Appendix A1 ABD Financial Limits 2022

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

$8400

$12,600

N/A

1-22

QDWI

$4000

$6000

N/A

1-89

Spousal Impoverishment

N/A

N/A

$135,400+ 2000

=

$137,400.00

1-22
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

$841

$1261

1-22

B

$560.67

$840.67

C

$841

N/A

D

$30

N/A

Medicaid CAP

D

$2523

$5046

1-22

QDWI

A

$4615

$6189

3-22

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

C

$4379

N/A

D

$4379

N/A

QMB

A

$1133

$1526

4-22

SLMB

A

$1359

$1831

4-22

QI-1

A

$1529

$2060

3-22
CHART A1.3 - TRANSFER OF RESOURCE PENALTY DETERMINATION

Averaging Nursing Home Private Pay Billing Rate

$9034.00

4-22
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

$300.33

$440.33

$420.33

1-22

FBR

$300.33

$440.33

$420.33

1-22

QMB

N/A

N/A

$490.66

4-22

SLMB

N/A

N/A

$587.33

4-22

QI-1

N/A

N/A

$660.00

3-22
CHART A1.5 - SUBSTANTIAL GAINFUL ACTIVITY
Category Income Limit Effective Date

Non-Blind individuals

$1350

1-22

Blind individuals

$2260
CHART A1.6 – BREAK-EVEN POINTS

Living Arrangement

Earned Income

Unearned Income

Effective Date

Individual

Couple

Individual

Couple

A

$1767

$2607

$861

$1281

1-22

B

$1206.34

$1766.34

$580.67

$860.67

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

$6279.36 (31 days)

04/22

ICF/ID

$14,381.21 (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)
$170.10 (effective 2022)
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

$3435

1-22

Dependent Family Member Need Standard

$2289

4-22
TANF Standard of Need (SON)

HOUSEHOLD SIZE

SON

HOUSEHOLD SIZE

SON

EFF. DATE

1

$235.00

7

$672.00

2022

2

$356.00

8

$713.00

3

$424.00

9

$751.00

4

$500.00

10

$804.00

5

$573.00

11

$860.00

6

$621.00

12

$884.00
CHART A1.11- FEDERAL POVERTY LIMITS

HOUSEHOLD SIZE

100%

135%

150%

EFF. DATE

1

$13,590.00

$18,347.00

$20,385.00

2022

2

$18,310.00

$24,719.00

$27,465.00

3

$23,030.00

$31,091.00

$34,545.00

4

$27,750.00

$37,463.00

$41,625.00

5

$32,470.00

$43,835.00

$48,705.00

The FPL (100% level) is increased by $4,720 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 -

$9,900

Non-Q Track Couple -

$15,600

Individual - $15,510 Couple - $30,950

2022

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 $99.00

Up to $99.00

Coinsurance

up to $7050 Out of Pocket

$1.35 -

$4.00Copay

$3.95 - $9.85 Copay

15% Coinsurance

Catastrophic

5% or Copay

$0

$0

$3.95 - $9.85 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
2018 – 24.53
2019 - 25.68
2020 – 25.34
2021 - 29.80
2022- 32.38

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 - 12/31/21

58.5 cents per mile-

01/01/22 - 06/30/22

62.5 cents per mile-

07/01/22- present