TN 15 (02-97)
SI 02302.050 Individualized Threshold Calculation
The object of the individualized threshold calculation is to determine if the individual has earnings sufficient to replace all the benefits which he/she would actually receive in the absence of those earnings.
For purposes of determining section 1619(b) eligibility, attendant care (including personal care and other domestic assistance and supportive services) means assistance with:
work-related functions; or
personal needs such as bathing, communicating, cooking, dressing, homemaking, eating, and transportation regardless of whether such needs are work-related.
Attendant care for 1619 (b) purposes must be provided to the individual while at work or at home by an attendant paid from Federal, State, or local funds other than Medicaid.
1. Individualized Threshold
When an individual who is otherwise eligible for 1619(b) has gross earnings which exceed the amount in the applicable chart in SI 02302.200, determine whether the individual could be eligible under an individualized threshold calculation.
The individualized threshold calculation begins with the base amount from the appropriate state-by-state threshold chart and adds:
The higher of the individual's actual Medicaid expenditures (see SI 02302.050D.2.) or the average per capita Medicaid expenditure shown in SI 02302.200;
The higher of the State supplement rate for the individual's actual living arrangement or the “living alone” rate used in the chart in SI 02302.200;
Any IRWE or BWE the person has;
Amounts of income excluded under an approved PASS (as described in SI 00870.001 ff.); and
The value of publicly-funded personal/attendant care which the individual receives. (See SI 02302.050C.2., and SI 02302.050D.3.)
2. Attendant Care Expenses
Working blind or severely disabled SSI recipients may require the services of a paid attendant to assist with essential work-related and/or personal functions. The cost to the governmental entity of providing such services is considered when performing the individualized threshold calculation if:
Assistance was/is provided by a person who is paid under a publicly-funded program other than Medicaid (see B. above); and
The SSI individual would no longer qualify for attendant care service due to his/her earnings in an amount that causes ineligibility for SSI benefits.
NOTE: Attendant services paid for under Medicaid are considered under the Medicaid component of the individualized threshold and must not be counted again as non Medicaid attendant/personal care services.
3. Verification Period
The initial threshold determination is made prospectively for a 12 month period when 1619(b) status begins. Subsequent determinations are made at each redetermination. See SI 02302.045A.
For an initial determination, Medicaid expenses and attendant/personal care costs are verified for the past 12 months. Subsequently, these costs will be verified at each redetermination.
Follow this procedure each time an individualized threshold calculation is required:
1. Performing Calculations
When performing calculations:
Use the worksheet provided in SI 02302.300 to perform individualized threshold calculations.
Develop only enough IRWE, BWE, income excluded under a PASS, attendant /personal care, and/or actual Medicaid expenditures to raise the total of items 1-6 in the worksheet in SI 02302.300 to equal or exceed the individual's gross earned income.
NOTE:There is no specific order for development of these items. If the individual does not have any of these expenses, he/she is ineligible for 1619(b).
EXCEPTION: Completely develop IRWE, BWE, and PASS expenditures if the potential for reinstatement of cash benefits exists.
Develop actual Medicaid expenses according to 2, below.
Develop attendant/personal care expenses according to 3, below.
Input the results of the threshold determination per SM 01305.975.
2. Determining Actual Medicaid Expenses
Using the following procedure when determining actual Medicaid expenses. See SI 02302.050 D.1.b for exceptions to this procedure.
Record the following information on actual Medicaid expenses during the verification period (see C.3 above) on an SSA-5002:
When services were or are being received;
Names and addresses of providers; and
Description of the services. (e.g., “physical therapy”).
Obtain a signed release (SSA-827) from the individual for each source of information about use of services as needed.
Verify alleged Medicaid expenditures by one of the following methods:
Examine records from the Medicaid agency, its contractor when applicable, or the provider of services, that are in the recipient's possession (e.g., prescription receipts).
Contact with the Medicaid agency (or its contractor, when applicable); or
Contact with the provider(s) of services.
NOTE: Specific procedures for verification differ from one state to another. Refer to regional instructions for specific procedures. Unless prohibited by regional instructions, use the telephone to verify expenditures with the Medicaid agency or provider(s).
|4||Record the information in file on an RC.|
|5||Reconcile any differences which could affect the determination. Discuss the situation with the individual.|
| ||NOTE: Medicaid agencies (or their contractors) respond only to bills they receive from providers and may have no record of the individual's use of Medicaid services in their system until the bill is received and processed.|
| || |
Based on the above information, estimate the Medicaid expenses for the period for which the determination is being made (as described in SI 02302.045 A.3.).
3. Determining Attendant Care Expenses
Use the following procedure when determining attendant care expenses.
Obtain the following information (and record on an SSA-5002):
Period for which services were provided or will be provided if a projection;
Nature of services;
Source of payment to attendant; and
Name of the agency funding payments.
Secure a signed release (SSA-8510) for each contact.
Contact the agency providing or funding the attendant/personal care services and verify:
That the attendant/personal care services were (or will be) provided to the recipient;
The amount of gross payment which was made (or will be made) to the attendant for services provided to the recipient and the approximate number of billing units (e.g., hours, days, weeks) involved;
That services were funded in whole or in part by Federal, State, or local public funds other than Medicaid;
That the individual would no longer qualify for attendant/personal care services because of his/her earnings in an amount that causes ineligbility for SSI benefits; and
That the agency will not be reimbursed for the attendant/personal care services under Medicaid.
|4||Record on an RC the information obtained from the funding agency.|
| ||NOTE: Precedent files may be cited in lieu of redevelopment of information concerning the source of funds, eligibility criteria, and Medicaid involvement.|
|5||If a precedent file is cited put a copy of the precedent file in the folder.|
Based on the above information:
Estimate the potential costs of continuing the established level of attendant care to the individual for the 12-month period as described in SI 02302.045A.3;
Take all predictable fluctuations into account when projecting future expenses; and
Document the basis for the estimate.