E1201 ALTCS Share of Cost (SOC) Examples

1)    Family Allowance (Non-Community Spouse) Example

The customer lives in a nursing facility.  His wife lives at home with their three young children.  There is no proof of legal marriage. The wife has gross earned income of $600/month.  Each child gets Social Security Survivors benefits of $132 per month.

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

2)    Home Maintenance Needs Allowance Examples

Expected to be Institutionalized Six Months or Less

The customer is an unmarried woman.  She entered the nursing home in October.  She applied for ALTCS in November.  On December 15, the ALTCS local office received a written statement from the customer’s doctor certifying that she is likely to return to her home sometime in April. 

October through April is exactly six months.  The customer qualifies for a home maintenance allowance for the months of November through April.

Expected to be Institutionalized More Than Six Months

The customer is an unmarried man.  He entered a nursing home in August.  He applied for ALTCS at the end of August.  The customer’s doctor provided a statement that certifying that the customer would most likely return to his home in April 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.

3)    Community Spouse Monthly Income Allowance Example

The customer applies in November 2021.  His spouse lives at home and has the following counted monthly income and expenses:

·        $1200 – Pension benefit

·        $400 – Mortgage (includes property taxes)

·        $130 - Condominium maintenance fee (includes $15 utility charge)

·        $70 – Homeowner’s insurance

The spouse’s CSMIA calculation is shown in the following table:

4)    Community Spouse Family Allowance Examples

Customer is receiving ALTCS and has two dependents living at home with the community spouse. One dependent is the spouse’s brother, and the other is the 30-year old child of the customer and spouse.

The brother’s total monthly income is $824 in Social Security Retirement benefits.  His family allowance amount is calculated below:

The adult child’s total monthly income is $300 in spousal support (alimony). Her family allowance amount is calculated below:

The total Community Spouse Family Allowance is $1076.99.

5)    Prorating Health Insurance Premiums Example

The following table shows how to convert a premium to a monthly amount when the customer chooses this option.

Example

Ms. H is billed quarterly for a $120.00 health insurance premium. The quarterly payment is divided by three to get a monthly amount of $40.00.

6)    Pension Supplement for Health Insurance Premiums Examples

Example 1

The customer receives $200 from his pension plan every month to help pay for his medical insurance.  His premium is $250.  The $200 payment is not counted as income because the entire amount is a reimbursement for a medical expense he pays. 

Since the reimbursement does not cover the whole cost of the insurance, the customer gets a $50.00 SOC deduction for the portion of his insurance premium payment that is not covered by the pension supplement.

Example 2

The customer receives a pension supplement of $100 as partial reimbursement for medical insurance premiums for himself and his spouse.  He pays $150 per month for health insurance for both of them ($75 each).  Because the amount he actually pays in medical insurance premiums is higher than the reimbursement he receives, the entire $100 is not counted as income. 

For SOC, only the customer’s share of the premium is considered.  Since the $100 reimbursement is more than his share of the premium ($75), no SOC deduction is allowed.

Example 3

The customer receives a pension supplement of $192.80 per month designated as reimbursement of Medicare premiums for himself and his spouse.  Social Security deducts Medicare premiums of $96.40 from each spouse’s gross benefit. 

The half of the reimbursement that covers the customer’s Medicare premium is not counted as income.  The customer does not receive a SOC deduction for Medicare expenses because the pension supplement reimburses his cost. 

Because his wife pays her own Medicare premium as a deduction from her benefit, the other half of the pension supplement ($96.40) is counted unearned income to the customer.  When AHCCCS begins paying the customer’s Medicare Part B premium, the entire $192.80 will be counted unearned income to the customer.

7)    Extra Help Medicare Part D Coverage Example

The customer receives Extra Help from the Social Security Administration to help pay her Medicare Part D premium.  Her Part D premium is $37.00 per month and Extra Help pays $34.20 of that amount.  Since she pays more for her premium than the Extra Help covers, she gets a $2.80 SOC deduction for the part of her Part D premium that is not covered by the Extra Help program.

8)    Expenses Incurred While an Application is Pending Examples

Example 1

The customer applied for ALTCS in July and is eligible.  She has an unpaid bill for a non-covered medical expense incurred in June.  The unpaid expense is deducted from the July SOC.  If the expense is more than the share of cost without the deduction, the remaining unpaid balance is allowed as a share of cost deduction for August and ongoing months until the full amount has been allowed.

Example 2

The customer applies for ALTCS in May.  He does not qualify for ALTCS in May, but is approved for June and ongoing.  The customer incurred and paid a non-covered medical expense in May.  Since the bill was paid in a month in which the customer was ineligible, it cannot be allowed as a SOC deduction for a later eligible month.

9)    Current Payments for Services Example

The customer is on ALTCS and has a SOC of $583.00.  On August 5th, she turns in proof that she paid a $700 dental bill on July 30th.  The $700 payment is allowed as a SOC deduction for July only, reducing the July SOC from $583.00 to zero.

10) Unpaid Balances Example

The customer’s SOC is $120.00.  In May, he provides proof that he incurred expenses of $525.00 for dentures and a dental check-up during January.  The proof also shows that Mr. L’s insurance company paid $225.00 of the expenses, leaving a balance of $300.00 for which the customer is responsible. 

The unpaid balance is higher than the customer’s monthly SOC, so the SOC is reduced to $0.00 for June, $0.00 for July and $60.00 for August, when the full $300 has been allowed.

11) Allowable SOC Deduction Amount Calculation Example

The customer has been on ALTCS since January.  In February, he incurred a bill of $400.00 for a hearing aid and batteries.  Blue Cross paid only $100.00 of this bill, leaving a $300 unpaid balance, which is the customer’s responsibility.  He began paying $25.00 per month toward the bill starting in March. 

It is now July and the customer remembers to report the bill to the ALTCS worker. In July (current month), he reports this bill to the Eligibility Specialist.  The worker gets proof of the total bill, the amount paid by Blue Cross and all payments made from February through July.  The amount of allowable non-covered medical expense is calculated as follows:

The current payments are deducted from the SOC for the months in which the payments were made ($25 in June and $25 in July).  The unpaid balance is deducted from the SOC for the next month (August).

12)  Calculating the Share of Cost (SOC) deduction for Non-Covered Medical Expenses Example

The customer has been receiving ALTCS benefits since January.  In February, the customer received a bill of $400.00 for a hearing aid and batteries.  Blue Cross paid only $100.00 of this bill.  In March, the customer began paying $25.00 per month toward the bill.  In July (the current month), the customer reports this bill to an Eligibility Specialist.  The Eligibility Specialist obtains verification of the total bill, the amount paid by TPL, and all payments made from February through July.  The amount of allowable non-covered medical expense is calculated as follows:

The current payments are deducted from the SOC for the months when the payments were made (June and July).  The unpaid balance is deducted from the SOC for the next prospective month (August).

13)  Personal Needs Allowance (PNA) Calculation for Garnished Child Support or Spousal Support Example

The customer is on ALTCS and has total income of $1000.00 per month. He lives in a nursing facility. His PNA for August 2019 is $115.65.

In September 2019, a court-ordered child support garnishment of $100.00 per month takes effect.  The $100.00 garnishment is added to his PNA, increasing it to $215.65.