Appendix A1 ABD Financial Limits 2021

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

$7970

$11,960

N/A

1-21

QDWI

$4000

$6000

N/A

1-89

Spousal Impoverishment

N/A

N/A

$130,380+ 2000

=

$132,380.00

1-21
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

$794

$1191

1-21

B

$529.34

$794

C

$794

N/A

D

$30

N/A

Medicaid CAP

D

$2382

$4764

1-21

QDWI

A

$4379

$5893

3-21

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

C

$4379

N/A

D

$4379

N/A

QMB

A

$1074

$1452

4-21

SLMB

A

$1288

$1742

4-21

QI-1

A

$1449

$1960

3-21
CHART A1.3 - TRANSFER OF RESOURCE PENALTY DETERMINATION

Averaging Nursing Home Private Pay Billing Rate

$8821.00

4-21
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

$284.66

$417.00

$397.00

1-21

FBR

$284.66

$417.00

$397.00

1-21

QMB

N/A

N/A

$490.66

4-21

SLMB

N/A

N/A

$587.33

4-21

QI-1

N/A

N/A

$660.00

3-21
CHART A1.5 - SUBSTANTIAL GAINFUL ACTIVITY
Category Income Limit Effective Date

Non-Blind individuals

$1310

1-21

Blind individuals

$2190
CHART A1.6 – BREAK-EVEN POINTS

Living Arrangement

Earned Income

Unearned Income

Effective Date

Individual

Couple

Individual

Couple

A

$1673

$2467

$814

$1211

1-21

B

$1143.68

$1673

$549.34

$814

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

$6344.46 (31 days)

04/21

ICF/MR

$14,846.21 (31 days)

A1.8 – MEDICARE EXPENSES

Medicare Part B Premium rate: $104.90 (effective 1-14)
$121.80 (effective 1-16)
$134.00 (effective 2017 and 2018)
$135.50 (effective 2019)
$144.60 (effective 2020)
$148.50 (effective 2021)
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

$70

Effective 7-19

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

$70

Effective 7-19

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

$3259.50

1-21

Dependent Family Member Need Standard

$2178.00

4-21

CHART A1.11- FEDERAL POVERTY LIMITS

HOUSEHOLD SIZE

100%

135%

150%

EFF. DATE

1

$12,880.00

$17,388.00

$19,320.00

2021

2

17,420.00

23,517.00

26,130.00

3

21,960.00

29,646.00

32,940.00

4

26,500.00

35,775.00

39,750.00

5

31,040.00

41,904.00

46,560.00

The FPL (100% level) is increased by $4,540 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 -

$9,470

Non-Q Track Couple -

$14,960

Individual - $14,790 Couple - $29,520

2021

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 $92.00

Up to $92.00

Coinsurance

up to $3600 Out of Pocket

$1.30 -

$4.00Copay

$3.70 - $9.20Copay

15% Coinsurance

Catastrophic

5% or $2/$5 Copay

$0

$0

$3.70 - $9.20Copay

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
2018 – 24.53
2019 - 25.68
2020 – 25.34
2021 - 29.80

A1.13 – Medically Needy Mileage Re-Imbursement Rate
48.5 cents per mile – 09/10/05 – 12/31/05
44.5 cents per mile – 01/01/06 – 01/31/07
48.5 cents per mile – 02/01/07 – 03/31/08
50.5 cents per mile – 04/01/08 – 07/31/08
58.5 cents per mile – 08/01/08 – 12/31/08
55.0 cents per mile – 01/01/09 – 12/31/09
50.0 cents per mile – 01/01/10 – 12/31/10
51.0 cents per mile – 01/01/11 – 04/16/12
55.5 cents per mile – 04/17/12 – 12/31/12
56.5 cents per mile – 01/01/13 – 12/31/13
56.0 cents per mile - 01/01/14 – 12/31/14
57.5 cents per mile – 01/01/15 – 12/31/15
54.0 cents per mile – 01/01/16 – 12/31/16
53.5 cents per mile – 01/01/17 - 12/31/17
54.5 cents per mile – 01/01/18 – 12/31/18
58.0 cents per mile – 01/01/19 - 12/31/19
57.5 cents per mile - 01/01/20 - 12/31/20
56.0 cents per mile - 01/01/21 - present