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Medicaid-Medicare Eligibility

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.

Application Forms for Medicare Premium Assistance Programs

The Ohio Department of Medicaid prefers Form ODM 07216 when applying for Medicare Premium Assistance Programs.  However, Medicare Premium Assistance Programs are not mentioned on this form.  Therefore, we have provided a form that highlights the areas that need to be completed, and we have also provided the old form (ODM 07103) which is still being accepted by some counties.  Please be sure to advise your county caseworker of all members of your household.

  • ODM 07216 (Preferred by Ohio Department of Medicaid)
  • ODM 07103 (Old form still accepted by some Ohio counties)

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.

Ohio Department of Medicaid Resources and Rules

Click here for a handy list of ODM’s resources and rules for the Medicaid practitioner or curious individual.  Pro Seniors makes every effort to update the list with the most current rules.  However, we can neither guarantee the list’s accuracy nor its appropriateness for any specific purpose.

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

2018

2019

Eff. 7-1 (See Medicaid Eligibility Procedure Letter (MEPL) 134)
(150% FPL for 2) (Eff. 2nd qtr. after new FPL per 42 USC 1396r-5(d)(3)(A))
MMMNA Standard $2,057.50
(eff. 7/1/18)
$
(eff. 7/1/19)
Eff. 1-1
(Indexed to CPI. 2019 CPI increase: 2.8% MEPL 139)
MMMNA Federal Cap $3,090
(eff. 1/1/18)
$ 3,160.50
(eff. 1/1/19)
Eff. 7-1 (MEPL 134)
(30% of MMMNA) (Eff. 2nd qtr. after new FPL per 42 USC 1396r-5(d)(3)(A))
Excess Shelter Allowance (ESA)Standard $617.25
(eff. 7/1/18)
$
(eff. 7/1/19)
Eff. 7-1
(1/3 MMMNA minus family member's gross income)
Family Allowance $677
(eff. 7/1/18)
$
(eff. 7/1/19)
Eff. 10-1
(MEPL 137)
Standard Utility Allowance $544
eff. 10/1/18
$
eff. 10/1/19
Eff. date varies
(MEPL 118)
Average Monthly Private Pay Rate $6,570
(eff. 9/1/16)
$6,570
(eff. 9/1/16)
Eff. 1-1 (MEPL 139)
(65% of the special income level)
Special Individual Maintenance Needs Allowance (SIMNA)
(Used to determine HCBS waiver patient liability )
$1,463
(eff. 1/1/18)
$1,503.45
(eff. 1/1/19)
Eff. 1-1 (MEPL 139)
(300% SSI for 1 living in own HH)
Special Income Level
(Institutional Medicaid income eligibility)
$2,250
(eff. 1/1/18)
$2,313
(eff. 1/1/19)
Eff. 1-1 (MEPL 139)
(100% SSI for 1 living in own HH)
Assisted Living Maintenance Needs Allowance $750
(eff. 1/1/18)
$771
(eff. 1/1/19)
Eff. 11-25-2016
PASSPORT Eligibility
Annual Cost Cap*
$176,400 $176,400
* A PASSPORT eligibility criteria is that the waiver service cost of the twelve-month service plan cannot exceed $14,700 per month for waiver services. See OAC 5160-31-03(A)(2).

Community Spouse Resource Allowance (CSRA)

(Indexed to CPI; MEPL 139)

2018

2019

Eff. 1-1
Spousal Resource Minimum $ 24,720 $25,284
Eff. 1-1
Spousal Resource Maximum $123,600 $126,420
Eff. 1-1
Home Equity Limit - Minimum $572,000 $585,000
See OAC 5160:1-3-05.17 Medicaid: Life Estates & Life Leases Life Estate Valuation Table Link to Table Link to Table
R.C. § 5163.33; (MEPL 139) Personal Needs Allowance $50
($30 - SSI)
($90 - VA)
$ 50
($30 - SSI)
($90 - VA)
 

Community Medicaid

[eff. 1-1]

Resource Standard

2018

2019

Individual $2,000 $2,000
Couple $3,000 $3,000

Medicaid Need Standards

(MEPL 139)

2018

2019

Individual (Living Alone) $750 $771
Couple (Living Alone) $1,125 $1,157
Individual (Living in Household of Another) $500 $514
Couple (Living in Household of Another) $750 $772

MAGI Medicaid Need Standards

(Non-Medicare-eligible Medicaid Expansion Adults up to 138% of the FPL, includes a 5% disregard) (Source) and (MEPL 130). See also Yearly Guidelines and Thresholds ; Medicaid Household Rules; and The NHeLP MAGI Guide

2018

2019

Individual $1,396 $
Couple $1,893 $
 

Assisted Living Waiver

 

2018

2019

Maintenance Needs Allowance
(ALMNA) (MEPL 139)
(Minimum Monthly Income - 100% SSI)
$750 $771
Special Income Level
(Maximum Monthly Income - 300% SSI)
$2,250 $2,313
Maximum Countable Assets $2,000 $2,000
Personal Needs Allowance $50 $50
Surviving Spouse VA
Aid and Attendance Pension Rate
(Source Eff. 12-1)
$1,176 $1,209
 

Medicare Premium Assistance Program (MPAP)

(eff. 4/1 - (See MEPL 124)

QMB Income Standard

(100% FPL plus $20 SS disregard)

2018

2019

Individual $1,032 $
Couple $1,392 $

SLMB Income Standard

(120% FPL plus $20 SS disregard)

2018

2019

Individual $1,234 $
Couple $1,666 $

Qualified Individuals-1

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

2018

2019

Individual $1,386 $
Couple $1,872 $

Qualified Working Disabled Individual
(QWDI) 

(200% FPL plus $20 SS disregard)

2018

2019

Individual $2,030 $
Couple $2,727 $

MPAP Resource Limit

(Not including $1,500 in a designated account for burial funds)

2018

2019

Individual $7,560 $7,560
Couple $11,340 $11,340
 

Medicare

[eff. 1-1]

Part A

2018

2019

Premium
(Monthly - Less than 30 covered quarters)
$422 $437
Premium
(Monthly - 30 to 39 covered quarters & certain others)
$232 $240
Deductible
(Per benefit period)
$1,340 $1,364
Daily Co-Insurance
(Days 0 to 60 per benefit period)
$0 $0
Daily Co-Insurance
(Days 61 to 90 per benefit period)
$335 $341
Daily Co-Insurance
(Days 91 to 150 per benefit period
Lifetime Reserve Days)
$670 $682
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)
$167.50 $170.50

Part B

Non-Income Related or Standard Premium (Monthly)

The standard monthly premium for Medicare Part B enrollees will be $134 for 2018, the same amount as in 2017. However, a statutory “hold harmless” provision applies each year to about 70 percent of enrollees. For these enrollees, any increase in Part B premiums must be lower than the increase in their Social Security benefits. After several years of no or very small increases, Social Security benefits will increase by 2.0 percent in 2018 due to the Cost of Living adjustment. Therefore, some beneficiaries who were held harmless against Part B premiums increases in prior years will have a premium increase in 2018. About 28 percent of all Part B enrollees are subject to the hold harmless provision in 2018 and will pay less than the full monthly premium of $134, because the increase in their Social Security benefit will not be large enough to cover the full Part B premium increase;
Generally, see, 42 U.S.C. 1395r(f); and Medicare 2018 Parts A & B Fact Sheet.

$135.50 Current and new beneficiaries (income up to $85,000)

Part B

Individual tax return with modified adjusted gross income

2018

2019

Income Related Premium (Monthly)

Note: Income related premiums are specifically excluded from SS's hold harmless provision. See Medicare 2018 Parts A & B Fact Sheet.

2017 Individual tax return with modified adjusted gross income ( Medicare 2018 Parts A & B Fact Sheet. )
$187.50
---------------------
$85,001-$107,000
$189.60
---------------------
$85,001-$107,000
Income Related Premium (Monthly)

2017 Individual tax return with modified adjusted gross income
$267.90
---------------------
$107,001-$133,500
$270.90
---------------------
$107,001-$133,500
Income Related Premium (Monthly)

2017 Individual tax return with modified adjusted gross income
  $348.30
---------------------
$133,501-$214,000
$352.20
---------------------
$133,501-$214,000
Income Related Premium (Monthly)

2016 Individual tax return with modified adjusted gross income
$428.60
---------------------
More than $214,000
$428.60
---------------------
More than $214,000

Married Couples Filing Separately

2018

2019

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:

2017 Separate tax return with modified adjusted gross income
$134.00
---------------------
up to $85,000
$135.50
---------------------
up to $85,000
$428.60
---------------------
$85,000 to $415,000
$433.40
---------------------
$85,000 to $415,000

Part B

2018

2019

Deductible (Annual)
(In 2005 this deductible was indexed to the increase
in the average cost of Part B services)
$183 $185
Co-Pay (Per Service) 20% 20%

Medicare Part D

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

Your Plan Premium
---------------------
up to $85,000

Part D

(Source)

2018

2019

Income Related Premium Adjustment (Monthly) (35%)



Individual tax return with modified adjusted gross income
$13.00 + Your Plan Premium
---------------------
$85,001-$107,000
$12.40 + Your Plan Premium
---------------------
$85,001-$107,000
Income Related Premium Adjustment (Monthly) (50%)

Individual tax return with modified adjusted gross income
$33.60 + Your Plan Premium
---------------------
$107,001-$133,500
$31.90 + Your Plan Premium
---------------------
$107,001-$133,500
Income Related Premium Adjustment (Monthly) (65%)

Individual tax return with modified adjusted gross income
$54.20 + Your Plan Premium
---------------------
$133,501-$160,000
$51.40 + Your Plan Premium
---------------------
$133,501-$160,000
Income Related Premium Adjustment (Monthly) (80%)

Individual tax return with modified adjusted gross income
$74.80 + Your Plan Premium
---------------------
$160,001-$500,000
$70.90 + Your Plan Premium
---------------------
$160,001-$500,000

Married Couples Filing Separately

2018

2019

Note:  Couples filing joint returns have twice the above income limits before their Part D 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
Your Plan Premium
---------------------
up to $85,000
Your Plan Premium
---------------------
up to $85,000
Individuals with incomes over $85,000 pay an Income-Related Monthly Adjustment Amount (IRMAA).  $74.80 + Your Plan Premium
---------------------
$85,001-$415,000
$70.90 + Your Plan Premium
---------------------
$85,001-$415,000

Part D Standard Benefit

2018

2019

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)
$35.02 $33.19
Deductible
(Source)
$405 $415
Initial Coverage Limit $3,750 $3,820
Out-of-Pocket Threshold $5,000 $5,100
Total Covered Part D Drug Out-of-Pocket Spending including Coverage Gap to Get to Catastrophic Limit (Source) $7,508.75 $7,653.75
Minimum Cost-Sharing in Catastrophic Coverage Benefit Portion

2018


Greater of 5% or amount below

2019


Greater of 5% or amount below
Generic/Preferred Multi-Source Drug $3.35 $3.40
Other $8.35 $8.50

Part D Low Income Subsidy Eligibility

2018

2019

Ohio Regional Benchmark
[maximum premium subsidy provided to people who get the full Part D low-income subsidy (LIS)/Extra Help] (Source)
$31.95 $32.92
Max Monthly Income Eligibility for Extra Help Program (150% FPL) (includes a $20 SSA income disregard) Single Person $1,538 $
Couples $2,078 $
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] Source
[See, SS POMS Medicare Part D Extra Help]
Single Person $14,100 $14,390
Couples $28,150 $28,720

Part D Full Subsidy Co-Pay


(Source)

2018

2019

Deductible $0 $0
Income <= 100% FPL Generic / Preferred Drugs $1.25 $1.25
Brand Name Drugs $3.70 $3.80
Income > 100% FPL Generic / Preferred Drugs $3.35 $3.40
Brand Name Drugs $8.35 $8.50
Maximum Catastrophic Co-payment $0 $0

Part D Partial Subsidy Co-Pay

2018

2019

Deductible $83 $85
Co-Insurance (Up to Catastrophic) 15% 15%
Catastrophic Co-Pay
(The greater of 5% or chart value. In 2019, co-pay for generic with retail price > $68 is 5%, brand names > $170 is 5%.)
Generic / Preferred Drugs $3.35 $3.40
Brand Name Drugs $8.35 $8.50
 

Supplemental Security Income (SSI)

[eff. 1-1]

Federal Payment Standard

2018

2019

Individual $750 $771
Couple $1,125 $1,157

Resource Limits

2018

2019

Individual $2,000 $2,000
Couple $3,000 $3,000

Substantial Gainful Activity Limit

2018

2019

Non-Blind
(Source)
$1,180 $1,220
Blind
(Source)
$1,970 $2,040
Trial Work Period
(Source)
$850 $880
 

 
 
 
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