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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

2016 2017
Eff. 7-1 (See Medicaid Eligibility Procedure Letter (MEPL) 121)
(150% FPL for 2) (Eff. 2nd qtr. after new FPL per 42 USC 1396r-5(d)(3)(A))
MMMNA $2,003
(eff. 7/1/16)
$2030
(eff. 7/1/17)
Eff. 1-1
(Indexed to CPI. 2017 CPI increase: 0.3% MEPL 106)
MMMNA Federal Cap $2,981
(eff. 1/1/16)
$3,023
(eff. 1/1/17)
Eff. 7-1 (MEPL 114)
(30% of MMMNA) (Eff. 2nd qtr. after new FPL per 42 USC 1396r-5(d)(3)(A))
Excess Shelter Standard $601
(eff. 7/1/16)
$609
(eff. 7/1/17)
Eff. 7-1
(1/3 MMMNA minus family member's gross income)
Family Allowance $668
(eff. 7/1/16)
$677
(eff. 7/1/17)
Eff. 10-1
(MEPL 127)
Standard Utility Allowance $513
eff. 10/1/16
$530
eff. 10/1/17
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 121)
(65% of the special income level)
Special Individual Maintenance Allowance
(Used to determine HCBS waiver patient liability )
$1,430
(eff. 1/1/16)
$1,434
(eff. 1/1/17)
Eff. 1-1 (MEPL 121)
(300% SSI for 1 living in own HH)
Special Income Level
(Institutional Medicaid income eligibility)
$2,199
(eff. 1/1/16)
$2,205
(eff. 1/1/17)
Eff. 1-1 (MEPL 121)
(100% SSI for 1 living in own HH)
Assisted Living Maintenance Needs Allowance $733
(eff. 1/1/16)
$735
(eff. 1/1/17)
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)

2016 2017
Eff. 1-1
(Indexed to CPI. MEPL 121)
Spousal Resource Minimum $ 23,844 $24,180
Eff. 1-1
(Indexed to CPI. MEPL 121)
Spousal Resource Maximum $119,220 $120,900
Eff. 1-1
(Indexed to CPI. MEPL 121)
Home Equity Limit $552,000 $560,000
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 Personal Needs Allowance $50
($30 - SSI)
($90 - VA)
$ 50
($30 - SSI)
($90 - VA)
 

Community Medicaid [eff. 1-1]

Resource Standard

2016 2017
Individual $2,000 $2,000
Couple $3,000 $3,000

Medicaid Need Standards (MEPL 121)

2016 2017
Individual (Living Alone) $733 $735
Couple (Living Alone) $1,100 $1,103
Individual (Living in Household of Another) $489 $490
Couple (Living in Household of Another) $734 $736
 

Assisted Living Waiver

  2016 2017
Maintenance Needs Allowance
(Minimum Monthly Income - 100% SSI)
$733 $735
Special Income Level
(Maximum Monthly Income - 300% SSI)
$2,199 $2,205
Maximum Countable Assets $2,000 $2,000
Personal Needs Allowance $50 $50
Surviving Spouse VA
Aid and Attendance Pension Rate
(Source)
$1,149 $1,153
 

Medicare Premium Assistance Program (MPAP)

(eff. 3/1 - (See MEPL 110)

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

2016 2017
Individual $1,010 $1,025
Couple $1,355 $1,373

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

2016 2017
Individual $1,208 $1,226
Couple $1,622 $1,644

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

2016 2017
Individual $1,357 $1,378
Couple $1,823 $1,848

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

2016 2017
Individual $2,000 $2,030
Couple $2,690 $2,727

MPAP Resource Limit

2016 2017
Individual $7,280 $7,390
Couple $10,930 $11,090
 

Medicare

[eff. 1-1]

Part A

2016 2017
Premium
(Monthly - Less than 30 covered quarters)
$411 $413
Premium
(Monthly - 30 to 39 covered quarters & certain others)
$226 $227
Deductible
(Per benefit period)
$1,288 $1,316
Daily Co-Insurance
(Days 0 to 60 per benefit period)
$0 $0
Daily Co-Insurance
(Days 61 to 90 per benefit period)
$322 $329
Daily Co-Insurance
(Days 91 to 150 per benefit period
Lifetime Reserve Days)
$644 $658
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)
$161 $183

Part B

Non-Income Related or Standard Premium (Monthly)

Due to Social Security COLA of 0.3% in 2017, SS's hold harmless provision applies to create different premium amounts for new beneficiaries;
Generally, if SS COLA increase of 0.3%, then Part B premium increase is also limited to 0.3% for current beneficiaries.See 42 U.S.C. 1395r(f)

Individual tax return with modified adjusted gross income

$109.00 Current beneficiaries

$134.00 New beneficiaries (income up to $85,000)

Part B (See Issue Brief)

2016 2017
Income Related Premium (Monthly)

Note: Income related premiums are specifically excluded from SS's hold harmless provision. See MedicareAdvocacy.org

2015 Individual tax return with modified adjusted gross income (Source)
$170.50

$85,001-$107,000
$187.50

$85,001-$107,000
Income Related Premium (Monthly)

2015 Individual tax return with modified adjusted gross income
$243.60

$107,001-$160,000
$267.90

$107,001-$160,000
Income Related Premium (Monthly)

2015 Individual tax return with modified adjusted gross income
  $316.70

$160,001-$214,000
$348.30

$160,001-$214,000
Income Related Premium (Monthly)

2015 Individual tax return with modified adjusted gross income
$389.80

More than $214,000
$428.60

More than $214,000

Married Couples Filing Separately

2016 2017
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:

2015 Separate tax return with modified adjusted gross income
$316.70

$85,001-$129,000
$348.30
---------------------
$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. $389.80

More than $129,000
$428.60

More than $129,000

Part B

2016 2017
Deductible (Annual)
(In 2005 this deductible was indexed to the increase
in the average cost of Part B services)
$166 $183
Co-Pay (Per Service) 20% 20%

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

$0

up to $85,000

Part D (See Issue Brief)

2016 2017
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 (Source)
$12.70

$85,001-$107,000
$13.30

$85,001-$107,000
Income Related Premium Adjustment (Monthly) (50%)

Individual tax return with modified adjusted gross income
$32.80

$107,001-$160,000
$34.20

$107,001-$160,000
Income Related Premium Adjustment (Monthly) (65%)

Individual tax return with modified adjusted gross income
$52.80

$160,001-$214,000
$55.20

$160,001-$214,000
Income Related Premium Adjustment (Monthly) (80%)

Individual tax return with modified adjusted gross income
$72.90

More than $214,000
$76.20

More than $214,000

Married Couples Filing Separately

2016 2017
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
$52.80

$85,001-$129,000
$55.20

$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) $72.90

More than $129,000
$76.20

More than $129,000

Part D Standard Benefit /h3>

2016 2017
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)
$34.10 $35.63
Deductible
(Source)
$360 $400
Initial Coverage Limit $3,310 $3,700
Out-of-Pocket Threshold $4,850 $4,950
Total Covered Part D Drugs to Get to
Catastrophic Limit
(Source)
$7,062 $7,425
Minimum Cost-Sharing in Catastrophic Coverage Benefit Portion 2016
Greater of 5% or amount below
2017
Greater of 5% or amount below
Generic/Preferred Multi-Source Drug $2.95 $3.30
Other $7.40 $8.25

Part D Low Income Subsidy Eligibility

2016 2017
Ohio Regional Benchmark
[maximum premium subsidy provided to people who get the full Part D low-income subsidy (LIS)/Extra Help] (Source)
$29.52 $32.30
Max Monthly Income Eligibility for Extra Help Program (150% FPL) Single Person $1,485 $1,508
Couples $2,003 $2,030
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 $13,640 $13,820
Couples $27,250 $27,600

Part D Full Subsidy Co-Pay
(Source)

2016 2017
Deductible $0 $0
Income <= 100% FPL Generic / Preferred Drugs $1.20 $1.20
Brand Name Drugs $3.60 $3.70
Income > 100% FPL Generic / Preferred Drugs $2.95 $3.30
Brand Name Drugs $7.40 $8.25
Maximum Catastrophic Co-payment $0 $0

Part D Partial Subsidy Co-Pay

2016 2017
Deductible $74 $82
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 $2.95 $3.30
Brand Name Drugs $7.40 $8.25
 

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

Federal Payment Standard

2016 2017
Individual $733 $735
Couple $1,100 $1,103

Resource Limits

2016 2017
Individual $2,000 $2,000
Couple $3,000 $3,000

Substantial Gainful Activity Limit

2016 2017
Non-Blind
(Source)
$1,130 $1,170
Blind
(Source)
$1,820 $1,950
Trial Work Period
(Source)
$810 $840
 

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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