COMMONWEALTH OF MASSACHUSETTS
DIVISION OF HEARINGS

*, SS	APPEAL NO.   *

______________________________________________________
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In Re: Matter of Application for Medical                                           )
Assistance of *                                                                                    )
_____________________________________________________	)

MEMORANDUM OF *, APPELLANT, 
REQUESTING ADJUSTMENT TO HER/HIS
COMMUNITY SPOUSE RESOURCE ALLOWANCE

I.  ISSUE PRESENTED
	The issue to be presented at this hearing is whether, pursuant to 130 CMR 520.017, the community spouse should be allowed to retain a higher community spouse resource allowance ("CSRA") than that authorized at 130 CMR 505.180, in order to generate the shortfall that exists between her/his own income and her/his minimum monthly maintenance needs allowance (“MMMNA”)  
II.  STATEMENT OF FACTS
	*  is * years of age and suffers from *.  On ___________, ______, he/she was admitted to __________ Nursing Home in ___________Massachusetts, where he/she currently resides.
	* monthly income consists of a Social Security benefit in the net amount of $____. __________ monthly income consists of her/his Social Security in the gross amount of $___.  (See Exhibit 1, Social Security Statement.)
	The Division of Medical Assistance (the “DMA”) determined in its Denial Notice dated ___________, ____, that _____________ and ____________ have countable assets totaling $__________.  (See Exhibit 2, Notice of Denial.)  The DMA determined _________ MMMNA to be $________.  (See Exhibit 3, Spousal Income Allowance Worksheet.)
	__________ has privately paid $_______ to _______________ for his care through ________ . ________________ purchased burial insurance in the amount of $________ ($________ + $_______ = $______) on __________, ____.  (See Exhibit 4, verification of irrevocable burial insurance.)
	
III.  PROCEDURAL HISTORY
	_________’s Medicaid application was denied in a notice dated ___________, ____, for reasons of excess assets. ___________ made a timely appeal on _______________, ____, requesting an increase in her/his resource allowance.  The fair hearing was scheduled for _______________, ____.

IV. ARGUMENT
WHERE THE ACTUAL INCOME OF THE COMMUNITY SPOUSE WITHOUT REFERENCE TO HER/HIS INCOME OF THE INSTITUTIONALIZED SPOUSE FALLS BELOW THE MMMNA, THE COMMUNITY SPOUSE IS ENTITLED TO RETAIN A LARGER SHARE OF THE COMBINED SPOUSAL RESOURCES.

	When a married person applies for Medicaid coverage for nursing home care, the DMA is required to: 
revise the community spouse resource allowance to permit the community spouse to retain a larger share of the combined spousal resources if the income of the community spouse, without reference to the income of the institutionalized spouse, falls below the minimum monthly maintenance needs allowance of the community spouse.

 M.G.L. c. 118E, §21A(c).  
	This statutory protection has been implemented by the DMA through 130 CMR 520.017, pursuant to which interest income on the investment of the CSRA is to be imputed at the rates reported in the Bank Rate Monitor (BRM) Index on the date of the hearing.  Interest income is imputed using the BRM Index for money market accounts for the standard maximum allowable asset allowance, which at present is $________, and the BRM Index for 2 ½-year CD accounts is used for assets in excess of $_____.  130 CMR 520.017(A)(2).  
	According to The Boston Globe, the BRM Index for money market accounts was _______ percent and for 2 ½-year CD accounts was____ percent as of ___________. (See Exhibit 5, Verification of Interest Rate.) 
	____________'s monthly Social Security income is $_____.  Her resource allowance of $_________ is deemed to earn interest income of $______ per month ($_____ x _____ = $_______ per year, $_____ ÷ 12 = $____ per month).  Thus, her/his total monthly income, including interest from the standard CSRA is deemed to be $_____ ($______ + $_____ = $____). __________'s MMMNA is $_______, leaving her/him with  a monthly income shortfall of $________ between the MMMNA and her/his actual income ($_______ - $_______ = $_____).  
	_________'s CSRA should, therefore, be increased so that sufficient interest income is generated to bring her monthly income up to the MMMNA.   At an interest rate of ______ percent, _________ needs to keep an additional $________ in order to generate sufficient income to equal her/his MMMNA:
		$______ x 12 = $______ per year
		$______÷ ______% = $_______ 
	___________ CSRA should, therefore, be increased to $______($_________ + $_________)and _______ should be eligible for Medicaid benefits on the date Mr. and Mrs. * have spent down their countable assets to $_____ ($______ + $2,000). * will not be entitled to any share of *  income.

V. CONCLUSION
	Based upon the facts and the law discussed above, the appellant asks the Division of Hearings to find that:  (1) * is entitled to an adjusted CSRA of $_____; and (2) that * will be eligible for Medical Assistance when *. and *. ’s joint assets have been spent down to $________.
						Respectfully submitted,
						* 			
						by her/his attorney:

                                                           
 *, Esq.
						 *

Dated: _________, ____