No exceptional circumstances and no significant financial duress; none of the itemized expenses arose from medical condition, frailty or similar special needs of the community spouse; the community spouse asserted monthly expenses exceeding the current MMMNA maximum by $65; the hearing officer concluded this was too small of a difference to constitute significant financial duress.
MassHealth correctly calculated community spouse’s MMMNA and appellant’s PPA; spouse had monthly medical bills of $177; hearing officer said this was not causing significant financial duress, especially given that there were other living expenses that could have been reduced in order to pay the medical bills; other expenses which community spouse wished to have covered were not necessities arising from the medical condition, frailty, or similar special needs of the community spouse.
No increase in MMMNA warranted; community spouse has financial duress but no exceptional circumstances; past due medical bills consisting of small co-pay amounts accumulated since 2014; these are small typical charges incurred in the normal course by individuals with health insurance.
Appellant suffers from medical conditions that cause her to incur high out-of-pocket expenses; these expenses cause financial distress; these medical issues plus financial distress constitute exceptional circumstance; MMMNA increased and patient paid amount decreased.
Spouse needed to live in assisted living facility due to medical problems; exceptional circumstances resulting in financial duress; MMMNA increased.
- 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.
The MassHealth regulation only allows an increase to the MMMNA for exceptional circumstances as outlined in the regulation and such circumstances do not include shelter costs, unless the shelter cost is related to the community spouse’s medical condition as in the case of an assisted living resident; the community spouse is 58 years old and there is no evidence of a medical condition that results in high out of pocket medical expenses; community spouse does not have extraordinary uncovered medical expenses arising from her medical condition that result in significant financial duress.