Texas Health and Human Services Commission
Medicaid for the Elderly and People with Disabilities Handbook
Revision: 12-3
Effective: September 1, 2012

H-5000

ICF/IID Co-Payments

To determine the co-payment for a person living in an approved public or private ICF/IID facility, use the following budget steps. The difference in the co-payment calculation for this group is that a person who has earned income in excess of $30 per month may receive an additional allowance. The purpose of the additional allowance is to provide the ICF/IID person who has a short- or long-term objective of semi-independent or independent living the additional resources to make the transition possible.

H-5100  ICF/IID Individual and Couple Cases

Revision 12-3; Effective September 1, 2012

For individuals and couples, follow the steps in this section.

HHSC nets the person's and spouse's earned income each month by subtracting the following mandatory payroll deductions:

  • income tax,
  • Social Security tax,
  • required retirement withholdings, and
  • required uniform expenses.

H-5110  ICF/IID Individual

Revision 12-3; Effective September 1, 2012

Determine the person’s monthly net earned and gross unearned income.

Note: When income tax is withheld from retirement, pension and disability benefits, use the net income amount in the co-payment calculation. Use the gross amount for the eligibility calculation.

Determine the personal needs allowance for a person as follows:

Person earns $30 or less.

Step Description

1:

Deduct the $60 PNA from unearned income.

2:

To the extent that unearned income is less than $60, the difference is deducted from earned income.

3:

Deduct all remaining earned income up to $30.

4:

Add deductions from Steps 1 through 3 to determine the total PNA/PEI allowance.

Note: The total PNA/PEI must be at least $60.

Example: Person receives $300 RSDI and earns $30 per month.

Step Description
1: $300 unearned – $60 PNA = $240
2: NA
3: $30 earned – $30 PEI = $0
4: $60 PNA + $30 PEI = $90 PNA/PEI

Person's earnings exceed $30 but not $120.

Step Description
1: Deduct the $60 PNA from unearned income.
2: To the extent that unearned income is less than $60, the difference is deducted from earned income.
3: Deduct from remaining earned income $30, plus one-half the remainder.
4: Add deductions from Steps 1 through 3 to determine the total PNA/PEI deduction.

Example: Person earns $120 per month and receives $12.50 SSI.

Step Description
1: $12.50 unearned – $60 PNA = –$47.50
2: $120 earned – $47.50 = $72.50
3: $72.50 remaining earned – $30 = $42.50 divided by 2 = $21.25
4: $12.50 + $47.50 + $30 + $21.25 = $111.25 PNA/PEI

Person's earnings exceed $120.

Step Description

1:

Deduct the $60 PNA from unearned income.

2:

To the extent that unearned income is less than $60, the difference is deducted from the first $120 of earned income.

3:

Of monies remaining from the first $120 of earned income, deduct $30 and one-half the remainder.

4:

Deduct 30% of earnings in excess of $120.

5:

Add deductions from Steps 1 through 4 to determine the total PNA/PEI allowance.

Example 1: Person receives $300 RSDI and earns $250.

Step Description

1:

$300 unearned – $60 PNA = $240

2:

NA

3:

$120 earned – $30 = $90 divided by 2 = $45

4:

$250 earned – $120 = $130 x 30% = $39

5:

$60 PNA + $30 + $45 + $39 = $174 PNA/PEI

Example 2: Person receives $7.50 SSI and earns $130.

Step Description

1:

$7.50 unearned – $60 = – $52.50

2:

$120 earned – $52.50 = $67.50

3:

$67.50 remaining earned – $30 = $37.50 divided by 2 = $18.75

4:

$130 earned – $120 = $10 x 30% = $3

5:

$7.50 + $52.50 + $30 + $18.75 + $3 = $111.75 PNA/PEI

References:

  • Subtract guardian fee allowance, if applicable.
  • Subtract incurred medical expenses.
  • Subtract home maintenance allowance, if applicable.
  • Total net earned income and gross unearned income minus the total personal needs allowance and other allowable deductions is the co-payment.

H-5120  ICF/IID Couple

Revision 12-3; Effective September 1, 2012

  • Determine the personal needs allowance for a couple as follows:
    1. If neither spouse has earned income, or if the only spouse with earned income does not have an ICF/IID level of care, the personal needs allowance for the couple is $60 for each spouse.
    2. If either spouse is an ICF/IID person who has monthly earned income, determine the personal needs allowance for each separately based on their individual monthly incomes.

    Note: If one spouse has a level of care other than an ICF/IID level of care, the personal needs allowance for that individual is $60, regardless of whether the individual has earned income. Combine the individual personal needs allowance for the couple.
  • Subtract the total personal needs allowance from the total of net earned income and gross unearned income of the couple.

References

  • Subtract guardian fee allowance, if applicable.
  • Subtract incurred medical expenses.
  • Subtract home maintenance allowance, if applicable.
  • Divide the remainder by two to determine the co-payment for each spouse.

H-5130  ICF/IID Companion

Revision 12-3; Effective September 1, 2012

A separate deduction for maintenance of the home is not allowable in companion cases.

The spousal allowance provides for home maintenance in those cases.

To determine the co-payment budget for a companion situation, use the following steps:

Step Procedure

1

Determine the countable net earned and gross unearned income of the person.

2

Subtract the personal needs allowance, including the protected earned income allowance (if any) of the person based on his own net income.

Subtract guardian fee allowance, if applicable.

3

Add the spouse's countable net earned and gross unearned income to the remainder.

4

Subtract the spousal allowance.

5
  1. If there are no dependents, go to Step 6.
  2. If there are dependents, determine the dependent allowance.
  3. Subtract the dependent allowance.

6

 Subtract incurred medical expenses.

The remainder is the co-payment.

Example: The couple has the following income:

Person

Spouse

$250

 RSDI

$800

Net Earnings

$130

 Net Earnings

 

Calculation for personal needs and protected earned income allowance:

$250

 RSDI unearned income

−  60

 PNA

$190

 remainder

Calculation for protected earned income when earnings are greater than $120:

$120

 Deduct $30 from the first $120 of earned income

−  30

 

$  90

 divided by 2 = $45 and get one-half the remainder

Calculation for 30% of earnings in excess of $120:

$130

 Earnings

−120

 First $120 of earned income

$  10

 x .3 = $3 (30% of earnings in excess of $120)

Calculation for Total PNA/PEI:

$  60

 PNA

30

 $30 deduction

45

 One-half the remainder deduction

+   3

(30% of earnings in excess of $120)

$138

 Total PNA/PEI

Co-payment calculation:

 

$   250

 RSDI
 

+   130

 Net earnings

Step 1:

$   380

Total

Step 2:

−   138

 Total PNA/PEI

 

$   242

 Income available for diversion

Step 3:

+   800

 Spouse's income

 

$1,042

 Total

Step 4:

−2,841

 Spousal allowance

Step 5:

  

NA

Step 6:

  

NA

 

$      0

Co-payment