Appendix A1 ABD Financial Limits 2012

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

$6940

$10,410

N/A

1-12

QDWI

$4000

$6000

N/A

1-89

Spousal Impoverishment

N/A

N/A

$113,640 + 2000 = $115,640.00

1-12
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

$698

$1048

1-12

B

$465.34

$698.00

C

$698

N/A

D

$30

N/A

Medicaid CAP

D

$2094

$4188

1-12

QDWI

A

$3789

$5109

3-12

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

C

$3789

N/A

D

$3789

N/A

QMB

A

$931

$1261

4-12

SLMB

A

$1117

$1513

4-12

QI-1

A

$1257

$1703

3-12
CHART A1.3 - TRANSFER OF RESOURCE PENALTY DETERMINATION

Averaging Nursing Home Private Pay Billing Rate

$4988.33

4-12
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

$252.66

$369.33

$337.00

1-12

FBR

$256.66

$369.33

$337.00

1-12

QMB

N/A

N/A

$427.00

4-12

SLMB

N/A

N/A

$511.00

4-12

QI-1

N/A

N/A

$574.33

3-12
CHART A1.5 - SUBSTANTIAL GAINFUL ACTIVITY
Category Income Limit Effective Date

Non-Blind individuals

$1010

1-12

Blind individuals

$1690
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

$4332.00

05/12

ICF/MR

$8895.00

A1.8 – MEDICARE EXPENSES

Medicare Part B Premium rate: $99.90 (effective 1-12).

Medicare Part D Base Premium rate: 31.18 (effective January 2012)

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

$2841.00

1-12

Dependent Family Member Need Standard

$1892

4-12
HOUSEHOLD SIZE 100% 135% 150% EFF. DATE

1

$11,170.00

$15,080.00

$16,755.00

2012

2

15,130.00

20,426.00

22,695.00

3

19,090.00

25,772.00

28,635.00

4

23,050.00

31,118.00

34,575.00

5

27,010.00

36,404.00

40,515.00

The FPL (100% level) is increased by $3,960 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 - $8,440

Non Q Track Couple - $13,410

Individual - $12,910

Couple - $25,010

2012

Income Limit

Full Medicaid

Q Track

or

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 $62.00

Coinsurance up to $3600 Out of Pocket

$1.10 - $3.30 Copay

$2.60 - $6.50 Copay

15% Coinsurance

Catastrophic 5% or $2/$5 Copay

$0

$0

$2.60 - $6.50 Copay

Low-Income Part D Premium Subsidy Amount

2010 – 29.62
2011 – 32.83
2012 – 31.18

A1.13 – Medically Needy Mileage Reimbursement 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 – 03/31/08
50.5 cents per mile – 4/1/08 – 7/31/08
58.5 cents per mile – 8/1/08 – 12/31/08
55 cents per mile – 1/1/09 – 12/31/09
50 cents per mile – 1/1/10 – 12/31/2010
51 cents per mile – 01/01/11 – 04/16/2012
55.5 cents per mile – 04/17/2012 – to present