A. Chapter Contents

This chapter contains the following Topics:

Topic

1201.00    Share of Cost (SOC)

1202.00    Income Used for the SOC

1202.01 SSI Cash Recipient Residing in a Nursing Facility

1203.00    SOC Deductions

1203.01 Personal Needs Allowance

1203.02 Spousal Allowance (Non-Community Spouse)

1203.03 Family Allowance (Non-Community Spouse)

1203.04 Home Maintenance Allowance (Non-Community Spouse)

1203.05 Community Spouse Monthly Income Allowance (CSMIA)

1203.06 Utility Allowance

1203.07 Excess Shelter Allowance

1203.08 Community Spouse Family Allowance

1203.09 Medicare and other TPL Health Insurance Premiums

1203.10 Remedial or Non-Covered Medical Expenses

1203.11 Special Deduction for Some Residents of the Arizona State Veteran Home

1204.00    SOC Standards

1205.00    Co-Payments

1206.00    AHCCCS Freedom to Work Premiums

1206.01 Premium Billing and Payment

1206.02 Nonpayment of Premiums

1207.00   SSDI - Temporary Medical Coverage Program Premiums

1207.01 Premium Billing and Payment

1207.02 Non-payment of Premiums

B. Introduction

By reading this chapter you will learn:

• How to calculate Share of Cost for ALTCS and AHCCCS Freedom to Work-ALTCS customers;

• How share of cost is collected;

• Options available if a representative fails to pay the customer's share of cost;

• Who is required to pay co-payments and the co-payments amounts;

• How to determine premium payments for AHCCCS Freedom to Work (FTW) customers who are eligible for AHCCCS Medical Services; and

• Penalties for non-payment of AHCCCS FTW premiums.

A. Definition

The amount an ALTCS recipient is required to pay toward the cost of long term care services is called the share of cost. Share of Cost (SOC) is determined on a month-by-month basis.

B. SOC Amount

The following variables determine the share of cost amount:

• The customer's counted income (MS 1202.00);

• The customer's living arrangement (long term care medical facility, HCBS setting, or ALTCS acute);

• The period of time the customer resides in a medical facility during a calendar month;

• The level of service: Individuals who qualify for acute care services only do not have a share of cost;

• The SOC deductions for which the customer qualifies (MS 1203.00).

The maximum SOC that can be collected in a month is limited to the monthly capitation rate for the customer.

C. Who is Assessed a SOC?

Use the following chart to determine whether or not an ALTCS or AHCCCS FTW customer is assessed a share of cost:

Program

Medical Institution

HCBS

ALTCS Acute Care Only

No SOC

No SOC

ALTCS

SOC

SOC

AHCCCS FTW

SOC

Zero SOC

D. AHCCCS FTW-ALTCS

Calculate an institutional SOC for each AHCCCS FTW-ALTCS customer who is living in an institution. 

Recalculate the institutional SOC each time there is a change in the customer's income or the amount of the SOC deductions. Remember that changes in the income or shelter expenses of a spouse or dependent children may affect the amount of the customer's SOC deductions. 

An AHCCCS FTW-ALTCS customer who resides in an HCBS setting is never expected to pay a SOC. However, ALTCS program contractors need the alternate SOC to complete a cost-effectiveness study for HCBS customers. The alternate SOC for an AHCCCS FTW-ALTCS customer who resides in an HCBS living arrangement is always zero. 

E. SOC for the Month of Death

During the month in which a customer dies, the capitation rate is prorated. Share of cost must still be collected for the month in which the customer died, but the amount must not exceed the prorated capitation amount. 

When the program contractor determines that the customer's SOC exceeded the prorated capitation amount, the program contractor sends an ALTCS Member Change Report form to the ALTCS Local Office requesting a SOC adjustment for the month of death. 

Disposition the SOC adjustment based on the program contractor's request.

G. SOC Refund

If a customer who is enrolled with a program contractor is residing in a nursing facility at the beginning of the month and then moves home (or into an HCBS setting) sometime during the month, the share of cost must be returned to the customer. The community PNA applies because the customer did not reside in a nursing facility for the entire calendar month.  

Recalculate the SOC using 300% of the FBR for the Personal Needs Allowance. 

H. SOC Collection

The ALTCS Program Contractor is responsible for collecting the share of cost.

• When the customer resides in a nursing facility, the program contractor may delegate this responsibility to the nursing facility. 

• When the customer receives HCBS, the program contractor may designate this responsibility to the HCBS provider that provides the majority of the home service.

If the member...

Then the Program Contractor...

Is eligible, but not enrolled during a specific month

Is not responsible for collecting the member's share of cost for that month.

Is eligible and is enrolled with a ALTCS Program Contractor for one or more days within a month

Is responsible for collecting the share of cost

Changes program contractors during the month

Each ALTCS Program Contractor is entitled to a portion of the monthly share of cost, based on the number of days the member is enrolled with each program contractor. 

The program contractor with whom the member is first enrolled during the month is responsible for:

• Collecting the share of cost;

• Calculating each program contractor's prorated share of cost; and

• Transferring the correct prorated SOC amount to the receiving program contractor.

EXAMPLE: September is a 30-day month. The customer's share of cost is $500.00. The customer is enrolled with Program Contractor A for 7 days and with Program Contractor B for 23 days. Each program contractor's portion of the monthly SOC is calculated as follows:

• Program Contractor A: 7 /30 = .233 x $500 = $116.50

• Program Contractor B: 23/30 = .767 x $500 = $383.50

I. Non-Payment of SOC

When a legal representative or any other representative is responsible for paying a customer's share of cost but does not, and Social Security funds are involved in the SOC payment the nursing facility can ask the program contractor to initiate a fraud referral (MS 1806).  

The program contractor may also seek recourse by making a referral to the entity (e.g., Probate Court) that appointed the legal representative to make that entity aware that the representative is not fulfilling required responsibilities. 

A. Income Counted in the SOC Calculation

In general, use the customer's counted gross income, determined according to MS 600.00, for the share of cost calculation. 

The amount of counted income used for the income eligibility calculation is the same amount used for the share of cost calculation, with the following exceptions:

When the customer...

Then...

• Receives SSI-Cash; and

• Resides in a nursing facility

Count less than the actual amount of SSI-Cash received by the customer (MS 1202.01).

• Is a veteran or the surviving spouse of a veteran;

• Has no spouse or dependents; and

• Is a resident of the Arizona State Veteran Home

Count for the share of cost calculation all VA benefit amounts received by the customer for:

• Aid and attendance (MS 607.92); and

• Unusual medical expenses (MS 607.97). 

(Payments for aid and attendance and unusual medical expenses are unavailable in determining income eligibility.)

Has ALTCS eligibility determined using AHCCCS FTW policy

Count all of the customer's gross income, both earned and unearned, in the SOC calculation. The income disregards that are used in determining AHCCCS FTW income eligibility do not apply to the SOC calculation.

Has eligibility determined using Community Spouse policy

Count only the customer's income for the share of cost calculation, even when community property rules are used to determine income eligibility.

A. Policy

Do not use the actual SSI cash payment in the SOC calculation when all of the following (two) conditions are met:

Condition

Verification

The customer receives an SSI cash payment.

• SDX microfiche;

• A WTPY; or

• PMMIS screen RP-285, Inquire Eligibility and Enrollment

The customer resides in a certified medical institution. 

Call the medical facility and verify the customer's residence, then find the facility name on the Living Arrangement tab of the Personal Data window. 

NOTE: The full amount of SSI-Cash benefits currently being received by the customer is used when determining whether ALTCS is or will be paying more than 50% of the cost-of-care.

B. Anticipating Action by the SSA

When the Social Security Administration (SSA) receives notification that a SSI Cash recipient is eligible for ALTCS and residing in a certified medical institution, SSA reduces the SSI payment to either $30.00 or less, or discontinues SSI Cash depending on the amount of other income the individual receives. In addition the SSA initiates an overpayment collection process to recover SSI payments made during prior months that exceeded the reduced amount of SSI for which the individual was eligible.

Estimate the reduced SSI Cash amount and use the reduced amount in the share of cost calculation until SSA actually reduces or discontinues the SSI Cash payment.

C. How to Estimate the Reduced SSI Amount

Apply the following rules to determine whether to reduce the amount of the SSI Cash payment to $30.00 or zero for the share of cost calculation:

If the customer has...

Then reduce the amount of the SSI Cash to...

Only SSI income

Reduce the SSI payment to $30.00

• SSI; and

• Other income that is equal to or greater than $50.00

Reduce the SSI payment to zero. 

• SSI; and

• Other income that is less than $50.00

Reduce the SSI payment to the difference between $50.00 and the other income, but not to exceed $30.00.

D. Applications

If an applicant meets the two conditions in A, anticipate that the income reduction beginning with the first month the applicant is determined ALTCS eligible and continuing until such time as SSA actually reduces or discontinues SSI.

EXAMPLE: An ALTCS application dated January 10^th is ready to be dispositioned on March 20, and the customer received SSI of $579.00 in January, February and March and no other income. Use SSI income of $30.00 for January, February, March and ongoing until SSA actually reduces the SSI benefit amount. 

Even though the customer already received full SSI payments for January, February and March, SSA will collect the overpayment so counting only $30.00 as income is appropriate. 

E. SOC Change for an On-going Case

When an ALTCS recipient who is receiving SSI Cash enters a nursing facility reduce SSI income to the anticipated reduced amount beginning with the first prospective month for which a change can be made. This month can be determined using the Timeliness Schedule.

F. Entering the Reduced Amount in ACE

Pending verification from SSA, adjust the SSI-Cash in ACE to the estimated reduced amount. When it appears that SSA will terminate SSI benefits, enter the SSI amount as zero. Do not delete the SSI income type until you receive confirmation that SSA has stopped the payments.

F. Notifying the SSA

Send a DE-139 (SSA Notification Form) to SSA when the following changes occur:

• A SSI-Cash recipient residing in a nursing facility is approved for ALTCS;

• An ALTCS recipient who receives SSI-Cash enters a nursing facility; or

• An ALTCS recipient who is receiving SSI-Cash is discharged from a nursing facility to a HCBS setting.

G. Confirmation from the SSA

When you receive verification of the changed amount of SSI from SSA, compare this amount to the estimated amount previously entered in ACE. 

.

If the customer...

Then...

Continues to be eligible for a reduced SSI amount

Ensure that the actual amount of SSI cash is included in the SOC calculation for the next available processing month (taking into consideration adverse action cutoff if the projected amount was less than the actual amount).

Is no longer eligible for SSI Cash

Remove the SSI Cash income type for the next available processing month.

A. Overview

To calculate the share of cost amount, certain deductions (when applicable) are allowed from the customer's total counted income. The allowable deductions vary depending upon the policy used to determine eligibility.

All ALTCS customers receive a Personal Needs Allowance. ALTCS customers must meet the specific conditions described in this chapter to qualify for any of the other deductions.

B Non-Community Spouse Policy

A customer who does not have a community spouse may qualify for the following share of cost deductions. Subtract these deductions from the customer's total counted income in the following order: 

• Personal Needs Allowance (MS 1203.01);

• One of the following maintenance needs allowances:

o  Spousal Needs Allowance (MS 1203.02);

o  Family Needs Allowance (MS 1203.03); or

o  Home Maintenance Needs Allowance (MS 1203.04);

• Medicare and Other TPL Health Insurance Premiums (MS 1203.09);

• Remedial or Non-Covered Medical Expenses (MS 1203.10); and

• Special deduction for some residents of the Arizona State Veteran Home (MS 1203.11).

C. Community Spouse SOC Policy

A customer may qualify for the following share of cost deductions when the customer has a community spouse (MS 509.00) and the customer's income eligibility for ALTCS services is determined using either ALTCS or AHCCCS Freedom to Work income budgeting. 

Subtract these deductions from the customer's total counted income in the following order:

• Personal needs allowance (MS 1203.01);

• Community spouse monthly income allowance (CSMIA). The income of the institutionalized spouse must actually be made available to the community spouse to allow this deduction in the share of cost calculation (MS 1203.05);

• A family allowance, for each family member. The income of the family member must be verified in order to allow this deduction from the share of cost. Family members include only minor or dependent children, dependent parents, or dependent siblings of the institutionalized or community spouse who are residing with the community spouse (MS 1203.08);

• Medicare and Other TPL Health Insurance Premiums (MS 1203.09);

• Remedial or Non-Covered Medical Expenses (MS 1203.10); and

• Special deduction for some residents of the Arizona State Veteran Home (MS 1203.11).

D. AHCCCS FTW-ALTCS Policy

A customer whose eligibility for ALTCS services is determined using AHCCCS FTW policy is assessed a SOC only when residing in a medical institution (MS 1201.C) and may qualify for the following share of cost deductions. Subtract these deductions from the customer's total counted income in the following order: 

• Increased Personal Needs Allowance (MS 1203.01);

• Either a non-Community Spouse maintenance needs allowance (MS 1203.02, MS 1203.03 or MS 1203.04) or a Community Spouse CSMIA (MS 1203.05) and a Community Spouse Family Allowance (MS 1203.08), as applicable);

• Medicare and Other TPL Health Insurance Premiums (MS 1203.09);

• Remedial or Non-Covered Medical Expenses (MS 1203.10); and

• Special deduction for some residents of the Arizona State Veteran Home (MS 1203.11).

A. PNA Amount

The amount of the personal needs allowance is determined on a month-by-month basis.

The amount of the personal needs allowance depends on whether the customer is in a long term care medical facility for an entire calendar month. A long term care medical facility is a medical institution other than an acute care hospital. To be in a long term care medical facility for an entire calendar month, the customer must enter a long term care medical facility in a prior month and not be discharged to an acute care hospital or a non-medical living arrangement during the month. The customer may transfer among long term care medical facilities during the month.

When the customer enters an acute care hospital during the month, consider the living arrangement that the customer resided in prior to entering the hospital to be the living arrangement during the period of hospitalization. For example, if the customer is discharged from a nursing facility and enters an acute care hospital, the customer is still considered to be residing in the nursing facility during the period of hospitalization.

The amount of personal needs allowance is calculated as follows:

If the customer ...

Then the PNA is...

Resides in a long term care medical facility for an entire calendar month

15% of the FBR

Note: Temporary absence due to an acute care hospitalization does not affect the PNA

Resides during any portion of the calendar month in:

• His or her home;

• An alternative residential setting;

• A penal institution (MS 523.00).

300% of the FBR

Note: Temporary absence from the long term care medical facility due to acute care hospitalization does not affect the PNA.

Is an applicant and resides in an acute care hospital for one or more entire calendar months beginning with the month of application and is medically eligible for those months

300% of the FBR if the applicant resided in an approvable HCBS setting prior to admission to the hospital; or

15% of the FBR if the applicant resided in an approved long term care medical institution prior to entering the hospital.

Note: No share of cost is assessed if the applicant resided in an ALTCS acute care living arrangement described at MS 519.04.B or MS 519.04.C prior to the hospitalization.

B. PNA for IMD Placements

Institutions for Mental Diseases (IMDs) include Psychiatric Hospitals described at MS 519.00.C. Generally ALTCS eligibility in an IMD is limited to persons under age 21, or persons under 22 who entered the IMD prior to age 21, and persons aged 65 and older. 

However, a federal waiver allows limited Medicaid coverage for persons from the ages of 21 through 64 who enter an Institution for Mental Disease (IMD). Persons between the ages of 21 and 64 who enter an IMD can be determined eligible for AHCCCS long term and acute care benefits for 30 days per occurrence and 60 days per contract year (July 1 through June 30). 

How the share of cost is determined for these individuals depends on the length of placement in an IMD and the customer's other living arrangements during a budget month. MS 516.00 contains additional information about applicants age 21 through 64 who enter an IMD and MS 1500.00 provides more information about recipients in that age group who enter an IMD. 

Determine the PNA amount as follows:

If a customer...

Then allow a PNA equal to...

Resides in an IMD for an exact 30-day calendar month (which coincides with their eligible 30-day period)

15% of the FBR

Resides in an IMD (during an eligible period up to 30-days) and another long term care medical facility for the balance of the month, then the individual lived in a long term care medical facility for the full month. 

15% of the FBR.

Resides in an HCBS living arrangement and in an IMD (during an eligible period up to 30-days) in the same month

300% of the FBR

Has an eligible 30-day period that ends in a month, and there are days of ineligibility in that month, no SOC is assessed for that month. 

N/A

Notify the Technical Service Center to manually remove the SOC calculated for the month.

C. Increased PNA for AHCCCS FTW-ALTCS

A customer who qualifies for ALTCS services under AHCCCS FTW and resides in a long term care medical institution receives an increased PNA equal to the standard institutional PNA (15% of the FBR) plus 50% of the customer's gross earned income for the month.

Remember: A self-employed customer's net income from self-employment (gross income of the business minus all business expenses) is his or her gross earned income.

EXAMPLE: A customer earns $1,000.00 per month and lives in a NF:

Standard Institutional PNA $ 95.55

Plus 50% of $1,000 $500.00

Increased PNA $ 595.55

A. Who qualifies?

A customer with only a spouse residing in the home will have an amount deducted for the maintenance needs of the spouse. 

A customer may qualify for a Spousal Allowance when:

• Eligibility is determined for ALTCS or AHCCCS FTW-ALTCS using non-community spouse policy;

• The customer has only a spouse residing in the home, but is not legally married (MS 509.01).

The customer may be residing either in a medical facility or in the community. 

NOTE: Do not use this allowance if dependent children live with the spouse. Instead, determine eligibility for a Family allowance (MS 1203.03)

B. Amount

Determine the spousal maintenance needs allowance by subtracting the spouse's counted income from the amount of the Individual FBR shown in MS 1204.00.

A. Who Qualifies

A customer with children residing at home receives a deduction for the maintenance needs of the family (including a spouse who resides at home with the children). The customer may be residing either in a medical facility or in the community.

A customer may qualify for a Family Allowance when:

• Eligibility is determined For ALTCS or AHCCCS FTW-ALTCS using non-community spouse policy;

• The customer has children residing home.

A family may consist of:

• An eligible or ineligible spouse who is not legally married (MS 509.01) to the customer and eligible or ineligible children, or

• Eligible or ineligible children.

B. Amount

Determine the amount of the Family Allowance by subtracting the combined counted income of the spouse and children from the AFDC A-1 Need Standard (MS 1204.00.C) that corresponds to the number family members (excluding the customer).

C. Example

Mr. Z resides in a nursing facility.  Mrs. Z (who is not legally married to Mr. Z) lives at home with their three young children. Mrs. Z has gross earned income of $600/month. Each child receives a Social Security payment of $132 per month based on MR. G's eligibility for Social Security Disability.

AFDC Need Standard for a family of 4 (wife + 3 children)=$1,162.00

Income of spouse & children ($600 + $132 + $132 + $132)-$996.00

Family Allowance = $166.00

A. Who qualifies?

The customer may qualify for a Home Maintenance Needs Allowance when the customer:

• Has eligibility determined for ALTCS or AHCCCS FTW-ALTCS using non-community spouse policy;

• Resides in a medical institution for an entire calendar month;

• Does not have a spouse or child residing at home;

• Is responsible for paying expenses to maintain his or her home;

• Is likely to return to the home within 6 months of the date of institutionalization.

B. Shelter Expenses

The customer must provide documentation that he or she has shelter expenses that need to be paid to maintain the home. Shelter expenses may include rent, mortgage, property tax, homeowner's insurance and utilities. 

Shelter expenses must be verified and entered in ACE on the Expenses tab of the Expenses window. The Expenses window is located in the Financial menu.

C. Likely to Return Home

A physician must certify in writing that the customer is likely to return to the home within six months from the date of institutionalization.

• The physician's certification must be received prior to the date the customer is expected to return home and must contain the potential discharge date. 

• Once the physician's certification is received, the home maintenance needs allowance may be deducted beginning the first month following the month the customer entered the medical institution. However, retroactive share of cost adjustments are limited to the three-month period proceeding the current month.

D. Duration of Home Maintenance Needs Allowance

The home maintenance allowance can only be deducted for a period of up to six months from the date of institutionalization. 

The home maintenance allowance can be applied to separate periods of institutionalization for the same customer. A temporary absence from an institution, however, is not a basis for beginning a new 6-month period for the deduction. Each six-month period for a home maintenance allowance must be separated by a discharge from the institution.

E. Examples

EXAMPLE: The customer entered the nursing home in October. She applied for ALTCS in November. On December 15, the ALTCS local office received the written statement from the customer's doctor certifying that she was likely to return to her home sometime in April. The customer qualifies for a home maintenance allowance for the months of November through April.

EXAMPLE: The customer was institutionalized in August. He applied for ALTCS shortly after being admitted to the nursing home. The physician's statement certified that the customer would most likely return to his home in March the following year. Since he is expected to remain institutionalized for more than six months, he does not qualify for a home maintenance needs allowance.

F. Amount

When the customer qualifies for the Home Maintenance Needs Allowance, allow the standard deduction regardless of the actual amount of the customer's expenses. The home maintenance needs allowance standard changes periodically and is listed in MS 1204.00.D. 

In the case of institutionalized couples, only one Home Maintenance Needs Allowance is permitted. If both spouses are expected to return home within the six-month period, the Home Maintenance Needs Allowance is deducted from the share of cost of the spouse for whom it would be most beneficial.

G. System Instructions

Detailed instructions are in Chapter 47 of the ALTCS ACE Procedures Manual.  

The following information must be entered in ACE to enable a Home Maintenance Allowance:

Information

Location

1

An institutional living arrangement

Living Arrangement window

2

A potential discharge date

Living Arrangement window

3

Intent to return home

Living Arrangement window

4

Shelter expenses

Expenses tab of the Expense window

A. Who Qualifies?

A customer may qualify for a Community Spouse Monthly Income Allowance (CSMIA) when:

• Eligibility is determined For ALTCS or AHCCCS FTW-ALTCS using community spouse policy;

• The customer's spouse is living in the community; and

• The customer actually makes his or her income available to the community spouse. 

The customer may also qualify for a Community Spouse Family Allowance when a dependent family member lives with the community spouse.

B. Definitions

The following definitions apply to this subsection: