Spousal Impoverishment Provisions at Initial Request for Services

Spousal impoverishment provisions must be applied immediately in the following circumstances:

The client requests in-home support or otherwise indicates a need for IHSS and provides verification that he/she would required nursing facility level of care for 30 consecutive days in the absence of IHSS. This can be verified by:
- A completed MC 604 MDV
- A completed needs assessment by IHSS
The EW is made aware of the client’s request for any of the waivers listed below and provides verification that he/she would require nursing facility level of care for 30 consecutive days in the absence of the waiver. This can be verified by:
- A completed MC 604 MDV
- A completed needs assessment by IHSS

Note: Spousal impoverishment provisions also apply when an individual is already eligible for a waiver. This section only refers to those individuals who have requested a waiver or IHSS but have not yet been approved.

Impacted Waivers and Programs

The impacted waivers and programs are as follows:

Developmental Disabilities State Plan Services
Assisted Living Waiver
Cal Medi-Connect Duals Demonstration Project for members eligible to receive Home and Community-Based Services and who would require institutionalization in the absence of HCBS instead of institutional services provided under Care Plan Options
California Community Transitions Home and Community-Bases Services Money Follows the Person Grant
CBAS Medi-Cal 2020 Demonstration Waiver Benefit
Home and Community-Based Services for Persons with Developmental Disabilities (HCBS-DD) Waiver
Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) Waiver
Multi-purpose Senior Services Program (MSSP) Waiver
Home and Community-Based Alternatives (HCBA) Waiver (formerly NF/AH)
Pediatric Palliative Care Waiver
Program of All-Inclusive Care for the Elderly
Self-Directed Program for Persons with DD Waiver (program in the approval process)
Senior Care Action Network Fully Integrated Dual Eligible Special Needs Plan
IHSS Community First Choice Option (CFCO)

Important: If the Community Spouse becomes institutionalized or requests one of the Impacted Waivers or Programs, he or she no longer meets the definition of Community Spouse and the spousal impoverishment provisions no longer apply.

Doctor’s Verification Form (MC 604 MDV)

The MC 604 MDV can be used to verify that the client would likely require nursing facility level of care for 30 consecutive days in the absence of HCBS. This form must be used when there is no other verification from the Waiver administrator. The EW should complete the Patient’s Information section on the first page and the client must complete the Patient Authorization section on the second page.

Note: The Witness section is only required when the client signs their name with an X or illegible/foreign characters.

If the doctor does not return the form within 10 business days, contact the doctor’s office to confirm they received the form and send another copy if they did not. The client can bring the form to the doctor if they choose to, however, the doctor must return the form to the county. If the client returns the form to the county, the Eligibility Worker (EW) must call the doctor’s office to confirm the validity of the form. If the EW still does not receive the form after an additional 10 days, advise the client that they will be evaluated for Medi-Cal without the application of spousal impoverishment rules until a needs assessment is provided by the Waiver administrator or the MC 604 MDV is provided by a doctor.

If the needs assessment or MC 604 MDV is later provided, reevaluate MC using spousal impoverishment rules as of the date of application or date of initial request (whichever was more recent).

Continuous Period

Once it is determined that the client meets all of the above requirements, a Continuous Period period begins. The EW must instruct the client to report when they are approved or denied for the requested waiver/program. The EW must follow up at the next Redetermination if the client has not reported the status by then.

Continue to apply spousal impoverishment rules until:

Verification is received stating the client did not meet the requirements for the requested waiver,
The Community Spouse (non-Waiver spouse) becomes institutionalized or requests a waiver/program, OR
One of the following changes in circumstances occurs:
- Death,
- Moves out of state,
- Marriage ends, OR
- No longer in need of services

Important: A Continuous Period does not end when an individual on one of the Impacted
Waivers/Programs is institutionalized.

Waiver-Specific Exemptions

Special exemptions allowed by waivers (e.g., the board and care income deduction for the Assisted Living Waiver) must not be applied prior to approval for the waiver. After the deduction of the CSRA from the spouses’ combined community and separate property, any special waiver exemptions apply. After the deduction of the spousal income allocation, any special waiver deductions apply to the Waiver Spouse’s net nonexempt income remaining before the SOC result is determined.

If the waiver the individual becomes eligible for allows an income allocation to the Community Spouse, then institutional deeming no longer applies.

Spousal Impoverishment Process

Follow the steps below when an individual requests a Waiver/IHSS.

Refer the client to IHSS or a Waiver administrator as appropriate (refer to chart below).
1. Note: If the client has already applied for a Waiver or IHSS CFCO, a referral is not necessary.

If the client...	Then...
Is eligible for zero-SOC MC or unmarried,	Evaluate eligibility per normal business process.
Is married and ineligible due to property or is only eligible for MC with a SOC,	Complete the Patient’s Information section of the MC 604 MDV and mail to the client’s doctor. Note: If the client has a Needs Assessment from the waiver administrator or IHSS, the MC 604 MDV is not required.
	If the form is...	Then...
	Not returned, or indicates the client would not require 30 or more consecutive days of Skilled Nursing Facility level of care in the absence of the waiver/IHSS,	Evaluate eligibility per normal business process. Do not transfer the case.
	Returned indicating the client would require 30 or more consecutive days of Skilled Nursing Facility level of care in the absence of the waiver/IHSS,	Transfer the case to Intake at the Medi-Cal Benefit Assistance (MBA) office or to the Continuing Benefits Service Center (BSC) LTC unit (as applicable). These specialized units will proceed to the next step for processing.

Determine if the client is property eligible.
1. The Waiver/IHSS spouse’s property must be under the Community Spouse Resource Allowance plus $130,000 (the property limit for one) in order to be property eligible in the initial determination. Once eligibility is approved, the client would then have 90 days to transfer all but $130,000 of the property out of their name.
  1. Note: Periods of Ineligibility do not apply to this population as they are not in a Skilled Nursing Facility.
2. If the client is not property eligible, deny/discontinue the case.
Complete the “Budgets for HCBS Spousal Impoverishment” (SCD 2511) for evaluations on or prior to November 30, 2020.
Complete the “Budget Steps for HCBS SI_12/2020” (SCD 2589) for evaluations on or after December 1, 2020.
Complete the Potential Spousal Income Allocation section on page 1.
Complete Budget A which evaluates for A&D FPL. If the client is determined eligible at the end of Budget A, proceed to the next Step in this workflow.
1. If the client is ineligible at the end of Budget A, continue completing Budget B for 250% WDP eligibility.
2. If the client is ineligible at the end of Budget B, complete Budget C to determine if the client is eligible for MN/MI. Refer to Systems Announcement 338 for an example.
If the client is determined eligible under HCBS Spousal Impoverishment provisions while they are applying or on a waitlist for one of the specified waivers/programs, instruct the client to notify the county when they are approved/denied.

If the client...	Then...
Reports they have been approved for the waiver/program,	Document in the Journal page that the individual has been approved for the waiver/program.
Reports they have been denied for the waiver/program,	Reevaluate Medi-Cal without applying Spousal Impoverishment provisions. If the individual was removed from a combo CF/MC case and put on an MC-only case, discontinue the MC-only case and reevaluate the individual for MC on the original case with the rest of their household. Remove the Spousal Impoverishment Special Indicator. Case Comment
Does not report anything before the next RD,	The EW must follow up with the waiver/program administrator, or request verification from the client regarding whether or not the waiver has been approved/denied or if the client is still on the waitlist.

Community Spouse Applies for MC, Becomes Institutionalized, or Requests Waiver/Program

If the Community Spouse requests MC then he/she will need to spend down his/her property to the property limit for one. A spousal income allocation would still be allowed and the spouses can adjust the amount however they determine will best preserve their eligibility.

If the Community Spouse becomes institutionalized or requests a waiver/IHSS, spousal impoverishment provisions no longer apply. If after completing the Medi-Cal hierarchy the couple has a share of cost, institutional deeming is triggered and each spouse is placed in their own MFBU of one.

In cases where both Registered Domestic Partners (RDPs) participate in HCBS Waiver and Programs and request Medi-Cal, they are treated as unmarried individuals. Each RDP is in a separate MFBU and each RDP would benefit from the $130,000 property limit for one person.

Example

Israel, a Community Spouse, decides to apply for Medi-Cal and has net nonexempt income that is
$200.00 under the A&D FPL limit and had previously been receiving a higher spousal income allocation from Judy, the Waiver Spouse. If the couple decides it is more beneficial to ensure zero SOC eligibility for Israel, they may decide to reduce or stop the spousal income allocation, even though this would increase the net nonexempt income of Judy and potentially increase her SOC.

Judy’s Income	Israel’s Income
$2,000.00 (Social Security)	$900.00 (Social Security)
-$20.00 (Income Deduction)	-$120.90 (Medicare Premium)
-$120.90 (Medicare Premium)	=$779.10 (Gross income minus Other Health Insurance)
-$230.00 (Standard Deduction)	$3,023.00 (MMMNA for 2017)
-201.90 (Spousal Income Allocation)	+201.90 (Israel wants MC under the A&D FPL program, therefore only $201.90 may be allocated)
=$1,427.00 (Net nonexempt income)	=$981.00
-$600.00 Maintenance Need for 1	-$981.00 (A&D FPL Income Limit for 2017)
=$827.00 (SOC)	$0 (Excess Income)

Waiver and Programs Eligibility Chart

Program	Description	Target Criteria	Waiver Administrator	Referral Contact
Assisted Living Waiver	Offers Medi-Cal members the choice of residing in an assisted living setting as an alternative to long term care placement in a nursing facility.	Ages 21 and older Must be eligible for zero-SOC Full Scope Medi-Cal Must otherwise require Skilled Nursing Facility level of care Available in facilities located in the following counties: Alameda, Contra Costa, Fresno, Kern, Los Angeles, Orange, Riverside, Sacramento, San Bernardino, Santa Clara, San Diego, San Joaquin, San Mateo, and Sonoma.	Department of Health Care Services (DHCS)	Institute on Aging- Complete the online intake form.
Cal Medi-Connect Duals Demonstration Project	Fully integrated health plan model that provides coordinated health care and LTSS delivery to seniors and people with disabilities who are dually eligible for both Medicare and Medi-Cal.	Ages 21 and older Resides in Los Angeles, Orange, Riverside, San Bernardino, Santa Clara, San Diego, or San Mateo counties.	DHCS	Health Care Options: (844) 580-7272
California Community Transitions (CCT)- Money Follows the Person Grant	Funds the identification and transition of people with chronic conditions and disabilities from institutional settings back into a community home or homelike setting.	Reside in a state-licensed health care facility for a period of 90 consecutive days.	DHCS	Institute on Aging- Complete the online intake form.
Community-Based Adult Services (CBAS)- Medi-cal 2020 Waiver Benefit	CBAS is an outpatient, facility-based program that delivers skilled nursing care, social services, therapies, personal care, family/caregiver training and support, nutrition services, and transportation to Medi-Cal beneficiaries that meet CBAS eligibility criteria. CBAS is a Medi-Cal Managed Care benefit available to eligible Medi-Cal recipients enrolled in Medi-Cal Managed Care. Eligibility to participate in CBAS is determined by the recipient’s Medi-Cal Managed Care Plan.	Aged or disabled adults	California Department of Aging	(916) 419-7500
Home and Community-Based Services for Persons with Developmental Disabilities (HCBS-DD) Waiver	Serves people with developmental disabilities in their own homes and communities as an alternative to placing Medi-Cal eligible individual in hospitals, nursing facilities, or intermediate care facilities, while preserving their independence and ties to family and friends.	Developmental disabilities, Intellectual disabilities, No age limit Condition must be developed/diagnosed before 18th birthday	DDS	SARC
HIV/AIDS Waiver	Provides services to allow people with AIDS to remain in their homes, stabilize their health, improve their quality of life, and avoid costly institutionalization.	Diagnosed with HIV/AIDS No age limit	CA Department of Public Health	(916) 449-5900
IHSS Community First Choice Option (CFCO)	Help pay for services provided to a Medi-Cal member so that they are able to safely remain in their own home. Types of services authorized through IHSS: Housecleaning, meal preparation, laundry, grocery shopping, personal care services, accompaniment to medical appointments, and protective supervision for the mentally impaired.	No age limit, Aged, blind, or disabled, California resident, Medi-Cal approval Live at home Complete Health Care Certification form	IHSS, Santa Clara County
Multipurpose Senior Services Program (MSSP) Waiver	Arranges for and monitors the use of community services to prevent or delay premature institutional placement. MSSP provides comprehensive care management to assist frail elderly individuals to remain at home. Services provided through MSSP funds include: Adult day care, housing assistance, chore and personal care assistance, protective supervision, respite, transportation, meal services, etc.	Age 65 or older, Live within the Site’s service area	CA Department of Aging	(916) 419-7500
Home and Community-Based Alternatives Waiver	Provides Medi-Cal members with long-term medical conditions who meet one of the designated levels of care, the option of returning to and/or remaining in their home or home-like community setting in lieu of institutionalization.	No age limit	DHCS	Libertana
Pediatric Palliative Care (PPC) Waiver	Allows children who have a California Children’s Services eligible medical condition with a complex set of needs, and their families, the benefits of hospice-like services.	Ages 20 and younger	DHCS	(916) 552-9322
Program of All-inclusive for the Elderly (PACE)- Managed Care Product	Fully integrated health plan model that provides coordinated health care and LTSS delivery to seniors requiring nursing facility level of care with the goal of maintaining them in their homes and communities.	Ages 55 and older Resides in plan zip code service area in Alameda, Contra Costa, Fresno, Humboldt, Los Angeles, Orange, Riverside, Sacramento, San Bernardino, Santa Clara, San Diego, or San Francisco counties.	DHCS	(916) 440-7538
Section 1915(i)- State Plan Option	Serves people with developmental disabilities in their own homes and communities while preserving their independence and ties to family and friends.	Developmental Disabilities Intellectual Developmental Disabilities No Age Limit Condition must be developed/diagnosed by 18th birthday	Department of Developmental Services (DDS)	(916) 654-1972
Self-Directed Program for Persons with DD (SDP) Waiver	Serves people with developmental disabilities and allows the participants the opportunity to accept greater control and responsibility regarding their delivery of needed services.	Developmental disabilities, Intellectual developmental disabilities, No age limit	DHCS	(916) 654-1972
Senior Care Action Network (SCAN)- Fully Integrated Dual Eligible Special Needs Plan	Fully integrated health plan model that provides coordinated health care and LTSS delivery to seniors who are dually eligible for both Medicare and Medi-Cal	Ages 65 and older Medicare A/B Full Scope MC without SOC Resides in Los Angeles, Riverside, or San Bernardino counties. NOTE: NOT Santa Clara County	DHCS	(800) 559-3500 (SCAN) (844) 580-7272 (Health Care Options)