certification decision. See Section J-8000, After Initial Eligibility Period, for treatment of resources after certification.

J-5100, Spousal Steps at Application

Revision 09-4; Effective December 1, 2009

Steps in determining countable resources for a spousal application:

Step Procedure
1 Determine the couple's countable resources at 12:01 a.m. on the first day of the month of application (and three months prior).
2 Determine if an assessment of the SPRA was previously completed.

If so, continue.

Determine if the SPRA will be automatic, institutional or waiver.

Institutional — Determine the SPRA based on the countable resources as of 12:01 a.m. of the first day of the month of medical facility entry. The medical facility entry can start at the date of hospital admission if the person transfers directly from the hospital to the nursing facility without returning to a community setting.

Waiver — Determine the waiver SPRA based on the countable resources as of 12:01 a.m. of the first day of the month of receipt of the application.
3 Determine the SPRA, which is the greater of:
  • the spousal share or one-half of the couple's combined countable resources (not to exceed the maximum as set by federal law);

    or
  • the minimum spousal resource standard as set by federal law.
4 Subtract the SPRA from the combined countable resources.
5 Compare the remainder to the appropriate resource limit for an individual.

J-6100, Policy and Procedure for SPRA Expansion

Revision 12-3; Effective September 1, 2012

The expanded SPRA allows assets protection above the maximum SPRA set by federal law. The formula provides that the applicant can protect enough assets based on interest earned to create available income up to the minimum monthly maintenance needs allowance.

The SPRA is expanded by either the MEPD specialist via the individual's request and signature on Form H1275, Request for Expanded Protected Resource Assessment, or by a hearing officer via the fair hearing process.

There are two methodologies to determine the expanded SPRA. The date of the first continuous period of institutionalization determines which methodology to use to determine the expanded SPRA. Determine if the first continuous period of institutionalization was:

  • before Sept. 1, 2004; or
  • Sept. 1, 2004, or after.

Calculate an expanded institutional SPRA based on the month of entry into a medical care facility, not the date of application.

J-6200, Spousal Expansion Sept. 1, 2004, or After

Revision 13-4; Effective December 1, 2013

If the first continuous period of institutionalization was Sept. 1, 2004, or after, follow an income-first methodology in spousal impoverishment Medicaid eligibility evaluations. When using the income-first methodology, the institutionalized spouse must divert all non-resource income minus the institutionalized spouse's personal needs allowance to the community spouse.

If a resource is excluded, the income from such a resource is countable income in the expansion budgeting for the individual and community spouse. For example, an annuity is an excluded resource; thus, the income produced from that annuity is countable income in the spousal budgeting.

To determine the amount of the increased SPRA, the eligibility specialist or hearing officer determines the current interest rate of a one-year certificate of deposit (CD), as published in the local paper or provided by a local bank that offers one-year CDs. The eligibility specialist or hearing officer then determines the amount of resources required to produce income, at the specified interest rate, that would increase the spouse's income to the monthly maintenance needs allowance.

Determine the protected amount of resources by using the formula specified in the following steps. This formula is to be used to determine the maximum amount of resources to be protected regardless of the actual income a resource may or may not be producing at the time of the original SPRA or at the time of the appeal hearing. (Use Appendix XXVII, Worksheet for Expanded SPRA on Appeal.)

StepProcedure
1Subtract the community spouse's non-resource-producing income (including income diverted by the applicant/recipient, if any) from the monthly maintenance needs allowance (MMNA). The difference is additional monthly income needed by the community spouse.
2Multiply additional monthly income needed by the community spouse from Step 1 by 12. The product equals annual income needed by the community spouse.
3Multiply annual income needed by the community spouse from Step 2 by 100.
4Divide the product from Step 3 by the interest rate for a one-year CD (do not use a percentage).

Note: The expanded SPRA may not exceed the value of the couple's combined countable resources as of the first month of entry to a medical care facility for a continuous stay.

Example

DescriptionAmount
Community spouse's own income =$608.50
Income diverted from applicant/recipient =+ $750
Community spouse's total income =$1,358.50
CD interest rate =6%

Step 1:

AmountDescription
$2,610.00MMNA in effect at the time of the filing of the appeal
– $1,358.50community spouse's total income
$1,251.50monthly income needed

Step 2:

AmountDescription
$1,251.50monthly income needed
× 12months
$15,018annual income needed

Step 3:

AmountDescription
$15,018annual income needed
× 100multiplier
$1,501,800product

Step 4:

AmountDescription
$1,501,800annual income needed
÷ 6CD interest rate
$250,300amount needed to increase SPRA to meet MMNA

Step 5:

The expanded SPRA is the lesser of:

  • $250,300, or
  • the value of the couple's total combined countable resources as of the first month of entry to a medical care facility for a continuous stay.

When determining the post-eligibility co-payment and the amount available for spousal diversion, the eligibility specialist uses the actual dollar amount produced if the actual amount is in excess of the amount a one-year CD would produce. However, if the actual amount a resource produces is less than the amount a one-year CD would produce, the eligibility specialist uses the amount a one-year CD would produce. (Use Appendix XXVIII, Worksheet for Spouse's Income [Post-Expanded SPRA Appeals].)

The institutionalized spouse's income placed into a qualified income trust (QIT) is considered income in the calculation of the expanded SPRA.

The expanded SPRA cannot exceed the total countable assets determined for the initial SPRA.

Use Appendix XXVII.

Note: Form H1275, Request for Expanded Spousal Protected Resource Assessment, must be signed by the applicant/authorized representative.

J-6210 Sharing Required Information

Revision 09-4; Effective December 1, 2009

After the expanded SPRA appeal, income attributed to the institutionalized spouse (for both eligibility and co-payment purposes) is:

  • the total actual income from resources to which the institutionalized spouse has sole title; plus
  • one-half of actual income from resources to which the institutionalized spouse and the community spouse have joint title.

After the expanded SPRA appeal, income attributed to the community spouse (for purposes of determining the spousal diversion) is the higher of:

  • the total actual income from all resources to which the community spouse has sole title, plus one-half of actual income from resources to which the institutionalized spouse and community spouse have joint title; or
  • imputed income from all resources included in the expanded SPRA (whether or not the community spouse has title to those resources).

Consider the imputed income only during the initial eligibility period. After the initial eligibility period, actual income generated by a resource is countable to whichever spouse holds title. If the spouses have joint title, one-half of the actual income is countable to each spouse.

Examples:

  • Jon Janis enters the nursing facility on Jan. 2, 2009. He applies for Medicaid on Jan. 15, 2009. Before entering the facility, he lived with his wife, Josie. She still resides in their home. Their total countable combined resources is $500,000.

    DescriptionAmount
    Total Countable Combined Resources$500,000 ÷ 2 = $250,000, thus use
    SPRA– $109,560
    Compare= $390,444 > $2,000 Not eligible
  • Form H1275, Request for Expanded Protected Resource Assessment, is signed and Mr. Janis diverts all of his non-resource monthly income. Mr. Janis has monthly income of $1,900. Mrs. Janis has monthly income of $800. Both incomes are non-resource produced income. Income first method is used and $1,900 – $60 PNA = $1,840 + Mrs. Janis' income $800 = $2,640 < $2,739 MMMNA; this amount is determined to be available for the spouse. Enter this amount into Step 2 of Appendix XXVII. New SPRA is calculated. CD interest rate is 4.5%.

    Step 1:

    AmountDescription
    $2,739MMNA in effect at the time of the filing of the appeal
    – $2,650community spouse's total income
    $99monthly income needed

    Step 2:

    AmountDescription
    $99monthly income needed
    × 12months
    $1,188annual income needed

    Step 3:

    AmountDescription
    $1,188annual income needed
    × 100multiplier
    $118,800annual income needed

    Step 4:

    AmountDescription
    $118,800annual income needed
    ÷ 4.5CD interest rate
    $26,400amount needed to increase SPRA to meet MMNA

     Step 5:

    The expanded SPRA is less than the original SPRA of $109,560.

  • When the expanded SPRA is less than the original SPRA, use the original SPRA to determine eligibility.

    AmountDescription
    Total Countable Combined Resources$500,000
    Maximum SPRA– $109,560
    Compare= $390,440 > $2,000 Not eligible
  • Bob Barrister enters the nursing facility on Jan. 10, 2009. He applies for Medicaid on Feb. 15, 2009. Before entering the facility, he lived with his wife, Betty. She still resides in their home. Their total countable combined resources equal $500,000.

    AmountDescription
    Total Countable Combined Resources$500,000 ÷ 2 = $250,000, thus use
    SPRA– $109,560
    Compare= $390,440 > $2,000 Not eligible
  • Mr. Barrister has monthly income of $1,900. Mrs. Barrister has monthly income of $1,200. Both incomes are non-resource produced income. Since the first continuous period of institutionalization was on or after Sept. 1, 2004, use the income first method for determining the expanded SPRA.
  • Calculation: Mr. Barrister's income $1,900 – $60 PNA = $1,840 + Mrs. Barrister's income $1,200 = $3,040 > $2,739 MMMNA.
  • The calculation of the person's net non-resource produced income and the spouse's non-resource produced income resulted in an amount greater than the MMMNA.
  • Do not expand the SPRA.

J-6300, Expanded SPRA for Home and Community-Based Services Waiver Programs

Revision 15-3; Effective September 1, 2015

In waiver cases with a community spouse, the waiver individual (i.e., the institutionalized spouse) can make a request or file an appeal to increase the SPRA to produce additional income for the community spouse.

Usually in a waiver situation, income-first expanded SPRA is only considered when the individual has a QIT. The expanded SPRA cannot exceed the combined resources as of the SPRA assessment date for a waiver.

An expanded SPRA in a waiver case is available only:

  • after the waiver individual (i.e., the institutionalized spouse) diverts all of the waiver individual's available income (i.e., the waiver individual's gross income minus the current special income limit — 300 percent cap for an individual) to the community ineligible spouse, and
  • the community ineligible spouse's resulting total income is less than the current minimum monthly maintenance needs allowance (MMMNA).

Do not develop the expanded SPRA for a waiver if, after diverting all of the waiver individual's available income (i.e., the waiver individual's gross income minus the current special income limit — 300 percent cap for an individual) to the community ineligible spouse, the community ineligible spouse's resulting total income is equal to or more than the current MMMNA.

Calculate the expanded SPRA for a waiver if, after diverting all of the waiver individual's available income (i.e., the waiver individual's gross income minus the current special income limit — 300 percent cap for an individual) to the community ineligible spouse, the community spouse's resulting total income is less than the current MMMNA.

See Appendix XXXI, Budget Reference Chart, for the current amounts.

Procedure for Increased SPRA Consideration

Step Procedure

1

The waiver individual (i.e., the institutionalized spouse) diverts all of the waiver individual's available income (i.e., the waiver individual's gross non-resource produced [NRP] income minus the current special income limit — 300 percent cap for an individual) to the community ineligible spouse.

Gross NRP income
− 300 percent cap for an individual
= Amount available for diversion

2

Add the community ineligible spouse's gross NRP income to the amount from step 1.

Spouse's gross NRP income
+ Amount available for diversion
= Spouse's resulting total income

3

If the community ineligible spouse's resulting total income is less than the current MMMNA, increase the SPRA.

If the community ineligible spouse's resulting total income is equal to or more than the current MMMNA, do not increase the SPRA.

 

J-6310 Expanded SPRA for Home and Community-Based Services Waiver Applicants in an Assisted Living Facility or Adult Foster Care

Revision 15-3; Effective September 1, 2015

If the person is living in an assisted living facility or adult foster care setting and is receiving waiver services from the STAR+PLUS Waiver (SPW) program:

  • Do not develop the expanded SPRA for a waiver if, after diverting all of the waiver individual's available income (i.e., the waiver individual's gross income minus the current Supplemental Security Income [SSI] federal benefit rate [FBR] for an individual) to the community ineligible spouse, the community ineligible spouse's resulting total income is equal to or more than the current MMMNA.
  • Calculate the expanded SPRA for a waiver if, after diverting all of the waiver individual's available income (i.e., the waiver individual's gross income minus the current SSI FBR for an individual) to the community ineligible spouse, the community ineligible spouse's resulting total income is less than the current MMMNA.

Procedure for Increased SPRA Consideration for SPW in an Assisted Living Facility/Adult Foster Care Setting

Step Procedure

1

The waiver individual (i.e., the institutionalized spouse) diverts all of the waiver individual's available income (i.e., the waiver individual's gross non-resource produced [NRP] income minus the current SSI FBR) to the community ineligible spouse.

Gross NRP income
− SSI FBR for individual
= Amount available for diversion

2

Add the community ineligible spouse's gross NRP income to the amount from step 1.

Spouse's gross NRP income
+ Amount available for diversion
= Spouse's resulting total income

3

If the community ineligible spouse's resulting total income is less than the current MMMNA, increase the SPRA.

If the community ineligible spouse's resulting total income is equal to or more than the current MMMNA, do not increase the SPRA.

See Appendix XXXI, Budget Reference Chart, for the current amounts.

J-6400, SPRA Expansion before Sept. 1, 2004

Revision 12-4; Effective December 1, 2012

If the first continuous period of institutionalization was before Sept. 1, 2004, follow a resource-first methodology, which allows the $1 diversion procedure to calculate the expanded SPRA. The expanded SPRA looks at only the community spouse's income, plus an income diversion from the spouse in the nursing home, and only $1 diversion is required from the spouse in the nursing home when using the resource-first methodology. (Use Appendix XXVII, Worksheet for Expanded SPRA on Appeal.)

In nursing facility and waiver cases with a community spouse, the applicant/recipient can appeal to increase the SPRA to produce additional income for the spouse. The eligibility specialist or hearing officer may increase the SPRA to a level adequate to produce income up to but not to exceed the monthly maintenance needs allowance.

The couple can protect additional resources. The resources can be equal to the dollar amount that must be deposited in a one-year certificate of deposit (CD), at current interest rates, to produce interest income equal to the difference between the monthly maintenance needs allowance (in effect at the time of the filing of the appeal) and other countable income not generated by either spouse's countable resources. The couple is not required to invest in the CD as a condition of eligibility.

To determine the amount of the increased SPRA, the eligibility specialist or hearing officer determines the current interest rate of a one-year CD as published in the local paper or provided by a local bank that offers one-year CDs. The eligibility specialist or hearing officer then determines the amount of resources required to produce income, at the specified interest rate, that would increase the spouse's income to the monthly maintenance needs allowance.

Determine the protected amount of resources by using the formula specified in the following steps. This formula is to be used to determine the maximum amount of resources to be protected regardless of the actual income a resource may or may not be producing at the time of the original SPRA or at the time of the appeal hearing. (Use Appendix XXVII.)

Step Procedure
1 Subtract the community spouse's non-resource-producing income (including income diverted by the applicant/recipient, if any) from the monthly maintenance needs allowance (MMNA). The difference is additional monthly income needed by the community spouse.
2 Multiply additional monthly income needed by the community spouse from Step 1 by 12. The product equals annual income needed by the community spouse.
3 Multiply annual income needed by the community spouse from Step 2 by 100.
4 Divide the product from Step 3 by the interest rate for a one-year CD (do not use a percentage).

Note: The expanded SPRA may not exceed the value of the couple's combined countable resources as of the first month of entry to a medical care facility for a continuous stay.

Example

Description Amount
Community Spouse's own income = $608.50
Income diverted from applicant/recipient = + $750
Community spouse's total income = $1,358.50
CD interest rate = 6%

Step 1:

Amount Description
$2,610.00 MMNA in effect at the time of the filing of the appeal
– $1,358.50 community spouse's total income
$1,251.50 monthly income needed

Step 2:

Amount Description
$1,251.50 monthly income needed
× 12 months
$15,018 annual income needed

Step 3:

Amount Description
$15,018 annual income needed
× 100 multiplier
$1,501,800 product

Step 4:

Amount Description
$1,501,800 annual income needed
÷ 6 CD interest rate
$250,300 amount needed to increase SPRA to meet MMNA

Step 5:

The expanded SPRA is the lesser of:

  • $250,300, or
  • the value of the couple's total combined countable resources as of the first month of entry to a medical care facility for a continuous stay.

When determining the post-eligibility co-payment and the amount available for spousal diversion, the eligibility specialist uses the actual dollar amount produced if the actual amount is in excess of the amount a one-year CD would produce. However, if the actual amount a resource produces is less than the amount a one-year CD would produce, the eligibility specialist uses the amount a one-year CD would produce. (Use Appendix XXVIII.)

Note: Form H1275, Request for Expanded Spousal Protected Resource Assessment, must be signed by the applicant/authorized representative.

 

J-6410 Sharing Required Information

Revision 09-4; Effective December 1, 2009

If institutionalization was before Sept. 1, 2004, the eligibility specialist must know how much income the institutionalized spouse wishes to divert to the community spouse to determine the value of additional resources to be protected.

Hearing officers or eligibility specialists should inform the couple or the couple's authorized representative (AR) that the lower the income diversion amount, the higher the expanded SPRA, and that the institutionalized spouse must agree to divert at least $1 for the SPRA to be expanded.

The hearing officer or eligibility specialist should further inform the couple or the couple's AR that once the SPRA is expanded, an additional amount may be diverted to the community spouse whose total income (including income from the expanded SPRA) is less than the MMMNA. The new spousal diversion amount (after the SPRA is expanded) may be recalculated by either the hearing officer or the eligibility specialist.

After the expanded SPRA appeal, income attributed to the institutionalized spouse (for both eligibility and co-payment purposes) is:

  • the total actual income from resources to which the institutionalized spouse has sole title; plus
  • one-half of actual income from resources to which the institutionalized spouse and the community spouse have joint title.

After the expanded SPRA appeal, income attributed to the community spouse (for purposes of determining the spousal diversion) is the higher of:

  • the total actual income from all resources to which the community spouse has sole title, plus one-half of actual income from resources to which the institutionalized spouse and community spouse have joint title; or
  • imputed income from all resources included in the expanded SPRA (whether or not the community spouse has title to those resources).

Consider the imputed income only during the initial eligibility period. After the initial eligibility period, actual income generated by a resource is countable to whichever spouse holds title. If the spouses have joint title, one-half of the actual income is countable to each spouse.

J-7000, Income for Eligibility and Co-Payment

Revision 21-3; Effective September 1, 2021

If the recipient does not make the entire spousal allowance available at certification and at each redetermination, obtain a written statement from the recipient or the recipient's authorized representative as to the amount that is being made available and deduct only that amount.

A written statement is not required at redetermination if:

  • the community spouse is a Supplemental Security Income (SSI) recipient;
  • zero ($0) amount is being diverted to the community spouse; or
  • the amount of the spousal diversion at redetermination remains the same.

Diversion of VA income to the community-based spouse may affect the VA income amount. Inform the couple of this possibility and give them the option of not diverting VA income to the community-based spouse. Their decision should be documented in a signed statement.

Financial duress is defined as having insufficient funds to meet living expenses because of debts incurred for medical expenses for the institutionalized spouse, community-based spouse or dependent, or because of replacement of a resource lost through theft or acts of God.

J-7100, Spousal Companion Budget

Revision 09-4; Effective December 1, 2009

Using the special income limit for an individual, HHSC considers only the person's income in determining eligibility. The ineligible spouse's income is considered in determining the amount of co-payment.

J-7200, Spousal Co-Payment

Revision 23-3; Effective Sept. 1, 2023

Budget Steps

To determine the co-payment for a spousal companion case, determine the person and their community spouse's net monthly earned income by subtracting the following mandatory payroll deductions:

  • income tax;
  • Social Security tax;
  • required retirement withholdings; and
  • required uniform expenses.

Note: Mandatory payroll deductions also apply to a dependent's earned income in spousal impoverishment cases.

Do not count in-kind support and maintenance income the community spouse receives.

A separate deduction for maintenance of the home is not allowable in companion cases. The spousal allowance provides for home maintenance in those cases.

How to Determine Co-Payment for a Spousal Companion Case

StepProcedure
1Determine the countable net earned and gross unearned income of the person.
2Subtract the personal needs allowance (PNA) of $60 for the person. Subtract the guardianship fee allowance, if applicable.
3Add the community spouse's countable net earned and gross unearned income to the remainder. If the community spouse’s income is more than the minimum monthly maintenance needs allowance (MMMNA), count only the MMMNA.
4Subtract the spousal allowance.
5a) If there are no dependents, go to step 6.
b) If there are dependents, determine the dependent allowance.
c) Subtract the dependent allowance.
6

Subtract the person’s incurred medical expenses, if applicable. The remainder is the person’s co-payment.

See H-2000, Incurred Medical Expenses, for policy on the deduction of incurred medical expenses.

Notes:

  • Enter incurred medical expense deductions on the Medical Expense LUW in TIERS even if the co-payment is $0.
  • If the person has signed a statement and is refusing to make the spousal allowance available and there are no dependents, follow procedures for an individual co-payment budget.
  • If the community spouse's countable income is greater than the MMMNA, count only the MMMNA in step 3 above.

Examples

The following examples are for demonstration purposes only. They may not reflect the most recent protected resource amounts or dependent allowance.

Example 1:

A person and their community spouse have the following income:

  • Person
    • $265 RSDI
    • +$200 Private retirement
    • $465 Total
  • Community Spouse
    • $350 RSDI
    • + $285 Teacher's retirement
    • = $635 Total
  • Co-payment calculation:
    • $465 Person's gross income
    • – $60 PNA
    • = $405 Income available for diversion
    • + $635 Community Spouse's income
    • = $1,040 Total
    • – $3,715.50 Spousal allowance
    • = $0 Co-payment

Example 2:

A person and their community spouse have the following income:

  • Person
    • $490 RSDI
    • + $509 Private retirement
    • = $999 Total
  • Community Spouse
    • $450 RSDI
    • + $300 Private retirement
    • + $750 Net earnings
    • = $1,500 Total
  • Co-payment calculation:
    • $999 Person's gross income
    • – $60 PNA
    • = $939 Income available for diversion
    • + $1,500 Community Spouse's income
    • = $2,439 Total
    • – $3,715.50 Spousal allowance
    • = $0 Remainder
    • – $60 Incurred medical expenses
    • = $0 Co-payment

Example 3:

A person and their community spouse have the following income:

  • Person
    • $1,250 RSDI
    • + $800 Private retirement
    • = $2,050 Total
  • Community Spouse
    • $1,590 Net earnings
    • Monthly incurred medical expenses are $16.

The person's dependent brother lives with the community spouse. The brother’s only income is $500 per month in RSDI disability benefits.

  • The brother’s dependent allowance is:
    • $2,465 Base amount of dependent allowance
    • – $500 Dependent's gross income
    • = $1,965 Remainder
    • $1,965 divided by 3
    • = $655 Dependent allowance
  • Co-payment calculation:
    • $2,050 Person's gross income
    • – $60 PNA
    • = $1,990 Income available for diversion
    • + $1,590 Community Spouse's income
    • = $3,580 Total
    • – $3,715.50 Spousal allowance
    • = $0 Remainder
    • – $655 Dependent allowance
    • = $0.00 Remainder
    • – $16 Incurred medical expenses
    • = $0.00 Co-payment

Related Policy

Co-Payment, Chapter H

J-7300, ICF/IID Spousal Companion Cases

Revision 23-1; Effective March 1, 2023

A separate deduction for maintenance of the home is not allowable in companion cases. The spousal allowance provides for home maintenance in those cases.

To determine the co-payment for a spousal companion situation for a person with earnings who is in an ICF/IID, use the following steps:

Step Procedure
1 Determine the countable net earned and gross unearned income of the person.
2 Subtract the personal needs allowance, including the protected earned income allowance (if any) of the person based on their own net income. Subtract the guardian fee allowance, if applicable.
3 Add the spouse's countable net earned and gross unearned income to the remainder.
4 Subtract the spousal allowance.
5 a) If there are no dependents, go to step 6.
b) If there are dependents, determine the dependent allowance.
c) Subtract the dependent allowance.
6 Subtract incurred medical expenses. The remainder is the co-payment for the payment plan.

Reference: See Chapter H, Co-Payment, for the deduction of incurred medical expenses.

Example:

The couple has the following income:

  • Individual
    • $250 RSDI
    • + $130 Net earnings
  • Spouse
    • $800 Net earnings
    • Personal needs and protected earned income allowance calculation:
    • $250 RSDI unearned income
    • – $60 PNA
    • = $190 Remainder

Calculation for PEI when earnings are greater than $120:

  • Deduct $30 from the first $120 of earned income:
    • $120
    • – $30
    • = $90 Remainder of first $120 of earned income
  • Deduct one-half the remainder of the first $120 of earned income:
    • $90 Remainder of first $120 of earned income
    • / 2
    • = $45 One-half the remainder of the first $120 of earned income
  • Deduct 30 percent of earnings more than $120:
    • $130 Earnings
    • – $120 First $120 of earned income
    • = $10 Earnings more than $120
    • x .3
    • = $3 30 percent of earnings more than $120
  • Calculation of total PNA/PEI:
    • $60 PNA
    • + $30 PEI deduction from the first $120 of earned income
    • + $45 PEI deduction of one-half the remainder of the first $120 of earned income
    • + $3 PEI deduction of 30 percent of earnings more than $120
    • = $138 Total PNA/PEI
  • Co-payment calculation:
    • $250 RSDI
    • + $130 Net earnings
  • Step 1
    • = $380 Total
  • Step 2
    • – $138 Total PNA/PEI
    • = $242 Income available for diversion
  • Step 3
    • + $800 Spouse's income
    • = $1,042 Total
  • Step 4
    • – $3,715.50 Spousal allowance
  • Step 5 N/A
  • Step 6 N/A
    • = $0 Co-payment for payment plan

J-7400, Spousal Impoverishment Dependent Allowance

Revision 23-3; Effective Sept. 1, 2023

To calculate the dependent allowance for spousal cases, subtract the dependent's income from 150% of the monthly federal poverty level (FPL) for a family of two and divide the remainder by three. Mandatory payroll deductions also apply to a dependent's earned income.

Dependent family members were living in the institutionalized person’s home before the person entered a facility and are unable to support themselves outside the person’s home because of medical, social or other reasons. They may be either spouse's minor or dependent children, dependent parents or dependent siblings including half-brothers, half-sisters and siblings gained through adoption. 

Note: College students capable of supporting themselves do not meet the definition of a dependent.

The base amount (150% of the FPL for two) for calculating the dependent allowance is:

Date RangeAmount
July 1, 2023 to Present$2,465
July 1, 2022 to June 30, 2023$2,289
July 1, 2021 to June 30, 2022$2,178
July 1, 2020 to June 30, 2021$2,155
July 1, 2019 to June 30, 2020$2,114
July 1, 2018 to June 30, 2019$2,058
July 1, 2017 to June 30, 2018$2,030
July 1, 2016 to June 30, 2017$2,003
July 1, 2015 to June 30, 2016$1,992
July 1, 2014 to June 30, 2015$1,967
July 1, 2013 to June 30, 2014$1,939
July 1, 2012 to June 30, 2013$1,892
July 1, 2011 to June 30, 2012$1,839

Deduct the entire dependent allowance even if it is not made available to the dependent.

The community spouse can appeal the dependent allowance amount based on undue hardship caused by financial duress. Only hearing officers can set higher diversion amounts for cases of undue hardship. Review cases of undue hardship every six months to monitor for changes in circumstances.

Related Policy

General Information for Co-Payment, H-1000
Dependent Allowance, H-1600
Spousal Co-Payment, J-7200

J-8000, After Initial Eligibility Period

Revision 09-4; Effective December 1, 2009

After the initial eligibility period of the institutionalized spouse, HHSC does not apply the spousal protected resource amount and counts only the institutionalized spouse's resources for the purpose of eligibility redetermination, in accordance with Chapter F, Resources.

 

J-9000, Notice and Fair Hearing

Revision 09-4; Effective December 1, 2009

The couple may not appeal the SPRA at the time of the assessment.

The couple may appeal the SPRA after an application for Medicaid is filed.