Medicaid Eligibility Allen Bryan, Centers for Medicare and Medicaid (CMS) Bethany Hamm, MaineCare

Medicaid Eligibility

Allen Bryan, Centers for Medicare and Medicaid (CMS)Bethany Hamm, MaineCare

Marybeth McCaffrey, Vermont AHS, Economic Services Division

June 2009

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Section 2: Medicaid Eligibility ProcessTable of Contents

Category General Eligibility Factors, Other Than

Category Financial Eligibility Factors Eligibility Determination ProcessCoverage-Medicaid and SCHIP Benefits

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Category

Disability

Aged

Blind

Children

Parent/Caretaker Relative

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General Eligibility Factors Other Than Category

After establishing age or disability category, other eligibility factors need to be determined U.S. Citizenship and identity (n/a to SSI, SSDI,

Medicare recipients Residency Who is living with applicant? What resources are owned by applicant and

family? How much income is received by applicant and

family? Retroactive coverage for up to 3 months before

month of application provided all eligibility requirements met 4

Financial Eligibility Factors

Key terms

Financial responsibility

Methodologies

Standards

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Financial Eligibility Factors: Key Terms

Federal Poverty Level (FPL) Income tests based on FPL FPL is adjusted annually according to the cost of living

Medically Needy Income Level (MNIL) Levels are based on law and cannot exceed 133 1/3% of

1931 income standards Compares a group’s countable income to MNIL to

determine financial eligibility for Medicaid

Spenddown Groups who fail MNIL will have income Spenddown to meet

before Medicaid services are covered Similar to deductible associated with medical insurance Usually for six month period

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Financial Eligibility Factors: Financial Responsibility

Whose income and resources to count?

Very challenging to analyze Household composition? Which family members are requesting

coverage?

General rules Parents are financially responsible for their

minor children Spouses are financially responsible for each

other 7

Financial Eligibility Factors: Methodologies

What income and resources are countable vs. excludable?

Resource methodologies Burial funds Term life insurance Personal property (not real property) Home One car Annuities are special

Income methodologies Excluded income (e.g. gifts, food stamp benefits, senior

companion) Countable income

Disregarded income ($20) Deductions from countable income (varies)

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Financial Eligibility Factors: Standards

Resource standards$2000 for individual$3000 for group of two

Income standards

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Income StandardsEffective 1/2009

1 2 3 4 5 6 7 8 Asset Limit

Infants up to age 1185%

$1670 $2247

$2823

$3400 $3976

$4553

$5130

$5706

NONE

Age 1 through Age 5133%

$1201 $1615

$2030

$2444 $2859

$3273

$3688

$4102

NONE

Age 6 through Age 18 125%

$1129 $1518

$1908

$2297 $2687

$3077

$3466

$3856

NONE

SCHIP & Pregnant Women200%

$1805 $2429

$3052

$3675 $4922

$4922

$5545

$6169

NONE$2000NONE

Age 1 –Age 18150%

$1354 $1822

$2289

$2757 $3224

$3692

$4159

$4627

NONE

Age 19-20 (150%)Parents 100-150%0-100%

$1354 $1822

$2289

$2757 $3224

$3692

$4159

$4627

$2000

SSI-Related Medicaid(100%)

$903 $1215

$2000$3000

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Eligibility Determination Process

Takes into account category, general eligibility factors and financial eligibility factors (previous 3 sections)

Determines whether person meets eligibility coverage for any coverage group

Based on income, person may need to contribute in order to enroll or access certain coverage Cost sharing (e.g. may be required for

prescription coverage) Premiums (e.g. may be required before person

can be enrolled Deductibles

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Coverage-Medicaid & SCHIP Benefits

Medicaid & SCHIP offer mandatory and optional services

States have latitude to offer optional services

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Contact Information

Allen Bryan [email protected]

Bethany [email protected]

Marybeth McCaffrey [email protected]

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Medicaid Eligibility Allen Bryan, Centers for Medicare and Medicaid (CMS) Bethany Hamm, MaineCare

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