Pro Seniors Inc. - Medicaid-Medicare Eligibility Information

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Medicaid - Medicare Eligibility Information

This site provides general information only and not legal advice. The law is complex and changes frequently. Before you apply any information to a particular situation, call Pro Seniors' Legal Hotline or consult an attorney in elder law. The numbers listed below change annually on the effective date listed in the first column.

Pamphlets
For more general information regarding Medicare and Medicaid see our complete list of pamphlet titles. Pro Seniors provides legal information pamphlets on a variety of subjects. Single copies are available to individuals free of charge. Contact Pro Seniors, Inc. and we will mail you pamphlets which are of interest to you.

Medicaid Eligibility Standards
Pro Seniors receives frequent requests from professionals for the current Medicaid eligibility standards. Pro Seniors makes every effort to update the numbers below with the most current releases. However, we cannot guarantee the accuracy of the numbers below, nor their appropriateness for any specific purpose.

Institutional Medicaid
Spousal Impoverishment Standards & Allowances (See CMS Website)		2011	2012
Eff. 7-1 (See Medicaid Eligibility Procedure Letter (MEPL) 48) (150% FPL for 2)	MMMNA	$ 1,839 (eff. 7/1/11)	$ 1,891 (eff. 7/1/12)
Eff. 1-1 (Indexed to CPI. MEPL 59)	MMMNA Federal Cap	$ 2,739 (eff. 1/1/11)	$ 2,841 (eff. 1/1/12)
Eff. 7-1 (MEPL 41) (30% of MMMNA)	Excess Shelter Standard	$ 552 (eff. 7/1/11)	$ 568 (eff. 7/1/12)
Eff. 7-1 (1/3 MMMNA minus family member's gross income)	Family Allowance	$ 613 (eff. 7/1/11)	$ 631 (eff. 7/1/12)
Eff. 10-1-year (MEPL 57)	Standard Utility Allowance	$ 599 eff. 10/1/10	$ 599 eff. 10/1/11
Eff. date varies (MEPL 36)	Average Monthly Private Pay Rate	$ 6,023 (eff. 7/1/09)	$ 6,023 (eff. 7/1/09)
Eff. 1-1 (MEPL 59) (65% of the special income level)	Special Individual Maintenance Allowance (HCBS Waivers)	$ 1,315	$ 1,362
Eff. 1-1 (300% SSI for 1 living in own HH)	Special Income Level (HCBS Waivers)	$ 2,022	$ 2,094
Eff. 1-1 (100% SSI for 1 living in own HH)	Assisted Living Maintenance Needs Allowance	$ 674	$ 698
Eff. 7-1 (60% of NF Cost of Care based on SFY 2009 average annual Medicaid NF per diem rate)	PASSPORT Eligibility Annual Cost Cap*	$ 35,594	$ 35,594
Note: PASSPORT enrollment individual cost limit is 60% of NF cost. But after enrollment, a PASSPORT waiver participant's service package costs can increase up to 100% of average annual Medicaid NF per diem rate. Service package costs exceeding 60% of the cost cap require supervisory approval at the PASSPORT Administrative Agency level. See OAC 5101:3-31-03(A)(2).
Community Spouse Resource Allowance (CSRA)		2011	2012
Eff. 1-1 (Indexed to CPI. MEPL 59)	Spousal Resource Minimum	$ 21,912	$ 22,728
Eff. 1-1 (Indexed to CPI. MEPL 59)	Spousal Resource Maximum	$ 109,560	$ 113,640
Eff. 1-1 (Indexed to CPI. MEPL 59)	Home Equity Limit	$ 506,000	$ 524,000
R.C. § 5111.114	Personal Needs Allowance	$ 40 ($30 - SSI) ($90 - VA)	$ 40 ($30 - SSI) ($90 - VA)
Community Medicaid [eff. 1-1]
Resource Standard		2011	2012
Individual		$ 1,500	$ 1,500
Couple		$ 2,250	$ 2,250
Medicaid Need Standard (MEPL 59)		2011	2012
Individual (Living Alone)		$ 589	$ 611
Couple (Living Alone)		$ 1,011	$ 1,048
Individual (Living in Household of Another)		$ 393	$ 408
Couple (Living in Household of Another)		$ 674	$ 699
Assisted Living Waiver
		2011	2012
Maintenance Needs Allowance (Minimum Monthly Income - 100% SSI)		$ 674	$ 698
Special Income Level (Maximum Monthly Income - 300% SSI)		$ 2,022	$ 2,094
Maximum Countable Assets		$ 1,500	$ 1,500
Personal Needs Allowance		$ 50	$ 50
Medicare Premium Assistance Program [eff. 1-1-11 because no Social Security COLA - See MEPL 53]
QMB Income Standard (100% FPL plus $20 SS disregard)		2011	2012
Individual		$ 928	$ 931
Couple		$ 1,246	$ 1,261
SLMB Income Standard (120% FPL plus $20 SS disregard)		2011	2012
Individual		$ 1,109	$ 1,118
Couple		$ 1,491	$ 1,514
Qualified Individuals-1 (QI-1) (135% FPL plus $20 SS disregard)		2011	2012
Individual		$ 1,246	$ 1,257
Couple		$ 1,675	$ 1,703
Qualified Working Disabled Individual (QWDI) (200% FPL plus $20 SS disregard)		2011	2012
Individual		$ 1,835	$ 1,882
Couple		$ 2,472	$ 2,542
QMB/SLMB Resource Standard		2011	2012
Individual		$ 6,680	$ 6,940
Couple		$ 10,020	$ 10,410
Medicare [eff. 1-1]
Part A		2011	2012
Premium (Monthly - Less than 30 covered quarters)		$ 450	$ 451
Premium (Monthly - 30 to 39 covered quarters & certain others)		$ 248	$ 248
Deductible (Per benefit period)		$ 1,132	$ 1,156
Daily Co-Insurance (Days 0 to 60 per benefit period)		$ 0	$ 0
Daily Co-Insurance (Days 61 to 90 per benefit period)		$ 283	$ 289
Daily Co-Insurance (Days 91 to 150 per benefit period Lifetime Reserve Days)		$ 566	$ 578
Skilled Nursing Facility Co-insurance (Days 0 to 20 per benefit period)		$ 0	$ 0
Skilled Nursing Facility Co-insurance (Days 21 to 100 per benefit period)		$ 141.50	$ 144.50
Part B			2012
Non-Income Related or Standard Premium (Monthly) --------------------------------------------------------------------------------------------- Due to a 3.6% Social Security COLA in 2012, SS's hold harmless provision no longer applies to create different premium amounts for new beneficiaries; Generally, if no SS COLA then no Part B premium increase. See 42 U.S.C. 1395r(f) --------------------------------------------------------------------------------------------- Individual tax return with modified adjusted gross income			$ 99.90 --------------------- up to $85,000
Part B (See Issue Brief)		2011	2012
Income Related Premium (Monthly) ----------------------------- Note: Income related premiums are specifically excluded from SS's hold harmless provision. See MedicareAdvocacy.org ----------------------------- Individual tax return with modified adjusted gross income		$ 161.50 --------------------- $85,001-$107,000	$ 139.90 --------------------- $85,001-$107,000
Income Related Premium (Monthly) ----------------------------- Individual tax return with modified adjusted gross income		$ 230.70 --------------------- $107,001-$160,000	$ 199.80 --------------------- $107,001-$160,000
Income Related Premium (Monthly) ----------------------------- Individual tax return with modified adjusted gross income		$ 299.90 --------------------- $160,001-$214,000	$ 259.70 --------------------- $160,001-$214,000
Income Related Premium (Monthly) ----------------------------- Individual tax return with modified adjusted gross income		$ 369.10 --------------------- More than $214,000	$ 319.70 --------------------- More than $214,000
Married Couples Filing Separately		2011	2012
Note: Couples filing joint returns have twice the above income limits before their Part B premiums are increased to the next level. But married couples filing separately are subject to a special rate increase: ----------------------------- Separate tax return with modified adjusted gross income		$ 299.90 --------------------- $85,001-$129,000	$ 259.70 --------------------- $85,001-$129,000
Individuals with incomes between $85,000 & $129,000 pay $299.90 and those with incomes over $129,000 pay $369.10. See CMS Fact Sheet.		$ 369.10 --------------------- More than $129,000	$ 319.70 --------------------- More than $129,000
Part B		2011	2012
Deductible (Annual) (In 2005 this deductible was indexed to the increase in the average cost of Part B services)		$ 162	$ 140
Co-Pay (Per Service)		20%	20%
Part D		2011	2012
Part D			2012
Part D Income Related Premium Adjustment (Monthly) --------------------------------------------------------------------------------------------- Medicare Part D prescription drug plan premiums vary from plan to plan. Beginning in 2011, Part D enrollees whose incomes exceed the same thresholds that apply to higher income Part B enrollees must also pay a monthly adjustment amount. The regular plan premium is paid to the Part D plan, and the income-related adjustment is paid to Medicare. --------------------------------------------------------------------------------------------- Individual tax return with modified adjusted gross income			$ 0 --------------------- up to $85,000
Part D (See Issue Brief)		2011	2012
Income Related Premium Adjustment (Monthly)(35%) ----------------------------- Note: Income related premiums are specifically excluded from SS's hold harmless provision. See MedicareAdvocacy.org ----------------------------- Individual tax return with modified adjusted gross income		$ 12.00 --------------------- $85,001-$107,000	$ 11.60 --------------------- $85,001-$107,000
Income Related Premium Adjustment (Monthly)(50%) ----------------------------- Individual tax return with modified adjusted gross income		$ 31.10 --------------------- $107,001-$160,000	$ 29.90 --------------------- $107,001-$160,000
Income Related Premium Adjustment (Monthly)(65%) ----------------------------- Individual tax return with modified adjusted gross income		$ 50.10 --------------------- $160,001-$214,000	$ 48.10 --------------------- $160,001-$214,000
Income Related Premium Adjustment (Monthly) (80%) ----------------------------- Individual tax return with modified adjusted gross income		$ 69.10 --------------------- More than $214,000	$ 66.40 --------------------- More than $214,000
Married Couples Filing Separately		2011	2012
Note: Couples filing joint returns have twice the above income limits before their Part B premiums are increased to the next level. But married couples filing separately are subject to a special rate increase: ----------------------------- Separate tax return with modified adjusted gross income		$ 50.10 --------------------- $85,001-$129,000	$ 48.10 --------------------- $85,001-$129,000
Individuals with incomes between $85,000 & $129,000 pay $299.90 and those with incomes over $129,000 pay $369.10. See CMS Fact Sheet.		$ 69.10 --------------------- More than $129,000	$ 66.40 --------------------- More than $129,000
Part D Standard Benefit		2011	2012
National Average Monthly Part D Beneficiary Premium (Part D base beneficiary premium)		$ 32.34	$ 31.08
Deductible		$ 310	$ 320
Initial Coverage Limit		$ 2,840	$ 2,930
Out-of-Pocket Threshold		$ 4,550	$ 4,700
Total Covered Part D Drugs to Get to Catastrophic Limit		$ 6,447.50	$ 6,657.50
Minimum Cost-Sharing in Catastrophic Coverage Benefit Portion		2011 Greater of 5% or amount below	2012 Greater of 5% or amount below
Generic/Preferred Multi-Source Drug		$ 2.50	$ 2.60
Other		$ 6.30	$ 6.50
Part D Low Income Subsidy Eligibility		2011	2012
Ohio's Low-Income Premium Subsidy Amount [See, Regional Rates Benchmarks]		$ 29.67	$ 29.41
Max Monthly Income Eligibility for Extra Help Program (150% FPL)	Single Person	$ 1,362	$ 1,397
	Couples	$ 1,839	$ 1,892
Max Resource Eligibility for Extra Help Program (If no intention to use a portion of assets for funeral or burial expenses, subtract $1,500 for single and $3,000 from couple's resource limit) [Indexed to CPI] [See, Extra Help Fact Sheet]	Single Person	$ 12,640	$ 13,410
	Couples	$ 25,260	$ 26,120
Part D Full Subsidy Co-Pay See Chart		2011	2012
Deductible		$ 0	$ 0
Income <= 100% FPL	Generic / Preferred Drugs	$ 1.10	$ 1.10
Income <= 100% FPL	Brand Name Drugs	$ 3.30	$ 3.30
Income > 100% FPL	Generic / Preferred Drugs	$ 2.50	$ 2.60
Income > 100% FPL	Brand Name Drugs	$ 6.30	$ 6.50
Maximum Catastrophic Co-payment		$ 0	$ 0
Part D Partial Subsidy Co-Pay		2011	2012
Deductible		$ 63	$ 65
Co-Insurance (Up to Catastrophic)		15%	15%
Catastrophic Co-Pay (The greater of 5% or chart value. In 2012, co-pay for generic with retail price > $52 is 5%, brand > $130 is 5%.)	Generic / Preferred Drugs	$ 2.50	$ 2.60
	Brand Name Drugs	$ 6.30	$ 6.50
Supplemental Security Income (SSI) [eff. 1-1]
Federal Payment Standard		2011	2012
Individual		$ 674	$ 698
Couple		$ 1,011	$ 1,048
Resource Limits		2011	2012
Individual		$ 2,000	$ 2,000
Couple		$ 3,000	$ 3,000
Substantial Gainful Activity Limit		2011	2012
Non-Blind		$ 1,000	$ 1,010
Blind		$ 1,640	$ 1,690
Trial Work Period		$ 720	$ 720


Links
For Medicare Changes Click Here
For Social Security Changes Click Here

* 5101:3-31-03(A)(2) The cost of the twelve-month service plan does not exceed the cost cap. The cost cap is calculated annually. The "cost cap" is a dollar amount adjusted for inflation equal to sixty percent of the total Medicaid cost including consumer copayment for NF services for the most recent state fiscal year for which data is available.

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