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

(Source: MEPL 170)

2024

2023

Eff. 7-1 (See Medicaid Eligibility Procedure Letter (MEPL) 177)
(150% FPL for 2) (Eff. 2nd qtr. after new FPL per 42 USC 1396r-5(d)(3)(A))
MMMNA Standard $0.00
(eff. 7/1/24)
$2,465
(eff. 7/1/23)
Eff. 1-1
(Indexed to CPI.)
MMMNA Federal Cap $3,853.50
(eff. 1/1/24)
$3,715.50
(eff. 1/1/23)
Eff. 7-1
(30% of MMMNA) (Eff. 2nd qtr. after new FPL per 42 USC 1396r-5(d)(3)(A))
Excess Shelter Allowance (ESA)Standard $0.00
(eff. 7/1/24)
$739.50
(eff. 7/1/23)
Eff. 7-1
(1/3 MMMNA minus family member's gross income)
Family Allowance $0.00
(eff. 7/1/24)
$823
(eff. 7/1/23)
Eff. 10-1
(MEPL 176)
Standard Utility Allowance $0.00
(eff. 10/1/24)
$724
(eff. 10/1/23)
Eff. date varies; See (MEPL 168)
Average Monthly Private Pay Rate $7,453
(eff. 9/1/22)
$7,453
(eff. 9/1/22)
Eff. 1-1
(65% of the special income level)
Special Individual Maintenance Needs Allowance (SIMNA)
(Used to determine HCBS waiver patient liability )
$1,839
(eff. 1/1/24)
$1,783
(eff. 1/1/23)
Eff. 1-1
(300% SSI for 1 living in own HH)
Special Income Level
(Institutional Medicaid income eligibility)
$2,829
(eff. 1/1/24)
$2,742
(eff. 1/1/23)
Eff. 1-1
(100% SSI for 1 living in own HH)
Assisted Living Maintenance Needs Allowance $943
(eff. 1/1/24)
$914
(eff. 1/1/23)
Eff. 7-16-2021
PASSPORT Eligibility
Individual Monthly Cost Limit*
$14,700 $14,700
* A PASSPORT eligibility criteria is that the waiver service monthly cost of the service plan cannot exceed $14,700. See OAC 5160-31-03(A)(2).

Community Spouse Resource Allowance (CSRA)

(Indexed to CPI; MEPL 177)

2024

2023

Eff. 1-1
Spousal Resource Minimum $ 30,828 $29,724
Eff. 1-1
Spousal Resource Maximum $154,140 $148,620
Eff. 1-1
Home Equity Limit - Maximum $713,000 $688,000
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 177) Personal Needs Allowance $50
($30 - SSI)
($90 - VA)
$ 50
($30 - SSI)
($90 - VA)
 

Community Medicaid

[eff. 1-1]

Resource Standard

2024

2023

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

Medicaid Need Standards

(MEPL 177)

2024

2023

Individual (Living Alone) $943 $914
Couple (Living Alone) $1,415 $1,371
Individual (Living in Household of Another) $629 $610
Couple (Living in Household of Another) $943 $914

MAGI Medicaid Need Standards

(Non-Medicare-eligible Medicaid Expansion Adults up to 138% of the FPL, includes a 5% disregard) (Source) and (MEPL 179). See also Yearly Guidelines and Thresholds ; Medicaid Household Rules; and The NHeLP MAGI Guide

2024

2023

Individual $1,732 $1,677
Couple $2,350 $2,268
 

Assisted Living Waiver

 

2024

2023

Maintenance Needs Allowance
(ALMNA) (MEPL 177)
(Minimum Monthly Income - 100% SSI)
$943 $914
Special Income Level
(Maximum Monthly Income - 300% SSI)
$2,829 $2,742
Maximum Countable Assets $2,000 $2,000
Personal Needs Allowance $50 $50
Surviving Spouse VA
Aid and Attendance Maximum Monthly Pension Rate
(Source Eff. 12-1)
$1,479 $1,433
 

Medicare Premium Assistance Program (MPAP)

(eff. 3/1 - (See MEPL 179)

QMB Income Standard

(100% FPL plus $20 SS disregard)

2024

2023

Individual $1,275 $1,235
Couple $1,724 $1,663

SLMB Income Standard

(120% FPL plus $20 SS disregard)

2024

2023

Individual $1,526 $1,478
Couple $2,065 $1,992

Qualified Individuals-1

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

2024

2023

Individual $1,714 $1,660
Couple $2,320 $2,239

Qualified Working Disabled Individual
(QWDI) 

(200% FPL plus $20 SS disregard)

2024

2023

Individual $2,530 $2,450
Couple $3,427 $3,307

MPAP Resource Limit

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

2024

2023

Individual $9,430 $9,090
Couple $14,130 $13,630
 

Medicare

[eff. 1-1] See Medicare 2024 Parts A & B Fact Sheet.

Part A

2024

2023

Premium
(Monthly - Less than 30 covered quarters)
$505 $506
Premium
(Monthly - 30 to 39 covered quarters & certain others)
$278 $278
Deductible
(Per benefit period)
$1,632 $1,600
Daily Co-Insurance
(Days 0 to 60 per benefit period)
$0 $0
Daily Co-Insurance
(Days 61 to 90 per benefit period)
$408 $400
Daily Co-Insurance
(Days 91 to 150 per benefit period
Lifetime Reserve Days)
$816 $800
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)
$204 $200

Part B

Non-Income Related or Standard Premium (Monthly)

The standard monthly premium for Medicare Part B enrollees will be $174.70 for 2024. 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 last year's very large increase, Social Security benefits will increase by 3.2 percent in 2024 due to the Cost of Living adjustment. Therefore, some beneficiaries who were held harmless against Part B premiums increases in prior years will do so again in 2023. About 28 percent of all Part B enrollees were subject to the hold harmless provision in 2021 and paid less than the full monthly premium of $174.70, because the increase in their Social Security benefit was not large enough to cover the full Part B premium increase;
Generally, see, 42 U.S.C. 1395r(f); and Medicare 2023 Parts A & B Fact Sheet. ; and SSA COLA Information.

$174.70 Current and new beneficiaries (income up to $103,000)

Part B

Individual tax return with modified adjusted gross income

2024

2023

Income Related Premium (Monthly)

Note: Income related premiums are specifically excluded from SS's hold harmless provision. See Medicare 2024 Parts A & B Fact Sheet.

2021 Individual tax return with modified adjusted gross income ( Medicare 2024 Parts A & B Fact Sheet. )
$244.60
---------------------
$103,001-$129,000
$230.80
---------------------
$97,001-$123,000
Income Related Premium (Monthly)

2021 Individual tax return with modified adjusted gross income
$349.40
---------------------
$129,001-$161,000
$329.70
---------------------
$123,001-$153,000
Income Related Premium (Monthly)

2022 Individual tax return with modified adjusted gross income
  $454.20
---------------------
$1612,001-$193,000
$428.60
---------------------
$153,001-$183,000
Income Related Premium (Monthly)

2022 Individual tax return with modified adjusted gross income
$559.00
---------------------
More than $193,000 and less than $500,000
$527.50
---------------------
More than $183,000 and less than $500,000

Married Couples Filing Separately

2024

2023

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:

2022 Separate tax return with modified adjusted gross income
$174.70
---------------------
up to $103,000
$164.90
---------------------
up to $97,000
$559.00
---------------------
$103,000 to $397,000
$527.50
---------------------
$97,001 to $403,000

Part B

2024

2023

Deductible (Annual)
(In 2005 this deductible was indexed to the increase
in the average cost of Part B services)
$240 $226
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 $103,000

Part D

See Medicare 2024 Parts A & B Fact Sheet.

2024

2023

Income Related Premium Adjustment (Monthly) (35%)



Individual tax return with modified adjusted gross income
$12.90 + Your Plan Premium
---------------------
$103,001-$129,000
$12.20 + Your Plan Premium
---------------------
$97,001-$123,000
Income Related Premium Adjustment (Monthly) (50%)

Individual tax return with modified adjusted gross income
$33.30 + Your Plan Premium
---------------------
$129,001-$161,000
$31.50 + Your Plan Premium
---------------------
$123,001-$153,000
Income Related Premium Adjustment (Monthly) (65%)

Individual tax return with modified adjusted gross income
$53.80 + Your Plan Premium
---------------------
$161,001-$193,000
$50.70 + Your Plan Premium
---------------------
$153,001-$183,000
Income Related Premium Adjustment (Monthly) (80%)

Individual tax return with modified adjusted gross income
$74.20 + Your Plan Premium
---------------------
$193,001-$500,000
$70.00 + Your Plan Premium
---------------------
$183,001-$500,000

Married Couples Filing Separately

2024

2023

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 $103,000
Your Plan Premium
---------------------
up to $97,000
Individuals with incomes over $97,000 pay an Income-Related Monthly Adjustment Amount (IRMAA).  $74.20 + Your Plan Premium
---------------------
$103,001-$397,000
$70.00 + Your Plan Premium
---------------------
$97,001-$403,000

Part D Standard Benefit

2024

2023

National Base
Beneficiary Premium
[Part D late-enrollment penalty premium is 1% of the base beneficiary premium amount, multiplied by the number of penalty months] (Source)
$34.70 $32.74
Deductible
(Source)
$545 $505
Initial Coverage Limit $5,030 $4,660
Out-of-Pocket Threshold $8,000 $7,400
Total Covered Part D Drug Spending, including Coverage Gap, to Get to Catastrophic Limit (Source) $12,447 $11,206
Cost-Sharing in Catastrophic Coverage Benefit

2024


2024 change: No copayment or coinsurance for covered Part D drugs for the rest of the calendar year

2023


Greater of 5% or amount below
Generic/Preferred Multi-Source Drug $0.00 $4.15
Other $0.00 $10.35

Part D Low Income Subsidy Eligibility

2024

2023

Ohio Regional Benchmark
[maximum premium subsidy provided to people who get the full Part D low-income subsidy (LIS)/Extra Help] (Source)
$40.87 $34.71
Max Monthly Income Eligibility for Extra Help Program (150% FPL) (includes a $20 SSA income disregard) Single Person $1,903 $1,843
Couples $2,576 $2,485
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 $17,220 $16,660
Couples $34,360 $32,240

Part D Full Benefit Dual Eligible Beneficiaries


(Source)

2024

2023

Deductible $0 $0
Income <= 100% FPL Generic / Preferred Drugs $1.55 $1.45
Brand Name Drugs $4.60 $4.30
Income Between 100% & 150% FPL Generic / Preferred Drugs $4.50 $4.15
Brand Name Drugs $11.20 $10.35
Institutionalized or Receiving Home & Community Based Services - All Drugs $0 $0

Non-Full Benefit Dual Eligible Beneficiaries

2024

2023

Deductible $0.00 $104
Non-Full Benefit Dual Eligible Beneficiaries
(Eligible for MPAP, QMB-Only, SLMB-Only, QI or SSI (but not Medicaid; or income less than 150% FPL & Resource Eligible.)
Generic / Preferred Drugs $4.50 $4.15
Brand Name Drugs $11.20 $10.35
 

Supplemental Security Income (SSI)

[eff. 1-1]

Federal Payment Standard

2024

2023

Individual $943 $914
Couple $1,415 $1,371

Resource Limits

2024

2023

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

Substantial Gainful Activity Limit

2024

2023

Non-Blind
(Source)
$1,550 $1,470
Blind
(Source)
$2,590 $2,460
Trial Work Period
(Source)
$1,110 $1,050