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	2010
Eff. 7-1 (MEPL 41) (150% FPL for 2)	MMMNA	$ 1,821 (eff. 7/1/09)	$ 1,821 (eff. 7/1/10)
Eff. 1-1 (Indexed to CPI. MEPL 41)	MMMNA Federal Cap	$ 2,739 (eff. 1/1/09)	$ 2,739 (eff. 1/1/10)
Eff. 7-1 (MEPL 41) (30% of MMMNA)	Excess Shelter Standard	$ 547 (eff. 7/1/09)	$ 547 (eff. 7/1/10)
Eff. 7-1 (1/3 MMMNA minus family member's gross income)	Family Allowance	$ 607 (eff. 7/1/09)	$ 607 (eff. 7/1/10)
Eff. 10-1-year (MEPL 41)	Standard Utility Allowance	$ 586 eff. 10/1/09	$ 588 eff. 10/1/10
Eff. varies (MEPL 41)	Average Monthly Private Pay Rate	$ 6,023 (eff. 7/1/09)	$ 6,023
Eff. 1-1 (65% of the special income level)	Special Individual Maintenance Allowance (HCBS Waivers)	$ 1,315	$ 1,315
Eff. 1-1 (300% SSI for 1 living in own HH)	Special Income Level (HCBS Waivers)	$ 2,022	$ 2,022
Eff. 1-1 (100% SSI for 1 living in own HH)	Assisted Living Maintenance Needs Allowance	$ 674	$ 674
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	2010
Eff. 1-1 (Indexed to CPI. MEPL 41)	Spousal Resource Minimum	$ 21,912	$ 21,912
Eff. 1-1 (Indexed to CPI. MEPL 41)	Spousal Resource Maximum	$ 109,560	$ 109,560
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	2010
Individual		$ 1,500	$ 1,500
Couple		$ 2,250	$ 2,250
Medicaid Need Standard (MEPL 41)		2009	2010
Individual (Living Alone)		$ 589	$ 589
Couple (Living Alone)		$ 1,011	$ 1,011
Individual (Living in Household of Another)		$ 393	$ 393
Couple (Living in Household of Another)		$ 674	$ 674
Medicare Buy-In Programs [eff. 4-1]
QMB Income Standard (100% FPL plus $20 SS disregard)		2009	2010
Individual		$ 923	$ 923
Couple		$ 1,235	$1,235
SLMB Income Standard (120% FPL plus $20 SS disregard)		2009	2010
Individual		$ 1,103	$ 1,103
Couple		$ 1,477	$ 1,477
Qualified Individuals-1 (QI-1) (135% FPL plus $20 SS disregard)		2009	2010
Individual		$ 1,239	$ 1,239
Couple		$ 1,660	$ 1,660
Qualified Working Disabled Individual (QWDI) (200% FPL plus $20 SS disregard)		2009	2010
Individual		$ 1,826	$ 1,826
Couple		$ 2,448	$ 2,448
QMB/SLMB Resource Standard		2009	2010
Individual		$ 4,000	$ 4,000
Couple		$ 6,000	$ 6,000
Medicare [eff. 1-1]
Part A		2009	2010
Premium (Monthly - Less than 30 covered quarters)		$ 443	$ 461
Premium (Monthly - 30 to 39 covered quarters & certain others)		$ 244	$ 254
Deductible (Per benefit period)		$ 1,068	$ 1,100
Co-Pay (Days 0 to 60 per benefit period)		$ 0	$ 0
Co-Pay (Days 61 to 90 per benefit period)		$ 267	$ 275
Co-Pay (Days 91 to 150 per benefit period Lifetime Reserve Days)		$ 534	$ 550
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	$ 137.50
Part B No 2010 premium increase. See SS's hold harmless provision 42 U.S.C. 1395r(f)	2009	2010 Enrolled before 11-1-2009	2010 Enrolled on or after 11-1-2009
Premium (Monthly) ----------------------------- Individual tax return with income	$ 96.40 --------------------- up to $85,000	$ 96.40 --------------------- up to $85,000	$ 110.50 --------------------- up to $85,000
Premium (Monthly) ----------------------------- Individual tax return with income	$ 134.90 --------------------- $85,001-$107,000	$ 134.90 --------------------- $85,001-$107,000	$ 154.70 --------------------- $85,001-$107,000
Premium (Monthly) ----------------------------- Individual tax return with income	$ 192.70 --------------------- $107,001-$160,000	$ 192.70 --------------------- $107,001-$160,000	$ 221 --------------------- $107,001-$160,000
Premium (Monthly) ----------------------------- Individual tax return with income	$ 250.50 --------------------- $160,001-$214,000	$ 250.50 --------------------- $160,001-$214,000	$ 287.30 --------------------- $160,001-$214,000
Premium (Monthly) ----------------------------- Individual tax return with income	$ 308.30 --------------------- More than $214,000	$ 308.30 --------------------- More than $214,000	$ 353.60 --------------------- More than $214,000
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 & $129,000 pay $250.50 and those with incomes over $129,000 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	$ 155
Co-Pay (Per Service)		20%	20%
Part D http://www.kff.org/medicare/upload/7327-05.pdf		2009	2010
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 > 2010 > Regional rates and benchmarks 2010]		$ 28.40	$ 30.47
National Average Monthly Part D Beneficiary Premium		$ 28.40	$ 31.94
Deductible		$ 295	$ 310
Initial Coverage Limit		$ 2,700	$ 2,830
Out-of-Pocket Threshold		$ 4,350	$4,554
Total Covered Part D Drugs to Get to Catastrophic Limit		$ 6,153.75	$ 6,440
Part D Low Income Subsidy Eligibility		2009	2010
Max Monthly Income Eligibility for Extra Help Program (150% FPL)	Single Person	$ 1,355	$ 1,355
	Couples	$ 1,821	$ 1,821
Max Resource Eligibility for Extra Help Program [Indexed to CPI] [See, SocialSecurity.gov]	Single Person	$ 12,510	$ 12,510
	Couples	$ 25,010	$ 25,010
Part D Full Subsidy Co-Pay See Chart		2009	2010
Deductible		$ 0	$ 0
Income <= 100% FPL	Generic / Preferred Drugs	$ 1.10	$ 1.10
Income <= 100% FPL	Brand Name Drugs	$ 3.20	$ 3.30
Income > 100% FPL	Generic / Preferred Drugs	$ 2.40	$ 2.50
Income > 100% FPL	Brand Name Drugs	$ 6.00	$ 6.30
Part D Partial Subsidy Co-Pay		2009	2010
Deductible		$ 60	$ 63
Co-Insurance (Up to Catastrophic)		15%	15%
Catastrophic Co-Pay	Generic / Preferred Drugs	$ 2.40	$ 2.50
Catastrophic Co-Pay	Brand Name Drugs	$ 6.00	$ 6.30
Supplemental Security Income (SSI) [eff. 1-1]
Federal Payment Standard		2009	2010
Individual		$ 674	$ 674
Couple		$ 1,011	$ 1,011
Resource Limits		2009	2010
Individual		$ 2,000	$ 2,000
Couple		$ 3,000	$ 3,000
Substantial Gainful Activity Limit [Non-Blind]		$ 980	$ 1,000

Links
For 2010 Medicare Changes Click Here
For 2010 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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