Appendix A1 ABD Financial Limits 2009

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

$109,560 + 2000 =

$111,560.00

1-09
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

$674

$1011

1-09

B

$449.34

$674.00

C

$674

N/A

D

$30

N/A

Medicaid CAP

D

$2022

$4044

1-09

QDWI

A

$3675

$4922

3-09

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

C

$3675

N/A

D

$3675

N/A

QMB

A

$903

$1215

4-09

SLMB

A

$1083

$1457

4-09

QI-1

A

$1219

$1640

3-09
CHART A1.3 - TRANSFER OF RESOURCE PENALTY DETERMINATION

Averaging Nursing Home Private Pay Billing Rate

$4916.55

4-09
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

$244.66

$357.00

$337.00

1-09

FBR

$244.66

$357.00

$337.00

1-09

QMB

N/A

N/A

$411.66

4-09

SLMB

N/A

N/A

$492.33

4-09

QI-1

N/A

N/A

$553.33

3-09
CHART A1.5 - SUBSTANTIAL GAINFUL ACTIVITY
Category Income Limit Effective Date

Non-Blind individuals

$980

1-09

Blind individuals

$1640
CHART A1.6 – BREAK-EVEN POINTS

Living Arrangement

Earned Income

Unearned Income

Effective Date

Individual

Couple

Individual

Couple

A

$1271

$1873

$603

$904

1-06

B

$869

$1271

$402

$603

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: $96.40 (effective 1-09).

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

$50

Effective 7-06

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

$50

Effective 7-06

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 NOW/COMP

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

$2739

1-09

Dependent Family Member Need Standard

$1822

4-09

HOUSEHOLD SIZE

100%

135%

150%

EFF. DATE

1

$10,830.00

$14,620.50

$16,245.00

2009

2

14,570.00

19,669.50

21,855.00

3

18,310.00

24,718.50

27,465.00

4

22,050.00

29,767.50

33,075.00

5

25,790.00

34,816.50

38,685.00

The FPL (100% level) is increased by $3,740 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 -

$7,620

Non Q Track Couple -

$12,190

Individual - $11,710 Couple - $23,410

2009

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

Up to $53.00

Up to $53.00

Coinsurance

up to $3600 Out of Pocket

$1.10 -

$3.20

Copay

$2.40 - $6.00 Copay

15% Coinsurance

Catastrophic

5% or $2/$5 Copay

$0

$0

$2.40 - $6.00 Copay
A1.13 – Medically Needy Mileage Re-imbursement Rate
48.5 cents per mile – 9/10/05 – 12/31/05

44.5 cents per mile – 1/1/06 – 1/31/07

48.5 cents per mile – 2/1/07 – 03/31/2008

50.5 cents per mile – 04/01/2008 – 7/31/08

58.5 cents per mile – 8/1/08 – 12/31/08

.55 cents per mile – effective 1/01/2009 to present