- MassHealth approved appellant for long-term care benefits and established a PPA but the appellant’s community spouse is appealing for an increase based upon significant financial duress arising from exceptional circumstances. Appeal denied.
Category: MMMNA
Appeal 1702339
- 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.
Appeal 1511917
Community spouse has not shown significant financial duress resulting from exceptional circumstances arising from her own medical condition, frailty, or similar special needs; regulations do not allow for the consideration of an institutionalized spouse’s outstanding bills in determining whether exceptional circumstances exist to warrant an increase in the SMND.
Appeal 1508928
Health insurance premiums are not an extraordinary uncovered medical expense as the very nature of health insurance is that it covers certain medical services, thus insurance in and of itself would never be a covered medical expense; the MassHealth regulation only allows an increase to the MMMNA for exceptional circumstances as outlined in the above regulation and such circumstances do not include high shelter costs, unless the shelter cost is related to the community spouse’s medical condition as in the case of an assisted living resident.
Appeal 1505979
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.
Appeal 1409043
Appellant-wife submitted no evidence to substantiate her claim that she has unusual medical expenses constituting the “exceptional circumstances” that would justify an increase in the SMND when calculating the appellant-husband’s PPA.
Appeal 1209592
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.
Appeal 1104896
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.
Appeal 1009605
Community spouse has gross monthly income of $1,061.50 and MassHealth has calculated an MMMNA of $2,191.00; regulations dictate MassHealth consider the institutionalized spouse’s income for the community spouse when there is a shortfall between the community spouse’s income and the MMMNA; appellant or institutional spouse has income of $1,628.52 (after subtraction of the appellant’s health insurance of $113.20 and his personal needs allowance of $72.80); community spouse retains $1,129.50 of the institutional spouse income to meet the MMMNA; the PPA is correct.
Appeal 1000302
Community spouse resides in assisted living facility; monthly fee of $4,775.00 covers rent, meals, heat, hot water and electricity; no duplication of expenses by eliminating the MMMNA calculation and applying the assisted living monthly fee so that the community spouse can continue to reside in the assisted living facility; exceptional circumstances.
MassHealth Appeals 