Spouse needed to live in assisted living facility due to medical problems; exceptional circumstances resulting in financial duress; MMMNA increased.
Community spouse resides in assisted living facility; monthly fee includes heat, hot water, electricity, meals, and health insurance premium; hearing officer concluded no duplication of expenses by eliminating the MMMNA calculation and applying the actual costs associated with residing in the facility, so that spouse could continue to reside in facility.
There is a sound basis to increase the MMMNA; the community spouse has medical issues which require ongoing care and him residing in an assisted living facility.
- Issue is whether Appellant is entitled to an adjustment to the PPA where his spouse was living in an assisted living facility. Appeal denied.
- MassHealth determined that appellant is not eligible to receive MassHealth benefits due to excess countable assets. Ordered to rescind notice, re-open application, and determine the appellant’s eligibility based on the determination that the excess asset amount is now $0.
- MassHealth denied the appellant’s application. Ordered to re-determine eligibility based on the determination that the excess asset amount is now $0 after a shift of excess assets to the community spouse to help pay for a necessary stay in assisted living.
- MassHealth denied the Appellant’s application for long term care benefits due to excess assets. Ordered to allocate all income (minus PNA) and excess assets to the Community Spouse and to establish eligibility date consistent with the application date.
Exceptional circumstances; the expenses presented by the appellant’s spouse included costs for assisted living effective January 2012; an adjustment was made to accommodate the special support service that the community spouse needed at the assisted living facility; increased MMMNA.
Adjust the MMMNA to account for the community spouse’s assisted living costs and adjustment to the SMNA; exceptional circumstances exist; an adjustment shall be made to accommodate the special support service that the community spouse needs at the assisted living facility; community spouse’s gross income is less than what she needs to meet the expenses caused by the exceptional circumstances.