VOLUME II/MA, MT 50-05/16 Section A1-1 (2014)
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1 Type CHART A1.1 - ABD MEDICAID RESOURCE LIMITS Individual Couple LA-D Individual With a Community Spouse 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, = $121, Type CHART A1.2 - ABD MEDICAID NET INCOME LIMITS (GROSS - $20) Individual Couple LA AMN All $317 $ FBR (SSI ) A $733 $ B $ $ C $733 N/A D $30 N/A Medicaid CAP D $2199 $ QDWI A C $4045 $4045 $5425 N/A 3-16 Note: 3-98, ISM no D $4045 N/A longer applies to this COA eliminating LA-B. QMB A $990 $ SLMB A $1188 $ QI-1 A $1337 $ VOLUME II/MA, MT 50-05/16 Section A1-1 (2014)
2 CHART A1.3 - TRANSFER OF RESOURCE PENALTY DETERMINATION Averaging Nursing Home Private Pay Billing Rate $ CHART A1.4 - PRESUMED MAXIMUM VALUE (PMV) OF ISM AND LIVING ALLOWANCE TO EACH INELIGIBLE CHILD Income PMV for an Individual PMV for a Couple Living Allowance AMN $ $ $ FBR $ $ $ QMB N/A N/A $ SLMB N/A N/A $ QI-1 N/A N/A $ CHART A1.5 - SUBSTANTIAL GAINFUL ACTIVITY Category Income Non-Blind individuals $ Blind individuals $1820 CHART A1.6 BREAK-EVEN POINTS Living Arrangement Earned Income Unearned Income Individual Couple Individual Couple A $1271 $1873 $603 $904 B $869 $1271 $402 $ D $145 $205 $50 $ CHART A1.7 MONTHLY AVERAGED MEDICAID RATES FOR KATIE BECKETT Level of Care Monthly Amount Skilled Nursing Facility $ /16 ICF/MR $ Hospital $163, /16 VOLUME II/MA, MT 50-05/16 Section A1-2 (2014)
3 A1.8 MEDICARE EXPENSES Medicare Part B Premium rate: $ (effective 1-14) or ( effective 1-16) 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 THEN use the following as the PNA in the IF the LA-D Recipient is Patient Liability/Cost Share Budget: an individual in a nursing home or Institutionalized Hospice a VA pensioner or his/her surviving spouse in a nursing home who has dependents a VA pensioner or his/her surviving spouse in a nursing home who has no dependents NOTE: The VA check for these individuals is reduced to the amount of the PNA, regardless of other income. an individual in CCSP an individual in ICWP an individual in NOW/COMP $ $ $ ( 1-93 for the Surviving Spouse) the current amount of the Individual FBR for LA-A the current amount of the Community Spouse Maintenance Need Standard the current Medicaid Cap CHART A NEED STANDARDS FOR DIVERSION OF INCOME TO A COMMUNITY SPOUSE OR DEPENDENT FAMILY MEMBER IN A PATIENT LIABILITY/COST SHARE BUDGET Diversion Standard Amount Community Spouse Maintenance Need Standard $ Dependent Family Member Need Standard $ VOLUME II/MA, MT 50-05/16 Section A1-3 (2014)
4 HOUSEHOLD SIZE 100% 135% 150% 1 $11, $16, $17, , , , , , , , , , , , , EFF. DATE 2016 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 Resource None Non Q Track Individual - $8,780 Non Q Track Couple - $13,930 Income Full Medicaid Q Track or Less than 135% of FPL Individual - $13,640 Couple - $27,250 Less than 150% of FPL Monthly Premium $0 $0 Sliding Scale Deductible Per Year $0 Up to $74.00 Up to $74.00 Coinsurance up to $3600 Out of Pocket Catastrophic 5% or $2/$5 Copay $ $3.60 Copay $ $7.40 Copay 15% Coinsurance $0 $0 $ $7.40 Copay Eff Low-Income Part D Premium Subsidy Amount VOLUME II/MA, MT 50-05/16 Section A1-4 (2014)
5 A1.13 Medically Needy Mileage Re-imbursement Rate 48.5 cents per mile 9/10/05 12/31/ cents per mile 1/1/06 1/31/ cents per mile 2/1/07 03/31/ cents per mile 4/1/08 7/31/ 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/ cents per mile 01/01/11 04/16/ cents per mile 04/17/ /31/ cents per mile 01/01/ /31/ cents per mile -- 01/01/ /31/ cents per mile 01/01/ /31/ cents per mile 01/01/ Present VOLUME II/MA, MT 50-05/16 Section A1-5 (2014)
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