10:71-5.7 Post-eligibility treatment of income; institutionalized individuals
(a) The amounts specified in (b) through (h) of this section shall be deducted from the
income of an institutionalized individual prior to the application of his or her income to the
cost of the long term care. These deductions apply only after the individual is determined
eligible for Medicaid and shall not be deducted in the determination of income eligibility.
1. Should the total deductions authorized under this section exceed the institutionalized
individual's income, no assistance is available from the Medicaid program to make up the deficit. In such circumstances, available funds shall first be used to provide the
institutionalized individual with his or her personal needs allowance. Any remaining
deductible income may be distributed to the community spouse or other family members as
decided by the institutionalized individual, not to exceed the amount authorized under this
section for any individual.
2. The deductions authorized in (c) through (e) below for the maintenance of the
community spouse and other family members apply only so long as there is a community
spouse as defined in (c) below. Deductions for the community spouse and other family
members shall cease in the first full-calendar month after the community spouse dies,
becomes divorced, or is institutionalized.
(b) A personal needs allowance in the amount of $35.00 shall be deducted from the
institutionalized individual's income. In addition, gross income derived from employment
that is considered essential toward satisfying the individual's developmental need to achieve
a certain amount of independence shall be deducted from the individual's income. The
combination of these deductions shall not exceed the amount in Table B for an individual
living alone as found at N.J.A.C. 10:71-5.6(c)5.
(c) There shall be deducted from the institutionalized individual's income an amount for the
maintenance of the community spouse. Except as specifically provided below, the deduction
for the maintenance of the community spouse shall not exceed $1,383. For purposes of this
section, a community spouse shall be defined as an individual who is legally married to an
institutionalized individual under the provisions of State law and who is not himself or herself
institutionalized. In arriving at the amount that may be deducted for the maintenance of the
community spouse, the deductions authorized by this section shall be reduced by the gross
income of the community spouse. The community spouse deduction is authorized only to
the extent that the income deducted is actually made available to (or for the benefit of) the
community spouse. No amount of the community spouse's maintenance deduction may be
retained by the institutionalized individual.
1. If the community spouse's average monthly shelter expenses for his or her principal
place of residence exceed $414.00, the amount of that excess shall increase the maximum
community spouse maintenance deduction. Shelter expenses are limited to rent or
mortgage (including principal and interest), taxes and insurance, a utility standard for the
individual's utility expenses, and in the case of a condominium or cooperative, the monthly
required maintenance charge.
2. A utility allowance shall not be authorized unless the community spouse directly incurs
charges for utilities. A community spouse who directly incurs charges for heating fuel (in
accordance with food stamp regulations at N.J.A.C. 10:87-5.10(a)5iv) separate and apart
from their rent or mortgage payments, shall be entitled to a utility allowance in the amount
specified as the "Heating Utility Allowance" at N.J.A.C. 10:87-12.1. If the community spouse
does not directly incur heating fuel charges but does directly incur charges for a utility other
than telephone, water, sewerage, or garbage collection, a utility allowance in the amount
specified as "Standard Utility Allowance" at N.J.A.C. 10:87-12.1 shall be authorized. If the
only direct utility charge incurred by the community spouse separate and apart from the rent
or mortgage is the telephone the amount specified at N.J.A.C. 10:87-12.1 as "Uniform Telephone Allowance" shall be added to the community spouse's monthly shelter costs.
The telephone allowance shall not be used if either of the above utility allowances have
been used because those standard allowances include telephone charges.
(d) When the institutionalized individual's income is insufficient to provide the maximum
authorized deduction for the community spouse, either the institutionalized spouse or the
community spouse can request a fair hearing in accordance with N.J.A.C. 10:71-8.4. If
either member can establish at the fair hearing that the income generated from the
community spouse's share of the couple's resources is inadequate to raise the community
spouse's income (together with the community spouse maintenance deduction) to the
maximum authorized level, additional resources (beyond the community spouse's share as
established at N.J.A.C. 10:71-4.8) may be set aside for the community spouse. The amount
of resources to be set aside shall be that amount that is determined sufficient to generate
sufficient income to raise the community spouse's gross income to the maximum authorized
level.
(e) If either the institutionalized spouse or the community spouse is dissatisfied with the
determination of the amount of the community spouse maintenance deduction, he or she
may request a fair hearing in accordance with N.J.A.C. 10:71-8.4. If it is established at the
fair hearing that the community spouse needs income above the amount established by the
community spouse maintenance deduction due to exceptional circumstances resulting in
financial duress, there shall be substituted for the community spouse maintenance
deduction such amount as is necessary to alleviate the financial duress and for so long as
directed in the final hearing decision.
(f) If a court has entered an order against an institutionalized spouse for monthly income for
the support of a community spouse and the amount of the order is greater than the amount
of the community spouse deduction, the amount so ordered shall be used in place of the
community spouse deduction.
(g) A family member maintenance deduction shall be calculated for each family member of
the institutionalized individual.
1. For purposes of this section, family members must reside with the community spouse
and shall be limited to the following persons:
i. Children of either member of the couple who are under the age of 21;
ii. Children over the age of 21 who are claimed as dependents by either member of a
couple for tax purposes under the Internal Revenue Code;
iii. Parents of either member of a couple who are claimed as dependents for tax purposes
under the Internal Revenue Code as dependents by either spouse; or
iv. A brother or sister (including half-brothers and half-sisters and siblings gained through
adoption) of either member of a couple and who are claimed as dependents for tax
purposes under the Internal Revenue Code.
2. The family member deduction shall be computed as follows. The family member's gross
income shall be subtracted from $1,383. One-third of the remaining amount shall be the
family member deduction for that family member. (h) If a physician has certified that the individual will be institutionalized for a temporary
period only and is likely to return to the residence within six months of the date of
institutionalization, a maximum of $150.00 may be deducted from the institutionalized
individual's income for the maintenance of his or her home in the community. This
deduction shall be limited to the actual costs of such maintenance (for example, mortgage
or rent payments, taxes, insurance, and other incidental costs) or $150.00, whichever is
less. This deduction may be applied against the individual's income for no longer than six
months. This deduction may not be applied if a deduction has been made for the
maintenance of a community spouse or other family member residing in that residence.
1. This deduction must be applied to the costs of maintaining the residence and may not
be accumulated by the institutionalized individual.
(i) If the institutionalized individual has health insurance covering himself or herself, the
amount of the insurance premiums shall be deducted.
1. If the premium is billed other than monthly, the amount of the premium shall be prorated
and deducted accordingly.
2. If the premium covers other individuals in addition to the institutionalized individual, only
that portion of the premium attributable to the institutionalized individual shall be deducted.
(j) No portion of a cash reward provided to any individual by the Division for providing
information about fraud and/or abuse in any program administered in whole or in part by the
Division shall be included in the computation of income for financial eligibility purposes.