An ALJ may increase the community spouse income allocation (CSIA) if the community spouse does not have enough income to pay his or her “necessary and basic maintenance needs.” In this case, ALJ Kelly Cochrane summarily ordered the income allocation increased to allow for housing costs, a phone bill, and car insurance.
This decision was published with support from the Wisconsin chapter of the National Academy of Elder Law Attorneys.
Preliminary Recitals
Pursuant to a petition filed on October 24, 2024, under Wis. Stat. § 49.45(5), and Wis. Admin. Code § HA 3.03, to review a decision by the Racine County Department of Human Services regarding Medical Assistance (MA), a hearing was held on December 3, 2024, by telephone.
The issue for determination is whether petitioner’s community spouse income allocation can be increased.
There appeared at that time the following persons:
PARTIES IN INTEREST:
Petitioner:
—
Petitioner’s Representative:
Attorney Melissa Ridgway
Demark, Kolbe & Brodek
7418 Washington Avenue
Racine, WI 53406
Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: Renee MacDonald, Lead ESS
Racine County Department of Human Services
1717 Taylor Ave
Racine, WI 53403-2497
ADMINISTRATIVE LAW JUDGE:
Kelly Cochrane
Division of Hearings and Appeals
Findings of Fact
- Petitioner (CARES # —) is a resident of Racine County and is institutionalized for MA purposes. Her spouse has remained in the community.
- On October 18, 2024, the agency issued written notice to the petitioner advising that she would have to contribute $1186.65 toward her MA care expenses (patient liability). The agency allowed a community spouse income allocation of $1169.96.
- Petitioner’s community spouse has a gross monthly income of $2062 in Social Security benefits. Petitioner’s monthly gross income is $1538 in Social Security benefits and $1806.39 in retirement benefits.
- Petitioner’s community spouse’s allowable monthly expenses total $3,065.48 per month.
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. Wis. Stat., § 49.455 sets forth the law regarding the protection of the community spouse’s income and resources.
After an institutionalized person is found eligible, s/he may allocate some of his/her income to the community spouse if the community spouse’s gross monthly income does not exceed the Maximum Community Spouse Income Allocation (MCSIA), which is the lesser of $3,406.66 plus excess shelter allowance up to a maximum of $3,853.50. See MA Eligibility Handbook (MEH), § 18.6.2, available online at http://www.emhandbooks.wisconsin.gov/meh-ebd/meh.htm. In this case, the agency allocated $1169.96 to the community spouse. The agency also gave the personal needs deduction, a health insurance deduction, and a special exempt income deduction to determine petitioner’s patient liability.
The community spouse maintains that he cannot get by on his income and allocation alone. The agency does not have discretion to allocate income to him that would cause his “income plus allocation” total to exceed the MCSIA. However, I have some limited discretion and have determined that his income is short of what he needs to cover basic living expenses. The statute allows the allocation to be raised to avert financial duress, created by exceptional circumstances, for the community spouse. See Wis. Stat., § 49.455(8)(c). The acceptable monthly expenses for the community spouse are as follows:
| Mortgage | $1,520 |
| Condo Association Dues | $490.00 |
| Phone | $266.43 |
| — Insurance (car) | $200.33 |
| Pond Association Dues | $39.58 |
| Utilities | $549.14 |
| TOTAL | $3,065.48 |
Based on the foregoing, I will order that the community spouse income allowance be raised to $3,065.48 per month, and the agency shall then change petitioner’s monthly patient liability based upon the new allowance.
Conclusions of Law
Due to exceptional circumstances, the petitioner’s community spouse requires a $3,065.48 Maximum Community Spouse Income Allocation effective October 1, 2024.
THEREFORE, it is
Ordered
That the petition for review herein be remanded to the agency with instructions to increase petitioner’s community spouse’s Maximum Community Spouse Income Allocation to $3,065.48 effective October 1, 2024, to change the monthly patient liability accordingly, and to issue a notice of decision regarding same. This action shall be taken within 10 days of the date of this Decision. In all other respects, the petition is dismissed.
[Request for a rehearing and appeal to court instructions omitted.]
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