Appendix A1 ABD Financial Limits 2017

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

$7390

$11,090

N/A

1-17

QDWI

$4000

$6000

N/A

1-89

Spousal Impoverishment

N/A

N/A

$120,900 + 2000 =

$122,900.00

1-17
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

$735

$1103

1-17

B

$490.00

$735.33

C

$735

N/A

D

$30

N/A

Medicaid CAP

D

$2205

$4410

1-17

QDWI

A

$4105

$5499

3-17

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

C

$4105

N/A

D

$4105

N/A

QMB

A

$1005

$1354

4-17

SLMB

A

$1206

$1624

4-17

QI-1

A

$1357

$1827

3-17
CHART A1.3 - TRANSFER OF RESOURCE PENALTY DETERMINATION

Averaging Nursing Home Private Pay Billing Rate

$6360.00

4-17
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

$265.00

$387.67

$367.67

1-17

FBR

$265.00

$387.67

$367.67

1-17

QMB

N/A

N/A

$458.00

4-17

SLMB

N/A

N/A

$548.00

4-17

QI-1

N/A

N/A

$615.67

3-17

4

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

Non-Blind individuals

$1170

1-17

Blind individuals

$1950
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

$5,404.54

04/17

ICF/MR

$14,669.20

Hospital

$5,680.95

4/17

A1.8 – MEDICARE EXPENSES

Medicare Part B Premium rate: $104.90 (effective 1-14) 121.80 (effective 1-16) 134.00 (effective 2017)
Effective 01/2016 Medicare Part B Premium rates may vary check BENDEX for applicable rate.

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

$3022.50

1-17

Dependent Family Member Need Standard

$2030.00

4-17

HOUSEHOLD SIZE

100%

135%

150%

EFF. DATE

1

$12,060.00

$16,281.00

$18,090.00

2017

2

16,240.00

21,924.00

24,360.00

3

20,420.00

27,567.00

30,630.00

4

24,600.00

33,210.00

36,900.00

5

28,780.00

38,853.00

43,170.00

The FPL (100% level) is increased by $4140 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 -

$8,890

Non Q Track Couple -

$14,090

Individual - $13,820 Couple - $27,600

2017

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 $82.00

Up to $82.00

Coinsurance

up to $3600 Out of Pocket

$1.20 -

$3.70

Copay

$3.30 - $8.25 Copay

15% Coinsurance

Catastrophic

5% or $2/$5 Copay

$0

$0

$3.30-$8.25 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
2016 – 25.78
2017 - 26.43

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 – 12/31/15
54.0 cents per mile – 01/01/2016 – 12/31/16
53.5 cents per mile- 01/01/2017- Present