Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities: 2009 State Profiles

Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities: 2009 State Profiles Julie Stone Specialist in Health Care Financing June 28, 2011 Congressional Research Service 7-5700 www.crs.gov R41899 CRS Report for Congress Prepared for Members and Committees of Congress Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Summary Medicaid is a means-tested, state-operated program providing health and long-term services and supports (LTSS) to certain people who are unable to afford private insurance or pay out-of-pocket for services. Under federal law, Medicaid has approximately 50 distinct eligibility groups; some are mandatory, meaning that states participating in Medicaid must cover them, while others are optional. People aged 65 and over and certain persons with disabilities are among the population groups who may qualify. Eligibility groups are differentiated, in part, by their income and asset thresholds. These financial thresholds are set by states within federal guidelines. The groups and thresholds that states cover determine who has access to Medicaid in that state and who does not. At the request of states, Congress is currently debating whether and how to allow states to cut back on certain optional eligible populations. Congress demonstrated a similar interest in containing Medicaid eligibility, and therefore spending, around the time of passage of the Deficit Reduction Act of 2005 (DRA, P.L. 109-173). DRA amended federal law to create more limitations on coverage for people who might have transferred assets to meet Medicaid’s means testing requirements. Although this interest in containing Medicaid eligibility is not new, Congress recently made changes to federal law to allow states additional options to expand coverage. Under the Patient Protection and Affordable Care Act (PPACA, P.L. 111-148), for example, states were provided new flexibility to extend coverage to certain people aged 65 and over and younger persons with disabilities with LTSS needs, among other populations. Despite this activity, recent information to help Congress and other stakeholders evaluate how legislation would affect Medicaid eligibility for aged and disabled individuals is limited. Among the information that would be potentially helpful are profiles of states’ eligibility rules. In 2009, CRS partnered with AARP’s policy research group to conduct a survey of the 50 states and the District of Columbia’s Medicaid eligibility rules for the major aged and disabled groups, including eligibility rules for accessing certain LTSS. This report presents the results of the survey by describing the major eligibility groups and other rules states used to allow people aged 65 and older and younger persons with disabilities to qualify for Medicaid in 2009. It also includes profiles of each state’s eligibility rules. The report begins with background on the general rules for determining eligibility in Medicaid for aged and disabled individuals. It then provides an explanation of the major eligibility groups about which states were surveyed and the income and resources thresholds associated with each of these groups. Next, the report provides a general explanation of the types of Medicaid services that individuals might be eligible to obtain, by eligibility group. Finally, profiles of each state and the District of Columbia are provided, including a description of the major groups covered and their associated financial thresholds. These state profiles include information on the types of Medicaid benefits that are available to beneficiaries by eligibility group. Congressional Research Service Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Contents Introduction ................................................................................................................................1 Overview of Medicaid Eligibility for Aged and Disabled.............................................................2 Overview of Survey ....................................................................................................................4 Major Eligibility Groups .......................................................................................................4 Spousal Impoverishment Rules .............................................................................................7 Post-Eligibility Treatment of Income by LTC Setting ............................................................8 Benefits by Eligibility Group ......................................................................................................8 Traditional Benefits...............................................................................................................8 Benefits for Medically Needy................................................................................................9 Benefits for Individuals Qualifying through Institutional Rules .............................................9 Home and Community-Based Services (HCBS) Waivers.......................................................9 Analysis of Selected Survey Findings........................................................................................ 10 State Profiles............................................................................................................................. 19 Alabama ............................................................................................................................. 20 Alaska................................................................................................................................. 21 Arizona............................................................................................................................... 22 Arkansas............................................................................................................................. 23 California............................................................................................................................ 25 Colorado............................................................................................................................. 26 Connecticut......................................................................................................................... 27 Delaware ............................................................................................................................ 28 District of Columbia............................................................................................................ 29 Florida ................................................................................................................................ 30 Georgia ............................................................................................................................... 31 Hawaii ................................................................................................................................ 32 Idaho .................................................................................................................................. 33 Illinois ................................................................................................................................ 34 Indiana................................................................................................................................ 35 Iowa ................................................................................................................................... 36 Kansas ................................................................................................................................ 37 Kentucky ............................................................................................................................ 38 Louisiana ............................................................................................................................ 39 Maine ................................................................................................................................. 40 Maryland ............................................................................................................................ 41 Massachusetts ..................................................................................................................... 42 Michigan ............................................................................................................................ 43 Minnesota ........................................................................................................................... 44 Mississippi.......................................................................................................................... 45 Missouri.............................................................................................................................. 46 Montana.............................................................................................................................. 47 Nebraska............................................................................................................................. 48 Nevada ............................................................................................................................... 49 New Hampshire .................................................................................................................. 50 New Jersey ......................................................................................................................... 51 New Mexico ....................................................................................................................... 52 Congressional Research Service Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities New York............................................................................................................................ 53 North Carolina .................................................................................................................... 54 North Dakota ...................................................................................................................... 55 Ohio ................................................................................................................................... 56 Oklahoma ........................................................................................................................... 57 Oregon................................................................................................................................ 58 Pennsylvania....................................................................................................................... 59 Rhode Island....................................................................................................................... 60 South Carolina .................................................................................................................... 61 South Dakota ...................................................................................................................... 62 Tennessee ........................................................................................................................... 63 Texas .................................................................................................................................. 64 Utah.................................................................................................................................... 65 Vermont .............................................................................................................................. 66 Virginia............................................................................................................................... 67 Washington ......................................................................................................................... 68 West Virginia ...................................................................................................................... 69 Wisconsin ........................................................................................................................... 70 Wyoming ............................................................................................................................ 71 Tables Table 1. Medicaid Enrollment, by State and Basis of Eligibility for Aged and Disabled, FY2008.................................................................................................................................. 11 Table 2. Upper Income Threshold for Non-Working Aged and Disabled Medicaid Applicants, 2009 .................................................................................................................... 13 Table 3. Upper Income Threshold for Applicants Meeting the State’s Level-of-Care Criteria for Institutional LTSS ................................................................................................ 15 Table 4. Monthly Maintenance of Need Allowance (MMNA) for Enrollees in Home and Community-Based Waiver Services........................................................................................ 17 Table 5. Eligibility Pathways for Medicaid and Long-Term Care in Alabama, 2009 ................... 20 Table 6. Eligibility Pathways for Medicaid and Long-Term Care in Alaska, 2009 ...................... 21 Table 7. Eligibility Pathways for Medicaid and Long-Term Care in Arizona, 2009..................... 22 Table 8. Eligibility Pathways for Medicaid and Long-Term Care in Arkansas, 2009................... 23 Table 9. Eligibility Pathways for Medicaid and Long-Term Care in California, 2009 ................. 25 Table 10. Eligibility Pathways for Medicaid and Long-Term Care in Colorado, 2009................. 26 Table 11. Eligibility Pathways for Medicaid and Long-Term Care in Connecticut, 2009 ............ 27 Table 12. Eligibility Pathways for Medicaid and Long-Term Care in Delaware, 2009 ................ 28 Table 13. Eligibility Pathways for Medicaid and Long-Term Care in the District of Columbia, 2009...................................................................................................................... 29 Table 14. Eligibility Pathways for Medicaid and Long-Term Care in Florida, 2009.................... 30 Table 15. Eligibility Pathways for Medicaid and Long-Term Care in Georgia, 2009................... 31 Table 16. Eligibility Pathways for Medicaid and Long-Term Care in Hawaii, 2009.................... 32 Congressional Research Service Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Table 17. Eligibility Pathways for Medicaid and Long-Term Care in Idaho, 2009 ...................... 33 Table 18. Eligibility Pathways for Medicaid and Long-Term Care in Illinois, 2009.................... 34 Table 19. Eligibility Pathways for Medicaid and Long-Term Care in Indiana, 2009 ................... 35 Table 20. Eligibility Pathways for Medicaid and Long-Term Care in Iowa, 2009 ....................... 36 Table 21. Eligibility Pathways for Medicaid and Long-Term Care in Kansas, 2009.................... 37 Table 22. Eligibility Pathways for Medicaid and Long-Term Care in Kentucky, 2009 ................ 38 Table 23. Eligibility Pathways for Medicaid and Long-Term Care in Louisiana, 2009................ 39 Table 24. Eligibility Pathways for Medicaid and Long-Term Care in Maine, 2009 ..................... 40 Table 25. Eligibility Pathways for Medicaid and Long-Term Care in Maryland, 2009................ 41 Table 26. Eligibility Pathways for Medicaid and Long-Term Care in Massachusetts, 2009......... 42 Table 27. Eligibility Pathways for Medicaid and Long-Term Care in Michigan, 2009 ................ 43 Table 28. Eligibility Pathways for Medicaid and Long-Term Care in Minnesota, 2009............... 44 Table 29. Eligibility Pathways for Medicaid and Long-Term Care in Mississippi, 2009 ............. 45 Table 30. Eligibility Pathways for Medicaid and Long-Term Care in Missouri, 2009 ................. 46 Table 31. Eligibility Pathways for Medicaid and Long-Term Care in Montana, 2009 ................. 47 Table 32. Eligibility Pathways for Medicaid and Long-Term Care in Nebraska, 2009 ................ 48 Table 33. Eligibility Pathways for Medicaid and Long-Term Care in Nevada, 2009 ................... 49 Table 34. Eligibility Pathways for Medicaid and Long-Term Care in New Hampshire, 2009 ...................................................................................................................................... 50 Table 35. Eligibility Pathways for Medicaid and Long-Term Care in New Jersey, 2009 ............. 51 Table 36. Eligibility Pathways for Medicaid and Long-Term Care in New Mexico, 2009........... 52 Table 37. Eligibility Pathways for Medicaid and Long-Term Care in New York, 2009 ............... 53 Table 38. Eligibility Pathways for Medicaid and Long-Term Care in North Carolina, 2009........ 54 Table 39. Eligibility Pathways for Medicaid and Long-Term Care in North Dakota, 2009.......... 55 Table 40. Eligibility Pathways for Medicaid and Long-Term Care in Ohio, 2009 ....................... 56 Table 41. Eligibility Pathways for Medicaid and Long-Term Care in Oklahoma, 2009............... 57 Table 42. Eligibility Pathways for Medicaid and Long-Term Care in Oregon, 2009 ................... 58 Table 43. Eligibility Pathways for Medicaid and Long-Term Care in Pennsylvania, 2009 .......... 59 Table 44. Eligibility Pathways for Medicaid and Long-Term Care in Rhode Island, 2009........... 60 Table 45. Eligibility Pathways for Medicaid and Long-Term Care in South Carolina, 2009........ 61 Table 46. Eligibility Pathways for Medicaid and Long-Term Care in South Dakota, 2009.......... 62 Table 47. Eligibility Pathways for Medicaid and Long-Term Care in Tennessee, 2009 ............... 63 Table 48. Eligibility Pathways for Medicaid and Long-Term Care in Texas, 2009...................... 64 Table 49. Eligibility Pathways for Medicaid and Long-Term Care in Utah, 2009 ....................... 65 Table 50. Eligibility Pathways for Medicaid and Long-Term Care in Vermont, 2009.................. 66 Table 51. Eligibility Pathways for Medicaid and Long-Term Care in Virginia, 2009 .................. 67 Table 52. Eligibility Pathways for Medicaid and Long-Term Care in Washington, 2009............. 68 Congressional Research Service Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Table 53. Eligibility Pathways for Medicaid and Long-Term Care in West Virginia, 2009.......... 69 Table 54. Eligibility Pathways for Medicaid and Long-Term Care in Wisconsin, 2009............... 70 Table 55. Eligibility Pathways for Medicaid and Long-Term Care in Wyoming, 2009................ 71 Appendixes Appendix A. Eligibility Groups Excluded from the Survey........................................................ 72 Appendix B. Medicaid’s Resources Rules for Aged and Disabled Eligibility Pathways .............. 73 Contacts Author Contact Information ...................................................................................................... 74 Acknowledgments .................................................................................................................... 74 Congressional Research Service Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Introduction Medicaid is a means-tested health insurance program funded by both the federal and state governments. In 2009, the program covered 67.8 million low-income individuals in the United States.1 People qualify for Medicaid if they meet the program’s categorical thresholds and have income and assets equal to or below state-specified thresholds. Under federal law, Medicaid has approximately 50 distinct eligibility groups; some are mandatory, meaning that states participating in Medicaid must cover them, while others are optional. Eligibility groups are differentiated, in part, by their income and asset thresholds. These financial thresholds are set by states within federal guidelines. The groups and thresholds that states adopt determine who has access to coverage under Medicaid in that state and who does not. Eligibility groups, and income and asset thresholds, vary considerably among states. For instance, individuals in similar circumstances of need for acute, post-acute, or long-term services and supports (LTSS) may be automatically eligible for coverage in one state, be required to assume a certain portion of their medical expenses before they can obtain coverage in a second state, and not be eligible at all in a third state. At the request of states, Congress is currently debating whether and how to allow states to cut back on optional eligible populations.2 Congress demonstrated a similar interest in containing Medicaid eligibility, and therefore spending, around the time of passage of the Deficit Reduction Act of 2005 (DRA, P.L. 109-173). DRA amended federal law to create more limitations on coverage for people who might have transferred assets to meet Medicaid’s means testing requirements. 3 Although this interest in containing Medicaid eligibility is not new, Congress also recently made changes to federal law to allow states additional options to expand coverage. Under the Patient Protection and Affordable Care Act (PPACA, P.L. 111-148), for example, states were provided new flexibility to extend coverage to certain people aged 65 and over and younger persons with disabilities with long-term services and supports (LTSS) needs, 4 among other populations. Current information to help Congress and other stakeholders evaluate how legislation would affect Medicaid eligibility for aged and disabled individuals is limited. Among the information that would be potentially helpful are profiles of states’ eligibility rules. The last time such comprehensive state profiles were available was in 2003, when the results of a 50-state survey on eligibility, conducted by CRS and the American Public Human Services Association (APHSA), were made available on the APHSA website. 5 1 Congressional Budget Office, “Spending and Enrollment Detail for CBO’s March 2009 Baseline: Medicaid,” Washington, DC. At https://www.cbo.gov/budget/factsheets/2009b/medicaid.pdf. This figure is the total number of individuals enrolled in Medicaid at any point during the fiscal year and include enrollment in the territories. 2 For more information, see CRS Report R41835, Medicaid and CHIP Maintenance of Effort (MOE): Requirements and Responses, by Evelyne P. Baumrucker. 3 For more information, see CRS Report RL33593, Medicaid Coverage for Long-Term Care: Eligibility, Asset Transfers, and Estate Recovery, by Julie Stone. 4 For more information, see CRS Report R41210, Medicaid and the State Children’s Health Insurance Program (CHIP) Provisions in PPACA: Summary and Timeline, coordinated by Julie Stone. 5 This information is no longer available on the APHSA website. Congressional Research Service 1 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities In 2009, CRS partnered with AARP’s research policy group to conduct a survey of each state and the District of Columbia’s Medicaid eligibility rules for the major aged and disabled groups, including eligibility rules for accessing certain LTSS. The survey was web-based, but numerous follow-up calls to clarify unclear, confusing, or blank survey responses were made. Except Alabama, all states and the District of Columbia responded. To complete Alabama’s survey, information on the state’s website and waiver application was used. Additional information about states’ Medicaid Buy-In programs was obtained from Mathematica Policy Research, Inc.6 When needed, state section 1915(c) waiver applications were used to verify eligible populations. 7 This report presents the survey results for all the major eligibility groups and other rules states use to allow people aged 65 and older and younger persons with disabilities to qualify for Medicaid. All information is based on 2009 rules and data and therefore does not include any changes made to eligibility by PPACA. An explanation of the eligibility groups not included in this survey is provided in Appendix A. The report begins with background on the general rules for determining eligibility in Medicaid for aged and disabled individuals. It then provides an explanation of the major eligibility groups about which states were surveyed and the income and resources thresholds associated with each of these groups. Next, the report provides a general explanation of the types of Medicaid services that individuals might be eligible to obtain, by eligibility group. Finally, profiles of each state and the District of Columbia are provided, including a description of the major groups covered and their associated financial thresholds. These state profiles include information on the types of Medicaid benefits that are available to beneficiaries by eligibility group. Overview of Medicaid Eligibility for Aged and Disabled Medicaid is a means-tested, state-operated program providing health and LTSS to certain people who are unable to afford private insurance or pay out-of-pocket for services. To qualify for Medicaid, an individual must meet both categorical and financial eligibility requirements. Categorical eligibility requirements relate to the age or other characteristics of an individual. People aged 65 and over and certain persons with disabilities are among the categories of individuals who may qualify.8 6 Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. 7 To grant states additional flexibility to offer a broad range of home and community-based LTSS as an alternative to institutional care, Congress authorized the use of the HCBS waiver program under section 1915(c) of the Social Security Act in 1981. To date, most states have chosen to make these waivers available to targeted populations (other states have used section 1115 waivers for similar purposes). Section 1915(c) gives states the option to extend a broad range of home and community-based services to selected populations of individuals with the level-of-need that would otherwise be offered in Medicaid-covered institutions, such as a nursing home, ICF/MR, or a hospital. For HCBS waivers to be approved, states also must meet other requirements, such as a cost-effectiveness test, under which average Medicaid expenditures for waiver participants do not exceed costs that would have been incurred if these individuals resided in institutions. 8 Some aged and disabled recipients apply to Medicaid as children after being born with disabling conditions; others apply as working-age adults with inherited or acquired disabling conditions, and still others enroll much later as aging retirees who have lost the ability to care for themselves. Congressional Research Service 2 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities The program’s financial eligibility requirements place limits on the amount of income and resources or assets individuals may possess and still be eligible for Medicaid. These thresholds, or standards, specify the maximum amount of countable income and resources a person may have to qualify; income and resources above these amounts generally make an individual ineligible for coverage. The specific income and asset limitations that apply to each eligibility group are set through a combination of federal parameters and state definitions. 9 In addition to categorical and financial requirements, individuals in need of LTSS may be required to meet level-of-care eligibility criteria that demonstrate difficulty performing activities necessary for self-care and independent living.10 Many Medicaid beneficiaries with disabilities and individuals aged 65 and older have complex health conditions that require specialized care. 11 Many have multiple chronic conditions, physical disabilities, and/or cognitive impairments. A number of beneficiaries have limitations in activities of daily living (ADLs), such as bathing, dressing, feeding, and toileting; and/or instrumental activities of daily living (IADLs), such as managing money, shopping, getting around outside the house, and taking medications. Traditionally, Medicaid eligibility rules for aged and disabled individuals have been linked to the federal cash welfare program, Supplemental Security Income (SSI).12 To qualify for SSI, a person must satisfy the program criteria for age or disability and meet SSI’s income and resources requirements. For adults, disability is defined as the inability to engage in substantial gainful activity (SGA) by reason of a medically determinable physical or mental impairment expected to result in death or last at least 12 months. In general, the worker must be unable to do any kind of work that exists in the national economy, taking into account age, education, and work experience. A child under the age of 18 may qualify as disabled if he or she has an impairment that results in “marked and severe” functional limitations.13 Individuals receiving SSI automatically qualify for Medicaid in all but 11 209(b) states that may use financial and disability criteria that are more restrictive that SSI. Other non-SSI pathways for aged and disabled individuals are generally required to use SSI’s rules for counting income and assets, as well as SSI’s definition of disability. 14 Examples include the more restrictive SSI-related pathways used by 209(b) states, the 100% of federal poverty level (FPL) pathway, medically needy pathways for people with high medical expenses, and buy-in pathways for working disabled individuals. However, section 1902(r)(2) of the Social Security Act grants states flexibility to modify the financial (but not disability) criteria for these pathways. This provision allows states to use more liberal thresholds for computing income and resources than are specified under SSI. Some states use section 1902(r)(2) to ignore or disregard certain types or amounts of income and assets, thereby extending Medicaid to individuals with income and/or assets too high to otherwise qualify under the specified rules for that eligibility pathway. Additional information about Medicaid’s countable resource rules is provided in Appendix B. 9 The federal government mandates states to meet certain minimum eligibility standards and gives states flexibility to establish additional criteria that are more generous and, in some limited instances, more restrictive. 10 The survey did not ask about level-of-care criteria, which can vary state. 11 See Tables 3B, 4B, and 5B, Medicaid and CHIP Payment and Access Commission (MACPAC), Report to Congress: The Evolution of Managed Care in Medicaid, Washington, DC, June 2011. 12 For more information about SSI program rules, see CRS Report 94-486, Supplemental Security Income (SSI), by Umar Moulta-Ali. 13 See CRS Report 94-486, Supplemental Security Income (SSI), by Umar Moulta-Ali. 14 In this report, the terms pathway and eligibility group are used interchangeably. Congressional Research Service 3 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities To understand which aged and disabled individuals in each state are eligible for Medicaid, the survey solicited information on the major eligibility groups they cover and what the states’ income and resource thresholds are for each of those groups. In addition, it requested information on spousal impoverishment and post-eligibility treatment of income for beneficiaries receiving LTSS in a nursing home or HCBS waiver. Overview of Survey The following is an explanation of these major eligibility groups and other rules, including background on the federal rules for setting income thresholds. The state profiles, presented later in this report, provide more detailed information on the groups each state has selected as well as the income and resources thresholds by group. Additional survey questions asked states to report on their use of section 1902(r)(2) to deviate from SSI program rules (usually used by states for counting income and resources) for the income and resources counting. These results are not included in the state profiles below. Major Eligibility Groups States were surveyed about their income and asset rules for the one mandatory pathway relevant to this population. This pathway is based on the program rules for the Supplemental Security Income (SSI) program. It is described below in two parts: SSI-related and SSI-related: 209(b). 1. SSI-related: Federal law requires states to provide Medicaid coverage to recipients of SSI and relies on SSI eligibility rules, established at the national level, as the basis for Medicaid eligibility for aged and disabled individuals who are not receiving SSI. To qualify for SSI, a person must satisfy the program criteria for age or disability and meet SSI’s income and resources requirements. In addition, applicants must meet certain citizen and residency requirements. 2. SSI-related: 209(b): Under section 209(b) of the Social Security Amendments of 1972 (P.L. 92-603), states may elect to use eligibility criteria, including income and resources thresholds that are more restrictive than SSI but no more restrictive than those in effect on January 1, 1972. Unlike non-209(b) states, receipt of SSI does not guarantee eligibility for Medicaid in a 209(b) state. These 11 209(b) states may require persons to meet a lower income threshold than SSI’s or may use more restrictive policies for defining countable income. They may also have lower limits for the amount of resources a person may have. Each of the 209(b) states has at least one eligibility standard (income, resources, or definition of disability) that is more restrictive than SSI thresholds. States that use more restrictive eligibility rules under section 209(b) must also allow applicants to deduct medical expenses from countable income when determining eligibility. This process is sometimes referred to as the “209(b) spend-down.”15 15 An example of 209(b) spend-down is as follows: if an applicant has a monthly income of $700 (not including any SSI or certain other cash payments) and the states’ maximum allowable income standard for spend-down eligibility is $600, the applicant would qualify for Medicaid after incurring $100 in medical expenses in that month. As discussed below, the spend-down process is also used in establishing eligibility for the medically needy. Congressional Research Service 4 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Other optional pathways for aged and disabled applicants use the SSI program’s definition of disability for eligibility purposes. 3. Income up to 100% of the Federal Poverty Level (FPL, 100% FPL): The enactment of the Omnibus Budget Reconciliation Act of 1986 (OBRA 86) offered states an option for covering persons whose income exceeds SSI or 209(b) levels. This option allows states to cover aged or disabled individuals with incomes up to 100% of the FPL ($903 for an individual and $1,214 for a couple per month in 2009) as long as they meet the SSI definition for aged or disabled. States use the same resources rules for this eligibility pathway as they use for the SSI groups. 4. Medicaid Buy-In (Buy-In): Many individuals with disabilities who work have historically been ineligible for Medicaid because their incomes were too high. Congress established special rules to help guarantee health insurance for certain working individuals with disabilities for whom employer-sponsored health insurance is not available. Two statutory authorities have established what is known as the Medicaid Buy-In groups. These authorities have created three distinct Buy-In options. a. The first option was established by the Balanced Budget Act of 1997 (BBA 97, P.L. 105-33). BBA 97 allows states to extend Medicaid coverage to working individuals with disabilities whose family’s net income, after exclusions following the SSI income counting methodology, does not exceed 250% of FPL.16 Under BBA 97, states are also permitted to establish cost-sharing whereby a person with a disability who is working purchases or “buys into” Medicaid coverage through the payment of premiums and/or co-payments. b. The second option, referred to as the Basic Eligibility group, was established by the Ticket to Work and Work Incentives Improvement Act of 1999 (TWWIIA, P.L. 106170). For this Basic group, TWWIIA provisions allow states to expand Medicaid coverage to working individuals with disabilities between the ages of 16 and 64. Under this option, states may establish state-defined income and resource levels that are not limited by the 250% of FPL under BBA 97’s option one authority. Further, this option establishes limitations on the amounts of premiums and other cost-sharing that beneficiaries could pay. c. The third Buy-In option, referred to as the Medical Improvement Group, is available only to those states that cover the Basic Eligibility group. Under this option, also established under TWWIIA, states may continue to cover people who still have a significant impairment. Individuals must be employed and earning at least the federal minimum wage and must be working at least 40 hours per month. The state may establish a different definition of employment subject to the approval of the Secretary of the Department of Health and Human Services (HHS). The medically needy optional pathway is intended for applicants with high medical expenses relative to their income and who meet SSI’s definition of aged or disabled. 16 States may also disregard additional income and resources under section 1902(r)(2) of the Social Security Act. There is no limit on the amount of additional income and resources that may be disregarded under section 1902(r)(2). Congressional Research Service 5 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities 5. Medically Needy (MN): Under this eligibility group, aged or disabled individuals qualify when their medical expenses (on such things as nursing home [NH] care, prescription drugs, etc.) deplete, or “spend down,” their income and assets to specified Medicaid thresholds. For example, if an individual has monthly income of $1,000 and the state’s income threshold is $480, then the applicant would be required to incur $520 in out-of-pocket medical expenses before he or she would be eligible for Medicaid. States use a specific time period for calculating a person’s medical expenses, often referred to as a “budget period,” generally ranging from one to six months.17 States may also use spend down groups to extend Medicaid coverage to persons who are members of one of the broad categories of Medicaid covered groups (i.e., are aged or have a disability) but do not meet the applicable income requirements and, in some instances, resources requirements for other eligibility pathways. The Special Income Rule is intended for applicants with higher income and who require a level of care offered in an institution. 6. Special Income Rule, Miller Trust: States also have an option to extend coverage of certain institutional services, as well as other traditional benefits, to individuals who are in nursing facilities or other institutions. States can establish a special income rule, known as “the 300% rule,” to allow these persons to qualify for Medicaid coverage of their NH care and other institutional long-term services and supports. To be eligible, persons must (1) require care provided by a NH or other medical institution for no less than 30 consecutive days, (2) meet the resources threshold determined by the state, and (3) have income that does not exceed a specified level—no greater than 300% of the maximum SSI payment applicable to a person living at home ($2,022 per month in 2009). Medicaid law requires those states that use only the special income rule, and not the medically needy pathway, to allow applicants to place income in excess of the special income level in a special Miller Trust, and receive Medicaid coverage for their care. States that use the combination of the special income rule with a Miller Trust effectively allow individuals to qualify for institutional care and Medicaid’s traditional benefits with higher income. Following the individual’s death, the state becomes the beneficiary of amounts in this trust. The Katie Beckett and hospice only coverage pathways are also optional groups about which states were surveyed. 7. Katie Beckett: To address the barriers to home and community-based care for certain children with disabilities, 18 Medicaid law allows states to extend 17 The calculation becomes the basis for determining the amount of a person’s spend-down requirement. Generally a shorter time period is more beneficial to the applicant. For example, if the state has a one-month spend-down calculation period, the individual would be required to incur $520 in medical expenses in a month, after which services would be covered by Medicaid. On the other hand, if the state had a six-month calculation period, the individual would have to incur a projected amount of $3,120 ($520 times six) in medical expenses before Medicaid would begin coverage. The length of the spend-down period does not significantly affect total out-of-pocket expenditures for persons with predictable and recurring medical expenses, such as persons with chronic illnesses or disabling conditions. However, individuals faced with acute nonrecurring problems generally benefit more from a shorter calculation period. 18 Generally, Medicaid rules require that the income and resources of the parents of a child with a disability (under age 21) be automatically considered available for medical care expenses; they are “deemed” to the child. These deeming (continued...) Congressional Research Service 6 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Medicaid coverage to certain disabled children under 18 who are living at home and who would be eligible for Medicaid if in a hospital, nursing facility, or an intermediate care facility for the mentally retarded (ICF/MR). Under the Katie Beckett option, the state must determine that (1) the child requires the level of care provided in an institution, (2) it is appropriate to provide care outside the facility, and (3) the cost of care at home is no more than institutional care. States electing this option are required to cover all disabled children who meet these criteria on a statewide basis. 8. Hospice Only Coverage: Medicaid law allows states to cover, as an eligibility group, individuals who are terminally ill and elect to receive hospice care only,19 provided that they would be eligible for Medicaid if they were in a medical institution.20 Spousal Impoverishment Rules States were also surveyed about their spousal impoverishment rules. These rules are intended to prevent the impoverishment of a spouse whose husband or wife seeks Medicaid coverage for institutional LTSS or home and community-based services (HCBS) waivers. These rules address the treatment of income and assets of married couples, allowing the community spouse to retain higher amounts of income and assets (on top of non-countable assets such as a house, car, etc.) than allowed under general Medicaid rules. Regarding income, federal law exempts all of a community spouse’s income (e.g., pension or Social Security) in his or her name from being considered available to the other spouse for purposes of Medicaid eligibility. For community spouses with limited income, federal law allows institutionalized spouses to transfer income to the community spouse up to a state-determined maximum level. Federal law specifies that this limit may be no greater than $2,739 per month, and no less than $1,821 per month in 2009 (same amounts for 2010, the most recent year available). Regarding assets, federal law allows states to select the amount of assets a community spouse may be allowed to retain. It specified that this limit could not exceed $109,560 in 2009 (same amount for 2010, the most recent year available) and could be no less than $21,912 in total countable assets in 2009 (same amount for 2010, the most recent year available).21 (...continued) rules have presented eligibility barriers for children with disabilities who could be provided needed care in their homes. If the same child is institutionalized, however, after the first month away from home, the child no longer is considered to be a member of the parent’s household and only the child’s financial resources are considered available for care. The child then is able to qualify for Medicaid. 19 Social Security Act §1902(a)(10)(A)(ii)(VII); State Medicaid Manual, Pub. 45, §3580 et seq. 20 Hospice generally covers palliative medical care, that is, relief from pain, and supportive social and counseling services for terminally ill beneficiaries and their families. Services are provided primarily in the patient’s home, but may also be provided in institutional settings, such as NHs. 21 For purposes of determining how many assets the community spouse may retain, all assets of the couple are combined, counted, and split in half, regardless of which of the two spouses possesses ownership. If the community spouse’s assets are less than the state standard, then the Medicaid beneficiary must transfer his or her share of the assets to the community spouse until the community-spouse’s share reaches the standard. All other non-exempt assets must be depleted before the applicant can qualify for Medicaid. Congressional Research Service 7 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Post-Eligibility Treatment of Income by LTC Setting Finally, the survey solicited information from states about the amounts they allow beneficiaries receiving certain LTC services to retain for personal needs allowances and monthly maintenance needs allowances (MMNA). Once eligible for Medicaid, persons qualifying through certain eligibility groups are required to apply their income above specified amounts toward the cost of their care. The amounts they may retain vary by setting. For example, Medicaid beneficiaries in a NH may retain a personal needs allowance. Persons receiving services in home and communitybased settings may retain an MMNA, which is higher than a personal needs allowance because it is intended to pay for the living expenses of a person living in the community. These amounts vary by states. All income amounts above these levels, including what may be available in a Miller Trust, must be applied toward the cost of their care. Benefits by Eligibility Group Not all Medicaid benefits that a state offers in its program are available to all Medicaid beneficiaries. The benefits a Medicaid beneficiary is eligible for depend, in part, upon the eligibility group through which the individual enters Medicaid. The following provides a brief description of the types of benefits that are available to beneficiaries based on eligibility group. The state profiles that follow show which type of benefits are available to which group of beneficiaries. Traditional Benefits Once enrolled in Medicaid, individuals who entered the program through SSI-related, 100% FPL, Buy-In, and special income rule groups are entitled to what are often referred to as “traditional Medicaid benefits.” 22 Traditional Medicaid benefits include a broad, and often comprehensive, range of mandatory and optional benefits. Examples of benefits that are mandatory for these aged and disabled individuals include inpatient hospital services (excluding services for mental disease); services provided by federally qualified health centers; laboratory and x-ray services; physician services; and home health care for those entitled to NH care. Nursing home services for individuals age 21 and over are also a mandatory benefit for categorically needy eligibility groups. The optional benefits available under Medicaid vary across states. Examples of optional benefits that states cover are prescribed drugs (covered by all states); routine dental care; physiciandirected clinic services; services provided by other licensed practitioners (e.g., optometrists, podiatrists, psychologists); inpatient psychiatric care for the elderly and for individuals under age 21; nursing facility services for individuals under age 21; and consumer-directed personal care attendant services beginning in 2011. In addition, the breadth of coverage for a given mandatory or optional benefit can and does vary from state to state. For example, states may place different limits on the amount of inpatient 22 Beginning in 2006, as an alterative to traditional benefits, states were given the option to provide what are called “benchmark” benefit packages to certain Medicaid subpopulations. These plans can also be limited to substate areas. Congressional Research Service 8 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities hospital services a beneficiary can receive in a year (e.g., up to 15 inpatient days per year in one state versus unlimited inpatient days in another state). Benefits for Medically Needy Special benefit rules apply to optional medically needy populations. States may offer a more restrictive benefit package than is provided to “aged” and “disabled” populations under the traditional benefits rules, but at a minimum, must offer (1) prenatal, delivery, and postpartum services for pregnant women; (2) ambulatory services as defined in the state Medicaid plan for individuals under 18 and those entitled to institutional services; and (3) home health services for individuals entitled to nursing facility care.23 Among the optional benefits states may select for medically needy eligibles is nursing home care. As part of this survey, states were asked whether they extended nursing home care to this population. Twenty-nine of the 33 states with medically needy pathways extended nursing home care to this population. Benefits for Individuals Qualifying through Institutional Rules Medicaid covers institutional services for people who meet the state’s level-of-care criteria. These services include care in a nursing home, ICF/MR, and institution for mental disease (IMD), among others. Nursing home care includes room and board, skilled nursing care, rehabilitation, and other health and supportive services. ICF/MR services include room and board and a wide range of specialized therapeutic services to assist persons in functioning at optimal levels.24 IMDs provide diagnosis and treatment or care of persons with mental diseases, including medical attention, nursing care, and related services. States use a number of pathways to allow individuals to qualify for institutional care under Medicaid. First, states must allow individuals who qualify for Medicaid through the mandatory SSI-related pathways to access those institutional services covered under the state’s traditional benefits package if the individuals meet the state’s medically necessary criteria for that benefit. States electing to cover individuals through the 100% FPL and/or the Buy-In groups must make traditional benefits, including certain institutional care services, available to people who meet the state’s medically necessary criteria. States also have an option to extend coverage of certain institutional services, as well as other traditional benefits, to individuals who qualify for Medicaid through the Special Income Rule, and this pathway’s accompanying Miller Trusts. Home and Community-Based Services (HCBS) Waivers States have the option of providing a narrow or comprehensive package of LTSS to a limited number of persons in home and community-based settings if they would otherwise require institutional care paid for by Medicaid. States make these packages of LTSS available to certain persons with disabilities using HCBS waivers, generally authorized under section 1915(c) of the 23 Broader requirements apply if a state has chosen to provide coverage for medically needy persons in institutions for mental disease and intermediate care facilities for the mentally retarded. 24 “Active treatment” is defined by regulation as aggressive, consistent implementation of a program of specialized and generic training, treatment, health and related services directed toward acquisition of behaviors necessary for the client to function with as much self-determination and independence as possible, and the prevention or deceleration of regression or loss of optional functional status. Congressional Research Service 9 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Social Security Act. Some states also use section 1115 waiver authority to design LTSS packages in the community following similar rules as under section 1915(c). To qualify, a person generally must be a member of one of the following target groups who would otherwise be eligible for institutional care: the aged, persons with disabilities, persons with mental retardation or developmental disabilities, or persons with mental illness. States must apply for separate waivers to serve each of these different groups. Services that states may choose to cover under HCBS waivers include case management; homemaker; home health aide; personal care; adult day health; habilitation; respite care; day treatment or other partial hospitalization services; psychosocial rehabilitation and clinic services for individuals with chronic mental illness; and other services requested by the state and approved by Secretary. HCBS waiver services must meet both financial and level-of-care eligibility requirements set by state and federal law. Under HCBS waivers, states may limit coverage to those persons receiving SSI or allow persons to qualify under other groups, such as the SSI-related, 100% of FPL, BuyIn, or medically needy pathways. States also have the option of setting financial eligibility limits for income as high as 300% of SSI benefit level. Those states that use the 300% rule may also allow eligibles to establish a Miller Trust if those states do not also have medically needy programs. States also have the option of applying spousal impoverishment protections for couples when only one of the spouses requires Medicaid coverage of long-term care expenses. Our survey questioned states about which aged and disabled eligibility groups they allow to be potentially eligible for their largest HCBS waiver and whether spousal impoverishment rules were used for eligibility determinations. States’ answers are provided in the profiles below. When insufficient information was obtained from the survey, CRS reviewed the state’s waiver applications to discover which eligibility groups allow for access to HCBS waivers in that state. Analysis of Selected Survey Findings The survey looked at states’ criteria for access to Medicaid for people aged 65 and over and certain people with disabilities. Questions concerning the income and asset thresholds associated with each eligibility pathway available in each state were among the many issues surveyed. In general, states’ responses helped to measure the level of generosity or restrictiveness of a states’ eligibility rules. States with higher income thresholds, for example, allow people with higher income levels to access Medicaid, while states with lower thresholds are more restrictive. Although information on income thresholds is useful for comparative purposes, it does not tell the entire picture. To more accurately measure a state’s generosity or restrictiveness for eligibility purposes, the wealth status of the state, the size of its population, and its demands on Medicaid enrollment should be considered. For example, a poorer state may have lower income thresholds than a richer state but have higher enrollment. Simultaneously, a richer state may have higher thresholds and have comparable, or even lower, enrollment numbers. Although an analysis of this complexity is not included in this report, Table 1 shows state-by-state enrollment numbers for the aged and disabled. The survey was conducted in calendar year (CY) 2009; the most recent enrollment data available are for FY2008. Congressional Research Service 10 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Table 1. Medicaid Enrollment, by State and Basis of Eligibility for Aged and Disabled, FY2008 (thousands) State Alabama Aged Disabled Total 103 221 324 Alaska 7 16 23 Arizona 84 142 226 Arkansas 70 132 202 California 793 1,154 1,947 Colorado 55 85 140 Connecticut 66 68 134 Delaware 13 23 36 District of Columbia 10 38 48 Florida 369 560 929 Georgia 138 286 424 Hawaii 22 26 316 Idaho 16 37 53 Illinois 169 345 514 Indiana 84 158 242 Iowa 42 74 116 Kansas 36 68 104 Kentucky 72 244 316 Louisiana 110 204 314 Maine 57 59 116 Maryland 59 143 202 Massachusetts 160 502 662 Michigan 136 313 449 Minnesota 93 117 210 Mississippi 77 171 248 Missouri 92 185 277 Montana 10 20 30 Nebraska 24 36 60 Nevada 24 40 64 New Hampshire 15 24 39 New Jersey 113 199 312 New Mexico 27 69 96 New York 454 746 1,200 North Carolina 182 295 477 Congressional Research Service 11 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities State North Dakota Aged Disabled Total 9 11 20 188 362 550 Oklahoma 65 109 174 Oregon 51 86 137 Pennsylvania 234 537 771 Rhode Island 21 44 65 South Carolina 77 151 228 South Dakota 10 19 29 Tennessee 98 357 455 Texas 431 569 1,000 Utah 14 38 52 Vermont 18 24 42 Virginia 99 166 265 Washington 90 184 274 West Virginia 38 114 152 Wisconsin 136 152 288 Wyoming 6 10 16 5,369a 9,733a 15,100 Ohio Total Source: Medicaid and CHIP Payment and Access Commission (MACPAC), Report to Congress on Medicaid and CHIP, Washington, DC, March 2011, Table 2. Notes: Numbers reflect individuals ever enrolled during the year, even if for a single month. FY2008 unavailable for Hawaii; FY2007 shown instead. a. Components do not sum to totals due to a small number of enrollees with unknown status. Below, the aged and disabled are divided into two groups: (1) applicants who are non-working regardless of whether they require LTSS and (2) applicants with higher income who apply to Medicaid for LTSS and require the level-of-care offered in an institution. 25 The following analysis looks at the highest income thresholds available in each state for both groups. Decisions states make about these thresholds often reflect the amount of state revenue they want to dedicate toward Medicaid for aged and disabled populations in general and LTSS in particular. Table 2 summarizes the highest level of income, in 2009, that non-working elderly or disabled applicants could have and qualify for Medicaid by state. Specifically, it includes the upper income threshold, as a percent of the federal poverty level, for the SSI-related, 100% FPL, and medically needy pathways. (Table 2 does not describe the upper threshold for applicants applying to Medicaid because they require LTSS. These pathways are described in Table 3.) 25 For an analysis of income thresholds for working disabled, among other issues, see the body of work available at Mathematica Policy Research, at http://www.mathematica-mpr.com/publications/SearchList2.aspx?jumpsrch=yes& txtSearch=buy-in. Congressional Research Service 12 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Thirty-one states (30 used medically needy rules and 1 used spend-down rules) had no limit on the amount of income an aged or disabled individual (or individual with high medical expenses) could have to qualify for Medicaid. In these states, applicants could access Medicaid with higher income levels than in other states. Benefit packages for those who qualify for Medicaid through the SSI-related and 100% FPL pathways are generally more comprehensive than the benefit packages offered to medically needy individuals. Among the 21 states with income caps for the non-working elderly and disabled applicants, 4 states (Arizona, Massachusetts, Utah, and Vermont) allowed applicants to qualify with income up to 100% FPL while the remaining states set thresholds at lower levels. Table 2. Upper Income Threshold for Non-Working Aged and Disabled Medicaid Applicants, 2009 State Upper Income Threshold Alabama 75% FPL Alaska 61% FPL Arizona 100% FPL Arkansas 80% FPL or no limit under medically needy California 100% FPL or no limit under medically needy Colorado 75% FPL Connecticut 93% FPL or no limit under medically needy Delaware 75% FPL District of Columbia 100% FPL or no limit under medically needy Florida 88% FPL or no limit under medically needy Georgia 75% FPL or no limit under medically needy Hawaii 100% FPL (Aged) and 97% (Disabled) or no limit under medically needy Idaho 75% FPL Illinois 100% FPL or no limit under medically needy Indiana 75% FPL or no limit under medically needy Iowa 75% FPL or no limit under medically needy Kansas 75% FPL or no limit under medically needy Kentucky 75% FPL or no limit under medically needy Louisiana 75% FPL or no limit under medically needy Maine 100% FPL or no limit under medically needy Maryland 75% FPL or no limit under medically needy Massachusetts 100% FPL (Aged) or 133% FPL (blind or disabled) Michigan 100% FPL or no limit under medically needy Minnesota 95% FPL or no limit under medically needy Mississippi 75% FPL Missouri 85% FPL Congressional Research Service 13 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities State Upper Income Threshold Montana 75% FPL Nebraska 100% FPL or no limit under medically needy Nevada 75% FPL New Hampshire 76% FPL or no limit under medically needy New Jersey 100% FPL or no limit under medically needy New Mexico 75% FPL New York 75% FPL or no limit under medically needy North Carolina 100% FPL or no limit under medically needy North Dakota 75% FPL or no limit under medically needy Ohio 65% FPL or no limit under medically needy Oklahoma 100% FPL or no limit under 209(b) spend down Oregon 75% FPL Pennsylvania 100% FPL or no limit under medically needy Rhode Island 100% FPL or no limit under medically needy South Carolina 100% FPL South Dakota 75% FPL Tennessee 75% FPL Texas 75% FPL Utah 100% FPL Vermont 100% FPL or no limit under medically needy Virginia 80% FPL or no limit under medically needy Washington 75% FPL or no limit under medically needy West Virginia 75% FPL Wisconsin 100% FPL or no limit under medically needy Wyoming 75% FPL Source: CRS Analysis of CRS/AARP State Survey, 2009. Notes: Table excludes eligibility for LTSS through the Special Income Rule and the Medicaid Buy-In pathway. Table shows the maximum threshold for individuals. In 2009, the federal poverty level (100% FPL) in the lower 48 states and the District of Columbia was $10,830 for an individual; in Hawaii, it was $12,460; and in Alaska, it was $13,330. See Federal Poverty Guidelines for 2009 at http://aspe.hhs.gov/poverty/09poverty.shtml. Under the medically needy pathway, aged or disabled individuals qualify when their medical expenses (on such things as nursing home [NH] care, prescription drugs, etc.) deplete, or “spend down,” their income and assets to specified Medicaid thresholds. Table 3 summarizes the upper income threshold for applicants applying to Medicaid because they require LTSS and meet the state’s criteria for institutional care. LTSS in Table 3 is divided into two service types: nursing homes and states’ largest HCBS waivers. By showing the upper income thresholds for both service types, one can begin to evaluate the extent to which parity exists between these services. However, to fully evaluate parity, additional information is needed about the number of waiver slots a state offers compared to demand as well as the amount of income an individual is allowed to retain to pay for living expenses in a home and communitybased setting (i.e., MMNA). The latter of these measures is presented in Table 4. Congressional Research Service 14 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Although states have many rules for determining eligibility, 45 states had no maximum income limit for accessing nursing home care in their state (see Table 3). In addition, 39 states had no income limit for accessing their states’ largest HCBS waiver program. In general, a state’s use of either the medically needy pathway or miller trust, in conjunction with the special income rule, results in no upper income limit. This shows that at least six states (Connecticut, Louisiana, Massachusetts, Michigan, New Jersey, and Washington) allow applicants with higher income to access nursing home care, while limiting access to HCBS waiver services to individuals with lower income levels. Parity between nursing home and HCBS waivers was not as great in these states as in others. Table 3. Upper Income Threshold for Applicants Meeting the State’s Level-of-Care Criteria for Institutional LTSS State Upper Income Threshold for Nursing Home Care Upper Income Threshold for State’s Largest HCBS Waiver Alabama No upper limit No upper limit Alaska No upper limit No upper limit Arizona 644% FPL in urban areas, 572% FPL in rural areas 644% FPL in urban areas, 572% FPL in rural areas Arkansas No upper limit No upper limit California No upper limit No upper limit Colorado Limit of the regional private pay rate of nursing home Limit of the regional private pay rate of nursing home Connecticut No upper limit 224% FPL Delaware No upper limit No upper limit District of Columbia No upper limit No upper limit Florida No upper limit No upper limit Georgia No upper limit No upper limit Hawaii No upper limit No upper limit Idaho No upper limit No upper limit Illinois No upper limit No upper limit Indiana No upper limit No upper limit Iowa No upper limit No upper limit Kansas No upper limit No upper limit Kentucky No upper limit No upper limit Louisiana No upper limit 224% FPL Maine No upper limit No upper limit Maryland No upper limit No upper limit Massachusetts No upper limit 224% FPL Michigan No upper limit 100% FPL Minnesota No upper limit No upper limit Mississippi No upper limit No upper limit Congressional Research Service 15 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities State Upper Income Threshold for Nursing Home Care Upper Income Threshold for State’s Largest HCBS Waiver Missouri 85% FPL 85% FPL Montana No upper limit No upper limit Nebraska No upper limit No upper limit Nevada No upper limit No upper limit New Hampshire No upper limit No upper limit New Jersey No upper limit 224% FPL New Mexico No upper limit No upper limit New York No upper limit No upper limit North Carolina No upper limit No upper limit North Dakota No upper limit No upper limit Ohio No upper limit No upper limit Oklahoma 332% FPL 332% FPL Oregon 720% FPL 720% FPL Pennsylvania No upper limit No upper limit Rhode Island No upper limit No upper limit South Carolina No upper limit No upper limit South Dakota No upper limit No upper limit Tennessee No upper limit No upper limit Texas No upper limit No upper limit Utah No upper limit No upper limit Vermont No upper limit No upper limit Virginia No upper limit No upper limit Washington No upper limit 224% FPL West Virginia 224% FPL 224% FPL Wisconsin No upper limit No upper limit Wyoming No upper limit No upper limit Source: CRS Analysis of CRS/AARP State Survey, 2009. Notes: Table shows the maximum threshold for individuals. In 2009, the federal poverty level (100% FPL) in the lower 48 states and the District of Columbia was $10,830 for an individual; in Hawaii, it was $12,460; and in Alaska, it was $13,330. See Federal Poverty Guidelines for 2009 at http://aspe.hhs.gov/poverty/09poverty.shtml. States with no upper income limit either use the medically needy pathway, in which medical expenses (on such things as nursing home [NH] care, prescription drugs, etc.) deplete, or “spend down,” income and assets to specified Medicaid thresholds, or the special income rule with a Miller Trust, for eligibility purposes. Table 4 shows each state’s monthly maintenance of need allowance (MMNA). The MMNA is the maximum amount of income an individual enrolled in the state’s HCBS wavier program may retain for living expenses; amounts above the MMNA are applied toward the cost of the Congressional Research Service 16 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities beneficiary’s care. Waiver enrollees use these funds to pay for living expenses, including housing, food, transportation, clothing, personal care products, among others.26 Higher MMNAs allow Medicaid beneficiaries more income to live in their homes or community setting while accessing Medicaid. Lower MMNAs leave individuals less income to reside in home and community-based settings, increasing the likelihood that individuals will seek institutional care to meet their LTSS and housing needs. Fifteen states have MMNAs of less than $1,000 for all or some beneficiaries, while the remainder of states have MMNAs of higher than $1,000. Although the information provided in Table 4 is useful for comparative purposes, it is not adjusted for differences in the cost of living across states. Table 4. Monthly Maintenance of Need Allowance (MMNA) for Enrollees in Home and Community-Based Waiver Services State Maintenance Needs Allowance Alabama $1,658 Alaska $1,656, or unlimited with a Miller Trust Arizona $2,022, or $5,808 with a Miller Trust Arkansas $2,022, or unlimited with a Miller Trusta California $600 for an individual, $934 for a couplea Colorado $2,022, or unlimited with a Miller Trusta Connecticut $1,806 Delaware $1,685, or unlimited with a Miller Trust District of Columbia $2,022 Florida $674, or unlimited with a Miller Trusta Georgia $674, or unlimited with a Miller Trust Hawaii At Home = $1,038, At Care Facility = $674a Idaho $1,011 (w/mortgage or rent), $674 (w/no mortgage or rent), or unlimited with a Miller Trusta Illinois $674a Indiana $2,022, or unlimited with a Miller Trust Iowa $2,022, or unlimited with a Miller Trust Kansas $727a Kentucky $694, or unlimited with a Miller Trust Louisiana $2,022 Maine $1,129 Maryland $2,022 Massachusetts $2,022a 26 Room and board, food, and some personal care products, among others, are provided to nursing home beneficiaries by Medicaid. Congressional Research Service 17 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities State Maintenance Needs Allowance Michigan $2,022a Minnesota $935 Mississippi $2,022, or unlimited with a Miller Trust Missouri $2,022a Montana $674 (Categorically Needy), $625 (Medically Needy) Nebraska $903a Nevada $2,022, or unlimited with a Miller Trusta New Hampshire $2,022 New Jersey $674 for residents in Assisted Living Facilities, $2,022 for all othersa New Mexico $2,022, or unlimited with a Miller Trusta New York $787 North Carolina $903 North Dakota $750 Ohio $1,314 Oklahoma $1,011, or $3,000 with a Miller Trust Oregon $1,822, or $6,494 with a Miller Trust Pennsylvania $2,022 Rhode Island $923 South Carolina Not available South Dakota $694, or unlimited with a Miller Trusta Tennessee $1,348, or unlimited with a Miller Trust Texas $2,022, or unlimited with a Miller Trust Utah $903 Vermont $991 Virginia $2,022 Washington $903 West Virginia $2,022b Wisconsin $2,022 Wyoming $2,022, or unlimited with a Miller Trusta Source: CRS Analysis of CRS/AARP State Survey, 2009. a. Information collected per telephone, e-mail, or contact with the state’s Medicaid office. b. Information collected from the state’s section 1915(c) waiver application. Congressional Research Service 18 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities State Profiles The following tables and subsequent state profiles show the eligibility groups and other rules states selected for calendar year 2009. Congressional Research Service 19 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Alabama Table 5. Eligibility Pathways for Medicaid and Long-Term Care in Alabama, 2009 Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) SSI-related $674 / $1,011 $2,000 / $3,000 Special Income Rule, Miller Trust $2,022 (no cap) $2,000 / $3,000 Eligibility Pathway Traditional Benefits Institutional LTC HCBS Waivers Yes Yes Yes Yes Yes Yes Source: State website, http://www.medicaid.alabama.gov/CONTENT/3.0_apply/ 3.2_Qualifying_for_Medicaid.aspx, and waiver application. Traditional Benefits All SSI recipients are eligible for Medicaid. The state makes the special income rule pathway available up to 300% of SSI. Amounts that can be deposited in a Miller Trust are unlimited. Institutional LTC The SSI-related and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment, the community spouse may retain up to $1,822 in income and between $25,000 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $30 monthly, with an additional $90 monthly supplement for veterans or widows of a veteran. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related and special income pathways. The state does not apply spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $1,658 in an MMNA. Other The Katie Beckett pathway is not available. The hospice only pathway is not available. Congressional Research Service 20 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Alaska Table 6. Eligibility Pathways for Medicaid and Long-Term Care in Alaska, 2009 Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) SSI-related $674 / $1,011 $2,000 / $3,000 Buy-In $2,819 (includes spousal income)a Special Income Rule, Miller Trust $1,656 (no cap) Eligibility Pathway Traditional Benefits Institutional LTC HCBS Waivers Yes Yes Yes $10,000 / $15,000 Yes Yes Yes $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. a. Unearned income must be at or below $1,156 per month. Traditional Benefits All SSI recipients are eligible for Medicaid. Individuals with disabilities may qualify under the state’s Buy-In pathway. The state makes the special income rule pathway available to individuals who have lived in an institution for at least 30 days. The state makes the special income rule pathway available up to 246% of SSI. Amounts that can be deposited in a Miller Trust are unlimited. Institutional LTC The SSI-related, Buy-In, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,739 in income and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $75 monthly or $90 monthly for veterans in LTC facilities. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related, Buy-In, and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $1,656 in an MMNA. Other The Katie Beckett pathway is available. The hospice only eligibility pathway is not available. Congressional Research Service 21 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Arizona Table 7. Eligibility Pathways for Medicaid and Long-Term Care in Arizona, 2009 Monthly Income Limit (Individual/Couple) Eligibility Pathway Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes 100% FPL $903 / $1,214 $2,000 / $3,000 Yes Yes No Buy-In $2,257 (excluding spousal income) No Resource Limit Yes Yes No Special Income Rule, Miller Trust $2,022, $5,808 cap in urban areas, $5,158 cap in rural areas $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. Traditional Benefits All SSI recipients are eligible for Medicaid. The 100% FPL pathway is available to individuals with incomes up to 100% of the FPL. Individuals with disabilities may qualify under the state’s Buy-In pathway. The state makes the special income rule pathway available up to 300% of SSI. Amounts that can be deposited in a Miller Trust may not exceed $5,808 in urban areas and $5,158 in rural areas. Institutional LTC The SSI-related, 100% FPL, Buy-In, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $1,822 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $101 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related, and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $2,022 in an MMNA or higher with a Miller Trust. Other The Katie Beckett pathway is not available. The hospice only eligibility pathway is available. Congressional Research Service 22 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Arkansas Table 8. Eligibility Pathways for Medicaid and Long-Term Care in Arkansas, 2009 Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) SSI-related $674 / $1,011 $2,000 / $3,000 100% FPL $722 / $971 Buy-In Eligibility Pathway Traditional Benefits Institutional LTC HCBS Waivers Yes Yes No $2,000 / $3,000 Yes Yes No $2,257 (excludes spousal income)a $4,000 / $6,000 Yes Yes No Medically Needy (MN) $108 / $217 $2,000 / $3,000 MN benefits onlyb No (NH care)c No Special Income Rule, Miller Trust $2,022 (no cap) $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. a. Net personal income (earned plus unearned, after SSI income exclusions); unearned income must be less than SSI threshold plus $20. b. The type, amount and scope of benefits offered to the medically needy population may be less than under traditional benefit packages. c. The state does not extend nursing home care to eligible medically needy individuals. Our survey did not ask whether states extend other institutional services to these individuals. Traditional Benefits All SSI recipients are eligible for Medicaid. The 100% FPL pathway is available to individuals with incomes up to 80% of the FPL. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a three month budget period to the state’s medically needy threshold. The state makes the special income rule pathway available up to 300% of SSI. Amounts that can be deposited in a Miller Trust are unlimited. Institutional LTC The SSI-related, 100% FPL, Buy-In, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain between $1,822 and $2,739 in income and $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $40 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the special income pathway. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $2,022 in a monthly maintenance needs allowance (MMNA), or an unlimited amount with a Miller Trust. Congressional Research Service 23 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Other Pathways The Katie Beckett pathway is available. The hospice only eligibility pathway is not available. Congressional Research Service 24 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities California Table 9. Eligibility Pathways for Medicaid and Long-Term Care in California, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes 100% FPL $903 / $1,214 $2,000 / $3,000 Yes Yes Yes Buy-In $2,257 (includes spousal income) a $2,000 / $3,000 Yes Yes No Medically Needy (MN) $600 / $934 $2,000 / $3,000 MN benefits onlyb Yes (NH care)c Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. a. Excludes disability-related income including SSDI benefits. b. The type, amount and scope of benefits offered to the medically needy population may be less than under traditional benefit packages. c. The state extends nursing home care to eligible medically needy individuals. Our survey did not ask whether states extend other institutional services to these individuals. Traditional Benefits All SSI recipients are eligible for Medicaid. The 100% FPL pathway is available to individuals with incomes up to 100% of the FPL. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a one month budget period to the state’s medically needy threshold. Institutional LTC The SSI-related, 100% FPL, medically needy, and Buy-In pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,739 in income and up to $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $35 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related, 100% FPL, and medically needy pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Individual waiver recipients may retain up to $600 in an MMNA. Couples that are both waiver recipients may retain up to $934 in an MMNA. Other Pathways The Katie Beckett pathway is available. The hospice only eligibility pathway is not available. Congressional Research Service 25 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Colorado Table 10. Eligibility Pathways for Medicaid and Long-Term Care in Colorado, 2009 Monthly Income Limit (Individual/Couple) Eligibility Pathway Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes Special Income Rule, Miller Trust $2,022, regional private pay rate cap $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Traditional Benefits All SSI recipients are eligible for Medicaid. The state makes the special income rule pathway available up to 300% of SSI. Amounts that can be deposited in a Miller Trust are capped by region. Institutional LTC The SSI-related and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,739 in income and up to $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $30 monthly for SSI recipients and higher for certain others with non-service connected disabilities. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $2,022 in an MMNA or higher with a Miller Trust. Other The Katie Beckett pathway is available. The hospice only eligibility pathway is available. Congressional Research Service 26 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Connecticut Table 11. Eligibility Pathways for Medicaid and Long-Term Care in Connecticut, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) SSI-related: 209(b) $842 / $1,286 $2,000 / $3,000 Buy-In $75,000 per year (excludes spousal income) Medically Needy (MN) Special Income Rule Traditional Benefits Institutional LTC HCBS Waivers Yes Yes Yes $10,000 / $15,000 Yes Yes No $611 / $778 $1,600 / $2,400 MN benefits only Yes (NH care) No $2,022 $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. Traditional Benefits Connecticut is a 209(b) state and applies more restrictive rules to the counting of income and resources than are applied under the federal government’s SSI thresholds. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a six month budget period to the state’s medically needy threshold. The state makes the special income rule pathway available up to 300% of SSI. Institutional LTC The SSI-related 209(b), Buy-In, medically needy, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain between $1,821 and $2,739 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $69 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related: 209(b) and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $1,806 in an MMNA. Other Pathways The Katie Beckett pathway is available. The hospice only eligibility pathway is not available. Congressional Research Service 27 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Delaware Table 12. Eligibility Pathways for Medicaid and Long-Term Care in Delaware, 2009 Eligibility Pathway Total Resources Limit (Individual/Couple) Monthly Income Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes No Special Income Rule, Miller Trust $1,685 (no cap) $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Traditional Benefits All SSI recipients are eligible for Medicaid. The state makes the special income rule pathway available up to 300% of SSI. Amounts that can be deposited in a Miller Trust are unlimited. Institutional LTC The SSI-related and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain between $1,821 and $2,739 in income and between $25,000 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $44 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the special income pathway. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $1,685 in an MMNA or higher with a Miller Trust. Other The Katie Beckett pathway is available. The hospice only eligibility pathway is available. Congressional Research Service 28 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities District of Columbia Table 13. Eligibility Pathways for Medicaid and Long-Term Care in the District of Columbia, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes 100% FPL $903 / $1,214 $2,000 / $3,000 Yes Yes Yes Medically Needy (MN) $577 / $607 $4,000 / $6,000 MN benefits only Yes (NH care) Yes Special Income Rule $2,022 $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Traditional Benefits All SSI recipients are eligible for Medicaid. The 100% FPL pathway is available to individuals with incomes up to 100% of the FPL. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses to the state’s medically needy threshold from a selected budget period between one and six months. The state makes the special income rule pathway available up to 300% of SSI. Institutional LTC The SSI-related, 100% FPL, medically needy, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,739 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $70 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related, 100% FPL, medically needy, and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $2,022 in an MMNA. Other The Katie Beckett pathway is not available. The hospice only eligibility pathway is not available. Congressional Research Service 29 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Florida Table 14. Eligibility Pathways for Medicaid and Long-Term Care in Florida, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes 100% FPL $794 / $1,068 $2,000 / $3,000 Yes Yes Yes Medically Needy (MN) $180 / $241 $5,000 / $6,000 MN benefits only No No Special Income Rule, Miller Trust $2,022 (no cap) $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Traditional Benefits All SSI recipients are eligible for Medicaid. The 100% FPL pathway is available to individuals with incomes up to 88% of the FPL. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a one month budget period to the state’s medically needy threshold. The state makes the special income rule pathway available up to 300% of SSI. Amounts that can be deposited in a Miller Trust are unlimited. Institutional LTC The SSI-related, 100% FPL, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $1,822 in income and up to $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $35 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related, 100% FPL and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain an unlimited amount for an MMNA. Other Pathways The Katie Beckett pathway is not available. The hospice only eligibility pathway is not available. Congressional Research Service 30 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Georgia Table 15. Eligibility Pathways for Medicaid and Long-Term Care in Georgia, 2009 Monthly Income Limit (Individual/Couple) Eligibility Pathway Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes Medically Needy (MN) $317 / $375 $2,000 / $3,000 MN benefits only No (NH care) No Special Income Rule, Miller Trust $2,022 (no cap) $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Traditional Benefits All SSI recipients are eligible for Medicaid. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a one month budget period to the state’s medically needy threshold. The state makes the special income rule pathway available up to 300% of SSI. Amounts that can be deposited in a Miller Trust are unlimited. Institutional LTC The SSI-related and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,739 in income and up to $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $50 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $674 in an MMNA or higher with a Miller Trust. Other The Katie Beckett pathway is available. The hospice only eligibility pathway is available. Congressional Research Service 31 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Hawaii Table 16. Eligibility Pathways for Medicaid and Long-Term Care in Hawaii, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related: 209(b) $1,039 / $1,397 (Aged) $674 / $1,011 (Disabled) $2,000 / $3,000 Yes Yes Yes 100% FPL $903 / $1,214 $2,000 / $3,000 Yes Yes Yes Medically Needy (MN) $469 / $632 $2,000 / $3,000 MN benefits only Yes (NH care) Yes Source: CRS/AARP State Survey, 2009. Traditional Benefits Hawaii is a 209(b) state and applies more restrictive rules to the counting of income and resources than are applied under the federal government’s SSI thresholds. The 100% FPL pathway is available to individuals with incomes up to 100% of the FPL. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a one month budget period to the state’s medically needy threshold. Institutional LTC The SSI-related: 209(b), 100% FPL, and medically needy pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,739 in income and up to $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $50 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related: 209(b), 100% FPL and medically needy pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $674 in an MMNA if they live in a residential care facility. All other waiver recipients may retain up to $1,038 in an MMNA. Other The Katie Beckett pathway is not available. The hospice only eligibility pathway is available. Congressional Research Service 32 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Idaho Table 17. Eligibility Pathways for Medicaid and Long-Term Care in Idaho, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes Buy-In Less than or equal to $4,513a $10,000 (includes spousal resources) Yes Yes Yes Special Income Rule, Miller Trust $2,022 (no cap) $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. a. Excludes retirement accounts, life insurance; earned income >15% of total earned and unearned. Traditional Benefits All SSI recipients are eligible for Medicaid. Individuals with disabilities may qualify under the state’s Buy-In pathway. The state makes the special income rule pathway available up to 300% of SSI. Amounts that can be deposited in a Miller Trust are unlimited. Institutional LTC The SSI-related and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $1,821 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $40 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related, Buy-In, and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients with a mortgage or rent may retain up to $1,011 in an MMNA. Waiver recipients with no mortgage or rent may retain up to $674 in an MMNA. Other The Katie Beckett pathway is available. The hospice only eligibility pathway is available. Congressional Research Service 33 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Illinois Table 18. Eligibility Pathways for Medicaid and Long-Term Care in Illinois, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related: 209(b) $903 / $1,214 $2,000 / $3,000 Yes Yes Yes 100% FPL $903 / $1,214 $2,000 / $3,000 Yes Yes Yes Buy-In $1,806 (includes spousal income)a $10,000 (includes spousal resources)b Yes Yes No Medically Needy (MN) $903 / $1,214 $2,000 / $3,000 MN benefits only Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. a. Increased to $3,160 in February 2009. b. Increased to $25,000 and exempts retirement and medical savings accounts. Traditional Benefits Illinois is a 209(b) state and applies more restrictive rules to the counting of income and resources and the definition of disability than are applied under the federal government’s SSI thresholds. The 100% FPL pathway is available to individuals with incomes up to 100% of the FPL. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a one month budget period to the state’s medically needy threshold. Institutional LTC The SSI-related: 209(b), 100% FPL, Buy-In, and medically needy pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,739 in income and up to $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $30 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related: 209(b), 100% FPL applicants. Waiver recipients may retain up to $674 in an MMNA. Other The Katie Beckett pathway is not available. The hospice only eligibility pathway is not available. Congressional Research Service 34 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Indiana Table 19. Eligibility Pathways for Medicaid and Long-Term Care in Indiana, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) SSI-related: 209(b) $674 / $1,011 $2,000 / $3,000 Buy-In $3,160 (excludes spousal income) Medically Needy (MN) Special Income Rule, Miller Trust Traditional Benefits Institutional LTC HCBS Waivers Yes Yes No $2,000 (excludes spousal resources) Yes Yes Yes $674 / $1,011 $2,000 / $3,000 MN benefits only Yes (NH care) Yes $2,022 (no cap) $2,000 / $3,000 Yes No Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. Traditional Benefits Indiana is a 209(b) state and applies more restrictive rules to the counting of income and resources than are applied under the federal government’s SSI thresholds. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a one month budget period to the state’s medically needy threshold. The state makes the special income rule pathway available up to 300% of SSI. Amounts that can be deposited in a Miller Trust are unlimited. Institutional LTC The SSI-related: 209(b), Buy-In, and medically needy pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,739 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $52 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the Buy-In, medically needy, and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $2,022 in an MMNA. Other The Katie Beckett pathway is not available. The hospice only eligibility pathway is not available. Congressional Research Service 35 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Iowa Table 20. Eligibility Pathways for Medicaid and Long-Term Care in Iowa, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes Buy-In $2,257 (includes spousal income) $12,000 / $13,000 Yes Yes No Medically Needy (MN) $483 $10,000 MN benefits only No (NH care) No Special Income Rule, Miller Trust $2,022 (no cap) $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. Traditional Benefits All SSI recipients are eligible for Medicaid. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a two month budget period to the state’s medically needy threshold. The state makes the special income rule pathway available up to 300% of SSI. Amounts that can be deposited in a Miller Trust are unlimited. Institutional LTC The SSI-related, Buy-In, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,739 in income and up to $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $50 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $2,022 in an MMNA. Other The Katie Beckett pathway is available. The hospice only eligibility pathway is not available. Congressional Research Service 36 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Kansas Table 21. Eligibility Pathways for Medicaid and Long-Term Care in Kansas, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes Buy-In $2,709 (includes spousal income) $15,000 (includes spousal resources) Yes Yes No Medically Needy (MN) $475 $2,000 / $3,000 MN benefits only Yes (NH care) Yes Special Income Rule $2,022 $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. Traditional Benefits All SSI recipients are eligible for Medicaid. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a six month budget period to the state’s medically needy threshold. The state makes the special income rule pathway available up to 300% of SSI. Institutional LTC The SSI-related, Buy-In, medically needy, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain between $1,821 and $2,739 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $62 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related, medically needy, and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $727 in an MMNA. Other The Katie Beckett pathway is not available. The hospice only eligibility pathway is not available. Congressional Research Service 37 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Kentucky Table 22. Eligibility Pathways for Medicaid and Long-Term Care in Kentucky, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes No Medically Needy (MN) $217 / $267 $2,000 / $4,000 MN benefits only Yes (NH care) No Special Income Rule, Miller Trust $2,022 (no cap) $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Traditional Benefits All SSI recipients are eligible for Medicaid. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses to the state’s medically needy threshold from a selected budget period between one and three months. The state makes the special income rule pathway available up to 300% of SSI. Amounts that can be deposited in a Miller Trust are unlimited. Institutional LTC The SSI-related, medically needy, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain between $1,822 and $2,739 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $40 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the special income pathway. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $694 in an MMNA. Other The Katie Beckett pathway is available. The hospice only eligibility pathway is available. Congressional Research Service 38 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Louisiana Table 23. Eligibility Pathways for Medicaid and Long-Term Care in Louisiana, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes 100% FPL $677 / $911 $2,000 / $3,000 Yes Yes Yes Buy-In $2,257 (excludes spousal income) $25,000 (excludes spousal resources) Yes Yes No Medically Needy (MN) $100 / $192 $2,000 / $3,000 MN benefits only Yes (NH care) No Special Income Rule $2,022 $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. Traditional Benefits All SSI recipients are eligible for Medicaid. The 100% FPL pathway is available to individuals with incomes up to 75% of the FPL. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a three month budget period to the state’s medically needy threshold. The state makes the special income rule pathway available up to 300% of SSI. Institutional LTC The SSI-related, 100% FPL, Buy-In, medically needy, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,739 in income and up to $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $38 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related, 100% FPL and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $2,022 in an MMNA. Other Pathways The Katie Beckett pathway is not available. The hospice only eligibility pathway is not available. Congressional Research Service 39 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Maine Table 24. Eligibility Pathways for Medicaid and Long-Term Care in Maine, 2009 Monthly Income Limit (Individual/Couple) Eligibility Pathway Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes 100% FPL $903 / $1,214 $2,000 / $3,000 Yes Yes Yes Buy-In $2,257 (on total income)a $12,000 (includes spousal resources) Yes Yes Yes Medically Needy (MN) $903 / $1,214 $2,000 / $3,000 MN benefits only Yes (NH care) Yes Special Income Rule $2,022 $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. a. Up to $903 on unearned income (includes spousal income). Traditional Benefits All SSI recipients are eligible for Medicaid. The 100% pathway is available to individuals with incomes up to 100% of the FPL. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a six month budget period to the state’s medically needy threshold. The state makes the special income rule pathway available up to 300% of SSI. Institutional LTC The SSI-related, 100% FPL, Buy-In, medically needy, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $1,822 in income and up to $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $40 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related, 100% FPL, Buy-In, and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $1,129 in an MMNA. Other The Katie Beckett pathway is available. The hospice only eligibility pathway is not available. Congressional Research Service 40 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Maryland Table 25. Eligibility Pathways for Medicaid and Long-Term Care in Maryland, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes Buy-In $2,709 (includes spousal income) $10,000 (includes spousal resources) Yes Yes Yes Medically Needy (MN) $350 / $392 $2,500 / $3,000 MN benefits only Yes (NH care) Yes Special Income Rule $2,022 $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. Traditional Benefits All SSI recipients are eligible for Medicaid. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a six month budget period to the state’s medically needy threshold. The state makes the special income rule pathway available up to 300% of SSI. Institutional LTC The SSI-related, Buy-In, medically needy, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain between $1,821 and $2,739 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $71 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related Buy-In, medically needy, and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $2,022 in an MMNA. Other The Katie Beckett pathway is not available. The hospice only eligibility pathway is not available. Congressional Research Service 41 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Massachusetts Table 26. Eligibility Pathways for Medicaid and Long-Term Care in Massachusetts, 2009 Monthly Income Limit (Individual/Couple) Eligibility Pathway Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes 100% FPL $903 / $1,214 $2,000 / $3,000 Yes Yes Yes Buy-In No Income Limit No Resource Limit Yes Yes No Medically Needy (MN) $522/ $650 $2,000 / $3,000 MN benefits only Yes (NH care) No Special Income Rule $2,022 $2,000 / $3,000 Yes No Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. Notes: 100% of FPL Pathway disregards 33% of income above 100% of the FPL if the beneficiary is blind or disabled. Traditional Benefits All SSI recipients are eligible for Medicaid. The 100% FPL pathway is available to individuals with incomes up to 100% of the FPL. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a six month budget period to the state’s medically needy threshold. The state makes the special income rule pathway available up to 300% of SSI. Institutional LTC The SSI-related, 100% FPL, Buy-In, and medically needy pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,739 in income and up to $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $73 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related, 100% FPL and special income pathways. The state does not apply spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $2,022 in an MMNA. Other The Katie Beckett pathway is available. The hospice only eligibility pathway is not available. Congressional Research Service 42 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Michigan Table 27. Eligibility Pathways for Medicaid and Long-Term Care in Michigan, 2009 Monthly Income Limit (Individual/Couple) Eligibility Pathway Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes No 100% FPL $903 / $1,214 $2,000 / $3,000 Yes Yes Yes Buy-In $903a $75,000 (excludes spousal resources) Yes Yes Yes Medically Needy (MN) $903 / $1,215 $2,000 / $3,000 MN benefits only Yes (NH care) No Special Income Rule $2,022 $2,000 / $3,000 Yes Yes No Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. a. Pre-enrollment: Total countable income (earned and unearned) cannot exceed $903 using SSI methodology. During enrollment: No limit on earned income, but unearned income cannot exceed $903. (Excludes spousal income) Traditional Benefits All SSI recipients are eligible for Medicaid. The 100% FPL pathway is available to individuals with incomes up to 100% of the FPL. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a one month budget period to the state’s medically needy threshold. The state makes the special income rule pathway available up to 300% of SSI. Institutional LTC The SSI-related, 100% FPL, Buy-In, medically needy, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,739 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $60 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the 100% FPL and Buy-In pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $2,022 in an MMNA. Other The Katie Beckett pathway is available. The hospice only eligibility pathway is available. Congressional Research Service 43 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Minnesota Table 28. Eligibility Pathways for Medicaid and Long-Term Care in Minnesota, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) SSI-related: 209(b) $482 / $602 $2,000 / $3,000 100% FPL $858/ $1,153 Buy-In Traditional Benefits Institutional LTC HCBS Waivers Yes Yes No $2,000 / $3,000 Yes Yes Yes No maximum. Lower limit of $65 of unearned income (excludes spousal income) $20,000 (excludes spousal resources) Yes Yes No Medically Needy (MN) $467 / $583 $3,000 / $6,000 MN benefits only Yes (NH care) Yes Special Income Rule $2,022 $2,000 / $3,000 Yes Yes Aged only Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. Traditional Benefits Minnesota is a 209(b) state and applies more restrictive rules to the counting of income and resources than are applied under the federal government’s SSI thresholds. The 100% FPL pathway is available to individuals with incomes up to 100% of the FPL. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a six month budget period to the state’s medically needy threshold. The state makes the special income rule pathway available up to 300% of SSI. Institutional LTC The SSI-related: 209(b), 100% FPL, Buy-In, medically needy, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain between $1,823 and $2,739 in income and between $31,094 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $89 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the 100% FPL, medically needy, and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $935 in an MMNA. Other The Katie Beckett pathway is available. The hospice only eligibility pathway is not available. Congressional Research Service 44 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Mississippi Table 29. Eligibility Pathways for Medicaid and Long-Term Care in Mississippi, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes Special Income Rule, Miller Trust $2,022 (no cap) $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Traditional Benefits All SSI recipients are eligible for Medicaid. The state makes the special income rule pathway available up to 300% of SSI. Amounts that can be deposited in a Miller Trust are unlimited. Institutional LTC The SSI-related and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,739 in income and up to $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $44 monthly. This amount can increase if the beneficiary participates in a work therapy program. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $2,022 in an MMNA. Other The Katie Beckett pathway is available. The hospice only eligibility pathway is not available. Congressional Research Service 45 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Missouri Table 30. Eligibility Pathways for Medicaid and Long-Term Care in Missouri, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related: 209(b) $768 / $1,033a $2,000 / $3,000b Yes Yes Yes 100% FPL $767 / $1,032 $2,000 / $3,000 Yes Yes No Source: CRS/AARP State Survey, 2009. Note: State-reported survey data shows an inconsistency about whether Missouri offers the Special Income Rule pathway. a. For the blind and/or, disabled, the income threshold is $903 for an individual and $1,215 for a couple. b. For the blind and/or disabled, the resource amount for a couple is $4,000. Traditional Benefits Missouri is a 209(b) state and applies more restrictive rules to the definition of disability than are applied under the federal government’s SSI thresholds. The 100% FPL pathway is available to individuals with incomes up to 85% of the FPL. Institutional LTC The SSI-related: 209(b) and 100% FPL pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain between $1,822 and $2,739 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $30 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related: 209(b) pathway. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $2,022 in an MMNA. Other Pathways The Katie Beckett pathway is not available. The hospice only eligibility pathway is available. Congressional Research Service 46 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Montana Table 31. Eligibility Pathways for Medicaid and Long-Term Care in Montana, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes Medically Needy (MN) $625 $2,000 / $3,000 MN benefits only Yes (NH care) Yes Source: CRS/AARP State Survey, 2009. Traditional Benefits All SSI recipients are eligible for Medicaid. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a one month budget period to the state’s medically needy threshold. Institutional LTC The SSI-related and medically needy pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $1,821 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $50 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related and medically needy pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Medically needy waiver recipients may retain up to $625 in an MMNA; other waiver recipients may retain $674. Other Pathways The Katie Beckett pathway is not available. The hospice only eligibility pathway is available. Congressional Research Service 47 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Nebraska Table 32. Eligibility Pathways for Medicaid and Long-Term Care in Nebraska, 2009 Monthly Income Limit (Individual/Couple) Eligibility Pathway Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes 100% FPL $903 / $1,214 $2,000 / $3,000 Yes Yes Yes Buy-In $903 $4,000 / $6,000 Yes Yes No Medically Needy (MN) $903 / $1,215 $4,000 / $6,000 MN benefits only Yes (NH care) Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. Traditional Benefits All SSI recipients are eligible for Medicaid. The 100% FPL pathway is available to individuals with incomes up to 100% of the FPL. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a one month budget period to the state’s medically needy threshold. Institutional LTC The SSI-related, 100% FPL, Buy-In, and medically needy pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,739 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $50 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related, 100% FPL, and medically needy pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $903 in an MMNA. Other Pathways The Katie Beckett pathway is available. The hospice only eligibility pathway is not available. Congressional Research Service 48 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Nevada Table 33. Eligibility Pathways for Medicaid and Long-Term Care in Nevada, 2009 Eligibility Pathway Total Resources Limit (Individual/Couple) Monthly Income Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes Buy-In $2,257 (earned income)a $15,000 (excludes spousal resources) Yes Yes No Special Income Rule, Miller Trust $2,022 (no cap) $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. a. Unearned income is capped at $699. Traditional Benefits All SSI recipients are eligible for Medicaid. Individuals with disabilities may qualify under the state’s Buy-In pathway. The state makes the special income rule pathway available up to 300% of SSI. Amounts that can be deposited in a Miller Trust are unlimited. Institutional LTC The SSI-related, Buy-In, and special income pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment, the community spouse may retain between $1,821 and $2,739 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $35 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI related and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $2,022 in an MMNA. Other The Katie Beckett pathway is available. The hospice only eligibility pathway is not available. Congressional Research Service 49 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities New Hampshire Table 34. Eligibility Pathways for Medicaid and Long-Term Care in New Hampshire, 2009 Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) SSI-related: 209(b) $688 / $1,012 $2,000 / $3,000 Buy-In $4,063 (earned income, includes spousal income) Medically Needy (MN) Special Income Rule Eligibility Pathway Traditional Benefits Institutional LTC HCBS Waivers Yes Yes Yes $24,991 / $37,487 Yes Yes Yes $591 / $675 $2,500 / $4,000 MN benefits only Yes (NH care) Yes $2,022 $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. Traditional Benefits New Hampshire is a 209(b) state and applies more restrictive rules to the definition of disability than are applied under the federal government’s SSI thresholds. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a one month or six month budget period to the state’s medically needy threshold. The state makes the special income rule pathway available up to 300% of SSI. Institutional LTC The SSI-related: 209(b), Buy-In, medically needy, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $1,822 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $56 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related: 209(b), Buy-In, medically needy, and special income pathways. The state does not apply spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $2,022 in an MMNA. Other Pathways The Katie Beckett pathway is not available. The hospice only eligibility pathway is not available. Congressional Research Service 50 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities New Jersey Table 35. Eligibility Pathways for Medicaid and Long-Term Care in New Jersey, 2009 Monthly Income Limit (Individual/Couple) Eligibility Pathway Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes No 100% FPL $903 / $1,214 $2,000 / $3,000 Yes Yes No Buy-In $2,257 earned income, $903 unearned incomea $20,000 (excludes spousal resources) Yes Yes No Medically Needy (MN) $367 / $434 $4,000 / $6,000 MN benefits only Yes (NH care) No Special Income Rule $2,022 $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. a. Unearned income threshold disregards SSDI benefits received under individual’s account (SSN, not survivor’s SSN). Traditional Benefits All SSI recipients are eligible for Medicaid. The 100% FPL pathway is available to individuals with incomes up to 100% of the FPL. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a six month budget period to the state’s medically needy threshold. The state makes the special income rule pathway available up to 300% of SSI. Institutional LTC The SSI-related, 100% FPL, Buy-In, medically needy, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,739 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $35 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the special income pathway. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients in an alternative living facility may retain up to $674 in an MMNA. All other waiver recipients may retain up to $2,022 in an MMNA. Other The Katie Beckett pathway is not available. The hospice only eligibility pathway is available. Congressional Research Service 51 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities New Mexico Table 36. Eligibility Pathways for Medicaid and Long-Term Care in New Mexico, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes Buy-In $2,257 earned income,a $1,226 unearned income (includes spousal income) $10,000 (excludes spousal resources) Yes Yes No Special Income Rule, Miller Trust $2,022 (no cap) $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. a. To be eligible for Medicaid Buy-In in New Mexico beneficiaries must earn at least $970 over three months. Traditional Benefits All SSI recipients are eligible for Medicaid. Working individuals with disabilities may also qualify for Medicaid state plan services through the state’s Buy-In pathway. The state makes the special income rule pathway available to individuals who have been in an institution for at least 30 days. The state makes the special income rule pathway available up to 300% of SSI. Amounts that can be deposited in a Miller Trust are unlimited. Institutional LTC The SSI-related, Buy-In, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment, the community spouse may retain up to $1,822 in income and up to $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $63 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $2,022 in an MMNA. Other The Katie Beckett pathway is not available. The hospice only eligibility pathway is not available. Congressional Research Service 52 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities New York Table 37. Eligibility Pathways for Medicaid and Long-Term Care in New York, 2009 Monthly Income Limit (Individual/Couple) Eligibility Pathway Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes Buy-In $2,257 $13,800 / $20,100 Yes Yes Yes Medically Needy (MN) $767 / $1,117 $13,800 / $20,100 MN benefits only Yes (NH care) Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. Additional information was obtained from, http://www.health.state.ny.us/health_care/medicaid/program/buy_in/index.htmState Plan. Traditional Benefits All SSI recipients are eligible for Medicaid. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a six month budget period to the state’s medically needy threshold. Institutional LTC The SSI-related, Buy-In, and medically needy pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,739 in income and between $74,820 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $50 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related, Buy-In, and special income pathways. The state does not apply spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $787 in an MMNA. Other The Katie Beckett pathway is available. The hospice only eligibility pathway is available. Congressional Research Service 53 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities North Carolina Table 38. Eligibility Pathways for Medicaid and Long-Term Care in North Carolina, 2009 Monthly Income Limit (Individual/Couple) Eligibility Pathway Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes 100% FPL $903 / $1,214 $2,000 / $3,000 Yes Yes Yes Buy-In $3,612 (excludes spousal income)a $20,880 (includes spousal resources) Yes Yes No Medically Needy (MN) $242 / $317 $2,000 / $3,000 MN benefits only Yes (NH care) Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. a. Phased implementation open to individuals with monthly incomes up to $1,354 in December 2009. Traditional Benefits All SSI recipients are eligible for Medicaid. The 100% FPL pathway is available to individuals with incomes up to 100% of the FPL. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a six month budget period to the state’s medically needy threshold. Institutional LTC The SSI-related, 100% FPL, Buy-In, and medically needy pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $1,822 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $30 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related, 100% FPL, and medically needy pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $903 in an MMNA. Other Pathways The Katie Beckett pathway is not available. The hospice only eligibility pathway is not available. Congressional Research Service 54 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities North Dakota Table 39. Eligibility Pathways for Medicaid and Long-Term Care in North Dakota, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related: 209(b) $750 / $1,008 $2,000 / $3,000 Yes Yes Yes Buy-In $2,031 (excludes spousal income) $13,000 (includes family income) Yes Yes Yes Medically Needy (MN) $750 / $1,008 $3,000 / $6,000 MN benefits Yes (NH care) Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. Traditional Benefits North Dakota is a 209(b) state and applies more restrictive rules to the counting of income and resources than are applied under the federal government’s SSI thresholds. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a one month budget period to the state’s medically needy threshold. Institutional LTC The SSI-related: 209(b), Buy-In, and medically needy pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,267 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $50 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related: 209(b), Buy-In, and medically needy pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $750 in an MMNA. Other Pathways The Katie Beckett pathway is not available. The hospice only eligibility pathway is available. Congressional Research Service 55 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Ohio Table 40. Eligibility Pathways for Medicaid and Long-Term Care in Ohio, 2009 Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) SSI-related: 209(b) $589 / $1,011 $1,011 / $2,250 Buy-In $2,257 (excludes spousal income)a Medically Needy (MN) Special Income Rule Eligibility Pathway Traditional Benefits Institutional LTC HCBS Waivers Yes Yes Yes $10,580 (includes spousal resources) Yes Yes Yes $589 / $1,011 $1,011 / $2,250 MN benefits only Yes (NH care) Yes $2,022 $1,011 / $2,250 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. a. Persons with a severe work disability are given an unearned income disregard of up to $20,000 per year. Traditional Benefits Ohio is a 209(b) state and applies more restrictive rules to the counting of income and resources than are applied under the federal government’s SSI thresholds. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a one month budget period to the state’s medically needy threshold. The state makes the special income rule pathway available up to 300% of SSI. Institutional LTC The SSI-related: 209(b), Buy-In, medically needy, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,739 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $40 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related: 209(b), Buy-In, medically needy, and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $1,314 in an MMNA. Other The Katie Beckett pathway is available. The hospice only eligibility pathway is not available. Congressional Research Service 56 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Oklahoma Table 41. Eligibility Pathways for Medicaid and Long-Term Care in Oklahoma, 2009 Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) SSI-related: 209(b) $716 / $1,054, if one spouse is ineligible ($1,094 if both spouses are eligible) $2,000 / $3,000 100% FPL $903 / $1,214 Special Income Rule, Miller Trust $2,022, $3,000 cap Eligibility Pathway Traditional Benefits Institutional LTC HCBS Waivers Yes Yes Yes $2,000 / $3,000 Yes Yes No $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Traditional Benefits Oklahoma is a 209(b) state and applies more restrictive rules to the counting of resources than is applied under the federal government’s SSI threshold. The 100% FPL pathway is available to individuals with incomes up to 100% of the FPL in Oklahoma. The state makes the special income rule pathway available up to 300% of SSI. No more than $3,000 can be deposited in a Miller Trust. Institutional LTC The SSI-related: 209(b), 100% FPL, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,739 in income and between $25,000 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $50 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related: 209(b) and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $1,011 in an MMNA or up to $3,000 with a Miller Trust. Other The Katie Beckett pathway is available. The hospice only eligibility pathway is not available. Congressional Research Service 57 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Oregon Table 42. Eligibility Pathways for Medicaid and Long-Term Care in Oregon, 2009 Monthly Income Limit (Individual/Couple) Eligibility Pathway Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes Buy-In $2,257 adjusted earned income (excludes spousal income) $5,000 (excludes spousal resources) Yes Yes Yes Special Income Rule, Miller Trust $2,022, or $6,494 cap $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. Traditional Benefits All SSI recipients are eligible for Medicaid. Individuals with disabilities may qualify under the state’s Buy-In pathway. The state makes the special income rule pathway available up to 300% of SSI. Up to $6,494 can be deposited in a Miller Trust are unlimited. Institutional LTC The SSI-related, Buy-In, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment, the community spouse may retain up to $1,822 in income and up to $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $30 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related, Buy-In, and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $1,822 in an MMNA or $6,494 with a Miller Trust. Other Pathways The Katie Beckett pathway is available. The hospice only eligibility pathway is not available. Congressional Research Service 58 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Pennsylvania Table 43. Eligibility Pathways for Medicaid and Long-Term Care in Pennsylvania, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes 100% FPL $903 / $1,214 $2,000 / $3,000 Yes Yes Yes Buy-In $2,257 (includes spousal income) $10,000 (includes spousal resources) Yes Yes Yes Medically Needy (MN) $2,550 / $2,650a $2,400 / $3,200 MN benefits only Yes (NH care) Yes Special Income Rule $2,022 $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. Pennsylvania 1915(c) waiver application, http://www.temple.edu/thetrainingpartnership/resources/mrBulletins/wv/00-09-04_attch2.pdf a. Income threshold evaluated across six months. Traditional Benefits All SSI recipients are eligible for Medicaid. The 100% FPL pathway is available to individuals with incomes up to 100% of the FPL. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a six month budget period to the state’s medically needy threshold. The state makes the special income rule pathway available up to 300% of SSI. Institutional LTC The SSI-related, 100% FPL Buy-In, medically needy, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain between $1,821 and $2,739 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $45 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related, 100% FPL, Buy-In, medically needy, and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $2,022 in an MMNA. Other The Katie Beckett pathway is not available. The hospice only eligibility pathway is available. Congressional Research Service 59 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Rhode Island Table 44. Eligibility Pathways for Medicaid and Long-Term Care in Rhode Island, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes 100% FPL $903 / $1,214 $2,000 / $3,000 Yes Yes Yes Buy-In $2,257 (excludes spousal income) $10,000 / $20,000 Yes Yes No Medically Needy (MN) $800 / $842 $4,000 / $6,000 MN benefits only Yes (NH care) Yes Special Income Rule $2,022 $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. Traditional Benefits All SSI recipients are eligible for Medicaid. The 100% FPL pathway is available to individuals with incomes up to 100% of the FPL. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a six month budget period to the state’s medically needy threshold. The state makes the special income rule pathway available up to 300% of SSI. Institutional LTC The SSI-related, 100% FPL, Buy-In, medically needy, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,739 in income and up to $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $50 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related, 100% FPL, medically needy, and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $923 in an MMNA. Other The Katie Beckett pathway is available. The hospice only eligibility pathway is not available. Congressional Research Service 60 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities South Carolina Table 45. Eligibility Pathways for Medicaid and Long-Term Care in South Carolina, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes 100% FPL $903 / $1,214 $2,000 / $3,000 Yes Yes Yes Special Income Rule, Miller Trust $2,022 (no cap) $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Traditional Benefits All SSI recipients are eligible for Medicaid. The 100% FPL pathway is available to individuals with incomes up to 100% of the FPL. The state makes the special income rule pathway available up to 300% of SSI. Amounts that can be deposited in a Miller Trust are unlimited. Institutional LTC The SSI-related, 100% FPL, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,739 in income and between $66,480 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $30 monthly.27 HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related, 100% FPL and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. MMNA was not available through survey or state contacts. Other The Katie Beckett pathway is available. The hospice only eligibility pathway is available. 27 http://www.dhhs.state.sc.us/dhhsnew/insidedhhs/bureaus/bureauofeligibilityprocessing/nursinghome.asp Congressional Research Service 61 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities South Dakota Table 46. Eligibility Pathways for Medicaid and Long-Term Care in South Dakota, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes Buy-In $2,257 (excludes spousal income) $8,000 (excludes spousal resources) Yes Yes Yes Special Income Rule, Miller Trust $2,022 (no cap) $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. Traditional Benefits All SSI recipients are eligible for Medicaid. Individuals with disabilities may qualify under the state’s Buy-In pathway. The state makes the special income rule pathway available up to 300% of SSI. Amounts that can be deposited in a Miller Trust are unlimited. Institutional LTC The SSI-related, Buy-In, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment, the community spouse may retain up to $1,821 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $60 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related, Buy-In, and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $694 in an MMNA or higher with a Miller Trust. Other The Katie Beckett pathway is available. The hospice only eligibility pathway is not available. Congressional Research Service 62 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Tennessee Table 47. Eligibility Pathways for Medicaid and Long-Term Care in Tennessee, 2009 Eligibility Pathway Total Resources Limit (Individual/Couple) Monthly Income Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes Special Income Rule, Miller Trust $2,022 (no cap) $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Traditional Benefits All SSI recipients are eligible for Medicaid. The state makes the special income rule pathway available up to 300% of SSI. Amounts that can be deposited in a Miller Trust are unlimited. Institutional LTC The SSI-related and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,739 in income and up to $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $50. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $1,348 in an MMNA or higher with a Miller Trust. Other The Katie Beckett pathway is not available. The hospice only eligibility pathway is not available. Congressional Research Service 63 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Texas Table 48. Eligibility Pathways for Medicaid and Long-Term Care in Texas, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes Buy-In $2,257 (excludes spousal income)a $5,000 (excludes spousal resources)b Yes Yes Yes Special Income Rule, Miller Trust $2,022 (no cap) $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. Texas section 1915(c) waiver application, http://www.dads.state.tx.us/providers/CBA/CBAWaiver.pdf a. To be eligible for Medicaid Buy-In in Texas beneficiaries must earn at least $1,090 in qualifying SSA quarter prior to application date. b. Half of any jointly owned (with spouse) assets considered. Traditional Benefits All SSI recipients are eligible for Medicaid. Individuals with disabilities may qualify under the state’s Buy-In pathway. The state makes the special income rule pathway available to individuals who have been in an institution for at least 30 days. The state makes the special income rule pathway available up to 300% of SSI. Amounts that can be deposited in a Miller Trust are unlimited. Institutional LTC The SSI-related, Buy-In, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment, the community spouse may retain up to $2,739 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $60 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI related, Buy-In, and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $2,022 in an MMNA or higher with a Miller Trust. Other The Katie Beckett pathway is not available. The hospice only eligibility pathway is available. Congressional Research Service 64 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Utah Table 49. Eligibility Pathways for Medicaid and Long-Term Care in Utah, 2009 Monthly Income Limit (Individual/Couple) Eligibility Pathway Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes 100% FPL $903 / $1,214 $2,000 / $3,000 Yes Yes Yes Buy-In $2,257 (includes spousal income) $15,000 (includes spousal resources) Yes Yes Yes Medically Needy (MN) $903 / $1,214 $2,000 / $3,000 MN benefits only Yes (NH care) Yes Special Income Rule $2,022 $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. Traditional Benefits All SSI recipients are eligible for Medicaid. The 100% FPL pathway is available to individuals with incomes up to 100% of the FPL. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a one month budget period to the state’s medically needy threshold. The state makes the special income rule pathway available up to 300% of SSI. Institutional LTC The SSI-related, 100% FPL, Buy-In, medically needy, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $1,822 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $45 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related, 100% FPL, Buy-In, medically needy, and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $903 in an MMNA. Other The Katie Beckett pathway is not available. The hospice only eligibility pathway is not available. Congressional Research Service 65 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Vermont Table 50. Eligibility Pathways for Medicaid and Long-Term Care in Vermont, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes 100% FPL $903 / $1,214 $2,000 / $3,000 Yes Yes Yes Buy-In $2,257a $5,000 / $6,000 Yes Yes No Medically Needy (MN) $991 $2,000 / $3,000 MN benefits only Yes (NH care) Yes Special Income Rule $2,022 $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. a. After disregarding SSDI and veteran’s benefits, income cannot exceed either the Medicaid protected income level for one, or the SSI/Aid to the Aged, Blind, and Disabled (AABD) payment level for two. Traditional Benefits All SSI recipients are eligible for Medicaid. The 100% FPL pathway is available to individuals with incomes up to 100% of the FPL. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses living in an LTC facility can spend down their income on medical expenses over a onemonth budget period (six-month, if living in the community) to the state’s medically needy threshold. The state makes the special income rule pathway available up to 300% of SSI. Institutional LTC The SSI-related, 100% FPL, Buy-In, medically needy, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $1,829 in income and up to $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $47 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related, 100% FPL, medically needy, and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $991 in an MMNA. Other The Katie Beckett pathway is available. The hospice only eligibility pathway is available. Congressional Research Service 66 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Virginia Table 51. Eligibility Pathways for Medicaid and Long-Term Care in Virginia, 2009 Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) SSI-related: 209(b) $722 / $972 $2,000 / $3,000 100% FPL $722 / $971 Buy-In Eligibility Pathway Traditional Benefits Institutional LTC HCBS Waivers Yes Yes No $2,000 / $3,000 Yes Yes Yes $722 (includes spousal income) $2,000 / $3,000 Yes Yes Yes Medically Needy (MN) $421 / $508 $2,000 / $3,000 MN benefits only Yes (NH care) Yes Special Income Rule $2,022 $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. Traditional Benefits Virginia is a 209(b) state and applies more restrictive rules to the counting of resources than is applied under the federal government’s SSI thresholds. The 100% FPL pathway is available to individuals with incomes up to 80% of the FPL. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a budget period to the state’s medically needy threshold. The state makes the special income rule pathway available up to 300% of SSI. Institutional LTC The SSI-related: 209(b), 100% FPL, Buy-In, medically needy, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,739 in income and up to $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $40 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the 100% FPL, medically needy, and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $2,022 in an MMNA. Other Pathways The Katie Beckett pathway is not available. The hospice only eligibility pathway is available. Congressional Research Service 67 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Washington Table 52. Eligibility Pathways for Medicaid and Long-Term Care in Washington, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes Buy-In $1,987 (includes spousal income) No Resource Limit Yes Yes Yes Medically Needy (MN) $467 / $592 $2,000 / $3,000 MN benefits only Yes (NH care) No Special Income Rule $2,022 $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. Traditional Benefits All SSI recipients are eligible for Medicaid. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a budget period to the state’s medically needy threshold. The beneficiary’s budget period may have a retroactive base period that is one, two, or three months depending on the client’s circumstances and eligibility. The prospective base period may be either three or six months and is the beneficiary’s option. The state makes the special income rule pathway available up to 300% of SSI. Institutional LTC The SSI-related, Buy-In, medically needy, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain between $1,821 and $2,739 in income and between $48,639 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $70 monthly for institutionalized persons. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related, Buy-In, and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $903 in an MMNA. Other The Katie Beckett pathway is not available. The hospice only eligibility pathway is available. Congressional Research Service 68 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities West Virginia Table 53. Eligibility Pathways for Medicaid and Long-Term Care in West Virginia, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes Buy-In $2,257a $2,000b Yes Yes No Special Income Rule $2,022 $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. a. Unearned income must be equal to or less than the SSI benefit plus $20. b. Liquid assets are excluded up to $5,000. Traditional Benefits All SSI recipients are eligible for Medicaid. Individuals with disabilities may qualify under the state’s Buy-In pathway. The state makes the special income rule pathway available up to 300% of SSI. Institutional LTC The SSI-related, Buy-In, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment, the community spouse may retain between $1,821 and $2,739 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $50 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related and special income pathways. The state does not apply spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $2,022 in an MMNA. Other Pathways The Katie Beckett pathway is available. The hospice only eligibility pathway is not available. Congressional Research Service 69 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Wisconsin Table 54. Eligibility Pathways for Medicaid and Long-Term Care in Wisconsin, 2009 Monthly Income Limit (Individual/Couple) Eligibility Pathway Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes 100% FPL $903 / $1,214 $2,000 / $3,000 No Yes Yes Buy-In $2,257 (includes spousal income) $15,000 (excludes spousal resources) Yes Yes Yes Medically Needy (MN) $592 $2,000 / $3,000 MN benefits only Yes (NH care) Yes Special Income Rule $2,022 $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. Traditional Benefits All SSI recipients are eligible for Medicaid. The 100% FPL pathway is available to individuals with incomes up to 100% of the FPL. Individuals with disabilities may qualify under the state’s Buy-In pathway. Under the medically needy pathway, certain individuals with high medical expenses can spend down their income on medical expenses over a six month budget period to the state’s medically needy threshold. The state makes the special income rule pathway available up to 300% of SSI. Institutional LTC The SSI-related, 100% FPL, Buy-In, medically needy, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment rules, the community spouse may retain up to $2,428 in income and between $21,912 and $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $45 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related, 100% FPL, Buy-In, medically needy, and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $2,022 in an MMNA. Other Pathways The Katie Beckett pathway is available. The hospice only eligibility pathway is available. Congressional Research Service 70 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Wyoming Table 55. Eligibility Pathways for Medicaid and Long-Term Care in Wyoming, 2009 Eligibility Pathway Monthly Income Limit (Individual/Couple) Total Resources Limit (Individual/Couple) Traditional Benefits Institutional LTC HCBS Waivers SSI-related $674 / $1,011 $2,000 / $3,000 Yes Yes Yes Buy-In $2,022a No Resource Limit Yes Yes Yes Special Income Rule, Miller Trust $2,022 (no cap) $2,000 / $3,000 Yes Yes Yes Source: CRS/AARP State Survey, 2009. Buy-In Pathway Data for 2009: Matthew Kehn, Sarah Croake, and Jody Schimmel, A Government Performance and Results Act (GPRA) Report: The Status of the Medicaid Infrastructure, Mathematica Policy Research, Inc., Final Report, Washington, DC, December 23, 2010. a. Gross countable income only. Traditional Benefits All SSI recipients are eligible for Medicaid. Individuals with disabilities may qualify under the state’s Buy-In pathway. The state makes the special income rule pathway available to individuals who have been in an institution for at least 30 days. The state makes the special income rule pathway available up to 300% of SSI. Amounts that can be deposited in a Miller Trust are unlimited. Institutional LTC The SSI-related, Buy-In, and special income rule pathways are available to individuals to qualify for institutional LTC. Under spousal impoverishment, the community spouse may retain up to $2,739 in income and up to $109,560 in assets. The personal needs allowance for an individual in an LTC facility is $50 monthly. HCBS Waiver For HCBS waiver services, individuals can qualify through the SSI-related, Buy-In, and special income pathways. The state applies spousal impoverishment rules to HCBS waiver applicants. Waiver recipients may retain up to $2,022 in an MMNA or higher with a Miller Trust. Other The Katie Beckett pathway is not available. The hospice only eligibility pathway is available. Congressional Research Service 71 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Appendix A. Eligibility Groups Excluded from the Survey Not all of Medicaid’s eligibility groups, or pathways, for these populations were surveyed, in part because (1) one group was recently established, (2) information on these groups are available through other sources, and/or (3) some groups do not bring in significant numbers of eligibles. Among the eligibility pathways not included in our survey are the pathways for dual eligibles (i.e., those eligible for both Medicare and Medicaid). Also not included is the new pathway established under the Patient Protection and Affordable Care Act (PPACA; P.L. 111-148). Section 2402 of PPACA gave states the option to extend certain home and community-based services (HCBS), as well as full Medicaid, to individuals with income no greater than 150% of the federal poverty level (FPL) and who meet a state’s needs-based criteria. This needs-based criteria, defined by states, can be no more stringent than the criteria the state uses to determine eligibility for institutional care in a nursing facility, ICF/MR, or hospital. Alternatively, states may choose to extend this eligibility pathway to persons with income up to 300% of the SSI benefit rate who are receiving HCBS services under a waiver authorized under sections 1915(c), (d) or (e) of the SSA. Also not included is the optional Medicaid eligibility group for families who have children with disabilities, known as the Family Opportunity Act (FOA). FOA was established by the Deficit Reduction Act of 2005 (DRA, P.L. 109-171). As of January 1, 2007, states have the option to allow families whose income is less than 300% of FPL to purchase Medicaid coverage for their disabled children through age 18. This Medicaid buy-in can cover all disabled children up to age 18. FOA has some restrictions, such as states must require working parents to enroll in and pay premiums for family coverage through employer-sponsored insurance, when it is offered. States also can require families to pay a portion of the cost of their children’s participation in Medicaid through monthly premiums using a sliding scale based on income, (i.e., families with income up to 200% of the FPL would be responsible for payments of 5% of income, and 7.5% of income for families with income between 200% and 300% of FPL). Congressional Research Service 72 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities Appendix B. Medicaid’s Resources Rules for Aged and Disabled Eligibility Pathways SSI, and thus Medicaid, limits the countable resources persons may have to qualify for benefits. Countable resources generally refer to liquid assets, such as money in bank accounts, stocks and bonds, mutual fund investments, and certificates of deposit. In general, an SSI recipient can have assets, with the exception of a home, car, and household items, worth no more than $2,000; beneficiary-couples can have countable assets worth no more than $3,000. Eligibility for SSI is restricted to otherwise qualifying individuals whose resources do not exceed $2,000 for an individual and $3,000 for a couple. Countable resources do not, however, include all resources that an individual or couple may own. They exclude, but are not limited to, a car used for essential transportation (or, if not essential, up to $4,500 of its current value), property essential to income-producing activity, household goods and personal effects totaling $2,000 or less, and life insurance policies with a combined face value of $1,500 or less.28 Under SSI, the entire value of the primary place of residence (i.e., his or her home) of Medicaid applicants is not counted. However, the Deficit Reduction Act of 2005 (DRA) amended Medicaid law (section 1917 of the Social Security Act) to restrict eligibility for Medicaid to certain individuals who apply for Medicaid coverage for nursing facility or other LTSS if the applicant’s equity interest in his or her home is greater than $500,000.29 A state may elect to substitute an amount that exceeds $500,000 but does not exceed $750,000.30 This restriction applies only to applicants who do not have a spouse, child under age 21, or child who is blind or disabled (as defined by the section 1614(a)(3) of the Social Security Act for the 50 states and the District of Columbia) lawfully residing in the home. 31 For purposes of qualifying for Medicaid, people who have home equity above the state-specified amount must reduce their total equity interest in the home. The income earned from a transaction, such as a reverse mortgage or home equity loan, is subject to repayment. It is not considered countable income for Medicaid eligibility purposes in the month it is received. Any amounts retained into the following month are counted as resources and would need to be depleted to the state’s asset thresholds before the individual could qualify for Medicaid. 32 A process exists for waiving the application of the home equity limit in the case of demonstrated hardship. 28 The SSI resource exclusions can be found in section 1613 of the Social Security Act (42 USC § 1382b) and in the Code of Federal Regulations at 20 CFR §§ 416.1210-416.1239. 29 Applies when applicants seek Medicaid coverage for the following services: nursing facility care; a level of care in any institution equivalent to nursing facility services; HCBS furnished under a waiver under sections 1915(c) or (d) of the Social Security Act; and services provided to a noninstitutionalized individual that are described in paragraph (7), (22), or (24) of section 1905(a) of the act, among other instances. 30 Beginning in 2011, these dollar amounts are increased from year to year based on the percentage increase in the consumer price index for all urban consumers, rounded to the nearest $1,000. 31 And who are determined eligible for certain long-term care services based on an application filed on or after January 1, 2006. 32 SSR 92-8p: Policy Interpretation Ruling Title XVI: SSI Loan Policy, Including its Applicability to Advances of Food and/or Shelter. Congressional Research Service 73 Medicaid Eligibility for Persons Age 65+ and Individuals with Disabilities For any beneficiary (and spouse, if any) who moves out of his or her home without the intent to return, the home becomes a countable resource because it is no longer the individual’s principal place of residence. If an individual leaves his or her home to live in an institution, the home is still considered to be the individual’s principal place of residence, irrespective of the individual’s intent to return, as long as a spouse or dependent relative of the eligible individual continues to live there. Author Contact Information Julie Stone Specialist in Health Care Financing jstone@crs.loc.gov, 7-1386 Acknowledgments Scott Talaga, health policy research intern at CRS from the Cornell Institute of Public Affairs, Cornell University, assisted in the verification of survey results and in compiling the state profiles. Thank you to Roy Trudel at CMS, April Grady at MACPAC, and Patricia A. Davis, David Newman, and Alison Mitchell at CRS, for their editorial comments and suggestions. Congressional Research Service 74