Husband hugging wife who is in a nursing homeWhen a single person is in the nursing home on Medicaid, the income and asset rules are fairly straightforward. Find the applicant's gross income, subtract $160 for the personal needs allowance and pay the remainder to the nursing home as part of the patient's responsibility.  Income issues are more complicated when there is a spouse at home.

Rather than requiring a couple to reduce their joint income to poverty level, Florida law permits the community spouse (the spouse at home) to maintain a higher income for self-support if his or her income falls below the minimum monthly maintenance needs allowance (MMMNA). In 2023, for example, Florida allows the community spouse to keep at least $2,289.00 in monthly income, or up to $3,716/m in certain cases as discussed below. 

First, any income the community spouse receives in his or her own name—Social Security, pension, or dividend income, for example—may be retained fully by the community spouse. Very importantly, no portion of the community spouse’s own income is required to be assigned to Medicaid or diverted to cover the cost of care for the institutionalized spouse. As a result, the community spouse’s income could exceed the allowed minimum of $2,289/month. In fact, the community spouse's income can be unlimited. It is only the community spouse's assets that affect the institutionalized spouse's Medicaid.

If, however, the minimum allowance of $2,289/month cannot be met by the community spouse’s income alone, Florida allows the institutionalized spouse to divert income to the community spouse to close the gap. This situation may occur, for example, when a husband with greater income is the institutionalized spouse and a wife with a smaller income is the community spouse (the spouse at home). In such cases, income that is paid to the institutionalized spouse (such as Social Security and pension income, for example) may be diverted to and retained by the community spouse to assist with his or her basic income needs.  The transfer of income from the institutionalized spouse to the community spouse is referred to as the spousal diversion. Calculating income can be confusing but remember that the government is not trying to impoverish the spouse at home and take away all of his or her income. The legal policy is that the government wants to provide a minimum level of support to the community spouse.

Example of the Community Spouse Income Diversion

For example, assume that Sharon and Randy are a senior couple, living in Florida on Randy’s monthly $1,500 Social Security and Sharon’s $1,000 monthly Social Security benefit. Randy’s health has declined severely and he needs to be in the nursing home on Medicaid for long-term care assistance. Because Sharon’s own income is less than the MMMNA, she will be able to retain, at a minimum, $1,289/m of Randy’s monthly income with the rest going to his patient's responsibility (minus his own $160/m personal needs allowance). (The minimum allowance of $2,289 minus Sharon's income of $1,000/month is $1,289.  This means that Sharon will get to keep a minimum of $1,289/month of Randy's income for her own benefit).

Raising the Spousal Diversion above the Minimum Allowance

In addition to the Minimum Monthly Maintenance Income Allowance of $2,465/m, the income diversion to the community spouse can be increased to the Maximum Monthly Maintenance Income Allowance of $3,716/month. Medicaid rules allow the income to be increased to the maximum level only through calculating the community spouse’s excess shelter costs. Basically, if the community spouse rents their home, has a mortgage, or the housing costs are above a certain level, the spouse can keep more of the institutionalized spouse’s income. The rules are generally as follows:

  • Housing costs must exceed the community spouse housing allowance of $687/month. 
  • Housing costs include mortgage payments, rent, insurance, condo maintenance fees and utilities.
  • Once the community spouse's shelter costs exceed the allowance of $654/month, the community spouse can start to divert more of the institutionalized spouse’s income, up to the maximum level of $3,716/month.

Calculating the Community Spouse's Excess Shelter Costs

This will be demonstrated further below and with the worksheet, but this language is extracted from Florida's Medicaid manual:

Step 1 - Add the community spouse’s monthly housing expenses. Allowed expenses are limited to rent or mortgage payment (including principal and interest), taxes, insurance (homeowners or renters), maintenance charges if a condominium and mandatory homeowner’s association fees. 

Step 2 - To the total obtained above, add the current food stamp standard utility disregard (est. $361/m). Allowed utilities are limited to water, sewage, gas, and electric. This basically gives a credit of $361/m for utilities, but if utilities are higher than this, you can raise above the $361.

Step 3 - To determine what portion of the total shelter costs is excess, subtract $361 from the total costs. The difference is the community spouse’s excess shelter costs.

Best Example of the Calculating the Spousal Diversion

This can all be pretty confusing, even to elder law attorneys, so hopefully the following helps.  Here, Dad is in the nursing home (the institutionalized spouse) and mom is doing well at home (as the community spouse).  They own a home with a mortgage of $800/month. Dad's income is $2,000/month and Mom's income is $1,000/month. Total assets are below $148,620 (2023) or they hired an elder law attorney (like our law firm!) to help protect assets over this level.

Without any excess shelter costs, Mom will be able to keep $1,465/month of the husband's income as the Minimum Monthly Maintenance Income Allowance (MMMNA), as well as keeping her own income.  Dad will keep $160/month as the personal needs allowance and the rest will need to be paid to the the nursing home as part of the patient's responsibility.

To try to get Mom more income diverted from Dad's own income (instead of going to the nursing home), we can calculate the excess shelter costs:

  •   $  800/m (mortgage)
  • +$  150/m (property tax)
  • +$  100/m (insurance)
  • +$  361/m (Standard Utility Allowance )
  • =$1,411/m (Total)
  • - $   687/m (normal standard housing costs)
  • =$   724/m (excess housing costs for the community spouse)

This means we raise the $2,465/month minimum by $724/month. Mom will now keep $3,000/month as she had housing costs exceeding the normal $647/month and the nursing home is paid only $0/month! ($3,000 total gross income minus the $3,000 ($1,000 of wife's income and $2,000 of husband's income) = $0 paid to the nursing home)

See our Worksheet! 

Please see our Florida Medicaid Spousal Diversion Worksheet.  We have reprinted this webpage along with a standalone worksheet for you to do your own calculations, allowing you put proverbial pen to paper to assist you and your loved ones calculate spousal diversion and the patient's responsibility for Medicaid purposes.

How does a Qualified Income Trust come into this?

If the institutionalized spouse's gross income exceeds the income cap ($2,742/m in 2023), then a qualified income trust ("QIT") will have to be established to lower the income to below the cap. Your elder law attorney would walk you through the use of the QIT and how it works with the spousal diversion.

What if the spouse cannot live on the Diversion Amount?

If there is court ordered support against an institutionalized spouse (for monthly support income for the community spouse), the community spouse's monthly income allowance cannot be less than the amount ordered. A good elder law attorney (such as our office) can work with the family to go to court to increase obtain a court order for spousal support.  

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