Posts Tagged ‘CSRA’

PA Federal Court Settlement May Affect Arizona’s ALTCS


A settlement finalized last month in a Pennsylvania Federal Court may have some effect on Arizona’s ALTCS program. The settlement was reached in a three-year-old class action filed by Medicaid long-term care recipients and their non-institutionalized spouses.

Under federal Medicaid law, the non-institutionalized spouse of a Medicaid recipient is entitled to retain sufficient income to ensure basic necessities of life. Currently, this means that the community spouse is entitled to at least $1,295 per month; if the community spouse’s own income does not reach that amount, he or she is entitled to special treatment in the application process.

Pennsylvania previously interpreted that Federal provision the same way as Arizona currently does: when the community spouse’s income is insufficient, he or she was permitted to retain a portion of the institutionalized spouse’s income to make up the difference. The lawsuit challenged that approach. Instead, argued lawyers for Pennsylvania Medicaid recipients, the community spouse should be first permitted to retain additional assets (beyond those already permitted by separate Medicaid provisions, usually referred to as the “Community Spouse Resource Allowance”). The additional assets should be sufficient, they argued, to provide the required additional income. Only if the couple’s total assets were insufficient to ensure the $1,295 per month to the community spouse should the institutionalized spouse’s own pension income be tapped.

The effect of this approach would be to permit the spouses of many Medicaid applicants to retain significantly larger portions of their joint assets. In cases where the institutionalized spouse is the first to die, this would also help the surviving, community spouse to afford living expenses after Medicaid eligibility no longer made any difference.

Pennsylvania’s Medicaid agency has now admitted that its approach to calculating the “share of cost” (which was identical to Arizona’s methodology) was incorrect. Instead, community spouses will be entitled to keep sufficient assets to purchase an annuity large enough to make up the difference in income between the community spouse’s pension and $1,295. Hurly v. Houston, U.S. District Court, Eastern District of Pennsylvania, July 1, 1996.

Increases in Health Care Spending Slowed in 1994

Federal figures for 1994, recently released, show that the cost of medical care continue to rise at a rate faster than inflation. Still, the good news is that the increase was the smallest in three decades.

According to HCFA Review, the quarterly journal of the Health Care Financing Administration, the 1994 increase in medical costs was 6.4%. The smaller increase, however, was larger than the general increase in cost of living, with the result that the portion of our Gross Domestic Product devoted to health care also increased slightly, from 13.6% to 13.7%.

Of the $949.4 billion spent on health care in 1994, the federal-state Medicaid program accounted for $122.9 billion (or about 13%). Of that figure, the federal government contributed $78.4 billion and the remaining $44.5 billion came from state governments.

While overall health care costs increased 6.4%, Medicaid costs increased by 7.7%. This figure, like the overall health care costs, represented a decrease in the growth rate. Medicare, the federal insurance program for health care for the elderly and disabled, increased its outlays during the same period by 11.4%.

The 1994 figures represent an expenditure of $3,510 by each American on health care costs.

MMMNA Increased

MAY 9, 1994 VOLUME 1, NUMBER 24

The 1994-1995 figure for the Minimum Monthly Maintenance Needs Allowance (or MMMNA) has been announced. Beginning July 1, 1994, community spouses of ALTCS patients will be entitled to retain sufficient income to guarantee at least $1,230 in total monthly income.

The new figure represents an increase of $51 per month over the previous level. Prior to the increase, a community spouse was permitted to retain $1179 of the total community income each month.

In addition to the MMMNA, the community spouse may be entitled to an excess shelter allowance of up to $369 per month. This also reflects an increase, from a maximum of $354 in fiscal year 1993-1994. In addition, the community spouse may retain excess income for extraordinary or exceptional costs, with a new cap on the total amount retained of $1817.

While the community spouse is permitted to retain as much of the institutionalized spouse’s income as necessary to reach the monthly maintenance needs allowance (between $1230 and $1817), the institutionalized spouse is also permitted to retain a personal needs allowance. In fact, the personal needs allowance is available to every institutionalized ALTCS patient. This allowance, which is also fixed by federal law, is set at 15% of the maximum monthly SSI benefit, which translates to $66.90 for calendar year 1994.

Numbers, Numbers …

As long as we’re talking about numbers, let’s review a few other important ones.

Income Eligibility

Of course, the most infamous of all long-term care numbers is the income eligibility limit. If an applicant for ALTCS benefit receives more than $1338 per month in income from all sources, he will simply not be eligible.

Two important variations on this hard-and-fast rule need mentioning. If the applicant is married, and “his” income exceeds $1338 per month but the total community income does not exceed $2676, he will still be eligible. And even if his (or their) income is too high, it may be possible to establish a “Miller”-type trust to permit eligibility.

The income eligibilty number changes with each calendar year. The 1993 number was $1304.


The Community Spouse Resource Allowance is the value of available assets the community spouse is allowed to retain and still have the institutionalized spouse obtain ALTCS benefits. This figure is one-half the value of available community resources held at the time of admission to the hospital or nursing home, with an upper and lower limit.

No matter how little a couple is worth, the community spouse is permitted to retain at least the first $14,532. And wealthier couples are not permitted to retain more than $72,660 as the community spouse’s “half.” This area is particularly complex, and care must be taken not to overlook techniques (many of them quite simple) for maximizing the community spouse’s “share.”

Average Cost of Care

The primary significance of this figure is in determining the penalty period suffered by ALTCS applicants who have made gifts during the previous three years. The estimate of typical nursing home care costs is divided into the total amount of gifts to determine the number of months of ineligibility.

Currently, the figure for Pima and Maricopa counties is $2406.30; for all other Arizona counties it is $2321.10. This despite the fact that long-term care actually costs as much as $3500 per month.

ALTCS and Community Resources


A little-known and seldom-used section of federal law may provide relief for married couples who have difficulty meeting asset limitation for Arizona Long Term Care System (ALTCS) eligibility. The relatively obscure provision requires ALTCS to increase the value of assets which a “community spouse” is entitled to retain under some circumstances.

Most workers who deal with ALTCS eligibility are familiar with the concept of a “Community Spouse Resource Allowance” (CSRA). When one spouse enters a hospital or nursing home, the community spouse may retain half the assets “available” to the community at the time of admission (plus the residence and some other assets). The maximum amount of this Allowance is usually $72,660.

For some poorer couples, the government’s largesse may permit retention o all (or nearly all) the community’s assets. No matter how little is available at the time of admission, the community spouse is always permitted to retail a minimum of $14,532 in addition to the residence, vehicle and some other assets.

Can You Pronounce MMMNA?

But the maximum CSRA is not really $72,660. The obscure (but highly useful) provision that requires a higher CSRA is found in 42 United States Code Section 1396r-5(e)(2)(C). That law, which is binding on Arizona’s ALTCS program, provides that:

If…the community spouse resource allowance… is inadequate to raise the community spouse’s income to the minimum monthly maintenance needs allowance, there shall be substituted, for the community spouse resource allowance…an amount adequate to provide such a minimum monthly maintenance needs allowance.

But what on earth is a “minimum monthly maintenance needs allowance?” In a different context, Congress decided that a community spouse should be entitled to retain the first $1179 of community income to ensure sufficient funds to maintain basic needs (this number can also be increased in some circumstances). All section 1396r-5(e)(2)(C) says is that the community spouse is entitled to retain enough assets to guarantee that he or she receives that $1179 per month, even though that may be more than the $72,660 (or whatever the CSRA equals in an individual case).

Fair Hearings

There is one catch to the increased CSRA. Eligibility officers are not able to invoke the provision during the initial eligibility application. The higher CSRA can only be granted after a “fair hearing”–usually in the course of an appeal from the denial of eligibility. But since most eligibility workers are unfamiliar with the provision, and since no one is telling applicants to appeal from denials (ALTCS usually just talks applicants into withdrawing applications), many eligible couples may be denied benefits to which they are entitled.

In such cases, it may be advisable for applicants to have legal counsel during the application process and subsequent appeal. Substantial assets may be retained by the community spouse, making the cost of legal advice seem reasonable by comparison.

Safe Return

Demented patients who wander away from home care settings can be very difficult to deal with. For many family members, the fear of losing a wandering family member may make it impossible to keep a patient at home.

While it does not provide a complete solution, the Alzheimer’s Association has come up with a plan to help families deal with anxiety about wandering. The “Safe Return” program provides an identifying bracelet, a national registry, an 800 number contact system, and wallet and garment tag identification for patients prone to wandering. The year-old national program may provide peace of mind for family caretakers, and has the potential to save patient’s lives and permit community placement in more instances. For information about Safe Return, contact the Alzheimer’s Association at (800)272-3900.

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