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.