The usual maximum for the Community Spouse Income Allocation (CSIA) can be increased by an ALJ if needed to pay for “necessary and basic” expenses. In this case, ALJ John Tedesco increased the CSIA to $4,078, largely to allow $825 to pay off credit card debt “as [the petitioner] should be allowed some means to pay off principal to avoid duress by avoiding the never-ending credit cycle.”
Preliminary Recitals
Pursuant to a petition filed on December 12, 2019, under Wis. Stat. § 49.45(5), and Wis. Admin. Code § HA 3.03(1), to review a decision by the Milwaukee Enrollment Services regarding Medical Assistance (MA), a hearing was held on March 17, 2020, by telephone.
The issue for determination is whether all or a portion of the petitioner’s income should be allocated to the community spouse for spousal impoverishment purposes.
There appeared at that time the following persons:
PARTIES IN INTEREST:
Petitioner:
—
Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: —
Milwaukee Enrollment Services
1220 W Vliet St
Milwaukee, WI 53205
ADMINISTRATIVE LAW JUDGE:
John P. Tedesco
Division of Hearings and Appeals
Findings of Fact
- Petitioner (CARES # —) is a resident of Milwaukee County.
- Petitioner has resided in a nursing home beginning 3/19/19.
- Petitioner in enrolled in long-term care Medicaid.
- Petitioner’s monthly income is $1,916 in 2020 from SS.
- Petitioner’s community spouse has average monthly income of $1,984 from SS and $1,077.40 from a pension. This amounts to a gross monthly income of $3,061.40.
- Payment of the following monthly expenses are basic and necessary for the maintenance of the community spouse:
MORTGAGE (incl. condo fees) 884.00
HOME INS. 75.00
PROPERTY TAXES 371.00
HOME MAINTENANCE 50.00
HOME PHONE/INTERNET 10.00
ELECTRICITY & GAS 160.00
WATER/SEWER 40.00
FOOD 400.00
CAR INSURANCE 70.00
BURLINGTON PHARM CO-PAY 10.00
MEDICAL SUPPLIES 141.00
DENTAL/VISION INS. 50.00
WPS SUPP. HEALTH 332.00
PART D PREMIUM (for spouse) 40.00
PART B PREMIUM (for spouse) 145.00
CREDIT CARDS 825.00
FEDERAL TAX 200.00
TAX PREP FEES 10.00
HAIRCUTS 25.00
CAR LICENSING 15.00
CAR MAINTENANCE 25.00
FUEL 125.00
CLOTHING 25.00
ENTERTAINMENT 50.00
TOTAL $4,078
- The following expenses claimed by petitioner’s community spouse at the hearing, or reflected in her documentary exhibits are not basic and necessary for her needs:
- Cell phone
- Life insurance payments
- Any expenses for petitioner’s needs
- The current maximum income allocation to the community spouse is the maximum $3,214.50/mo.
Discussion
Spousal impoverishment is an MA policy, created pursuant to the Medicare Catastrophic Coverage Act of 1988, which allows persons to retain assets and income that are above the regular MA financial limits. Spousal impoverishment policy applies only to institutionalized persons and their community spouses.
After an institutionalized person is found eligible, he may allocate some of his income to the community spouse if the community spouse’s gross monthly income does not exceed the Maximum Community Spouse Income Allocation (CSIA) of $3,216. See Medicaid Eligibility Handbook § 18.6.2. In this case, the income of the community spouse is $3,061 per month. That includes SS and pension.
The community spouse argues that she cannot get by on the $3,216 CSIA for herself. The county agency does not have discretion to allocate income to her that would cause her “income plus allocation” total to exceed $3,216. However, I have some limited discretion. The statute allows the allocation to be raised by an administrative law judge to avert financial duress, created by exceptional circumstances, for the community spouse. See Wis. Stat. § 49.455(8)(c). The Administrative Code explains that “‘exceptional circumstances resulting in financial duress’ means situations that result in the community spouse not being able to provide for his or her own necessary and basic maintenance needs.” Wis. Admin. Code § DHS 103.075(8)(c). The Medicaid Eligibility handbook explains that “A court or fair hearing can increase the community spouse income allocation if it determines the spouse is not able to provide for his or her necessary and basic maintenance needs with the amount allocated.” MEH at 18.6.2.
The spouse has claimed many expenses which are not basic and necessary for her maintenance. Life insurance for person without dependents is not necessary but an elective luxury. Cell phone, while convenient is similarly not basic or necessary when a land-line phone is available. I am allowing an excess of the credit card payments itemized by petitioner despite their being over the minimum payments as she should be allowed some means to pay off principal to avoid duress by avoiding the never-ending credit cycle. This will necessitate not using credit anymore. Future requests to increase the allocation based on additional incurred credit will likely be denied. I have modified some of petitioner’s claimed expenses to be more in line with basic necessity. I have also added in some expenses as assumed even though the community spouse did not itemize them or provide supporting documentation. These include car licensing, car maintenance, fuel, entertainment, and clothing.
The amounts set forth above ensure that the spouse does not become impoverished, that she has enough to eat and maintain a shelter, and then some. That is what the statute calls for. It does not call for her to maintain the same lifestyle that she has had in the past with the same material items.
Based on this, the new income allowance should be set at $4,078. The allocation from petitioner to the community spouse should be increased to reach this income plus allocation number.
Conclusions of Law
Petitioner has established that an increase in the CSIA is necessary to avoid duress.
THEREFORE, it is
Ordered
That this matter is remanded to the agency with the following instructions:
- The agency shall increase the community spouse’s income allocation to reach the amount of $4,078 effective as of the 3/9/19 institutional admission date.
These actions shall be completed within 10 days of the Decision.
[Request for a rehearing and appeal to court instructions omitted.]