Appendix A1 ABD Financial Limits 2004

CHART A1.1 - ABD MEDICAID RESOURCE LIMITS
Type Limit Individual Limit Couple Limit LA-D Individual With a Community Spouse Effective Date

SSI

$2000

$3000

N/A

7-88

AMN

$2000

$4000

N/A

4-90

QMB/SLMB/ QI-1/QDWI

$4000

$6000

N/A

1-89

Spousal Impoverishment

N/A

N/A

$92,760 + 2000 =

$94,760.00

1-04
CHART A1.2 - ABD MEDICAID NET INCOME LIMITS (GROSS - $20)
Type Limit LA Individual Limit Couple Limit Effective Date

AMN

All

$317

$375

10-90

FBR

(SSI Limit)

A

$564

$846

1-04

B

$376

$564

C

$564

N/A

D

$30

N/A

Medicaid CAP

D

$1692

$3384

1-04

QDWI

A

$3169

$4229

3-04

Effective 3-98, ISM no
longer applies to this COA
eliminating LA-B.

C

$3169

N/A

D

$3169

N/A

QMB

A

$776

$1041

4-04

SLMB

A

$931

$1249

4-04

QI-1

A

$1048

$1406

3-04

$600 TA

$12,569.00/yr.

$1047.42/mo.

$16,862.00/yr.

$1405.17/mo.

6/04
CHART A1.3 - TRANSFER OF RESOURCE PENALTY DETERMINATION

Averaging Nursing Home Private Pay Billing Rate

$3860

4-04
CHART A1.4 - PRESUMED MAXIMUM VALUE (PMV) OF ISM AND LIVING ALLOWANCE TO EACH INELIGIBLE CHILD
Income Limit PMV for an Individual PMV for a Couple Living Allowance Effective Date

AMN

$208

$302

$282

1-04

FBR

$208

$302

$282

1-04

QMB

N/A

N/A

$353.61

4-04

SLMB

N/A

N/A

$423

4-04

QI-1

N/A

N/A

$475.05

3-04
CHART A1.5 - SUBSTANTIAL GAINFUL ACTIVITY
Category Income Limit Effective Date

Non-Blind individuals

$810

1-04

Blind individuals

$1350
CHART A1.6 – BREAK-EVEN POINTS

Living Arrangement

Earned Income

Unearned Income

Effective Date

Individual

Couple

Individual

Couple

A

$1193

$1757

$564

$846

1-04

B

$817

$1193

$376

$564

D

$145

$205

$50

$80

7-88
CHART A1.7 – MONTHLY AVERAGED MEDICAID RATES FOR KATIE BECKETT
Level of Care Monthly Amount Effective Date

Skilled Nursing Facility

$3645

11/04

ICF/MR

$6667

A1.8 – MEDICARE EXPENSES

Medicare Part B Premium rate: $66.60 (effective 1-04).

Medicare Approved Drug Discount Card: up to $30 (effective 6/04)

CHART A1.9 - PERSONAL NEEDS ALLOWANCES (PNA) FOR AN LA-D RECIPIENT
IF the LA-D Recipient is THEN use the following as the PNA in the Patient Liability/Cost Share Budget:

an individual in a nursing home or Institutionalized Hospice

$30

Effective 01-92

Effective 04-03

a VA pensioner or his/her surviving spouse in a nursing home who has dependents

$30

Effective 1-92

a VA pensioner or his/her surviving spouse in a nursing home who has no dependents

The VA check for these individuals is reduced to the amount of the PNA, regardless of other income.

$90

Effective 1-92

(Effective 1-93 for the Surviving Spouse)

an individual in CCSP

the current amount of the Individual FBR for LA-A

an individual in ICWP

the current amount of the Community Spouse Maintenance Need Standard

an individual in MRWP

the current Medicaid Cap
CHART A1.10 - NEED STANDARDS FOR DIVERSION OF INCOME TO A COMMUNITY SPOUSE OR DEPENDENT FAMILY MEMBER IN A PATIENT LIABILITY/COST SHARE BUDGET
Diversion Standard Amount Effective Date

Community Spouse Maintenance Need Standard

$2319

1-04

Dependent Family Member Need Standard

$1582

4-04