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Frequently Asked Questions: Income Calculation for Payment of Room and Board in Substitute Care

Family Care Member Income Calculation for Payment of Room and Board in Substitute Care

Webcast (help) - Instructions for Standardizing Member Income Considered Available for Room and Board March 10, 2010; Presenters: Charles Jones and Deb Rathermel, Division of Long Term Care; 52 minutes (PowerPoint Handouts, PDF, 109 KB)

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Question: Should a member's VA aid and attendance allowance be counted as income on the room and board worksheets completed for members in substitute care facilities?

Answer: For purposes of considering funds available to pay for room and board, all VA allowances should be considered unearned income on line 11 of the automated PPS version or on line 4 of the Excel version of the tool for determining a member's income available to pay for room and board in substitute care.


Question: Can MRE/OTC (specialized medical supplies) be allowed to offset cost shares for people at the non-Nursing Home Level of Care?

Answer: Specialized medical equipment and supplies is a benefit that is not available at the non-Nursing Home Level of Care and therefore costs of OTC (over the counter) paid out-of-pocket by the member are considered deductions for purposes of determining both cost share and room and board.


Question: MCOs report medical/remedial expense information to Income Maintenance, but since this information is usually not relevant for Group A eligibles who have no cost share, it might not be entered by Income Maintenance in CARES. Is that alright?

Answer: Yes.


Question: A member has earned income that fluctuates from month to month. Thus, the member's unearned income fluctuates as well. The result is that the income information in CARES is unreliable. How should this situation be handled for purposes of determining the member's income available for room and board?

Answer: The MCO should examine available information about the member's earned and unearned income for the past 12 months and use it to calculate prospective average monthly earned and unearned income for the member. The MCO should enter that average monthly earned and unearned income information it has calculated into the appropriate fields in lines 10 and 11 of the automated room and board liability tool.

The examination of available information about the member's earned and unearned income for the past 12 months should be reviewed at least every six months and the prospective averages recalculated.


Question: What if the member is not found in PPS?

Answer: Only members who were enrolled using the central enrollment process or any new enrollments from a waitlist will be in PPS. Members can be moved in to PPS two ways: 

  1. In PPS select 'Basic Registration' from the left side navigation and enter basic information for the system to pull the member's information from CARES. (see instructions for detailed directions).
  2. In the Adult functional screen eligibility page select the link at the bottom of the page to create someone in PPS.

Question: What are the expectations of DHS for implementation of changes in the recently released DLTC numbered memo 2010-05 for standardizing room and board in substitute care?

Answer: The goal is to standardize the following three procedures. The expected implementation timelines for each are outlined below.

  1. A methodology for determining the room and board rate:
    As noted in the recently released DLTC numbered memo 2010-05 (PDF, 54 KB), a separate memo outlining the methodology will be circulated soon with implementation of the standardized methodology by all Managed Care Organizations (MCOs) expected by January 1, 2011.

    In the meantime, MCOs can set room and board rates using either a cost-based methodology or a flat-rate methodology based on some reasonable benchmark.

  2. Determination of member income available for room and board:
    As noted in the numbered memo, after April 1, 2010, MCOs are expected to use the new automated on-line tool to re-determine each memberís income available for room and board at either:

    1. The memberís next Medicaid recertification date, or

    2. At a sooner date (e.g., next member-care plan review, all members on April 1); if a sooner date is used, MCOs are asked NOT to report any change in medical/remedial expenses to income maintenance until the memberís next Medicaid recertification date.

  3. Documentation of member contribution to room and board and any MCO supplementation:
    As noted in the numbered memo, after April 1, 2010, all MCOs are expected to use the new automated on-line tool for determining each memberís income available for room and board Ė use of that tool is the only documentation needed by DHS, however MCOs are free to print a copy for membersí case records.

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Last Revised: April 23, 2014