2559 Patient Liability / Cost Share Budgeting | Medicaid

Georgia Division of Family and Children Services
Medicaid Policy Manual

Policy Title:

Patient Liability / Cost Share Budgeting

Effective Date:

December 2022

Chapter:

2550

Policy Number:

2559

Previous Policy Number(s):

MT 58

Updated or Reviewed in MT:

MT-68

Requirements

A patient liability/cost share budget is completed on all Medicaid recipients in a nursing home (NH), Institutionalized Hospice, CCSP/EDWP, ICWP or NOW/COMP.

Basic Considerations

A patient liability/cost share budget is completed at the following times:

at approval of the application
- to calculate the patient liability for the first month of eligibility
- to remove the protection of income deduction
when a change in income occurs
when a change in incurred medical expenses (IME) occurs
at the beginning of each new averaging period.

Procedures

Follow the steps below to complete the patient liability.

Step 1	Determine the amount of the A/R’s income to divert to his/her spouse/dependents at home. Refer to 2554 Diversion of Income for the correct maintenance need standard to use. Use the ADJUSTED GROSS income of the spouse/dependents, including In- Kind Support and Maintenance (ISM) received by the spouse/dependents. Refer to 2430 Living Arrangement and In-Kind Support and Maintenance for ABD Medicaid.
Step 2	If the recipient is Medicaid eligible under the Nursing Home, CCSP/EDWP, Institutionalized Hospice, ICWP or NOW/COMP classes of assistance, use average income and IMEs in the patient liability budget. Refer to 2557 Averaging Income and Incurred Medical Expenses. Proceed to Step 3.
Step 3	Calculate patient liability/cost share. The PL/CS should never exceed the monthly Medicaid billing rate for the facility in which the A/R resides. Complete Section C of Form 968 if a manual budget is used to calculate patient liability/cost share. Refer to 2552 Patient Liability/Cost Share Deductions for information on the deductions subtracted. Refer to 2418 VA Income for information on VA Aid and Attendance payments in the budget.

Special Considerations

CCSP/EDWP to Nursing Home

Calculate a CCSP/EDWP cost share for the month a recipient enters a nursing home from CCSP. There is no patient liability for the month of nursing home admission.

Nursing Home to CCSP/EDWP

Re-calculate the nursing home patient liability for the month an A/R goes into CCSP/EDWP from a nursing home using the FBR as the PNA. There is no cost share for the month of admission to CCSP.

A/R’s Income Exceeds the Medicaid Cap

If the A/R’s income is equal to or greater than the Medicaid Cap and the A/R has not established a Qualified Income Trust (QIT), the A/R is not eligible for the nursing home COA. If A/R is eligible under another COA, such as AMN there will be no vendor payment made to the NH nor payments for LTC services (LA-D Providers) on his/her behalf.

A/Rs who establish a QIT may meet the income eligibility requirement based on the income not placed in the QIT. However, the PL/CS calculation uses income the A/R receives and the income placed in the QIT. Refer to 2407 Qualified Income Trust for further instructions.

Transfer from out of state Nursing Home to Georgia Nursing Home

When an A/R transfers directly from an out-of-state nursing home to a nursing home in Georgia, calculate the patient liability for the month of admission using the actual payment made to the out-of-state nursing home as an IME.