Appendix A1 ABD Financial Limits 2005

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

SSI/LA-D

$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

$95,100 + 2000 =

$97,100.00

1-05
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

$579

$869

1-05

B

$386

$579

C

$579

N/A

D

$30

N/A

Medicaid CAP

D

$1737

$3474

1-05

QDWI

A

$3255

$4342

3-05

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

C

$3255

N/A

D

$3255

N/A

QMB

A

$798

$1069

4-05

SLMB

A

$958

$1283

4-05

QI-1

A

$1077

$1443

3-05

$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

$4167.33

4-05
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

$213

$309.67

$289.67

1-05

FBR

$213

$309.67

$289.67

1-05

QMB

N/A

N/A

$356.00

4-05

SLMB

N/A

N/A

$427.66

4-05

QI-1

N/A

N/A

$481.05

3-05
CHART A1.5 - SUBSTANTIAL GAINFUL ACTIVITY
Category Income Limit Effective Date

Non-Blind individuals

$830

1-05

Blind individuals

$1380
CHART A1.6 – BREAK-EVEN POINTS

Living Arrangement

Earned Income

Unearned Income

Effective Date

Individual

Couple

Individual

Couple

A

$1223

$1803

$579

$869

1-05

B

$837

$1223

$386

$579

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: $78.20 (effective 1-05).

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

$2377.50

1-05

Dependent Family Member Need Standard

$1624

4-05
CHART A1.11 – FEDERAL POVERTY LEVEL TABLES FOR MEDICARE PART D - LOW INCOME SUBSIDY
HOUSEHOLD SIZE 100% 135% 140% 145% 150% EFF. DATE

1

$9,570.00

$12,919.50

$13,398.00

$13,876.50

$14,355.00

2005

2

12,830.00

17,320.50

17,962.00

18,603.50

19,245.00

3

16,090.00

21,721.50

22,526.00

23,330.50

24,135.00

4

19,350.00

26,122.50

27,090.00

28,057.50

29,025.00

5

22,610.00

30,523.50

31,654.00

32,784.50

33,915.00

The FPL (100% level) is increased by $3,260 for each additional person in the household.

CHART A1.12 – COSTS AND GUIDELINES FOR RECEIPT OF MEDICARE PART D - LOW INCOME SUBSIDY
Group 1 Group 2 Group 3 Eff. Date

Resource Limit

None

Non Q Track Individual -

$6000

Non Q Track Couple -

$9000

Individual - $10,000 Couple - $20,000

2005

Income Limit

100% of

FPL or full Medicaid

Less than 135% of FPL

Less than 150% of FPL

Monthly

Premium

$0

$0

Sliding Scale

Deductible

Per Year

$0

$0

$50.00

Coinsurance

up to $3600 Out of Pocket

$1 - $3

Copay

$2 - $5 Copay

15% Coinsurance

Catastrophic

5% or $2/$5 Copay

$0

$0

$2 - $5 Copay