Neb. Admin. Code tit. 469 — Assistance to the Aged, Blind, or Disabled Program

Chapter 1 General Background

Neb. Admin. Code tit. 469, ch. 1 General Background {#sec-469-nac-1 omnilex-key=us-ne-regs-official--title-469--469 NAC 1}

001. SCOPE AND AUTHORITY . The Assistance to the Aged, Blind, or Disabled Program was established to provide financial aid and medical assistance to individuals in need who are age 65 and older, or, who are age 64 and younger and have been determined to be blind or disabled according to the Retirement, Survivors, and Disabled Insurance or Supplemental Security Income Program via the Social Security Administration. The State Disability Program was established to provide financial aid and medical assistance to individuals who are blind or disabled and who meet the program definition of blindness or disability but do not meet the duration requirements.

002. DEFINITIONS . The following definitions apply:

002.01 ASSISTANCE TO THE AGED, BLIND, OR DISABLED PAYMENT. The financial assistance payment portion of the Assistance to the Aged, Blind, or Disabled Program.

002.02 ADEQUATE NOTICE. A notice of the case action, which includes a statement of what action is intended, the reason for the intended action, and the specific regulation that supports the action, or a change in federal or state law that requires the action.

002.03 AGED. An individual who is age 65 or older.

002.04 APPLICANT. An individual who is seeking an eligibility for himself or herself through the submission of an application.

002.05 APPLICATION. The request for Economic Assistance benefits submitted by, or on behalf of, an individual via a Department approved format.

002.06 APPLICATION DATE. For new and reopened cases, the date a valid application is received, or the received date by the Department on a paper application, a phone application, or an electronic application. When adding a program to a properly signed application, this is the date that the new program is requested.

002.07 APPLICATION SIGNATURE. Applications may be signed in writing, telephonic signature, or electronic signature.

002.08 APPLICATION SUBMISSION. Applications may be submitted in person, by mail, fax, phone, or electronic device.

002.09 APPROVAL OR DENIAL DATE. The date that the new or reopened case is determined eligible, or eligibility is denied, by the Department.

002.10 AVAILABLE RESOURCES. For the determination of eligibility, available resources include cash, or other liquid assets of any type, of real or personal property, or interest in property that the applicant or recipient owns and may convert into cash to be used for the care and support of the individuals applying.

002.11 AUTHORIZED REPRESENTATIVE. A person or organization authorized by an applicant, recipient, or court of competent jurisdiction to represent the applicant or recipient in any matters.

002.12 BLIND. A category of eligibility for individuals who are age 64 and younger and are blind.

002.13 BURIAL INSURANCE. Insurance whose terms specifically indicate that the proceeds can only be used to pay the burial expenses of the insured.

002.14 CASH SURRENDER VALUE. The amount in which the insurer will pay the owner if the policy is cancelled before maturity of the policy or death of the insured.

002.15 CATEGORICAL ASSISTANCE. Assistance administered by the Department. For the purposes of this definition, it includes the following programs: Aid to Dependent Children; Child Welfare Payment and Medical Services Program; Assistance to the Aged, Blind, or Disabled Program; State Disability Program; and Refugee Resettlement Program.

002.16 CONTRIBUTIONS OR CASH SUPPORT. Verified payments that are paid to or for a State Disability Program recipient.

002.17 DEEMING. The process of determining the amount of income and resources of a parent or sponsor which must be considered available to meet the recipient’s needs.

002.18 DEPARTMENT. The Nebraska Department of Health and Human Services.

002.19 DISABLED. A category of eligibility for individuals who are age 64 and younger and are disabled as determined by the Social Security Administration or State Review Team.

002.20 ELIGIBILITY DETERMINATION. An approval, denial, renewal, or termination of eligibility.

002.21 ELIGIBILITY OF RELEASE OF INFORMATION. Before information can be released about an applicant or recipient, the Department must obtain the applicant or recipient’s written permission.

002.22 EQUITY. The fair market value of property minus the total amount owed on it.

002.23 ESSENTIAL PERSON. A spouse or other specified adult relative who is needed in the home full-time to help take care of the aged, blind, or disabled recipient. The related individual will meet the following criteria:

(A) The individual lives in the home of the recipient;

(B) The individual is not eligible for medical assistance under another program; and

(C) It has been established, via the Assistance to the Aged, Blind, or Disabled Essential Person Medically Necessary Form, that the individual’s presence is medically necessary in the home, full-time, in order to assist the recipient with the recipient’s needs and well-being.

002.24 FAIR MARKET VALUE. The price an item of a particular make, model, size, material, or condition will sell for on the open market.

002.25 GRANT CASE. A case receiving a state supplement payment. Either term, grant or payment, may be used to make reference to the state supplement.

002.26 HEARING. An administrative proceeding before the Director of Children and Family Services, or the Director’s representative.

002.27 HOME. Any shelter which the individual owns and uses as his or her principle place of residence. The home includes any land on which the house is located and any related outbuildings necessary for the operation of the residence.

002.28 IN-KIND INCOME. The value of food, clothing, shelter, or other items received in lieu of wages.

002.29 IRREGULAR INCOME. Earned or unearned income which varies in the amount from month-to-month, or, which is received at irregular intervals.

002.30 LEGAL GUARDIAN. An individual appointed by a court of competent jurisdiction to be in charge of the affairs for a person who cannot effectively manage his or her own affairs due to his or her incapacity.

002.31 NOTICE OF ACTION. A statement sent by the Department to an applicant, recipient, or their authorized representative that includes a short, plain statement of actions taken by the Department, the factual reasons for the actions, and the references of the applicable regulatory laws that authorize the actions.

002.32 PARENT OR RELATIVE CAREGIVER. A relative of a dependent child by blood, adoption, or marriage with whom the child is living, who assumes primary responsibility for the child’s care, and is one of the following:

(A) The child’s father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece;

(B) The spouse of such parent or relative, even after the marriage has terminated by death or divorce; or

(C) Another relative of the child based on blood, adoption, or marriage recognized by the State of Nebraska, or an adult with whom the child is living, and who has verified guardianship or conservatorship of the child.

002.33 PAYMENT. A recipient receiving a state supplement grant. Either term, payment or grant, may be used to make reference to the state supplement.

002.34 POWER OF ATTORNEY. A written statement allowing one person to act for another person. A Power of Attorney may be authorized generally for the management of a specified business or enterprise, or for the accomplishment of a particular transaction.

002.35 RECIPIENT. An individual receiving assistance.

002.36 RETROACTIVE PAYMENT. Any payment made during the current month for a previous month.

002.37 SHARE OF COST. A recipient’s financial out-of-pocket obligation for State Disability Program medical services when countable income exceeds the medical maintenance income level. The share of cost amount is the difference between the recipient’s countable income and the appropriate medical maintenance income level. This amount must be obligated or paid to medical providers before Medicaid will pay towards the remaining medical bills.

002.38 SPECIFIED LIVING ARRANGEMENT. The specified living arrangements are:

(A) An adult family home,

(B) A long term care facility including assisted living with waiver,

(D) A center for the developmentally disabled.

002.39 STATE DISABILITY PROGRAM. A program consisting of financial assistance and medical assistance, or medical assistance only. The term State Disability Program is used when reference is made to both the grant and medical portions of the program.

002.40 STATE DISABILITY PROGRAM MEDICAL. The medical assistance portion of the State Disability Program. Two types of state disability cases are included in the medical assistance only category:

(A) State Disability Program medical assistance with no share of cost medical only is a case in which there is income sufficient to meet daily maintenance needs but insufficient to meet medical needs.

(B) State Disability Program medical assistance with a share of cost medical only is a case in which there is sufficient income to meet daily maintenance needs and a portion, but not all the unit’s medical needs. The case is opened for medical assistance with no payment for medical services made until the share of cost is obligated toward medical services that have been paid for.

002.41 STATE DISABILITY PROGRAM PAYMENT. The financial assistance payment portion of the State Disability Program.

002.42 STANDARD OF NEED. The maximum standard allowed according to eligible unit size and living arrangement.

002.43 THIRD PARTY MEDICAL PAYMENT. A payment from any health insurance plan, individual or group, for medical expenses.

002.44 TIMELY NOTICE. A notice of case action dated and mailed at least ten calendar days before the date the action becomes effective.

002.44 WITHDRAWAL. A voluntary written retraction of an application.

003. APPLICANT OR RECIPEINT RESPONSIBILITIES . The applicant or recipient is required to:

(A) Provide complete and accurate information. State and federal law provides penalties of a fine, imprisonment, or both for individuals found guilty of obtaining assistance or services, for which they are not eligible, by making false statements or failing to report any changes in their circumstances within the timeframe allowed, depending upon the request and its requirements;

(B) Report a change in circumstances no later than ten days following the change. This includes reporting:

(i) Change of address;

(ii) Change in living arrangement;

(iii) Change of payee;

(iv) Change of payment method for grant such as a debit card, bank account, or facility resident account;

(v) Disability or blind status;

(vi) Monthly expenses;

(vii) Resources or other financial circumstances;

(viii) Employment status;

(ix) The composition of the household;

(x) A temporary absence from the home of any unit member; and

(xi) Changes in the amount of monthly income, including:

(1) All changes in unearned income; and

(2) Changes in the source of employment, in the wage rate, and in employment status, such as part-time to full-time or fulltime to part-time. For reporting purposes for Assistance to the Aged, Blind, or Disabled Program, 30 hours per week is considered full-time;

(D) Inform the medical provider and Department of any health insurance plan, any individual, or any group that may be liable for his or her medical expenses;

(E) Cooperate in obtaining any third party medical payments;

(F) Enroll in a health plan and maintain enrollment if:

(i) One is available to the applicant or recipient;

(ii) The applicant or recipient is able to enroll on his or her own behalf; and

(iii) The Department has determined that enrollment in the plan is cost effective;

(G) Reimburse to the Department or pay the provider any third party medical payments received directly for services which are payable by State Disability Program or the Nebraska Medicaid Program;

(H) Pay any unauthorized medical expenses;

(I) Pay any required medical copayment;

(J) Cooperate with state and federal quality control; and

(K) Contact the agency for an interview as advised by the agency.

003.01 SANCTION FOR REFUSAL TO COOPERATE. Failure to cooperate with the Department may result in a loss of benefits.

003.01(A) SANCTION FOR NON-COOPERATION WITH THE CHILD SUPPORT PROGRAM. If the applicant or recipient fails, or refuses, to cooperate and there is no good cause shown, a sanction will be applied. If the reason for the noncooperation is the applicant or recipient’s failure, or refusal, to provide information about, or obtain third-party resources, the applicant or recipient is ineligible. Eligibility of a child, or the children, is not affected. Ineligibility continues for the applicant or recipient until the individual cooperates.

003.01(B) SANCTION FOR NON-COOPERATION WITH QUALITY CONTROL. The applicant or recipient is expected to cooperate with state and federal quality control as a condition of eligibility. If an applicant or recipient fails to cooperate, the individual is ineligible for one month.

004. APPLICANT’S AND RECIPIENT’S RIGHTS . The applicant or recipient has the right to:

(A) Apply. Anyone who wishes to apply for assistance must be given the opportunity to do so. No one is denied the right to apply for public assistance;

(B) Action on the individual’s application for assistance within the allowed timeframe per regulation;

(D) Appeal to the Director for a hearing on any action, or inaction, with regard to an application, the amount of the assistance payment, or failure to act within the allowed timeframe per regulation. The appeal must be filed in writing within 90 days of the action or inaction.

(E) Have his or her information treated confidentially;

(F) Have his or her civil rights upheld. No person may be subjected to discrimination on the grounds of his or her race, color, national origin, sex, age, disability, religion, or political belief; and

(G) Have the program requirements and benefits fully explained.

005. APPLICATION SUBMITTAL . An application for assistance may be made in person, by mail, telephone, fax, or electronic submission and may be made by the applicant, the applicant’s guardian or conservator, an individual acting under a duly executed power of attorney, or another person authorized to act for the applicant.

005.01 VALID APPLICATION. An application is considered valid the date it is received by the Department and contains:

(A) Name;

(B) Address; and

005.02 ALTERATIONS TO THE APPLICATION. Information may be added to an application up to the decision date.

005.03 ACTION TAKEN ON APPLICATIONS WITHIN ALLOWED TIMEFRAMES PER REGULATION. Eligibility determinations are made 45 days from the date of the application for the blind or aged category, and within 60 days from the date of application for the disabled category.

005.04 STATE DISABILITY PROGRAM MEDICAL APPLICATION WITH SHARE OF COST. An application for State Disability Program medical assistance for an individual with a share of cost who has a medical need may be approved with no medical payments authorized until the applicant has met the share of cost obligation.

005.06 ASSISTANCE TO AGED, BLIND, OR DISABLED AND STATE DISABILITY PROGRAM APPLICATION WITH EXCESS RESOURCES. An application for assistance for an individual who has excess resources is denied. The applicant can reapply when the resources have been spent down.

005.07 APPLICATION WITHDRAWAL. The applicant may voluntarily withdraw an application verbally or in writing. A notice of action is sent to the applicant.

005.08 AUTHORIZATION FOR RELEASE OF INFORMATION. The applicant or recipient must sign a release of information form if the Department requests.

005.09 NEW APPLICATION NEEDED. A new application is required after one calendar month of ineligibility.

005.10 NOTICE OF FINDING. A notice of action is sent to inform the applicant or recipient of any action affecting the assistance case. The types of notices are:

005.10(A) ADEQUATE NOTICE. An adequate notice includes a statement of what actions are being taken, the reasons for the intended actions, and the regulation that support the actions or the change in federal, or state, law that requires the actions.

005.10(B) TIMELY NOTICE. A timely notice is dated and mailed at least ten calendar days before the date that action would become effective, which is always the first day of the month.

005.10(C) ADEQUATE AND TIMELY NOTICE. In cases of intended adverse action, including action to discontinue, terminate, suspend, or reduce assistance, or to change the manner, or form, of payment, or service, to a more restrictive method, such as a protective payee, the applicant or recipient is given adequate and timely notice.

005.11 SITUATIONS REQUIRING ADEQUATE NOTICE. In some instances, timely notice is not needed, but adequate notice is still required.

(A) The agency has factual information confirming the death of a client;

(B) The agency receives a written and signed statement from the client

(i) Stating that assistance is no longer required; or

(ii) Giving information which requires termination or reduction of assistance; and

(iii) Indicating, in writing, that the client understands the consequence of supplying the information;

(D) The client has been placed in skilled nursing care, intermediate care, long-term hospitalization, or Assisted Living Waiver;

(F) The client’s whereabouts are unknown and agency mail directed to the client has been returned by the post office indicating no known forwarding address;

(G) The client has been accepted for assistance in another state and that fact has been established;

(H) A change in level of medical care; or

(I) A special allowance granted for a specific period is terminated and the client has been informed in writing at the time of initation that the allowance automatically terminates at the end of the specified period.

005.12 WAIVER OF NOTICE. An applicant or recipient may agree to waive his or her right to a timely notice in situations requiring timely notice by providing a signed statement indicating his or her choice to waive the notice.

005.13 NOTICES IN FRAUD CASES. At least five days advance written notice is given if:

(A) The agency has facts indicating that action should be taken to discontinue, suspend, terminate, or reduce assistance because of probable fraud by the applicant or recipient; and

(B) The facts have been verified where possible through collateral sources.

005.14 CONTINUATION OF BENEFITS DURING AN APPEAL. In cases of adverse action, a timely and adequate notice is sent. When the applicant or recipient requests an appeal hearing within ten days following the date a notice of action is mailed, the adverse action is not taken until a fair hearing decision is made. This regulation does not apply to those situations where only an adequate, but not timely, notice is needed.

005.14(A) ON-GOING CASE MANAGEMENT. Normal case activities, and implementing changes to the assistance case, that are not directly related to the appeal issue is still completed.

005.14(B) ADVERSE ACTION. Adverse action pending an appeal is not carried out if:

(i) The case action being appealed required adequate and timely notice;

(ii) The applicant or recipient requests an appeal hearing within ten days following the date the notice of finding is mailed; and

(iii) The applicant or recipient does not refuse continued assistance.

005.14(C) RECOUPMENT CIRCUMSTANCES. If the appealed action is sustained by the hearing decision, the benefits received by the applicant or recipient while the hearing was pending will be subject to recoupment.

005.15 REFUSAL OF CONTINUED BENEFITS DURING AN APPEAL. An applicant or recipient has the right to refuse the continuation of benefits pending an appeal hearing by checking the statement to that effect on the Request for Fair Hearing form, or by handwriting a refusal request.

005.16 REDETERMINATION OF ELIGIBILITY FOR THE AGED, BLIND, OR DISABLED PAYMENT OR STATE DISABILITY PROGRAM. Whenever there is a reported, or suspected, ineligibility of benefits for an applicant or recipient, immediate action to determine current eligibility is taken. A review and eligibility determination is completed according to the following:

005.16(A) REDETERMINATION FOR THE ASSISTANCE TO THE AGED, BLIND OR DISABLED PROGRAM. Every twelve months for the Assistance to the Aged, Blind, or Disabled Payment program, although the eligibility may be redetermined in less than twelve months to coordinate review dates for more than one program.

005.16(B) REDETERMINATION FOR THE STATE DISABILITY PROGRAM. At the end of twelve months or the disability ruling by a medical consultant for the State Disability Program medical assistance only, or State Disability Program medical assistance with a share of cost and no further medical needs are apparent or indicated. The disability time frame from the medical consultant may dictate less than twelve months of eligibility and the individual is ineligible when the disability ruling ends. The case is then closed and a notice sent.

005.16(C) REDETERMINATION FOR SUPPLEMENTAL SECURITY INCOME RECIPIENTS. Every twelve months, or less, for a recipient who are current pay Supplemental Security Income status. An application is not required at the time of the review.

005.16(D) REDETERMINATION FOR SUPPLEMENTAL SECURITY INCOME 1619(b) PROVISION RECIPIENTS. Every twelve months, or less, for individuals who are determined eligible by Supplemental Security Income for the 1619(b) provision are not required to complete an application at the time of review.

005.16(E) TEMPORARY NONPAY STATUS FOR SUPPLEMENTAL SECURITY INCOME RECIPIENTS. A determination of eligibility review is not required for periodic Supplemental Security Income non-pay status for income due to an extra pay period.

005.17 INCOME REVIEW. An income review is completed every twelve months for the Assistance to the Aged, Blind, or Disabled Payment program.

005.17(A) INCOME REVIEW NOT REQUIRED. An income review is not required for recipients of Supplemental Security Income.

005.18 DISABILITY REVIEW. When the initial disability determination was made by the Department, all procedures necessary for a redetermination of disability are required for recipients of the Assistance to the Aged, Blind or Disabled payment program or the State Disability Program. A redetermination of disability must be made no later than twelve months after the initial determination of disability.

005.19 PRUDENT PERSON PRINCIPLE. When the statements of the client are incomplete, unclear, or inconsistent, or when other circumstances in the particular case indicate to a prudent person that further inquiry must be made, additional verification is obtained before eligibility is determined.

005.19(A) PRIMARY RESPONSIBILITY. The client has the primary responsibility for providing verification of information relating to eligibility.

005.19(B) VERIFICATION METHODS. Verification may be supplied in person, through electronic submission, the mail, or another source.

005.19(C) AVAILABLE ASSISTANCE. When it would be extremely difficult, or impossible, for the individual to provide verification in a timely manner, the individual may ask the Department for assistance.

History

Effective 2022-06-06

Chapter 2 Eligibility Requirements

Neb. Admin. Code tit. 469, ch. 2 Eligibility Requirements {#sec-469-nac-2 omnilex-key=us-ne-regs-official--title-469--469 NAC 2}

001. ELIGIBILITY . In order to be eligible to receive assistance under the Aged, Blind, or Disabled Program the individual must:

(A) Submit an application;

(B) Be a United States citizen or have a qualified alien status as required by Nebraska Revised Statute (Neb. Rev. Stat.) § 4-111;

(D) Have a Social Security number;

(E) Meet the age requirements of section 005;

(F) Be responsible for relative financial support as required by section 006;

(G) Be determined blind or disabled by the Social Security Administration;

(H) Meet resource limits;

(I) Meet income requirements;

(J) Cooperate in obtaining third-party medical payments; and

(K) Not be receiving any other state funded cash assistance.

001.01 MEDICAL ASSISTANCE. All medical assistance criteria in this title refers to the State Disability Program only.

002. APPLICATION . An application for Assistance to the Aged, Blind, or Disabled or State Disability Program must be completed and submitted.

003. VERIFYING CITIZENSHIP OR ALIEN STATUS . The applicant or recipient must sign an attestation form required by Neb. Rev. Stat. § 4-111. The applicant or recipient’s status must be able to be verified in accordance with Neb. Rev. Stat. § 4-112.

004. RESIDENCE . To be eligible, the applicant or recipient must be living in the state voluntarily with the intent of making Nebraska their home. Residence starts the month the applicant moves into the state, even if the individual received categorical assistance in another state.

004.01 INCAPABLE OF INDICATING INTENT. An individual is considered incapable of indicating intent if:

(A) The individual has an Intelligence Quotient of 49 or less, or a mental age of seven or less, based on tests acceptable to the State developmental disabilities agency;

(B) The individual is judged legally incompetent; or

(C) Medical documentation obtained from a physician, psychologist, or other person licensed by the State in the field of developmental disability, or other documentation acceptable to the State supports a finding that the individual is incapable of indicating intent.

004.02 RESIDENCE OF APPLICANTS ENTERING THE STATE INTO A LICENSED HOME. The intent of an individual to establish Nebraska as his or her residence is investigated if the individual comes into the state and immediately enters a facility licensed by the Nebraska Department of Health and Human Services Division of Public Health.

(A) The applicant is considered a Nebraska resident if the individual entered because they:

(i) Desired to be near close friends or relatives in the State;

(ii) Previously resided in the State; or

(iii) Has other contacts in the State.

(B) If the applicant indicates a plan to establish residence, but the situation seems to indicate otherwise, additional factors will be reviewed, such as:

(i) When the individual entered the state;

(ii) Whether, or not, the individual owns property of any kind in another state;

(iii) The place of residence of the spouse or other immediate family members;

(iv) The medical eligibility in the previous state of residence for the individual;

(v) How the individual was referred to the facility in Nebraska, such as by a family member, hospital staff, or social worker in the previous state;

(vi) Where the individual would reside if the facility placement was no longer needed; and

(vii) Any other related factors.

004.03 PLACEMENT IN AN OUT-OF-STATE INSTITUTION. If a state arranges for an individual to be placed in an institution located in another state, the state making the placement is the individual’s state of residence, regardless of the individual’s indicated intent or ability to indicate intent.

004.04 INDIVIDUALS RECEIVING A STATE SUPPLEMENTAL PAYMENT. For any individual who is receiving a State Supplemental Payment, the state paying the State Supplemental Payment is the state of residence.

004.05 INSTITUTIONALIZED INDIVIDUALS. The state where the institution is located is the individual’s state of residence unless it is determined that the individual is a resident of another state, according to the following:

(A) Institutionalized individuals age 20 or younger, or age 21 or younger and who became incapable of indicating intent before reaching age 21, the state of residence is:

(i) That of the individual’s parents or legal guardian at the time of placement;

(ii) That of the parents or legal guardian if the individual is institutionalized in that state.

(B) Institutionalized individuals who became incapable of indicating intent at or after reaching age 21, the state of residence is the state in which the individual is physically present except where another state makes a placement.

004.06 NON-INSTITUTIONALIZED INDIVIDUALS. The following applies to individuals not residing in an institution:

004.06(A) AGE 20 AND YOUNGER. For an individual who is not institutionalized, who is age 20 or younger, and whose eligibility is based on blindness or disability, the individual’s state of residence is the state where the individual is living. Any other individual who is not institutionalized, age 20 or younger is a resident of the state in which the individual is living other than on a temporary basis.

004.06(B) INDIVIDUALS AGE 21 AND OLDER. For individuals who are not institutionalized, but are incapable of indicating their intent regarding their residency, state residence is the state where the individual is living.

004.07 ABSENCE FROM THE STATE. Assistance is not denied because an individual has not resided in the state for a specific period of time.

004.07(A) TEMPORARY ABSENCE. An individual’s eligibility may not be terminated because of that person’s temporary absence from the state if the person intends to return. A temporary absence is typically 90 days or less.

004.07(B) LOSS OF STATE RESIDENCE. Eligibility ends if the family unit leaves Nebraska with the intent of establishing its home in another state;

(i) A family unit may not receive an Assistance to the Aged, Blind, or Disabled payment or State Disability Program assistance from Nebraska beyond the month they have been found eligible for categorical assistance from another state;

(ii) Individuals who leave the state for longer than two months may continue to receive an Assistance to the Aged, Blind, or Disabled payment or State Disability assistance in Nebraska if they are absent for a temporary purpose and intend to return.

004.07(C) OUT-OF-STATE MEDICAL. If an out-of-state provider does not sign an agreement with the State Disability Medical program or Medicaid, and accept the reimbursement rate, the individual receiving State Disability Program medical is liable for his or her own medical bills. Payments may be approved for services provided outside Nebraska in the following situations:

(i) When an emergency arises from accident or sudden illness while a recipient is visiting in another state and the recipient’s health would be endangered if care is postponed until the recipient returned to Nebraska or by traveling to Nebraska;

(ii) When the recipient customarily obtains service in another state because the service is more accessible;

(iii) When the recipient requires a medically necessary service that is not available in Nebraska but is available in another state; and

(iv) When long term care services are provided in another state.

004.08 DISQUALIFICATION FOR MISREPRESENTING RESIDENCE. Any person convicted in federal or state court of having fraudulently misrepresented residence in order to obtain Assistance to the Aged, Blind, or Disabled payment or State Disability Program assistance in two or more states is ineligible for Assistance to the Aged, Blind, or Disabled payment or State Disability Program assistance for ten years from the date of conviction.

004.09 SOCIAL SECURITY NUMBER REQUIREMENT. All eligible members of the Assistance to the Aged, Blind, or Disabled Payment or State Disability unit must furnish Social Security numbers. The Social Security Number, in conjunction with other information, provides evidence of identity of the individual.

005. AGE . An applicant’s age is considered in determining eligibility for Assistance to the Aged, Blind and Disabled benefits.

005.01 AGE LIMITS. To be eligible for Assistance to the Aged, Blind, or Disabled payment or State Disability Program, an individual must meet the following age limits:

(A) To qualify as Aged, an individual must be age 65 or older;

(B) To qualify as Blind, an individual must be age 64 or younger;

006. RELATIVE FINANCIAL RESPONSIBILITY . There are two categories of relative responsibility, spouse-for-spouse and parent-for-child.

006.01 SPOUSE FOR SPOUSE. A divorce dissolves the marriage of a couple and there is no longer spouse-for-spouse responsibility. A legal separation does not dissolve the marriage.

006.02 PARENT FOR CHILD. The income and resources of a parent is deemed to a child age 17 or younger if living in the same household.

007. BLINDNESS OR DISABILITY . The eligibility requirements and definitions for blindness and disability follow:

007.01 ELIGIBILITY REQUIREMENTS APPLICABLE ONLY TO BLIND OR DISABLED. All applicants for Assistance to the Aged, Blind, or Disabled payment or State Disability Program after January 1, 1974, must meet the medical definitions of blindness or disability of the Retirement, Survivors, Disability Insurance or Supplemental Security Income Programs as administered by the Social Security Administration. The determination by Social Security Administration that an individual is disabled or blind must be accepted for eligibility for Assistance to the Aged, Blind, or Disabled. In some cases, the State Review Team may make the determination of blindness or disability.

007.02 DEFINITIONS OF DISABILITY AND BLINDNESS. The following definitions are used by the Social Security Administration and the Department’s designated Medical Consultant Review process in making a determination for the Assistance to the Aged, Blind, or Disabled payment program and the State Disability Program:

(A) An individual is considered disabled for the Assistance to the Aged, Blind, or Disabled payment program when it is not possible for the individual to engage in any substantial gainful activity due to any medically determined physical or mental impairment which can be expected to result in death or which has lasted, or can be expected to last, for a continuous period of not less than 12 months. A child through age 17 is considered disabled if the individual suffers from any medically determined physical or mental impairment of comparable severity.

(B) An individual is considered blind for the Assistance to the Aged, Blind, or Disabled payment program if that individual has central visual acuity of 20 over 200, or less, in the better eye with correcting lens, or a field defect in which the peripheral field has contracted to such an extent that the widest diameter of visual field subtends an angular distance of no greater than 20 degrees.

(C) An individual is considered disabled for the State Disability Program if it is not possible for the individual to engage in any substantial gainful activity by reason of a medically determined physical or mental impairment which can be expected to result in death or which has lasted, or can be expected to last, for a continuous period of not less than 6 months from onset and not more than 12 months. The Department’s designated medical reviewer always makes the determination for the State Disability Program. The individual cannot be ineligible for other Medicaid programs.

007.03 DETERMINATION OF ELIGIBILITY FOR THE BLIND OR DISABLED.

(A) When the Social Security Administration has made the disability determination, all eligibility requirements for the Assistance to the Aged, Blind, or Disabled payment program, except for the disability determination, are the responsibility of the Department.

(B) To have the State’s Medical Consultant make the disability determination for the State Disability Program the individual must be denied by Social Security for a ‘lack of duration’.

(C) To be eligible for Assistance to the Aged, Blind, or Disabled payment program, the individual must have been determined disabled by the Social Security Administration, and be currently eligible to receive Supplemental Security Income or Retirement, Survivors, Disability Insurance, or be determined disabled by the State Review Team.

(D) To be eligible for a State Disability Program payment, the individual must have been denied Supplemental Security Income due to a ‘lack of duration’ of their disability, and was determined disabled by the Department’s Medical Consultant.

(E) The cost of medical examinations to determine initial or continuing State Disability eligibility may not exceed the established Medicaid allowable fee. The cost of a medical examination to determine eligibility is an allowable Title XIX expenditure if the individual is eligible for medical benefits on the date of the examination. If the initial application is rejected, the cost of the examination must be paid from administrative funds.

008. INSTITUTIONALIZATION . An individual may qualify for Assistance to the Aged, Blind, or Disabled while living in an institution only if the institution is subject to the licensing requirements of the Department.

008.01 PATIENTS IN A MEDICAL INSTITUTION AND CONVALESCENT LEAVE. Assistance may be provided for an individual who is a patient in a medical institution, such as a hospital or nursing home, if all other eligibility factors are met. Psychiatric units of medical hospitals are considered part of the medical institution and are not subject to the restriction on psychiatric care identified previously.

008.02 LICENSED INSTITUTIONS. Nebraska currently has the following public institutions licensed for the treatment of mental diseases and developmental disabilities:

(A) Hastings Regional Center;

(B) Norfolk Regional Center;

(D) Beatrice State Developmental Center.

008.03 LEVELS OF CARE. The previously listed facilities may be licensed by the Department’s Division of Public Health and certified under Medicaid as one or more of the following types of facilities:

(A) Acute hospital;

(B) Psychiatric; and

(i) Coverage may be provided to persons of all ages in the previously listed facilities for acute hospital and intermediate care facility for persons with developmental disabilities levels of care if the individuals are otherwise determined eligible.

(ii) Psychiatric care is available to State Disability Plan medically eligible individuals.

(iii) An individual is not eligible to receive an Assistance to the Aged, Blind, or Disabled Payment or State Disability Program if in a prison, unless the individual is hospitalized while in prison, jail or in a veteran's hospital.

008.04 PATIENTS IN A MEDICAL INSTITUTION. Assistance may be provided for a recipient who is a patient in a medical institution, such as a hospital or nursing home, if all other eligibility factors are met. Psychiatric wards of medical hospitals are considered part of the medical institution and are not subject to the restriction on psychiatric care.

008.05 CONVALESCENT LEAVE. Eligibility of individuals on convalescent leave or visit from public medical institutions is determined in accordance with the usual program standards. Eligibility is based on their living situation and needs while on leave.

008.06 RESPONSIBILITY FOR DETERMINING NATURE OF INSTITUTION. The Department determines the public, or private, nature of an institution, and whether a public institution is one in which otherwise eligible individuals may receive assistance.

008.07 CRITERIA FOR DETERMINING THE PUBLIC NATURE OF INSTITUTIONS. Prisons and jails are designated in the law as public institutions whose inmates are ineligible to receive assistance. Governmental participation in financial support of an institution, in policy formulation, or in the application of policy to specific situations, is evidence of the public control which makes it a public institution. Payment from public funds to, or in support of, individuals in a private institution is not considered governmental participation in support of the institution.

009. RESOURCES . The total equity value of available non-excluded resources of the individual or individual and responsible relative, or individual and essential person is determined and compared with the established maximum for available resources which the individual may own and still be considered eligible. If the total equity value of available non-excluded resources exceeds the established maximum, the individual is ineligible. The assets of each spouse are considered available to the other unless there is a divorce.

(A) Resource limits are:

(i) $2,000 for a single individual; or

(ii) $3,000 for a couple.

009.01 COUNTED RESOURCES.

(i) Cash on hand;

(ii) Cash in saving or checking accounts;

(iii) Certificates of deposit;

(iv) Stocks;

(v) Bonds;

(vi) Investments;

(vii) Collectable unpaid notes or loans;

(viii) Promissory notes;

(ix) Mortgages;

(x) Land Contracts;

(xi) Land leases;

(xii) Revocable burial funds;

(xiii) Trust or guardianship funds;

(xiv) Cash value of insurance policies;

(xv) A home;

(xvi) Additional pieces of property;

(xvii) Trailer houses;

(xviii) Burial spaces;

(xix) Motor vehicles;

(xx) Life estates;

(xxi) Farm and business equipment;

(xxii) Livestock;

(xxiii) Poultry and crops;

(xxiv) Household goods and other personal effects;

(xxv) Contents of a safe deposit box;

(xxvi) Tax Refunds;

(xxvii) Elective share of a spouse’s augmented estate; and

(xxviii) Revocable, assignable, or saleable annunity.

009.02 VERIFICATION OF RESOURCES. Before determining eligibility of an Assistance to the Aged, Blind, or Disabled or State Disability applicant who does not receive Supplemental Security Income, all individuals’ resources must be verified and documented in the case record.

009.03 DEFINITION OF AVAILABLE RESOURCES. For the determination of eligibility, available resources include cash or other liquid assets or any type of real or personal property or interest in property that the applicant or recipient owns and may convert into cash to be used for support and maintenance.

009.03(A) UNAVAILABILITY OF RESOURCE. Regardless of the terms of ownership, if it can be documented in the case record that the resource is unavailable to the individual, the value of that resource is not used in determining eligibility.

009.03(B) EXCLUDED RESOURCES. Disregarded income is also disregarded as a resource unless there is regulation stating otherwise. Additionally, the following resources are excluded:

(i) Real property which the individual owns and occupies as a home;

(ii) Household goods and personal effects of a moderate value used in the home;

(iii) Cash surrender value of life insurance policies with combined face values of $1,500 or less per individual;

(iv) A specified maximum in proceeds from an insurance policy irrevocably assigned for the purpose of burial of the applicant or recipient;

(v) Irrevocable burial trusts up to the specified amount per individual and the interest if irrevocable;

(vi) Burial space items or a contract for the purchase of burial space items owned by an applicant or recipient or designated family member;

(vii) Burial space;

(viii) Up to $1,500 set aside for burial arrangements;

(ix) One motor vehicle if it is used for employment, medical transportation, or as the applicant or recipient's home. If the individual has more than one motor vehicle, the individual may designate the vehicle to be excluded;

(x) Certain trusts, including guardianships, where the person in whose behalf the trust is established may be ineligible but this may not affect eligibility of the other person in the household unit;

(xi) Certain life estates in real property;

(xii) Income received annually, semi-annually, or quarterly which is prorated on a monthly basis and included in the budget, during the period of time it is being considered as income;

(xiii) The unspent portion of any Retirement, Survivors, Disability Insurance or Supplemental Security Income retroactive payments for six months following the month of receipt;

(xiv) U.S. savings bonds, for the initial six-month mandatory retention period;

(xv) A resource used in the recipient's trade or business;

(xvi) A maximum of $6,000 equity value of nonbusiness property, real or personal, that is used to produce goods or services essential to daily activities;

(xvii) The unspent portion of an Aged, Blind, or Disabled or State Disability Program retroactive payment for six months following the month of receipt;

(xviii) Victims compensation payments, such as payments received from a state or local government to aid victims of crime. These are excluded for nine months beginning with the first month after receipt;

(xix) Payments received from a state or local government to assist in relocation, excluded for nine months beginning with the first month after receipt;

(xx) An unavailable job-related retirement account that is held by the employer;

(xxi) An Individual Development Account, set up for postsecondary education or purchase of an individual’s first home;

(xxii) Medicare set-aside accounts that may be used only for payment of medical bills of Medicare beneficiaries; and

(xxiii) Funds held in an Achieving a Better Life Experience account, also known as an ABLE account.

009.04 DETERMINATION OF OWNERSHIP OF RESOURCES. A resource which appears on record in the name of an applicant or responsible relative is considered as belonging to the applicant.

009.04(A) JOINTLY OWNED RESOURCES. When an applicant has a jointly owned resource that is considered available, the following applies:

009.04(A)(i) RESOURCES OWNED WITH OTHER RECIPIENTS. If an applicant owns a resource with another individual who is on categorical assistance, the value of the resource will be divided by the number of owners, regardless of the terms of ownership.

009.05 CONSIDERATION OF RELATIVE RESPONSIBILITY. When the applicant has a relative responsibility for an individual in another assistance unit, and the responsible relative owns the resource, the value must be divided by the number of units to determine the amount to be counted to each. An Assistance to the Aged, Blind, or Disabled or State Disability Program Medical Assistance or State Disability Program Medical Assistance couple is considered one unit.

009.06 INHERITANCE. When an applicant receives an inheritance, verified payment of debts or obligations of the deceased are subtracted from the settlement.

009.07 VALUE AND EQUITY. Equity is the actual value of property or the price at which it could be sold, less the total of encumbrances against it such as the mortgages, mechanic's liens, other liens and taxes, and estimated selling expenses.

009.07(A) SECURED DEBTS. The total value of unpaid personal taxes and other personal debts secured by mortgages, liens, promissory notes, and judgments, other than those on which the statute of limitations applies, is subtracted from the gross value of the encumbered property to find the equity.

009.07(B) DETERMINATION OF VALUE. The use of public tax records may be used to determine the sale value of a resource.

009.08 TYPES OF RESOURCES. Resources can be divided into two categories: liquid and non-liquid.

009.08(A) LIQUID RESOURCES. Liquid resources are assets that are in cash or financial instruments which are convertible to cash.

009.08(A)(i) CASH, SAVINGS, INVESTMENTS, MONEY DUE. Cash on hand, cash in checking and savings accounts, salable stocks or bonds, certificates of deposit, promissory notes and other collectable unpaid notes or loans and other investments are available resources.

009.08(A)(i)(1) ABLE ACCOUNTS. In December 2014, the Achieving a Better Life Experience (ABLE) Act was signed into law authorizing individuals with disabilities to save more than the Social Security limit in assets ($2,000).

009.08(A)(ii) LAND CONTRACTS. A land contract, or real estate contract of sale, is considered a resource to the seller of the property if the contract can be sold.

009.08(A)(iii) FUNDS SET ASIDE FOR BURIAL. A specified maximum may be disregarded if it is set aside for the purpose of paying burial expenses. The individual may choose to put the money in one of the following:

(a) A pre-need burial trust. If the individual has an irrevocable burial trust for more than the specified maximum, the excess is considered an available resource;

(b) A policy of burial insurance. If the individual has irrevocably assigned more than the specified maximum in burial insurance, the excess is not an available resource; or

009.08(A)(iii)(1) IRREVOCABLE BURIAL TRUSTS. If the money was put in an irrevocable burial trust on July 16, 1982, or later, it is not considered an available resource. According to Nebraska law, an individual is allowed to deposit funds up to the specified maximum in an irrevocable trust fund created for the purpose of a prearranged funeral plan.

009.08(A)(iii)(1)(a) INTEREST ON BURIAL TRUSTS. For irrevocable burial trusts contracted on December 31, 1986, or earlier, the individual was allowed to stipulate whether the interest, or dividends, accruing to the trust fund were irrevocable. If the interest, or dividends, are irrevocable, they are disregarded.

009.08(A)(iii)(2) BURIAL INSURANCE. Burial insurance is defined as insurance whose terms specifically require that the proceeds can be only be used to pay the burial expenses of the insured, or a life insurance policy that is irrevocably assigned for the specific purpose of burial. When the proceeds of a life insurance policy are irrevocably assigned for the purpose of burial, the cash value is not available and is disregarded as a resource.

009.08(A)(iii)(3) MONEY DESIGNATED FOR BURIAL. Up to $1,500 may be disregarded for each individual if it is set aside for the purpose of paying burial arrangements for the individual, or the individual's spouse. This exclusion is in addition to the burial space exclusion. This exclusion is not in addition to a burial trust or burial insurance that has been irrevocably assigned.

009.08(A)(iii)(4) BURIAL SPACES. The value of burial spaces held for the purpose of providing a place for the burial of the individual, their spouse, and members of the individual’s immediate family are not counted as an available resource. The immediate family includes minor and adult children, including adopted children and stepchildren, brothers, sisters, parents, adoptive parents, and the spouses of these individuals. A burial space includes a crypt, mausoleum, urn, casket, marker, vault, or other repository for the remains of a deceased person. This exemption also applies to markers, vaults, and the charges for opening and closing the grave, but does not include services or burial fees. These items are exempt only if they are actually purchased. If the recipient has a life insurance policy for the purchase of burial items, the cash value is included in the specified maximum if the policy is irrevocably assigned.

009.08(A)(iii)(5) BURIAL SPACE ITEMS HELD IN A CONTRACT. Burial space items may be disregarded when they are held for an individual by way of a contract. To meet the requirement that the item is actually purchased, the contract must state that the individual has purchased a particular item for a specified price. Revocability is not an issue for burial space contracts as long as the agreement itself represents the individual's ownership.

009.08(A)(iv) LIFE INSURANCE TERMS. Definitions regarding life insurance that may be used in determining eligibility are:

(a) Cash surrender value is the amount the insurer will pay, usually to the owner, upon cancellation of the policy before death of the insured or before maturity of the policy.

(b) Face value is the basic death benefit of the policy exclusive of dividend additions or additional amounts payable because of accidental death or under other special provisions. In determining the face value of a policy, the original face value of the policy is used.

(d) Insurer refers to the company that insures others.

(e) Owner refers to the person who has the right to change the policy.

009.08(A)(iv)(1) CASH SURRENDER VALUE. Using the following criteria, the cash surrender value of life insurance owned by the recipient is considered a resource. If the combined original face value of all the life insurance policies owned by the recipient exceeds $1,500, the cash surrender value of all the policies is considered a countable resource. Each person in the unit is allowed the $1,500 exemption for the face value of their life insurance.

009.08(A)(iv)(2) ADJUSTMENT. The recipient can usually adjust a large insurance policy to a smaller amount providing limited protection and allowing the individual to benefit from accumulated savings.

009.08(A)(iv)(3) INTEREST AND DIVIDENDS. Interest and dividends actually paid to the recipient from all life insurance policies are treated as income unless the total is less than $10 per individual.

009.08(A)(v) TRUST, GUARDIANSHIP, CONSERVATORSHIP, AND ANNUITY FUNDS. When a guardianship, conservatorship, annuity, or trust has been established on behalf of an individual and the individual who has applied has resources exceeding the total resource limit for an Aged, Blind, or Disabled Program grant program or State Disability Program grant or medical program, the trust, guardianship, conservatorship, or annuity will be verified if it is available to the applicant.

009.08(A)(v)(1) DEFINITIONS. For the purposes of these regulations, the following definitions apply.

(a) ANNUITY. A right to receive periodic payments, either for life or a term of years.

(b) BENEFICIARY. Any individual, or individuals, designated in the trust to receive any disbursal from the corpus of the trust, or from income generated by the trust, which benefits the party receiving it. A payment from a trust may include actual cash, as well as non-cash or property disbursements, such as the right to use and occupy real property.

(i) The recipient;

(ii) The recipient’s spouse;

(iii) A person, including a court or administrative body, with legal authority to act in place of, or on behalf of, the individual or the individual’s spouse or guardian or conservator; or

(iv) A person, including a court or administrative body, acting at the direction or upon the request of the recipient or the recipient’s spouse.

(d) IRREVOCABLE TRUST. A trust which cannot, in any way, be revoked by the grantor.

(e) POOLED TRUST. A trust containing the assets of a disabled individual that is established and managed by a nonprofit association in a separate account solely for the benefit of a disabled individual.

(f) REVOCABLE TRUST. A trust which can be revoked by the grantor. A trust which provides that the trust can only be modified or terminated by a court is considered to be a revocable trust, since the grantor, or representative can petition the court to terminate the trust. A trust called irrevocable, but which will terminate if some action is taken by the grantor, is a revocable trust for purposes of these regulations.

(g) SPECIAL NEEDS TRUST. A trust containing the assets of an individual age 64, or younger, who is disabled and that is established for the sole benefit of that individual by a parent, grandparent, legal guardian, or a court.

(h) TESTAMENTARY TRUST. A trust established through a will.

(i) TRUST. For purposes of these regulations, a trust is any arrangement in which an individual, known as the grantor, transfers property to another person, known as the trustee, with the intention that it be held, managed, or administered by the trustee for the benefit of the grantor or certain designated beneficiaries. The trust must be valid under state law and manifested by a valid trust instrument of agreement. A trustee holds a fiduciary responsibility to manage the trust’s corpus and income for the benefit of the beneficiaries.

009.08(A)(v)(2) TESTAMENTARY TRUSTS. Testamentary trusts may be excluded as resources, depending on the availability of the funds to the individual or their spouse as specified in the terms of the trust.

009.08(A)(v)(3) ANNUITIES.

009.08(A)(v)(3)(a). PURCHASED OR ANNUITIZED BEFORE FEBRUARY 8, 2006. Where the individual cannot assign or change the ownership or payee, the annuity is unavailable. A determination must then be made if a deprivation has occurred. If the expected return on the annuity is commensurate with the life expectancy of the individual, the annuity can be deemed actuarially sound and no deprivation has occurred.

009.08(A)(v)(3)(b). ANNUITY TRANSACTION ON OR AFTER FEBRUARY 8, 2006. Revocable and assignable annuities are a countable resource. A saleable annuity which has not been sold is a countable resource for the amount annuitized, less the payment amount already received. A saleable annuity which has been sold for a value consistent with the secondary market is a countable resource in the amount of the proceeds. If a saleable annuity is sold for less than a value consistent with the secondary market, it will be valued at the current secondary market amount.

009.08(A)(v)(3)(b)(i) ANNUITIES EXCLUDED FROM RESOURCES. An annuity which has been annuitized will be excluded from countable resources if it meets the following conditions:

(1) The annuity is considered either an individual retirement annuity according to Internal Revenue Code, or a deemed Individual Retirement Account under a qualified employer plan by Internal Revenue Code;

(2) The annuity is purchased with the proceeds from a simplified employee pension; and

(3) The annuity is irrevocable and non-assignable, the individual who owned the retirement account or plan is receiving equal monthly payments with no deferral or balloon payments, and the scheduled payout period is actuarially sound based on the individual’s life expectancy. The applicant or recipient must verify that the annuity meets these requirements.

009.08(A)(v)(4) REVOCABLE TRUSTS. In the case of a revocable trust:

(a) The entire corpus of the trust is counted as an available resource to the applicant or recipient;

(b) Any payments from the trust made to or for the benefit of the applicant or recipient are counted as income;

(c) Any payments from the trust which are not made to, or on behalf of, the applicant or recipient are considered assets disposed of for less than fair market value; and

(d) If the applicant or recipient must go to court to access the funds, the individual or guardian or conservator of the individual is allowed 60 days to initiate court action. For the applicant, 60 days from the approval date is allowed; for the recipient, 60 days from the notification of the requirement to file for access is allowed.

009.08(A)(v)(5) GUARDIANSHIPS OR CONSERVATORSHIPS. When a fund is established in the process of the appointment of a guardianship or conservatorship, determine if the funds are available without court approval.

(a) The individual is ineligible for categorical assistance until the guardian gives the Department written notice of refusal to spend guardianship or conservatorship monies for the care and maintenance of the individual. In order to be considered current notice, it must be given within one year of its use in determining eligibility for categorical assistance.

(b) After current notice has been given, the individual, if otherwise eligible, may receive benefits if all judicial remedies are pursued to determine the availability of the funds. This may include an appeal to the proper district court and, if necessary, to the Court of Appeals and the Nebraska Supreme Court.

(c) Certain guardianships and conservatorships are not reasonably available and judicial review may be waived; these include some guardianships or conservatorships where the guardian or conservator's discretion is limited and certain guardianships or conservatorships established from the proceeds of a personal injury case on behalf of a child.

(d) The child, guardian, or conservator must file a request for access to the funds in a court of competent jurisdiction within, for the applicant, 60 days from the approval date; for the recipient, 60 days from the notification of the requirement to file for access.

(e) If the petition or application has not been filed after 60 days, the individual is no longer eligible for Aged, Blind, or Disabled payment or State Disability Program.

009.08(A)(v)(6) IRREVOCABLE TRUSTS.

009.08(A)(v)(6)(a) TRUSTS ESTABLISHED BEFORE AUGUST 11, 1993. For a qualifying trust established before August 11, 1993, the maximum amount that could have been distributed from either the income or principal is considered an available resource. A qualifying trust is a trust, or similar legal device, that was established by an applicant or recipient, or their spouse, under which:

(1) The individual is the beneficiary of all or part of the payments from the trust; and

(2) The amount of the distribution is determined by one or more trustees who are permitted to exercise any discretion with respect to the amount to be distributed to the individual and the distributable amount from a qualifying trust has no use limitation.

009.08(A)(v)(6)(a)(i) A trust that was established by an individual's guardian or legal representative, acting on the individual's behalf, falls under the definition of a qualifying trust. If an individual is not legally competent, for example, a trust established by a legal guardian, including a parent, using the individual's assets, can be treated as having been established by the individual, since that individual could not establish the trust for himself or herself.

009.08(A)(v)(6)(b) TRUSTS ESTABLISHED ON OR AFTER AUGUST 11, 1993. In accordance with Sections 1917 (c) and (d) of the Social Security Act, the following regulations apply to all trusts created on or after August 11, 1993:

(i) These regulations apply to any recipient who establishes a trust, who is a beneficiary of a trust, and who is an applicant or recipient of the Aged, Blind, or Disabled, or State Disability Program. An individual is considered to have established a trust if their assets or assets of a spouse were used to form a part or the entire corpus of the trust other than by will. These include trusts established by:

(1) The individual;

(2) The individual’s spouse;

(3) A person, including a court or administrative body, with legal authority to act in place of or on behalf of the individual or the individual’s spouse; or

(4) A person, including any court or administrative body, acting at the direction or upon the request of the individual or the individual’s spouse.

(ii) Where a trust includes the assets of another person, as well as the assets of the applicant or recipient, or this individual’s spouse, the rules in this section apply only to the portion of the trust attributable to the assets of the applicant or recipient and this individual’s spouse.

009.08(A)(v)(6)(c) PAYMENT CAN BE MADE FROM TRUST. The following applies when payment may be made to the individual or the individual’s spouse under the terms of the trust:

(1) Payments from income, or from the corpus, made to or for the benefit of the applicant or recipient or this individual’s spouse are treated as income to the individual.

(2) If there are any circumstances under which payment from the trust corpus could be made to or for the benefit of the applicant or recipient, or this individual’s spouse, the portion of the corpus from which payment to or for the benefit of the applicant or recipient, or this individual’s spouse could be made must be considered a resource that is available to the individual.

(3) Any portion of the corpus that could be paid to or for the benefit of the applicant or recipient, or this individual’s spouse is treated as an available resource.

(4) Payments from income or from the corpus that are not made to or for the benefit of the applicant or recipient, or this individual’s spouse, are treated as transfers of assets for less than fair market value.

009.08(A)(v)(6)(c)(i) EXCEPTIONS. A trust is not considered available if it is established for a disabled recipient age 64 or younger, receiving or eligible to receive State Supplemental Income; Retirement, Survivors, Disability Insurance; or Aid to the Aged, Blind, or Disabled and is:

(1) A Special Needs Trust containing the assets of the applicant or recipient and established solely for the benefit of this individual by the individual's parent, grandparent, legal guardian, or a court if the State will receive all amounts remaining in the trust upon the death of the individual or upon termination of the trust up to the amount of total medical assistance paid on behalf of the individual; or

(2) A Pooled trust containing the assets of the applicant or recipient and is:

(a) Established and managed by a non-profit association; or

(b) A separate account maintained for each beneficiary of the trust, but, for purposes of investment and management of assets, the trust pools these accounts;

(c) Accounts in the trust that are established solely for the benefit of individuals who are blind or disabled receiving, or eligible to receive, Supplemental Security Income, Retirement, Survivors, Disability Insurance, or Aged, Blind, or Disabled; and

(d) A trust containing the provision that the State of Nebraska will receive all amounts remaining in the trust for the beneficiary upon the death of the applicant or recipient up to the amount of total medical assistance paid on behalf of the individual.

009.08(A)(v)(6)(d) PAYMENT CANNOT BE MADE FROM TRUST. When payments from some portion or all of the trust cannot under any circumstances be made to or for the benefit of the individual, or where there is some portion of the trust from which no payments can be made to or for the benefit of the individual, all of the corpus, or income on the corpus, which cannot be paid to the individual is considered a transfer of assets for less than fair market value.

009.08(A)(v)(6)(e) HARDSHIP PROCEDURES. A trust will not be considered available if denial of assistance would cause undue hardship.

009.08(B) NON-LIQUID RESOURCES. Non-liquid resources are tangible properties which need to be sold if they are to be used for the maintenance of the recipient. They include all properties not classified as liquid resources, such as:

(i) A home;

(ii) Additional pieces of property;

(iii) Trailer houses;

(iv) Burial lots;

(v) Motor vehicles;

(vi) Life estates;

(vii) Farm and business equipment;

(ix) Livestock;

(x) Poultry and crops; and

(xi) Household goods and other personal effects.

009.08(B)(i) EXEMPTION OF HOME. The Aged, Blind, or Disabled Payment or State Disability Program applicant or recipient's home is exempt from consideration as an available resource, with the following limitations.

009.08(B)(i)(1) DEFINITION OF HOME. A home is defined as any shelter which the individual owns and uses as the principal place of residence. The home includes any land on which the house is located and any related outbuildings necessary to the operation of the home.

009.08(B)(i)(2) ADJACENT LOTS. Lots adjacent to the home are considered available if they can be sold separately from the home. If it is determined and documented in the case record that the lots adjacent to the home cannot be sold or are not saleable due to the location or condition of the property, the adjacent lots are also exempt.

009.08(B)(i)(3) HOME EQUITY VALUE. For applications on January 1, 2006, or later, the individual is not eligible for any long-term care services if the equity value interest in the home exceeds the specified amount.

009.08(B)(ii) REMOVAL FROM HOME. If the individual moves away from the home and does not plan, or is unable, to return to it, the Department determines when the home becomes an available resource in accordance with the following provisions:

(a) The home continues to be exempt as a resource while it is actually occupied by the individual's spouse or dependent relative. A dependent relative includes the individual's:

(i) Child, stepchild, or grandchild age 17 or younger;

(ii) Child, stepchild, or grandchild age 18 or older if aged, blind, or disabled and receiving, or eligible to receive, Supplemental Security Income; Aged, Blind, or Disabled payment; State Disability Program; and, other categorical assistance; or

(iii) Brother, sister, stepbrother, stepsister, half-brother, half-sister, parent, stepparent, grandparent, aunt, uncle, niece, nephew, or the spouse of any persons previously named, even after the marriage has been terminated by death or divorce who is receiving, or who would be eligible for, categorical assistance except for income and resources, and who lived in the home at any time one year before the recipient moved away from the home.

(b) When the individual moves to a nursing home, or to an assisted living facility, and is receiving Aged or Disabled waiver services, and it is not possible to determine immediately if the individual will be able to return home, a maximum of six months may be allowed to make that determination. Unless the individual or the individual’s representative signs a statement that the individual will not return to the home, or the home is already listed for sale, it is not possible to determine immediately if the individual will return home.

(c) After a maximum of six months, the home may no longer be considered the individual's principal place of residence and must be considered an available resource. However, the individual is allowed time to liquidate the property before it affects eligibility. The six months begin with the first full month following the month of admission.

(d) After the individual is admitted, if the home is exempt because it is occupied by one or more of the relatives identified previously, the six months begin with the first full month following the month that the home is no longer allowed the exemption for occupation.

009.08(B)(ii)(1) LIQUIDATION OF HOME. As soon as the determination is made that the recipient will not be able to return home, time must be allowed for the individual to liquidate the property. The recipient is also allowed time for liquidation if the home if left for a reason other than entering a medical institution.

009.08(B)(iii) SALE OF HOME. If the Aged, Blind, or Disabled payment or State Disability Program individual sells his or her home, the net proceeds become an available resource unless reinvested immediately in another home. In order to be allowed time to reinvest the proceeds, the individual must be residing in the home at the time of the sale and move directly to the new home. Net proceeds are the remainder after payment of the mortgage, realtor's fees, legal fees, and any other sales-related costs. Any deductions must be verified.

009.08(B)(iv) LIQUIDATION OF REAL PROPERTY. When an individual has excess resources because of real property, the individual may be eligible to receive an Aged, Blind, or Disabled grant or the State Disability Program pending liquidation of the resource in some instances. The eligibility of individuals who own excess real property other than the individual’s home is determined in the month when the Agreement to Sell Real Property and Repay Assistance is signed. The instances that allow eligibility during the liquidation period are according to the following regulations:

009.08(B)(iv)(1) DEFINITION OF REAL PROPERTY. Real property is defined as land, houses, or buildings.

009.08(B)(iv)(2) TIME LIMITS FOR LIQUIDATION. Exclude real property which the recipient is making a good faith effort to sell.

009.08(B)(iv)(3) EXTENSION OF TIME LIMIT. If the individual is unable to liquidate the property in six calendar months, the Department may authorize an additional three calendar months. In determining whether to allow a three-calendar-month extension, the Department considers:

(a) If the property has been placed on the market with a real estate licensee or;

(b) If the individual is asking a fair price for the property;

(d) If the individual understands the requirement for liquidation of the property;

(e) If the recipient has not refused a reasonable offer to purchase, which if there is not a better offer, a reasonable offer is defined as at least two-thirds of either the estimated current market value or the proven actual value;

(f) The economic conditions in the area and if real estate is selling; and,

(g) The three calendar months are counted whether or not the individual is receiving assistance. If the individual moves back to the home during the three-month period and subsequently moves out again, only the months remaining in the three months are allowed.

009.08(B)(iv)(4) JOINT OWNERSHIP. Real property that is jointly owned is excluded if sale of the property would cause the other owner, whether the other owner receives assistance or not, undue hardship. However, if undue hardship ceases to exist, the property is included in countable resources and handled according to the following regulations:

(a) If the individual owns the property with other persons who are not receiving assistance, and the real property is not the principal place of residence of the other owner, the other owner shall be contacted to determine if they are willing to liquidate their interest in the property. If all parties are willing to liquidate, proceed with the liquidation process.

(b) If one or more of the parties do not wish to liquidate, the individual must take legal action to force a sale of the property.

009.08(B)(iv)(5) ADDITIONAL PIECES OF REAL PROPERTY. In computing the amount of the unit's total available resources, the potential sales value of all real property, other than the allowed exemption for the home, is determined and used.

009.08(B)(iv)(6) MOTOR VEHICLES. One Motor vehicle is disregarded regardless of its value as long as it is necessary for the recipient or a member of their household for employment, medical treatment, or is used as the home. If the individual has more than one motor vehicle, the vehicle with the greatest equity is excluded.

(a) Any other motor vehicles are treated as non-liquid resources and the equity is counted in the resource limit. The individual's verbal statement that the motor vehicle is used for employment or medical treatment is sufficient.

(b) A recipient in a nursing home or receiving services through an Assisted Living Waiver is not allowed the disregard of any motor vehicles because medical transportation is included in the payment to the facility.

009.08(B)(iv)(7) DETERMINATION OF FAIR MARKET VALUE. For motor vehicles that are counted in the resource total, the Department uses the fair market value. Cars, trucks, SUVs, vans, motorcycles, recreational vehicles, motorboats and watercraft, and planes are included in the category of motor vehicles.

009.08(B)(iv)(8) LIFE ESTATES. The owner of a life estate in real property is generally unable to sell the property. The Department, includes the net income from the life estate in the budget rather than considering the life estate as an available resource. If the owner of a life estate transfers it to another individual, it must be determined if it is deprivation of a resource. If the life estate is sold, the proceeds are counted as a resource. It is a disposal of assets to purchase a life estate interest in another individual’s home unless the purchaser resides in the home for at least 12 months after the date of purchase.

009.08(B)(iv)(9) HOUSEHOLD GOODS AND PERSONAL EFFECTS. Household goods and personal effects of moderate value used in the home are exempt. Household goods are defined as including household furniture, furnishings and equipment used in the operation, maintenance, and occupancy of the home or in the functions and activities of the home and family life, as well as those items which are for comfort and accommodation. Personal effects include clothing, jewelry, items of personal care, and other similar items.

009.08(B)(iv)(10) LOANS. A bona fide loan to a recipient or financially responsible relative is disregarded as a resource. A bona fide loan is defined as one that must be repaid. The agreement for repayment may be verbal or written and the loan may be owed to an individual or to an organization or agency. Using prudent person principle, the individual's statement is adequate verification that the loan must be repaid.

009.08(B)(iv)(11) ESSENTIAL PROPERTY. If the individual owns a resource that is used in a trade or business, the resource is disregarded, regardless of the value. This includes real property such as land, houses, or buildings as well as personal property such as farm machinery, business equipment, livestock, poultry, crops, tools, safety equipment, or business bank accounts as long as the funds are separated from other liquid resources. The individual or a responsible relative, such as a spouse or parent, must be actively involved in the day-to-day operation of the trade or business as a primary means of earning a livelihood. If the individual or responsible relative is not actively involved in the trade or business, it must be due to circumstances that are beyond the individual's control, such as illness, and there must be a reasonable expectation that the use will resume.

009.08(B)(iv)(11)(a) NONBUSINESS PROPERTY. A maximum of $6,000 equity value of nonbusiness property, real or personal, that is used to produce goods or services essential to daily activities is excluded from resources. For instance, an individual may maintain livestock for consumption in his or her own household.

(i) The property must be in current use or there is the reasonable expectation that use will resume.

(ii) A vehicle such as a garden tractor may qualify for this exemption; an automobile does not qualify.

(iii) Any equity in excess of $6,000 is counted as a resource. If the excess resource is real property, see the regulations on liquidating real property.

009.08(B)(iv)(12) TRAILER HOUSES AND OTHER PORTABLE HOUSING UNITS. If an individual occupies a trailer house, or other portable housing unit as his or her home, the property is allowed the resource exemption for a home. If the recipient enters a nursing home, the allowed exemption of a home for up to six months applies.

(a) If the trailer house, or other portable housing unit, is used for the recipient's trade or business, it may qualify as essential property regarding an exemption.

(b) If it is used to produce goods for the individual's own consumption or use, it may qualify as nonbusiness property regarding an exemption.

009.08(B)(iv)(13) FARM EQUIPMENT. If the farm equipment is used for the individual's trade or business, see Essential Property in this section. If it is used to produce goods for the individual's own consumption or use, see nonbusiness property in this section.

009.08(B)(iv)(14) BUSINESS EQUIPMENT, FIXTURES, AND MACHINERY. If business equipment is used for the individual's trade or business, see essential property in this section. If it is used to produce goods for the individual's own consumption or use, see nonbusiness property in this section.

009.08(B)(iv)(15) LIVESTOCK, POULTRY, CROPS THAT ARE GROWING AND ON HAND. If the livestock, poultry, and crops are grown for the individual's trade or business, see essential property in this section. If they are grown for the individual's own consumption or use, see nonbusiness property in this section.

009.09(C) MAXIMUM AVAILABLE RESOURCE LEVELS FOR GRANT ELIGIBILITY. The established maximum for available resources which an individual, or an individual and responsible relative or essential person may own and still be considered eligible for a grant, according to unit size, are as follows:

(i) One member unit – applicant or recipient only: $2,000

(1) If there is an eligible spouse and an ineligible spouse, the resource level for the eligible spouse is $2,000; or

(2) If the ineligible spouse later becomes eligible, each spouse is allowed $2,000.

(ii) Two member unit: $3,000

(1) Individual and eligible spouse;

(2) Individual and ineligible spouse;

(3) Individual and ineligible spouse who have designated resources but the individual returns home or no longer is eligible for waiver services; or

(4) Recipient and other essential person. This may be a disabled minor child and one parent if that parent is considered an essential person; and

(iii) Three or more member unit: $3,000 plus $25 for each additional essential person

(1) Recipient and spouse; or

(2) Recipient and other essential person; and

(3) Additional essential persons.

009.09(D) RESOURCES OF A SPOUSE, PARENT, OR OTHER ESSENTIAL PERSON. All resources of an individual and spouse or other essential person who is included in the budget and who share the same home are considered available for the support of both unless one spouse is eligible for or receiving waiver services. Relative responsibility includes eligible spouse for spouse, whether the spouse is eligible or ineligible, and parents for children who are age 17, or younger, and still considered part of their household.

009.09(E) DEEMING OF RESOURCES OF A PARENT. In considering the resources of a parent who is not considered an Essential Person towards an eligible child age 17, or younger, and living in the parent's household, the following resources are considered to the child whether or not they are actually made available:

(i) All resources exceeding $2,000 in the case of one parent; or

(ii) All resources exceeding $3,000 in the case of:

(1) Two parents;

(2) One parent and spouse of the parent; or

(3) One parent and one minor sibling; and

(iii) $25 for each additional minor sibling in the parents' household.

009.09(F) DEPRIVATION OF RESOURCES. Any action taken by the individual, or any other person or entity, that reduces or eliminates the individual’s, or spouse’s, recorded ownership or control of the asset for less than fair market value is a deprivation of resources. This includes:

(1) Recorded transfer of ownership of real property;

(2) Not receiving the spousal share of an augmented estate;

(3) Purchase of a life estate in another individual’s home without meeting the 12-month requirement to reside there;

(4) Promissory notes, loans, mortgages, and contract sales for less than fair market value and not enforced;

(5) Purchase of an irrevocable, non-assignable annuity if State Disability Program is not the preferred beneficiary and the annuity is issued on February 8, 2006, or later;

(6) Any transfer above the protected spousal reserved amount to a community spouse; and

(7) Purchase of any contract or financial instrument, including an endowment or insurance, where the criteria for fair market value are not met.

009.09(F)(i) The criteria for fair market value are not met when:

(1) The term of the instrument exceeds the life expectancy of the applicable individual;

(2) The instrument does not provide for equal monthly or annual payments commencing immediately during the term of the contract;

(3) The instrument does not provide for the recovery of assets in the event of default; or

(4) The instrument contains exculpatory or cancellation terms of balance due.

009.09(F)(ii) A service given for free at the time cannot later be claimed as an amount owed.

009.09(F)(iii) When an asset is placed in an annuity on February 8, 2006 or later, the annuity regulations apply.

009.09(F)(iv) Trust regulations may take precedence over deprivation when an asset is placed in a trust.

009.09(F)(v) When real property in which the individual has a life estate is sold, the individual or spouse must receive, as a lump sum, their life estate interest from the net proceeds, or the entire net proceeds invested and the individual who has the life estate receives all the income.

009.09(F)(vi) DEPRIVATION OF RESOURCES FOR A GRANT. The Department investigates for deprivation of a resource if an individual, or an individual’s spouse, applies for, or becomes eligible for, a grant.

009.09(F)(vi)(1) LOOK-BACK PERIOD. If it is determined that an individual disposed of a resource in order to qualify for an Aged, Blind, or Disabled payment, look back 36 months from when the individual applies for Aged, Blind, or Disabled grant assistance or, if later, the date on which the individual or spouse disposes of resources for less than fair market value. The look-back period for grant is always 36 months.

009.09(F)(vi)(2) PERIOD OF INELIGIBILITY FOR A GRANT. If it is determined that an individual disposed of a resource, the applicant or recipient is ineligible for a grant for the number of months calculated by dividing the uncompensated value of the resources disposed of, by the maximum Aged, Blind, or Disabled payment to the individual. The number of months the individual is ineligible for a grant must not exceed 36. If the applicant or recipient is eligible for Supplemental Security Income but for a period of ineligibility due to a disposal, the Aged, Blind, or Disabled grant period of ineligibility is the same as the Supplemental Security Income period of ineligibility. Ineligibility for a grant begins with the month of transfer. Receipt of any grant during the period of ineligibility results in an overpayment and recoupment procedures apply.

009.09(F)(vii) DEPRIVATION OF RESOURCES FOR STATE DISABILITY PROGRAM MEDICAL ASSISTANCE. Investigate for deprivation of a resource only if an individual, or an individual’s spouse, resides in a specified living arrangement which is defined as:

(a) Residing in a nursing home;

(b) Receiving the skilled level of care in a hospital, such as swing bed services;

(c) Requesting or Receiving Home and Community Based Services including an Assisted Living waiver, home health care, or personal care services; or

(d) Residing in an Intermediate Care Facility for Persons with Developmental Disabilities.

009.09(F)(vii)(1) EXCEPTIONS TO DEPRIVATION RULE. An exception may be made when a transfer was made for less than fair market value, but the individual can verify that the intent was to dispose of the resource for fair market value, or for other valuable consideration, that the transfer was not made to qualify for assistance, or that denial of assistance would cause undue hardship. For all disposals of assets, regardless of date, an exception may be made if:

(a) A satisfactory showing is made to the State that the individual intended to dispose of the assets either at fair market value or for other valuable consideration;

(b) The assets were transferred exclusively for a purpose other than to qualify for State Disability Program medical assistance; or

009.09(F)(vii)(2) Disposal or Transfer of Resources:

009.09(F)(vii)(2)(a) LOOK-BACK PERIOD. If it is determined that an individual disposed of a resource to qualify for medical assistance, look back 60 months before the month of application.

(i) For State Disability Program Medical, the look-back is triggered when the individual first applies for Medicaid and is in a specified living arrangement, or is on State Disability Program Medical and enters a specified living arrangement. When an individual applies for State Disability Program Medical more than once, the look back period is based on the first date the individual meets both requirements.

(ii) To determine the countable value disposed of:

(1) Take the equity in the resource, which is the fair market value minus encumbrances;

(2) Subtract any compensation received by the individual; and

(3) Subtract the allowable resource level from the result of step 2 if this is the first disposal.

009.09(F)(vii)(3) PERIOD OF INELIGIBILITY FOR STATE DISABILITY PROGRAM MEDICAL. If it is determined that an individual disposed of a resource, the applicant or recipient is ineligible for State Disability Program Medical for the number of months determined by dividing the countable value of the resource, by the actual monthly cost of care in the specified living arrangement at the current private pay rate. If the period of ineligibility is longer than 12 months, the State Disability Program case is closed or denied and the recipient will need to apply for Medicaid. If the period of ineligibility is less than 12 months, the period of ineligibility begins:

(a) If the individual is on State Disability Program Medical, with the month of entry into a specified living arrangement; or

(b) If the individual is not on State Disability Program Medical, the month of application if in a specified living arrangement.

(c) If the individual is eligible for State Disability Program Medical, except for the deprivation of resources, in the month of application. It does not apply to an application month in which the individual is ineligible because of excess resources or other eligibility criteria.

(d) If the division results in a fraction, the fraction is converted to a dollar amount and includes that amount as unearned income for the applicable month.

009.09(F)(vii)(4) AVAILABILITY OF HARDSHIP WAIVER PROCESS. The individual may request in writing, to the Department, a hardship waiver exception when an imposed period of ineligibility for a transfer of assets would deprive the individual of medical care so that their health or life would be endangered. A notice of discharge from the facility is not necessary to demonstrate that health or life would be endangered. Undue hardship also exists when the imposed period of ineligibility for a transfer of assets would deprive the individual of food, clothing, shelter, or other necessities of life.

009.09(F)(vii)(5) TRANSFERS NOT CONSIDERED DEPRIVATION FOR GRANT. It is not considered a deprivation if:

(a) An applicant or recipient transferred a resource to his or her spouse or to an individual with power of attorney or a guardian or conservator for the sole benefit of the applicant or recipient’s spouse;

(b) An applicant or a recipient’s spouse transferred a resource to an individual with power of attorney or a guardian or conservator for the sole benefit of the applicant or recipient’s spouse;

(c) A resource was transferred to a trust established solely for the benefit of the individual’s son or daughter who is blind or disabled and who is receiving, or eligible to receive, Supplemental Security Income; Retirement, Survivors, Disability Insurance; Aged, Blind, or Disabled payment, or Medicaid;

(d) A resource was transferred to the individual’s son or daughter who is blind or disabled, who is receiving, or eligible to receive, Supplemental Security Income; Retirement, Survivors, Disability Insurance; Assistance to the Aged, Blind, or Disabled; or Medicaid;

(e) A resource was transferred to a trust established solely for the benefit of an individual age 64 or younger who is disabled, receiving or eligible to receive Supplemental Security Income; Retirement, Survivors, Disability Insurance; Aged, Blind, or Disabled payment; or Medicaid.

009.09(F)(vii)(6) TRANSFER OF A HOME. It is not considered a deprivation of a resource if a home is transferred by an applicant or recipient to:

(a) Spouse;

(b) Son or daughter who:

(i) Is age 20 or younger;

(ii) Is blind or disabled receiving, or eligible to receive, Supplemental Security Income; Retirement, Survivors, Disability Insurance; Aged, Blind, or Disabled payment or Medicaid based on blindness or disability; or,

(iii) Was residing in the home for at least two years before assistance was requested for the parent, or entered an alternate living arrangement and that individual provided care, which permitted the parent to reside at home rather than be institutionalized or receive Home and Community-Based Waiver Services; or

(c) Sibling who has an equity interest in the home, and who was residing in the home for at least one year immediately before assistance was requested for a sibling or an alternate living arrangement was needed.

009.09(G) REDUCTION OF RESOURCES. The applicant or recipient may reduce available resources to the allowable limit if the case record contains documentation that the resources have been reduced and the unit is within the allowable resource limits.

010. INCOME . Need is determined by considering the amount of total net income of the Aged, Blind or Disabled or State Disability Program individual, and spouse or other essential person whose needs are included in the budget, in relation to individual requirements.

010.01 DEFINITION OF INCOME. Income is defined as gain or recurrent benefit received in money, or in-kind, from employment, business, property, investments, gifts, benefits, or annuities, at regular, or irregular, intervals of time.

010.01(A) AVAILABILITY. All income, whether earned, or unearned, is considered if received and currently available for the use of the individual.

010.01(B) TYPES OF INCOME.

010.01(B)(i) EARNED INCOME. Earned income is money received from wages, tips, salary, commissions, profits from activities in which an individual is engaged as a self-employed person or as an employee, or items of need received at no cost in lieu of wages.

010.01(B)(i)(1) EMPLOYMENT-RELATED REIMBURSEMENT. Reimbursement for employment-related expenses such as mileage, lodging, or meals is not considered earned income.

010.01(B)(i)(2) CONTRACTUAL INCOME. Income paid on a contractual basis is prorated over the number of months covered under the contract, even if the recipient is paid in fewer months than the contract covers.

010.01(B)(i)(3) IN-KIND INCOME. In-kind income is the value of food, clothing, shelter, or other items received in lieu of wages.

010.01(B)(i)(4) DISREGARDS FOR SELF-EMPLOYMENT. Operating expenses related to producing the goods or services, and without which the goods or services could not be produced, are deducted from gross income. Operating expenses may include:

(a) Cost of goods sold;

(b) Advertising;

(d) Bank service charges;

(e) Car and truck expenses;

(f) Commission;

(g) Employee benefit programs;

(h) Freight or shipping costs;

(i) Insurance;

(j) Interest on business indebtedness;

(k) Laundry and cleaning;

(l) Legal and professional services;

(m) Office supplies and postage;

(n) Rent on business property;

(o) Repairs and maintenance;

(p) Supplies;

(q) Utilities and telephone;

(r) Wages; and

(s) Transportation other than to and from work and child care.

010.01(B)(i)(5) OPERATING EXPENSES - FARM INCOME. The following expenses related to farm income are considered operating expenses:

(i) Cost of goods sold;

(ii) Cost of labor;

(iii) Repairs and maintenance;

(iv) Interest;

(v) Rent of farm, pasture;

(vi) Feed purchased;

(vii) Seeds, plants purchased;

(viii) Fertilizers, lime, and chemicals;

(ix) Cost of machines leased;

(x) Supplies purchased;

(xi) Breeding fees;

(xii) Veterinary fees, medicine;

(xiii) Gasoline, fuel, or oil;

(xiv) Storage, warehousing;

(xv) Insurance;

(xvi) Utilities;

(xvii) Freight, trucking;

(xviii) Conservation expenses;

(xix) Land clearing expenses; and

(xx) Employee benefit programs.

010.01(B)(i)(5)(a) OPERATING EXPENSES NOT ALLOWED. The following expenses are not allowed as operating expenses:

(i) Depreciation;

(ii) Personal business expenses such as subscriptions, dues to professional organizations and unions, training courses;

(iii) Personal transportation;

(iv) Purchase of capital equipment;

(v) Payments on the principal of loans; and

(vi) Business-related entertainment expenses.

010.01(B)(i)(5)(b) 1040 TAX DOCUMENT VERIFICATION. If the 1040 tax document is used to verify income, do not allow depreciation as a cost of operation and do not count capital gains and other gains from lines 13, 14, and 15 of Form 1040 as income.

010.01(B)(i)(5)(c) OFFSET OF EARNINGS. If an individual has a combination of farm or self-employment income and regular earned income, the regular earnings may be offset with a loss from the self-employment or farm operation.

010.01(B)(ii) UNEARNED INCOME. Unearned income includes but is not limited to:

(a) Retirement, Survivors, and Disability benefits;

(b) Railroad Retirement;

(d) Military service benefits;

(e) Civil service benefits;

(f) Unemployment compensation;

(g) Gifts;

(h) Disability insurance benefits;

(i) Disability benefits paid by an employer, not including sick leave; and

(j) Returns from securities or investments, such as stocks, bonds, annuities, or savings, in which the individual is not actively engaged.

010.01(B)(ii)(1) SUPPLEMENTAL SECURITY INCOME BENEFITS. Supplemental Security Income benefits are not used in computing the budgets, but the Federal Benefit Rate is used by the system to calculate the amount of the state supplemental payment.

010.01(B)(ii)(2) CONTRIBUTIONS. Contributions are verified payments which are paid to or for the unit. Contributions received regularly to aid in the support of the recipient, either in the form of money payments or items of need, are considered unearned income.

010.01(B)(ii)(2)(a) TEMPORARY CRISIS ASSISTANCE. In determining initial eligibility only, a contribution is not counted when the applicant states that:

(i) The individual has no income and has been forced to share a living arrangement with a self-supporting individual; or

(ii) An individual who is not in the household is paying the applicant's shelter costs; and

(iii) The applicant plans to make other arrangements such as move, pay all or a share of the expenses, as soon as the applicant has income.

010.01(B)(ii)(2)(b) NURSING FACILITY, ASSISTED LIVING WAIVER, OR HOSPITAL CARE. Contributions to, or for, an individual who is receiving nursing facility, Assisted Living Waiver, or hospital care are considered unearned income in the applicant or recipient’s budget if Medicaid is or will be paying any part of the nursing facility, Assisted Living Waiver, or hospital care.

010.01(B)(ii)(3) LIFE INSURANCE PREMIUMS. Payment of premiums on small protective life insurance policies is not considered a contribution.

010.01(B)(ii)(4) HEALTH INSURANCE PREMIUMS. Payment of a health insurance premium by another individual is not considered a contribution as long as the premium is paid to the insurance company, not to the individual.

010.01(B)(ii)(5) THIRD PARTY MEDICAL PAYMENTS. Income received from a third party that pays the applicant or recipient directly is:

(i) Disregarded if it is refunded to the provider or the Department as reimbursement for a specific service; or

(ii) Counted as unearned income if the recipient fails or refuses to refund these payments.

010.01(B)(ii)(5)(a) INCOME-PRODUCING POLICIES. Income received from an insurance policy that supplements the applicant or recipient's income is treated as unearned income. These policies provide income regardless of the type of service being provided or the condition of the applicant or recipient. If it is verified that the income was applied to medical bills, the income is not counted in the applicant or recipient's budget.

010.01(B)(ii)(6) INHERITANCE AND GIFTS. If the applicant or recipient receives a gift or inheritance, it is considered unearned income in the month of receipt or report, and is used in the budget the first month possible, considering timely notice. Any unspent remainder is considered a resource in the following month.

010.01(B)(ii)(7) LIFE ESTATE OR LAND CONTRACT INCOME. If an applicant receives periodic life estate or land contract income annually, semi-annually or quarterly, and the last periodic payment has been spent before the application, the life estate or land contract income may be considered unavailable and not counted in the budget. When the application is approved notify the recipient that receipt of the next payment must be reported within ten days and that the life estate or land contract income must then be counted in the budget.

010.01(B)(iii) IRREGULAR INCOME. Irregular income is income, earned or unearned, which varies in amount from month-to-month or which is received at irregular intervals. This may be due to irregular employment, but even when an individual works regularly, the income may be irregular because of factors such as seasonal increases or decreases in employment and earnings, such as day labor, sales work on a commission basis, or child care.

010.01(B)(iv) ACCUMULATED BENEFIT PAYMENTS. Accumulated payments of Retirement, Survivors, and Disability Insurance; Railroad Retirement; Veteran's Benefits or Pensions; Workers’ Compensation; or other benefit payments which are received in a single sum are not considered income. Any unspent remainder is considered a resource in the month following the month of receipt, or report, taking into account the timely notice provision.

(1) Exception: The unspent portion of a Retirement, Survivors, and Disability Insurance; Supplemental Security Income; or state supplemental retroactive payment is excluded for six months following the month of receipt.

010.01(B)(v) COMBINED CASE WITH A LUMP SUM. When an individual in an Aid to Dependent Children case or an individual in an Assistance to the Aged, Blind, or Disabled case receives a lump sum, the way the money is treated depends upon which individual the lump sum is intended for. Retirement, Survivor, Disability Insurance and Supplemental Security Income lump sums are excluded as a resource for up to six months.

010.01(B)(v)(1) ASSISTANCE TO THE AGED, BLIND, OR DISABLED PARENT AND AID TO DEPENDENT CHILDREN CHILD. If the lump sum is intended for an Aged, Blind, or Disabled parent, the money is considered for the parent. The following month the money becomes a resource and must be divided proportionately between the cases.

010.01(B)(v)(2) ASSISTANCE TO THE AGED, BLIND, OR DISABLED CHILD AND AID TO DEPENDENT CHILD PARENT. If the lump sum is intended for a Blind or Disabled child, the money is considered for the child. As the child does not have relative responsibility for other members of the family, the money is considered only for the child’s Blind or Disabled case.

010.01(B)(vi) POTENTIAL INCOME. Potential income is defined as income based on entitlement, or need, which is usually determined by an administering agency as a result of an application for benefits by the individual. Potential income includes, but is not limited to, Retirement, Survivors, Disability Insurance, categorical assistance, Railroad Retirement, Veterans or Military Service benefits, Unemployment Compensation, Disability Insurance benefits, and Workers’ Compensation. Medicare is not considered a potential benefit.

010.01(B)(vi)(1) NEED TO APPLY AND COMPLY WITH REQUIREMENTS. A recipient is expected to make grant application for, and accept benefits, immediately after the recipient is notified of the apparent entitlement to the benefits. The recipient is notified on a Notice of Action of the number of days left in which to apply.

010.01(B)(vi)(2) VETERAN'S BENEFITS. Applicants or recipients who are veterans, their spouses, and the widows of veterans may be eligible for Aid and Attendant services. This service may be available and should be explored if the individual resides in a nursing home, in his or her own home, in an Adult Foster Home or other alternate arrangement when the individual requires aid with daily living activities.

010.01(B)(vi)(3) SUPPLEMENTAL SECURITY INCOME PROGRAM. If an applicant or recipient has not applied for Supplemental Security Income Program, an application must be filed immediately.

010.01(B)(vi)(3)(a) SUPPLEMENTAL SECURITY INCOME REFERRAL. An applicant or recipient must be referred to Supplemental Security Income if:

(i) The individual lives alone and has monthly unearned income less than the referral amount for an individual;

(ii) An eligible couple are living together and have monthly unearned income less than the referral amount for a couple; both must apply for Supplemental Security Income; or

(iii) An individual is in a nursing home and has unearned income of less than $50 per month.

010.01(B)(vii) SCHOOL DISTRICT PAYMENTS. If a school-aged child is receiving nursing home care, including an Intermediate Care Facility, Intermediate Care Facility for Developmental Disability, Skilled Nursing Facility, or chronic care, and the school district is contracting with the facility in providing the child's educational needs, the school district payment is disregarded as income if the payment is designated for educational services only.

(1) If any or all of the school district payment is for residential services, that portion must be shown as Payment on Services.

(2) If the school-aged child resides in a board and room or other alternative care facility, determine if the school provides payment for the child's board and room.

(3) If payment is being made to the facility, the payment is disregarded as income.

010.01(B)(viii) VERIFICATION OF INCOME. Income must be verified every 12 months.

010.01(B)(viii)(1) PROSPECTIVE BUDGETING. An average of the most recent three months’ actual income is used to arrive at the gross income amount for the income period. This figure is used to project medical eligibility for the next 12 months unless:

(i) There was a significant change in the income of the previous three months; or

(ii) A significant change is anticipated during the projected 12-month period.

(iii) Income is stable and only one month's income must be used.

(iv) Income fluctuates and an average of the three most recent consecutive months must be used.

010.01(B)(viii)(1)(a) CHANGE. The recipient must report the following changes:

(i) New employment must be reported to the Department and if receiving Supplemental Security Income to Social Security Administration within 10 days;

(ii) Termination of employment;

(iii) Change in the amount of monthly income, including:

(1) All changes in unearned income, including the beginning and termination of unearned income;

(2) Changes in the source of employment, in the wage rate, and in employment status, such as part-time to full-time, or full-time to part-time. The recipient must report new employment within ten days of receipt of the first paycheck, and a change in wage rate or hours within ten days of the change.

(3) Change in household composition, such as the addition or loss of a unit member; or

(4) Change, or receipt of, a resource including cash on hand, stocks, bonds, money in a checking or savings account, or a motor vehicle.

010.01(B)(ix) RETROACTIVE STATE DISABILITY PROGRAM MEDICAL ELIGIBILITY. To determine retroactive State Disability Medical Program eligibility, the month's actual income is used.

010.01(B)(x) INCOME AS IT APPLIES TO RESOURCES. Income received by a recipient during any one month for maintenance costs may not be considered a resource for that month. Any income not spent for maintenance is considered a resource in the subsequent month.

010.01(B)(xi) COMPUTATION OF INCOME AND INCOME DISREGARDS. The following list allowable income disregards:

010.01(B)(xi)(1) GENERAL $20 DISREGARD. Every unit receives a $20 income disregard. A married couple who is living together and budgeted together is considered a household unit and gets one $20 disregard. The income disregard is applied to unearned income first; any remainder is subtracted from earned income for:

(a) Recipients who are receiving Assisted Living Aged and Disabled Waiver services receive the $20 disregard.

(b) Recipients who are living in a nursing home, public institution, hospital or other medical institution, do not receive a $20 disregard.

010.01(B)(xi)(2) EARNED INCOME DISREGARDS. The amount deducted from adjusted gross earned income or the amount after deduction of the cost of operation if self-employment income, and the remainder of the general disregard from wages or self-employment, for each unit is as follows:

010.01(B)(xi)(2)(a) AGED OR DISABLED RECIPIENTS. The earned income disregards apply to:

(1) Aged or disabled individuals;

(2) The aged, blind, or disabled recipients;

(3) Ineligible spouses;

(4) Essential persons; or

(5) Sponsors of aliens for deeming purposes.

010.01(B)(xi)(2)(a)(i) Disregard the first $65 plus one-half of the remainder in determining countable income.

010.01(B)(xi)(2)(b) BLIND OR BLIND AGED RECIPIENTS. Determine net income for blind or blind aged recipients by disregarding the first $85 plus one-half of the remainder.

010.01(B)(xii) DEEMING INCOME OF RESPONSIBLE PERSONS. Income of the following individuals is considered in determining a recipient's eligibility when they do not receive Supplemental Security Income:

(a) Parent for child age 17 or younger and still considered part of the household; and

(b) Sponsor for an alien.

010.01(B)(xii)(1) PARENT. If the individual does not receive Supplemental Security Income the following guidelines must be used to determine if the parent income is deemed:

(a) If the minor is living in the same household with parent, the parent’s income must be deemed.

(b) If the minor is temporarily absent from the home but is still considered part of the household, the parent’s income must be deemed. Temporary absence includes, but is not limited to, school attendance where the minor returns to the home on a regular basis such as weekends, vacations, or summers.

(c) If the minor is permanently out of the home and no longer considered part of the household, the parent’s income must not be deemed. This includes facilities for persons with developmental disabilities or mental illness.

010.01(B)(xii)(2) EXCEPTIONS TO THE DEEMING REGULATIONS. If a child age 17 or younger leaves a nursing facility or hospital where that child was receiving an institutional personal needs amount payment from Supplemental Security Income, then goes home under a waiver, the Social Security Administration must be notified of the waiver eligibility. Even though income and resources of the parent may make the child ineligible for State Supplemental Income, if the child is waiver-eligible, Supplemental Security Income continues the institutional personal needs payment amount without deeming income and resources of the parent.

010.01(B)(xii)(3) DEEMING OF INCOME OF SPONSORS OF ALIENS. One-hundred percent of the income and resources of a sponsor, and sponsor’s spouse if they are living together, must be considered when determining the eligibility of an eligible alien who applies for Assistance to the Aged, Blind, or Disabled payment or State Disability Program if the sponsor has signed an affidavit of support under Section 213A of the Immigration and Nationality Act. The sponsor’s income and resources will be considered available to the alien until the alien:

(1) Becomes a U.S. citizen;

(2) Has worked 40 qualifying quarters of coverage as defined under Title II of the Social Security Act or can be credited with the qualifying quarters as provided under Section 435 and the alien did not receive any federal means tested public benefit during that time period.

010.01(B)(xii)(3)(a) DEFINITION OF A SPONSOR. A sponsor is an individual who:

(i) Is a citizen or national of the United States or an alien who is lawfully admitted to the United States for permanent residence;

(ii) Is 18 years of age or older;

(iii) Lives in any of the 50 states or the District of Columbia;

(iv) Is the person petitioning for the admission of the alien under Section 204 of the Immigration and Nationality Act; and

(v) An organization is not considered a sponsor.

010.01(B)(xii)(3)(b) ALIEN DUTIES. As an eligibility requirement, the alien is responsible for:

(i) Providing income and resource information from the sponsor; and

(ii) Obtaining the necessary cooperation from the sponsor.

(iii) If the alien does not provide the necessary information, they are not eligible for assistance.

010.01(B)(xii)(3)(c) SPONSOR OF MORE THAN ONE ALIEN. When an individual is a sponsor for two or more aliens who are living in the same home, the amount of deemed income and resources of the sponsor, and the sponsor's spouse if living with the sponsor, is divided equally among the aliens.

(i) When an individual sponsors several aliens but not all apply for assistance, the sponsor's total deemable income and resources are applied to the needs of the aliens who apply for assistance.

010.01(B)(xii)(3)(d) DEEMING EXCEPTION. If a sponsored immigrant demonstrates that they or their children have been battered or subjected to extreme cruelty by a spouse or a parent or by a member of the spouse's or parent's family who is residing in the same household as the alien, deeming may be waived if a judge, administrative law judge, or Immigration and Naturalization recognize the battery or cruelty.

010.01(B)(xiii) COMPUTATION OF NET INCOME.

010.01(B)(xiii)(1) INCOME DISREGARDED. Income disregarded for the Assistance to the Aged, Blind, or Disabled Payment or State Disability Program recipient is not considered in determining the eligibility of or the amount of assistance for the recipient or any other individual. Savings from disregarded income are considered the same as assets accumulated from any other source.

010.01(B)(xiii)(2) INCOME TAXES PAID. Income taxes that are paid on unearned income are not deducted from the income for budgeting purposes.

010.01(B)(xiii)(3) GARNISHMENTS AND OVERPAYMENTS. If income, earned or unearned, is being garnished, the garnishment is not deducted from income in the budgeting process. If unearned income is being reduced because of a previous overpayment, the amount of the benefit before the deduction of the overpayment is considered as income.

010.01(B)(xiii)(4) OFFSET OF EARNINGS. If a recipient has a combination of farm, self-employment, and regular earned income, a loss from one source of income may be used to offset a gain from another source.

011. COOPERATION IN OBTAINING THIRD PARTY MEDICAL PAYMENTS . The application for State Disability Program medical assistance constitutes an automatic assignment of the recipient's rights to third party payments made on behalf of the recipient for medical care or services which are payable under the State Disability Program. As a requirement for assistance, the recipient must also cooperate, unless good cause for noncooperation can be verified, in securing any third party medical payments.

011.01 THIRD PARTY PAYMENTS NOT ASSIGNED. The following third party payments are not subject to the automatic assignment provision:

(A) Medicare benefits; and

(B) Payments from income-producing policies which subsidize the individual’s income while the individual is hospitalized or receiving medical care, regardless of the type of medical service being provided.

011.02 COOPERATION REQUIREMENTS. The recipient must cooperate in obtaining third party payments unless good cause for noncooperation can be established. Cooperation includes any or all of the following:

(1) Providing complete information about third party medical coverage for the recipient or the children in their care. This includes third party medical coverage provided by any other person or agency;

(2) Providing any additional information or signing claim forms which may be necessary for identification and collection of potential third party payments;

(3) Appearing as a witness in a court or another proceeding, if necessary;

(4) Notifying the Department of any actions being initiated to recover money from a liable third party for medical care or services. This includes the identity of the third party and the entire amount of any settlement, court award, or judgment; and

(5) Reimbursing the Department, or paying the provider, from any payments received directly from a third party for any services payable by State Disability Program Medical Assistance; and

(6) Taking any other reasonable steps to secure medical support payments.

011.02(A) REFUSAL TO COOPERATE. Non-cooperation by the recipient is based on the individual’s failure or refusal to fulfill the requirements listed in this Section.

011.02(B) OPPORTUNITY TO CLAIM GOOD CAUSE.

011.02(C) NOTIFICATION OF RIGHTS. The individual must be notified of the right to claim good cause for non-cooperation at the intake interview, redetermination, or whenever cooperation becomes an issue.

011.01(C)(i) DEPARTMENT’S ACTIONS IF GOOD CAUSE CLAIMED. If the recipient claims good cause, the Department will:

(1) Explain that the individual has the burden of establishing the existence of a good cause circumstance; and

(2) Obtain a signed statement from the recipient listing the reason for claiming good cause. The individual is allowed 20 days to present evidence of the claim.

011.01(C)(ii) ACCEPTABLE CIRCUMSTANCES FOR GOOD CAUSE. Good cause claims must be substantiated by signed statements. When documentary evidence is not available, the individual must furnish sufficient information as to the location of the information.

011.01(C)(ii)(1) DOCUMENTARY EVIDENCE. Documentary evidence which indicates these circumstances includes:

(a) Medical records which document physical or emotional health history and present physical or mental health of the recipient;

(b) Written statements from a physician or mental health professional indicating the diagnosis or prognosis concerning the individual's physical or emotional condition;

(c) Court, medical, criminal, protective services, social services, psychological, or law enforcement records which indicate that the third party might inflict serious physical or emotional harm on the individual; or

(d) Signed statements from individuals other than the recipient with knowledge of the circumstances which provide the basis for the claim.

011.01(C)(ii)(2) EVIDENCE NOT SUBMITTED BY RECIPIENT. When corroborative evidence is not submitted in support of a claim:

(a) The Department investigates the good cause claim when it is believed that the claim is credible without corroborative evidence and the evidence is not available; and

(b) The Department will find good cause if the recipient's statement and the investigation indicate that the individual has good cause for refusing to cooperate.

011.01(C)(ii)(3) DEPARTMENT CONSIDERATIONS. If the determination of good cause is not substantiated by documentary evidence, the following evidence must be considered:

(a) The present physical or mental state of the recipient;

(b) The physical or mental health history of the recipient;

(d) The degree of cooperation required by the recipient.

011.01(C)(ii)(4) DECISION ON GOOD CAUSE. The recipient will receive written notice of the Department’s decision on good cause. If it is determined that good cause does not exist, the individual is allowed ten days from the date that the notice of action was mailed to respond. If the recipient does not cooperate, withdraw the application or request the case closed, and a sanction is imposed.

011.01(C)(ii)(5) DELAY OF ASSISTANCE PENDING DETERMINATION. The good cause determination does not deny, delay, or discontinue assistance, while it is pending, if the recipient has complied with the requirements of providing acceptable evidence or other necessary information. In most instances, a good cause determination must be made within 30 days following the receipt of a good cause claim.

011.01(C)(ii)(6) REVIEW OF GOOD CAUSE. At the time of each redetermination, review a good cause claim based on a circumstance that is subject to change. If circumstances remain the same, no action is required. A new determination is necessary if circumstances have changed. If good cause no longer exists, the requirement to cooperate is enforced.

011.02(D) SANCTION FOR REFUSAL TO COOPERATE. If the recipient fails or refuses to cooperate and there is no good cause claim or determination, the appropriate sanction is applied. If the reason for non-cooperation is the recipient's failure or refusal to provide information about or obtain third party medical payments, the individual is ineligible for grant and medical. Ineligibility continues until the individual cooperates or cooperation is no longer an issue.

011.02(E) THIRD PARTY MEDICAL PAYMENTS RECEIVED DIRECTLY. If the recipient receives a third party medical payment directly, and the medical expense for which the third party medical payment is intended is payable by the State Disability Program Medical Assistance, the payment is considered unearned income unless reimbursed by the recipient. If the insurance payment exceeds Medicaid rates, the excess is considered unearned income unless paid out on other medical services or supplies. Regardless of the existence of a good cause claim, any third party medical payment that is received directly by the recipient must be reimbursed.

012. CHILD SUPPORT ENFORCEMENT SERVICES . Child Support Enforcement services are provided to an Assistance to the Aged, Blind, or Disabled child age 18 or younger who has a noncustodial parent. If an adult does not have good cause, and refuses to cooperate with Child Support for a child in the individual’s care, the Assistance to the Aged, Blind, or Disabled adult’s grant is closed. The child continues to be eligible.

013. RECEIPT OF OTHER ASSISTANCE . An individual who receives a payment or whose needs are included in a payment of Assistance to the Aged, Blind, or Disabled or State Disability Program may not receive a payment at the same time of another type of categorical assistance administered by the Department. This does not preclude the recipient of another type of assistance from being the payee for an Aid to Dependent Children grant made on behalf of a child in the individual’s care.

014. INELIGIBILITY OF FLEEING FELON . An individual is ineligible for Aged Blind or Disabled grant and State Disability Program assistance during any period in which the individual is:

(A) Fleeing to avoid prosecution or custody or confinement after conviction for a crime or attempt to commit a crime that is a felony under the law of the place from which the individual is fleeing; or

(B) Violating a condition of federal or state probation or parole.

History

Effective 2022-06-06

Chapter 3 Determination of Benefits

Neb. Admin. Code tit. 469, ch. 3 Determination of Benefits {#sec-469-nac-3 omnilex-key=us-ne-regs-official--title-469--469 NAC 3}

001. DESCRIPTION OF BENEFITS . Assistance to the Aged, Blind, or Disabled Payment Program or State Disability Program payment assistance consists of money payments to the recipient. State Disability Program Medical Payments are made directly to the provider for medical care and services.

002. PLANNING THE ASSISTANCE BUDGET . The assistance budget is planned with the recipient by discussing and explaining the following:

(A) Budgeting process;

(B) Individual requirements;

(D) Use of items supplied or obtained in-kind;

(E) Use of any income;

(F) Determination of the amount of the assistance payment;

(G) Provision of medical services; and

(H) Why it is necessary for a recipient to keep the Department informed of changes in the individual’s circumstances which affect his or her needs.

003. INDIVIDUAL REQUIREMENTS INCLUDED IN ASSISTANCE BUDGETS . The individual requirements are:

(A) Standard of need;

(B) Shelter up to the maximum; and

003.01 STANDARD OF NEED. The standard of need is a consolidation of items necessary for basic subsistence with amounts based on unit size. Included in this standard are food, clothing, sundries, home supplies, utilities, laundry, telephone, garbage collection, and recreation. Also included in this standard amount are meals prepared away from home, therapeutic diet, special clothing allowance, meals furnished to a household employee, transportation for shopping, and special taxes or use charge.

003.01(A) ALTERNATE LIVING ARRANGEMENTS. The standard of need for alternate living arrangements is a consolidated allowance for items necessary for basic subsistence. Included in this standard are:

(1) Board;

(2) Room;

(3) Clothing;

(4) Personal needs;

(5) Laundry; and

(6) Transportation.

003.01(A)(i) LICENSING OF FACILITIES. In determining the appropriate standard to be allowed, verify the current licensure or certification of the facility.

003.01(A)(ii) BOARD AND ROOM. Board and room does not include care or supervision and may be with a relative.

003.01(A)(iii) LICENSED BOARDING HOME. Boarding homes provide the following to four or more individuals who are essentially capable of managing their own affairs:

(1) Sleeping and other living accommodations;

(2) A dining room, cafe, or common kitchen; and

(3) Domestic services requested by the individuals which will assist them in daily living activities.

003.01(A)(iv) LICENSED ASSISTED LIVING FACILITY. An Assisted Living facility provides accommodation and board and care, such as personal assistance in feeding, dressing, and other essential daily living activities, for four or more individuals not related to the owner, occupant, manager, or administrator. These individuals are unable to sufficiently or properly care for themselves or manage their own affairs because of illness, disease, injury, deformity, disability, or physical or mental infirmity.

003.01(A)(v) CERTIFIED ADULT FAMILY HOME. An Adult Family Home is a residential living unit which provides full-time residence with minimal supervision and guidance to not more than three individuals age 19 or older. Service includes board and room with meals, standard furnishings, equipment, household supplies, and facilities to ensure recipient comfort. These individuals are essentially capable of managing their own affairs but are in need of supervision. This may include supervision of nutrition by the facility on a regular, continuing basis, but not necessarily on a consecutive 24-hour basis.

003.01(A)(vi) LICENSED GROUP HOME FOR CHILDREN AND CHILD CARING AGENCY. This group care facility provides 24-hour accommodation for minors including care and supervision. The home provides services to two or more individuals who are developmentally disabled.

003.01(A)(vii) LICENSED CENTER FOR THE DEVELOPMENTALLY DISABLED. A center for the developmentally disabled is any facility, place, or building not licensed as a hospital which provides accommodation, board, training, and other services when appropriate, primarily or exclusively, for four or more persons who are developmentally disabled. Staff in a center for the developmentally disabled may assist individuals residing there in taking routine oral or external medication and also provide for storage and handling of the medication.

003.01(A)(vii)(1) CENTER DEFINED. The term "center" includes:

(a) GROUP RESIDENCE. Any group of rooms located within a dwelling and forming a single habitable unit with living, sleeping, cooking, and eating facilities for 4 through 15 developmentally disabled persons.

(b) INSTITUTION FOR THE DEVELOPMENTALLY DISABLED. Any facility other than a skilled nursing facility or an intermediate care facility I or II where 16 or more developmentally disabled persons reside.

003.01(A)(viii) LONG TERM CARE FACILITY. The payment to a long term care facility includes an allowance for personal needs of the recipient which is determined by the licensure or certification of the facility where the recipient resides.

003.01(A)(ix) ASSISTED LIVING WAIVER. The Standard of Need chart explains the standard for an individual receiving Assisted Living Waiver services. The monthly standard includes an allowance for personal needs of the recipient.

003.01(A)(x) LICENSED MENTAL HEALTH CENTER. Mental health center means a facility where shelter, food, counseling, diagnosis, treatment, care, or related services are provided for a period of more than 24 consecutive hours to persons residing at the facility who have a mental disease, disorder, or disability.

003.01(B) ASSISTANCE TO THE AGED, BLIND, OR DISABLED OR STATE DISABILITY PROGRAM STANDARD OF NEED. The standard of need for independent living and shelter costs, or the consolidated standard for alternate living, when Social Security determines that the recipient will continue to receive full Supplemental Security Income payment for up to three months because the individual is likely to return to the previous living arrangement. Follow procedures for allowing shelter and utilities when:

(i) Supplemental Security Income reduces or terminates the payment at the end of the three-month extension;

(ii) Supplemental Security Income determines that the individual does not qualify for the full benefit for the three-month period; or

(iii) The recipient was not receiving Supplemental Security Income before admission to the medical facility.

003.02 SHELTER. The item shelter includes rent and the expenses of home ownership.

003.02(A) MAXIMUM SHELTER ALLOWANCE.

(1) The single shelter amount for one; or

(2) The multiple shelter amount for:

(a) A married couple who are living together;

(b) An Assistance to the Aged, Blind, or Disabled or State Disability Program parent living with a minor child; or

(c) An Assistance to the Aged, Blind or Disabled, or State Disability Program recipient living with other essential persons whose needs are included in the budget.

003.02(A)(i) RENT. The allowance for rent should be sufficient to provide the family with decent quarters comparable to the standard for persons of modest circumstances in the same community.

003.02(A)(ii) HOME OWNERSHIP.

003.02(A)(ii)(1) EXPENSES. Expenses of home ownership may be allowed if the recipient or spouse owns the home in which the individual lives, provided the allowance does not exceed the maximum shelter limit allowed.

(a) If the recipient or spouse has only a life interest in the home, the terms of the conveyance must be examined in determining whether the recipient or the title-holder is responsible for the expenses of home ownership. The case record must contain an explanation if an allowance is included in the budget.

003.02(A)(ii)(2) STANDARDS FOR DETERMINING COSTS. The cost of interest or payments on mortgages or contract purchases, current taxes, and insurance may be allowed in the assistance budget as follows:

(a) Interest and payments on the mortgage or purchase contract on the home may be included in the budget.

(b) Current taxes on the home occupied by the recipient may be allowed on a monthly prorated basis unless the payment of taxes is included in the monthly payment on the mortgage or contract purchase.

(d) The amount of the homeowner's insurance is included in the budget on a prorated or lump sum basis, unless insurance is a part of the payment on the mortgage or purchase contract.

(e) The total cost of home ownership must not exceed the maximum shelter allowance.

003.03 SPECIAL REQUIREMENTS. Special requirements are those items that are essential because of the particular circumstances of an individual's situation.

003.03(A) ITEMS THAT MAY BE ALLOWED AS SPECIAL REQUIREMENTS. The following items may be used as a special requirement:

(i) Transportation;

(ii) Household furniture and appliances;

(iii) Expenses of moving;

(iv) Back taxes;

(v) Subsistence to obtain medical care;

(vi) Maintenance for a service animal;

(vii) Guardian or conservator fee of $10 per month;

(viii) Medical expenses of an essential person;

(ix) Cost of home repair;

(x) Automobile liability insurance;

(xi) Lifelines;

(xii) Vehicle repair;

(xiii) Home modification and assistive technology equipment; and

(xiv) Specialized diet allowance.

003.03(B) ITEMS THAT ARE NOT ALLOWED AS SPECIAL REQUIREMENTS. The following items are not allowed as special requirements:

(i) Personal computers because they are considered a vocational rehabilitation and educational item;

(ii) Smoking cessation programs because there are no national standards or official oversight of these programs. Guaranteed one time, long term smoking cessation success is not demonstrated by current programs;

(iii) Health club memberships and exercise or fitness equipment because these are related to weight loss and rehabilitation and essential components to assess the success of the individual program and to monitor the recipient's progress are unavailable;

(iv) Weight loss programs because there are no national recommendations and standards for these programs. Safety and efficacy issues are unresolved on the national level with no federal Department of Agriculture or official oversight of this industry. Essential components for individualization for each person's special circumstances are not available;

(v) Lawn care service, snow removal, and the equipment and supplies for them; and

(vi) Medical services and goods which are not covered by Medicaid or State Disability Medical Program because of limits on amount, scope, or duration established by the Department.

004. BUDGET COMPUTATION . When an application for assistance is approved during the initial 30 day period, the first month’s payment begins with date of application, if all eligibility factors are met. If eligibility is determined during the additional 30 day period, the payment is prorated from the date the department receives sufficient information to verify eligibility.

004.01 BUDGETING PROCESS FOR INDIVIDUALS NOT RECEIVING STATE SUPPLEMENTAL INCOME, INCLUDING INDIVIDUALS DETERMINED ELIGIBLE FOR 1619(B) STATUS BY SOCIAL SECURITY ADMINISTRATION. The budget process for determining eligibility for and amount of assistance payment is completed through the Department of Health and Human Services-designated electronic system.

004.01(A) ASSISTANCE TO THE AGED, BLIND, OR DISABLED PAYMENT BUDGETING PROCESS FOR RECIPIENTS RECEIVING SUPPLEMENTAL SECURITY INCOME. The budget for recipients who are receiving State Supplemental Income is completed through the Department of Health and Human Services-designated electronic system. To determine need:

(i) Only the following available net income is computed. This income is not allowed the $20 general income disregard:

(1) Income of non-spouse essential persons;

(2) Veteran's Aid and Attendant benefits;

(3) Income allocated from another assistance unit; and

(4) Income of an ineligible spouse not used by the Social Security Administration in the calculation of the recipient's Supplemental Security Income payment. Social Security disregards the deemed income if it is less than the difference between the federal benefit rate for an individual and a couple. Social Security calculates the Supplemental Security Income payment based on the federal benefit rate for an individual.

004.01(B) DEDUCTIONS FOR MEDICAL INSURANCE. Assistance to the Aged, Blind, or Disabled Payment Program does not allow for deductions for medical insurance premiums, such as private policies, Medicare, or Medicare supplements in the budget. The State Disability Medical Program budget can reflect medical insurance deductions.

004.02 PERSONS INCLUDED IN THE BUDGET. The assistance budget is computed to determine the need of a recipient for assistance. Consideration is given to the fact that the presence of other related persons living in the home may be essential to the individual’s needs and well-being and affect the individual’s need. The individual requirements of these essential persons may be included in the budget of the recipient. Essential persons in the home may include the spouse, minor or adult children, grandchildren, parents, sisters, or brothers. The decision of whether another related individual is essential to the recipient rests with the recipient. If it has been determined that the related individual is not eligible for medical assistance under another program, and it has been determined that the individual must be in the presence of our recipient full time, then the individual can be an essential person. An individual, who meets the above criteria and who is considered a spouse by Social Security, even though the individual is not married to the recipient, is considered an essential person in the Aged, Blind or Disabled budget. The essential person’s income and resources are included in the recipient’s Aged, Blind or Disabled budget, and their combined income and resources do not exceed standards.

(1) A spouse or specified relative can be an essential person; unless:

(i) They are not living together;

(ii) The spouse or specified relative is an ineligible alien;

(iii) The spouse or specified relative is a fleeing felon;

(iv) The spouse or specified relative is eligible for assistance in his or her own right, such as receives medical assistance from another program;

(v) The spouse or specified relative is sanctioned;

(vi) The spouse is receiving Veteran’s benefits and the recipient is current pay Supplemental Security Income; or

(vii) The spouse or specified relative failed to comply or apply for potential benefits. Medical health insurance premium and paid medical expenses may be paid for essential persons under Aged, Blind, or Disabled Special Requirements.

(2) The needs of an ineligible spouse are not included as an essential person in the recipient's budget. If the ineligible spouse is receiving Veterans benefits based on need that Social Security is disregarding in determining the recipient's Supplemental Security Income, the individual cannot be an essential person.

(3) The needs of an essential person may be included in the budget to determine eligibility for payment. When an essential person has been included in the recipient's budget, their combined income and resources cannot exceed standards.

(4) If there is no budgetary need, close the case and determine State Disability Payment medical eligibility with a Share of Cost using the appropriate income level. The appropriate maintenance level for the State Disability Medical Program is determined by considering the recipient and the essential person only if the essential person is the spouse or minor child.

(5) If the ineligible parent of a minor Assistance to the Aged, Blind, or Disabled or State Disability Program recipient does not have income which has been considered for deeming purposes, the individual’s needs may be included in the minor's budget if it has been determined that the parent's continued full-time presence in the home is necessary for the child's well-being. If the parent has income which is being considered for deeming, the individual’s needs have already been recognized in this process. If a parent's needs have been removed from an Aid to Dependent Child unit for noncooperation, such as Employment First employability or child support, that individual’s needs may not be included in the Blind, Disabled, or State Disability Program child's budget.

004.02(A) POTENTIAL ASSISTANCE FOR ESSENTIAL PERSONS. Essential persons are required to apply for any financial assistance for which they appear to be eligible.

004.02(B) DETERMINING TOTAL REQUIREMENTS. In determining the amount of the individual requirements in the following subparts, living independently includes rent, allowances for the cost of home ownership, and the cost of a room when the recipient is living in a boarding home and paying room only. Alternate living arrangements include board and room, licensed boarding homes, assisted living, certified adult family homes, licensed group homes for children or child caring agencies, and centers for the developmentally disabled. Care facilities include nursing homes and public institutions for the treatment of mental diseases or developmental disabilities.

004.02(B)(i) LIVING ALONE. The following items show in the budget of an Aged, Blind, or Disabled or State Disability Program recipient:

004.02(B)(i)(1) LIVING INDEPENDENTLY. The budget of an Aged, Blind, or Disabled or State Disability Program recipient who is living alone in an independent living situation shows:

(a) The standard of need for one;

(b) The actual shelter expense up to the single shelter amount; and

004.02(B)(i)(2) LIVING IN AN ALTERNATE LIVING ARRANGEMENT. The budget of an Aged, Blind, or Disabled or State Disabled Program recipient who is living alone in an alternate living arrangement shows:

(a) The standard of need for the alternate living situation; and

(b) Special requirements, if applicable.

004.02(B)(ii) LIVING WITH ESSENTIAL PERSON. The following living arrangements are considered when the recipient is living with the essential person:

004.02(B)(ii)(1) LIVING INDEPENDENTLY. The budget of an Aged, Blind, or Disabled or State Disability Program recipient who is living with an essential person in an independent living situation shows:

(a) The standard of need for the recipient plus essential person’s;

(b) Actual shelter expense paid up to the multiple shelter amount; and

004.02(B)(ii)(2) LIVING IN A BOARD AND ROOM ARRANGEMENT. The budget of an Assistance to the Aged, Blind, or Disabled or State Disability Program recipient who is living with an essential person in a board and room arrangement shows:

(a) Board and room as paid plus an allowance for personal needs up to the maximum for the recipient and essential person; and

(b) Special requirements, if applicable, for the recipient and essential person.

004.02(B)(iii) LIVING WITH RECIPIENTS WITH RELATIVE RESPONSIBILITY. When the Assistance to the Aged, Blind, or Disabled or State Disability Program recipient is living with an eligible individual for whom there is relative responsibility, payment is computed according to the guidelines in the following subparts.

004.02(B)(iv) SPOUSE ON AGED, BLIND, OR DISABLED OR STATE DISABLED PROGRAM. The needs of the eligible Assistance to the Aged, Blind, or Disabled or State Disability Program couple who are living together, either independently or in an unlicensed board and room, are shown on the same budget form and the payment is divided equally.

004.02(B)(iv)(1) LIVING INDEPENDENTLY. When the couple is in an independent living situation, the budget must show:

(a) The standard of need for two;

(b) Actual shelter expense paid up to the multiple shelter amount; and

004.02(B)(iv)(2) LIVING IN A BOARD AND ROOM ARRANGEMENT. When the couple is in an unlicensed board and room arrangement, the budget must show:

(a) The actual amount of the board and room up to the maximum for the Assistance to the Aged, Blind, Disabled or State Disability Program recipient and the Assistance to the Aged, Blind, or Disabled or State Disability Program spouse; and

(b) Special requirements for an Aged, Blind, or Disabled or State Disability recipient or an Aged, Blind, or Disabled or State Disability spouse.

004.02(B)(iv)(3) SPOUSE ON AID TO DEPENDENT CHILDREN OR REFUGEE RESETTLEMENT PROGRAM. If an Assistance to the Aged, Blind, or Disabled or State Disability Program recipient lives with a spouse who is receiving Aid to Dependent Children or Refugee Resettlement Program assistance, the budgets must be computed separately. Neither the needs nor the income of the Aid to Dependent Children or Refugee Resettlement Program recipient may be considered in the Assistance to the Aged, Blind, or Disabled, or State Disability Program budget.

004.02(B)(iv)(3)(a) LIVING INDEPENDENTLY. When the couple is in an independent living situation, the budget for the Assistance to the Aged, Blind, or Disabled or State Disability Program recipient will show:

(1) The prorated share of the standard of need based on the total number in the case;

(2) The prorated share of the shelter allowance up to the multiple shelter amount based on the total number in the case; and

(3) Special requirements, if applicable.

004.02(B)(iv)(2)(a)(i) LIVING IN AN ALTERNATE LIVING ARRANGEMENT. When the Assistance to the Aged, Blind, or Disabled or State Disability Program recipient is in an alternate living arrangement, the budget for the Assistance to the Aged, Blind, or Disabled or State Disability Program individual will show:

(1) The standard of need for the appropriate alternate living arrangement; and

(2) Special requirements, if applicable.

004.02(B)(iv)(4) LIVING WITH AN ELIGIBLE MINOR CHILD OR PARENT. If a recipient lives with an eligible minor child or parent, such as an Aged, Blind, or Disabled, State Disability parent or an Aid to Dependent Children, Assistance to the Aged, Blind, or Disabled, or State Disability Program child, the budgets are computed separately.

004.02(B)(iv)(4)(a) LIVING INDEPENDENTLY. When the individual and the eligible child are in an independent living situation, the budget for each must show:

(1) The prorated share of the standard of need based on the total number in the case;

(2) The prorated share of the actual shelter paid up to the multiple shelter amount based on the total number in the case; and

(3) Special requirements, if applicable.

004.02(B)(iv)(4)(b) LIVING IN AN ALTERNATE LIVING ARRANGEMENT. When the Assistance to the Aged, Blind, or Disabled or State Disability Program recipient is in an alternate living arrangement, the budget for each Aged, Blind, or Disabled or State Disability recipient must show:

(1) The standard of need for the appropriate alternate living arrangement; and

(2) Special requirements, if applicable.

004.02(B)(v) LIVING WITH PERSONS WITH NO RELATIVE RESPONSIBILITY. Only the needs of the recipient are considered in the budget when the recipient is living with other individuals for whom there is no relative responsibility.

004.02(B)(v)(1) LIVING WITH SELF-SUPPORTING INDIVIDUALS WITH NO RELATIVE RESPONSIBILITY. If a recipient is sharing a household with a self-supporting individual for whom the recipient has no relative responsibility, the budget is computed:

(a) On a board and room basis, if the recipient is required to pay board and room;

(b) On an expense-sharing plan when in an independent living arrangement using:

(i) The standard of need for one;

(ii) Shelter costs, not to exceed the maximum, determined by:

(1) The prorated share of total shelter costs based on the number of persons in the case not to exceed the maximum single shelter amount; or

(2) The actual amount of shelter paid up to the single shelter amount if the recipient can verify that they pay an amount other than the prorated share; and

(iii) Special requirements, if applicable.

004.02(B)(v)(2) LIVING WITH OTHER RECIPIENTS WITH NO RELATIVE RESPONSIBILITY. The budget of an Assistance to the Aged, Blind, or Disabled or State Disability Program recipient living in the same household with other recipients for whom the Assistance to the Aged, Blind or Disabled or State Disability Program recipient has no relative responsibility is computed according to an independent living arrangement.

004.02(B)(v)(2)(a) INDEPENDENT LIVING ARRANGEMENT. When the Assistance to the Aged, Blind, or Disabled or State Disability Program recipient is in an independent living arrangement, the budget will show:

(i) The standard of need for one;

(ii) The prorated share of total shelter costs based on the number of persons in the case not to exceed the single shelter amount; and

(iii) Special requirements if applicable.

004.02(B)(v)(2)(b) LIVING IN A BOARD AND ROOM ARRANGEMENT. When the Assistance to the Aged, Blind or Disabled or State Disability Program recipient is in a board and room or boarding home arrangement, the budget will show:

(i) Board and room as paid plus personal requirements up to the maximum; and

(ii) Special requirements, if applicable.

004.02(B)(vi) RECIPIENT LIVING IN A CARE FACILITY. The budget of a recipient living in a care facility shows:

(1) The standard of need for the correct living arrangement; and

(2) An amount up to $10 when the recipient has a guardian or conservator who requests a fee.

004.02(B)(vii) ASSISTANCE TO THE AGED, BLIND, DISABLED, OR STATE DISABILITY PROGRAM CHILD LIVING WITH SELF-SUPPORTING PARENTS. If a Blind or Disabled, or State Disability minor child lives with a self-supporting parent, the child's budget will show:

(1) The prorated share of the standard of need based on the total number in the case;

(2) The prorated share of the actual shelter paid up to the multiple shelter amount; and

(3) Special requirements, if applicable.

005. PAYMENTS FOR ASSISTANCE . Aged, Blind, or Disabled or State Disability Program payments may be made as follows:

005.01 TO A GUARDIAN, CONSERVATOR, OR DULY EXECUTED POWER OF ATTORNEY. If an Assistance to the Aged, Blind, Disabled, or State Disability Program recipient has a guardian, conservator, or individual acting under a duly executed power of attorney, Assistance to the Aged, Blind, Disabled, or State Disability Program payments may be made to the appointed person on behalf of the recipient. Certified copies of the letter of guardianship, conservatorship, or power of attorney are filed with the local office.

005.02 TO A PROTECTIVE PAYEE. Protective payments may be made on behalf of a recipient who has a physical or mental impairment which causes an inability to manage Assistance to the Aged, Blind, Disabled, or State Disability Program payments.

005.03 ERRONEOUS STATE SUPPLEMENT PAYMENTS. Underpayments and overpayments are processed as follows:

005.03(A) UNDERPAYMENTS. If a state supplement payment is made for an amount less than the amount the recipient was entitled to receive, a correction must be made. The retroactive corrective payments may be made for the 12 months preceding the month in which the underpayment is discovered. State supplement payments made to correct an underpayment are not considered income or a resource in the month paid or the month following the month paid.

005.03(B) OVERPAYMENTS. There are two types of overpayments:

(i) Departmental errors caused by inaccurate budget computation or because the worker failed to take action; and

(ii) Household errors caused because the recipient who failed to provide information, or the information provided was inaccurate or incomplete, resulting in an overpayment.

005.03(C) All overpayments, regardless of cause, must be recouped.

005.03(C)(i) RECOUPMENT OF OVERPAYMENTS. If a state supplement payment was made for an amount greater than the amount the recipient was entitled to receive, the overpayment is recouped by:

(1) Reducing the current state supplement payments by at least ten percent; or,

(2) If the recipient is no longer eligible for a grant, the individual may make arrangements to repay it on their own.

005.03(C)(ii) Recoupment is limited to the amount of overpayment which occurred in the 12 months preceding the month in which the overpayment was discovered.

History

Effective 2022-06-06

Chapter 4 State Disability Program – Medical

Neb. Admin. Code tit. 469, ch. 4 State Disability Program – Medical {#sec-469-nac-4 omnilex-key=us-ne-regs-official--title-469--469 NAC 4}

001. DESCRIPTION OF BENEFITS . The State Disability Medical Program provides medical care and services to those who do not have sufficient income to meet their medical needs and who qualify according to the program definitions as blind or disabled, but only if they have also had their Social Security Administration Disability application denied due to lack of duration, then determined blind or disabled by the Department of Health and Human Services designated medical consultant reviewer.

001.01 REFERENCES TO MEDICAL. All references to medical in this Chapter refer to the State Disability Program cases only. Nebraska Medicaid eligibility guidelines are found in Title 477 NAC.

002. ELIGIBILITY CATEGORIES . To qualify for the disability determination for the State Disability Program:

002.01 INDIVIDUALS ELIGIBLE FOR STATE DISABILITY MEDICAL PROGRAM. Individuals who would have been denied disability by the Social Security Administration due to lack of duration but found disabled by the medical consultant review and meet all other State Disability Program eligibility criteria except eligibility for a grant.

002.02 INDIVIDUALS INELIGIBLE FOR STATE DISABILITY PROGRAM GRANT BUT ELIGIBLE FOR STATE DISABILITY MEDICAL ONLY. Individuals who have income or resources in excess of the budgetary standards for the State Disability Program are ineligible for an assistance grant but must be reviewed for State Disability Medical. The eligibility criteria for State Disability Medical Program are the same as for Assistance to the Aged, Blind, or Disabled and State Disability Program payments, with the exception of income and resource standards to be used if over the income or resource standards for a grant.

003. COOPERATION IN OBTAINING HEALTH INSURANCE . As a condition of eligibility for the State Disability Program, an individual is required to enroll in an available health plan if the Department has determined that it is cost effective and the individual is able to enroll. The Department then pays the premiums, deductibles, coinsurance, and other cost sharing obligations.

004. EFFECTIVE DATE OF STATE DISABILITY MEDICAL ELIGIBILITY . If an individual is eligible for medical assistance one day of the month, the individual is eligible the entire month. The effective date of eligibility for State Disability Program Medical is determined as follows:

(A) Prospective eligibility is effective the first day of the month of request if the individual was eligible for State Disability Program Medical in that same month and had a medical need.

(i) The State Disability Program Medical eligibility cannot begin prior to the start date of the disability as determined by the medical consultant review.

(B) Retroactive State Disability Program Medical eligibility can be no earlier than the first day of the third month before the month of request date or application date if there is no request date, if the following conditions are met:

(i) Eligibility is determined and a budget calculated separately for each of the three months;

(ii) A medical need exists; and

(iii) Elements of eligibility are met for each month.

005. USE OF MEDICAL BUDGET FOR STATE DISABILITY PROGRAM MEDICAL . Determine eligibility for medical assistance only and medical assistance share of cost cases. If at any time factors change that affect the budget, the budget must be recomputed.

006. TREATMENT OF RESOURCES FOR STATE DISABILITY PROGRAM MEDICAL . The application for an individual who has excess resources, other than real property, may be held pending until the resources are reduced. Excess resources may be reduced by paying obligations for medical costs. State Disability Program Medical eligibility begins with the first day of the month of the incurred obligation which was used to reduce the resources to the allowable maximum. Medical eligibility may not be established earlier than the three-month retroactive period.

006.01 MAXIMUM AVAILABLE RESOURCE LEVELS. The established maximum for available resources which the recipient, or the recipient and responsible relative, may own and still be considered eligible for Medical under the State Disability Program according to unit size, are as follows:

(1) One member unit - recipient only $4,000

(a) If a couple has a valid designation of resources and:

(1) There is an eligible spouse and an ineligible spouse, the resource level for the eligible spouse is $4,000; or

(2) The ineligible spouse later becomes eligible, each spouse is allowed $4,000.

(2) Two member unit $6,000

(a) Applicant or recipient and eligible spouse; or

(b) Applicant or recipient and ineligible spouse.

(3) If two or more related Assistance to the Aged, Blind, Disabled, or State Disability Program applicants or recipients, other than a married couple, such as an eligible Assistance to the Aged, Blind, or Disabled parent or eligible Blind or Disabled minor child, or two or more unrelated eligible Assistance to the Aged, Blind, or Disabled recipients, reside in the same household, each applicant or recipient is entitled to a resource maximum of $4,000.

(4) If the total equity value of available non-excluded resources exceeds the maximums specified above, the applicant or recipient is ineligible. Resources must be below the maximum resource level for one day in the month in order for the applicant or recipient to be eligible for that month.

006.01(A) DEEMING RESOURCES OF A PARENT. In considering the resources of a parent, who is not considered an Essential Person in another case, towards an eligible child age 17 or younger and who is living in the parent's household, the following resources are considered to the child whether or not they are actually made available:

(i) All resources exceeding $4,000 in the case of one parent;

(ii) All resources exceeding $6,000 in the case of:

(1) Two parents:

(2) One parent and spouse of the parent; or

(3) One parent and one minor sibling;

(iii) $25 for each additional minor sibling in the parents' household; and

(iv) If income of a parent is not deemed, resources are also not deemed.

007. TREATMENT OF INCOME . The following disregards are allowed:

007.01 MEDICAL INSURANCE DISREGARDS. A deduction for the cost of medical insurance premiums is allowable in the State Disability Program budget. The cost of premiums for policies that are not considered health insurance are not allowed as a deduction for medical budgeting.

007.02 GUARDIAN OR CONSERVATOR FEE. The expense of a guardian or conservator fee is allowed as paid, up to a maximum of $10 per month. If the guardian or conservator is required by the court to purchase a bond and file an annual report with the court, the amount allowed by the court for expenses, in excess of $120, may also be disregarded.

007.03 REPAYMENT OF STATE DISABILITY MEDICAL BENEFITS PROVIDED IN ERROR. When an error has occurred in the paid amount of State Disability Program Medical benefits received by the recipient because of erroneously reported income, changes in income, or private health insurance premiums, not including Medicare, under Neb. Rev. Stat. § 68-138, repayment cannot be required unless such benefits were obtained through misrepresentation or fraud. Voluntary repayment in the following situations:

(1) The recipient failed to report a change timely and the amount of benefits in error is $76 or more;

(2) The recipient reported a change timely but the Department failed to take action in the first month possible and the amount of benefits in error is $251 or more; or

(3) The recipient failed to report a change timely and the Department failed to take action in the first month possible with the amount of benefits in error is $251 or more.

007.03(A) AMOUNT OF BENEFITS IN ERROR. The amount of benefits in error for a recipient of the Assistance to the Aged, Blind, Disabled or State Disability grant or medical, or State Disability Program Medical only, but should have been, State Disability Program Medical with a share of cost, or who was State Disability Program Medical with share of cost but who should have had a larger share of cost, is the smaller of:

(i) The amount of State Disability Program Medical services received for that month; or,

(ii) The amount of share of cost in error.

008. COMPUTING A STATE DISABILITY MEDICAL BUDGET . When computing a State Disability Medical budget, the amount of income when compared to the Federal Poverty Level will determine the applicant or recipient’s State Disability Medical eligibility for medical, medical with a share of cost, or ineligibility.

008.01 ENTERING LONG TERM CARE. When a recipient enters long term care, the standard is not reduced to the long term care level or Assisted Living Waiver level until the first full month that the recipient resides in long term care, or at a later month if certain other criteria is are met, such as home liquidation.

008.02 INCOME WHEN ONE RECIPIENT OF THE HOUSEHOLD IS IN A SPECIFIED LIVING ARRANGEMENT. The following definitions apply when the eligible spouse is in a specified living arrangement and the ineligible spouse or family member is in the community:

(A) COMMUNITY SPOUSE. A spouse who is:

(i) Not applying for or receiving assistance;

(ii) Not residing with the alternate care spouse unless the alternate care spouse is in the home and eligible for Home and Community-Based Waiver Services; and,

(iii) Not in a hospital, skilled nursing facility, intermediate care facility, or intermediate care facility for persons with developmental disabilities.

(B) FAMILY MEMBERS. Minor children residing with a community spouse, or dependent parents or siblings of the community spouse or alternate care spouse who reside with the community spouse and could be claimed as dependents for tax purposes.

(C) MAINTENANCE ALLOWANCE. The amount deducted from an alternate care spouse's income to meet the home maintenance needs of the community spouse and family members.

(D) MAINTENANCE NEED STANDARD. The income standard to which the community spouse's and other family members' income is compared for the purpose of determining the amount of allowance which may be made from the alternate care spouse's income.

008.03 ALLOCATION OF INCOME. When computing the State Disability Program medical assistance budget for an alternate care spouse in a specified living arrangement, only that individual’s income is considered. Income of a community spouse is not considered available to the alternate care spouse. Some of the income of the alternate care spouse may be allocated to the community spouse or family members to bring their income up to a minimum monthly allowable amount.

(A) The alternate care spouse must be residing in one of the following living arrangements for these special budgeting procedures to apply:

(i) A long term care facility;

(ii) An adult family home;

(iii) A licensed assisted living facility;

(iv) A center for the developmentally disabled; or

(v) Receiving services in a Home and Community Based Service Waiver.

008.04 DETERMINING OWNERSHIP OF INCOME. All income must be verified and the amount of income received by each individual determined. If payment is made in the name of both spouses, half is considered available to each spouse. If the income received does not specify either spouse, one-half of the amount is considered available to each spouse. Ownership of income may be appealed by the recipient.

009. REQUIRED COPAYMENTS . Individuals who receive State Disability Program assistance are exempt from paying copayments.

History

Effective 2022-06-06

Neb. Admin. Code tit. 469 — Assistance to the Aged, Blind, or Disabled Program

Chapter 1 General Background

Neb. Admin. Code tit. 469, ch. 1 General Background {#sec-469-nac-1 omnilex-key=us-ne-regs-official--title-469--469 NAC 1}

Chapter 2 Eligibility Requirements

Neb. Admin. Code tit. 469, ch. 2 Eligibility Requirements {#sec-469-nac-2 omnilex-key=us-ne-regs-official--title-469--469 NAC 2}

Chapter 3 Determination of Benefits

Neb. Admin. Code tit. 469, ch. 3 Determination of Benefits {#sec-469-nac-3 omnilex-key=us-ne-regs-official--title-469--469 NAC 3}

Chapter 4 State Disability Program – Medical

Neb. Admin. Code tit. 469, ch. 4 State Disability Program – Medical {#sec-469-nac-4 omnilex-key=us-ne-regs-official--title-469--469 NAC 4}

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