Legal Services

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)

2009 2008
Eff. 7-1 (MEPL 18)
(150% FPL for 2)

MMMNA

$ 1,821
(eff. 7/1/09)

$ 1,750
(eff. 7/1/08)

Eff. 1-1
(Increased by CPI per ACT 236)

MMMNA Federal Cap

$ 2,739
(eff. 1/1/09)

$ 2,610
(eff. 1/1/08)

Eff. 7-1 (MEPL 18)
(30% of MMMNA)

Excess Shelter Standard

$ 547
(eff. 7/1/09)

$ 525
(eff. 7/1/08)

Eff. 7-1
(1/3 MMMNA minus family member's gross income)

Family Allowance

$ 607
(eff. 7/1/09)

$ 583
(eff. 7/1/08)

Eff. 10-1-year
(MEPL 29)

Standard Utility Allowance

$
eff. 10/1/09

$ 586
eff. 10/1/08

Eff. varies
(MEPL 36)

Average Monthly Private Pay Rate

$ 6,023
(eff. 7/1/09)

$ 5,247
(eff. 6/1/07)

Eff. 1-1
(65% of the special income level)

Special Individual Maintenance Allowance (HCBS Waivers)

$ 1,315

$ 1,243

Eff. 1-1
(300% SSI for 1 living in own HH)

Special Income Level
(HCBS Waivers)

$ 2,022

$ 1,911

Eff. 1-1
(100% SSI for 1 living in own HH)

Assisted Living Maintenance Needs Allowance

$ 674

$ 637

Eff. 7-1
(60% of NF Cost of Care based on ODJFS paid claims data)

PASSPORT Eligibility
Annual Cost Cap*

$ 35,594

$  35,594

Note:  PASSPORT enrollment cost cap is 60% of NF cost.  But after enrollment, a PASSPORT waiver participant's service package costs can increase up to 100% of SFY 2009 nursing facility costs, or
$ 59,323.  Service package costs exceeding 60% of the cost cap require supervisory approval at the PASSPORT Administrative Agency level before being implemented.

Community Spouse Resource Allowance (CSRA)

2009

2008

Eff. 1-1
(Increased by CPI per ACT)

Spousal Resource Minimum

$ 21,912

$ 20,880

Eff. 1-1
(Increased by CPI per ACT)

Spousal Resource Maximum

$ 109,560

$ 104,400

R.C. § 5111.114

Personal Needs Allowance

$ 40
($30 - SSI)
($90 - VA)

$ 40
($30 - SSI)
($90 - VA)

Community Medicaid [eff. 1-1]

Resource Standard

2009
2008

Individual

$ 1,500

$ 1,500

Couple

$ 2,250

$ 2,250

Medicaid Need Standard (MEPL 30)

2009

2008

Individual (Living Alone)

$ 589

$ 556

Couple (Living Alone)

$ 1,011

$ 956

Individual (Living in Household of Another)

$ 393

$ 371

Couple (Living in Household of Another)

$ 674

$ 637

Medicare Buy-In Programs [eff. 4-1]

QMB Income Standard
(100% FPL)

2009

2008

Individual

$ 903
$ 867

Couple

$ 1,214
$1,167

SLMB Income Standard
(120% FPL)

2009

2008

Individual

$ 1,084
$ 1,040

Couple

$ 1,457
$ 1,400

Qualified Individuals-1
(QI-1)  (135% FPL)

2009

2008

Individual

$ 1,219
$ 1,170

Couple

$ 1,639
$ 1,575

Qualified Working Disabled Individual
(QWDI)  (200% FPL)

2009

2008

Individual

$ 1,806
$ 1,734

Couple

$ 2,428

$ 2,334

QMB/SLMB Resource Standard

2009

2008

Individual

$ 4,000
$ 4,000

Couple

$ 6,000
$ 6,000

Medicare [eff. 1-1]

Part A

2009

2008

Premium
(Monthly - Less than 30 covered quarters)

$ 443
$ 423

Premium
(Monthly - 30 to 39 covered quarters & certain others)

$ 244
$ 233

Deductible
(Per benefit period)

$ 1,068
$ 1,024

Co-Pay
(Days 0 to 60 per benefit period)

$ 0
$ 0

Co-Pay
(Days 61 to 90 per benefit period)

$ 267
$ 256

Co-Pay
(Days 91 to 150 per benefit period
Lifetime Reserve Days)

$ 534

$ 512

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)

$ 133.50
$ 128

Part B

2009

2008

Premium (Monthly)
-----------------------------
income

$ 96.40
---------------------
up to $85,000
$ 96.40
---------------------
up to $82,000

Premium (Monthly)
-----------------------------
income

$ 134.90
---------------------
$85,001-$107,000
 $ 122.20
---------------------
$82,001-$102,000

Premium (Monthly)
-----------------------------
income

$ 192.70
---------------------
$107,001-$160,000
 $ 160.90
---------------------
$102,001-$153,000

Premium (Monthly)
-----------------------------
income

$ 250.50
---------------------
$160,001-$213,000
 $ 199.70
---------------------
$153,001-$205,000

Premium (Monthly)
-----------------------------
income

$ 308.30
---------------------
More than $213,000
$ 238.40
---------------------
More than $205,000
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:  Individuals with incomes between $85,000 & $128,000 pay $250.50 and those with incomes over $128,000 pay $308.30.  See CMS Fact Sheet.    

Deductible (Yearly)
(In 2005 this deductible was indexed to the increase
in the average cost of Part B services)

$ 135
$ 135

Co-Pay (Per Service)

20%
20%

Part D

2009

2008

Ohio's Low-Income Premium Subsidy Amount
[See, www.cms.hhs.gov > Medicare > Medicare Advantage - Rates & Statistics (under the Health Plans header) > Ratebooks & Supporting Data > 2009 > Regional rates and benchmarks 2009]

$ 28.40
$ 26.82

Deductible

$ 295
$ 275

Initial Coverage Limit

$ 2,700
$ 2,510

Out-of-Pocket Threshold

$ 4,350
$ 4,050

Total Covered Part D Drugs to Get to
Catastrophic Limit

$ 6,153.75

$ 5,726.25

Part D Low Income Subsidy Eligibility

2009

2008

Max Monthly Income Eligibility for Extra Help Program (150% FPL) Single Person

$ 1,355

$ 1,300

Couples

$ 1,821

$ 1,750

Max Resource Eligibility for Extra Help Program [Indexed to CPI]
[See, SocialSecurity.gov]
Single Person

$ 12,510

$ 11,990

Couples

$ 25,010

$ 23,970

Part D Full Subsidy Co-Pay
See Chart

2009

2008

Deductible

$ 0
$ 0
Income <= 100% FPL Generic / Preferred Drugs

$ 1.10

$ 1.05

Brand Name Drugs

$ 3.20

$ 3.10

Income > 100% FPL Generic / Preferred Drugs

$ 2.40

$ 2.25

Brand Name Drugs

$ 6.00

$ 5.60

Part D Partial Subsidy Co-Pay

2009

2008

Deductible

$ 60
$ 56

Co-Insurance (Up to Catastrophic)

15%
15%

Catastrophic Co-Pay

Generic / Preferred Drugs

$ 2.40

$ 2.25

Brand Name Drugs

$ 6.00

$ 5.60

Supplemental Security Income (SSI) [eff. 1-1]

Federal Payment Standard

2009

2008

Individual

$ 674
$ 637

Couple

$ 1,011
$ 956

Resource Limits

2009

2008

Individual

$ 2,000
$ 2,000

Couple

$ 3,000
$ 3,000

Substantial Gainful Activity Limit [Non-Blind]

$ 980

$ 940

 

Links

For 2008 Medicare Changes Click Here

For 2008 Social Security Changes Click Here

For AARP Public Benefits Updates 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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