Appendix A1 ABD Financial Limits 2015

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

$7280

$10,930

N/A

1-15

QDWI

$4000

$6000

N/A

1-89

Spousal Impoverishment

N/A

N/A

$119,220 + 2000 =

$121,220.00

1-15
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

$733

$1100

1-15

B

$488.67

$733.33

C

$733

N/A

D

$30

N/A

Medicaid CAP

D

$2199

$4398

1-15

QDWI

A

$3989

$5375

3-15

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

C

$3989

N/A

D

$3989

N/A

QMB

A

$981

$1328

4-15

SLMB

A

$1177

$1593

4-15

QI-1

A

$1325

$1793

3-15
CHART A1.3 - TRANSFER OF RESOURCE PENALTY DETERMINATION

Averaging Nursing Home Private Pay Billing Rate

$5931.00

4-15
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

$264.33

$386.67

$366.67

1-15

FBR

$264.33

$386.67

$366.67

1-15

QMB

N/A

N/A

$437.00

4-14

SLMB

N/A

N/A

$525.00

4-14

QI-1

N/A

N/A

$590.00

3-14

4

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

Non-Blind individuals

$1090

1-15

Blind individuals

$1820
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

$5164.60

04/15

ICF/MR

$14729.96

Hospital

$5432.06

4/15

A1.8 – MEDICARE EXPENSES

Medicare Part B Premium rate: $104.90 (effective 1-14).

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

$2980.00

1-15

Dependent Family Member Need Standard

$1992.00

4-15

HOUSEHOLD SIZE

100%

135%

150%

EFF. DATE

1

$11,770.00

$15,889.00

$17,655.00

2015

2

15,930.00

21,505.00

23,985.00

3

20,090.00

27,121.00

30,135.00

4

24,250.00

32,737.00

36,375.00

5

28,410.00

38,353.00

42,615.00

The FPL (100% level) is increased by $4,060 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 -

$8,780

Non Q Track Couple -

$13,930

Individual - $13,640 Couple - $27,250

2015

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 $66.00

Up to $66.00

Coinsurance

up to $3600 Out of Pocket

$1.20 -

$3.60

Copay

$2.65 - $6.60 Copay

15% Coinsurance

Catastrophic

5% or $2/$5 Copay

$0

$0

$2.65 - $6.60 Copay

Low-Income Part D Premium Subsidy Amount
2010 – 29.62
2011 – 32.83
2012 – 31.18
2013 – 34.22
2014 – 29.32
2015 – 26.47

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 – 03/31/08
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 – 12/31/2012
56.5 cents per mile – 01/01/2013 – 12/31/2013
56 cents per mile — 01/01/2014 – 12/31/2014
57.5 cents per mile – 01/01/2015 - Present