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

2013 2014
Eff. 7-1 (See Medicaid Eligibility Procedure Letter (MEPL) 79)  (150% FPL for 2) (Eff. 2nd qtr. after new FPL per 42 USC 1396r-5(d)(3)(A))

MMMNA

$ 1,939
(eff. 7/1/13)

$ 1,967
(eff. 7/1/14)

Eff. 1-1
(Indexed to CPI.
MEPL 83)

MMMNA Federal Cap

$ 2,898
(eff. 1/1/13)

$ 2,931
(eff. 1/1/14)

Eff. 7-1 (MEPL 79)
(30% of MMMNA) (Eff. 2nd qtr. after new FPL per 42 USC 1396r-5(d)(3)(A))

Excess Shelter Standard

$ 582
(eff. 7/1/13)

$ 590
(eff. 7/1/14)

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

Family Allowance

$ 647
(eff. 7/1/13)

$ 656
(eff. 7/1/14)

Eff. varies
(MEPL 82)

Standard Utility Allowance

$ 456
eff. 1/1/13

$ 463
eff. 1/1/14

Eff. date varies
(MEPL 74)

Average Monthly Private Pay Rate

$ 6,114
(eff. 2/1/13)

$ 6,114
(eff. 2/1/13)

Eff. 1-1 (MEPL 83)
(65% of the special income level)

Special Individual Maintenance Allowance
(Used to determine HCBS waiver patient liability)

$ 1,385
(eff. 1/1/13)

$ 1,406
(eff. 1/1/14)

Eff. 1-1 (MEPL 83)
(300% SSI for 1 living in own HH)

Special Income Level
(HCBS Waiver eligibility)

$ 2,130
(eff. 1/1/13)

$ 2,163
(eff. 1/1/14)

Eff. 1-1 (MEPL 83)
(100% SSI for 1 living in own HH)

Assisted Living Maintenance Needs Allowance

$ 710
(eff. 1/1/13)

$ 721
(eff. 1/1/14)

Eff. 7-1
(60% of NF Cost of Care based on SFY 2010 average annual Medicaid NF per diem rate)

PASSPORT Eligibility
Annual Cost Cap*

$ 36,624

$ 36,624

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)

2013

2014

Eff. 1-1
(Indexed to CPI.
MEPL 83)

Spousal Resource Minimum

$ 23,184

$ 23,448

Eff. 1-1
(Indexed to CPI.
MEPL 83)

Spousal Resource Maximum

$ 115,920

$ 117,240

Eff. 1-1
(Indexed to CPI.
MEPL 83)

Home Equity Limit

$ 533,000

$ 543,000

See MEPL 68 for correct table as OAC 5101:1-39-32(F) references an incorrect table

Life Estate Valuation Table

Table

Table

R.C. 5163.33

Personal Needs Allowance

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

$ 45
($30 - SSI)
($90 - VA)

Community Medicaid [eff. 1-1]

Resource Standard

2013
2014

Individual

$ 1,500

$ 1,500

Couple

$ 2,250

$ 2,250

Medicaid Need Standards (MEPL 83)

2013

2014

Individual (Living Alone)

$ 622

$ 632

Couple (Living Alone)

$ 1,066

$ 1,082

Individual (Living in Household of Another)

$ 415

$ 422

Couple (Living in Household of Another)

$ 711

$ 722

Assisted Living Waiver

 

2013
2014

Maintenance Needs Allowance
(Minimum Monthly Income - 100% SSI)

$ 710

$ 721

Special Income Level
(Maximum Monthly Income - 300% SSI)

$ 2,130

$ 2,163

Maximum Countable Assets

$ 1,500

$ 1,500

Personal Needs Allowance

$ 50

$ 50

Surviving Spouse VA
Aid and Attendance Pension Rate
(Source)

$ 1,112

$ 1,130

Medicare Premium Assistance Program

QMB Income Standard
(100% FPL plus $20 SS disregard)

2013

2014

Individual

$ 978
$ 993

Couple

$ 1,313
$ 1331

SLMB Income Standard
(120% FPL plus $20 SS disregard)

2013

2014

Individual

$1,169
$ 1,187

Couple

$ 1,571
$ 1,593

Qualified Individuals-1
(QI-1)  (135% FPL plus $20 SS disregard)

2013

2014

Individual

$ 1,313
$ 1,333

Couple

$ 1,765
$ 1,790

Qualified Working Disabled Individual
(QWDI)  (200% FPL plus $20 SS disregard)

2013

2014

Individual

$ 1,935
$ 1,965

Couple

$ 2,605

$ 2,642

MPAP Resource Limit

2013

2014

Individual

$ 7,080
$ 7,160

Couple

$ 10,620
$ 10,750

Medicare [eff. 1-1]

Part A

Part A

2013

2014

Premium
(Monthly - Less than 30 covered quarters)

$ 441
$ 426

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

$ 243
$ 234

Deductible
(Per benefit period)

$ 1,184
$  1,216

Daily Co-Insurance
(Days 0 to 60 per benefit period)

$ 0
$ 0

Daily Co-Insurance
(Days 61 to 90 per benefit period)

$ 296
$ 304

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

$ 592

$ 608

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)

$ 148.00
$ 152

Part B

Part B

2014

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


$ 104.90
---------------------
up to $85,000

Part B (See Issue Brief)

2013

2014

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

 $ 146.90
---------------------
$85,001-$107,000
 $ 146.90
---------------------
$85,001-$107,000

Income Related Premium (Monthly)
-----------------------------
Individual tax return with modified adjusted gross income

$ 209.80
---------------------
$107,001-$160,000
 $ 209.80
---------------------
$107,001-$160,000

Income Related Premium (Monthly)
-----------------------------
Individual tax return with modified adjusted gross income

 $ 272.70
---------------------
$160,001-$214,000
 $ 272.70
---------------------
$160,001-$214,000

Income Related Premium (Monthly)
-----------------------------
Individual tax return with modified adjusted gross income

$ 335.70
---------------------
More than $214,000
$ 335.70
---------------------
More than $214,000

Married Couples Filing Separately

2013

2014

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
 $ 272.70
---------------------
$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
$ 335.70
---------------------
More than $129,000

Part B

2013

2014

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

$ 147
$ 147

Co-Pay (Per Service)

20%
20%

Part D

Part D

2014

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)

2013

2014

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

 $ 11.60
---------------------
$85,001-$107,000
 $ 12.10
---------------------
$85,001-$107,000

Income Related Premium Adjustment (Monthly)(50%)
-----------------------------
Individual tax return with modified adjusted gross income

$ 29.90
---------------------
$107,001-$160,000
 $ 31.10
---------------------
$107,001-$160,000

Income Related Premium Adjustment (Monthly)(65%)
-----------------------------
Individual tax return with modified adjusted gross income

 $ 48.30
---------------------
$160,001-$214,000
 $ 50.20
---------------------
$160,001-$214,000

Income Related Premium Adjustment (Monthly) (80%)
-----------------------------
Individual tax return with modified adjusted gross income

$ 66.60
---------------------
More than $214,000
$ 69.30
---------------------
More than $214,000

Married Couples Filing Separately

2013

2014

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

 $ 48.30
---------------------
$85,001-$129,000
 $ 50.20
---------------------
$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.  (Source)
$ 66.60
---------------------
More than $129,000
$ 69.30
---------------------
More than $129,000

Part D Standard Benefit

2013

2014

National Average Monthly
Part D Beneficiary Premium
[Part D late-enrollment penalty premium is 1% of the base beneficiary premium amount, multiplied by the number of penalty months] (Source)

$ 31.17
$ 32.42

Deductible
(Source)

$ 325
$ 310

Initial Coverage Limit

$ 2,970
$ 2,850

Out-of-Pocket Threshold

$ 4,750
$ 4,550

Total Covered Part D Drugs to Get to
Catastrophic Limit
(Source)

$ 6,733.75

$ 6,455

Minimum Cost-Sharing in Catastrophic Coverage Benefit Portion

2013
Greater of 5% or amount below

2014
Greater of 5% or amount below

          Generic/Preferred Multi-Source Drug

$ 2.65

$ 2.55

          Other

$ 6.60

$ 6.35

Part D Low Income Subsidy Eligibility

2013

2014

Ohio Regional Benchmark
[maximum premium subsidy provided to people who get the full Part D low-income subsidy (LIS)/Extra Help] (Source)

$ 29.87

$ 28.93
Max Monthly Income Eligibility for Extra Help Program (150% FPL) Single Person

$ 1,436

$ 1,459

Couples

$ 1,939

$ 1,966

Max Resource Eligibility for Extra Help Program (with burial exclusion) (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, SS POMS Medicare Part D Extra Help]
Single Person

$ 13,300

$ 13,440

Couples

$ 26,580

$  26,860

Part D Full Subsidy Co-Pay
(Source)

2013

2014

Deductible

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

$ 1.15

$ 1.20

Brand Name Drugs

$ 3.50

$ 3.60

Income > 100% FPL Generic / Preferred Drugs

$ 2.65

$ 2.55

Brand Name Drugs

$ 6.60

$ 6.35

Maximum Catastrophic Co-payment

$ 0
$ 0

Part D Partial Subsidy Co-Pay

2013

2014

Deductible

$ 66
$ 63

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

$ 2.65

$ 2.55

Brand Name Drugs

$ 6.60

$ 6.35

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

Federal Payment Standard

2013

2014

Individual

$ 710
$ 721

Couple

$ 1,066
$ 1,082

Resource Limits

2013

2014

Individual

$ 2,000
$ 2,000

Couple

$ 3,000
$ 3,000

Substantial Gainful Activity Limit

2013

2014

Non-Blind
(Source)

$ 1,040
$ 1,070

Blind

$ 1,740
$ 1,800

Trial Work Period
(Source)

$ 750
$ 770

Other

Ohio and CMS contract with Integrated Care Delivery System (ICDS) plans to coordinate all covered Medicare and Medicaid services for participating Medicare-Medicaid enrollees in
 demonstration project.

 
 
* 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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