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 Helpline 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 Ohio’s Medicare Premium Assistance Programs (MPAP)
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)
Fact Sheets
For more general information regarding Medicare and Medicaid see our complete list of fact sheet titles. Pro Seniors provides legal fact sheets on a variety of subjects. Single copies are available to individuals free of charge. Contact Pro Seniors, Inc. and we will mail the fact sheets 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 |
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Spousal Impoverishment Standards & Allowances(Source: MEPL 184) |
2024 |
2025 |
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Eff. 7-1 (See Medicaid Eligibility Procedure Letter (MEPL) 184) (150% FPL for 2) (Eff. 2nd qtr. after new FPL per 42 USC 1396r-5(d)(3)(A)) |
MMMNA Standard |
$2,550 (eff. 7/1/24) |
$ (eff. 7/1/25) |
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Eff. 1-1 (Indexed to CPI.) |
MMMNA Federal Cap |
$3,853.50 (eff. 1/1/24) |
$3,948 (eff. 1/1/25) |
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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 |
$766.50 (eff. 7/1/24) |
$ (eff. 7/1/25) |
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Eff. 7-1 (1/3 MMMNA minus family member's gross income) |
Family Allowance |
$850 (eff. 7/1/24) |
$ (eff. 7/1/25) |
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Eff. 10-1 (MEPL 183) |
Standard Utility Allowance |
$746 (eff. 10/1/24) |
$ (eff. 10/1/25) |
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Eff. date varies; See (MEPL 181) |
Average Monthly Private Pay Rate |
$7,787 (eff. 9/1/24) |
$7,787 (eff. 9/1/24) |
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| 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) |
$1,886 (eff. 1/1/25) |
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Eff. 1-1
(300% SSI for 1 living in own HH) |
Special Income
Level (SIL) (Institutional Medicaid income eligibility) |
$2,829 (eff. 1/1/24) |
$2,901 (eff. 1/1/25) |
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Eff. 1-1
(100% SSI for 1 living in own HH) |
Assisted Living Maintenance Needs Allowance (ALMNA) |
$943 (eff. 1/1/24) |
$967 (eff. 1/1/25) |
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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 184) |
2024 |
2025 |
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Eff. 1-1 |
Spousal Resource Minimum | $ 30,828 | $31,584 | |
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Eff. 1-1 |
Spousal Resource Maximum | $154,140 | $157,920 | |
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Eff. 1-1 |
Home Equity Limit - Maximum | $713,000 | $730,000 | |
| 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 184) | Personal Needs Allowance |
$50 ($30 - SSI) ($90 - VA) |
$ 50 ($30 - SSI) ($90 - VA) |
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Community Medicaid[eff. 1-1] |
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Resource Standard |
2024 |
2025 |
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| Individual | $2,000 | $2,000 | ||
| Couple | $3,000 | $3,000 | ||
Medicaid Need Standards(MEPL 184) |
2024 |
2025 |
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| Individual (Living Alone) | $943 | $967 | ||
| Couple (Living Alone) | $1,415 | $1,450 | ||
| Individual (Living in Household of Another) | $629 | $645 | ||
| Couple (Living in Household of Another) | $943 | $967 | ||
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 |
2025 |
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| Individual | $1,732 | $ | ||
| Couple | $2,350 | $ | ||
Assisted Living Waiver |
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2024 |
2025 |
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Maintenance Needs Allowance (ALMNA) (MEPL 184) (Minimum Monthly Income - 100% SSI) |
$943 | $967 | ||
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Special Income Level (Maximum Monthly Income - 300% SSI) |
$2,829 | $2,901 | ||
| Maximum Countable Assets | $2,000 | $2,000 | ||
| Personal Needs Allowance | $50 | $50 | ||
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Surviving Spouse VA Aid and Attendance Maximum Monthly Pension Rate (Source Eff. 12-1) |
$1,479 | $1,516 | ||
Medicare Premium Assistance Program (MPAP)(eff. 3/1 - (See MEPL 179) |
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QMB Income Standard
(100% FPL plus $20 SS disregard) |
2024 |
2025 |
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| Individual | $1,275 | $ | ||
| Couple | $1,724 | $ | ||
SLMB Income Standard(120% FPL plus $20 SS disregard) |
2024 |
2025 |
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| Individual | $1,526 | $ | ||
| Couple | $2,065 | $ | ||
Qualified
Individuals-1
(QI-1) (135% FPL plus $20 SS disregard) |
2024 |
2025 |
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| Individual | $1,714 | $ | ||
| Couple | $2,320 | $ | ||
Qualified Working Disabled Individual (200% FPL plus $20
SS disregard) |
2024 |
2025 |
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| Individual | $2,530 | $ | ||
| Couple | $3,427 | $ | ||
MPAP Resource Limit(Not including $1,500 in a designated account for burial funds) |
2024 |
2025 |
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| Individual | $9,430 | $9,660 | ||
| Couple | $14,130 | $14,470 | ||
Medicare[eff. 1-1] See Medicare 2025 Parts A & B Fact Sheet. |
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Part A |
2024 |
2025 |
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Premium
(Monthly - Less than 30 covered quarters) |
$505 | $518 | ||
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Premium (Monthly - 30 to 39 covered quarters & certain others) |
$278 | $285 | ||
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Deductible
(Per benefit period) |
$1,632 | $1,676 | ||
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Daily Co-Insurance (Days 0 to 60 per benefit period) |
$0 | $0 | ||
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Daily Co-Insurance (Days 61 to 90 per benefit period) |
$408 | $419 | ||
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Daily Co-Insurance (Days 91 to 150 per benefit period Lifetime Reserve Days) |
$816 | $838 | ||
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Skilled Nursing Facility Co-insurance (Days 0 to 20 per benefit period) |
$0 | $0 | ||
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Skilled Nursing Facility Co-insurance (Days 21 to 100 per benefit period) |
$204 | $209.50 | ||
Part B |
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Non-Income Related or Standard Premium (Monthly) The standard monthly premium for Medicare Part B enrollees will be $185.00 for 2025. 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 2.5 percent in 2025 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 2025. 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, 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 2025 Parts A & B Fact Sheet. ; and SSA COLA Information. |
$185.00 Current and new beneficiaries (income up to $106,000) |
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Part BIndividual tax return with modified adjusted gross income |
2024 |
2025 |
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Income
Related Premium (Monthly) Note: Income related premiums are specifically excluded from SS's hold harmless provision. See Medicare 2025 Parts A & B Fact Sheet. 2023 Individual tax return with modified adjusted gross income ( Medicare 2025 Parts A & B Fact Sheet. ) |
$244.60 --------------------- $103,001-$129,000 |
$259.00 --------------------- $106,001-$133,000 |
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Income Related Premium (Monthly) 2023 Individual tax return with modified adjusted gross income |
$349.40 --------------------- $129,001-$161,000 |
$370.00 --------------------- $133,001-$167,000 |
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Income
Related Premium (Monthly) 2023 Individual tax return with modified adjusted gross income |
$454.20 --------------------- $161,001-$193,000 |
$480.90 --------------------- $167,001-$200,000 |
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Income Related Premium (Monthly) 2023 Individual tax return with modified adjusted gross income |
$559.00 --------------------- More than $193,000 and less than $500,000 |
$591.90 --------------------- More than $200,000 and less than $500,000 |
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Married Couples Filing Separately |
2024 |
2025 |
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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: 2023 Separate tax return with modified adjusted gross income |
$174.70 --------------------- up to $103,000 |
$185.00 --------------------- up to $106,000 |
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$559.00 --------------------- $103,000 to $397,000 |
$591.80 --------------------- $106,001 to $394,000 |
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Part B |
2024 |
2025 |
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Deductible (Annual) (In 2005 this deductible was indexed to the increase in the average cost of Part B services) |
$240 | $257 | ||
| Co-Pay (Per Service) | 20% | 20% | ||
Medicare Part D |
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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 $106,000 |
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Part DSee Medicare 2025 Parts A & B Fact Sheet. |
2024 |
2025 |
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Income Related Premium Adjustment (Monthly) (35%) Individual tax return with modified adjusted gross income |
$12.90 + Your Plan Premium --------------------- $103,001-$129,000 |
$13.70 + Your Plan Premium --------------------- $106,001-$133,000 |
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Income Related Premium Adjustment (Monthly) (50%) Individual tax return with modified adjusted gross income |
$33.30 + Your Plan Premium --------------------- $129,001-$161,000 |
$35.30 + Your Plan Premium --------------------- $133,001-$167,000 |
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Income Related Premium Adjustment (Monthly) (65%) Individual tax return with modified adjusted gross income |
$53.80 + Your Plan Premium --------------------- $161,001-$193,000 |
$57.00 + Your Plan Premium --------------------- $167,001-$200,000 |
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Income Related Premium Adjustment (Monthly)
(80%) Individual tax return with modified adjusted gross income |
$74.20 + Your Plan Premium --------------------- $193,001-$500,000 |
$78.60 + Your Plan Premium --------------------- $200,001-$500,000 |
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Married Couples Filing Separately |
2024 |
2025 |
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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 $106,000 |
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| Individuals with incomes over $106,000 pay an Income-Related Monthly Adjustment Amount (IRMAA). |
$74.20 + Your Plan Premium --------------------- $103,001-$397,000 |
$78.60 + Your Plan Premium --------------------- $106,001-$394,000 |
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Part D Standard Benefit |
2024 |
2025 |
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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 | $36.78 | ||
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Deductible (Source) |
$545 | $590 | ||
| Out-of-Pocket Spending Cap (Donut hole exit point, based on enrollee's drug cost.) | $3,000 | $2,000 | ||
| Out-of-Pocket Spending Cap (Donut hole exit point, based on retail drug cost.) | $8,000 | $6,230 | ||
| Total Covered Part D Drug Spending, including Coverage Gap, to Get to Catastrophic Limit (Source) | $12,447 | $8,590 | ||
| Cost-Sharing in Catastrophic Coverage Benefit |
20242024 change: No copayment or coinsurance for covered Part D drugs for the rest of the calendar year |
2025No copayment or coinsurance for covered Part D drugs for the rest of the calendar year |
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| Generic/Preferred Multi-Source Drug | $0.00 | $0.00 | ||
| Other | $0.00 | $0.00 | ||
Part D Low Income Subsidy Eligibility |
2024 |
2025 |
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Ohio
Regional Benchmark [maximum premium subsidy provided to people who get the full Part D low-income subsidy (LIS)/Extra Help] (Source) |
$40.87 | $39.30 | ||
| Max Monthly Income Eligibility for Extra Help Program (150% FPL) (includes a $20 SSA income disregard) | Single Person | $1,903 | $ | |
| Couples | $2,576 | $ | ||
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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 | $17,600 | |
| Couples | $34,360 | $35,130 | ||
Part D Full Benefit Dual Eligible Beneficiaries(Source) |
2024 |
2025 |
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| Deductible | $0 | $0 | ||
| Income <= 100% FPL | Generic / Preferred Drugs | $1.55 | $1.60 | |
| Brand Name Drugs | $4.60 | $4.80 | ||
| Income Between 100% & 150% FPL | Generic / Preferred Drugs | $4.50 | $4.90 | |
| Brand Name Drugs | $11.20 | $12.15 | ||
| Institutionalized or Receiving Home & Community Based Services - All Drugs | $0 | $0 | ||
Non-Full Benefit Dual Eligible Beneficiaries |
2024 |
2025 |
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| Deductible | $0.00 | $0.00 | ||
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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 | $4.90 | |
| Brand Name Drugs | $11.20 | $12.15 | ||
Supplemental Security Income (SSI)[eff. 1-1] |
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Federal Payment Standard |
2024 |
2025 |
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| Individual | $943 | $967 | ||
| Couple | $1,415 | $1,450 | ||
Resource Limits |
2024 |
2025 |
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| Individual | $2,000 | $2,000 | ||
| Couple | $3,000 | $3,000 | ||
Substantial Gainful Activity Limit |
2024 |
2025 |
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Non-Blind (Source) |
$1,550 | $1,620 | ||
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Blind (Source) |
$2,590 | $2,700 | ||
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Trial Work Period (Source) |
$1,110 | $1,160 | ||
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