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)		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
Income <= 100% FPL	Brand Name Drugs	$ 3.20	$ 3.10
Income > 100% FPL	Generic / Preferred Drugs	$ 2.40	$ 2.25
Income > 100% FPL	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
Catastrophic Co-Pay	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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